Do Trauma Patients Need An Aspirin?

Acute traumatic injury has been shown to produce a prothrombotic state that predisposes trauma patients to an increased risk of venous thromboembolic events. But are these patients also at increased risk for stroke?

Researchers at the University of Louisville report that trauma patients were 1.6 times more likely to develop a cerebrovascular accident (CVA) after admission than medical and surgical controls matched for known CVA risk factors such as age, hypertension, diabetes, atrial fibrillation, and tobacco use.

On logistic regression, trauma was the only significant risk factor for CVA between the two groups, Dr. Jason W. Smith reported at the recent meeting of the Eastern Association for the Surgery of Trauma.

By Patrice Wendling/Elsevier Global Medical News

Dr. Smith called for more studies concerning the etiology and management of post-traumatic hypercoagulability and suggested that “CVA prophylaxis may be warranted in select trauma patients.”

The analysis identified 64 strokes after admission among 7,633 trauma admissions from 2008-2010, for an overall CVA rate of 0.8%. Out of this group, 23 strokes were found to be related to TBI and blunt cervical vascular injury, leaving 41 patients with non-injury related CVA in the analysis. The medical/surgical controls included 14,121 patients obtained from the university’s hospital database over the same time period.

When compared with a second control group of 120 trauma patients matched for Injury Severity Score and mechanism of action, the 41 trauma-related CVA patients presented with significantly more stroke risk factors, including older age, pre-existing hypertension, diabetes, and tobacco use.

Their chance of placement in an extended care facility also skyrocketed from 28% to 81%, while mortality rates more than tripled from 7% in controls to 22% in the trauma-related CVA patients, Dr. Smith and his co-authors reported.

The one bright spot was that on follow-up in the medical/surgical analysis, trauma patients had higher six-month post-CVA functional assessment compared with the controls.

–Patrice Wendling

New Questions on Lung Cancer Screening

Would you allow patients to self-refer for a CT lung cancer screening? Would you screen a never-smoker? What size nodule would trigger a follow-up exam? What is your lower age limit and lower pack-year limit for screening?

These are just a few of the questions tackled during an interactive lung cancer screening session at the recent Radiological Society of North America meeting, and that highlight the uncharted waters physicians face in the wake of the pivotal National Lung Screening Trial.

The NLST demonstrated a 20% reduction in lung cancer mortality when low-dose CT screening was used, compared to chest X-ray, among 53,000 asymptomatic current or former heavy smokers. However, CT produced more than three times the number of positive results and a higher false-positive rate than radiography.

Without a clear plan to manage abnormal findings or a firm handle on cost, policymakers and payors are hesitant to back reimbursement for widespread lung cancer screening. Results of the ongoing NLST cost-effectiveness analysis are expected early next year. Based on already published data, however, a crude back-of-the-envelope estimate puts the incremental cost-effectiveness ratio at $38,000 per life-year gained, NLST investigator Dr. William Black told attendees.

“That actually is a pretty good deal compared to a lot of things we do in medicine, and in fact most people would put the threshold for acceptability somewhere between $50,000 to $100,000 per life-year gained,” he said. “So it certainly is feasible”

Dr. Black pointed out that low-dose CT saved one lung cancer death per 346 persons screened in NLST, which again is very favorable compared to the rate of 1 per 2,000 patients for mammography.

Although the session provided just a small snapshot in time, audience responses suggest there is much work ahead. A full 77% of attendees were not using low-dose CT to screen for lung cancer and 72% reported not being familiar with the recently published National Comprehensive Cancer Network guidelines for lung cancer screening.

One-quarter of the audience had no lower age limit for screening, and 34% said they did not provide either decision support or obtain informed consent.

Dr. Caroline Chiles. Image by Patrice Wendling/Elsevier Global Medical News

Radiologist and NLST collaborator Dr. Caroline Chiles said informed consent in NLST helped prepare patients for the potential risks of a screen, the likelihood of a positive result and that a positive result didn’t mean they had lung cancer.

“It made a huge difference once they got that letter saying they had a positive screen, because at that point you don’t want everyone rushing out to a surgeon to get that nodule resected,” she added.

What attendees and panelists could agree on is the need for smoking cessation to be included in any future lung cancer CT screening program, with 60% of attendees saying they already do so.

Dr. Chiles pointed out that 16.6% of participants in the NELSON lung screening trial quit smoking compared with 3%-7% in the general public, but that participants were less likely to stay non-smokers. She also cited a recent MMWR that found 70% of adult smokers want to quit smoking, but only about half had been advised by a health professional to quit.

“We really have to think of lung cancer screening as being a teachable moment,” she said.

She suggested physicians visit www.smokefree.gov for help in guiding their patients. Dr. Black also noted that the NLST team is working on a lung cancer screening fact sheet for physicians and patients that will be ready in a few weeks and made available on the Internet.

—Patrice Wendling

Hypnosis Takes the Bite Out of MRI Anxiety

I’d rather have an MRI.

OK, it doesn’t have the same ring as the traditional punch line, but for many patients the fear of being slipped in a scanner surrounded by the clicking and banging sounds of an MRI ranks right up there with a root canal.

Rather than sedating these patients, a radiology group in France has been offering hypnosis on a daily basis since 2004.

Over a 15-month period, 45 patients were identified as being claustrophobic and refused the scheduled MRI, including four patients who experienced a panic attack.

All 41 patients who agreed to undergo a brief 3- to 5-minute single session of hypnosis just before the MRI completed the exam, including those with panic attacks.

Conversely, none of the four patients who refused hypnosis were able to withstand the procedure, radiologist and co-author Dr. Bruno Suarez reported at the Radiological Society of North America  meeting.

Dr. Bruno Suarez

“The more a patient is claustrophobic, the more hypnosis is efficient,” Dr. Suarez, with L’Hôpital Privé de Thiais in the outskirts of Paris, said in an interview. “For us it’s a surprise. It’s a very interesting technique.”

The technique is based on the late American psychiatrist Dr. Milton Erickson’s approach to hypnosis, but modified to integrate the repetitive noise of the MRI. Patients are given a tour of the MRI room, assured that the scanner and its magnets are safe and prompted to mentally recall a pleasant memory involving a repetitive noise while the MRI exam is performed.

During hypnosis, the brain is more susceptible to suggestions, Dr. Suarez said, noting that a Belgian study showed that hypnosis reduces the perception of pain by 50%.

Hypnosis requires a good memory and language skills, so it’s not used on those under five years of age or those with dementia or Alzheimer’s, he added.

So far, a radiologist, two MRI technicians and even the two office receptionists have been trained in the technique.

Marc Andre Fontaine (left) and Dr. Suarez

“I like the contact with the patient, and I want the best results for the patient,” MR technician and co-author Marc Andre Fontaine said in an interview.

The 45 patients in the series represent just 1.4% of the roughly 3,300 patients seen by the group over the 15 months, but the appeal of the drug-free method has attracted referrals from other centers. It’s also a big financial boon due to shorter exam times, fewer appointment cancellations and no procedural side effects, Dr. Suarez said.

A recent study by interventional radiologist and hypno-analgesia pioneer Dr. Elvira Lang reported that self-hypnotic relaxation added an extra 58 minutes to the room time for an outpatient radiologic procedure, but still saved $338 per case compared with standard IV conscious sedation.

That’s a big savings for just getting patients to relax with a few words, especially when you consider that  nine out of ten patients are probably already muttering something under their breath during their MRI.

—Patrice Wendling

Images by Patrice Wendling/Elsevier Global Medical News

A.W.O.L. in the Hospital

Ask any new parent to part with her baby in the hospital for even a few moments and it’s likely to set in motion a mental high-speed, Guy Ritchie-like montage, complete with squealing tires, deranged abductors, and shadowy baby-sale rings. (Well, it did for me.)

When it comes to why children go A.W.O.L. in the hospital, however, researchers say we want to look a little closer to home.

It turns out that some parents are taking off the ID bands used to keep track of their child in the hospital.

Photos by Patrice Wendling

A learning collaborative of six hospitals found that the overwhelming (90%) reason for pediatric ID band failure was that the band was simply not in place. The most frequent reasons were that it fell off, was taken off by the parent or the patient, or was put on another object such as a crib,  Dr. Shannon Phillips and her co-authors reported at Pediatric Hospital Medicine 2011.

“A lot of times, the patients had been at the hospital for a long time and the parent would say ‘Everyone knows my child’or ‘I’m always here at the bedside,’ co-author Dr. Michele Saysana explained. “Many of the parents were taking [the ID band] off, but when we educated them on the importance of keeping the ID band on, they had a better understanding.”

In addition to family/patient education, the collaborative staged other interventions including educating front-line staff on the importance of correct ID bands as a safety strategy; conducting audits, often by night nursing administrators; and changing to softer ID bands, including luggage tag-type bands in some NICUs.

“In bigger systems with adults, you must have different bands,” said Dr. Saysana, who directs the pediatric hospitalist program at Riley Hospital for Children in Indianapolis. “The one-size-fits-all doesn’t work for the little guys.”

Dr. Michele Saysana

Post-intervention, the collaborative saw a 13% absolute reduction, corresponding to a 77% relative reduction, in pediatric band failures between September 2009 and September 2010. Their goal had been to reduce errors across the collaborative by 50% in 12 months.

The keys to sustaining this kind of success?

“The lessons learned are having leadership be involved, having continuous audits, and just doing education every time you catch something,” she said.

—Patrice Wendling

Can You Keep a Secret … at Medical Meetings?

Image courtesy of Flickr user velo_city (CC)

Tuesday morning I sat through the late-breaker session at the annual meeting of the American Society of Hypertension.  The last two oral abstracts were based on work from the International Consortium for Blood Pressure Genome-wide Association Studies (GWAS), whose goal is to identify genetic variants in known and novel genes that influence blood pressure in the general population. In the first talk, Dr. Mark Caulfield discussed the consortium’s methodology and the indentification of 29 single nucleotide polymorphisms (SNPs) associated with blood pressure — 16 of which were at novel loci.

In the second talk, Dr. Daniel Levy discussed the development of a genetic risk score that incorporated all 29 alleles identified in the GWA and the score’s associations with several blood pressure-related clinical outcomes (such as target organ damage and cardiovascular events).  Before doing so though, he asked everyone in the audience to refrain from photographing the slides or recording the presentation due to an upcoming publication of the study.

As a reporter, I don’t consider myself bound by such requests for secrecy.  If it’s presented in a public forum, it’s fair game in my book. 

My question is to physicians, many of whom are now quite well-published themselves, thanks to everyman’s news outlets — blogs and social media.  Would you refrain from discussing the study in a widely-read (or completely unknown) blog or online forum?  Are you going to scoop reporters, who comply with the request? Do you think that such requests slow medical research?

We really want to know what you think.

— Kerri Wachter

Where did all the disclosures go?

 

Each afternoon, the sound of bagpipes drifted through Chicago’s McCormick Place during this year’s Digestive Disease Week.

Pipes & Drums Chicago P.D., image by Wendling

The idea was for the Chicago Police Department’s Pipes & Drums  to serve as “pied pipers” to draw attention to the daily drawings for everything from a brand new Kindle to a free pass to next year’s DDW plus hotel accommodations, explained Rose Horcher, vice president of client services for the Chicago Convention and Tourism Bureau .

Since attendees had to get stickers from 10 different exhibitors before they could put their entry into the giant gold raffle drum, it seemed to have a lot more to do with drumming up exhibit attendance, but I won’t quibble.

The gimmick worked.

Each afternoon, attendees followed the pipers through the exhibit hall, weaving their way round the book stands, past the giant inflated green stomach exhibit and by the instrument table with signs reading “cheap” and “really cheap” scopes.  (Yes, they really said that.)

Some attendees struck a more patriotic note, requesting the National Anthem in honor of Team Six. Even jaded reporters were heard asking about the mysterious, midafternoon melodies.

As the meeting wore on, I couldn’t help but wish for a little assistance from the boys in blue in tracking down which of the very same exhibitors had a hand in the cutting-edge research I was hearing.

Meeting policy required that financial relationships for all individuals with the ability to affect the content of an educational activity be disclosed to the audience.

The financial disclosures were generated by Freeman AV and automatically displayed as the first slide for 6 seconds in the session room before going into the presentation, DDW program manager Crystal Young said in an interview.

I may have been the second to last kid in third grade to learn to tell time properly, but 6 seconds, it was not. Blink and those disclosures were gone.

Even more worrisome was that many of the presentations simply stated that while the lead author had no disclosures, the coauthors did. You just weren’t told what they were.

A line on the screen stated only: “Please visit www.ddw.org to view all DDW speaker disclosures.”

Any journalist worth their salt did just that, but what about the attendees?

Are they really going to go back home and dig up the disclosures before sharing what they’ve learned with their colleagues? The online resource certainly doesn’t make it easy. Coauthors have to be looked up individually by their last names since no single search by abstract number is possible.

Disclosing relevant financial relationships up front provides context for the potentially practice-changing data the physicians are about to hear. If an author or coauthor is an employee or board member of the study sponsor, the physician should know that. If the analyses were conducted by the device or drugmaker, that should be out there, too.

Image courtesy of Wikimedia in the public domain

 

 

Without it, the Pied Piper has a much better chance of leading us astray. 

By Patrice Wendling

Seeing Red: Heart Disease and Women

The Red Dress Campaign has caught women’s attention regarding the very real dangers of cardiovascular disease, but a new study shows they may not be taking the message to heart.

Photo courtesy of The Heart Truth®, NHLBI, NIH

The study, presented at the recent American College of Cardiology meeting, found that the overall incidence of acute MI decreased among 315,246 patients admitted to New Jersey hospitals 1986-2007. The decrease was significant among both men and women, but was more prominent among men.

The incidence of acute MI fell from 598 to 311 per 100,000 men and from 321 to 197 per 100,000 women, according to cardiologist Dr. Liliana Cohen and her colleagues at the Robert Wood Johnson Medical School in New Brunswick, N.J. They also identified a growing gap in the rates of left heart catheterization and percutaneous coronary intervention between men and women.

The rates of catheterization increased fivefold in women and threefold in men over the 22-year study period, but the likelihood of catheterization remained lower for women. Moreover, the difference among male and female cath patients going on to receive PCI increased from 2.2% in 1986 to 9.4% in 2007.

Finally, both in-hospital and 1-year mortality remained higher among women, and failed to show a significant decrease after 2002 – the year the National Heart Lung and Blood Institute launched the Red Dress campaign.

“Although awareness of cardiovascular disease in women has increased in the general population, there has been much less translation of this into clinical practice,” Dr. Cohen told me.

This may be due to women presenting later because they doubt an MI can happen to them or that physicians still are not treating women as aggressively as they treat men, she said. It also may relate to the fact that women have more difficult cardiac anatomy, so that once they receive cardiac cath, PCI remains difficult.

Photo courtesy of The Heart Truth®, NHLBI, NIH

Dr. Cohen suggests that in its next phase, the campaign needs to continue to focus on public health awareness, but also on research into how to translate public awareness into clinical practice by focusing on physicians and into newer techniques of PCI for the smaller blood vessels in women.

Quibble if you will about the generalizability of data from a single state or the potential impact of a single PR campaign, but it’s hard to ignore these disappointing outcomes.

I once heard a bold and blistering guest lecture at a cancer meeting by Nancy Goodman Brinker, founder and CEO of Susan G. Komen for the Cure, who told several thousand — mostly male — oncologists that a survival rate topping 90% for early stage breast cancer simply wasn’t good enough.  Truer words were never spoken.

— Patrice Wendling

Fort Hood Shooting: A Cautionary Tale for Tucson

    I don’t care how many special news reports I see or read on the shootings in Tucson, I’m convinced we won’t fully understand what happened there for months, if ever. What we can be certain of is that more mass casualties will occur and that there will be missteps by both medical and journalism professionals.

I say this because of a recent post-mortem I heard on the November 2009 shootings at Fort Hood, where in a span of roughly 10 minutes, 32 people were injured and 10 died. Ultimately, 13 individuals lost their lives in that tragedy.

In the rush to report the news, two news helicopters hovered over the Scott & White Hospital, located 30 miles from Fort Hood, and the only level I trauma center in the area. The FAA was called in to clear the airspace, but not before the helicopters interfered with the transport of patients.

Back in Atlanta, CNN broadcast the Scott & White command center referral line, and over a 1-hour period, the hospital received 1,300 phone calls, which “essentially crippled our phone systems,” Dr. Jeff Wild, a surgical resident at that hospital, told his colleagues at the Western Surgical Association meeting.

The overload meant that Darnall Army Hospital in Fort Hood and nearby Metroplex Hospital, both of which were receiving shooting victims, couldn’t reach staff. Communication problems ultimately led to the transfer of two patients from Metroplex to an out-of-region hospital.

Triage was minimally organized and patients were maldistributed, with the closer facilities becoming saturated with shooting victims, he said. Darnall Army Hospital, a level III hospital, evaluated 27 patients and performed five operations on 4 patients, with one death. Scott & White prepared 6 trauma bays, made 16 of its 24 ORs available and posted one trauma surgeon in the OR and another in the ED, which proved invaluable in triaging patients, noted Dr. Wild. Over roughly a 2-hour period, they received 10 patients, of which five were taken urgently to the OR. Metroplex, which had only one emergency department physician and two general surgeons in the level IV facility at the time, received seven patients, including a civilian police officer who helped take down the perpetrator, and had no deaths. “I think we’re quite lucky that none of the patients transferred here had any adverse events,” he said.

I was beginning to squirm in my seat at this point, until Dr. Wild acknowledged the hospitals had alternative means of communication. The only problem was that personnel didn’t know how to properly work the radios and Web-based computer program.

Security was also an issue for the hospital. The alleged perpetrator, psychiatrist Maj. Nidal Hasan, was in the same ICU as six of his shooting victims and their families. The hospital elected to move Hasan to an isolated OR that served as his ICU until he was transported out of the hospital.

Since the shootings, Scott & White has hosted several disaster drills that included the army hospital, which had not been done before, Dr. Wild reported on behalf of senior author Dr. Randall Smith, Scott & White interim chief of trauma, critical and acute care surgery. Staff has been educated on various communication pathways, and twice a month, all the hospitals and EMS agencies in the area talk on the radios to make sure they’re working properly and that staff knows how to use them.

“Scott and White hospital has taken part in four mass casualty events in the past 25 years and, although these are considered somewhat a rarity, they seem to be more commonplace,” Dr. Wild said. “And if you haven’t already, it’s very likely a lot of you will take part in one of these events over your careers.”

From my own perspective, I just hope everyone knows the drill, including my colleagues at the mic.

  Patrice Wendling (on Twitter @pwendl)

Renaissance RSNA

This year’s meeting of the Radiologic Society of North America felt as foreign to the current American landscape as Harry Potter’s Hogwarts School of Witchcraft and Wizardry.

While politicians in Washington played hide-and-go-seek with desperately needed government funding and unemployment benefits,  rows and rows of glistening CT and MRI machines spanned the floor of Chicago’s McCormick Place. Physicians clutching cups of made-to-order espresso were wooed into private imaging suites created with elaborate screens and partitions. One was even shaped to resemble a pagoda, with an exquisite black and floral kimono inside.

“I believe one of the exhibitors said in a meeting that we had down here that they considered this the Renaissance RSNA, everything’s back solid and strong,” says RSNA assistant executive director Steve Drew.

When asked the dollar value of the equipment on display, Drew says they’ve never stopped to calculate it, but that $100 million would probably be a “very conservative guess.”

Exhibits have remained solid in terms of the amount of space being bought and the size of the booths, with about 700 exhibitors on hand this year, down slightly from an all-time high in the mid-700s.

“We feel good about it,” he says. “Based on information gathered through partnership meetings we have with our major exhibitors and market indicators, we had actually budgeted down 7% and we’re about even with where we were last year. So, depending on how you look at it, it’s almost a 7% increase.”

RSNA isn’t the only one feeling good about this year’s meeting.

The city of Chicago, which struggled this past year to retain its competitive edge in the convention trade, anticipates that the 6-day show will bring in $120 million, says Meghan Risch, director of public relations for the Chicago Convention and Tourism Bureau.

The economic impact of RSNA, arguably one of the biggest medical meetings in the world, has remained relatively constant, she contends, despite the economic downturn.

Attendance this year was about 57,500, according to unaudited attendance figures. Of these, 36,000 were professional registrants, defined as everyone but exhibitors and guests.

“We’re running about 4% ahead on professional attendance and the really good numbers there are the non-North American registrants, which came in at 36% of the professional registrants,” Mr. Drew says.

The average hotel stay for RSNA is five days – roughly double that for most medical meetings. Its international makeup is also probably the highest of Chicago conventions, according to Ms. Risch.

“International attendance is growing and RSNA is a great example,” she says.

–Patrice Wendling (on Twitter @pwendl)

A Hidden Gem

Reporters at Elsevier Global Medical News cover a whole lot of medical meetings–in fact, we’ll cover about about 400 this year. We cover all the big ones–the ASCOs, the ADAs, the RSNAs–same as everyone else. But we also cover many small, unheralded meetings. In fact, I’m the only reporter at most of the meetings I attend. I’ve written about this before, here and here, even developing a list of Excellent but Little Known Medical Conferences.

Well, I’ve found a new gem of a medical meeting, and I’m there right now. It’s the annual meeting of the Western Thoracic Surgical Association, and once again I’m the only reporter in the room with a couple of hundred leading thoracic surgeons.

The content of this meeting is almost all meat, with very little fat. Virtually every talk reveals the results of a new study, most of which are both important and newsworthy. None of the talks are broad, such as “The History and Future of CABG.”  All of the talks target very specific topics. Here are two examples, which I’ll be writing about in coming days.

One study looked at how long patients survive after lung transplant and asked the question: Do the patients who receive lungs even though they have low “lung allocation scores” actually survive longer after receiving the transplant than if they had stayed on the waiting list? It turns out, counterintuitively, that on average they would have lived longer if they had not received the transplant, although possibly with a worse quality of life.

Another study examined an interesting dilemma. Thoracic surgeons have become so good at saving infants and young children with congenital heart disease, that more and more of them are living into adulthood. But when they need additional treatment as adults, it turns out that they tend to do worse when they’re operated on by thoracic surgeons with lots of experience with adult heart disease, and better when a specialist in surgery for pediatric congenital heart disease performs the operation.

Those are just two of the little golden nuggets I’ve found in this hidden gem of a meeting. Journalists tend to be pack animals, but I’m happy to work for an organization that doesn’t always travel with the pack.

—Bob Finn