AP, (http://www.washingtonpost.com/wp-dyn/content/article/2008/08/12/AR2008081202224.html)

Watson Pharmaceuticals Inc. said one lot of 75 microgram-per-hour Fentanyl Transdermal System patches is being recalled from wholesalers and pharmacies because some of the lot’s patches have leaked fentanyl gel, possibly exposing patients or caregivers directly to the gel. This might lead to serious effects, including difficulty breathing and possible overdose, which may be fatal. No injuries have been reported in connection with this recalled lot, according to the Corona, Calif., company.

The painkiller, made by Watson Laboratories Inc., was sold in the United States. The recalled patches are from lot No. 92461850 and have expiration dates of Aug. 31, 2009. Any reactions should be reported to the Food and Drug Administration’s MedWatch adverse event reporting program at http://www.fda.gov/medwatch/report.htm. For more information, call the FDA at 888-463-6332 or the company at 888-667-1508.

UPI, 8/13/08 reports that a national survey conducted by researchers at the University of Michigan C.S. Mott Children’s Hospital indicates that, “[i]n U.S. communities with retail health clinics, one in six parents have used a clinic to provide their child with medical care.” The pollsters used “a random sample of 2,064 adults weighted to reflect U.S. population figures” to discern just who was frequenting the “retail clinics — staffed by nurse practitioners or physician’s assistants” — to receive treatment for a variety of problems, including “rashes, sore throats, pink eye, and ear infections.”

        The visits were likely to take place in clinics in which 22 percent of parents would pay out of pocket for them, WebMD (8/12, Colihan) added. Still, two out of three “parents who used a retail clinic said they ‘were likely, or very likely,’ to return.” Among caretakers “who had never taken a child to a retail clinic, but who lived near one, one out of seven said they are ‘likely or very likely’ to use one.” Currently, “there are more than 900 such retail clinics in the U.S.”

Intro:  Maybe it’s not really John Edwards’ fault that he went a-plowing in another corn field.  Maybe he was trying to avoid health insurance complexities.

In a front-page article, the New York Times (8/13, A1, Sack) reports that, “[i]n a country where insurance is out of reach for many, it is not uncommon for couples to marry, or even to divorce, at least partly so one spouse can obtain or maintain health coverage.” While “[t]here is no way to know how often it happens,” the Times notes that “lawyers and patient advocacy groups say they see cases regularly.” A poll conducted by the Kaiser Family Foundation, a health-policy research group, found that “seven percent of adults said someone in their household had married in the past year to gain access to insurance.” And, “[i]n some instances, the need for insurance may prolong unhappy marriages.”

A Discussion on ectopic pregnancy (http://cme.medscape.com/viewarticle/578988_2):

“…The incidence of ectopic pregnancy is 19.7 per 1000 pregnancies in the United States; however, the prevalence is between 6% and 16% in patients who present with first-trimester bleeding and/or pain.^[1] This rate has increased over the last several decades as a result of better surveillance and the increased use of in vitro fertilization techniques to induce conception. The incidence of ectopic pregnancy increases with age, with the highest rates occurring in women aged 35-44 years. Ectopic pregnancies are responsible for approximately 10% of pregnancy-related deaths, because if they are untreated, ectopic pregnancies may lead to eventual rupture and hemodynamic collapse.^[2]

The prime window for developing an ectopic pregnancy is approximately 6-8 weeks after the last menstrual period. The classic triad of findings is abdominal pain, vaginal bleeding, and amenorrhea; however, in only 45% of patients are all of these findings present.^[3] Hypotension, light-headedness, or other signs or symptoms of hemodynamic instability raise the concern of a rupture.

Ectopic pregnancy occurs as a result of extrauterine implantation of the developing blastocyst. Although the vast majority of ectopic pregnancies occur within the fallopian tubes (95-98%), they may rarely be found in the cervix (1%), abdominal cavity (<1%), or cesarean scar sites (<1%). Risk factors for the development of ectopic pregnancy include current intrauterine device usage, tubal surgery, pelvic inflammatory disease, use of assisted reproductive technology, in utero diethylstilbestrol exposure, infertility, cervicitis, and a history of ectopic pregnancy; however, the majority of patients have no known risk factors.

The differential diagnosis for a pregnant patient with abdominal pain must include obstetric, gynecologic, gastrointestinal, and renal etiologies. The obstetric and gynecologic causes include normal early pregnancy, spontaneous abortion, molar pregnancy, degenerating uterine leiomyoma, pelvic inflammatory disease, ovarian torsion, dysfunctional uterine bleeding, dysmenorrhea, tubo-ovarian abscess, and hemorrhagic corpus luteum cyst. The major gastrointestinal and renal causes include appendicitis, diverticulitis, nephrolithiasis, and urinary tract infections.

The major goals of early detection of ectopic pregnancies are to prevent the major morbidities and mortality associated with an eventual rupture and to allow time for effective medical management of the condition. The diagnostic workup begins with a thorough history, with particular attention focused on the above-described risk factors. Although confirmation or exclusion of an ectopic pregnancy is not possible on physical examination alone, valuable findings, such as adnexal fullness and tenderness, may be appreciated. The vital signs must be closely monitored, because a change in hemodynamic status may be the only overt sign of a rupture. Laboratory and imaging studies are necessary for definitive evaluation. A positive urine hCG will confirm pregnancy status, while a low serum hCG value (for the gestational age) advances the case for an ectopic pregnancy.^[4] Low serum progesterone levels indicate a nonviable pregnancy, but they are not helpful in determining the pregnancy location. No serum marker exists to accurately distinguish an ectopic from an intrauterine pregnancy.^[5] Transabdominal and/or transvaginal ultrasonographic imaging are the most useful diagnostic tests for evaluating pregnancy. These examinations allow for confirmation of an intrauterine pregnancy and may demonstrate direct signs (eg, a developing blastocyst within a fallopian tube, which is seen in only a minority of cases) or indirect signs (eg, free fluid, lack of intrauterine pregnancy) of an ectopic pregnancy; however, because of the large number of potential alternative foci, it may not be possible to locate an ectopic pregnancy. The concept of a discriminatory zone of the β-hCG level (ie, the level at which an intrauterine pregnancy should be visible; this is 6000-6500 mIU/mL on transabdominal ultrasonography and 1500-1800 mIU/mL for high-resolution, transvaginal ultrasonography) can validate the findings of the ultrasonogram.^[6] If ultrasonographic views at these levels do not demonstrate an intrauterine pregnancy, the pregnancy is most likely abnormal (and can either be an abnormal intrauterine pregnancy or an extrauterine pregnancy).

It is also important to recognize that a visualized intrauterine pregnancy does not absolutely exclude an additional ectopic pregnancy. Heterotopic pregnancy is rare, with rate of 1 in 30,000-80,000 cases for spontaneous pregnancy; however, the incidence is greater in patients utilizing assisted reproduction strategies. If the clinical suspicion is very high and an ectopic pregnancy cannot be confirmed or excluded by other means, a direct, intraoperative laparoscopic visualization may then be necessary. The combination of serum hCG and transvaginal ultrasonographic findings, however, is enough to confirm the presence of an ectopic pregnancy. Early consultation with colleagues in obstetrics and gynecology is necessary for cases of suspected ectopic pregnancy, with or without rupture.

The natural history of ectopic pregnancy is balanced between medical interventions and surgical management to reduce the risk of rupture and subsequent morbidity or mortality.^[1] If the ectopic pregnancy has not ruptured and the patient is stable, then medical and surgical treatments are available. Medical management of ectopic pregnancy utilizes either single or multiple dose regimens of methotrexate, and it is the preferred alternative whenever possible. Medically managed patients have a slightly increased rate of long-term complications when compared with surgical patients. Surgical intervention usually takes the form of a laparoscopic salpingostomy or salpingectomy, and it has comparable short-term outcomes to medical management; however, in cases of a ruptured ectopic pregnancy, surgical intervention is the most appropriate course of action. It is possible for an ectopic pregnancy to spontaneously regress; in a small subset of patients with very low serum hCG without an identifiable implantation site on ultrasonographic examination (ectopic pregnancy or incomplete spontaneous abortion [SAB] may be possible in this scenario), expectant management may be considered….”

References

1. Murry H, Baakdah H, Bardell T, Tulandi T. Diagnosis and treatment of ectopic pregnancy. CMAJ. 2005;173:905-12. Abstract
2. Della-Giustina D, Denny M. Ectopic pregnancy. Emerg Med Clin North Am. 2003;21:565-84. Abstract
3. Levine D. Ectopic pregnancy. Radiology. 2007;245:385-397. Abstract
4. Silva C, Sammel MD, Zhou L, Gracia Cl, Hummel AC, Barnhart K. Human chorionic gonadotropin profile for women with ectopic pregnancy. Obstet Gynecol. 2006;107:605-10. Abstract
5. Sowter MC, Farquhar CM. Ectopic pregnancy: an update. Curr Opin Obstet Gynecol. 2004;16:289-93. Abstract
6. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 94: Medical management of ectopic pregnancy. Obstet Gynecol. 2008;111:1479-85. Abstract

The case (http://cme.medscape.com/viewprogram/17086?src=emed_case_nl_0):  A 34-year-old woman presents to the ED with a 2-hour history of severe abdominal pain, 2 episodes of light-headedness, and loss of consciousness. She is about 6 weeks pregnant; the pain started suddenly the morning of presentation. She has a history of a spontaneous abortion that complicated a prior pregnancy 4 years ago.

The Answer: 

The presentation of severe abdominal pain, hemodynamic instability, and transient loss of consciousness in the setting of a nonconfirmed intrauterine pregnancy raised the suspicion for a ruptured ectopic pregnancy. The demonstration of free fluid in the Morrison pouch on the bedside ultrasonogram confirmed the presence of intra-abdominal hemorrhage, and a confirmatory transvaginal ultrasonogram demonstrated no viable intrauterine pregnancy. The β-hCG was confirmed at 12,200 mIU/mL. At surgery, an ectopic pregnancy was located within the left fallopian tube.

Source:  Rheims S, et al “Greater response to placebo in children than in adults: A systematic review and meta-analysis in drug resistant partial epilepsy” PLoS Med 2008; 5(8): e166.

Full Text:  http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0050166

ABSTRACT

MSNBC, 8/13/08 reports, “Spurred by government and industry actions,” a growing number of hospitals are vowing not to charge patients for so-called “never events.” This “list has more than doubled since February, when an MSNBC.com analysis showed that hospital associations in 11 states urged their members to waive payment for specific errors dubbed ‘never events’ because they should never happen at all.” Currently, “23 states…have approved non-payment policies for specific mistakes, with at least three more expected to do so by fall, a new review shows.” Meanwhile, “[h]ospitals in another eight states have agreed to general guidelines that advise eliminating bills on a case-by-case basis for errors proven to be both serious and preventable.” MSNBC adds, “The idea of cutting payments for avoidable errors has gained considerable momentum in the year since federal officials sparked the shift by announcing that, starting Oct. 1, Medicare will no longer reimburse hospitals for the extra costs of treating certain injuries, infections and complications that occur after admission.”

MedPage Today, 8/13/08 :  http://www.medpagetoday.com/PrimaryCare/ExerciseFitness/tb/10532:

“…Among young women in high school, 65.1% of all severe sports injuries from 1982 to 2007 were related to cheerleading, and at the college level the percentage was 66.7%, according to the annual report released by the National Center for Catastrophic Sport Injury Research at the University of North Carolina…

Catastrophic cheerleading injuries — which include death, permanent disability, or a severe injury such as fractured vertebrae — are occurring more now than 25 years ago, when the center released its first report.

Over the first decade of collecting data, there were 25 catastrophic cheerleading accidents in high school and college, including two deaths. From 1997 through 2007, there were 58 injuries, including one death.

Increases in catastrophic injuries coincided with a rise in emergency room visits related to cheerleading. The Consumer Product Safety Commission estimated that the number of visits increased from 4,954 in 1980 to 28,414 in 2004…”

Source: 

Cardiac Magnetic Resonance With T2-Weighted Imaging Improves Detection of Patients With Acute Coronary Syndrome in the Emergency Department.
 Journal:  Circulation. 2008 Aug 4.

ABSTRACT

BACKGROUND: -Cardiac magnetic resonance (CMR) imaging permits early triage of patients presenting to the emergency department with acute chest pain but has been limited by the inability to differentiate new from old myocardial infarction. Our objective was to evaluate a CMR protocol that includes T2-weighted imaging and assessment of left ventricular wall thickness in detecting patients with acute coronary syndrome in the emergency department.

Methods and Results-In this prospective cohort observational study, we enrolled patients presenting to the emergency department with acute chest pain, negative cardiac biomarkers, and no ECG changes indicative of acute ischemia. The CMR protocol consisted of T2-weighted imaging, first-pass perfusion, cine function, delayed-enhancement magnetic resonance imaging, and assessment of left ventricular wall thickness. The clinical outcome (acute coronary syndrome) was defined by review of clinical charts by a consensus panel that used American Heart Association/American College of Cardiology guidelines. Among 62 patients, 13 developed acute coronary syndrome during the index hospitalization. The mean CMR time was 32+/-8 minutes. The new CMR protocol (with the addition of T2-weighted and left ventricular wall thickness) increased the specificity, positive predictive value, and overall accuracy from 84% to 96%, 55% to 85%, and 84% to 93%, respectively, compared with the conventional CMR protocol (cine, perfusion, and delayed-enhancement magnetic resonance imaging). Moreover, in a logistic regression analysis that contained information on clinical risk assessment (c-statistic=0.695) and traditional cardiac risk factors (c-statistic=0.771), the new CMR protocol significantly improved the c-statistic to 0.958 (P<0.0001).

Conclusions-The present study indicates that a new CMR protocol improves the detection of patients with acute coronary syndrome in the emergency department and adds significant value over clinical assessment and traditional cardiac risk factors.