Newsweek (http://www.newsweek.com/id/164922)

The modern emergency room, as most people think of it, has an emergency of its own: It’s packed, costly, noisy, and overrun by uninsured freeloaders who can’t legally be turned away once they walk through the ER doors. If you’ve actually been in an ER in the past few years, you know the first three things are true—but how much do you know about the rest of the people in the waiting room? As it turns out, they’re not disproportionately uninsured patients with nowhere else to turn. They’re more likely to be people who do have insurance, and according to a new study in the Journal of the American Medical Association, the reasons they’re backing up in ERs go much deeper than who’s paying for their care. NEWSWEEK’s Mary Carmichael asked Dr. Manya Newton, an emergency physician at the University of Michigan, Robert Wood Johnson Clinical Scholar, and the lead author of the new paper, to explain the problem. Excerpts:

NEWSWEEK: You looked at some common assumptions about why emergency rooms are so crowded. A lot of them turned out to be untrue. What were these myths, and how did people come to believe in them?
Manya Newton: First, there was a belief that the uninsured are all coming to the emergency department for non-urgent care. That’s a tricky one to talk about, because there’s no good definition of what “non-urgent care” is—if you have a big cut on your face, or if your baby has a fever and it’s one in the morning, that is coded as “non-urgent” by doctors even though it’s urgent to you. But when people talk about crowded ERs and the uninsured coming in for “non-urgent care,” they’re thinking about things like the sniffles, or the back pain these people have had for 11 years. And if you actually look at the uninsured, they’re not coming in for sniffles or back pain, because they’re the only group that bears the full cost of an ER visit. Yes, a $50 co-pay is painful, but a $5,000 bill is really painful.

So they actually come to the ER less often than people with insurance do? 
Yes. They’re underrepresented in ERs compared to the overall population—17 percent of people in our country are uninsured, but they account for somewhere between ten and 15 percent of visits to the ER. When they do come in, they tend to put it off until the last possible moment, until they’re really sick. So it’s not the uninsured who are causing crowding. It’s everybody.

Why do you think people came to believe the opposite—that the uninsured were responsible for crowded ERs? 
Before the 1990s, at least in the medical literature, it was widely understood that the uninsured were putting off care, showing up sicker [and] showing up less often. But then there were some big changes in the medical system. The Emergency Medical Treatment and Active Labor Act went into effect in 1986. This is the act that’s often misquoted as “you can get free care in the emergency department,” which is absolutely not right. The fact is that if you show up and you’re sick, we do have to treat you—we can’t look in your wallet first. But it’s not free. You still get billed. Also, there were a bunch of changes at that time regarding managed care, and the result was that ERs found themselves strapped for money. A lot of emergency departments across the country closed, so all the remaining ERs were seeing more patients—and I think the uninsured became our scapegoat.

What people don’t understand is that in general, the uninsured are people who are working two or three jobs trying to hold their families together, and none of their jobs offer insurance. There’s this presumption that they’re choosing not to have insurance—there’s a feeling that these people are unworthy, that they’d have insurance if they just worked harder. And we can’t make policy based on assumptions like that, because a lot of times what “everybody knows” turns out to be wrong.

So if the uninsured aren’t to blame for overcrowding, who is? 
It’s multi-factorial. The population is getting older and sicker, so more people are coming to the ER for real emergencies. Use-per-person has also gone up, and we’re not sure why that’s happening. Part of it is because there are fewer primary care doctors now, so it’s hard to get appointments. If you call your doctor’s office and you say, “I’m super-sick and coughing up green stuff,” and they say, “we’ll see you three weeks from Tuesday,” you might think you need to go to the ER instead. And you might be right.

But you might be wrong, in which case you’re in the ER unnecessarily.

You also write that the actual number of beds in ERs has gone down, at the same time the need has apparently gone up. Why?
That would be a whole other paper—but it has to do with changes in reimbursement and the nursing shortage.

Basically, there’s not enough money for beds? 
Right. So, let’s say your grandmother breaks her hip and comes in and has surgery. There are fewer beds upstairs on the inpatient units, as well as fewer in the ER. So if Grandma can’t go home after her surgery, there are fewer places we can put her. Now we’re looking for a bed upstairs for a week or two weeks, which means the next grandmother with a broken hip waits and waits behind her in the emergency department, because I can’t get someone upstairs to a bed that doesn’t exist.

This has to be affecting patient care. 
Absolutely. We are fantastic at treating emergencies, but we do not run an intensive-care unit as well as the intensivists can. And we know that increasing the wait time to see a doctor in the emergency department can lead to worse patient outcomes.

So now that we know what the problem is, how the heck do we fix it?
There are no easy solutions. The ER can work on through-put issues—do we need to hire more nurses? Do we need to streamline our system? But that’s a tiny fraction of the problem. We cannot control how many people show up at our door. We cannot control how soon someone can get a bed. One of the keys is that you can’t blame any one part of the system. You can’t say this is the ER’s fault, or the inpatient services’, or primary care’s. If we keep pointing fingers and blaming people, we’re not going to change anything. This is a system wide problem. All parts of the system need to sit down and discuss it as a whole.

There’s no specific reform you can think of that would make a difference?
We could change the way primary care doctors are reimbursed and make it more affordable for them to see lower-income patients, or more attractive for them to have longer hours. That would probably be where I’d start.

Is there anything in either of the presidential candidates’ platforms that would help? Their proposals seem mostly focused on getting more people insured.
Providing insurance to more people will help with overall health. It may help the currently uninsured find a primary care provider. But it is not going to help with ER overcrowding, because the primary care doctors are still going to be overbooked.

If anything, it might encourage the newly insured to come to the ER more than they do now. 
Right. It’s not a panacea. It’s a great thing to do, but it’s not going to solve this problem. 

NY Times, 10/24/08 (http://www.nytimes.com/2008/10/24/health/chen10-23.html?sq=+%22American%20Medical%20Association%22&st=nyt&scp=1&pagewanted=all)

The white-coated crowd with stethoscopes slung casually around their necks would have looked familiar to anyone who has attended morning hospital rounds. Resident physicians and medical students milled about, chatting animatedly, and at the appointed hour, the attending physician signaled to begin.

But instead of filing toward a patient’s room, the group at Saint Barnabas Medical Center in Livingston, N.J., settled into a conference room at the end of the hall, not to recite details of patient cases but to read “Empty Pockets,” a personal essay by Dr. Kevan Pickrel from The Annals of Internal Medicine. In the piece, Dr. Pickrel describes being unable to save a 36-year-old woman, then going to the waiting room to inform the woman’s family of her death:

“The youngest daughter sat on Dad’s lap looking at pictures in an outdoors magazine. The older sat watching her hands rest in her lap. [The] husband’s eyes lifted to me and met mine. I didn’t, couldn’t, say a word…. He turned back toward his daughters, a single father, and they lifted their eyes to his. As he drew a breath to begin, his eldest daughter knew.”

After the reading, the attending physician, Dr. Sunil Sapra, looked up at the group assembled. “Do you identify with any of these situations?” he asked.

“Yes, it happens all the time,” a resident responded immediately. Others nodded in agreement, and one resident flicked a tear away.

The next morning, in a similar room at New York-Presbyterian Hospital in upper Manhattan, a group of obstetrics and gynecology residents gathered to read E.B. White’s short story “The Second Tree From the Corner.” Told from the perspective of an anxiety-ridden patient, the story ends with the main character finding meaning in his life and suddenly feeling liberated:

“He felt content to be sick, unembarrassed at being afraid; and in the jungle of his fear he glimpsed (as he had so often glimpsed them before) the flashy tail feathers of the bird courage.”

As the reading ended, one of the young doctors commented on how personally fulfilling it was to help her patients and how those feelings invigorated her, even after many hours of work. Other doctors in the room nodded in agreement.

While it has long been understood that clinical practice influenced the youthful writing of doctor-authors like Chekhov and William Carlos Williams, there is now emerging evidence that exposure to literature and writing during residency training can influence how young doctors approach their clinical work. By bringing short stories, poems and essays into hospital wards and medical schools, educators hope to encourage fresh thinking and help break down the wall between doctors and patients.

“We’re teaching the humanities to our residents, and it’s making them better doctors,” said Dr. Richard Panush, a rheumatologist and chairman of the department of medicine at Saint Barnabas.

The idea of combining literature and medicine — or narrative medicine as it is sometimes called — has played a part in medical education for over 40 years. Studies have repeatedly shown that such literary training can strengthen and support the compassionate instincts of doctors.

Dr. Rita Charon and her colleagues at the program in narrative medicine at Columbia University’s College of Physicians and Surgeons found, for example, that narrative medicine training offered doctors opportunities to practice skills in empathy. Doctors exposed to literary works were more willing to adopt another person’s perspective, even after as few as three or four one-hour workshops.

“You want people to be able to leave their own individual place,” Dr. Charon said, “and ask what this might be like for the child dying of leukemia, the mother of that child, the family, the hospital roommate.”

Over the last 15 years, an ever-increasing number of medical schools have begun offering narrative medicine to medical students. These courses often involve writing, reading and discussing works by authors as diverse as Leo Tolstoy, Virginia Woolf, Lori Moore and various doctor-authors. Students then explore the relevance of these texts, and their own writing, to their clinical work.

But until recently, few educators have attempted to bring such literary training into residency programs.

Residency is the most intense period of a young doctor’s life. The years spent squirreled away in hospitals and clinics are rich in clinical learning, but the wealth of that experience comes at the cost of free time.

And with time at a premium, residency program directors and clinical educators have been hesitant to add narrative medicine to their curricula, particularly since it has never been clear that such an addition would have any effect other than further overworking the trainees.

That could be changing.

For over a year now, Dr. Panush, a tall, bespectacled, soft-spoken man with the lean physique of a runner, has been systematically incorporating literature into the daily rounds of every one of the internal medicine residents at Saint Barnabas Medical Center.

As part of the Accreditation Council for Graduate Medical Education’s Education Innovations Project, Dr. Panush and his faculty colleagues bring poetry, short stories and essays to rounds each day and discuss them in the context of the patients they see. These daily discussions, supplemented by offsite weekly conferences, form the core of the residents’ narrative medicine experience.

One year into the program, Dr. Panush and his colleagues looked at the effect of these daily discussions on the residents and their patients. What they found were significant improvements in patient evaluations of residents and patients’ health and quality of life, from hospital admission to discharge.

A handful of other residency programs across the country have taken steps toward establishing narrative medicine training for their residents, including Vanderbilt University’s Department of Surgery and New York/Presbyterian Hospital-Columbia’s Department of Obstetrics and Gynecology. As with the program at Saint Barnabas, it has been the doctors within these departments who have initiated the workshops, sessions and lectures.

“As we improve the technology of medicine, we also need to remember the patient’s story,” said Dr. A. Scott Pearson, an associate professor of surgery at Vanderbilt University Medical Center.

To that end, Dr. Pearson has completed a pilot study examining the feasibility of incorporating narrative medicine into Vanderbilt’s surgical residency and has plans to make such training available eventually to all surgical residents at his medical center. Dr. Pearson believes that narrative medicine will not only help residents reflect on what they are doing and how they might do better, but may also aid surgical educators in teaching professionalism and communication skills.

“Narrative medicine changed my entire approach to medicine,” said Dr. Abigail Ford, a senior resident in obstetrics and gynecology at New York-Presbyterian Hospital/Columbia who studied under Dr. Charon as a medical student. “As a doctor you are really a co-author of patients’ experiences and need to hear their story and take it on.”

With her former professor’s guidance, as well as the support of Dr. Rini Ratan, the residency program director, Dr. Ford has initiated a narrative medicine program for her fellow obstetrics and gynecology residents. While the program is still in its first year, “we’ve always run over,” said Dr. Ford. “People have to be dragged away.”

“Our hope is to look at it in terms of physician empathy,” added Dr. Ratan, “Does it add anything? Does it prevent natural jadedness over the course of the busy training process? Does it prevent burnout?”

In the near future, Dr. Ratan and Dr. Ford also hope to begin doing the kind of patient outcome evaluations that Dr. Panush and his colleagues have begun.

“To do what we’re doing is pretty simple,” said Dr. Panush. “But the measurement stuff is harder. The program needs to be supported institutionally and internally.”

Despite such challenges, the effects of these programs are striking. Dr. Benjamin Kaplan, a second-year resident at Saint Barnabas, remarked on the transformation he saw in fellow resident physicians during the first year of the humanities program.

“Their management of patients changed,” Dr. Kaplan said. “They remembered to do things that I don’t think they would have otherwise done, like always talking to the family, gently touching patients, and continually explaining the course of treatment and what the doctors are thinking so patients know.”

And the time commitment? “It does get pretty busy,” Dr. Kaplan conceded. “But if you want to make time for it, you can. Spending a half hour a day to remember that we are all human, not just doctors or pharmacists or nurses or patients, is important enough that I think you should do it.”

Although it is still too early to determine the long-term effects of narrative medicine on doctors in training, residents were quick to note that certain essays, short stories and poems they have read on rounds continue to influence their work.

Dr. Ramesh Guthikonda, a second-year resident at Saint Barnabas, spoke about a poem called “When You Come Into My Room,” by Stephen A. Schmidt. In the poem, published in The Journal of the American Medical Association, a man struggling with chronic illness lists all that he believes a doctor meeting him should know:

“When you come into my hospital room, you need to know the facts of my life

that there is information not contained in my hospital chart

that I am 40 years married, with four children and four grandchildren….

that I love earthy sensuous life, beauty, travel, eating, drinking J&B scotch, the theater, opera, the Chicago Symphony, movies, all kinds, water skiing, tennis, running, walking, camping…

that I am chronically ill, and am seeking healing, not cure.”

The poem so affected Dr. Guthikonda that he began regularly asking his patients about their hobbies and families, and he enrolled in a Spanish class so he could learn to better pronounce their names. “My rapport with patients, especially with my Hispanic patients, was not up to the mark,” he said. “I never asked about the patients’ lives, about who they are. I am much more sensitive to those issues now.”

Reflecting on the changes in Dr. Guthikonda, Dr. Panush said, “We changed the way he thinks and does medicine. You can’t put a p-value on that.”

Intro:  Let’s say you, as a law-abiding, generally-caring healthcare professional decide to take a stand and refuse to be dicatetd to any longer.  So, instead of being water-boarded into receiving a flu shot, you decide to mask up when seeing patients.  You sign that “informed declination” statement.  Now, should your patient or, perhaps anyone in the hospital comes down with a cough, might that put you at risk fior a medical malpractice suit?  It’s inevetaible.  I wonder if you can be designated a “Conscientious Objector?”  Maybe you have to flee to Canada to preserve your Libertarian rights?

http://www.ama-assn.org/amednews/2008/10/27/prbf1027.htm

Infection control group: Flu shot should be required for doctors

All physicians and other health care professionals with direct patient contact should be required to receive the influenza immunization annually, the Assn. for Professionals in Infection Control and Epidemiology said in an October position paper.

The group said hospitals, nursing homes, outpatient clinics, urgent care centers and home health agencies should implement a system of “informed declination.” Under this system, health professionals who refuse to be vaccinated for nonmedical reasons acknowledge in writing that they are exposing their patients to additional risk.

The Washington, D.C.-based APIC represents 12,000 members who direct infection-control programs in health care facilities. The national health worker immunization rate has stalled at about 40% during the last decade, according to the Centers for Disease Control and Prevention.

Here is the link to the complete text on the American Heart Association Scientific Statement on Post-Cardiac Arrest Care:

http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.108.190652v1

According to the U.S. Centers for Disease Control and Prevention (CDC)[http://www.medicalnewstoday.com/articles/126750.php], four times as many children age 5 to 14 years of age are killed on Halloween evening compared to any other night of the year because of falls, being hit by a vehicle or other accidents.

The National Fire Prevention Association (NFPA) also reports an average of seven deaths and $24.9 million in property damage each year in the United States as the result of home fires caused by Halloween decorations, the majority involving candles.

Medical News Today, 10/23/08 (http://www.medicalnewstoday.com/articles/126730.php)

Anyone with a nose knows the rotten-egg odor of hydrogen sulfide, a gas generated by bacteria living in the human colon. Now an international team of scientists has discovered that cells inside the blood vessels of mice – as well as in people, no doubt – naturally make the gassy stuff, and that it controls blood pressure.

Having discovered that hydrogen sulfide, or H2S, is produced in the thin, endothelial lining of blood vessels, the researchers, including scientists from Johns Hopkins, report today in Science that H2S regulates blood pressure by relaxing blood vessels. As the newest member of a family of so-called gasotransmitters, this messenger molecule is akin in function, if not form, to chemical signals like nitric oxide, dopamine and acetylcholine that relay signals between nerve cells and excite or put the brakes on mind-brain activities.

“Now that we know hydrogen sulfide’s role in regulating blood pressure, it may be possible to design drug therapies that enhance its formation as an alternative to the current methods of treatment for hypertension,” says Johns Hopkins neuroscientist Solomon H. Snyder, M.D., a co-author of the paper.

Conducting their investigations using mice missing a gene for an enzyme known as CSE, long suspected as responsible for making H2S, the researchers first measured hydrogen sulfide levels in a variety of tissues in the CSE-deficient mice and compared them to normal mice. They found that the gas was largely depleted in the cardiovascular systems of the altered mice, engineered by Rui Wang, M.D., Ph.D., of Lakehead University in Ontario, and Lingyun Wu, M.D., Ph.D., of the University of Saskatchewan, Canada. By contrast, normal mice had higher levels – clear evidence that hydrogen sulfide is normally made by mammalian tissues using CSE.

Next, the scientists applied tiny cuffs to the tails of the mice and measured their blood pressure, noting spikes of about 20 percent, comparable to serious hypertension in humans.

Finally, the team tested how blood vessels of CSE-deficient mice responded to the chemical neurotransmitter methacholine, known to relax normal blood vessels. The blood vessels of the altered mice relaxed hardly at all, indicating that hydrogen sulfide was largely responsible for relaxation.

Because gasotransmitters are highly conserved in mammals, the findings of the research are believed to have broad applications to human physiology and disease.

“In terms of relaxing blood vessels, it looks like hydrogen sulfide might be as important as nitric oxide,” Snyder says, referring to the first gasotransmitter that two decades ago was discovered to regulate blood pressure.

Just because these two gas molecules perform similar functions, doesn’t mean they’re redundant, says Wang, the paper’s principal author. “Nature has added on layer upon layer of complexity to provide a better and tighter control of body function – in this case, of blood pressure.”

Studying gaseous messengers can be tricky, explains Snyder, an authority on nitric oxide (NO) whose lab in 1990 discovered that the enzyme triggering NO production is activated by a protein mechanism known as calcium-calmodulin.

“When a nerve fires, it releases a bit of neurotransmitter. Then it fires again, very quickly, and releases more of the neurotransmitter, which is always in reserve and at the ready in large storage pools called vesicles. However, gasses can’t be stored; they diffuse. So every time there’s a nerve impulse, an enzyme must be activated to make it,” he says.”

Although CSE, the enzyme that activates hydrogen sulfide, was characterized more than half a century ago, the new work is the first to reveal that it is activated in the same way as the nitric oxide-forming enzyme, thus establishing how hydrogen sulfide regulates blood pressure by relaxing blood vessels.

“It’s difficult to overestimate the biological importance of hydrogen sulfide or its implications in hypertension as well as diabetes and neurodegenerative diseases,” Wang says. “In fact, most human diseases probably have something to do with gasotransmitters.”

Primary source: Circulation: Journal of the American Heart Association
Source reference:
Neumar R, et al “Post-cardiac arrest syndrome. Epidemiology, pathophysiology, treatment, and prognostication: a consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian Resuscitation Council, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, Resuscitation Council of Southern Africa, and the New Zealand Resuscitation Council); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council” Circulation 2008; DOI:

MedPage Today (http://www.medpagetoday.com/EmergencyMedicine/EmergencyMedicine/11436), 10/23/08: 

A wide range of medical interventions should be started immediately after cardiac arrest to improve survival, according to a consensus statement released by the American Heart Association.

Besides treating the underlying cause of the arrest, clinicians need to treat myocardial dysfunction and ischemia, and prevent neurological injury, according to a statement published online simultaneously in Circulation: Journal of the American Heart Association and Resuscitation.

The consensus statement comes from the International Liaison Committee on Resuscitation — members of which include the AHA and several international critical care and cardiology organizations — and is endorsed by the American College of Emergency Physicians, the Society for Academic Emergency Medicine, and the Society of Critical Care Medicine.

There is little evidence that the in-hospital mortality rate for cardiac arrest patients has changed in the last half century, despite advances in critical care, said Robert Neumar, M.D., Ph.D., co-chair of the consensus statement writing committee and associate director of the Center for Resuscitation Science at the University of Pennsylvania in Philadelphia.

“Although we have become better at restarting the heart, we are only beginning to learn and implement the best ways to keep patients alive and minimize brain damage after their heart is restarted,” said Dr. Neumar.

The statement stressed the importance of initiating measures to improve survival in cardiac arrest patients by treating the range of problems that arise after the resumption of spontaneous circulation — which the authors referred to as post-cardiac arrest syndrome — as soon as possible.

The authors pointed to recent studies showing the efficacy of therapeutic hypothermia as proof that post-cardiac arrest survival can be improved by treating the various components of the syndrome.

The statement suggested initiating treatments in four main categories: those for brain injury, for myocardial dysfunction, for systemic ischemia and reperfusion response, and for the underlying cause of the cardiac arrest.

Brain injury results from numerous pathways unfolding over a period of hours or days, the authors said.

“The relatively protracted duration of injury cascades and histological change suggest a broad therapeutic window for neuroprotective strategies after cardiac arrest,” they said.

Neurological injuries may be prevented by therapeutic hypothermia (cooling to 32 to 34°C for at least 12 to 24 hours), early hemodynamic optimization, airway protection and mechanical ventilation, seizure control, controlled reoxygenation, and controlled blood glucose concentrations, they said.

Myocardial dysfunction, typically resulting from acute coronary syndrome, also causes death following a cardiac arrest, and “a significant body of preclinical and clinical evidence … indicates that this phenomenon is both responsive to therapy and reversible,” Dr. Neumar and colleagues wrote.

Strategies for treating this condition include early revascularization of acute myocardial infarction patients, early hemodynamic optimization, and use of IV fluids, inotropes, left ventricular assist devices, and extracorporeal membrane oxygenation.

Additionally, they said, survivors should be evaluated for placement of a pacemaker or implantable cardioverter-defibrillator if the cardiac arrest is attributed to a primary dysrhythmia.

Patients who have suffered an ST-elevation myocardial infarction should undergo immediate coronary angiography and percutaneous coronary intervention if necessary; thrombolysis may be substituted if PCI is not available, they said.

Systemic ischemia and reperfusion response may clinically manifest as ongoing tissue hypoxia, hypotension, cardiovascular collapse, pyrexia, multiorgan failure, or infection.

It can be treated with methods such as early hemodynamic optimization, IV fluids, vasopressors, temperature control, and antibiotics, according to the statement.

Although early hemodynamic optimization is recommended, the authors said, neither specific targets nor the efficacy of the approach have been established in clinical trials of cardiac arrest patients.

In addition, “the pathophysiology of post-cardiac arrest syndrome is commonly complicated by persisting acute pathology that caused or contributed to the cardiac arrest itself,” the authors said, which also complicates treatment for the condition.

Therefore, they said, “specific treatment of these underlying disturbances must then be coordinated with specific support for post-cardiac arrest neurological and cardiovascular dysfunction.”

To get the best outcomes following cardiac arrest, the statement authors suggested that multidisciplinary teams develop comprehensive plans to handle patients in all conditions while making the most efficient use of available resources.

“In all cases,” they said, “treatment must focus on reversing the pathophysiological manifestations of the post-cardiac arrest syndrome with proper prioritization and timely execution.”

Similar approaches were advocated for pediatric populations but the authors acknowledged that few studies had been conducted on post-arrest care in children.

Another area highlighted in the consensus statement was the need for better tools for prognostication.

“Despite a large body of research in this area,” the authors said, “the timing and optimal approach to prognostication of futility [of care] are controversial.”

Finally, the authors suggested that regional cardiac arrest centers, similar to level 1 trauma centers, may improve outcomes and facilitate further research, although they acknowledged that this is not yet proven.

Intro:  Sure.  Why not?  We know it’s an independent risk factor for projectile vomiting and incontinence and morning-after malaise.

MedScape reported that, according to a study reported in the Oct. 2 Online First issue of Stroke, “Binge drinking is an independent risk factor for all strokes and for ischemic stroke.”

For the study, Laura Sundell, M.D., of Finland’s National Public Health Institute, and colleagues, analyzed data on “15,965 Finnish men and women age 25 to 64 years who had no history of stroke at baseline,” and who “were followed up for a 10-year period.” The researchers defined binge drinking “as consuming six or more drinks of the same alcoholic beverage in one session for men, or consuming four or more drinks for women.” After adjusting the data for “average alcohol consumption, age, sex, hypertension, smoking, diabetes, body mass index, educational status, study area, study year, and history of myocardial infarction,” the investigators found that “the risk for total and ischemic strokes was independently increased by binge drinking.”

LA Times (10/24, Ornstein, Weber) reports, “The California Board of Registered Nursing unanimously approved emergency regulations Thursday requiring all of its licensees to submit fingerprints, allowing law enforcement agencies to flag the nursing board any time a nurse is arrested.”

The board’s move is expected to “have the greatest effect on about 146,000 nurses who were licensed before 1990, when the board began requiring new applicants to provide fingerprints.” The new rules come “after a Times story earlier this month revealed that dozens of convicted criminals had kept their licenses for years.” In a joint investigation, “the Times and ProPublica, an investigative reporting newsroom, found more than 115 cases since 2002 in which the nursing board failed to act against nurses’ licenses until they had racked up three or more convictions.” The new regulations must now be approved by the state’s Office of Administrative Law.

NY Times, 10/24/08 (http://www.nytimes.com/2008/10/24/health/24placebo.html?ref=health&pagewanted=print)