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AAN 2014: Analyzing Traumatic Brain Injury Costs

The Particulars: Few studies have examined the predictors of hospital costs associated with traumatic brain injury (TBI). Data Breakdown: For a study, researchers analyzed information on costs for patients who suffered a moderate to severe TBI during the first 6 months of 2013. The average cost per patient, which included emergency services, was $162,523. Higher costs were associated with a lower likelihood of survival, increased hospital length of stay, and TBI caused by a mechanism other than a fall. Take Home Pearl: The cost of hospitalization for a TBI appears to be increased when patients have a longer hospital stay, lower survival chance, and injury sustained by a fall when compared with other...

AAN 2014: Comorbidities in Hospitalized Patients With MS

The Particulars: Little is known about the burden of hospitalizations for patients with multiple sclerosis (MS). Data Breakdown: Researchers compared the primary admitting diagnoses of more than 1 million patients with MS to those of patients without MS, analyzing data by age group. More than 82% of all MS hospitalizations occurred in patients aged 30 to 69. The average length of stay was 5.8 days for MS patients and 4.5 days for non-MS patients. More MS patients had Medicare than non-MS patients. Urinary tract infections (UTIs), septicemia, pneumonia, chronic skin ulcers, and lower limb and femoral neck fractures were more common in MS patients than in non-MS patients. Take Home Pearls: Hospitalized patients with MS appear to be younger, have longer lengths of stay, and use more Medicare resources than the general population. Systemic infection and inflammation appear to drive some MS relapses among patients with the...

AAN 2014: Examining Discharges for Stroke Patients

The Particulars: Stroke is among the most common admissions to inpatient neurology. Patients with stroke-like symptoms may not require admission, but barriers may exist to their discharge. Data Breakdown: A study looked at patients who presented to the ED with stroke-like symptoms buthad a negative brain MRI for stroke and did not receive tPA. Patients were divided into those who underwent brain MRIs in the ED and those who received this diagnostic test after hospital admission. Hospitalized patients had an average length of stay of 2 days, compared with 1 day for those who were discharged from the ED. Hospitalization was associated with an average cost of $27,241, compared with $11,220 for those who were discharged from the ED. Take Home Pearl: The cost of hospitalization appears to be nearly 60% higher when patients with stroke-like symptoms are hospitalized but have negative results for stroke following a brain MRI, when compared with discharging these patients from the...

AAN 2014: Fingernail Exams Deemed Helpful

The Particulars: Studies indicate that medical students, interns, and neurologists receive little training on the recognition of disorders of the nails. Neglecting to examine patients’ nails may lead clinicians to miss important conditions, including subungual melanoma, underlying collagen vascular disease, occult malignancy, or a treatable nutritional deficiency. Data Breakdown: A literature review was conducted using studies assessing nail disorders that may occur in neurologic disorders or in systemic conditions that may result in neurologic manifestations. Nail abnormalities offered important signs of a patient’s overall health, nutritional state, psychological state, drug and toxin exposure, occupation, and hobbies in the study. These exams also offered salient clues about neurologic and neuro-cutaneous disorders as well as dermatologic, oncologic, cardiopulmonary, rheumatologic, and systemic conditions that may be associated with neurologic complications. Take Home Pearls: Examination of the nails appears to an important part of neurologic examinations. These exams can provide vital clues about the nature of many underlying...

AAN 2014: A Brain Fitness Program for Cognitive Impairment

The Particulars: Cognitive impairment with aging is often the result of a combination of etiologies. Few studies have assessed different combinations of interventions in treating cognitive impairment in older patients. Data Breakdown: For a study, researchers analyzed the effect of a 3-month brain fitness program on cognitive impairment. The program included cognitive training, meditation, fitness training, and neuro-feedback for a total of 5 hours per week. Significant improvements were observed in overall neurocognitive function for patients who took part in the program. More than half experienced a 12% improvement in letter fluency, and significant improvements were also seen for color naming, word reading, and inhibition. Immediate and delayed recall also improved significantly in many patients. Take Home Pearl: A multifactorial brain fitness program appears to significantly improve multiple aspects of cognitive impairment in elderly...
Actor Seth Rogen’s Senate Hearing on Alzheimer’s Research

Actor Seth Rogen’s Senate Hearing on Alzheimer’s Research

Actor/Director Seth Rogen appeared on Capitol Hill recently to speak before the Senate Committee on Appropriations about the rising costs of Alzheimer’s disease on Americans, and to address the lack of funding for adequate treatment or a cure. Rogen has been married to screenwriter-actress Lauren Miller since 2011. Miller’s mother was first diagnosed with the disease almost 9 years ago. Source:...
Identifying Predictors of Osteoarthritis

Identifying Predictors of Osteoarthritis

Osteoarthritis (OA) is a significant health problem, with studies suggesting that the condition affects up to 10% of men and 18% of women over the age of 60. Previous research has suggested that some physical risk factors may be associated with a higher rate of early onset OA. “There is an increasing need to address joint damage and its relationship to injuries, participation in sports, being physically active, being overweight or obese, and occupational activity so that we can better inform patients on strategies to prevent OA,” says Sarah A. Richmond, CEP, MSc, PhD. “This information can also help clinicians address the rising healthcare burden associated with OA.” New Data In the Journal of Orthopaedic and Sports Physical Therapy, Dr. Richmond and colleagues published a systematic review and meta-analysis that addressed this issue. According to the results, there was an increased risk for either knee or hip OA in individuals with previous joint injuries, those who were overweight or obese, and those who had physically demanding occupations, especially jobs that involved squatting or kneeling activities. Some findings, however, remain inconclusive, including levels of physical activity and sport-specificity in individuals who did not suffer an injury.   “Overall, joint injury was a significant risk factor for knee OA, with individuals who had suffered a previous knee injury at a three- to eight-fold greater risk of OA than individuals with no history of injury,” Dr. Richmond says. Joint injury was also a risk factor for hip OA, as was previous meniscectomy with or without ACL injury. Important Implications Dr. Richmond notes that a clear understanding of the implications of the risk...
Quality of Care for Secondary HF

Quality of Care for Secondary HF

Current performance measures for heart failure (HF) from CMS target patients with a principal diagnosis of the disease. HF performance measures include evaluating left ventricular (LV) systolic function and providing a discharge prescription for either ACE inhibitors or angiotensin receptor blockers (ARBs). The American College of Cardiology, American Heart Association, and the American Medical Association-Physician Consortium for Performance Improvement have endorsed similar guidelines for adult HF care. Assessing Hospitalizations A study published in the Journal of the American College of Cardiology assessed the quality of care for HF patients who were hospitalized for all causes. Lead researcher Saul B. Blecker, MD, MHS, and colleagues assessed rates of compliance with care measures for 4,345 patients hospitalized with acute or chronic HF. “The majority of hospitalizations for individuals with HF had a principal diagnosis that was not HF,” says Dr. Blecker. Only 39.6% of patients had a primary diagnosis of HF.   The investigation also showed that, when compared with HF patients hospitalized for another primary indication, those with a primary HF diagnosis had higher rates of receiving guideline-recommended care, including evaluation of LV systolic function and higher rates of ACE inhibitor or ARB discharge prescriptions. HF patients assessed for LV systolic function had a 34% lower mortality rate in the year following discharge when compared with those who did not receive this evaluation. Prescription of ACE inhibitors or ARBs at discharge for patients with LV systolic dysfunction was associated with a 28% reduced 1-year mortality risk. “The quality of care for hospitalized HF patients could be dramatically improved by extending the same standards of care to patients with both a...

Media Flub: Squeezing Breasts Prevents Cancer?

The media often takes a research study’s findings completely out of context and confuses the public. Researchers from the University of California at Berkeley found that compression of breast cancer cells grown in a laboratory made them assume a normal growth pattern. Reports on this study may have been derailed by the university’s own press release which was entitled “To revert breast cancer cells, give them the squeeze.” The study was presented at a meeting and has not been published. If you read the press release, it is very clear that the research involved only cells. The authors played down any practical use of the information, saying that even a compression bra would probably not be any value. Specifically, they said “Compression, in and of itself, is not likely to be a therapy.” If you google “Squeezing breasts prevents cancer,” you will find over 50 hits. Most of them prominently feature photos of women in various stages of undress and articles with sophomoronic (A word I just made up–a combination of sophomoric + moronic) commentary. Fox News went with “Giving breasts a squeeze could hinder cancer growth.” [Somewhat NSFW photo] The article essentially replicated the Cal Berkeley press release. Here’s one take on the subject from the Daily Beast headlined “He-He Squeezing Breasts Can Prevent Cancer” with the lede “Now this is what you call a titillating breakthrough.” The brief story ended with “Even though the study was a success, the authors caution that it probably won’t lead to a specific cancer therapy. But was it fun?” Cosmopolitan magazine’s headline is “Can Squeezing Your Boobs Prevent Breast Cancer?” The...
Older Patients & Motor Vehicle Crashes

Older Patients & Motor Vehicle Crashes

According to current estimates, there are about 30 million licensed drivers in the United States aged 65 and older, but this figure is expected to jump to 57 million by 2030. Studies indicate that drivers aged 65 and older have higher rates of motor vehicle crashes (MVCs) per mile driven. Data also show that older motorists have higher rates of death and serious injury and incur greater costs for acute care and rehabilitation. “MVCs are the second leading cause of injury-related death among adults aged 65 and older,” says Jody A. Vogel, MD, MSc. “As the U.S. population ages, EDs will need to be prepared with appropriate resources and protocols to care for older adult MVC patients effectively.” Previous research has investigated the care of older adults with MVC-related injuries, but these analyses tend to focus mostly on how pain is managed and the inpatient characteristics of these patients. Few studies have compared ED visits after MVCs by older individuals with data on younger patients. It has been suspected that older MVC patients require more ED resources and are more likely to be admitted to the hospital after these events when compared with younger MVC patients. Taking a Closer Look In a study published in the Western Journal of Emergency Medicine, Dr. Vogel and colleagues used a national population-based dataset to describe the epidemiology of ED visits by older adults for MVCs. The study group compared the characteristics of MVC-related ED visits by older and younger adults in terms of EMS arrival, visit acuity, use of imaging studies, and injury diagnoses. They also compared the likelihood of hospitalization for...
ASCVD in Older Adults

ASCVD in Older Adults

About a decade ago, the American Heart Association (AHA) released an initial scientific statement on secondary prevention of atherosclerotic cardiovascular disease (ASCVD) for older patients, but there has been an explosion of studies addressing the treatment of hypertension, hyperlipidemia, diabetes, and antithrombotic therapy since that publication. AHA updated this scientific statement in 2013 to further clarify risks and benefits of secondary prevention in older adults. The statement, published in Circulation, is also intended to stimulate greater use of proven therapies for these patients. “Secondary prevention lifestyle changes may seem inappropriate in the context of advanced age, but they have the potential to improve function, quality of life, and functional independence,” explains Jerome L. Fleg, MD, who co-chaired the writing group that developed the AHA update. “Therefore, these changes should be actively considered for many older patients with ASCVD.” Addressing Challenges The proportion of adults older than 75 in most cardio-vascular trials is low, according to the AHA update. Furthermore, the patients enrolled are often healthier than elders in the community due to the desire of investigators to avoid the potential effects of comorbidities on trial outcomes. Consequently, generalizing the results of these trials to typical older patients is challenging. In addition, many older patients are not receiving evidence-based secondary prevention care. Comorbidities, polypharmacy, socioeconomic stresses, and cognitive limitations can also complicate how secondary prevention for ASCVD is utilized in older adults.   Per the recommendations, secondary preventive care for ASCVD should be personalized in patients aged 75 and older, given their wide range of comorbidities, lifestyles, and functional status. When not contraindicated, b-blockers, aspirin, and statins are recommended to...
Total Joint Arthroplasty: Addressing Unplanned Readmissions

Total Joint Arthroplasty: Addressing Unplanned Readmissions

Total joint arthroplasty has become a highly successful treatment option for sufferers of hip or knee arthritis, providing pain relief and return of joint function for most patients who undergo these procedures. By 2030, it is expected that more than 3 million total knee arthroplasties and 500,000 total hip arthroplasties will be performed annually in the United States. “With the projected exponential growth in total joint arthroplasty, there have been concerns about the overwhelming workload for the medical community and increasing financial burden on society,” says Javad Parvizi, MD, FRCS. Despite the great success that has been seen with arthroplasty, complications can still occur, leading to prolonged inpatient care, hospital readmission, or reoperation. Dr. Parvizi says that minimizing these complications is an important goal for patients and their surgeons because it would have a major impact on reducing the healthcare burden. “Early readmission following total joint arthroplasty has been of particular interest to clinicians and the healthcare system,” he says. “Limiting unplanned readmissions has become a driving force in many pay-for-performance compensation models.” Lingering Questions Readmission rates of 4.0% to 8.5% have been reported within 30 days of discharge following total joint arthroplasty in recent studies, and some research suggests that readmission rates after both primary and revision total hip arthroplasty have increased in elderly recipients of these procedures. This increase may be attributable to changes in the duration of hospital stay and discharge disposition, but studies are still lacking in this regard. “Although clinical investigations have made substantial contributions to our knowledge about readmission patterns, many questions remain,” says Dr. Parvizi. “Our efforts to decrease future readmission rates...
Life Expectancy Trends in HIV

Life Expectancy Trends in HIV

Considerable improvements in survival among patients with HIV have occurred since the introduction of combination antiretroviral therapy (ART) and as these drugs have become more effective, simpler to use, and better tolerated over time. Studies have consistently shown that ART helps increase the lifespan of people with HIV and reduce risks for new infections. “ART has revolutionized how clinicians care for HIV-positive individuals and has had a major effect at both the individual and societal levels,” says Hasina Samji, PhD. As life expectancy has increased since the introduction of ART, research has shown that more and more people with HIV are experiencing age-related comorbid conditions—as evidenced in the general population—such as cancer. “These comorbidities can impact the length of time people with HIV live as well as their quality of life,” says Robert S. Hogg, PhD. In published analyses, there has been a small but persistent gap with regard to the lifespan of people infected with HIV and those who are uninfected, especially within certain subgroups of patients. About 20 years ago, the estimated life expectancy was 57.0 years for men with HIV and 61.7 years for women with HIV living in the United States. For Canada, the corresponding rates were 59.7 years for men and 63.9 years for women. “While ART has been shown to help increase survival among adults with HIV on a global level, the effect of this therapy on life expectancy in the U.S. and Canada has not been well characterized,” says Dr. Samji. “Furthermore, there is a dearth of studies examining potential differences in life expectancy across sex, race, or transmission groups.” Longer Longevity In a study...

Pitfalls of Online Outcomes Data for Surgeons

Risk-adjusted 30- to 90-day outcome data for selected types of operations done by specific surgeons and hospitals are now being publicly posted online by England’s National Health Service. According to the site, “Any hospital or consultant [attending surgeon in the UK] identified as an outlier will be investigated and action taken to improve data quality and/or patient care.” After cardiac surgery outcomes data were made public in New York, some interesting unexpected consequences were noted. Surgeons and hospitals resorted to “gaming the system” by declining to operate on patients who were high-risk and tinkering with patient charts to make those they did operate on seem sicker. This can be done by scouring the charts for all co-morbidities and making sure none are overlooked when they are coded. An article from New York Magazine explains it in more detail. Interpreting outcomes data can be tricky. In a post 3 years ago about a report that nine Maryland hospitals had higher-than-average complication rates, I pointed out that whenever you have averages, some hospitals are going to be worse than average unless all hospitals perform exactly the same way or, like medical students, are all above average. A much more sophisticated way of looking at this subject appeared in a fascinating 2010 BBC News piece by Michael Blastland, who is the Nate Silver of England [or maybe Nate Silver is the Michael Blastland of the US], called “Can chance make you a killer?” Blastland set up a statistical chance calculator for a hypothetical set of 100 hospitals or 100 surgeons performing 100 operations each. The model assumes that every patient has the...
2014 Physician Compensation Report Highlights

2014 Physician Compensation Report Highlights

A newcomer snatched a spot in the top 3 highest earning specialties – check out which one in our summary of Medscape’s 2014 annual compensation report! In this year’s Medscape Physician Compensation Report, a great turnout of over 24,000 physicians across 25 specialties shared their salaries, hours worked, and details of how healthcare reform impacted their healthcare environment. Salary increases were seen in all but six specialties, compared with last year’s 2013 Physician Compensation Report. ♦ The top three earning specialties this year are Orthopedics ($413k), Cardiology ($351k), and both Urology and Gastroenterology at $348k. ♦ The lowest earners remain roughly the same as last year, with Infectious Diseases specialists ($174k), Family Medicine ($176k), and Endocrinologists ($181k).     Source: Medscape. Other highlights from the report include: ♦ Rheumatology hands down had the highest increase at 15% this year. ♦ Nephrology had the lowest increase (8%). ♦ Specialties whose compensation declined this year included Pathology (3%), Radiology (2%), Pulmonary Medicine (2%), and Cardiology (2%). ♦ On average, men made 31% more than women in 2013, down from 39% in 2010. ♦ The highest earners live in the North Central ($257k) and Great Lakes ($258k) regions. ♦ The lowest earners live in the Mid-Atlantic ($240k) and Northeast ($239k) regions. ♦ Almost a quarter of physicians (24%) participated in an Accountable Care Organization, compared with 16% in 2012 and only 3% in 2011. ♦ About 25% of responders said they would drop insurers that pay poorly, while 39% said they would not. Interestingly, in the satisfaction portion of the survey, top earners (plastic surgeons, surgeons, orthopedists, radiologists, and anesthesiologists) were the least likely to...
Triage Among Elderly Trauma Patients

Triage Among Elderly Trauma Patients

Patients with the most severe injuries can be taken to trauma centers that offer immediate specialized resources. However, instead of going to a trauma center, many elderly patients receive care in facilities without specialized expertise in trauma care. Research has shown that elderly patients are frequently undertriaged, but little is known about the associations between triage patterns and outcomes. Analyzing Undertriage In a study published in the Journal of the American College of Surgeons, Kristan L. Staudenmayer, MD, MS, FACS, and colleagues assessed how undertriaging elderly patients affects outcomes and whether they survived an injury 60 days later. This time frame is important because elderly patients often die after leaving the hospital rather than during hospitalization. Using in-hospital mortality can underestimate the true impact of injuries in this population. The study group reviewed data from emergency medical services in California and Utah from 6,015 patients aged 55 and older. There were no significant differences in 60-day mortality between trauma centers and non-trauma centers for patients who were severely injured in both unadjusted and adjusted analyses. Unadjusted 60-day mortality rates were 16% to 17%. Despite the lack of mortality benefit, severely injured elderly patients treated at trauma centers incurred greater costs. After adjusting for patient and injury characteristics, the median costs for patients at trauma centers were approximately 20% higher than at non-trauma centers. “It’s known that elderly patients don’t do as well as the young after injuries, but it’s difficult to argue that this is purely due to undertriage,” says Dr. Staudenmayer.  “In analyzing all deaths in the elderly, we found that mortality was more commonly associated with falls...
OSA & Subclinical Myocardial Injury

OSA & Subclinical Myocardial Injury

About 2% to 6% of Americans have obstructive sleep apnea (OSA), a condition that is largely underdiagnosed but has been associated with multiple cardiovascular diseases (CVDs), including coronary heart disease (CHD) and heart failure (HF). “Although the relationship between OSA and CVD has been well defined,” says Amil M. Shah, MD, MPH, “it has been challenging for clinicians to establish a causal relationship because of the association of OSA with other risk factors.” In clinical research, elevated levels of high sensitivity troponin T (hs-TnT), a marker of myocardial injury, have been predictive of both CHD and HF in the general population. Previous studies have been conflicting as to whether there is a link between OSA severity and troponin levels, particularly after accounting for comorbidities. “The relationship between OSA severity and hs-TnT levels has not been well described in the literature,” says Dr. Shah. “More severe OSA may be associated with subclinical myocardial injury.” Understanding the relationship between OSA and CVD pathway biomarkers may help explain the association between the diseases.   New Data Dr. Shah and colleagues had a study published in the American Journal of Respiratory and Critical Care Medicine to determine if more severe OSA, measured by the respiratory disturbance index, is associated with subclinical myocardial injury and increased myocardial wall stress. Subclinical myocardial injury was indicated by increased hs-TnT levels, while increased myocardial wall stress was indicated by elevated N-terminal pro B-type natriuretic peptide (NT-proBNP) levels. The analysis included 1,645 community-based, middle-aged and older patients who were part of the Atherosclerosis Risk in Communities and the Sleep Health studies. Participants were free of CHD and HF...
AAN 2014

AAN 2014

New research is being presented at AAN 2014, the annual meeting of the American Academy of Neurology, from April 26 to May 3, in Philadelphia. Meeting Highlights A Brain Fitness Program for Cognitive Impairment Fingernail Exams Deemed Helpful Examining Discharges for Stroke Patients Comorbidities in Hospitalized Patients With MS Analyzing Traumatic Brain Injury Costs Patient Knowledge of Stroke & Cerebrovascular Risk Factors   News From the Meeting New B-Cell Killer Stops MS Lesions No Link Between Pot Use and Stroke Risk Extended-Release Drug Aids Walking in MS Humans Beat Stroke Scales for ICH Prognosis Alemtuzumab Extension Shows Durable MRI Effects in MS Low Vitamin C Linked to Intracerebral Hemorrhage Cheap Drug Improves Social Function and More in Autism Pain Perception Linked to Genes Aerobic Exercise Preserves Cognition in Nondemented Elderly MS Drug Aids Walking in Rare Condition ‘Sensory Tricks’ in Dystonia Examined Vitamin D Analog Fights MS Fatigue Narrow Arteries Could Cloud Mind Scans Rule Out Alzheimer’s Stroke Age Disparity Growing Among Races Autopsy Confirms Negative Florbetaben Scan Excludes Amyloid Adding Estriol Reduces MS Relapse Rate Asymptomatic Carotid Stenosis Linked to Cognitive Impairment 120-Week Results Still Favor DMD Drug Seizures Common After Stroke Emerging Fungus Found in New York State Good Early Results for HERV Suppressor in MS Stroke Survivors Failing Health Measures CSF Tau May Help Diagnose ALS Exercise Might Slow Cognitive Decline MIRROR: Threshold Identified for Ofatumumab Therapy in MS Light Therapy Effective for Daytime Sleepiness in PD Gabapentin Enacarbil Benefits Patients With Severe RLS Beyond MS, Cannabis Unproven in Neurology DMD Drug Results Still Equivocal Study Suggests Targeting B Cells May Help with MS Novel Agents...
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