Proton-Pump Inhibitors and Clopidogrel: Important Interaction?

Coronary heart disease patients who received both drugs experienced fewer hospitalizations for gastrointestinal bleeding than did those who received clopidogrel alone.

Researchers have suggested that concomitant use of clopidogrel and proton-pump inhibitors (PPIs) is associated with elevated risk for cardiovascular disease (CVD) events. In this retrospective cohort study, investigators reviewed Tennessee Medicaid data for 20,596 patients who received clopidogrel after hospitalization for myocardial infarctions (MIs), coronary artery revascularization, or unstable angina during a 7-year period; 37% received concomitant PPI therapy.

PPI recipients experienced fewer hospitalizations for gastrointestinal bleeding than did nonrecipients (8.2 vs. 12.2 per 1000 person-years). Results remained significant (hazard ratio, 0.50) in analyses adjusted for demographics, other medication use, diagnosis and procedures, and a propensity score (a variable constructed from the data that makes the analysis more like that of a randomized trial). CVD hospitalizations (for acute MI, sudden death, stroke, or other CVD-related death) were similar for PPI recipients and nonrecipients (63.8 and 64.5 per 1000 person-years). In adjusted analyses, the hazard ratio was 0.99 (not significant).

Comment: PPIs could inhibit the transformation of clopidogrel to its active metabolite, thus reducing clopidogrel's beneficial antiplatelet effects. This large study, as well as several other recent studies (Journal Watch, Gen Med Feb 23 2010 and Journal Watch, Gen Med Oct 8 2009), suggest no adverse effects on cardiovascular outcomes with concomitant use of clopidogrel and PPIs. However, the authors point out that the confidence intervals around their best estimates of risk for adverse clinical outcomes mean that risks associated with PPIs could exceed benefits when risk for a CVD-related event is high and risk for gastrointestinal bleeding is low.

Source:
Ray WA. Outcomes with consurrent use of clopidogrel and proton-pump inhibitors: a cohort study. Ann Intern Med 2010 Mar 16;152(6):337-45. PMID:20231564.

Cancer Surgery, Diabetes & Mortality

In a systematic review and meta-analysis appearing in the April 2010 edition of Diabetes Care, researchers conclude that "cancer patients with preexisting diabetes are about 50% more likely to die after surgery than their nondiabetic counterparts".

The abstract of this article, Postoperative Mortality in Cancer Patients With Preexisting Diabetes, can be found online at: http://care.diabetesjournals.org/content/33/4/931

The Great Prostate Mistake

The inventor of the PSA test for prostate cancer screening Prof Richard Ablin, in a very recent op-ed in the NY Times, today regrets his invention and rues how it has led to a multi-billion dollar profit driven public health disaster in the USA . He writes - I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.

You can read the entire editorial at the following Web-link:
http://www.nytimes.com/2010/03/10/opinion/10Ablin.html

CDC Releases 2009 U.S. Health Stats

The CDC's National Center for Health Statistics has released its annual report, titled Health, United States, 2009. This year's edition contains a special focus on medical technology. The report is available for free online:

1. The complete report (PDF; 574 pages)
   
2. "In Brief" edition (PDF; 15 pages)
3. The CDC's Health United States Website also contains special topics and downloadable presentations and charts.
   

A couple of findings from the data:

• The gap in life expectancy at birth between white persons and black persons persists but has narrowed since 1990.
• After declining substantially between 1950 and 2000, infant, neonatal, and postneonatal mortality rates have remained constant in recent years.
• The prevalence of diabetes, serious heart conditions, and hypertension among adults 45 - 64 years of age is strongly associated with poverty status.
• The percentage of American adults who are obese has doubled over the past three decades to about one-third of all adults.
• The use of statin drugs increased almost 10-fold from 1988 - 1994 to 2003 - 2006; during the same period, the use of antidiabetic drugs increased by 50%.
• Personal health care expenditures paid by Medicaid have increased on average 9% per year, Medicare 8% per year, private health insurance 7% per year, and out-of-pocket payments 4% per year since 1990.

More From the Literature...

Draft of new DSM-5 available for comment

The definition, diagnosis and recommended treatment for some medical disorders are in the process of revision. After 16 years, the American Psychiatric Association wants to update the bible of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders universally known as the DSM.

The new draft of DSM-V includes important changes to bipolar disorder, binged eating, autism and substance abuse, changes that affect not only mental health professionals and their patients but the insurance companies that also use the DSM as a guide.

Over the years, the DSM has generated controversy and criticism for what it defines as a medical disorder and what it doesn't.

Related news stories:
Big changes in store for psychology's bible (NPR)
Psychiatry' draft new bible goes online (New Scientist)

Lancet retracts article linking vaccines and autism

The journal Lancet has retracted the 1998 article linking mercury in vaccines.

The text from the editors is short:
Following the judgment of the UK General Medical Council's Fitness to Practise Panel on Jan 28, 2010, it has become clear that several elements of the 1998 paper by Wakefield et al are incorrect, contrary to the findings of an earlier investigation. In particular, the claims in the original paper that children were "consecutively referred" and that investigations were "approved" by the local ethics committee have been proven to be false. Therefore we fully retract this paper from the published record.

Read news about this retraction at the New York Times

For more on the controversy surrounding vaccines and autism:

• View the original citation in PubMed to connect to various critiques and commentaries, as well as 2004 partial retraction, from the past 12 years.
• Or look for books available at the Duke libraries on vaccines and autism.
  

Want to keep up with the literature? See More from the Literature

New AHRQ Study Finds Failure to Order Needed Tests a Leading Cause of Diagnostic Errors

AHRQ researchers found that failure to order tests, report results to patients, or follow up with abnormal test findings are leading types of diagnostic errors. Results were based on a survey issued to nearly 300 primary care and specialist physicians who reported 583 cases of diagnosis error, the largest-ever study of diagnostic errors in medicine. Researchers also found that tests were overlooked because clinicians often failed to consider the diagnosis, leading to delays in ordering the tests or making the correct diagnosis. The most common missed or delayed diagnoses include pulmonary embolism, drug reactions or overdose, lung cancer, colorectal cancer, acute coronary syndrome, including heart attack, breast cancer and stroke.

The study, led by Gordon Schiff, M.D., associate director of Brigham and Women's Hospital Center for Patient Safety Research and Practice, Boston, which is part of the Cook County Hospital/Rush University AHRQ-supported Developmental Center for Research in Patient Safety. According to Dr. Schiff, the survey found that other major categories of errors involved failure to consider a diagnosis or overweighing a competing diagnosis, failures in history taking, physical examination, and referral or consultation delays. Findings from the study, "Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors," are published in the November 9 issue of the Archives of Internal Medicine.

JAMA focuses on fallout over Breast Cancer Screen Recommendations

Several commentaries in this week's JAMA (january 13, 2010) focus on the controversial 2009 U.S. Preventive Services Task Force recommendations on breast cancer screening. In one, a former member of the task force reminds readers that the organization does not represent the government. He faults the recommendation's "poor wording" as one cause of the controversy and observes that it was "unwise" for the task force not to plan for the inevitable political fallout. In another brief essay, two experts in health outcomes research examine the real harms of overdiagnosis and decry the politicization of healthcare. "Promoting screening irrespective of the evidence may garner votes," they write, "but will not create healthier voters." There are two other commentaries. One argues for better prescreening assessment and discussion of possible screening harms. The other commentary, by a breast-imaging radiologist, argues for annual screening after age 40 among those "willing to accept the downsides of false positives" -- a willingness, she writes, shared by "the overwhelming majority of women."

The 2009 Breast Cancer Screening Recommendations of the US Preventive Services Task Force

The Benefits and Harms of Mammography Screening: Understanding the Trade-offs

Mammography Screening for Breast Cancer: A View From 2 Worlds

Benefits of Screening Mammography

Asthma Return-on-Investment Calculator

Free tool helps calculate return on investment from better asthma care

Employers are seeking solutions that can help reduce their health care costs without sacrificing the health care services provided to their employees or harming worker productivity. A new online, evidence-based tool, the Asthma Return-on-Investment Calculator developed by the Agency for Healthcare Research and Quality (AHRQ), can help employers decide whether it is cost-effective to establish an asthma care management program for employees and their families. According to AHRQ's 2008 National Healthcare Quality Report, the annual cost of treating asthma is nearly $20 billion, which includes nearly $15 billion in direct medical costs and another $5 billion in costs due to lost productivity.

The Asthma Return-on-Investment Calculator can be used to calculate how a group of employees would fare under an asthma care management program. For example, if 10,000 privately insured New York employees who visited the hospital emergency department for asthma were enrolled in a care management program, ED visits could shrink by about 4,700. This reduction could save close to $1 million in hospital emergency room costs. After factoring in money saved by not admitting patients to hospitals and decreased use of asthma medications, an additional $4.2 million in savings could be realized.

To see how businesses can improve their bottom line by improving asthma care for employees, view AHRQ's free Asthma Return-on-Investment Calculator at statesnapshots.ahrq.gov/asthma.

Antidepressants more effective for severe depression; provide minimal to nonexistent benefit for mild to moderate depression

Antidepressant Drug Effects and Depression Severity
A Patient-Level Meta-analysis
Jay C. Fournier, MA; Robert J. DeRubeis, PhD; Steven D. Hollon, PhD; Sona Dimidjian, PhD; Jay D. Amsterdam, MD; Richard C. Shelton, MD; Jan Fawcett, MD
JAMA. 2010;303(1):47-53.

This meta-analysis looks at six large trials, three of Paxil and three of imipramine, and shows that the effectiveness of the drugs varies according to the level of severity of depression. While the drugs are effective for severe depression, they offer little to no benefit over placebo for mild to moderate depression.

JAMA abstract

Context Antidepressant medications represent the best established treatment for major depressive disorder, but there is little evidence that they have a specific pharmacological effect relative to pill placebo for patients with less severe depression.

Objective To estimate the relative benefit of medication vs placebo across a wide range of initial symptom severity in patients diagnosed with depression.

Data Sources PubMed, PsycINFO, and the Cochrane Library databases were searched from January 1980 through March 2009, along with references from meta-analyses and reviews.

Study Selection Randomized placebo-controlled trials of antidepressants approved by the Food and Drug Administration in the treatment of major or minor depressive disorder were selected. Studies were included if their authors provided the requisite original data, they comprised adult outpatients, they included a medication vs placebo comparison for at least 6 weeks, they did not exclude patients on the basis of a placebo washout period, and they used the Hamilton Depression Rating Scale (HDRS). Data from 6 studies (718 patients) were included.

Data Extraction Individual patient-level data were obtained from study authors.

Results Medication vs placebo differences varied substantially as a function of baseline severity. Among patients with HDRS scores below 23, Cohen d effect sizes for the difference between medication and placebo were estimated to be less than 0.20 (a standard definition of a small effect). Estimates of the magnitude of the superiority of medication over placebo increased with increases in baseline depression severity and crossed the threshold defined by the National Institute for Clinical Excellence for a clinically significant difference at a baseline HDRS score of 25.

Conclusions The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.

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The Top 10 Medical Advances of the Decade

The first decade of the 21st century brought a number of discoveries, mistakes and medical advances that influenced medicine from the patient's bedside to the medicine cabinet. In some cases, these advances changed deeply rooted beliefs in medicine. In others, they opened up possibilities beyond what doctors thought was possible years ago. ABC News, in collaboration with MedPage Today, reached out to more than 800 specialists for their suggestions. More than 125 experts in various fields and specialties responded. Their suggestions were then sent to the American Association for the History of Medicine, which narrowed the pool down to an authoritative list of 10 medical advances this decade that have had the most impact.

1. Human Genome Discoveries Reach the Bedside
2. Doctors and Patients Harness Information Technology
3. Anti-Smoking Laws and Campaigns Reduce Public Smoking
4. Heart Disease Deaths Drop by 40 Percent
5. Stem Cell Research: Laboratory Breakthroughs and Some Clinical Advances
6. Targeted Therapies for Cancer Expand With New Drugs
7. Combination Drug Therapy Extends HIV Survival
8. Minimally Invasive Techniques Revolutionize Surgery
9. Study Finds Heart, Cancer Risk With Hormone Replacement Therapy
10. Scientists Peer Into Mind With Functional MRI

Full article; http://abcnews.go.com/Health/Decade/genome-hormones-top-10-medical-advances-decade/story?id=9356853&page=1

From the Literature: CT Scans Increase Cancer Risk

Projected Cancer Risks From Computed Tomographic Scans Performed in the United States in 2007
Amy Berrington de Gonzalez, DPhil; Mahadevappa Mahesh, MS, PhD; Kwang-Pyo Kim, PhD; Mythreyi Bhargavan, PhD; Rebecca Lewis, MPH; Fred Mettler, MD; Charles Land, PhD
Arch Intern Med. 2009;169(22):2071-2077.

A study published in Archives of Internal Medicine this week projects that radiation from CT scans done in 2007 will cause 29,000 new cases of cancer. With recent discussions about health care reform and changes in cancer screening guidelines, this new article is sure to ignite more heated debate.

Background: The use of computed tomographic (CT) scans in the United States (US) has increased more than 3-fold since 1993 to approximately 70 million scans annually. Despite the great medical benefits, there is concern about the potential radiation-related cancer risk. We conducted detailed estimates of the future cancer risks from current CT scan use in the US according to age, sex, and scan type.

Methods: Risk models based on the National Research Council's "Biological Effects of Ionizing Radiation" report and organ-specific radiation doses derived from a national survey were used to estimate age-specific cancer risks for each scan type. These models were combined with age- and sex-specific scan frequencies for the US in 2007 obtained from survey and insurance claims data. We estimated the mean number of radiation-related incident cancers with 95% uncertainty limits (UL) using Monte Carlo simulations.

Results: Overall, we estimated that approximately 29 000 (95% UL, 15 000-45 000) future cancers could be related to CT scans performed in the US in 2007. The largest contributions were from scans of the abdomen and pelvis (n = 14 000) (95% UL, 6900-25 000), chest (n = 4100) (95% UL, 1900-8100), and head (n = 4000) (95% UL, 1100-8700), as well as from chest CT angiography (n = 2700) (95% UL, 1300-5000). One-third of the projected cancers were due to scans performed at the ages of 35 to 54 years compared with 15% due to scans performed at ages younger than 18 years, and 66% were in females.

Conclusions: These detailed estimates highlight several areas of CT scan use that make large contributions to the total cancer risk, including several scan types and age groups with a high frequency of use or scans involving relatively high doses, in which risk-reduction efforts may be warranted.

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Chest X-rays are Overused in the ICU

BACKGROUND: Present guidelines recommend routine daily chest radiographs for mechanically ventilated patients in intensive care units. However, some units use an on-demand strategy, in which chest radiographs are done only if warranted by the patient's clinical status. By comparison between routine and on-demand strategies, we aimed to establish which strategy was more efficient and effective for optimum patient care. METHODS: In a cluster-randomised, open-label crossover study, we randomly assigned 21 intensive care units at 18 hospitals in France to use a routine or an on-demand strategy for prescription of chest radiographs during the first of two treatment periods. Units used the alternative strategy in the second period. Each treatment period lasted for the time taken for enrolment and study of 20 consecutive patients per intensive care unit; patients were monitored until discharge from the unit or for up to 30 days' mechanical ventilation, whichever was first. Units enrolled 967 patients, but 118 were excluded because they had been receiving mechanical ventilation for less than 2 days. The primary outcome measure was the mean number of chest radiographs per patient-day of mechanical ventilation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00893672. FINDINGS: 11 intensive care units were randomly allocated to use a routine strategy to order chest radiographs in the first treatment period, and 10 units to use an on-demand strategy. Overall, 424 patients had 4607 routine chest radiographs (mean per patient-day of mechanical ventilation 1.09, 95% CI 1.05-1.14), and 425 had 3148 on-demand chest radiographs (mean 0.75, 0.67-0.83), which corresponded to a reduction of 32% (95% CI 25-38) with the on-demand strategy (p<0.0001). INTERPRETATION: Our results strongly support adoption of an on-demand strategy in preference to a routine strategy to decrease use of chest radiographs in mechanically ventilated patients without a reduction in patients' quality of care or safety. FUNDING: Assistance Publique-Hopitaux de Paris (Direction Regionale de la Recherche Clinique Ile de France). Lancet Nov 14 2009 374:1687

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From the literature: RCT compares masks for influenza prevention

Surgical mask vs N95 respirator for preventing influenza among health care workers: a randomized trial.

JAMA. 2009 Nov 4;302(17):1865-71. Epub 2009 Oct 1.

Loeb M, Dafoe N, Mahony J, John M, Sarabia A, Glavin V, Webby R, Smieja M, Earn DJ, Chong S, Webb A, Walter SD.

Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.

Comment in:
JAMA. 2009 Nov 4;302(17):1903-4.

CONTEXT: Data about the effectiveness of the surgical mask compared with the N95 respirator for protecting health care workers against influenza are sparse. Given the likelihood that N95 respirators will be in short supply during a pandemic and not available in many countries, knowing the effectiveness of the surgical mask is of public health importance.

OBJECTIVE: To compare the surgical mask with the N95 respirator in protecting health care workers against influenza.

DESIGN, SETTING, AND PARTICIPANTS: Noninferiority randomized controlled trial of 446nurses in emergency departments, medical units, and pediatric units in 8 tertiary care Ontario hospitals.

INTERVENTION: Assignment to either a fit-tested N95 respirator or a surgical mask when providing care to patients with febrile respiratory illness during the 2008-2009 influenza season.

MAIN OUTCOME MEASURES: The primary outcome was laboratory-confirmed influenza measured by polymerase chain reaction or a 4-fold rise in hemagglutinin titers. Effectiveness of the surgical mask was assessed as noninferiority of the surgical mask compared with the N95 respirator. The criterion for noninferiority was met if the lower limit of the 95% confidence interval (CI) for the reduction in incidence (N95 respirator minus surgical group) was greater than -9%.

RESULTS: Between September 23, 2008, and December 8, 2008, 478 nurses were assessed for eligibility and 446 nurses were enrolled and randomly assigned the intervention; 225 were allocated to receive surgical masks and 221 to N95 respirators. Influenza infection occurred in 50 nurses (23.6%) in the surgical mask group and in 48 (22.9%) in the N95 respirator group (absolute risk difference, -0.73%; 95% CI, -8.8% to 7.3%; P = .86), the lower confidence limit being inside the noninferiority limit of -9%.

CONCLUSION: Among nurses in Ontario tertiary care hospitals, use of a surgical mask compared with an N95 respirator resulted in noninferior rates of laboratory-confirmed influenza.

PMID: 19797474 [PubMed - indexed for MEDLINE]

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New Guidelines for Screening Mammography

Description: Update of the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for breast cancer in the general population.

Methods: The USPSTF examined the evidence on the efficacy of 5 screening modalities in reducing mortality from breast cancer: film mammography, clinical breast examination, breast self-examination, digital mammography, and magnetic resonance imaging in order to update the 2002 recommendation. To accomplish this update, the USPSTF commissioned 2 studies: 1) a targeted systematic evidence review of 6 selected questions relating to benefits and harms of screening, and 2) a decision analysis that used population modeling techniques to compare the expected health outcomes and resource requirements of starting and ending mammography screening at different ages and using annual versus biennial screening intervals.

Recommendations: The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient's values regarding specific benefits and harms. (Grade C recommendation)

Annals of Internal Medicine. November 17, 2009

Extended-Release Niacin Outperforms Ezetimibe in Lowering Cardiovascular Risk

In patients with high cardiovascular risk, extended-release niacin is associated with better outcomes than ezetimibe, according to a New England Journal of Medicine study released online.

Researchers randomized over 350 patients on long-term statins to added therapy with either niacin or ezetimibe. The primary endpoint was the difference in change of carotid artery intima-media thickness from baseline to 14 months between groups. After 208 patients had completed the trial, it was stopped when results significantly favored niacin.

Two accompanying editorials bemoan the trial's early end, arguing that all patients studied up to the point of stoppage should have been analyzed, not just those who completed 14 months' therapy. Nonetheless, both support the use of niacin over ezetimibe in high-risk patients, and both point to trials, now under way, that may provide more definitive results. In Journal Watch Cardiology, Dr. Harlan Krumholz says that these results "will not be available for many years. In the meantime, ezetimibe should be a drug of last resort, if it is used at all."

More from the Literature

A case study of medical grand rounds: are we using effective methods?

BACKGROUND:Grand rounds are a time-honored continuing medical education activity that is intended to keep doctors current and competent. In addition, health care leaders and medical educators often rely on grand rounds to change physician behavior and improve patient outcomes. However, the extent to which grand rounds programs are consistent with evidence-based educational practices is unknown.
METHOD: The authors used an instrumental case study approach in 2007 to determine whether one grand rounds program, such as medical grand rounds held at a U.S. academic medical center, adhered to well-accepted educational practices. Qualitative data collected from program planners, presenters, and participants via structured observations, key informant interviews, and a focus-group session allowed an assessment of consistency with five evidence-based practices. The authors used an intensive, inductive approach to analyze data to determine the extent to which the medical grand rounds program incorporated the five practices.
RESULTS: Studied during 2007, this traditional medical grand rounds program only minimally reflected the five evidence-based educational practices of needs assessment, multifaceted intervention strategy, sequencing, interaction, and commitment to change. Authors found grand rounds sessions to be slide-driven, passive presentations reflecting a broad range of subspecialty topics. Opportunities for questions were limited, and audience attendance was inconsistent and varied, particularly for nonfaculty participants.
CONCLUSIONS: This study has identified important opportunities for improving a specific grand rounds program and for researching similar examples of this common, traditional educational forum for physicians.

Source: Van Hoof TJ, Monson RJ, Majdalany GT, Giannotti TE, Meehan TP. A case study of medical grand rounds: are we using effective methods? Acad Med. 2009 Aug;84(8):1144-51. PubMed PMID: 19638786.

CSF Biomarkers May Predict Early-stage Alzheimer's Disease

Proteins in the cerebrospinal fluid (CSF) of patients with mild cognitive impairment (MCI), a precursor to Alzheimer's, disease were studied by researchers in Sweden to determine if the proteins could identify early-stage Alzheimer's disease. Patients (750) from 12 centers in Europe and the United States with mild cognitive impairment were studied. The researchers also studied proteins that form brain plaques in people with Alzheimer's disease. Three protein biomarkers accurately identified 62 percent of those who would develop Alzheimer's disease. This study could pave the way for better drug research and early detection of Alzheimer's disease.

ABSTRACT:
Context: Small single-center studies have shown that cerebrospinal fluid (CSF) biomarkers may be useful to identify incipient Alzheimer disease (AD) in patients with mild cognitive impairment (MCI), but large-scale multicenter studies have not been conducted.

Objective: To determine the diagnostic accuracy of CSF β-amyloid1-42 (Aβ42), total tau protein (T-tau), and tau phosphorylated at position threonine 181 (P-tau) for predicting incipient AD in patients with MCI.

Design, Setting, and Participants: The study had 2 parts: a cross-sectional study involving patients with AD and controls to identify cut points, followed by a prospective cohort study involving patients with MCI, conducted 1990-2007. A total of 750 individuals with MCI, 529 with AD, and 304 controls were recruited by 12 centers in Europe and the United States. Individuals with MCI were followed up for at least 2 years or until symptoms had progressed to clinical dementia.

Main Outcome Measures: Sensitivity, specificity, positive and negative likelihood ratios (LRs) of CSF Aβ42, T-tau, and P-tau for identifying incipient AD.

Results: During follow-up, 271 participants with MCI were diagnosed with AD and 59 with other dementias. The Aβ42 assay in particular had considerable intersite variability. Patients who developed AD had lower median Aβ42 (356; range, 96-1075 ng/L) and higher P-tau (81; range, 15-183 ng/L) and T-tau (582; range, 83-2174 ng/L) levels than MCI patients who did not develop AD during follow-up (579; range, 121-1420 ng/L for Aβ42; 53; range, 15-163 ng/L for P-tau; and 294; range, 31-2483 ng/L for T-tau, P < .001). The area under the receiver operating characteristic curve was 0.78 (95% confidence interval [CI], 0.75-0.82) for Aβ42, 0.76 (95% CI, 0.72-0.80) for P-tau, and 0.79 (95% CI, 0.76-0.83) for T-tau. Cut-offs with sensitivity set to 85% were defined in the AD and control groups and tested in the MCI group, where the combination of Aβ42/P-tau ratio and T-tau identified incipient AD with a sensitivity of 83% (95% CI, 78%-88%), specificity 72% (95% CI, 68%-76%), positive LR, 3.0 (95% CI, 2.5-3.4), and negative LR, 0.24 (95% CI, 0.21-0.28). The positive predictive value was 62% and the negative predictive value was 88%.

Conclusions: This multicenter study found that CSF Aβ42, T-tau, and P-tau identify incipient AD with good accuracy, but less accurately than reported from single-center studies. Intersite assay variability highlights a need for standardization of analytical techniques and clinical procedures.

CSF Biomarkers and Incipient Alzheimer Disease in Patients With Mild Cognitive Impairment
Niklas Mattsson; Henrik Zetterberg; Oskar Hansson; et al.
JAMA. 2009;302(4):385-393

Travel and Risk for Venous Thromboembolism

Editor's notes:
The body of evidence on the epidemiology of long-distance travel and venous thromboembolism (VTE) is heterogeneous and inconclusive. The reviewers found 14 eligible studies, which had significant between-study heterogeneity, and the pooled relative risk for VTE was 2.0 (95% CI, 1.5 to 2.7). The reviewers eliminated the heterogeneity by excluding 6 case control studies with biased selection of control participants. The relative risk was 2.8 (CI, 2.2 to 3.7) in the remaining included studies and 1.2 (CI, 0.9 to 1.6) in the excluded studies. By excluding studies with control participants who had a different risk for VTE than the source population for the case-patients, the authors clarified a confusing body of evidence.

BACKGROUND: The potential risk for travel-related venous thromboembolism (VTE) has become an important public health concern because of rapid increases in long-distance travel; however, previous studies on this relationship are surprisingly contradictory. PURPOSE: To estimate the risk for VTE in travelers, determine whether a dose-response relationship exists, and identify reasons for the contradictory results of previous studies. DATA SOURCES: MEDLINE, EMBASE, BIOSIS, CINAHL, grey-literature sources, contact with investigators, and reference lists of studies, without language restrictions. STUDY SELECTION: Reports were selected if they investigated the association between travel and VTE for persons that used any mode of transportation and had nontraveling persons for comparison. DATA EXTRACTION: Data on study and patient characteristics, risk estimates, and quality parameters were independently extracted by 2 investigators. Pooled effect estimates were obtained by using random-effect meta-analysis. DATA SYNTHESIS: Of 1560 identified abstracts, 14 studies (11 case-control, 2 cohort, and 1 case-crossover) met inclusion and exclusion criteria, including 4055 cases of VTE. Compared with nontravelers, the overall pooled relative risk for VTE in travelers was 2.0 (95% CI, 1.5 to 2.7). Significant heterogeneity was present because of the method for selecting control participants (P = 0.008): Whether the studies used control participants who had been referred for VTE evaluation or nonreferred control participants. Excluding the studies that used referred control participants, the pooled relative risk for VTE in travelers was 2.8 (CI, 2.2 to 3.7), without significant heterogeneity. A dose-response relationship was identified, with an 18% higher risk for VTE for each 2-hour increase in duration of travel by any mode (P = 0.010) and a 26% higher risk for every 2 hours of air travel (P = 0.005). Limitation: All available studies were from Western countries; generalizability to non-Western populations is expected but needs confirmation. CONCLUSION: Travel is associated with a nearly 3-fold higher risk for VTE, with a dose-response relationship of 18% higher risk for each 2-hour increase in travel duration. Heterogeneity in results of previous studies was identified as being due to selection bias toward the null from use of referred control participants.

Chandra D, Parisini E, Mozaffarian D. Travel and Risk for Venous
Thromboembolism. Ann Intern Med. 2009 Jul 6. [Epub ahead of print] PubMed PMID:
19581633.

Early CT scan of low risk patients with chest pain: A reduction in length of stay and expense

Low-Risk Patients With Chest Pain in the Emergency Department: Negative 64-MDCT Coronary Angiography May Reduce Length of Stay and Hospital Charges
American Journal of Roentgenology. 2009; 193:150-154
PMID: 19542407

Researchers at the University Of Washington School of Medicine in Seattle hypothesized that a negative coronary CTA combined with negative ECG and negative cardiac enzyme tests discovered early in the patient evaluation in low-risk patients with chest pain can shorten the length of stay in the emergency department as well as reduce the cost of care. Cardiac CT scan
versus the current standard-of-care (SOC) workup of low-risk patients with chest pain could rule out coronary artery disease early on. Three types of patient workups were analyzed for length of stay and charges incurred: (1) Standard of care, (2) Coronary CTA with observation, and (3) Coronary CTA without observation. Qualifying patients all had chest pain and a low TIMI risk score of 0-2.

ABSTRACT: The current standard-of-care workup of low-risk patients with chest pain in an emergency department takes 12-36 hours and is expensive. We hypothesized that negative 64-MDCT coronary angiography early in the workup of such patients may enable a shorter length of stay and reduce charges. The standard-of-care evaluation consisted of serial cardiac enzyme tests, ECGs, and stress testing. After informed consent, we added cardiac CT early in the standard-of-care workup of 53 consecutive patients. Fifty patients had negative CT findings and were included in this series. The length of stay and charges were analyzed using actual patient data for all patients in the standard-of-care workup and for two earlier discharge scenarios based on negative cardiac CT results: First, CT plus serial enzyme tests and ECGs during an observation period followed by discharge if all were negative; and second, CT plus one set of enzyme tests and one ECG followed by discharge if all were negative. Comparisons were made using paired Student's t tests. For standard of care and the two CT-based earlier discharge analyses, the mean lengths of stay were 25.4, 14.3, and 5.0 hours; mean charges were $7,597, $6,153, and $4,251. Length of stay and charges were both significantly less (p < 0.001) for the two CTbased analysis. In low-risk patients with chest pain, discharge from the emergency department based on negative cardiac CT, enzyme tests, and ECG may significantly decrease both length of stay and hospital charges compared with the standard of care.

Statin-associated Myopathy and Muscle Damage

Statins have been proven safe, effective and are widely prescribed for hypercholesterinemia therapy. Statin-associated myopathy can include pain and muscle weakness. Researchers at the University of Bern in Switzerland and Tufts-New England Medical Center in Boston biopsied the vastus lateralis muscle to determine muscle injury in patients. Significant injury was defined as 2% or more damaged fibres per biopsy sample. Patients identified as having statin-associated myopathy had complaints of myalgia, cramps or muscle weakness predominately in the trunk area.

ABSTRACT: Many patients taking statins often complain of muscle pain and weakness. The extent to which muscle pain reflects muscle injury is unknown. We obtained biopsy samples from the vastus lateralis muscle of 83 patients. Of the 44 patients with clinically diagnosed statin-associated myopathy, 29 were currently taking a statin, and 15 had discontinued statin therapy
before the biopsy (minimal duration of discontinuation 3 weeks). We also included 19 patients who were taking statins and had no myopathy, and 20 patients who had never taken statins and had no myopathy. We classified the muscles as injured if 2% or more of the muscle fibres in a biopsy sample showed damage. Using reverse transcriptase polymerase chain reaction, we
evaluated the expression levels of candidate genes potentially related to myocyte injury. Muscle injury was observed in 25 (of 44) patients with myopathy and in 1 patient without myopathy. Only 1 patient with structural injury had a circulating level of creatine phosphokinase that was elevated more than 1950 U/L (10x the upper limit of normal). Expression of ryanodine receptor 3 was significantly upregulated in patients with biopsy evidence of structural damage (1.7, standard error of the mean 0.3). Persistent myopathy in patients taking statins reflects structural muscle damage. A lack of elevated levels of circulating creatine phosphokinase does not rule out structural muscle injury. Upregulation of the expression of ryanodine receptor 3 is suggestive of an intracellular calcium leak.

Association between statin-associated myopathy and skeletal muscle damage
CMAJ. 2009 Jul 7;181(1-2):E11-8. PMID: 19581603.

Cost Conundrum - What a Texas town can teach us about health care

The Cost Conundrum by Atul Gawande from The New Yorker, Annals of Medicine, June 1 , 2009. "The primary cause of McAllen's extreme costs was, very simply, the across-the-board overuse of medicine. This is a disturbing and perhaps surprising diagnosis. Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse.

A few doctors took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers."

Some of the studies cited by Gawande appeared in Health Affairs.

Resident Duty Hours Report - Now Online

Resident Duty Hours:
Enhancing Sleep, Supervision, and Safety
Cheryl Ulmer, Dianne Miller Wolman, Michael M.E. Johns, Editors, Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, National Research Council

Note: click on the link above, then scroll down to read the report online for free.

Description from the National Academies Press:
Medical residents in hospitals are often required to be on duty for long hours. In 2003 the organization overseeing graduate medical education adopted common program requirements to restrict resident workweeks, including limits to an average of 80 hours over 4 weeks and the longest consecutive period of work to 30 hours in order to protect patients and residents from unsafe conditions resulting from excessive fatigue.

Resident Duty Hours provides a timely examination of how those requirements were implemented and their impact on safety, education, and the training institutions. An in-depth review of the evidence on sleep and human performance indicated a need to increase opportunities for sleep during residency training to prevent acute and chronic sleep deprivation and minimize the risk of fatigue-related errors. In addition to recommending opportunities for on-duty sleep during long duty periods and breaks for sleep of appropriate lengths between work periods, the committee also recommends enhancements of supervision, appropriate workload, and changes in the work environment to improve conditions for safety and learning.

All residents, medical educators, those involved with academic training institutions, specialty societies, professional groups, and consumer/patient safety organizations will find this book useful to advocate for an improved culture of safety.

2009 PSA Testing Guidelines from AUA

PSA testing has become one of the most controversial issues in health. Many men routinely undergo the blood test to try to spot prostate cancer early. There's no question the screening can do that, but many doctors have begun to challenge routine PSA testing because it often leads to unnecessary biopsies and treatment for a cancer that may never be life-threatening. Prostate cancer is often so slow growing that it never actually causes problems. Two major studies released last month fueled doubts about PSA testing when they failed to find clear evidence it reduced the chances of dying from prostate cancer.

But the American Urological Association begs to differ in its updated recommendations on PSA testing released Monday. The guidelines say PSA testing can be very useful in spotting cancer early and helping men and their doctors make decisions. The guidelines lower the age that it says doctors should offer it to men from 50 to 40.

The key, the guidelines say, is how the results are used. For example, the other big change the guidelines recommend is how the results are interpreted. Instead of doing a biopsy simply when the PSA level goes above a certain level, the guidelines say the PSA "velocity" is more important. That's how fast the PSA level is rising. If a man's PSA rises very quickly over a short period of time, the guidelines say, that's when a biopsy may be necessary.

Intensive Glucose Control May Raise ICU Mortality

Aggressive glucose control in critical illness seems to increase mortality, according to a New England Journal of Medicine study released online.
Investigators in the NICE-SUGAR trial attempted to define the best glucose target range by randomizing 6100 medical-surgical ICU patients either to intensive control (81 to 108 mg/dL) or to conventional control (180 mg/dL or less) with use of intravenous insulin. Death by 90 days (the primary outcome) occurred more often with intensive control than with conventional therapy. Intensive control also led to more episodes of severe hypoglycemia (blood glucose, 40 mg/dL or less). The authors estimate a number needed to harm of 38.

Editorialists point out that the NICE-SUGAR results "contrast starkly" with earlier trials. Their take on the study's lessons is that "there is no additional benefit from the lowering of blood glucose levels below the range of approximately 140 to 180."

Intensive versus Conventional Glucose Control in Critically Ill Patients. The NICE-SUGAR Study Investigators. NEJM published online March 24, 2009.

USPSTF Updates Recommendations on Aspirin for CVD Prophylaxis

The U.S. Preventive Services Task Force now recommends that aspirin be used in men to prevent MIs, and in women to prevent ischemic strokes, when these benefits outweigh the risks for gastrointestinal bleeding.
The task force considers older age and male sex as the major risk factors for gastrointestinal bleeding, followed by upper GI pain, ulcers, and NSAID use.
The recommendations, published in Annals of Internal Medicine, update the USPSTF's previous statement, released in 2002. The current statement factors in evidence from the Women's Health Study that "aspirin may have differential benefits and harms in men and women."
The task force also concludes that evidence is "insufficient" to weigh the benefits and harms of aspirin prophylaxis among people over age 79 and that use among men under 45 or women under 55 should not be encouraged.
An editorialist writes: "Aspirin continues to be underused, and the routine incorporation of the USPSTF's recommendations ... [will] prevent many thousands of cardiovascular events every year."

Annals of Internal Medicine March 17, 2009 150(6):394-404.

From the Literature: State of the USA Health Indicators

State of the USA Health Indicators: Letter Report

Researchers, policymakers, sociologists and doctors have long asked how to best measure the health of a nation, yet the challenge persists. The nonprofit State of the USA, Inc. (SUSA) is taking on this challenge, demonstrating how to measure the health of the United States. The organization is developing a new website intended to provide reliable and objective facts about the U.S. in a number of key areas, including health, and to provide an interactive tool with which individuals can track the progress made in each of these areas.
In 2008, SUSA asked the Institute of Medicine's Committee on the State of the USA Health Indicators to provide guidance on 20 key indicators to be used on the organization's website that would be valuable in assessing health. Each indicator was required to demonstrate:

• a clear importance to health or health care,
• the availability of reliable, high quality data to measure change in the indicators over time,
• the potential to be measured with federally collected data, and
• the capability to be broken down by geography, populations subgroups including race and ethnicity, and socioeconomic status.

Taken together, the selected indicators reflect the overall health of the nation and the efficiency and efficacy of U.S. health systems. The complete list of 20 can be found in the report brief and book.

From the Literature: Peanut Product Recall Blog

The FDA, CDC and HHS have partnered to create a new way to share information about the peanut recall - the Peanut Product Recall Blog. This blog was designed to foster communication and conversations, as well as provide ongoing information about the peanut butter and peanut-containing product recalls and outbreak investigations. The blog also contains links to podcasts and other social media methods. Moreover, the blog represents a transparent and low-cost way to share medical and public health information with clinicians and consumers quickly and easily. The blog also cuts across traditional bureaucratic lines: it will include posts from CDC, FDA and HHS representatives.

Of potential help to consumers and clinicians alike: the frequently updated map: "Investigation of Outbreak of Infections Caused by Salmonella Typhimurium 2008-2009" and the link to the product recall list.

What other kinds of medical information do you think could be published or shared in this way?

Global Health Recommendations for the Obama Administration: A New IOM Report

The U.S. Commitment to Global Health:
Recommendations for the New Administration
Authored by the Committee on the U.S. Commitment to Global Health
Available online at: http://www.nap.edu/catalog.php?record_id=12506

At this historic moment, the incoming Obama administration and leaders of the U.S. Congress have the opportunity to advance the welfare and prosperity of people within and beyond the borders of the United States through intensified and sustained attention to better health. The United States can improve the lives of millions around the world, while reflecting America's values and protecting and promoting the nation's interests.

The Institute of Medicine-with the support of four U.S. government agencies and five private foundations-formed an independent committee to examine the United States' commitment to global health and to articulate a vision for future U.S. investments and activities in this area.

Vitamin D Deficiency a Risk Factor for Cardiovascular Disease?

Lee JH, O'Keefe JH, Bell D, Hensrud DD, Holick MF.
Vitamin D deficiency an important, common, and easily treatable cardiovascular risk factor?
J Am Coll Cardiol. 2008 Dec 9;52(24):1949-56.

In this latest study to come out on vitamin D, the authors discuss the largely unrecognized problem of vitamin D deficiency in the general population and review the growing body of data from epidemiologic studies suggesting that low levels of 25-hydroxyvitamin D play an important role in the development of coronary risk factors and cardiovascular disease. They offer specific recommendations for monitoring and correction of vitamin D deficiency and maintenance of vitamin D levels for optimal health.

Just-in-time information improved decision-making in primary care: a randomized controlled trial.

McGowan J. Just-in-time information improved decision-making in primary care: a randomized controlled trial. PLoS ONE. 2008;3(11):e3785. Epub 2008 Nov 21. PMID: 19023446

The "Just-in-time Information" (JIT) librarian consultation service was designed to provide rapid information to answer primary care clinical questions during patient hours. This study evaluated whether information provided by librarians to answer clinical questions positively impacted time, decision-making, cost savings and satisfaction. METHODS AND FINDING: A randomized controlled trial (RCT) was conducted between October 2005 and April 2006. A total of 1,889 questions were sent to the service by 88 participants. The object of the randomization was a clinical question. Each participant had clinical questions randomly allocated to both intervention (librarian information) and control (no librarian information) groups. Participants were trained to send clinical questions via a hand-held device. The impact of the information provided by the service (or not provided by the service), additional resources and time required for both groups was assessed using a survey sent 24 hours after a question was submitted. The average time for JIT librarians to respond to all questions was 13.68 minutes/question (95% CI, 13.38 to 13.98). The average time for participants to respond their control questions was 20.29 minutes/question (95% CI, 18.72 to 21.86). Using an impact assessment scale rating cognitive impact, participants rated 62.9% of information provided to intervention group questions as having a highly positive cognitive impact. They rated 14.8% of their own answers to control question as having a highly positive cognitive impact, 44.9% has having a negative cognitive impact, and 24.8% with no cognitive impact at all. In an exit survey measuring satisfaction, 86% (62/72 responses) of participants scored the service as having a positive impact on care and 72% (52/72) indicated that they would use the service frequently if it were continued. CONCLUSIONS: In this study, providing timely information to clinical questions had a highly positive impact on decision-making and a high approval rating from participants. Using a librarian to respond to clinical questions may allow primary care professionals to have more time in their day, thus potentially increasing patient access to care. Such services may reduce costs through decreasing the need for referrals, further tests, and other courses of action.

Resident Duty Hours: Enhancing Sleep, Supervision, and Safety

Medical residency in the United States aims to prepare recent medical school graduates to practice medicine independently. One fundamental requirement of resident education is in-depth, firsthand experience caring for patients. During the three to seven years of training, residents often work long hours with limited time off to catch up on their sleep. They can experience fatigue on the job, contributing to increased errors and accidents. However, many medical educators believe extensive duty hours are essential to provide residents with the educational experiences they need to become competent in diagnosing and treating patients.

Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, a December 2008 report from the IOM, asserts that revisions to medical residents’ workloads and duty hours are necessary to better protect patients against fatigue-related errors and to enhance the learning environment for doctors in training. The report recommends that residency programs provide regular opportunities for sleep each day and each week during resident training. In addition, it recommends that the Accreditation Council for Graduate Medical Education provide better monitoring of duty hour limits and that residency review committees set guidelines for residents’ patient caseload. Patient handover procedures and supervision of residents should also be strengthened. Until these changes take place, residency programs are not providing what the next generation of doctors or their patients deserve. Link to report files.

More Evidence That Perioperative Beta-Blockers in Noncardiac Surgery Can Be Harmful

HYPOTHESIS: We hypothesized that the relationship among beta-blocker use, heart rate control, and perioperative cardiovascular outcome would be similar in patients at all levels of cardiac risk. DESIGN: Retrospective cohort study. SETTING: Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas. PATIENTS: Among all patients who underwent various noncardiac surgical procedures in 2000, those who received perioperative beta-blockers were matched and compared with a control group from the same patient population. MAIN OUTCOME MEASURES: Thirty-day stroke, cardiac arrest, myocardial infarction, and mortality, as well as mortality at 1 year. RESULTS: Patients at all levels of cardiac risk who received beta-blockers had lower preoperative and intraoperative heart rates. The beta-blocker group had higher rates of 30-day myocardial infarction (2.94% vs 0.74%, P =.03) and 30-day mortality (2.52% vs 0.25%, P =.007) compared with the control group. In the beta-blocker group, patients who died perioperatively had significantly higher preoperative heart rate (86 vs 70 beats/min, P =.03). None of the deaths occurred among the patients at high cardiac risk. CONCLUSION: Among patients at all levels of cardiac risk undergoing noncardiac surgery, administration of beta-blockers should achieve adequate heart rate control and should be carefully monitored in patients who are not at high cardiac risk. Arch Surg. 2008 Oct;143(10):940-4; discussion 944.

Exercise is Safe, Improves Outcomes for Patients with Heart Failure

From Duke Health.org...Working out on a stationary bicycle or walking on a treadmill just 25 to 30 minutes most days of the week is enough to modestly lower risk of hospitalization or death for patients with heart failure, say researchers from Duke Clinical Research Institute (DCRI).

The findings stem from the HF-ACTION trial (A Controlled Trial Investigating Outcomes Exercise TraiNing), the most comprehensive study to date examining the effects of exercise upon patients with heart failure. The study was reported today as a late-breaking clinical trial at the American Heart Association's Scientific Sessions 2008 by Christopher O'Connor M.D., director of the Duke Heart Center and principal investigator of the trial, and David Whellan, M.D., of Thomas Jefferson University, co-principal investigator. Full story.

Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein

Intensive lipid-lowering with rosuvastatin (Crestor) for not even two full years significantly and dramatically reduced the rate of myocardial infarction, stroke, and cardiovascular death in "apparently healthy men and women," researchers reported here.

Participants who took 20 mg of rosuvastatin for 1.9 years reduced median LDL cholesterol to 55 mg/dL, down from a median of 108 mg/dL, said Paul M. Ridker, M.D., of Brigham and Women's Hospital in Boston and principal investigator of the JUPITER trial. The corresponding reduction in the rate of MI stroke, arterial revascularization, or cardiovascular death was 44% (P<0.00001).

Dr. Ridker presented the findings at a late-breaking clinical trials session at the American Heart Association meeting here and the findings were published concurrently online in the New England Journal of Medicine.

Many Physicians Are Prescribing Non-Inert 'Placebo' Treatments

About half of a small random sample of U.S. physicians prescribe placebo treatments, according to a BMJ study released online. Using a mailed survey, researchers assessed the attitudes toward placebo treatments among some 700 internists and rheumatologists. (A placebo treatment was defined as one "whose benefits ... derive from positive patient expectations.") Roughly half the sample reported using placebo treatments at least two or three times a month. The placebos prescribed most often were over-the-counter analgesics and vitamins (each about 40%); antibiotics and sedatives were each used about 15% of the time. Physician characteristics such as age, sex, or practice region did not influence the likelihood of placebo use. BMJ 2008;337:a1938

From the Literature

2007 focused update to the ACC/AHA guidelines for
the management of patients with ST-segment elevation
myocardial infarction: implications for emergency
department practice.

Pollack CV Jr, Antman EM, Hollander JE; American College of Cardiology; American Heart Association.Ann Emerg Med. 2008 Oct;52(4):344-355.e1. Epub 2008 Jun 2.

The American College of Cardiology and American Heart Association
have issued a "focused update" of their 2004 guidelines for the
management of ST-segment elevation myocardial infarction (STEMI).
Several of the issues addressed involve new data and new
recommendations on treatment decisions that may be made in the
emergency department. In this review, we present the new
recommendations that are pertinent to emergency medicine practice
and comment on their potential implementation into an evidence-based,
multidisciplinary approach to the timely care of the STEMI patient.

From the Literature

The National Hospital Bill: The Most Expensive Conditions by Payer, 2006
By Roxanne M. Andrews, PhD
September 2008


The National Hospital Bill: The Most Expensive Conditions by Payer is a report prepared by the Agency for Healthcare Research and Quality (AHRQ). The report is useful as a benchmark to policymakers concerned with the rising costs of hospitalizations passed on to government, insurers, and consumers.

Issued as one of the Agency's Statistical Briefs, the reports track the growing burden of costs for inpatient hospitalizations in the United States by all payers. Highlighted in each report are the Top 20 Most Expensive Conditions taken from the HCUP Nationwide Inpatient Sample (NIS), a sample survey representative of all aggregate U.S. community hospitals. Included is the number of hospital admissions, the diagnosis based upon ICD-9-CM coding, the cost of procedures, how many billions were billed to Medicare, Medicaid, private insurance, and the uninsured. The statistics were generated from HCUPnet, a free, online query system that provides users with immediate access to largest set of publicly available, all-payer national, regional, and state-level hospital care databases from HCUP. Statistical reports include tables and charts.

This report does not include data for hospital outpatient visits, emergency care visits not resulting in admission, or fees for physician services. Separate data sets exist for emergency department visits and outpatient visits.


Source: Statistical Brief #59

From the Literature: Virtual Colonoscopy

Accuracy of CT Colonography for Detection of Large Adenomas and Cancers

C. Daniel Johnson, M.D., M.M.M., et al

NEJM 2008; 359 (12):1207-1217.

Early detection for colorectal cancer is key, and current recommendations are for men and women to be screened regularly beginning at 50 years old. However, for a variety of reasons including cost and discomfort, many patients are not adhering to current guidelines and are not undergoing colonoscopies. This study, which involved 2,600 patients at 15 medical centers, indicates that CT colonographies are about as good (90%) as the standard colonoscopies in detecting adenomas of 10 mm or more in diameter. And while the test is less effective for smaller polyps, the authors suggest that the less invasive nature of this procedure may make it an attractive alternative for low-risk patients.

From the Literature

In critical care medicine, it is unlikely that any single study has had the influence to match that of the study by van den Berghe et al of intensive insulin therapy in surgical intensive care patients. Published in 2001, the study reported that targeting normoglycemia in ventilated patients in a surgical intensive care unit (ICU) reduced the risk of in-hospital death by one-third. Although the size of the treatment effect seemed improbable, the underlying concept had face validity as improved glycemic control had been proven beneficial in other patients with severe acute illness. As a result, tight glycemic control in critically ill adults is now recommended by numerous organizations including the American Diabetes Association and the Institute for Healthcare Improvement. In this issue of JAMA, Wiener and colleagues report a meta-analysis of studies examining tight glycemic control in critically ill adults; their conclusions, that tight glycemic control does not significantly reduce in-hospital mortality, may surprise many clinicians.

Benefits and Risks of Tight Glucose Control in Critically Ill Adults: A Meta-analysis
Renda Soylemez Wiener, Daniel C. Wiener, and Robin J. Larson
JAMA. 2008;300(8):933-944.

Tight Glycemic Control in Critically Ill Adults (Editorial)
Simon Finfer and Anthony Delaney
JAMA. 2008;300(8):963-965.

Introducing "From the Literature"

A study of the science of taste: on the origins and influence of the core ideas by Robert Erickson, Emeritus Professor of Psychology and Brain Sciences, and Neurobiology at Duke University. Behavioral and Brain Sciences (2008), 31:59-75.

As part of our new Website, the From the Literature section will highlight thought-provoking and significant new journal articles from the medical literature. Today we launch this new feature with an article by Robert Erickson, in which the four basic tastes -- salty, sweet, bitter and sour -- are called into question. For years, Erickson has voiced concern over the extent that our words and techniques may distract us from the language of the nervous system. This article discusses the "across-fiber pattern" model originated in 1963 in the field of taste. Several other experts weigh in in discussions that follow the article.

In the coming weeks and months, we will feature articles from many disciplines, including research discoveries and new clinical applications. We want you to help us choose the important new articles to highlight. If you would like to suggest an article or serve as a guest blogger, please contact Megan von Isenburg at 660-1131.