Monthly Archives: June 2017

‘The worst pain a woman can go through’: ER docs misdiagnosed my twisted ovary

Today Show– June 28, 2017

In early June, Anne Wheaton, wife of “The Big Bang Theory” actor Wil Wheaton, began experiencing excruciating pain on her right side, pelvis and torso. In the ER doctors suggested it was a kidney stone, gave her medication and sent her home to see if it would pass. Days later, her agonizing pain was getting worse.
“I’ve had two kids, and it still wasn’t at that level of pain,” Anne Wheaton told TODAY. “The surgeon [later] told my husband that this is the worst pain a woman can go through.”
Eventually, Wheaton — who, like her husband, blogged about the experience — learned she had an ovarian torsion that occurred after a cyst caused a twist that cut off the connecting artery’s blood flow — and ultimately killed the ovary. But it would take days before she got a correct diagnosis and her doctor could remove the organ.
“Abdominal pain is difficult to diagnose,” said Wheaton’s doctor, Dr. Tina Koopersmith of the West Coast Women’s Reproductive Center, Sherman Oaks, California. “As an OBGYN, it was always drilled into us that with abdominal pain to never forget ovarian torsion. But it’s a diagnosis that gets missed.”
‘Our bodies are very different’
Getting a correct diagnosis for internal ailments can be tricky, especially for women patients. For example, women having a heart attack are more likely to be misdiagnosed than men and, as a result, are less likely to receive life-saving treatment. A 2001 study published in the Journal of Law, Medicine & Ethics showed that while female patients are more likely to express when they are in pain, they often receive lesser treatment.
Women’s pain is often downplayed — precisely because women tend to be more verbal about discomfort than men, said Anita J. Tarzian, Ph.D, RN, of the University of Maryland School of Nursing.
“The attribution of an emotional component, that the pain isn’t as authentic as a man’s pain because women are associated with being hysterical and overly dramatic and not valid reporters of subjective or objective pain — that could have an influence,” Tarzian, co-author of the 2001 pain study, told TODAY.
It’s not only women who are at risk: A 2014 study found that at least 1 in 20 adults who seek care in an emergency room walk away with the wrong diagnosis.
But Wheaton, a director at the Pasadena Humane Society and children’s book author, firmly believes that if she had been seen by a female ER doctor, she might have been spared days of pain and her ovary might have been saved.
“Men tend to think that a female is just a girl version of a male,” she told TODAY. “Our bodies are very different.”
For her, the ER experience was a frightening comedy of errors — among other things, she was given a pregnancy test despite having her uterus removed nine years ago.
Since writing about her experience in her blog, she’s heard from “hundreds of women” with similar stories. “Something needs to be done about this, so more women don’t go through it unnecessarily,” she said.
A 2016 study found that patients treated by female doctors have a greater survival rate. But it’s not clear that any one case — like Wheaton’s — was ignored or misdiagnosed because she wasn’t seen by a female doctor at the outset.
ER doctors are likely to be generalists who might not be able to think of every possible differential when diagnosing. “There is gender bias in everything,” said Koopersmith. “But I don’t like making blanket statements that are not backed up by fact. The error is that the doctor messed up as a physician, not because he’s male.”
Other factors in the ER
There’s also the issue of an often overwhelmed, chaotic emergency room where triage is the order of the day.
“ERs are so overwhelmed with patients who go in and don’t need to be there — sometimes, it’s so busy it’s easy to miss things, especially if they don’t think it’s an urgent situation,” says Dr. Linda Girgis, a veteran family doctor and clinical assistant professor at the Robert Wood Johnson Medical School in New Brunswick, NJ.
Tarzian thinks changes are coming, if slowly. “Now that women make up more than half the medical students and physicians, it’ll be interesting to see how this all changes,” she said. “Maybe the default will be in recognizing that you have better medical care if you talk to a patient.”
Have an advocate
In the end, the solution for issues like this is a familiar one: when you’re the patient, try to have someone advocating for you while you’re hospitalized.
“We’ve always heard about that,” says Wil Wheaton, “about advocating for yourself in the hospital. I just feel if this doctor had spent a little more time looking at her scans, he could have made a better diagnosis.'”

Medicaid Expansion States See Uptick in ER Visits

Broader health coverage under the ACA was supposed to reduce them

by John Commins, HealthLeaders Media June 25, 2017

States that expanded Medicaid coverage under the Affordable Care Act saw 2.5 emergency department visits more per 1,000 people after 2014, while the share of ED visits by the uninsured decreased by 5.3%, according to a study this week in Annals of Emergency Medicine.
“Medicaid expansion had a larger impact on the healthcare system in places where more people were expected to gain coverage,” study lead author Sayeh Nikpay, PhD, of Vanderbilt University, said in remarks accompanying the study. “The change in total visits was twice as large in a state like Kentucky, where most childless adults were ineligible for Medicaid at any income level before 2014, as in states like Hawaii, where childless adults were already eligible for Medicaid above the poverty line.”
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Nikpay and colleagues analyzed patient visits in 14 states that expanded Medicaid coverage and 11 that did not and found that the share of visits covered by private insurance remained constant for expansion states and increased by several percentage points for non-expansion states. Gains in insurance coverage in non-expansion states were almost entirely in the form of private coverage, not Medicaid.
Increases in ED visits were largest for injury-related visits. There was also a large change in payer mix for dental visits, because dental ED visits are most prevalent among low-income, non-elderly adults on Medicaid. Out-of-pocket dental costs were reported as one of the more unaffordable types of care among the target population for Medicaid expansion under the ACA.
Ari Friedman, MD, of Boston’s Beth Israel Deaconess Medical Center, wrote in an accompanying editorial that the increased ED visits in the expansion states “runs contrary to the prediction by many policymakers that by providing greater access to primary care, insurance expansion would break the decades-long trend of increasing ED volume.”
Friedman said there was scant evidence to support that prediction, but plenty of actual experience from states such as Oregon, which demonstrated that decreasing the cost of healthcare by providing for health insurance leads to an increase in care use of all kinds, be it in the ED or the primary care setting.
“More emergency department visits by Medicaid beneficiaries is neither clearly bad nor clearly good,” Friedman said. “Insurance increases access to care, including emergency department care. We need to move beyond the value judgments that have dominated so much study of emergency department utilization towards a more rational basis for how we structure unscheduled visits in the health system. If we want to meet patients’ care needs as patients themselves define them, the emergency department has a key role to play in a flexible system.”

This report is brought to you by HealthLeaders Media.

Two Very Important Stories about Ticks

Tick-borne diseases on the rise

By Dr. Manny Alvarez Published June 21, 2017 – Fox News

Ticks and tick-borne illnesses are found all over the U.S., and you can use these maps provided by the Centers for Disease Control and Prevention (CDC) to see which ticks are found in your area. Different types of ticks carry different viral and bacterial illnesses, so it’s important to know which ticks are near you. There are seven varieties of ticks in the U.S. alone, and they carry at least 10 different viral and bacterial pathogens.
The tragic death of an Indianapolis toddler earlier this month, likely from a tick-borne disease called Rocky Mountain spotted fever, has focused public attention on the fact that tick-borne diseases are on the rise. In fact, there have been five tick-borne diseases identified for the first time in the U.S. since 2009. (No one’s really sure why new tick-borne diseases are showing up so quickly, but it could be connected to the overall increase in the identification of new diseases in the last several decades.)
One factor that’s increasing the rates of transmission of these diseases is the rising tick population. If have a yard or lawn, you may have noticed more ticks in recent years, and that’s a trend that’s being observed all over the country. Deer ticks, the carriers of Lyme disease, have been particularly plentiful.
One factor contributing to the increasing tick population is an increase in prey animal populations. Deer ticks feed primarily on deer and mice, populations that have been growing in recent years. One reason for this in the Northeastern US, where Lyme disease is most prevalent, is the lack of predators.
Larger predators that once hunted deer have been scarce for generations, and smaller predators that snack on mice like hawks, owls, and foxes have suffered from the loss of undisturbed forest habitats. Mice, on the other hand, are highly adaptable and live just as happily in abandoned structures and yards as they do in the forest. Any mouse that has been bitten by an infected tick then carries Lyme disease and spreads it to every new, uninfected tick that bites it.
Many researchers also believe that rising global temperatures are allowing ticks populations to move northward and expanding the tick feeding season. There have even been recommendations to change Lyme disease awareness month from May to April, since the deer tick feeding season seems to be moving into earlier months.
So, how do you stay safe?
Some tick-borne diseases are treatable, but prevention is the most effective response. Ticks won’t usually bite as soon as they come into contact with you, and if they can be removed before they’re embedded, they can’t make you sick. But even quick removal of an embedded tick can prevent some illnesses. For example, Lyme disease transmission can be prevented if a tick is removed within 24 hours.
Most of us only remember to check ourselves for ticks if we’ve been hiking or visiting a state park, but experts recommend including a tick check in your daily routine if you live in a high risk area. Many tick bites occur after everyday activities like gardening or mowing the lawn. Favorite spots for ticks to bite include the groin area, under the arms, and behind the ears. The shower is a great place to check for ticks, and using a washcloth is usually enough to dislodge any that aren’t attached yet.
If you do remove an embedded tick, you can save it and get a good identification just in case you develop any unusual symptoms. Knowing which type of tick bit you can help doctors rule out specific diseases if you do get sick. If you see a doctor for symptoms like rash, fever, or headaches and know you’ve been bitten by a tick recently, always make sure to let your doctor know.

Tick that causes meat allergy in humans heads north

By Georeen Tanner Published June 26, 2017 – Fox News

A surge in an aggressive type of tick that triggers a meat allergy in humans has health officials on alert. While the tick is most commonly found in the southeastern and south central areas of the U.S., data has tracked its movements as far north as Duluth, Minnesota, and Hanover, New Hampshire.
The lone star tick, which is named for the white dot found on adult females and can be as small as a poppy seed, triggers an allergy to alpha-gal in victims, leaving patients unable to consume meat. Wired reports at least 100 cases have been reported in the eastern tip of New York’s Long Island.
“We have three ticks here,” Rebecca Young, a nurse who assists at the Tick-Borne Disease Resource Center at Southampton Hospital in New York, told Fox News. “The dog tick, the deer tick, and now there’s a huge surge in the lone star tick in the last six to seven years.
While the lone star tick is not thought to transmit Lyme disease, a bite can result in itchy hives, stomach cramps, breathing problems and even death.
“You have to be aware you’ve been bitten,” Young said. “If you eat meat and you notice a rash and shallow breathing then you can deduce that you have this allergy.”
Part of Young’s role at the hospital is helping people understand how to properly remove a tick, and to identify what type of tick it is. The lone star tick is able to transmit the allergy at all stages of its lifespan, causing health officials to urge people who spend time outdoors to be vigilant.
“Mosquitos are better when it comes to letting you know that you’re being bitten,” Dr. Scott Campbell, of the Suffolk County Health Department, told My Long Island TV. “Ticks are a little more stealthier. What they do is they quest. They actually will sit on vegetation and put their front legs out and wait for something to come by and they latch on.”
To avoid tick bites while outdoors, the Centers for Disease Control and Prevention (CDC), advises using repellent that contains 20 percent or more of DEET, picaridin or IR3535, and to walk in the center of trails.

Inspired by War Zones, Balloon Device May Save Civilians From Fatal Blood Loss

By DENISE GRADY – NY TIMES  JUNE 19, 2017

A high school senior mowed down by a car with other pedestrians in last month’s Times Square attack was hemorrhaging internally and transfusions could not keep up with the blood loss.
Doctors and nurses at NYC Health & Hospitals/Bellevue raced to save the student, Jessica Williams of Dunellen, N.J., who suffered severe injuries to her legs, abdomen and pelvis. But her pulse skyrocketed to 150. Her blood pressure dropped to 40/30.
“She was about to go into cardiac arrest,” said Dr. Marko Bukur, a trauma surgeon.
He grabbed a device that neither he nor anyone else at the hospital had ever used, except in training sessions on mannequins. It had arrived at Bellevue just days before.
The device, called an ER-Reboa catheter, was born on the battlefields of Iraq and Afghanistan, the brainchild of two military doctors who saw soldiers die from internal bleeding that medical teams in small field hospitals could not stop.
Their invention, made by Prytime Medical and cleared by the Food and Drug Administration in 2015, is gradually being adopted in civilian trauma centers around the country and has recently been used by the military. But medical teams need rigorous training to use it: Mishandled, it can be dangerous.
Dr. Bukur punctured Ms. Williams’s thigh, threaded a slim tube into her femoral artery and eased it up about 12 inches into her aorta, the major artery that carries blood from the heart to most of the body. Then he injected salt water to inflate a balloon near the tip of the tube, blocking the aorta and cutting off circulation to Ms. Williams’s pelvis and legs. Above the balloon, blood still flowed normally to her brain, heart, lungs and other vital organs.
Almost instantly, her blood pressure rose and her racing heart slowed down. The balloon stopped the hemorrhaging inside her pelvis, almost like turning off a faucet. Reboa stands for resuscitative endovascular balloon occlusion of the aorta, but some doctors describe it simply as an “internal tourniquet.”
The clock was ticking. Circulation could be safely cut off for only so long — ideally, no more than about 30 minutes. Beyond that, the lack of blood flow could severely damage Ms. Williams’s legs and internal organs. The balloon had only bought the medical team a bit of time to find the source of the blood loss and fix it. If they failed, when they deflated the balloon they would be back where they started, with Ms. Williams on the verge of bleeding to death.
In New York City, Dr. Sheldon H. Teperman, director of trauma and critical care services at NYC Health & Hospitals/Jacobi, and Dr. Aksim G. Rivera, a vascular surgeon there, have been teaching the procedure to trauma surgeons at city hospitals and other medical centers in the area. Bellevue surgeons trained with them.
A Jacobi team led by the trauma surgeon Dr. Edward Chao was the first in the city to use the ER-Reboa, in February. Their patient, Nanetta Hall, 60, a manager in the city’s Human Resources Administration, had been run over by a pickup truck. Like Ms. Williams, she nearly died from internal hemorrhaging caused by pelvic injuries.
“It’s a lifesaving instrument, but it needs to be handled with respect because turning off the blood supply to half the body is dangerous,” Dr. Teperman said, adding, “I lie awake at night worrying that maybe someone will use it improperly.”
Several patients in Japan had to have legs amputated after being treated with a related device that was left inflated for too long.
The idea for the ER-Reboa catheter came to Dr. Todd E. Rasmussen and Dr. Jonathan L. Eliason in 2006, while they were deployed as surgeons in Iraq. Improved tourniquets and transfusion techniques did prevent soldiers from bleeding to death from wounds in their arms and legs. But there was no similar solution for bleeding in the abdomen or pelvis, or what doctors call “noncompressible hemorrhage.”
The two doctors, both vascular surgeons, started to develop a new device based on an older balloon catheter designed to prevent bleeding in people having surgery on the aorta.
The older device can be used on trauma victims, but not easily. It is large and complex, and meant for use by vascular surgeons with X-rays to guide it. It was “really designed to be used in nice surgery centers, with well-staffed, fancy operating rooms,” said Dr. Rasmussen, an Air Force colonel, who is associate dean for research and an attending surgeon at the military medical school and medical center at the Uniformed Services University in Bethesda, Md.
“None of that translates well into when all hell is breaking loose and your patient is going to die in seven minutes,” said David Spencer, the president of Prytime Medical.
Dr. Rasmussen and Dr. Eliason set out to create a smaller, stripped-down version that could be placed quickly inside the aorta without X-rays by trauma surgeons and, eventually, by general surgeons, emergency room doctors and maybe medics.
Those doctors and medics are usually the first to reach people who are bleeding, in what trauma experts call the “golden hour” after an injury, Dr. Rasmussen said, adding, “That’s where the margin to save lives is greatest.”
By 2009, he and Dr. Eliason made a prototype, nicknamed their “Home Depot version” of the device.
It was pretty clunky,” Dr. Rasmussen said. But it was good enough to start testing in the lab. The results were promising, but large, traditional medical device companies showed no interest in developing it.
After a talk Dr. Rasmussen gave in 2009 that mentioned the lack of commercial interest in military medical research, Mr. Spencer, a technology entrepreneur and venture capitalist from San Antonio, offered to start a company to make and market the device. A self-described Army brat, Mr. Spencer said he liked the idea that something inspired by a military need could also save civilian lives.
The catheters, used once and then thrown away, cost about $2,000, which is relatively cheap compared with other devices used in vascular surgery. The ER in the product name stands for the last names of the two inventors, Eliason and Rasmussen.
The Defense Department and the University of Michigan hold the patent, Dr. Rasmussen said, and he makes no money from it.
People with pelvic injuries, like Ms. Williams and Ms. Hall, are ideal candidates for Reboa, surgeons say. Those injuries are a notorious cause of life-threatening hemorrhage. When the body is hit hard enough to break the pelvis, the impact almost always shears or severs hundreds of tiny veins and arteries that bleed profusely. Bleeding in the pelvis can be difficult or impossible to stop, because the area often cannot be compressed enough.
Dr. Sheldon H. Teperman, director of trauma and critical care services at NYC Health & Hospitals/Jacobi, and Dr. Edward Chao, a trauma surgeon at Jacobi, where the use of the new catheter saved the life of Nanetta Hall. Credit Sam Hodgson for The New York Times
Abdominal bleeding can also be stopped with the device, if it is pushed higher into the aorta.
The balloon almost certainly saved Ms. Williams’s life, Dr. Bukur said. With her circulation cut off, he was able to pack the damaged area with gauze to prevent more bleeding after the balloon was deflated. Another surgeon removed Ms. Williams’s spleen, which had ruptured and was also bleeding copiously.
Nearly a month later, Ms. Williams and her mother, Elaine, were stunned to learn that a plastic tube with a balloon on it had played a crucial role in saving her. She is recovering in one of the city’s rehabilitation hospitals. It will be months before she can walk again. She has no memory of being hit by the car that killed another person and injured 22 on May 18.
“I’m kind of happy I don’t remember,” she said. “I can focus on getting better and taking it one day at a time.”
She missed her high school prom, but was planning to watch her classmates graduate remotely.
Mr. Spencer said that the device had been used more than 1,000 times, and that 126 of those patients were known to have survived.
“We’re conservative on claiming it saved someone,” he said.
The device may prevent accident victims from bleeding to death, but they may have head injuries or organ damage that turn out to be fatal.
“Reboa is not the second coming of Jesus Christ,” Mr. Spencer said. “It is not going to miraculously save someone on a motorcycle who hit a car going 80 miles an hour. But it gives the surgeons a chance where maybe there wasn’t a chance before.”
One case, at the University of California, Davis Medical Center, involved a pregnant woman at high risk of bleeding to death from a placental abnormality. A Jehovah’s Witness, she could not accept blood transfusions. Using the balloon helped doctors perform a cesarean section that saved both her and the baby.
At a Reboa training course last week for about 50 trauma surgeons from the New York region, Dr. Teperman introduced a surprise guest: Nanetta Hall. Injured in February, she was just about to be released from a rehabilitation hospital. With a walker, she made her way slowly to the front of the auditorium to address the doctors. Without the Reboa procedure, she said, she almost certainly would not have survived.
Mr. Spencer, from Prytime, had just described a soldier’s death that had driven the military surgeons to create ER-Reboa. Gesturing to Ms. Hall, he said, “Because that man died, this lady is alive.”
Addressing the doctors, Ms. Hall said: “Please, please, take this seriously. And let the word be spread to everybody that this is a vital procedure that should be taught.”

Losing Fat, Gaining Brain Power, on the Playground

By GRETCHEN REYNOLDS NYTIMES JUNE 16, 2017

Better grades might be found on the playground. A new study of elementary-age children shows that those who were not part of an after-school exercise program tended to pack on a particular type of body fat that can have deleterious impacts on brain health and thinking. But prevention and treatment could be as simple as playing more games of tag.
Most children do not meet the federal health guidelines for exercise, which call for at least an hour of it a day for anyone under the age of 18. Physical inactivity can result in weight gain, especially around the midsection — including visceral fat, a type of tissue deep inside the abdomen that is known to increase inflammation throughout the body. It is also linked to heightened risks for diabetes and cardiovascular complications, even in children, and may contribute to declining brain function: Obese adults often perform worse than people of normal weight on tests of thinking skills.
But little has been known about visceral fat and brain health in children. For a soon-to-be-published study, researchers from Northeastern University in Boston and the University of Illinois at Urbana-Champaign tracked hundreds of 8-to-10-year-old children in a nine-month after-school exercise program in Urbana. Every day, one group of children played tag and other active games for about 70 minutes. The subjects in a control group continued with their normal lives, with the promise that they could join the program the following year. All the children completed tests of fitness, body composition and cognitive skills at the start and end of the program. The researchers did not ask the children to change their diets.
After the trial, the exercising children who were obese at the study’s onset had less visceral fat relative to their starting weight, even if they remained overweight. They also showed significant improvements in their scores on a computerized test that measures how well children pay attention, process information and avoid being impulsive. Notably, a similar effect was observed in children whose weight was normal at the start. Across the board, the more visceral fat a child shed during the nine months of play, the better he or she performed on the test.
The children in the control group, in contrast, had generally added to their visceral fat; this was particularly true among those who were already obese. They gained, on average, four times as much visceral fat as the normal-weight children in the control group, and also did not perform as well on the subsequent test.
Lauren Raine, a postdoctoral researcher at Northeastern University who conducted the study with Charles Hillman and others, says that the trial was designed to study aerobic fitness and children’s ability to think, not the relation of abdominal flab to inflammation. But a reduction in overall inflammation very likely plays a role, because it is thought to be unhealthy for the brain. More broadly, Raine says, the study suggests that getting children to run around won’t just enhance their bodies — it might also improve their report cards.

Exercise Has a Cascade of Positive Effects, Study Finds

Researchers say exercising helps people socialize more and accomplish more
By
Deborah Gage -The Wall Street Journal

Exercise has been shown to protect against diabetes, stroke and several other diseases and to improve our moods.
But does it also make us more likely to engage in other activities? Do people who exercise tend to have better social lives or achieve more of their goals?
The answer appears to be yes, according to a study that has been accepted for publication in the journal Personality and Individual Differences. Exercise not only makes us feel more positive, the study found, but it also increases the likelihood that we’ll do more positive things.
That supports the use of exercise to help treat people with depression, anxiety and other illnesses. It also suggests exercise could help healthy people improve their everyday lives.
The team of researchers at George Mason University recruited 179 college students from northern Virginia and asked them to record their exercise every day for 21 days. The students were asked each day if they had participated in any of eight activities including cycling, weight training or swimming, along with an “other” activity in case theirs wasn’t listed.
They were also asked if they’d had positive social interactions each day with friends, dates, family members or other people, or if they’d achieved something they wanted to get done, such as completing a project.
The students rated the importance to them of both types of activities on a scale of 1 to 4.
The results: On a given day, students who exercised also tended to participate in more social and achievement activities than on days when they didn’t exercise, the study found, and they engaged in activities that tended to matter to them more.
In addition, exercise on one day predicted positive social activity on the next day, but not achievement activity.
The researchers also found that positive social and achievement activities on one day didn’t predict exercise on the next day.
The results support an approach to treating depression called behavioral activation.
“When we become depressed or whatever it is we’re going through, we say to ourselves that we’ll get out when we feel better,” says Kevin Young, the study’s lead author, who is completing his doctorate in clinical psychology at George Mason University. “Unfortunately, what we also see is that we do not feel better until we get out.”
Mr. Young, who will be a clinical psychologist, adds, “We try and help someone start sprinkling activities again into their lives. That will result in improvement in mood, and [positive] emotion will follow.”
Mr. Young is now thinking about ways the study could be expanded. Does exercising with a group have a different impact on other activities than exercising alone? Can exercise affect future negative as well as positive activities? How much time do we have to spend exercising before positive activities follow?
And what is the mechanism that makes exercise work this way? Is it the improved mood after we exercise that leads us to have better relationships and get more done, or is it an improved sense of self-esteem?
Although he emphasizes that the study was done on healthy people who weren’t screened for depression, Mr. Young says he’s now more inclined to have his patients use exercise to help them re-engage with activities they enjoy. Depression, he says, saps people’s energy and makes them fatigued.
“It’s torture,” he says. “Exercise is one method of intervention we have.”
Ms. Gage is a writer in San Jose, Calif. She can be reached at reports@wsj.com

Most Parents Give Kids Wrong Doses

Pictographic instructions, milliliter-only lab tools could help reduce errors

by Alexandria Bachert MPH, Staff Writer, MedPage Today June 27, 2017

Action Points
• Parents often make measurement errors with their children’s medications, suggesting the need for tools to better match prescribed dose volumes in order to prevent accidental overdoses.
• Note that almost one third made at least one large error, but that when parents had dosing implements closely matched to prescribed dose volumes, the error rate was much lower.

Parents often make measurement errors with their children’s medications, suggesting the need for tools to better match prescribed dose volumes in order to prevent accidental overdoses, reported researchers.
According to results from a randomized trial involving nearly 500 parents, a large majority (83.5%) made at least one dosing error, reported H. Shonna Yin, MD, MS, of NYU Langone Medical Center, and colleagues in Pediatrics.
Almost one third made at least one large error, the researchers found. Among all errors, 12% involved an overdose.
But when parents had dosing implements closely matched to prescribed dose volumes, the error rate was much lower.
“Giving a parent a dosing tool, like an oral syringe, that is the right size, can have a big impact on whether a parents will dose a medication accurately,” Yin told MedPage Today.
“If the tool is too large, parents are more likely to overdose. If the tool is too small to allow the parent to measure the full dose with a single measurement, then parents will need to use math skills to figure out how to accurately measure more than one instrument-full, which increases the likelihood of a dosing error,” she explained.
Yin and colleagues recruited 491 parents from Feb. 20, 2015, to July 23, 2015 from three pediatrics outpatient clinics in New York City, Atlanta, and Atherton, Calif.
English- and Spanish-speaking parents with children ≤8 years old were randomly assigned to one of four groups:
• Text and pictogram instructions on the label, “mL”-only label and tool
• Text and pictogram instructions, “mL/tsp” label and tool
• Text-only instructions, “mL”-only label and tool
• Text-only instructions “mL/tsp” label and tool
Dosing error was determined by the weight of the measured dose compared with a reference weight (e.g., 5-mL dose defined as the average weight of 5 mL measured by 10 pediatricians using an oral syringe). If the measured amount was different from the amount listed on the label by >20%, the parent was considered to have made a clinically meaningful dosing error.
The researchers found that parents who received text and pictogram dosing instructions with “mL”-only labels and tools had decreased odds of making a dosing error compared with those who received “mL/tsp” labels and tools with or without pictographic dosing instructions.
There were more errors with the 2- and 7.5-mL doses tested compared with the 10-mL dose — 2 mL versus 10 mL: aOR 3.7 (95% CI 3.1–4.4) and 7.5 mL versus 10 mL: aOR 1.4 (95% 1.2–1.6).
For the 2-mL dose, the fewest errors were seen with the 5-mL syringe — 5- versus 10-mL syringe aOR: 0.3 (95% CI 0.2–0.4) and cup versus 10-mL syringe: aOR 7.5 (95% CI 5.7–10.0).
For the 7.5-mL dose, the fewest errors were with the 10-mL syringe — 5- versus 10-mL syringe: aOR 4.0 (95% CI 3.0–5.4) and cup versus 10-mL syringe: aOR 2.1 (95% CI 1.5–2.9).
Milliliter/teaspoon was linked to more errors than milliliter-only, aOR 1.3 (95% CI 1.05–1.6), noted the researchers.
“This study supports system-wide changes in the design of medication labels and provision of dosing tools that would help reduce medication errors in children,” Yin said in an interview.
She continued that the development of standards around the provision of dosing tools, by pharmacies and manufacturers of over-the-counter and prescription medications, along with increased awareness by providers and pharmacies, could help to better ensure that parents receive optimal dosing tools.
Looking forward, the researchers called for a comprehensive labeling and dosing strategy for pediatric liquid medications that they are now testing in a “real world” randomized trial.
Study limitations included the use of a hypothetical dosing scheme which might not have accurately reflected how parents dose at home, as well as a limited number of dosing tools, capacities, and volumes.

Eating Fish May Ease Rheumatoid Arthritis

Cross-sectional study ties fish with diminished disease activity

by Judy George, Contributing Writer, MedPage Today June 26, 2017

Action Points
• Eating fish high in omega-3 fatty acids may help reduce joint pain and inflammation, according to a new study among mostly middle-aged, white, college-educated females taking disease-modifying anti-rheumatic drugs (DMARDs) for seropositive, longstanding rheumatoid arthritis (RA).
• The disease activity difference between the highest and lowest categories of fish consumption was of clinically important magnitude and was approximately one-third the magnitude of previously reported pre- and post-treatment differences in disease activity among methotrexate users.
Eating fish — tuna, salmon, sardines, trout, sole, halibut, poke, and grouper — may help reduce joint pain and inflammation in rheumatoid arthritis (RA) patients, according to a new study in Arthritis Care & Research.

RA patients who ate baked, steamed, broiled, or raw fish 2 or more times per week had a significantly lower Disease Activity Score in 28 Joints with C-Reactive Protein (DAS28-CRP) — a score that measures tender and swollen joints, subjective disease activity, and C-reactive protein — than those who never ate fish or ate it less than once a month. The difference in DAS28-CRP between these two groups was -0.49 (95% CI, -0.97 to -0.02), according to Sara Tedeschi, MD, MPH, of Brigham and Women’s Hospital in Boston, and colleagues. With each additional serving of fish per week, DAS28-CRP dropped significantly by 0.18 (95% CI -0.35 to -0.004).
“This is a novel analysis of the relationship between consuming fish as a whole food, rather than consuming fish oil supplements, and rheumatoid disease activity,” the authors wrote. “Our observed difference in DAS28-CRP of 0.49 between the lowest and highest categories of fish consumption is approximately one-third the magnitude of previously reported pre- and post-treatment differences in DAS28 among methotrexate users.”
In their analysis, the Tedeschi team looked at baseline data from 176 rheumatoid arthritis patients who enrolled in the Evaluation of Subclinical Cardiovascular Disease and Predictors of Events in Rheumatoid Arthritis (ESCAPE-RA) cohort study from October 2004 to May 2006. Patients who had a prior cardiovascular event or who weighed over 300 pounds were not part of this sample.
The investigators studied the results of a 120-item food frequency questionnaire that participants completed at baseline, which assessed their usual diet over the past year. They defined fish consumption as cooked or raw sardines, tuna, or salmon (including sashimi and sushi), and broiled, steamed, baked, or raw fish like trout, sole, halibut, poke, grouper, and others, selecting those foods because of their higher omega-3 fatty acid content. They did not include fried fish, non-fried shellfish, or fish in mixed dishes, such as stir-fried fish with vegetables.
Participants recorded the frequency in which they ate fish on a 9-point scale ranging from “never to <1/month” to “≥2/day,” and indicated each serving size as small, medium, or large. If frequency was missing on a questionnaire, the researchers assigned it to “never to <1/ month.” If the serving size was missing, they assigned it medium.
The majority of people who participated in this study were middle-aged, white, college-educated females taking disease-modifying anti-rheumatic drugs (DMARDs) for seropositive, longstanding RA. Of the 176 participants, 19.9% were infrequent fish eaters (never to <1/month) while 17.6% were frequent eaters (≥2 times/week).
The researchers analyzed the association between how much fish participants ate and their baseline DAS28-CRP, adjusting for factors like age, gender, biologic DMARD use, fish oil supplement use, depression, smoking, and body mass index (BMI).
After adjusting for confounders, the researchers found that DAS28-CRP was 0.49 lower in individuals who ate fish ≥2 times/week than those who ate fish never to <1/month. Each additional serving of fish per week was associated with 0.18 lower DAS28-CRP.
The DAS28 difference between the highest and lowest categories of fish consumption is of clinically important magnitude, the authors observed, especially compared to results from recent trials.
“During the SWEFOT [Swedish Farmacotherapy] trial run-in period, mean DAS28 decreased by 1.2 among 258 subjects after 3-4 months with methotrexate,” they wrote. “In a cohort of 307 longstanding RA patients with moderate-to-high disease activity treated with methotrexate (without biologic DMARDs), mean DAS28 decreased by 1.6 after 6 months.” The DAS28 difference found in this study of fish consumption is about one-third the size of the methotrexate findings, the researchers noted.
The group that ate fish most frequently had some baseline traits that might be associated with improved disease activity, like lower BMI and higher socioeconomic status, but they also had the highest prevalence of smoking and the longest disease duration, making it difficult to see how confounders might affect the relationship between fish consumption and RA disease activity.
While the magnitude of difference in DAS28-CRP was striking, the researchers cautioned that this study was a cross-sectional analysis, so they could not draw firm conclusions about fish consumption and RA disease activity. Reverse causation might be one explanation for the association between fish intake and disease activity, they noted, and a randomized controlled trial may provide firm evidence that greater fish consumption lowers RA disease activity. Moreover, they added, the ESCAPE-RA cohort consisted of predominantly white, well-educated married women with longstanding RA, so the results of this study might not apply to other populations.

The study was supported by grants from the National Institutes of Health.

Patients in alternate ICUs get less attention on rounds

by Paige Minemyer | FierceHealth
Jun 21, 2017 11:17am

Patients housed in alternative intensive care units due to overcrowding face worse outcomes than those in the traditional ICU, and one of the causes may be that they receive less attention from clinicians, according to a new study.
Researchers at the Perelman School of Medicine at the University of Pennsylvania tracked 500 rounds within a Penn surgical ICU and found that caregivers spent 16% less time with “ICU boarders” than other ICU patients. Even when the study team adjusted for factors like age and health status, a significant gap remained.
Part of the reason, the study found, was that ICU patients housed in alternate wards were likely to be visited at the end of rounds, when clinical teams are most fatigued. About 71% of boarders were seen by caregivers in the last fifth of rounds, while just 13% of other ICU patients were seen in that same window.
Critical care clinicians are already stretched thin without the addition of two disparate wards to manage. Recent research suggests that nearly half (45%) of ICU clinicians face severe burnout, and for those in pediatric intensive care the rate increased to 71%.
Clinicians were also more likely to rely on “phone medicine” for the boarder patients. Doctors based in the “home” ICUs may also feel less of a sense of ownership over patients in the alternate ICUs, and nurses treating the boarder patients may also not have the full skill set to care for such vulnerable patients, according to the study.
“Together, all of these factors can create a ‘perfect storm’ leading to subpar clinical care of the critically ill patient,” José L. Pascual, M.D., an associate professor of traumatology, surgical critical care and emergency surgery at Penn and senior author on the study, said in an announcement.
As a result of the study, Penn’s surgical ICU teams are now encouraged to conduct rounds with boarder patients first and improve communication between nurses stationed at both wards, according to the announcement. Some are designating a nurse “generalist” who can care for ICU patients housed in either location. Further study is planned to see if any of these interventions bear fruit.

The new war on sepsis

By Anna Gorman  | Jun 19, 2017 11:19am

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
Dawn Nagel, a nurse at St. Joseph Hospital in Orange, California, knew she was going to have a busy day, with more than a dozen patients showing signs of sepsis. They included a 61-year-old mechanic with diabetes. An elderly man recovering from pneumonia. A new mom whose white blood cell count had shot up after she gave birth.
Nagel is among a new breed of nurses devoted to caring for patients with sepsis, a life-threatening condition that occurs when the body’s attempt to fight an infection causes widespread inflammation. She has a clear mission: identify and treat those patients quickly to minimize their chance of death. Nagel administers antibiotics, draws blood for testing, gives fluids and closely monitors her charges—all on a very tight timetable.
“We are the last line of defense,” Nagel said. “We’re here to save lives. If we are not closely monitoring them, they might get sicker and go into organ failure before you know it.”
Sepsis is the leading cause of death in U.S. hospitals, according to Sepsis Alliance, a nationwide advocacy group based in San Diego. More than 1 million people get severe sepsis each year in the U.S, and up to 50% of them die from it. It is also one of the most expensive conditions for hospitals to treat, costing $24 billion annually.
Most hospitals in the U.S. have programs aimed at reducing sepsis, but few have designated sepsis nurses and coordinators like St. Joseph’s. That needs to change, said Tom Ahrens, who sits on the advisory board of Sepsis Alliance.
“From a clinical point of view, from a cost point of view, they make a huge impact,” said Ahrens, a research scientist at Barnes-Jewish Hospital in St. Louis.
Recent federal rules could help foster such a change: The Centers for Medicare & Medicaid Services began requiring hospitals in 2015 to measure and report on their sepsis treatment efforts. They must make sure certain steps are completed within the first three hours after sepsis is identified, including getting blood cultures, giving intravenous fluids and starting patients on a broad-spectrum antibiotic.
Sepsis is difficult to diagnose, but if it’s caught early enough it can be treated effectively. If not, patients are at risk of septic shock, which can lead to organ failure and death.
St. Joseph Hoag Health, an integrated medical system in Orange County, California, that operates St. Joseph and six other hospitals, began employing dedicated sepsis nurses throughout the system in 2015. Hoag Hospital in Newport Beach and its namesake sister facility in Irvine were the first to try out the nurses about seven years ago, and four other hospitals have since followed.
The hospitals in the St. Joseph Hoag Health system treat about 8,000 cases of sepsis each year, at a cost of $130 million, according to Andre Vovan, M.D., a critical care physician who oversees St. Joseph Hoag’s anti-sepsis programs.
The health system also created sepsis care checklists and a mobile app to help coordinate care for patients at risk. But the nurses are at the core of the initiative. They know how to treat sepsis like “the back of their hands,” Vovan said. “Their familiarity allows them to do it faster.”
Speed is critical in sepsis: evidence shows that patients who get treatment quickly are more likely to survive.
“It’s so much easier to give someone salt water and antibiotics. It’s a lot harder when they are in the ICU and you are trying to get them off a ventilator,” said Cecille Lamorena, who is in charge of the sepsis nurses at St. Joseph Hospital.
Sepsis nurses give families an idea of what to expect—both during the patients’ hospital stay and after their discharge, Vovan said.
“We want the families to understand that just because you survive sepsis, it doesn’t mean you can get home and run a marathon,” Vovan said. “It can take weeks to months to recover.”
Sepsis nurses and coordinators also serve as on-site experts to ensure that required standards are followed by others, said David Carlbom, M.D., medical director at Harborview Medical Center in Seattle. The sepsis nurse coordinator there, Rosemary Mitchell Grant, educates staff and tracks data collected through the medical records. She also carries out projects to improve outcomes and helps organize an annual sepsis conference.
“Hospitals that don’t have a systematic approach could have a delay in recognition of sepsis,” Carlbom said, noting that busy acute care nurses might miss its subtle signs.
The St. Joseph Hoag Health effort seems to be working. From 2015 to 2016, the death rate for all of its hospitals dropped from 15% to 12% for severe sepsis/shock, and from 12% to 9% for all sepsis cases, Vovan said. The length of time patients stay in the health system’s hospitals is also dropping, he said. At St. Joseph Hospital in Orange, the number of patients who went into septic shock dropped 50% in the same two-year period, Lamorena said.
The sepsis program has support from doctors, including Matthew Mullarky, M.D., an emergency room physician at St. Joseph. He said he relies on the hospital’s sepsis nurses to help find and follow patients who are at risk. “With the knowledge they have, they ensure we are moving in the right direction quickly,” Mullarky said. “These patients are so overwhelmingly sick.”
At the hospitals in the St. Joseph Hoag network, there is always a dedicated sepsis nurse on duty. Dawn Nagel said that at St. Joseph Hospital, where she works, “sometimes I feel there should be three of us.”
Nagel weighs several factors as she tries to identify patients at risk. She scouts for signs they are worsening—a drop in blood pressure, confusion, increased heart rate, a high white-blood-cell count. And since sepsis is a response to infection, she wants to know if there is one. Pneumonia and urinary tract infections are the most common.
Nagel, who has worked as a nurse at St. Joseph for 18 years, seems to know everyone she passes in the halls. She spends the day bouncing between the emergency room, the maternity ward and the medical-surgical floor. She pitches in wherever needed, grabbing a pillow for one patient, starting an IV for another.
She carries a binder with tracking sheets for each patient. All potential sepsis patients are followed for at least 24 hours, during which they get visits from the sepsis nurse. Nagel’s phone rings constantly—nurses and doctors asking if she can check on patients. She also receives alerts on the in-house sepsis app embedded in her phone. When she meets with patients, she hands them a brochure on sepsis and explains more about it.
One afternoon in May, Nagel checked up on Donald Hammock, 82. He already was being treated for sepsis with fluids and antibiotics, and Nagel wanted to ensure they were working. “I’m just another set of eyes to make sure you’re getting better, not worse,” she told him. “I’m like your infection babysitter.”
Hammock said he was glad for the extra attention. He had been treated for severe sepsis in 2011 after spiking a fever, and his blood pressure had dropped precipitously. At the time, Hammock said, he didn’t know anything about the illness. “I could have died right there.”
“I’m glad you got in here,” Nagel replied. “As you know, you can get really sick with sepsis.”
After a quick exam, Nagel told Hammock his vitals looked stable, he seemed alert, and his lungs sounded clear. “You are looking good to me,” she said.
She crossed him off her list and headed to the next room.