Intro:  The lawsuit penalties that may result from a missed cancer or triple A, may be far less than the total cost of all the imaging studies that are routinely ordered.  So, to the insurer, it may make good economic sense to limit these studies, no matter the human cost to the patient and the family. 

Bloomberg (7/28, http://www.bloomberg.com/apps/news?pid=20601103&sid=aEXLaZPZ8o.U) reports, “Insurers, led by WellPoint Inc. and Magellan Health Services Inc., are increasingly rejecting imaging procedures recommended by U.S. doctors as the companies work to trim $30 billion a year they say is wasted on the tests.” According to a study by America’s Health Insurance Plans, “[a]lmost 50 percent of scans for some conditions fail to improve patients’ diagnoses or treatment.” Now, with “U.S. health costs projected to grow to 25 percent of the economy in 2025 from 16 percent now, insurers are turning to so-called radiology benefit managers who can reject scans determined to be unneeded.” According to Wayne DeVeydt, WellPoint’s chief financial officer, “We’ve seen radiology growth trends in the 20 percent-plus range drop to the low single digits.” He calls prior authorization “a huge growth area” for insurers.

BBC, 7/26/08 (http://news.bbc.co.uk/2/hi/health/7525932.stm): 

People who take blood have been warned not to get the patient to tightly clench their fist during the procedure.

UK researchers who examined 200,000 blood test results found clenching then relaxing the fist could raise potassium levels, potentially confusing results.

Raised potassium levels can indicate kidney or heart problems, the Annals of Clinical Biochemistry study said.

A UK expert said clenching was an outdated practice and staff taking blood should not ask patients to do so.

‘Hit or miss’

Vanessa Thurlow, a biochemistry expert and co-author of the report, first noticed a problem when GPs were questioning test results for a small number of patients.

When she retested them, their potassium levels were normal - but they had all started to clench their fists before the test.

It led Ms Thurlow to speak to managers of the phlebotomy - blood-taking - services in her trust, which then instructed staff not to use the clenching method.

Her study looks at 200,000 results from blood tests requested by GPs between 2002 and 2005. The updated training was offered in September 2003.

The percentage of tests showing worryingly high potassium levels fell significantly after the change.

The impact of fist-clenching while giving blood has been known since the 1960s, but she said procedure was being passed on from generation to generation of phlebotomists.

“It seems to be hit or miss whether they get trained to avoid using this procedure,” she said.

She said other factors such as exposure to cooler temperatures have been known to cause false raised-potassium levels, but she believes the impact of this hand-gripping is underestimated.

“We think that as a result patients might have to have their medication adjusted. We don’t know how widespread a problem this is in other parts of the country.”

Blood flow

Ms Thurlow admitted some patients were very difficult to bleed.

“The pressure on the phlebotomist to obtain some blood somehow, particularly with very nervous patients, can be high.

“Clenching and relaxing the fist does improve the blood flow and makes veins stand out, making it easier to get a sample.”

Jackie Hough, president of the National Association of Phlebotomists (NAP), agreed clenching the fist could alter the blood test results.

“But best practice advocates that patients don’t tightly clench but gently close their hand during needle insertion and that the hand is loosened prior to the collection of blood.

“Also the tourniquet should not be tightened on the arm for longer than 60 seconds or during the collection of the sample.”

According to the LA Times, 7/28 (http://www.latimes.com/features/health/la-he-architecture28-2008jul28,0,5907587.story):  The Centers for Disease Control and Prevention notes that “[t]wo million patients each year suffer from a hospital-acquired infection,…and nearly 100,000 of them die as a result.”

HealthDay, 7/25/08 (http://www.healthday.com/Article.asp?AID=617678):

High-dose hyperbaric oxygen therapy shows promise as a way to extend the window of opportunity to resuscitate a person whose heart has stopped during sudden cardiac arrest, a new study shows.

Researchers at the School of Medicine at the Louisiana State University Health Sciences Center in New Orleans report they used the technique to revive pigs up to 25 minutes after their hearts had stopped beating. In humans, if a patient’s heart is not restarted through some means (CPR, medications or electric shock) within 16 minutes, 100 percent of patients die, according to American Heart Association statistics.

Sudden cardiac arrest is the leading cause of death of Americans.

“To resuscitate any living organism after 25 minutes of heart stoppage at room temperature has never been reported and suggests that the time to successful resuscitation in humans may be extended beyond the stubborn figure of 16 minutes that has stood for 50 years,” study leader Keith Van Meter, a clinical professor of medicine at the LSU center, said in an university news release.

The findings were expected to be published in the August issue of Resuscitation.

In the study, LSU researchers stopped the heart of laboratory swine kept at room temperature and declared them dead from cardiac arrest. After waiting 25 minutes, they attempted advanced cardiac life support to resuscitate them accompanied by either normal or high doses of hyperbaric oxygen therapy. None of the swine received artificial breathing, CPR, medications, or electric shocks during their cardiac arrest.

Four of the six animals given high-dose hyperbaric oxygen, a dose one-third greater in strength than what is normally given to humans, were revived after a two-hour resuscitation period. No others survived.

“The present study shows that short-term, high-dose hyperbaric oxygen is an effective resuscitation tool and is safe in a small multi-place hyperbaric chamber,” Van Meter said. “A rehearsed team can easily load a patient in cardiopulmonary arrest into a small multi-place chamber in the pre-hospital or hospital setting without interrupting CPR or advanced cardiac life support. Successful resuscitation at 25 minutes suggests that if high-dose hyperbaric oxygen is used at the current ACLS limit of 16 minutes, a greater survival may be achieved in humans and allow application of more definitive treatment such as clot-dissolving drugs.”

Future studies are planned to evaluate this technique.

Medwire, 7/25/08 (http://www.medwire-news.md/40/76580/Lipidology/Statins_reduce_vasospasm_after_aneurysmal_SAH.html) : 

Statin therapy reduces the risk for vasospasm after subarachnoid hemorrhage (SAH), leading to improved outcomes, say researchers in the journal Stroke.

“SAH is a relatively rare cause of stroke with a high rate of morbidity and mortality, primarily due to the occurrence of delayed vasospasm,” comment Jeffrey Perry and colleagues from the University of Ottawa in Canada.

They add that “many therapies have been proposed to help prevent vasospasm, but very few have been proven effective.”

It is thought that the proposed pleiotropic effects of statins, such as their ability to reduce inflammation and cell proliferation, increase nitric oxide synthesis, and prevent thrombogenesis may make them effective anti vasospasm agents.

Perry and colleagues carried out a meta-analysis of previous studies to look at the impact of statin treatment following SAH on vasospasm.

Three studies that assessed incidence of vasospasm as a primary outcome were selected for analysis. Two of the studies treated patients with 80 mg/d simvastatin and one with 40 mg/d pravastatin for either 14 days or the length of patients’ stay in the intensive care unit. The total pooled number of participants was 158, of whom 78 received statins and 80 received placebo.

The authors report that the incidence of vasospasm was significantly decreased in patients receiving statins following SAH, with a relative risk (RR) of 0.73 and a number needed to treat (NNT) of 6.1.

In addition, occurrence of vasospasm-related ischemic deficits (RR=0.38, NNT=5.0) and mortality (RR=0.22, NNT=6.7) was also lower in patients treated with statins compared with those who were not.

Perry et al recognize that the number of patients in these studies is low, and say that further research is needed.

“Physicians should consider initiating statin therapy immediately after diagnosis of SAH,” they suggest.

But they concede: “The optimal duration and dose of therapy cannot be determined from this study.”