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20-05-2012 | Article

Global medical news in review: May 13-19, 2012

MedWire News: A roundup of select stories of interest to US physicians from the univadis Global Medical News wire.

Pretest probability identifies stress-test candidates

Most patients with low-risk chest pain undergo stress testing regardless of pretest probability for coronary artery disease (CAD), a study has revealed.

However, abnormal test results were uncommon and rarely acted upon, found Srikanth Penumetsa (Baystate Medical Center, Springfield, Massachusetts) and team.

"Low-risk chest pain is a common cause of hospital admission, however to our knowledge, there are no guidelines regarding the appropriate use of stress testing in such cases," they write in the Archives of Internal Medicine.

The team conducted a retrospective cohort study of 2107 patients aged 21 years and older who were admitted to a tertiary care center with chest pain in 2007 and 2008.

Of these patients, 1474 (69.9%) underwent stress testing and the results were abnormal in 184 (12.5%) patients.

Within 30 days, 22 (11.6%) patients with abnormal test results underwent cardiac catheterization, nine (4.7%) underwent revascularization, and two (1.1%) were readmitted for myocardial infarction.

Of patients with low (<10%) pretest probability for CAD, 68.0% underwent stress testing, but only 4.5% of these had abnormal test results. After adjusting for patient age, comorbidities, insurance status, and house staff coverage, intermediate (10‑90%) pretest probability for CAD was significantly associated with stress test ordering, at a relative risk of 1.41, compared with low pretest probability.

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Girls, younger athletes slower to recover from concussion

Gender and age should be taken into account when dealing with sports-related head injury in young people, as girls and younger athletes take longer to recover from concussion than boys and older athletes, researchers say.

Tracey Covassin (Michigan State University, East Lansing, USA) and colleagues analyzed data from 222 young people (157 male; 65 female), aged 14 to 25 years, (150 in high school; 72 in college) who had sustained a sports-related concussion and been enrolled in a 2-year multistate follow-up study.

The participants completed the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) and Post-Concussion Symptom Scale (PCSS) at enrollment and 2, 7, and 14 days after their head injury. They also completed the Balance Error Scoring System (BESS) 1, 2, and 3 days after sustaining concussion.

Female athletes scored significantly worse than male athletes both on visual memory tests (mean score of 65.1 vs 70.1% at all time points) and total number of postconcussive symptoms (mean number of symptoms of 14.4 vs 10.1).

High-school students (mean age 15.5 years) performed worse than college students (mean age 19.2 years) on both verbal and visual memory tests after concussion, with a mean score for all time points of 78.8% versus 82.7%, and 65.8% versus 69.4%, respectively.

"If we can develop treatments that speak directly to sex and age, I think we can better protect athletes from the long-term side effects of concussions," concluded Covassin in The American Journal of Sports Medicine.

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Better insurance means better post-stroke care

Insurance status is an independent predictor for health resource use among stroke survivors of working age, US research indicates.

The disparity in both use and intensity of institutional poststroke acute care (PAC) could help explain why privately insured stroke patients have better outcomes than uninsured and Medicaid-enrolled patients, the study authors suggest in Neurology.

Lesli Skolarus (University of Michigan, Ann Arbor) and team retrospectively analyzed data on 33,917 stroke survivors aged 65 years and under.

In all, 19.3% were uninsured, 19.8% were enrolled in Medicaid, and the remainder had private health insurance. Most patients were discharged home while 22.7% were discharged to PAC (14.8% to an inpatient rehabilitation facility and 8.0% to a skilled nursing facility).

A comparison of patients by insurance status revealed that Medicaid enrollees were more likely to be female and had more comorbidities than privately insured individuals; Medicaid enrollees and uninsured patients were more likely to be admitted to urban hospitals than privately insured patients.

With regard to postdischarge healthcare, PAC was used by 33%, 22%, and 14% of Medicaid, privately insured, and uninsured individuals, respectively. The between-group comparisons were statistically significant, note Skolarus et al.

After adjusting for a raft of patient- and hospital-level factors, uninsured stroke patients were 47% less likely to be discharged to PAC than privately insured patients. Conversely, Medicaid-insured patients were 40% more likely to be discharged to PAC than privately insured patients.

Insurance status predicted not only the use of PAC but also its intensity, report the authors. Among patients who were discharged to PAC, Medicaid enrollees and uninsured individuals were 73% and 52% less likely, respectively, than privately insured patients to go to an inpatient rehabilitation facility rather than to a skilled nursing facility.

Stroke survivors with Medicaid coverage were 2.5 times as likely as privately insured patients to use a skilled nursing facility rather than be discharged home. Meanwhile, uninsured stroke survivors were 55% less likely than privately insured patients to use an inpatient rehabilitation facility, and 27% less likely to use a nursing facility, rather than be discharged home.

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Many a slip 'twixt the sippy cup and the lip Injury from baby bottles, pacifiers, or sippy cups in children under the age of 3 years is more common than might be expected, say researchers.

The team believes that the large majority of these injuries could be avoided by making sure that children are transitioned from bottles and sippy cups to standard lidless cups at 1 year of age, as recommended by the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD).

Parents are also advised to wean their children off pacifier use from 6 months of age as, in addition to injury risk, their use also increases the risk for ear infections.

As reported in Pediatrics, Sarah Keim (The Ohio State University, Columbus) and colleagues used data from the National Electronic Injury Surveillance System to estimate that 43,398 children younger than 3 years of age were treated in emergency departments for injuries sustained from these products between 1991 and 2010, translating to an average of 2270 cases per year.

Of these injuries, 65.8% were from bottles, 19.9% from pacifiers, and 14.3% from sippy cups. The most common injury was to the mouth, in 71.0% of cases, followed by the head, face, or neck in 19.6% of cases.

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Colonoscopy bowel prep made easy

Laxative-free computed tomographic colonography (CTC) is as effective for detection of polyps of 10 mm in size or larger as conventional imaging techniques, research suggests.

Recognizing that colon cleansing before optical colonography (OC) and standard CTC is considered unpleasant and discourages patients from undergoing colorectal cancer screening, the team investigated the efficacy of electronic cleansing software and computer-aided detection.

"Laxative-free CTC addresses an important barrier to screening, and its potential effect on screening merits further investigation," say Michael Zalis (Massachusetts General Hospital, Boston, USA) and co-authors.

As reported in the Annals of Internal Medicine, 605 patients aged 50 to 85 years with a moderate risk for colon cancer underwent laxative-free CTC after ingesting contrast material that tags feces, allowing electronic removal of the material from the images. The same patients were then screened using standard OC with preparative laxative.

Per-patient analysis showed that for adenomas of size 10 mm or larger, per-patient sensitivity (0.91 vs 0.95) and specificity (0.85 vs 0.89) did not significantly differ between laxative-free CTC and OC.

However, laxative-free CTC was significantly less sensitive than OC for detection of adenomas 8 mm or larger (0.70 vs 0.88) and 6 mm or larger (0.59 vs 0.76). Specificity was also significantly lower with CTC than OC at both the 8-mm (0.88 vs 0.91), and 6-mm (0.76 vs 0.94) thresholds.

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Save skin cancer prevention messages for younger crowd

Physicians should counsel individuals aged 10‑24 years about the risk for developing skin cancer as a consequence of sun exposure, whereas older individuals may not benefit from such advice, the US Preventive Services Task Force (USPSTF) suggests.

In its new guidance, the Task Force recognizes that "clinical decisions involve more considerations than evidence alone." It continues: "Clinicians should understand the evidence but individualize decision-making to the specific patient or situation."

In 2003, recommendations on counseling about skin cancer prevention from the USPSTF applied to individuals of any age. But the current review reveals consistent, significant evidence of a preventive impact of counseling only when given to young people, which the guideline notes is "at the age of greatest vulnerability to UV radiation exposure."

The updated USPSTF guidance is based on new evidence from a targeted search of the literature on the risk for sunburn and skin cancer in association with counseling on sun protection.

Traditional messages about cancer prevention and information about the effect of sun exposure on a person's appearance improved cancer preventive behavior in some people, the paper says.

In contrast with the clear benefits of counseling young adults, the USPSTF notes in the latest guidance that "evidence of the effectiveness of counseling interventions in adults older than 24 years or in parents of young children is limited."

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By Neil Osterweil