Posted on the Pediatric SuperSite on May 29, 2009 (http://www.pediatricsupersite.com/view.aspx?rid=40405)

Some physicians struggle with diagnosing pertussis in adolescents

One out of seven physicians were not able to accurately diagnose pertussis and too few physicians are testing adolescent patients for this illness, according to a survey conducted by University of Michigan researchers. Amanda Dempsey, MD, PhD, MPH, assistant professor of pediatrics and communicable diseases at the University of Michigan Medical School, said their findings demonstrate a need to increase provider education in recognizing pertussis to ensure fewer outbreaks.

The survey of 702 general pediatricians and family medicine physicians revealed testing, recognition of clinical symptoms and case management of pertussis in teens is insufficient, with 86% of physicians saying they experienced at least one barrier to pertussis testing.

Physicians said they struggle with delays in obtaining test results (52%), inaccurate sample collection (29%), a shortage of testing supplies (29%) and a lack of familiarity with testing protocols (28%). Cost was also cited a barrier.

Ten percent of the physicians in the survey believed that their clinical judgment alone was enough to diagnose a case of pertussis.

“Clearly, the importance of clinical acumen in combination with a high index of suspicion cannot be overstated,” Dempsey and colleagues noted in the study. “But whopping cough often resembles other respiratory diseases early in the course of illness.”

The study also highlighted important specialty-based differences in testing practices. The researchers noted that family practitioners were less likely than pediatricians to diagnose an adolescent with the illness in the past, test adolescents in their current practice and report cases to the health department.

Consequently, “efforts must be made to improve doctors’ knowledge about diagnosing, treating, and preventing pertussis, especially to reflect the specific needs of all medical communities,” Dempsey and colleagues wrote.

Preventive Medicine. 48(5); 2009, 500-504.

Fiat is going to produce a new model for Chrysler. It’s called the “Vaticano.” It has a rather conservative, unimaginative design, but when it’s on the road, all the traffic lights ahead of it turn green automatically!

But I digress……

We mentioned in the past that there are some docs who are eschewing the groin and going to the wrist vessels for an angioplasty. Though the number of doctors who perform wrist angioplasty remains small in the U.S. — just 1.3 percent of the one million angioplasties performed yearly in the United States, according to one study — the number is growing as practitioners tout its benefits: less pain, less bleeding and shorter hospital stays.

http://omniphysicians.com/2009/06/03/wrist-angioplasties/

Adolescents get depressed. How depressed? One way to gauge is to check out the parents. Depressed parents breed depressed kids. If you’re assessing an adolescent for depression and a rope party, see what medications the parents are on. It might give you more insight into the gravity of the situation. Hope Octo-Mom isn’t depressed. Her kids will have a mass suicide. Anyway, proper interventions will assist.
http://omniphysicians.com/2009/06/03/adolescents-depression/

The incidence of SAH deaths was studied in the meta-analysis. Despite an increase in the mean age of patients with SAH, case-fatality rates have decreased by 17% between 1973 and 2002 and show potentially important regional differences. Way to go, team!
http://omniphysicians.com/2009/06/04/case-fatality-of-aneurysmal-subarachnoid-haemorrhage/

There’s a push to avoid paying hospitals when in-patients fall and hurt themselves. As many as one of five patients fall at least once during their time in the hospital, leading to injuries, longer stays, lawsuits, and hospital bills higher by about $4,000, according to previous research. This one doctor’s opinion to be published this week says that this is such a big problem, that falls will continue despite ways to prevent them. So don’t take it out on the poor, little old hospitals.
http://omniphysicians.com/2009/06/04/why-blame-us-when-they-fall/

Paul R.

Link: http://www.forbes.com/feeds/ap/2009/06/03/ap6498263.html

Health insurer UnitedHealth Group says it is developing a service that will allow people to talk to a doctor at any time on the phone or online through a collaboration with American Well Corp.

The proposed service would be offered nationwide to the 60 million patients covered by UnitedHealth Group Inc. ( UNH – news – people )’s OptumHealth subsidiary. UnitedHealth said it would combine Web technology developed by each company: OptumHealth’s eSync Platform sends a patient’s health care information to doctors, and American Well’s Online Care platform allows patients and doctors to talk in real time.

OptumHealth patients would have 24-hour-a-day access to local doctors through two way video chat, secure online chat, phone or company health care sites. The companies said doctors would be able to expand their practices, while patients would get expanded access to health care.

Minnetonka, Minn.-based UnitedHealth is the nation’s largest managed care company based on revenue. American Well was founded in 2006 and is based in Boston.

Boston Globe, 6/3/09

Patient falls and the injuries they cause are considered such a crisis that in October, the federal government stopped paying hospitals for extra care if a fall is deemed preventable. Now, a Boston doctor is warning that the pressure to keep patients from falling may lead to greater harm through the use of restraints, reversing a trend of greater mobility among hospitalized patients.

Writing in tomorrow’s New England Journal of Medicine, Dr. Sharon K. Inouye of Harvard Medical School and her co-authors argue that because falls have proved to be such an intractable problem despite broad efforts to reduce them, they should not be included on a list of avoidable medical errors that result in hospitals not being paid.

As many as one of five patients fall at least once during their time in the hospital, leading to injuries, longer stays, lawsuits, and hospital bills higher by about $4,000, according to previous research cited in the opinion piece. Falls are often caused by the illnesses or impairments patients have and the medications and other treatments they receive to treat them, Inouye said, meaning falls can happen despite the best hospital care.

Without well-established guidelines on preventing falls, Inouye said she fears restraints will be used.

“We have to do something to counteract what may be people’s natural tendency to think to stop falls, we’ve got to tie everyone up,” Inouye said in an interview. “We want to open people’s eyes to the fact that restraints are actually associated with lots of complications.”

Patients who are in restraints can become agitated or delirious, both of which can lead to falls. They also are more likely to develop bed sores, breathing problems, or die, research has shown.

A hospital-group representative said measures designed to keep a closer watch on patients and to keep them moving are more likely to be used than restraints.

“People never talk about restraints. We’re always trying to prevent that,” said Patricia Noga, senior director of clinical affairs at the Massachusetts Hospital Association and a member of a statewide coalition to prevent falls. “We are always looking at other ways to keep the patients moving and as free and functional as possible.”

As director of the Aging Brain Center at the Institute for Aging Research at Hebrew Senior Life, Inouye has spent more than 20 years studying ways to prevent delirium, a state of acute confusion common among the hospitalized elderly. Her research has shown that efforts to prevent delirium, minimize certain medications, and maintain mobility, combined with lowered beds and scheduled trips to the toilet, reduce falls. She has watched the use of restraints — straps to confine patients to beds or chairs — decline by two-thirds over those two decades, but now she fears their use will return.

“We don’t want to give the message at all that falls are fine to occur in the hospitals,” Inouye said. “We just feel this is a very blunt instrument in making them a no-payment condition.”

Dr. Thomas Valuck, medical officer and senior adviser in the Center for Medicare Management at the Centers for Medicare & Medicaid Services, disagreed, saying the policy encourages alternatives to restraints.

“I think it’s totally appropriate to use the Medicare payment incentive to encourage adherence to those best practices,” he said.

The Mass. Hospital Association’s Patients First initiative posts on its website tallies of falls and the number of resulting injuries at the state’s acute care hospitals. Some hospitals have care teams visit vulnerable patients more frequently — as often as once an hour — to check on them, helping them use the toilet more often, or checking on other needs, Noga said.

Patricia Rutherford, vice president of the Institute for Healthcare Improvement in Cambridge, also said such measures are working.

“Falls and patient injury from falls are a significant problem,” she said. “We do need to catalyze action around it. There are a few simple interventions starting to show promise that help to reduce patient injuries from falls.”

Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis
Original TextDennis J Nieuwkamp MD a , Larissa E Setz MD a, Ale Algra MD a b, Francisca HH Linn MD a c, Nicolien K de Rooij MD a, Gabriël JE Rinkel MD a

Summary

Background
In a systematic review, published in 1997, we found that the case fatality of aneurysmal subarachnoid haemorrhage (SAH) decreased during the period 1960—95. Because diagnostic and treatment strategies have improved and new studies from previously non-studied regions have been published since 1995, we did an updated meta-analysis to assess changes in case fatality and morbidity and differences according to age, sex, and region.

Methods
A new search of PubMed with predefined inclusion criteria for case finding and diagnosis identified reports on prospective population-based studies published between January, 1995, and July, 2007. The studies included in the previous systematic review were reassessed with the new inclusion criteria. Changes in case fatality over time and the effect of age and sex were quantified with weighted linear regression. Regional differences were analysed with linear regression analysis, and the regions of interest were subsequently defined as reference regions and compared with the other regions.

Findings
33 studies (23 of which were published in 1995 or later) were included that described 39 study periods. These studies reported on 8739 patients, of whom 7659 [88%] were reported on after 1995. 11 of the studies that were included in the previous review did not meet the current, more stringent, inclusion criteria. The mean age of patients had increased in the period 1973 to 2002 from 52 to 62 years. Case fatality varied from 8·3% to 66·7% between studies and decreased 0·8% per year (95% CI 0·2 to 1·3). The decrease was unchanged after adjustment for sex, but the decrease per year was 0·4% (−0·5 to 1·2) after adjustment for age. Case fatality was 11·8% (3·8 to 19·9) lower in Japan than it was in Europe, the USA, Australia, and New Zealand. The unadjusted decrease in case fatality excluding the data for Japan was 0·6% per year (0·0 to 1·1), a 17% decrease over the three decades. Six studies reported data on case morbidity, but these were insufficient to assess changes over time.

Interpretation
Despite an increase in the mean age of patients with SAH, case-fatality rates have decreased by 17% between 1973 and 2002 and show potentially important regional differences. This decrease coincides with the introduction of improved management strategies.