Commotio Cordis and the Epidemiology of Sudden Death in Competitive
Lacrosse
Barry J. Maron, Joseph J. Doerer, Tammy S. Haas, N.A. Mark Estes, James S.
Hodges, and Mark S. Link
Pediatrics 2009;124 966-971
http://pediatrics.aappublications.org/cgi/content/abstract/124/3/966?etoc

OBJECTIVE: Athletic field risks associated with blunt, nonpenetrating chest blows (commotio cordis) are receiving increasing attention, but the epidemiology of these events is incomplete.

METHODS: We assessed our Sudden Death in Young Athletes Registry, 1980–2008, to formulate a clinical profile of those sudden deaths attributed to commotio cordis (and other causes) occurring in competitive lacrosse, the most rapidly growing youth sport in the United States.

RESULTS: Twenty-three sudden deaths or cardiac arrests were identified in high school and college lacrosse participants. Ages were 18 ± 2 years; each athlete was male. Ten died after blunt precordial blows, including 4 goalies wearing commercially available chest protectors. Twelve others collapsed because of presumed or documented cardiovascular disease, including hypertrophic cardiomyopathy, long QT syndrome, mitral valve prolapse, or ruptured cerebral aneurysm. The mortality rate associated with lacrosse was 1.46 deaths per 100000 person-years and was similar to that of other sports including baseball, basketball, football, and hockey. However, deaths attributed to commotio cordis were more frequent in lacrosse (0.63 deaths per 100000 person-years) than in other sports (P < .02), with the exception of hockey.

CONCLUSIONS: Sudden deaths in competitive lacrosse participants are rare and no more common than in most other sports. These catastrophic events were caused disproportionately by commotio cordis and included athletes wearing chest barriers, thereby underscoring the importance of developing effective chest protection to create a safer athletic environment for our youth.

Physical Education Class Injuries Treated in Emergency Departments in the
US in 1997-2007
Nicolas G. Nelson, Maya Alhajj, Ellen Yard, Dawn Comstock, and Lara B.
McKenzie
Pediatrics 2009;124 918-925
http://pediatrics.aappublications.org/cgi/content/abstract/124/3/918?etoc

OBJECTIVE: The goal was to describe the epidemiological features of physical education (PE)-related injuries treated in US emergency departments.

METHODS: A retrospective analysis was conducted with data for children and adolescents (5–18 years of age) from the National Electronic Injury Surveillance Study of the US Consumer Product Safety Commission, from 1997 through 2007. Sample weights provided by the National Electronic Injury Surveillance System were used to calculate national estimates of PE-related injuries. Trend significance of the number of PE-related injuries over time was analyzed by using linear regression analysis.

RESULTS: An estimated 405305 children and adolescents were treated in emergency departments for PE-related injuries. The annual number of cases increased 150% during the study period (P = .001). Nearly 70% of PE-related injuries occurred during 6 activities, that is, running, basketball, football, volleyball, soccer, and gymnastics. Boys’ injuries were more likely to involve the head, to be diagnosed as a laceration or fracture, to be attributable to contact with a person or structure, and to occur during group activities. Girls’ injuries were more likely to involve the lower extremities, to be strains and sprains, to be acute noncontact injuries, and to occur during individual activities.

CONCLUSION: More research is needed to identify the cause of the increase in PE-related injuries, to examine the gender difference in PE-related injuries, and to determine appropriate injury prevention solutions and policies.

Efficacy and Safety of Spinosad and Permethrin Creme Rinses for Pediculosis
Capitis (Head Lice)
Dow Stough, Susan Shellabarger, John Quiring, and Alvin A. Gabrielsen, Jr
Pediatrics 2009;124 e389-e395
http://pediatrics.aappublications.org/cgi/content/abstract/124/3/e389?etoc

OBJECTIVE: Studies compared spinosad creme rinse and permethrin lice treatment under “actual-use” conditions for pediculosis capitis (head lice).

SUBJECTS AND MATERIALS: Two phase-3, multicenter, randomized, evaluator/investigator-blinded studies compared 0.9% spinosad without nit-combing to 1% permethrin with combing (according to product instructions) in 1038 males and females aged 6 months. Spinosad-with-combing groups were included for descriptive, noninferential purposes only. Within 391 households, youngest members having 3 live lice were designated primary participants. All household members with lice received the same treatment. Participants administered product 1 to 2 times during the 21-day home-use period on the basis of complete lice eradication after a single use or the presence of lice requiring a second treatment. Scalp evaluations were performed at baseline, day 7, and day 14 (and day 21 for participants treated twice). The primary end point was the proportion of lice-free primary participants 14 days after last treatment.

RESULTS: A total of 84.6% (study 1) and 86.7% (study 2) of spinosad-treated participants were lice free versus 44.9% and 42.9% permethrin-treated participants (P < .001). Most spinosad-treated participants required 1 application, whereas most permethrin-treated participants required 2 applications. Few adverse events were reported, but those occurring were mild to moderate, including eye irritation (permethrin), ocular hyperemia, and application-site erythema/irritation (both medications). No laboratory measure changed significantly.

CONCLUSIONS: Spinosad, which did not require nit combing, was significantly more effective than permethrin in 2 studies reflecting actual-use conditions, and most spinosad-treated participants required only 1 application. Spinosad is a more convenient and effective treatment for pediculosis capitis.

Link:  http://healthday.com/Article.asp?AID=630423

FRIDAY, Aug. 28 (HealthDay News) — Researchers say they’ve discovered a new way to detect evidence of brain damage after concussions, potentially paving the way toward more effective treatments for head injuries.

By detecting damage from concussions early with the help of the latest brain scanning technology, doctors could begin cognitive rehabilitation treatment and prevent complications, study author Dr. Michael Lipton, an associate director of the Gruss Magnetic Resonance Research Center at Albert Einstein College of Medicine of Yeshiva University, explained in a university news release.

An estimated 1 million Americans suffer from concussions each year, often as a result of accidents and mishaps at sporting events. It can be difficult for doctors to gauge the severity of concussions since symptoms can appear much later; an estimated 30 percent suffer permanent impairment.

In the new study, researchers used diffusion tensor imaging to scan the brains of 20 people who experienced concussions and 20 healthy people.

MRI and CT scans showed no signs of trouble in the brains of the concussion patients, but the diffusion tensor imaging scans did in 15 of them.

“For the first time, we appear to be able to identify the subtle pathology sometimes caused by concussion, providing researchers a ‘pathology target’ for the development of therapies to reduce or eliminate the damage,” study co-author Craig Branch, director of the Gruss Magnetic Resonance Research Center, said in the news release.

The findings appear in the Aug. 26 issue of Radiology.

Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers

Link:  http://www.ama-assn.org/amednews/2009/08/31/prsa0831.htm

75% of discharge summaries don’t mention pending test results

Primary care physicians often are left in the dark about what tests to follow up on.

By Kevin B. O’Reilly, AMNews staff. Posted Aug. 31, 2009.

Link:  http://www.philly.com/philly/wires/ap/news/state/new_jersey/20090830_ap_njmandatingfullerhospitalerrordisclosures.html

AP, 8/30/09:  

New Jersey hospitals will soon have to make public more detailed information on medical errors.

The legislation , which also bars hospitals from charging insurers or patients for procedures to correct certain medical mistakes or hospital-acquired conditions , is due to be signed into law Monday by Gov. Jon S. Corzine.

Proponents say it will allow the public to make more informed health care choices and entice poorer performing hospitals to improve patient safety, though critics say medical mistakes are not always the hospital’s fault.

“Everybody needs a report card to see how they are performing , I get one from the public every two years when I run for election, and the hospitals will benefit from one as well” Assemblyman Paul Moriarty, D-Turnersville, said Friday. He sponsored the measure along with colleagues Linda Greenstein, D-Hamilton, Lou Greenwald, D-Voorhees, Nilsa Cruz Perez, D-Barrington, and Herb Conaway, D-Delanco.

“This (legislation) helps (hospitals) get better by reporting their errors and forcing them to look inward, to see why they may be doing well in some areas, but not in others,” Moriarty said. “Consumers deserve meaningful health quality information, and that’s what this law will give them.”

The measure requires the Health and Senior Services Department to publish how often certain egregious errors , such as operating on the wrong body part or leaving a sponge or instrument inside a patient’s body , occur at each hospital. Health care facilities already report preventable medical mistakes, but the state has published only the number of errors, not the data for individual hospitals.

Lawmakers backing the changes say more transparency is needed.

“People can find out all sorts of safety information about cars and household appliances. They should be able to access that same information about hospitals,” Greenstein said.

USA Today (8/31) reports that a USA Today analysis found that 24 US hospitals “near popular travel destinations, as compiled by the National Travel Monitor,” have higher than average mortality rates.

For example, Las Vegas visitors would be treated at the University Medical Center of Southern Nevada, “where the heart attack death rate of 21.1 percent” is higher than the US average “of 16.6 percent.” Moreover, a separate analysis, which utilized data from CMS’ Hospital Compare data, indicated “one of every four hospitals with high death rates for heart attack, heart failure or pneumonia” is near a state park.

Four hospitals in the San Diego area, for example, “have high death rates for heart failure or pneumonia.” The high mortality rates were not confined to western states, however; the studies indicated “poor-performing facilities are scattered nationwide.” An interactive state-by-state mortality rate map is available in the online version of the article.

 The Geographic Distribution, Ownership, Prices, and Scope of Practice at
Retail Clinics
Rena Rudavsky, Craig Evan Pollack, and Ateev Mehrotra
Ann Intern Med 2009;151 315-320

Link:  http://www.annals.org/cgi/content/abstract/151/5/315?etoc

Background: Retail clinics are clinics within a retail store that provide simple acute and preventive care services for a fixed price without an appointment.

Objective: To describe characteristics of retail clinics, including their location, scope of practice, prices, acceptance of insurance, and ownership, and to estimate the proportion of the U.S. population that lives within a short driving distance of such a clinic.

Design: Cross-sectional descriptive study.

Setting: United States.

Participants: All 982 retail clinics operating as of August 2008.

Measurements: Population living within a 5- and 10-minute driving distance of a retail clinic.

Results: In August 2008, 42 operators ran 982 clinics in 33 states; 88.4% were located in urban areas. Nearly half (44%) of all clinics were located in 5 states (Florida, California, Texas, Minnesota, and Illinois). All offered sore throat treatment (average price, $78) and more than 95% offered treatment of skin conditions, immunizations, pregnancy testing, and lipid or diabetes screening. Almost all (97%) accepted private insurance and Medicare fee-for-service (93%). Among 42 clinic operators, 25 are existing health care companies that operate 11% of the clinics, and 3 are for-profit retail chains that operate 73% of the clinics. An estimated 10.6% of the total U.S. and 13.4% of the urban U.S. population lives within a 5-minute driving distance of a retail clinic, whereas 28.7% (total) and 35.8% (urban) live within a 10-minute driving distance.

Limitation: Our inventory of clinics stopped in August 2008 and estimates of proximity are based on 2000 census data.

Conclusion: Retail clinics are positioned to provide immunizations and care for simple acute conditions for a substantial segment of the urban U.S. population.

Primary Funding Source: California Healthcare Foundation.

Link:  http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm175843.htm

Tumor Necrosis Factor (TNF) Blockers (marketed as Remicade, Enbrel, Humira, Cimzia, and Simponi) August 2009

Audience: Rheumatologists, gastroenterologists, oncologists, dermatologists

[UPDATED 08/31/2009] Supplemental Q&As added

[Posted 08/04/2009] FDA notified healthcare professionals that it has completed its analysis of tumor necrosis factor (TNF) blockers and has concluded that there is an increased risk of lymphoma and other cancers associated with the use of these drugs in children and adolescents. This new safety information is now being added to the Boxed Warning for these products. FDA has also identified new safety information related to the occurrence of leukemia and new-onset psoriasis in patients treated with TNF blockers. The current prescribing information for TNF blockers does contain a warning for malignancies, but does not specifically mention leukemia. FDA is also requiring updates to the current Medication Guide to help patients understand the risks associated with TNF blocker therapy.

TNF blockers are approved for the treatment of one or more of a number of immune system diseases including juvenile idiopathic arthritis (JIA), rheumatoid arthritis, psoriatic arthritis, plaque psoriasis, Crohn’s disease, and ankylosing spondylitis.

Primary source: The Lancet
Source reference:
Calverley P, et al “Roflumilast in symptomatic chronic obstructive pulmonary disease: two randomized clinical trials” Lancet 2009; 374: 685-694.

Background    The phosphodiesterase-4 inhibitor roflumilast can improve lung function and prevent exacerbations in certain patients with chronic obstructive pulmonary disease (COPD). We therefore investigated whether roflumilast would reduce the frequency of exacerbations requiring corticosteroids in patients with COPD.

Methods         In two placebo-controlled, double-blind, multicentre trials (M2-124 and M2-125) with identical design that were done in two different populations in an outpatient setting, patients with COPD older than 40 years, with severe airflow limitation, bronchitic symptoms, and a history of exacerbations were randomly assigned to oral roflumilast (500 μg once per day) or placebo for 52 weeks. Primary endpoints were change in prebronchodilator forced expiratory volume in 1 s (FEV1) and the rate of exacerbations that were moderate (glucocorticosteroid-treated) or severe. Analysis was by intention to treat. The trials are registered with ClinicalTrials.gov, number NCT00297102 for M2-124, and NCT00297115 for M2-125.

Findings            Patients were assigned to treatment, stratified according to smoking status and treatment with longacting β2 agonists, and given roflumilast (n=1537) or placebo (n=1554). In both studies, the prespecified primary endpoints were achieved and were similar in magnitude. In a pooled analysis, prebronchodilator FEV1 increased by 48 mL with roflumilast compared with placebo (p<0·0001). The rate of exacerbations that were moderate or severe per patient per year was 1·14 with roflumilast and 1·37 with placebo (reduction 17% [95% CI 8—25], p<0·0003). Adverse events were more common with roflumilast (1040 [67%]) than with placebo (963 [62%]); 219 (14%) patients in the roflumilast group and 177 (12%) in the placebo group discontinued because of adverse events. In the pooled analysis, the difference in weight change during the study between the roflumilast and placebo groups was −2·17 kg.

Interpretation                Since different subsets of patients exist within the broad spectrum of COPD, targeted specific therapies could improve disease management. This possibility should be explored further in prospective studies.

Link:  http://pubs.acs.org/doi/abs/10.1021/jf901169y?prevSearch=kudzu&searchHistoryKey=

Chronic Dietary Kudzu Isoflavones Improve Components of Metabolic Syndrome in Stroke-Prone Spontaneously Hypertensive Rats

J. Agric. Food Chem., 2009, 57 (16), pp 7268–7273

The present study tested the long-term effects of dietary kudzu root extract supplementation on the regulation of arterial pressure, plasma glucose, and circulating cholesterol in stroke-prone spontaneously hypertensive rats (SP-SHR). Female SP-SHR were maintained for 2 months on a polyphenol-free diet, with or without the addition of 0.2% kudzu root extract. Half of the rats in each diet group were ovariectomized, whereas the other half remained intact. Following 2 months on the diets, the 0.2% kudzu root extract supplementation (compared to control diet) significantly lowered arterial pressure (11−15 mmHg), plasma cholesterol, fasting blood glucose (20−30%), and fasting plasma insulin in both the ovariectomized and intact SP-SHR. These results indicate that long-term dietary kudzu root extract supplementation can improve glucose, lipid, and blood pressure control in intact and ovariectomized SP-SHR.

US News & World Report (8/28, Payne) explores the AHRQ report showing that “368,000 hospital stays” in 2007 ended “when patients left against medical advice.”

In fact, there were several “categories of people” who were more apt to do so, including patients who were “worried about medical bills.” The report also reveals that people admitted for alcoholism “were 11.6-times more likely” and “those admitted for substance abuse disorders were 10.8-times more likely” to check out early. In addition, people with nonspecific chest pain “were 3.6-times more likely” to sign-out against doctors’ orders.