Due to the potential risk of cancer from exposure to ionizing radiation, efforts should be made to avoid CT scanning for headache when the likelihood of serious illness is low. Evidence-based decision rules that identify which patients with headache do not require neuroimaging may decrease the use of CT scans in situations of little benefit.
Abstract
Background
Concerns exist about potential overuse of computed tomography (CT) scans for headache in ambulatory care.
Methods
We sought to examine health services use, brain tumor diagnosis, and death during the year after CT scanning for headache by linking records of an audit of 3930 outpatient CT brain scans performed in 2005 in Ontario, Canada, to administrative databases.
Results
Of 623 patients receiving CT scans for a sole indication of headache, few (2.1%) scans contained findings potentially causing their headache. For most patients, the index CT scan was the only one received over an 11-year period. However, 28.4% of patients received 1 or more CT brain scans during the preceding decade and 6.7% received 1 or more CT brain scans during the subsequent year. Of the 473 patients (75.9%) whose index scan was ordered by a primary care physician, most (80.3%) did not see a specialist during follow-up. One patient with an indeterminate finding on the index scan was diagnosed with a malignant brain tumor (0.2%), and 6 patients (1.0%) died during follow-up. Among the 4 deaths in which the cause could be determined, none were due to central nervous system causes.
Conclusion
Because of the potential risk of cancer from exposure to ionizing radiation, efforts should be made to avoid CT scanning for headache when the likelihood of serious illness is low. Evidence-based decision rules that identify which patients with headache do not require neuroimaging may decrease the use of CT scans in situations of little benefit.
To read this article in its entirety, please visit our website.
-- John J. You, MD, MS, Jonathan Gladstone, MD, Sean Symons, MD, MPH, Dalia Rotstein, MD, Andreas Laupacis, MD, MS, Chaim M. Bell, MD, PhD
This article originally appeared in the January 2011 issue of The American Journal of Medicine.
Jumat, 28 Januari 2011
Selasa, 18 Januari 2011
AJM editor publishes book on academic medicine (video)
Dr. James E. Dalen, associate editor for The American Journal of Medicine, has published a new book on academic medicine-- University Hospitals, Doctors and Patients.
Research conducted at university hospitals has contributed to medical advances in recent decades, but it has also contributed to the dramatic increase in healthcare cost and the increase in the use of medical technology. Hear about the book in Dalen's own words by clicking on the video, above.
As an editor, Dalen reviews many of the cardiology and healthcare policy manuscripts submitted to AJM and often contributes original articles to the Journal. He has written extensively on healthcare reform:
We Can Reduce US Health Care Costs
Only in America: Bankruptcy Due to Health Care Costs
It's Time to Bail Out Seniors Trapped in the Medicare Donut Hole!
Dalen, a noted cardiologist and medical educator, has spent his entire career in university hospitals in Massachusetts and Arizona. The former Dean of Medicine and Vice President for Health Sciences at The University of Arizona, he is now Professor Emeritus and teaches medicine and public health.
Jumat, 14 Januari 2011
Recent Trends in the Incidence, Treatment, and Outcomes of Patients with STEMI and NSTEMI
This population-based study revealed decreases in the magnitude of ST-segment elevation myocardial infarction, as well as increased longevity among ST- and non-ST-segment elevation myocardial infarction patients. The authors suggest that prevention programs and improved treatment efforts may have contributed to these positive changes.
Abstract
Background
Despite the widespread use of electrocardiographic changes to characterize patients presenting with acute myocardial infarction, little is known about recent trends in the incidence rates, treatment, and outcomes of patients admitted for acute myocardial infarction further classified according to the presence of ST-segment elevation. The objectives of this population-based study were to examine recent trends in the incidence and death rates associated with the 2 major types of acute myocardial infarction in residents of a large central Massachusetts metropolitan area.
Methods
We reviewed the medical records of 5383 residents of the Worcester (MA) metropolitan area hospitalized for either ST-segment elevation acute myocardial infarction (STEMI) or non-ST-segment acute myocardial infarction (NSTEMI) between 1997 and 2005 at 11 greater Worcester medical centers.
Results
The incidence rates (per 100,000) of STEMI decreased appreciably (121 to 77), whereas the incidence rates of NSTEMI increased slightly (126 to 132) between 1997 and 2005. Although in-hospital and 30-day case-fatality rates remained stable in both groups, 1-year postdischarge death rates decreased between 1997 and 2005 for patients with STEMI and NSTEMI.
Conclusions
The results of this study demonstrate recent decreases in the magnitude of STEMI, slight increases in the incidence rates of NSTEMI, and decreases in long-term mortality in patients with STEMI and NSTEMI. Our findings suggest that acute myocardial infarction prevention and treatment efforts have resulted in favorable decreases in the frequency of STEMI and death rates from the major types of acute myocardial infarction.
To read this article in its entirety, please visit our website.
-- David D. McManus, MD, FACC, Joel Gore, MD, FACC, Jorge Yarzebski, MD, MPH, Frederick Spencer, MD, Darleen Lessard, MS, Robert J. Goldberg, PhD
This article originally appeared in the January 2011 issue of The American Journal of Medicine.
Abstract
Background
Despite the widespread use of electrocardiographic changes to characterize patients presenting with acute myocardial infarction, little is known about recent trends in the incidence rates, treatment, and outcomes of patients admitted for acute myocardial infarction further classified according to the presence of ST-segment elevation. The objectives of this population-based study were to examine recent trends in the incidence and death rates associated with the 2 major types of acute myocardial infarction in residents of a large central Massachusetts metropolitan area.
Methods
We reviewed the medical records of 5383 residents of the Worcester (MA) metropolitan area hospitalized for either ST-segment elevation acute myocardial infarction (STEMI) or non-ST-segment acute myocardial infarction (NSTEMI) between 1997 and 2005 at 11 greater Worcester medical centers.
Results
The incidence rates (per 100,000) of STEMI decreased appreciably (121 to 77), whereas the incidence rates of NSTEMI increased slightly (126 to 132) between 1997 and 2005. Although in-hospital and 30-day case-fatality rates remained stable in both groups, 1-year postdischarge death rates decreased between 1997 and 2005 for patients with STEMI and NSTEMI.
Conclusions
The results of this study demonstrate recent decreases in the magnitude of STEMI, slight increases in the incidence rates of NSTEMI, and decreases in long-term mortality in patients with STEMI and NSTEMI. Our findings suggest that acute myocardial infarction prevention and treatment efforts have resulted in favorable decreases in the frequency of STEMI and death rates from the major types of acute myocardial infarction.
To read this article in its entirety, please visit our website.
-- David D. McManus, MD, FACC, Joel Gore, MD, FACC, Jorge Yarzebski, MD, MPH, Frederick Spencer, MD, Darleen Lessard, MS, Robert J. Goldberg, PhD
This article originally appeared in the January 2011 issue of The American Journal of Medicine.
Rabu, 12 Januari 2011
You Only Have to Exercise on the Days that You Eat
Evidence continues to increase supporting the idea that the inclusion of frequent exercise in our modern, 21st century lives is very important for health maintenance and improvement. One recent review study found a decrease in the development of coronary heart disease ranging from 10% to more than 60% when patients exercised regularly. Higher levels of exercise each week were associated with increased benefit. Decreased all-cause mortality also was reported from the Copenhagen City Heart Study with increasing leisure time exercise. A series of experiments in mice revealed that regular exercise prevented cellular senescence in circulating leukocytes as well as in the vascular tree. King et al demonstrated prompt benefit when middle-aged adults adopted healthier lifestyles including regular exercise. Reduced colds were reported in postmenopausal obese women who exercised 45 minutes per day, 5 days per week for 1 year. Moreover, patients with peripheral vascular disease, hypertension, and heart failure all benefited from regular exercise. Numerous other studies have supported the concept that frequent exercise can improve quality and quantity of life.
I have often wondered how and why regular exercise became so important for human beings.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
Editor-in-Chief, The American Journal of Medicine
This article originally appeared in the January 2011 issue of The American Journal of Medicine.
I have often wondered how and why regular exercise became so important for human beings.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
Editor-in-Chief, The American Journal of Medicine
This article originally appeared in the January 2011 issue of The American Journal of Medicine.
Selasa, 11 Januari 2011
AJM website: New design features expanded capabilities and video
The American Journal of Medicine website received a makeover with the coming of the new year.
Our new and improved home page features two Diagnostic Image articles, a free Clinical Research article, an editorial by AJM editor-in-chief Dr. Joseph S. Alpert, and Continuing Medical Education (CME) Multimedia Center-- along with links to the Journal's search function, articles in press, the manuscript submission website, author instructions, and other information.
Sub-pages of journal articles include interactive features that allow website visitors to download full-text articles and related images or Power Point slides; request reprints; export citations; and perform other high-level functions.
In addition, the website has improved video capabilities. Now an author can supply video and/or Power Point slides as supplements to a research paper, and these appendices will be uploaded to AJM's website if the manuscript is accepted.
In the near future, watch for video vignettes on clinical research from Dr. Alpert!
Register on AJM's website and receive our free e-newsletter and TOC alerts
Want to stay up-to-date with internal medicine breakthroughs? With a few clicks on our website, you can subscribe to The American Journal of Medicine's free, weekly e-newsletter-- AJM Plus-- and monthly table of contents (TOC) alerts.Keep current with these free AJM services.
Senin, 10 Januari 2011
Tucsonans Gather to Support Our Congresswoman Gabrielle Giffords
Blog Commentary
As many of you know, The American Journal of Medicine Editorial Office is located in Tucson, Arizona. As a tourist destination, Tucson is known for clear blue skies, warm temperatures, breathtaking mountain vistas, and The University of Arizona (UA) wildcats.
After the tragic events of Saturday, January 8, Tucson now also will be remembered for the mass shooting of 18 people-- including the assassination attempt on Congresswoman Gabrielle Giffords (above) and the murder of six other people at a suburban Tucson grocery store.
At the time of this post, Giffords is in the intensive care unit of the UA's University Medical Center (UMC)-- where AJM editor-in-chief Dr. Joseph S. Alpert practices medicine and teaches. Although she is still in intensive care, UMC trauma surgeons are cautiously optimistic.
Since her time in the Arizona Legislature, Giffords has been a strong supporter of healthcare, public health, and The University of Arizona.
Please join all of us in the AJM Editorial Office in wishing our Congresswoman Gabrielle Giffords a full and speedy recovery.
As many of you know, The American Journal of Medicine Editorial Office is located in Tucson, Arizona. As a tourist destination, Tucson is known for clear blue skies, warm temperatures, breathtaking mountain vistas, and The University of Arizona (UA) wildcats. After the tragic events of Saturday, January 8, Tucson now also will be remembered for the mass shooting of 18 people-- including the assassination attempt on Congresswoman Gabrielle Giffords (above) and the murder of six other people at a suburban Tucson grocery store.
At the time of this post, Giffords is in the intensive care unit of the UA's University Medical Center (UMC)-- where AJM editor-in-chief Dr. Joseph S. Alpert practices medicine and teaches. Although she is still in intensive care, UMC trauma surgeons are cautiously optimistic.
Since her time in the Arizona Legislature, Giffords has been a strong supporter of healthcare, public health, and The University of Arizona.
Please join all of us in the AJM Editorial Office in wishing our Congresswoman Gabrielle Giffords a full and speedy recovery.
Leadership in Academic Medicine
Over the many years that I have been involved in academic medicine, I have held a variety of leadership positions involving 3 coronary care units, a division of cardiovascular medicine, and a department of medicine. During this time period, a number of colleagues have asked me for my thoughts on the qualities that foster excellence in leadership. This editorial is a short summary of the advice that I gave at that time.1
There are as many styles of leadership as there are leaders. Some leaders prefer the “top-down” style of leadership involving strict hierarchical and authoritarian control. This style of leadership was common in the past but is rapidly fading away. Today, most leaders espouse a more democratic, inclusive style. I, too, favor this leadership style, which usually involves an executive committee that shares decision-making power with the head of the department.
I also prefer the “General Patton” style of leadership. This form of leadership involves the head of the enterprise in the day-to-day, hands-on running of the unit. In a clinical enterprise, this means that the leader shares in the daily clinical workload. The advantage of this style is that the leader is visible, approachable, and intimately involved in the daily running of the enterprise.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
Editor-in-Chief, The American Journal of Medicine
This article originally appeared in the December 2010 issue of The American Journal of Medicine.
There are as many styles of leadership as there are leaders. Some leaders prefer the “top-down” style of leadership involving strict hierarchical and authoritarian control. This style of leadership was common in the past but is rapidly fading away. Today, most leaders espouse a more democratic, inclusive style. I, too, favor this leadership style, which usually involves an executive committee that shares decision-making power with the head of the department.
I also prefer the “General Patton” style of leadership. This form of leadership involves the head of the enterprise in the day-to-day, hands-on running of the unit. In a clinical enterprise, this means that the leader shares in the daily clinical workload. The advantage of this style is that the leader is visible, approachable, and intimately involved in the daily running of the enterprise.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
Editor-in-Chief, The American Journal of Medicine
This article originally appeared in the December 2010 issue of The American Journal of Medicine.
Jumat, 07 Januari 2011
Achieving Hunter-gatherer Fitness in the 21st Century: Back to the Future
Humans are genetically adapted to lead physically challenging lives. As the last vestiges of the hunter-gatherer lifestyle are being eclipsed by modern civilization, scientists are beginning to realize how important this way of life is to our health.
Abstract
The systematic displacement from a very physically active lifestyle in our natural outdoor environment to a sedentary, indoor lifestyle is at the root of many of the ubiquitous chronic diseases that are endemic in our culture. The intuitive solution is to simulate the indigenous human activity pattern to the extent that this is possible and practically achievable. Suggestions for exercise mode, duration, intensity, and frequency are outlined with a focus on realigning our daily physical activities with the archetype that is encoded within our genome.
Characteristics of a Hunter-Gatherer Fitness Program
1.A large amount of background daily light-to-moderate activity such as walking was required. Although the distances covered would have varied widely, most estimates indicate average daily distances covered were in the range of 6 to 16 km. The hunter-gatherers' daily energy expenditures for physical activity typically were at least 800 to 1200 kcal,41 or about 3 to 5 times more than the average American adult today.
2.Hard days were typically followed by an easier day. Ample time for rest, relaxation, and sleep was generally available to ensure complete recovery after strenuous exertion.
3.Walking and running were done on natural surfaces such as grass and dirt, often over uneven ground. Concrete and asphalt surfaces are largely foreign to our genetic identity.
4.Interval training sessions, involving intermittent bursts of moderate- to high-level intensity exercise with intervening periods of rest and recovery, should be performed once or twice per week.
5.Regular sessions of weight training and other strength and flexibility building exercises are essential for optimizing musculoskeletal and general health and fitness. These need to be performed at least 2 or 3 times per week, for at least 20 to 30 minutes per session.
6.Virtually all of the exercise was done outdoors in the natural world.
7.Much of the physical activity was done in context of a social setting (small bands of individuals out hunting or foraging). Exercising with one or more partners improves adherence and mood.23
8.Except for the very young and the very old, all individuals were, by necessity, physically active almost their entire lives.
To read this article in its entirety, please visit our website.
-- James H. O'Keefe, MD, Robert Vogel, MD, Carl J. Lavie, MD, Loren Cordain, PhD
This article originally appeared in the December 2010 issue of The American Journal of Medicine.
Abstract
The systematic displacement from a very physically active lifestyle in our natural outdoor environment to a sedentary, indoor lifestyle is at the root of many of the ubiquitous chronic diseases that are endemic in our culture. The intuitive solution is to simulate the indigenous human activity pattern to the extent that this is possible and practically achievable. Suggestions for exercise mode, duration, intensity, and frequency are outlined with a focus on realigning our daily physical activities with the archetype that is encoded within our genome.
Characteristics of a Hunter-Gatherer Fitness Program
1.A large amount of background daily light-to-moderate activity such as walking was required. Although the distances covered would have varied widely, most estimates indicate average daily distances covered were in the range of 6 to 16 km. The hunter-gatherers' daily energy expenditures for physical activity typically were at least 800 to 1200 kcal,41 or about 3 to 5 times more than the average American adult today.
2.Hard days were typically followed by an easier day. Ample time for rest, relaxation, and sleep was generally available to ensure complete recovery after strenuous exertion.
3.Walking and running were done on natural surfaces such as grass and dirt, often over uneven ground. Concrete and asphalt surfaces are largely foreign to our genetic identity.
4.Interval training sessions, involving intermittent bursts of moderate- to high-level intensity exercise with intervening periods of rest and recovery, should be performed once or twice per week.
5.Regular sessions of weight training and other strength and flexibility building exercises are essential for optimizing musculoskeletal and general health and fitness. These need to be performed at least 2 or 3 times per week, for at least 20 to 30 minutes per session.
6.Virtually all of the exercise was done outdoors in the natural world.
7.Much of the physical activity was done in context of a social setting (small bands of individuals out hunting or foraging). Exercising with one or more partners improves adherence and mood.23
8.Except for the very young and the very old, all individuals were, by necessity, physically active almost their entire lives.
To read this article in its entirety, please visit our website.
-- James H. O'Keefe, MD, Robert Vogel, MD, Carl J. Lavie, MD, Loren Cordain, PhD
This article originally appeared in the December 2010 issue of The American Journal of Medicine.
Improving Practices in US Hospitals to Prevent Venous Thromboembolism: Lessons from ENDORSE
Currently there is an underuse of guideline-recommended prophylaxis in medical and surgical patients at risk for venous thromboembolism. Adoption of hostipal-wide protocols and periodic audits could improve prophylaxis processes.
Abstract
Background
Venous thromboembolism prophylaxis is suboptimal in the US despite long-standing evidence-based recommendations. The aim of this subset analysis of the Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) study was to identify characteristics of hospitals with high guideline-recommended prophylaxis use.
Methods
Between September and November 2006, charts from eligible patients aged ≥40 years with an acute medical illness or age ≥18 years and undergoing a surgical procedure were reviewed from randomly selected US acute-care hospitals. Hospitals were ranked based on the proportion of at-risk patients who received American College of Chest Physicians–recommended types of prophylaxis. Hospital characteristics were compared to determine factors related to more frequent prophylaxis use. Hospitals were followed up 1 year after the chart audit.
Results
Overall, 9257 patients were evaluated from 81 hospitals. Appropriate types of prophylaxis were prescribed to more at-risk patients in hospitals in the highest quartile compared with the lowest quartile of prophylaxis use (74% vs 36%). All quartiles had a similar percentage of at-risk patients (61%-65%). Significantly more hospitals in the highest quartile had residency training programs (43% vs 5%), a larger median number of beds (277 vs 140), and had adopted hospital-wide prophylaxis protocols (76% vs 40%). In the follow-up survey, more hospitals overall had adopted hospital-wide written guidelines for venous thromboembolism prevention.
Conclusions
These findings support the value of hospital-wide protocols and local audits for VTE prevention, as recommended by several national quality-of-care groups.
To read this article in its entirety, please visit our website.
-- Frederick A. Anderson Jr, PhD, Samuel Z. Goldhaber, MD, Victor F. Tapson, MD, Jean-Francois Bergmann, MD, Ajay K. Kakkar, MD, Bruno Deslandes, MD, Wei Huang, MS, Alexander T. Cohen, MD, ENDORSE Investigators
This article originally appeared in the December 2010 issue of The American Journal of Medicine.
Abstract
Background
Venous thromboembolism prophylaxis is suboptimal in the US despite long-standing evidence-based recommendations. The aim of this subset analysis of the Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) study was to identify characteristics of hospitals with high guideline-recommended prophylaxis use.
Methods
Between September and November 2006, charts from eligible patients aged ≥40 years with an acute medical illness or age ≥18 years and undergoing a surgical procedure were reviewed from randomly selected US acute-care hospitals. Hospitals were ranked based on the proportion of at-risk patients who received American College of Chest Physicians–recommended types of prophylaxis. Hospital characteristics were compared to determine factors related to more frequent prophylaxis use. Hospitals were followed up 1 year after the chart audit.
Results
Overall, 9257 patients were evaluated from 81 hospitals. Appropriate types of prophylaxis were prescribed to more at-risk patients in hospitals in the highest quartile compared with the lowest quartile of prophylaxis use (74% vs 36%). All quartiles had a similar percentage of at-risk patients (61%-65%). Significantly more hospitals in the highest quartile had residency training programs (43% vs 5%), a larger median number of beds (277 vs 140), and had adopted hospital-wide prophylaxis protocols (76% vs 40%). In the follow-up survey, more hospitals overall had adopted hospital-wide written guidelines for venous thromboembolism prevention.
Conclusions
These findings support the value of hospital-wide protocols and local audits for VTE prevention, as recommended by several national quality-of-care groups.
To read this article in its entirety, please visit our website.
-- Frederick A. Anderson Jr, PhD, Samuel Z. Goldhaber, MD, Victor F. Tapson, MD, Jean-Francois Bergmann, MD, Ajay K. Kakkar, MD, Bruno Deslandes, MD, Wei Huang, MS, Alexander T. Cohen, MD, ENDORSE Investigators
This article originally appeared in the December 2010 issue of The American Journal of Medicine.
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