Denise Napoli

The combination of the connective tissue diseases questionnaire plus rheumatoid factor and anti-cyclic citrullinated peptide antibody positivity had a 95% sensitivity and 32% specificity for identifying people with at least one swollen joint at free community health fairs.

The study, presented at the Western Regional Meeting of the American Federation for Medical Research, is one of few to examine rheumatoid arthritis (RA) screening techniques in the community health fair setting, where more prevalent conditions, such as diabetes receive more attention.

A total of 601 participants were screened at five health fair sites in the greater Denver area administered by the nonprofit 9Health. The researchers administered the 30-item connective tissue diseases questionnaire (Ann. Epidemiol. 1995 Jul;5:297–302) as well as blood tests for rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (anti-CCP). Patients also had a joint examination by a rheumatologist who was unaware of the assay and questionnaire results.

The 601 patients who elected to undergo RA screening represented 16% of the total fair attendees, and more than half said they sought RA screening because they had joint symptoms. A television and Internet ad campaign in the region prior to the fairs helped to raise public awareness about RA symptoms and risk factors.

A total of 84 people (14%) had one or more swollen joints that would be consistent with possible inflammatory arthritis, according to Dr. Kevin Deane, the principal investigator on the study. “Of those individuals with one or more swollen joints, nine met at least four ACR criteria for RA but never had a prior diagnosis,” he said.

“An additional 15 people had a swollen joint and RF or CCP positivity, but met fewer than four ACR RA criteria. They may have early RA,” he added. And another 41 people had either RF or anti-CCP positivity but didn't have any arthritis. “So something is going on immunologically, but no arthritis yet,” said Dr. Deane of the division of rheumatology at the University of Colorado, Denver.

The cost of the screening effort is $42 per person. The RF and anti-CCP assays were paid for by Abbott Laboratories, Inc., which was a cosponsor of the fair, along with Quest Diagnostics and GE Healthcare. The authors disclosed no relevant conflicts of interest.

The combination of the connective tissue diseases questionnaire plus rheumatoid factor and anti-cyclic citrullinated peptide antibody positivity had a 95% sensitivity and 32% specificity for identifying people with at least one swollen joint at free community health fairs.

The study, presented at the Western Regional Meeting of the American Federation for Medical Research, is one of few to examine rheumatoid arthritis (RA) screening techniques in the community health fair setting, where more prevalent conditions, such as diabetes receive more attention.

A total of 601 participants were screened at five health fair sites in the greater Denver area administered by the nonprofit 9Health. The researchers administered the 30-item connective tissue diseases questionnaire (Ann. Epidemiol. 1995 Jul;5:297–302) as well as blood tests for rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (anti-CCP). Patients also had a joint examination by a rheumatologist who was unaware of the assay and questionnaire results.

The 601 patients who elected to undergo RA screening represented 16% of the total fair attendees, and more than half said they sought RA screening because they had joint symptoms. A television and Internet ad campaign in the region prior to the fairs helped to raise public awareness about RA symptoms and risk factors.

A total of 84 people (14%) had one or more swollen joints that would be consistent with possible inflammatory arthritis, according to Dr. Kevin Deane, the principal investigator on the study. “Of those individuals with one or more swollen joints, nine met at least four ACR criteria for RA but never had a prior diagnosis,” he said.

“An additional 15 people had a swollen joint and RF or CCP positivity, but met fewer than four ACR RA criteria. They may have early RA,” he added. And another 41 people had either RF or anti-CCP positivity but didn't have any arthritis. “So something is going on immunologically, but no arthritis yet,” said Dr. Deane of the division of rheumatology at the University of Colorado, Denver.

The cost of the screening effort is $42 per person. The RF and anti-CCP assays were paid for by Abbott Laboratories, Inc., which was a cosponsor of the fair, along with Quest Diagnostics and GE Healthcare. The authors disclosed no relevant conflicts of interest.

The combination of the connective tissue diseases questionnaire plus rheumatoid factor and anti-cyclic citrullinated peptide antibody positivity had a 95% sensitivity and 32% specificity for identifying people with at least one swollen joint at free community health fairs.

The study, presented at the Western Regional Meeting of the American Federation for Medical Research, is one of few to examine rheumatoid arthritis (RA) screening techniques in the community health fair setting, where more prevalent conditions, such as diabetes receive more attention.

A total of 601 participants were screened at five health fair sites in the greater Denver area administered by the nonprofit 9Health. The researchers administered the 30-item connective tissue diseases questionnaire (Ann. Epidemiol. 1995 Jul;5:297–302) as well as blood tests for rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (anti-CCP). Patients also had a joint examination by a rheumatologist who was unaware of the assay and questionnaire results.

The 601 patients who elected to undergo RA screening represented 16% of the total fair attendees, and more than half said they sought RA screening because they had joint symptoms. A television and Internet ad campaign in the region prior to the fairs helped to raise public awareness about RA symptoms and risk factors.

A total of 84 people (14%) had one or more swollen joints that would be consistent with possible inflammatory arthritis, according to Dr. Kevin Deane, the principal investigator on the study. “Of those individuals with one or more swollen joints, nine met at least four ACR criteria for RA but never had a prior diagnosis,” he said.

“An additional 15 people had a swollen joint and RF or CCP positivity, but met fewer than four ACR RA criteria. They may have early RA,” he added. And another 41 people had either RF or anti-CCP positivity but didn't have any arthritis. “So something is going on immunologically, but no arthritis yet,” said Dr. Deane of the division of rheumatology at the University of Colorado, Denver.

The cost of the screening effort is $42 per person. The RF and anti-CCP assays were paid for by Abbott Laboratories, Inc., which was a cosponsor of the fair, along with Quest Diagnostics and GE Healthcare. The authors disclosed no relevant conflicts of interest.

Newly introduced federal legislation would allow registered respiratory therapists to provide services such as smoking cessation, asthma management, and inhaler training to patients without direct on-site supervision by a physician.

A previous version of the bill was introduced in 2007, but the legislation stalled in a House subcommittee and never came to a vote.

The Medicare Respiratory Therapy Initiative Act of 2009 (S. 343) would give patients increased access to treatment, explained two of the bill's cosponsors, Sen. Blanche Lincoln (D-Ark.) and Sen. Mike Crapo (R-Idaho). “This access will be very beneficial to the people of Idaho, many of whom live in rural areas, to get the proper health care they need with the expenses being covered by Medicare,” Sen. Crapo said in a statement.

Under current law, registered respiratory therapists (RRTs), who have a bachelor's degree but no medical school training, may provide services to patients only under the direct, on-site supervision of a physician. The new legislation would amend that to allow “general” physician supervision, such that a physician would need to be available to the RRT and patient during care, but not necessarily physically present on-site.

It's too early to tell whether the bill will meet with success this time around, said Lynne Marcus, vice president of health affairs at the American College of Chest Physicians. However, she hopes it will at least call attention to the need for increased access. “We want to support the better utilization of nonphysician providers,” she said.

Newly introduced federal legislation would allow registered respiratory therapists to provide services such as smoking cessation, asthma management, and inhaler training to patients without direct on-site supervision by a physician.

A previous version of the bill was introduced in 2007, but the legislation stalled in a House subcommittee and never came to a vote.

The Medicare Respiratory Therapy Initiative Act of 2009 (S. 343) would give patients increased access to treatment, explained two of the bill's cosponsors, Sen. Blanche Lincoln (D-Ark.) and Sen. Mike Crapo (R-Idaho). “This access will be very beneficial to the people of Idaho, many of whom live in rural areas, to get the proper health care they need with the expenses being covered by Medicare,” Sen. Crapo said in a statement.

Under current law, registered respiratory therapists (RRTs), who have a bachelor's degree but no medical school training, may provide services to patients only under the direct, on-site supervision of a physician. The new legislation would amend that to allow “general” physician supervision, such that a physician would need to be available to the RRT and patient during care, but not necessarily physically present on-site.

It's too early to tell whether the bill will meet with success this time around, said Lynne Marcus, vice president of health affairs at the American College of Chest Physicians. However, she hopes it will at least call attention to the need for increased access. “We want to support the better utilization of nonphysician providers,” she said.

Newly introduced federal legislation would allow registered respiratory therapists to provide services such as smoking cessation, asthma management, and inhaler training to patients without direct on-site supervision by a physician.

A previous version of the bill was introduced in 2007, but the legislation stalled in a House subcommittee and never came to a vote.

The Medicare Respiratory Therapy Initiative Act of 2009 (S. 343) would give patients increased access to treatment, explained two of the bill's cosponsors, Sen. Blanche Lincoln (D-Ark.) and Sen. Mike Crapo (R-Idaho). “This access will be very beneficial to the people of Idaho, many of whom live in rural areas, to get the proper health care they need with the expenses being covered by Medicare,” Sen. Crapo said in a statement.

Under current law, registered respiratory therapists (RRTs), who have a bachelor's degree but no medical school training, may provide services to patients only under the direct, on-site supervision of a physician. The new legislation would amend that to allow “general” physician supervision, such that a physician would need to be available to the RRT and patient during care, but not necessarily physically present on-site.

It's too early to tell whether the bill will meet with success this time around, said Lynne Marcus, vice president of health affairs at the American College of Chest Physicians. However, she hopes it will at least call attention to the need for increased access. “We want to support the better utilization of nonphysician providers,” she said.

WASHINGTON — Massive budget shortfalls in 40 states, coupled with greater demand for Medicaid coverage, made it tough for states to expand health care coverage for their residents last year, according to the annual survey of state health care and insurance legislation conducted by the Blue Cross Blue Shield Association.

Indeed, these massive budget deficits and the current economic crisis meant that most expansion efforts fell short in 2008, even in high-profile states that had governor backing, like California, New Mexico, and Pennsylvania, according to the annual State of the States report.

“There has not been a consensus [to mandate universal coverage] since Massachusetts, now going on 3 years ago,” said Susan Laudicina, director of state policy and research at the Blue Cross Blue Shield Association. And that effort is not likely to be repeated any time soon, though several states passed laws in 2008 to raise their coverage modestly or intend to phase in increased coverage in 2009.

Additionally, some states are now developing universal care strategies that they will try to pass into law in 2009, she said, including Connecticut, Hawaii, Minnesota, Oregon, and Washington.

The expansion of coverage for children was not spared from states' fiscal problems last year, according to the report. However, some states did manage to modestly expand their Children's Health Insurance Programs (CHIP), including Colorado, Florida, Kansas, and Minnesota.

In New Jersey, the Health Care Reform Act (SB 1537) mandated coverage for all children under the age of 18 years, though without any minimum benefit requirements. “Parents can comply with the mandate program by purchasing a licensed private product or by enrolling in Medicaid or CHIP,” according to the report.

However, the funding source for such an expansion has yet to be determined, as does the enforcement mechanism.

The survey also reported on health care transparency efforts. In the 20 states that introduced such bills in 2008, nine laws were enacted, Ms. Laudicina said.

Some of these, like HB 1393 in Colorado, require hospitals to display charges for common inpatient procedures on a publicly accessible Web site. Others, like Louisiana's Right to Know Act (SB 287), require that the state's department of health and hospitals display not only cost data, but also data on quality measures among medical facilities, individual physicians, and health plans.

Regarding health information technology measures, Ms. Laudicina said that, over the past 3 years, 33 states have enacted legislation promoting the adoption of electronic medical records, and bills are pending in 12 more. And the financial incentives for EMR adoption in the recently passed stimulus package should mean that even more physicians and facilities will implement them voluntarily.

However, concerns about compliance with yet-to-be-set federal health IT standards will likely cause some states to put IT legislation on the back burner.

Other proposals that were considered by states in 2008 included mandated coverage of adult dependent children until age 25, 26, or even 30 years, said Alissa Fox, who is senior vice president of the Office of Policy and Representation at the Blue Cross Blue Shield Association. This possibility will remain on states' agendas in 2009.

The report is based on a survey of the 39 independent Blue Cross and Blue Shield companies across the nation.

WASHINGTON — Massive budget shortfalls in 40 states, coupled with greater demand for Medicaid coverage, made it tough for states to expand health care coverage for their residents last year, according to the annual survey of state health care and insurance legislation conducted by the Blue Cross Blue Shield Association.

Indeed, these massive budget deficits and the current economic crisis meant that most expansion efforts fell short in 2008, even in high-profile states that had governor backing, like California, New Mexico, and Pennsylvania, according to the annual State of the States report.

“There has not been a consensus [to mandate universal coverage] since Massachusetts, now going on 3 years ago,” said Susan Laudicina, director of state policy and research at the Blue Cross Blue Shield Association. And that effort is not likely to be repeated any time soon, though several states passed laws in 2008 to raise their coverage modestly or intend to phase in increased coverage in 2009.

Additionally, some states are now developing universal care strategies that they will try to pass into law in 2009, she said, including Connecticut, Hawaii, Minnesota, Oregon, and Washington.

The expansion of coverage for children was not spared from states' fiscal problems last year, according to the report. However, some states did manage to modestly expand their Children's Health Insurance Programs (CHIP), including Colorado, Florida, Kansas, and Minnesota.

In New Jersey, the Health Care Reform Act (SB 1537) mandated coverage for all children under the age of 18 years, though without any minimum benefit requirements. “Parents can comply with the mandate program by purchasing a licensed private product or by enrolling in Medicaid or CHIP,” according to the report.

However, the funding source for such an expansion has yet to be determined, as does the enforcement mechanism.

The survey also reported on health care transparency efforts. In the 20 states that introduced such bills in 2008, nine laws were enacted, Ms. Laudicina said.

Some of these, like HB 1393 in Colorado, require hospitals to display charges for common inpatient procedures on a publicly accessible Web site. Others, like Louisiana's Right to Know Act (SB 287), require that the state's department of health and hospitals display not only cost data, but also data on quality measures among medical facilities, individual physicians, and health plans.

Regarding health information technology measures, Ms. Laudicina said that, over the past 3 years, 33 states have enacted legislation promoting the adoption of electronic medical records, and bills are pending in 12 more. And the financial incentives for EMR adoption in the recently passed stimulus package should mean that even more physicians and facilities will implement them voluntarily.

However, concerns about compliance with yet-to-be-set federal health IT standards will likely cause some states to put IT legislation on the back burner.

Other proposals that were considered by states in 2008 included mandated coverage of adult dependent children until age 25, 26, or even 30 years, said Alissa Fox, who is senior vice president of the Office of Policy and Representation at the Blue Cross Blue Shield Association. This possibility will remain on states' agendas in 2009.

The report is based on a survey of the 39 independent Blue Cross and Blue Shield companies across the nation.

WASHINGTON — Massive budget shortfalls in 40 states, coupled with greater demand for Medicaid coverage, made it tough for states to expand health care coverage for their residents last year, according to the annual survey of state health care and insurance legislation conducted by the Blue Cross Blue Shield Association.

Indeed, these massive budget deficits and the current economic crisis meant that most expansion efforts fell short in 2008, even in high-profile states that had governor backing, like California, New Mexico, and Pennsylvania, according to the annual State of the States report.

“There has not been a consensus [to mandate universal coverage] since Massachusetts, now going on 3 years ago,” said Susan Laudicina, director of state policy and research at the Blue Cross Blue Shield Association. And that effort is not likely to be repeated any time soon, though several states passed laws in 2008 to raise their coverage modestly or intend to phase in increased coverage in 2009.

Additionally, some states are now developing universal care strategies that they will try to pass into law in 2009, she said, including Connecticut, Hawaii, Minnesota, Oregon, and Washington.

The expansion of coverage for children was not spared from states' fiscal problems last year, according to the report. However, some states did manage to modestly expand their Children's Health Insurance Programs (CHIP), including Colorado, Florida, Kansas, and Minnesota.

In New Jersey, the Health Care Reform Act (SB 1537) mandated coverage for all children under the age of 18 years, though without any minimum benefit requirements. “Parents can comply with the mandate program by purchasing a licensed private product or by enrolling in Medicaid or CHIP,” according to the report.

However, the funding source for such an expansion has yet to be determined, as does the enforcement mechanism.

The survey also reported on health care transparency efforts. In the 20 states that introduced such bills in 2008, nine laws were enacted, Ms. Laudicina said.

Some of these, like HB 1393 in Colorado, require hospitals to display charges for common inpatient procedures on a publicly accessible Web site. Others, like Louisiana's Right to Know Act (SB 287), require that the state's department of health and hospitals display not only cost data, but also data on quality measures among medical facilities, individual physicians, and health plans.

Regarding health information technology measures, Ms. Laudicina said that, over the past 3 years, 33 states have enacted legislation promoting the adoption of electronic medical records, and bills are pending in 12 more. And the financial incentives for EMR adoption in the recently passed stimulus package should mean that even more physicians and facilities will implement them voluntarily.

However, concerns about compliance with yet-to-be-set federal health IT standards will likely cause some states to put IT legislation on the back burner.

Other proposals that were considered by states in 2008 included mandated coverage of adult dependent children until age 25, 26, or even 30 years, said Alissa Fox, who is senior vice president of the Office of Policy and Representation at the Blue Cross Blue Shield Association. This possibility will remain on states' agendas in 2009.

The report is based on a survey of the 39 independent Blue Cross and Blue Shield companies across the nation.

A combination of ultrasound and a novel two-barrel syringe significantly decreased the nonresponder rate in intra-articular injections compared with a traditional, palpation-guided, single-barrel syringe method, according to findings from a study of 148 patients.

In fact, the nonresponder rate fell a significant 62%, from 28.4% in the traditional injection method group to 10% with the new, ultrasound-guided method.

Moreover, the ultrasound-guided technique reduced pain at 2 weeks by 75% compared with the traditional method.

The study was randomized but not double-blinded, since both the physician and patient could see which method was used, and was presented at the Western Regional Meeting of the American Federation for Medical Research.

The novel injection method consisted of manual palpation of the joint, followed by superficial marking and assessment with ultrasound to “define the anatomy, determine the presence of effusion, and confirm the optimal anatomic approach,” Dr. Kye S. Park of the University of New Mexico, Albuquerque, said in an interview.

Then, using a two-syringe needle known as the reciprocating procedure device (RPD), one barrel delivered local anesthesia and performed aspiration, if necessary, while the second barrel injected the therapeutic agent—in this study, triamcinolone acetonide.

“It's a two-barrel syringe, and essentially you control it with one hand,” Dr. Park said. “You aspirate and inject by pushing one or the other plunger. Normally when you put in a one-barrel traditional syringe, when you inject, you're pressing your flexor. Then to aspirate, you have to pull out. With this, you're using the same motion to inject and aspirate, but when you push one plunger to aspirate, the other [chamber of the syringe] is the one that's actually filling up with fluid,” he explained.

The traditional method used palpation-guided injections with a standard needle.

The average patient age in the ultrasound group was 52 years, compared with 56 years in the traditional group. In both groups, more than 80% of patients were female, and nearly three-quarters had inflammatory arthritis. Pain was assessed on a 0- to 10-cm visual analog scale (as opposed to the more conventionally used 0- to 100-mm scale). Nonresponders were defined as having significant persistent joint pain that was rated as being greater than or equal to 5 cm at 2 weeks following treatment.

Although physicians are becoming more aware of the benefits of ultrasound-guided intra-articular injections, the RPD is still relatively unknown among rheumatologists, said Dr. Park. It is particularly useful if a rheumatologist intends to be the sole operator of both the ultrasound and the needle, because the physician does not need to change positions, he added.

However, both ultrasound and the RPD add cost—the ultrasound itself can cost an additional $75-$150 per procedure, and the RPD tacks on an extra $1.50 per injection. The use of ultrasound about doubles the time it takes to perform the injection. Therefore, regarding “the implications of something like this being used widespread, there obviously needs to be a cost analysis,” said Dr. Park.

Dr. Park said that the utility of the new method is especially pronounced in dry joints (without effusion), where “the actual space between the cartilage and the synovium is really small. So when we put a needle in, we're finding that sometimes we're not in the place we think we are, and we're actually injecting into subcutaneous tissue,” he said. “What we can see in real time with ultrasound is the synovial space actually expanding when you put in fluid.” And while he conceded that joints with large effusions (less than 10% of joint injections) may stand to benefit less from this technique, “In a joint without effusion that has collapsed down (90% of injections), it's a benefit. And that is the great majority of injections.”

Ultrasound-guided injections may also benefit obese patients. “We're finding we need much larger or longer needles to get into those joint spaces. So it's been tremendously helpful in those areas.”

One of Dr. Park's research colleagues, Dr. Wilmer Sibbitt, was a developer of the Food and Drug Administration-approved reciprocating procedure device, now marketed by Avanca Medical Devices Inc. He reported having no other conflicts to disclose.

To watch a related video, go to www.youtube.com/FamilyPracticeNews

A physician uses ultrasound and the reciprocating procedure device. Courtesy Dr. Kye S. Park

A combination of ultrasound and a novel two-barrel syringe significantly decreased the nonresponder rate in intra-articular injections compared with a traditional, palpation-guided, single-barrel syringe method, according to findings from a study of 148 patients.

In fact, the nonresponder rate fell a significant 62%, from 28.4% in the traditional injection method group to 10% with the new, ultrasound-guided method.

Moreover, the ultrasound-guided technique reduced pain at 2 weeks by 75% compared with the traditional method.

The study was randomized but not double-blinded, since both the physician and patient could see which method was used, and was presented at the Western Regional Meeting of the American Federation for Medical Research.

The novel injection method consisted of manual palpation of the joint, followed by superficial marking and assessment with ultrasound to “define the anatomy, determine the presence of effusion, and confirm the optimal anatomic approach,” Dr. Kye S. Park of the University of New Mexico, Albuquerque, said in an interview.

Then, using a two-syringe needle known as the reciprocating procedure device (RPD), one barrel delivered local anesthesia and performed aspiration, if necessary, while the second barrel injected the therapeutic agent—in this study, triamcinolone acetonide.

“It's a two-barrel syringe, and essentially you control it with one hand,” Dr. Park said. “You aspirate and inject by pushing one or the other plunger. Normally when you put in a one-barrel traditional syringe, when you inject, you're pressing your flexor. Then to aspirate, you have to pull out. With this, you're using the same motion to inject and aspirate, but when you push one plunger to aspirate, the other [chamber of the syringe] is the one that's actually filling up with fluid,” he explained.

The traditional method used palpation-guided injections with a standard needle.

The average patient age in the ultrasound group was 52 years, compared with 56 years in the traditional group. In both groups, more than 80% of patients were female, and nearly three-quarters had inflammatory arthritis. Pain was assessed on a 0- to 10-cm visual analog scale (as opposed to the more conventionally used 0- to 100-mm scale). Nonresponders were defined as having significant persistent joint pain that was rated as being greater than or equal to 5 cm at 2 weeks following treatment.

Although physicians are becoming more aware of the benefits of ultrasound-guided intra-articular injections, the RPD is still relatively unknown among rheumatologists, said Dr. Park. It is particularly useful if a rheumatologist intends to be the sole operator of both the ultrasound and the needle, because the physician does not need to change positions, he added.

However, both ultrasound and the RPD add cost—the ultrasound itself can cost an additional $75-$150 per procedure, and the RPD tacks on an extra $1.50 per injection. The use of ultrasound about doubles the time it takes to perform the injection. Therefore, regarding “the implications of something like this being used widespread, there obviously needs to be a cost analysis,” said Dr. Park.

Dr. Park said that the utility of the new method is especially pronounced in dry joints (without effusion), where “the actual space between the cartilage and the synovium is really small. So when we put a needle in, we're finding that sometimes we're not in the place we think we are, and we're actually injecting into subcutaneous tissue,” he said. “What we can see in real time with ultrasound is the synovial space actually expanding when you put in fluid.” And while he conceded that joints with large effusions (less than 10% of joint injections) may stand to benefit less from this technique, “In a joint without effusion that has collapsed down (90% of injections), it's a benefit. And that is the great majority of injections.”

Ultrasound-guided injections may also benefit obese patients. “We're finding we need much larger or longer needles to get into those joint spaces. So it's been tremendously helpful in those areas.”

One of Dr. Park's research colleagues, Dr. Wilmer Sibbitt, was a developer of the Food and Drug Administration-approved reciprocating procedure device, now marketed by Avanca Medical Devices Inc. He reported having no other conflicts to disclose.

To watch a related video, go to www.youtube.com/FamilyPracticeNews

A physician uses ultrasound and the reciprocating procedure device. Courtesy Dr. Kye S. Park

A combination of ultrasound and a novel two-barrel syringe significantly decreased the nonresponder rate in intra-articular injections compared with a traditional, palpation-guided, single-barrel syringe method, according to findings from a study of 148 patients.

In fact, the nonresponder rate fell a significant 62%, from 28.4% in the traditional injection method group to 10% with the new, ultrasound-guided method.

Moreover, the ultrasound-guided technique reduced pain at 2 weeks by 75% compared with the traditional method.

The study was randomized but not double-blinded, since both the physician and patient could see which method was used, and was presented at the Western Regional Meeting of the American Federation for Medical Research.

The novel injection method consisted of manual palpation of the joint, followed by superficial marking and assessment with ultrasound to “define the anatomy, determine the presence of effusion, and confirm the optimal anatomic approach,” Dr. Kye S. Park of the University of New Mexico, Albuquerque, said in an interview.

Then, using a two-syringe needle known as the reciprocating procedure device (RPD), one barrel delivered local anesthesia and performed aspiration, if necessary, while the second barrel injected the therapeutic agent—in this study, triamcinolone acetonide.

“It's a two-barrel syringe, and essentially you control it with one hand,” Dr. Park said. “You aspirate and inject by pushing one or the other plunger. Normally when you put in a one-barrel traditional syringe, when you inject, you're pressing your flexor. Then to aspirate, you have to pull out. With this, you're using the same motion to inject and aspirate, but when you push one plunger to aspirate, the other [chamber of the syringe] is the one that's actually filling up with fluid,” he explained.

The traditional method used palpation-guided injections with a standard needle.

The average patient age in the ultrasound group was 52 years, compared with 56 years in the traditional group. In both groups, more than 80% of patients were female, and nearly three-quarters had inflammatory arthritis. Pain was assessed on a 0- to 10-cm visual analog scale (as opposed to the more conventionally used 0- to 100-mm scale). Nonresponders were defined as having significant persistent joint pain that was rated as being greater than or equal to 5 cm at 2 weeks following treatment.

Although physicians are becoming more aware of the benefits of ultrasound-guided intra-articular injections, the RPD is still relatively unknown among rheumatologists, said Dr. Park. It is particularly useful if a rheumatologist intends to be the sole operator of both the ultrasound and the needle, because the physician does not need to change positions, he added.

However, both ultrasound and the RPD add cost—the ultrasound itself can cost an additional $75-$150 per procedure, and the RPD tacks on an extra $1.50 per injection. The use of ultrasound about doubles the time it takes to perform the injection. Therefore, regarding “the implications of something like this being used widespread, there obviously needs to be a cost analysis,” said Dr. Park.

Dr. Park said that the utility of the new method is especially pronounced in dry joints (without effusion), where “the actual space between the cartilage and the synovium is really small. So when we put a needle in, we're finding that sometimes we're not in the place we think we are, and we're actually injecting into subcutaneous tissue,” he said. “What we can see in real time with ultrasound is the synovial space actually expanding when you put in fluid.” And while he conceded that joints with large effusions (less than 10% of joint injections) may stand to benefit less from this technique, “In a joint without effusion that has collapsed down (90% of injections), it's a benefit. And that is the great majority of injections.”

Ultrasound-guided injections may also benefit obese patients. “We're finding we need much larger or longer needles to get into those joint spaces. So it's been tremendously helpful in those areas.”

One of Dr. Park's research colleagues, Dr. Wilmer Sibbitt, was a developer of the Food and Drug Administration-approved reciprocating procedure device, now marketed by Avanca Medical Devices Inc. He reported having no other conflicts to disclose.

To watch a related video, go to www.youtube.com/FamilyPracticeNews

A physician uses ultrasound and the reciprocating procedure device. Courtesy Dr. Kye S. Park

WASHINGTON — Massive budget shortfalls in 40 states coupled with greater demand for Medicaid coverage made it tough for states to expand health care coverage for their residents last year, according to the annual survey of state health care and insurance legislation conducted by the Blue Cross Blue Shield Association.

Indeed, these massive budget deficits and the current economic crisis meant that most expansion efforts fell short in 2008, even in high-profile states with governor backing, like California, New Mexico, and Pennsylvania, according to the annual State of the States report.

“There has not been a consensus [to mandate universal coverage] since Massachusetts, now going on 3 years ago,” said Susan Laudicina, director of state policy and research at the Blue Cross Blue Shield Association. And that effort is not likely to be repeated any time soon, though several states passed laws in 2008 to raise their coverage modestly or intend to phase in increased coverage in 2009.

Additionally, some states are now developing universal care strategies that they will try to pass into law in 2009, she said, including Connecticut, Hawaii, Minnesota, Oregon, and Washington.

Expansion of coverage for children was not spared from states' fiscal problems last year, according to the report. However, some states did modestly expand their Children's Health Insurance Programs (CHIP), including Colorado, Florida, Kansas, and Minnesota.

In New Jersey, the Health Care Reform Act (SB 1537) mandated coverage for all children under age 18 years, though without any minimum benefit requirements. “Parents can comply with the mandate program by purchasing a licensed private product or by enrolling in Medicaid or CHIP,” according to the report.

However, the funding source for such an expansion has yet to be determined, as does the enforcement mechanism.

The survey also reported on health care transparency efforts. In the 20 states that introduced such bills in 2008, nine laws were enacted, Ms. Laudicina said. Some of these, like HB 1393 in Colorado, require hospitals to display charges for common inpatient procedures on a publicly accessible Web site. Others, like Louisiana's Right to Know Act (SB 287), require that the state's department of health and hospitals displays not only cost data, but also data on quality measures among medical facilities, individual physicians, and health plans.

Over the past 3 years, 33 states have enacted legislation promoting the adoption of electronic medical records, and bills are pending in 12 more, Ms. Laudicina said. The financial incentives for EMR adoption in the new stimulus package should mean that even more physicians and facilities implement EMRs voluntarily.

However, concerns about compliance with yet-to-be-set federal health IT standards will likely cause some states to put IT legislation on the back burner.

Other proposals considered by states in 2008 included mandated coverage of adult dependent children until age 25, 26, or even 30 years, said Alissa Fox, senior vice president of the Office of Policy and Representation at the Blue Cross Blue Shield Association. This possibility will remain on states' agendas in 2009.

The report is based on a survey of the 39 independent Blue Cross and Blue Shield companies across the nation.

WASHINGTON — Massive budget shortfalls in 40 states coupled with greater demand for Medicaid coverage made it tough for states to expand health care coverage for their residents last year, according to the annual survey of state health care and insurance legislation conducted by the Blue Cross Blue Shield Association.

Indeed, these massive budget deficits and the current economic crisis meant that most expansion efforts fell short in 2008, even in high-profile states with governor backing, like California, New Mexico, and Pennsylvania, according to the annual State of the States report.

“There has not been a consensus [to mandate universal coverage] since Massachusetts, now going on 3 years ago,” said Susan Laudicina, director of state policy and research at the Blue Cross Blue Shield Association. And that effort is not likely to be repeated any time soon, though several states passed laws in 2008 to raise their coverage modestly or intend to phase in increased coverage in 2009.

Additionally, some states are now developing universal care strategies that they will try to pass into law in 2009, she said, including Connecticut, Hawaii, Minnesota, Oregon, and Washington.

Expansion of coverage for children was not spared from states' fiscal problems last year, according to the report. However, some states did modestly expand their Children's Health Insurance Programs (CHIP), including Colorado, Florida, Kansas, and Minnesota.

In New Jersey, the Health Care Reform Act (SB 1537) mandated coverage for all children under age 18 years, though without any minimum benefit requirements. “Parents can comply with the mandate program by purchasing a licensed private product or by enrolling in Medicaid or CHIP,” according to the report.

However, the funding source for such an expansion has yet to be determined, as does the enforcement mechanism.

The survey also reported on health care transparency efforts. In the 20 states that introduced such bills in 2008, nine laws were enacted, Ms. Laudicina said. Some of these, like HB 1393 in Colorado, require hospitals to display charges for common inpatient procedures on a publicly accessible Web site. Others, like Louisiana's Right to Know Act (SB 287), require that the state's department of health and hospitals displays not only cost data, but also data on quality measures among medical facilities, individual physicians, and health plans.

Over the past 3 years, 33 states have enacted legislation promoting the adoption of electronic medical records, and bills are pending in 12 more, Ms. Laudicina said. The financial incentives for EMR adoption in the new stimulus package should mean that even more physicians and facilities implement EMRs voluntarily.

However, concerns about compliance with yet-to-be-set federal health IT standards will likely cause some states to put IT legislation on the back burner.

Other proposals considered by states in 2008 included mandated coverage of adult dependent children until age 25, 26, or even 30 years, said Alissa Fox, senior vice president of the Office of Policy and Representation at the Blue Cross Blue Shield Association. This possibility will remain on states' agendas in 2009.

The report is based on a survey of the 39 independent Blue Cross and Blue Shield companies across the nation.

WASHINGTON — Massive budget shortfalls in 40 states coupled with greater demand for Medicaid coverage made it tough for states to expand health care coverage for their residents last year, according to the annual survey of state health care and insurance legislation conducted by the Blue Cross Blue Shield Association.

Indeed, these massive budget deficits and the current economic crisis meant that most expansion efforts fell short in 2008, even in high-profile states with governor backing, like California, New Mexico, and Pennsylvania, according to the annual State of the States report.

“There has not been a consensus [to mandate universal coverage] since Massachusetts, now going on 3 years ago,” said Susan Laudicina, director of state policy and research at the Blue Cross Blue Shield Association. And that effort is not likely to be repeated any time soon, though several states passed laws in 2008 to raise their coverage modestly or intend to phase in increased coverage in 2009.

Additionally, some states are now developing universal care strategies that they will try to pass into law in 2009, she said, including Connecticut, Hawaii, Minnesota, Oregon, and Washington.

Expansion of coverage for children was not spared from states' fiscal problems last year, according to the report. However, some states did modestly expand their Children's Health Insurance Programs (CHIP), including Colorado, Florida, Kansas, and Minnesota.

In New Jersey, the Health Care Reform Act (SB 1537) mandated coverage for all children under age 18 years, though without any minimum benefit requirements. “Parents can comply with the mandate program by purchasing a licensed private product or by enrolling in Medicaid or CHIP,” according to the report.

However, the funding source for such an expansion has yet to be determined, as does the enforcement mechanism.

The survey also reported on health care transparency efforts. In the 20 states that introduced such bills in 2008, nine laws were enacted, Ms. Laudicina said. Some of these, like HB 1393 in Colorado, require hospitals to display charges for common inpatient procedures on a publicly accessible Web site. Others, like Louisiana's Right to Know Act (SB 287), require that the state's department of health and hospitals displays not only cost data, but also data on quality measures among medical facilities, individual physicians, and health plans.

Over the past 3 years, 33 states have enacted legislation promoting the adoption of electronic medical records, and bills are pending in 12 more, Ms. Laudicina said. The financial incentives for EMR adoption in the new stimulus package should mean that even more physicians and facilities implement EMRs voluntarily.

However, concerns about compliance with yet-to-be-set federal health IT standards will likely cause some states to put IT legislation on the back burner.

Other proposals considered by states in 2008 included mandated coverage of adult dependent children until age 25, 26, or even 30 years, said Alissa Fox, senior vice president of the Office of Policy and Representation at the Blue Cross Blue Shield Association. This possibility will remain on states' agendas in 2009.

The report is based on a survey of the 39 independent Blue Cross and Blue Shield companies across the nation.

Preschool-aged children taking a multispecies probiotic showed a significant reduction in gastrointestinal infection, both over the short and long term, according to a Taiwanese study.

Although single-strain probiotics did not have such an effect on gastrointestinal diseases, consumption of Lactobacillus casei rhamnosus reduced the incidence of respiratory infections, the investigators said, and the long-term use of Lactobacillus rhamnosus T cell-1 may decrease the incidence of bacterial infection overall.

“This investigation strongly suggests that there is a need for rational probiotic selection and detailed evaluation prior to application in food or health care products,” wrote Dr. Jun-Song Lin of the department of pediatrics at the Buddhist Tzu Chi General Hospital in Hualien, Taiwan, and colleagues (Vaccine 2009;27:1073–9).

The study randomized 1,062 preschool children ages 5 years or younger into four groups receiving commercially available probiotic oral pills. Overall, 986 children completed the study.

A total of 285 children received L. casei rhamnosus 5 days a week, while 222 children received Lactobacillus rhamnosus T cell-1 for 5 days per week. A third group of 286 children took a multispecies probiotic with a mixture of 12 bacterial strains for 5 days per week, and 193 patients served as controls.

The investigators' goal was to assess the three probiotics' short- and long-term efficacy in preventing viral infectious disease, gastrointestinal disease, respiratory disease, and bacterial infectious disease.

Efficacy was assessed after 3.3 months of treatment and then again at 7.3 months of treatment. Intervention began when children entered preschool, a time when the incidence of all diseases typically increases.

The researchers saw no difference in the number of gastrointestinal diseases between baseline and the intervention period in the single-strain group. However, children in the multiple-strain probiotic group “experienced a significant reduction in gastrointestinal infection both during the short term … and the long term,” the researchers noted.

The degree of reduction was 42% after 3.3 months of treatment and 44% after 7.3 months of treatment, wrote Dr. Lin and associates.

Bacterial infections were significantly reduced in the long term by an average of 1.8 times in the group of children that took L. casei rhamnosus, and by an average of 1.92 times for the group taking L. rhamnosus T cell-1. The multispecies probiotic supplement, however, had no significant effect on the prevention of bacterial infections, the researchers said, which might be caused by antagonism among the different strains in the supplement.

In the L. casei rhamnosus group, the incidence of viral infectious diseases was 18% lower than among the control group over the short term. That effect possibly resulted from “probiotics positively influencing systemic organs by modulating immune function, stimulating virus-specific antibody production, and affecting intestinal mucosa absorption and secretion,” the authors said.

The incidence of respiratory infections was also reduced both in the short and long term for the L. casei rhamnosus group by 17% and 18%, respectively, compared with the control group.

The authors declared no personal conflicts of interest, but disclosed that the study was funded by Success Medical Corp., Chang Gung Biotechnology Corp., and Multipower Enterprise Corp., all of which make probiotic supplements.

Preschool-aged children taking a multispecies probiotic showed a significant reduction in gastrointestinal infection, both over the short and long term, according to a Taiwanese study.

Although single-strain probiotics did not have such an effect on gastrointestinal diseases, consumption of Lactobacillus casei rhamnosus reduced the incidence of respiratory infections, the investigators said, and the long-term use of Lactobacillus rhamnosus T cell-1 may decrease the incidence of bacterial infection overall.

“This investigation strongly suggests that there is a need for rational probiotic selection and detailed evaluation prior to application in food or health care products,” wrote Dr. Jun-Song Lin of the department of pediatrics at the Buddhist Tzu Chi General Hospital in Hualien, Taiwan, and colleagues (Vaccine 2009;27:1073–9).

The study randomized 1,062 preschool children ages 5 years or younger into four groups receiving commercially available probiotic oral pills. Overall, 986 children completed the study.

A total of 285 children received L. casei rhamnosus 5 days a week, while 222 children received Lactobacillus rhamnosus T cell-1 for 5 days per week. A third group of 286 children took a multispecies probiotic with a mixture of 12 bacterial strains for 5 days per week, and 193 patients served as controls.

The investigators' goal was to assess the three probiotics' short- and long-term efficacy in preventing viral infectious disease, gastrointestinal disease, respiratory disease, and bacterial infectious disease.

Efficacy was assessed after 3.3 months of treatment and then again at 7.3 months of treatment. Intervention began when children entered preschool, a time when the incidence of all diseases typically increases.

The researchers saw no difference in the number of gastrointestinal diseases between baseline and the intervention period in the single-strain group. However, children in the multiple-strain probiotic group “experienced a significant reduction in gastrointestinal infection both during the short term … and the long term,” the researchers noted.

The degree of reduction was 42% after 3.3 months of treatment and 44% after 7.3 months of treatment, wrote Dr. Lin and associates.

Bacterial infections were significantly reduced in the long term by an average of 1.8 times in the group of children that took L. casei rhamnosus, and by an average of 1.92 times for the group taking L. rhamnosus T cell-1. The multispecies probiotic supplement, however, had no significant effect on the prevention of bacterial infections, the researchers said, which might be caused by antagonism among the different strains in the supplement.

In the L. casei rhamnosus group, the incidence of viral infectious diseases was 18% lower than among the control group over the short term. That effect possibly resulted from “probiotics positively influencing systemic organs by modulating immune function, stimulating virus-specific antibody production, and affecting intestinal mucosa absorption and secretion,” the authors said.

The incidence of respiratory infections was also reduced both in the short and long term for the L. casei rhamnosus group by 17% and 18%, respectively, compared with the control group.

The authors declared no personal conflicts of interest, but disclosed that the study was funded by Success Medical Corp., Chang Gung Biotechnology Corp., and Multipower Enterprise Corp., all of which make probiotic supplements.

Preschool-aged children taking a multispecies probiotic showed a significant reduction in gastrointestinal infection, both over the short and long term, according to a Taiwanese study.

Although single-strain probiotics did not have such an effect on gastrointestinal diseases, consumption of Lactobacillus casei rhamnosus reduced the incidence of respiratory infections, the investigators said, and the long-term use of Lactobacillus rhamnosus T cell-1 may decrease the incidence of bacterial infection overall.

“This investigation strongly suggests that there is a need for rational probiotic selection and detailed evaluation prior to application in food or health care products,” wrote Dr. Jun-Song Lin of the department of pediatrics at the Buddhist Tzu Chi General Hospital in Hualien, Taiwan, and colleagues (Vaccine 2009;27:1073–9).

The study randomized 1,062 preschool children ages 5 years or younger into four groups receiving commercially available probiotic oral pills. Overall, 986 children completed the study.

A total of 285 children received L. casei rhamnosus 5 days a week, while 222 children received Lactobacillus rhamnosus T cell-1 for 5 days per week. A third group of 286 children took a multispecies probiotic with a mixture of 12 bacterial strains for 5 days per week, and 193 patients served as controls.

The investigators' goal was to assess the three probiotics' short- and long-term efficacy in preventing viral infectious disease, gastrointestinal disease, respiratory disease, and bacterial infectious disease.

Efficacy was assessed after 3.3 months of treatment and then again at 7.3 months of treatment. Intervention began when children entered preschool, a time when the incidence of all diseases typically increases.

The researchers saw no difference in the number of gastrointestinal diseases between baseline and the intervention period in the single-strain group. However, children in the multiple-strain probiotic group “experienced a significant reduction in gastrointestinal infection both during the short term … and the long term,” the researchers noted.

The degree of reduction was 42% after 3.3 months of treatment and 44% after 7.3 months of treatment, wrote Dr. Lin and associates.

Bacterial infections were significantly reduced in the long term by an average of 1.8 times in the group of children that took L. casei rhamnosus, and by an average of 1.92 times for the group taking L. rhamnosus T cell-1. The multispecies probiotic supplement, however, had no significant effect on the prevention of bacterial infections, the researchers said, which might be caused by antagonism among the different strains in the supplement.

In the L. casei rhamnosus group, the incidence of viral infectious diseases was 18% lower than among the control group over the short term. That effect possibly resulted from “probiotics positively influencing systemic organs by modulating immune function, stimulating virus-specific antibody production, and affecting intestinal mucosa absorption and secretion,” the authors said.

The incidence of respiratory infections was also reduced both in the short and long term for the L. casei rhamnosus group by 17% and 18%, respectively, compared with the control group.

The authors declared no personal conflicts of interest, but disclosed that the study was funded by Success Medical Corp., Chang Gung Biotechnology Corp., and Multipower Enterprise Corp., all of which make probiotic supplements.

Two forms of postnatal intervention—one with trained nurses or midwives, and another with a peer—significantly reduced the likelihood of postnatal depression, according to the findings of two studies.

The studies “add to the growing evidence that postnatal depression can be effectively treated and possibly prevented,” Dr. Cindy-Lee Dennis of the department of psychiatry at the University of Toronto and one of the lead investigators, wrote in an accompanying editorial.

The first study assessed the impact of an intervention conducted by “health visitors” trained to identify depressive symptoms using the Edinburgh postnatal depression scale (EPDS) and to use clinical mood assessment skills, wrote Dr. C. Jane Morrell of the University of Huddersfield (England) and her colleagues.

The health visitors provided weekly 1-hour counseling sessions in the mother's home for up to 8 weeks. A control group was given usual care, without the in-home sessions.

A total of 4,084 eligible women consented to participate, and 595 had a 6-week EPDS score greater than or equal to 12, which indicates the possibility of depression. The maximum score is 30. Ultimately, 418 women had follow-up EPDS scores at 6 months and were analyzed.

At 6 months, the 271 women in the intervention group whose 6-week score had been greater than or equal to 12 were 40% less likely to have a score greater than or equal to 12, compared with the 147 women in the control group. The differences in the mean EPDS scores were sustained at 12 months (BMJ 2009;338:a3045[doi:10.1136/bmj.a3045]). The study was funded entirely by the NHS.

The second randomized, controlled trial looked at the impact of a telephone-based intervention with nonmedical professional peers for postnatal women with an EPDS greater than 12.

A total of 315 women received usual care with follow-up information available at 12 weeks. In contrast, the 297 women who were randomized to the intervention group and had follow-up data at 12 weeks received usual care plus telephone access to a peer volunteer—a mother who had personally experienced postnatal depression.

“Women in the intervention group were significantly less likely to have symptoms of depression at the 12-week assessment than [were] those in the control group (odds ratio 2.1),” wrote the authors, led by Dr. Dennis. “Specifically, 14% (40/297) of women in the intervention group had a score greater than 12, compared with 25% (78/315) in the control group” (BMJ 2009;338:a3045[doi:10.1136/bmj.a3064]).

The study was supported by the Canadian Institutes of Health.

Authors from both studies reported having no conflicts of interests.

Two forms of postnatal intervention—one with trained nurses or midwives, and another with a peer—significantly reduced the likelihood of postnatal depression, according to the findings of two studies.

The studies “add to the growing evidence that postnatal depression can be effectively treated and possibly prevented,” Dr. Cindy-Lee Dennis of the department of psychiatry at the University of Toronto and one of the lead investigators, wrote in an accompanying editorial.

The first study assessed the impact of an intervention conducted by “health visitors” trained to identify depressive symptoms using the Edinburgh postnatal depression scale (EPDS) and to use clinical mood assessment skills, wrote Dr. C. Jane Morrell of the University of Huddersfield (England) and her colleagues.

The health visitors provided weekly 1-hour counseling sessions in the mother's home for up to 8 weeks. A control group was given usual care, without the in-home sessions.

A total of 4,084 eligible women consented to participate, and 595 had a 6-week EPDS score greater than or equal to 12, which indicates the possibility of depression. The maximum score is 30. Ultimately, 418 women had follow-up EPDS scores at 6 months and were analyzed.

At 6 months, the 271 women in the intervention group whose 6-week score had been greater than or equal to 12 were 40% less likely to have a score greater than or equal to 12, compared with the 147 women in the control group. The differences in the mean EPDS scores were sustained at 12 months (BMJ 2009;338:a3045[doi:10.1136/bmj.a3045]). The study was funded entirely by the NHS.

The second randomized, controlled trial looked at the impact of a telephone-based intervention with nonmedical professional peers for postnatal women with an EPDS greater than 12.

A total of 315 women received usual care with follow-up information available at 12 weeks. In contrast, the 297 women who were randomized to the intervention group and had follow-up data at 12 weeks received usual care plus telephone access to a peer volunteer—a mother who had personally experienced postnatal depression.

“Women in the intervention group were significantly less likely to have symptoms of depression at the 12-week assessment than [were] those in the control group (odds ratio 2.1),” wrote the authors, led by Dr. Dennis. “Specifically, 14% (40/297) of women in the intervention group had a score greater than 12, compared with 25% (78/315) in the control group” (BMJ 2009;338:a3045[doi:10.1136/bmj.a3064]).

The study was supported by the Canadian Institutes of Health.

Authors from both studies reported having no conflicts of interests.

Two forms of postnatal intervention—one with trained nurses or midwives, and another with a peer—significantly reduced the likelihood of postnatal depression, according to the findings of two studies.

The studies “add to the growing evidence that postnatal depression can be effectively treated and possibly prevented,” Dr. Cindy-Lee Dennis of the department of psychiatry at the University of Toronto and one of the lead investigators, wrote in an accompanying editorial.

The first study assessed the impact of an intervention conducted by “health visitors” trained to identify depressive symptoms using the Edinburgh postnatal depression scale (EPDS) and to use clinical mood assessment skills, wrote Dr. C. Jane Morrell of the University of Huddersfield (England) and her colleagues.

The health visitors provided weekly 1-hour counseling sessions in the mother's home for up to 8 weeks. A control group was given usual care, without the in-home sessions.

A total of 4,084 eligible women consented to participate, and 595 had a 6-week EPDS score greater than or equal to 12, which indicates the possibility of depression. The maximum score is 30. Ultimately, 418 women had follow-up EPDS scores at 6 months and were analyzed.

At 6 months, the 271 women in the intervention group whose 6-week score had been greater than or equal to 12 were 40% less likely to have a score greater than or equal to 12, compared with the 147 women in the control group. The differences in the mean EPDS scores were sustained at 12 months (BMJ 2009;338:a3045[doi:10.1136/bmj.a3045]). The study was funded entirely by the NHS.

The second randomized, controlled trial looked at the impact of a telephone-based intervention with nonmedical professional peers for postnatal women with an EPDS greater than 12.

A total of 315 women received usual care with follow-up information available at 12 weeks. In contrast, the 297 women who were randomized to the intervention group and had follow-up data at 12 weeks received usual care plus telephone access to a peer volunteer—a mother who had personally experienced postnatal depression.

“Women in the intervention group were significantly less likely to have symptoms of depression at the 12-week assessment than [were] those in the control group (odds ratio 2.1),” wrote the authors, led by Dr. Dennis. “Specifically, 14% (40/297) of women in the intervention group had a score greater than 12, compared with 25% (78/315) in the control group” (BMJ 2009;338:a3045[doi:10.1136/bmj.a3064]).

The study was supported by the Canadian Institutes of Health.

Authors from both studies reported having no conflicts of interests.

Each beach vacation from birth to age 6 by white Colorado children was associated with a 5% increase in small nevi when the children were examined at age 7, but not with large nevi development.

In addition, the total estimated UV dose received on waterside vacations and the number of days spent on vacation were not significantly related to nevi count, suggesting that a threshold dose of UV exposure is received relatively early during each waterside vacation, such that 3-day-long getaways may have the same effect on nevi development as 10-day trips, according to the authors.

Although it is the larger nevi (greater than or equal to 2 mm) that are most commonly associated with skin cancer, increased numbers of small nevi in childhood also confer melanoma risk.

“Parents should be aware of the effect that vacations may have on their children's risk for developing melanoma as adults, and they should be cautious about selection of vacation locations,” wrote Dr. Kelly J. Pettijohn, from the department of community and behavioral health at the Colorado School of Public Health, Denver, and associates.

A total of 681 children born in 1998 who were lifetime residents of Colorado were studied. Patients' parents were asked in 20- to 30-minute phone interviews about the child's vacation history, sunburn history, and demographic data. Skin exams were also conducted in 2005, when the patients were 7 years old (Cancer Epidemiol. Biomarkers Prev. 2009;18:454–63).

A history of severe sunburn, of sunscreen use, of hat use, or of sun sensitivity failed to predict the development of nevi. “The only significant linear relationship between vacations and nevi less than 2 mm was for number of waterside vacations before age 6,” wrote the authors.

Each vacation was associated with a 5% increase in these small nevi after controlling for other factors.

In addition, the authors found that waterside vacations taken within 1 year of the skin exam did not affect small nevi counts. This finding suggests a time lag of at least 1 year may be necessary for the effects of sun exposure during waterside vacations to result in new nevi, they noted. The authors reported no potential conflicts of interest.

Parents should be made aware of the effect that vacations have on their children's risk of melanoma. Louise A. Koenig/Elsevier Global Medical News

Each beach vacation from birth to age 6 by white Colorado children was associated with a 5% increase in small nevi when the children were examined at age 7, but not with large nevi development.

In addition, the total estimated UV dose received on waterside vacations and the number of days spent on vacation were not significantly related to nevi count, suggesting that a threshold dose of UV exposure is received relatively early during each waterside vacation, such that 3-day-long getaways may have the same effect on nevi development as 10-day trips, according to the authors.

Although it is the larger nevi (greater than or equal to 2 mm) that are most commonly associated with skin cancer, increased numbers of small nevi in childhood also confer melanoma risk.

“Parents should be aware of the effect that vacations may have on their children's risk for developing melanoma as adults, and they should be cautious about selection of vacation locations,” wrote Dr. Kelly J. Pettijohn, from the department of community and behavioral health at the Colorado School of Public Health, Denver, and associates.

A total of 681 children born in 1998 who were lifetime residents of Colorado were studied. Patients' parents were asked in 20- to 30-minute phone interviews about the child's vacation history, sunburn history, and demographic data. Skin exams were also conducted in 2005, when the patients were 7 years old (Cancer Epidemiol. Biomarkers Prev. 2009;18:454–63).

A history of severe sunburn, of sunscreen use, of hat use, or of sun sensitivity failed to predict the development of nevi. “The only significant linear relationship between vacations and nevi less than 2 mm was for number of waterside vacations before age 6,” wrote the authors.

Each vacation was associated with a 5% increase in these small nevi after controlling for other factors.

In addition, the authors found that waterside vacations taken within 1 year of the skin exam did not affect small nevi counts. This finding suggests a time lag of at least 1 year may be necessary for the effects of sun exposure during waterside vacations to result in new nevi, they noted. The authors reported no potential conflicts of interest.

Parents should be made aware of the effect that vacations have on their children's risk of melanoma. Louise A. Koenig/Elsevier Global Medical News

Each beach vacation from birth to age 6 by white Colorado children was associated with a 5% increase in small nevi when the children were examined at age 7, but not with large nevi development.

In addition, the total estimated UV dose received on waterside vacations and the number of days spent on vacation were not significantly related to nevi count, suggesting that a threshold dose of UV exposure is received relatively early during each waterside vacation, such that 3-day-long getaways may have the same effect on nevi development as 10-day trips, according to the authors.

Although it is the larger nevi (greater than or equal to 2 mm) that are most commonly associated with skin cancer, increased numbers of small nevi in childhood also confer melanoma risk.

“Parents should be aware of the effect that vacations may have on their children's risk for developing melanoma as adults, and they should be cautious about selection of vacation locations,” wrote Dr. Kelly J. Pettijohn, from the department of community and behavioral health at the Colorado School of Public Health, Denver, and associates.

A total of 681 children born in 1998 who were lifetime residents of Colorado were studied. Patients' parents were asked in 20- to 30-minute phone interviews about the child's vacation history, sunburn history, and demographic data. Skin exams were also conducted in 2005, when the patients were 7 years old (Cancer Epidemiol. Biomarkers Prev. 2009;18:454–63).

A history of severe sunburn, of sunscreen use, of hat use, or of sun sensitivity failed to predict the development of nevi. “The only significant linear relationship between vacations and nevi less than 2 mm was for number of waterside vacations before age 6,” wrote the authors.

Each vacation was associated with a 5% increase in these small nevi after controlling for other factors.

In addition, the authors found that waterside vacations taken within 1 year of the skin exam did not affect small nevi counts. This finding suggests a time lag of at least 1 year may be necessary for the effects of sun exposure during waterside vacations to result in new nevi, they noted. The authors reported no potential conflicts of interest.

Parents should be made aware of the effect that vacations have on their children's risk of melanoma. Louise A. Koenig/Elsevier Global Medical News

WASHINGTON — The United States gets a C- in support of emergency care, according to a report by the American College of Emergency Physicians.

Among the states, Massachusetts scored the highest, B, and Arkansas the lowest, D-.

After Massachusetts, the highest overall grades were received by the District of Columbia (B-), Rhode Island (B-), Maryland (B-), and Nebraska (C+). After Arkansas, the lowest overall grades went to Oregon (D), Nevada (D), New Mexico (D), and Oklahoma (D).

The report card does not measure the quality of care in individual hospitals or by individual emergency providers, but “considers the legislative and regulatory environment, the existing infrastructure, and the available workforce that constitute the emergency care system we all rely upon every day,” according to an executive summary released at a press briefing.

Two years in the making, it is the second such report issued by ACEP since 2006. Its committee, made up of 14 physicians and ACEP regional heads, drew on unpublished medical reports, as well as data from the Centers for Disease Control and Prevention, the National Highway Traffic Safety Administration, the Centers for Medicare and Medicaid Services, the American Medical Association, other physician associations, and a survey of state health officials.

The report reviewed five major categories affecting care and weighed them according to their importance to the overall delivery of emergency services: access to care (30%); the quality and patient safety environment (20%); the medical liability environment (20%); public health and injury prevention legislation (15%); and disaster preparedness (15%), a new category that was not included in the original 2006 report card.

The nation's overall C-reflects an especially low grade in the access-to-care category: a D-, according to the report. That's due primarily to the combined effect of an aging population and a simultaneous shortage of emergency departments and emergency care workers.

“While national data for hospital crowding, emergency department patient boarding, ambulance diversions, and shortages of on-call specialists are available, there is a critical lack of detailed and state-specific data related to these and other major emergency care access issues,” the report stated. “Collection and analysis of such data should be a priority for states as they work to address these issues and ensure adequate access to care.”

Nationally, the areas receiving the highest grades (C+) were in the quality and patient safety environment category, which “has benefited from extensive efforts to continually improve the quality of care provided,” according to the report, and in the disaster preparedness category.

The report card outlined eight recommendations to improve the nation's overall grade:

1. Alleviate boarding in emergency departments and hospital crowding, identified in surveys and studies as one of the top concerns of emergency physicians. It's a problem with simple, “high-impact” solutions—such as coordinating inpatient discharge times and moving patients to beds as soon as they are admitted.

2. Pass the Access to Emergency Medical Services Act, also known as the Access Act. Among other things, the proposed federal legislation calls for the CMS to collect data on boarding for the purpose of developing new standards and guidelines.

3. Enact federal and state medical liability reforms, primarily those that help retain physicians and ensure access to specialists nationwide.

4. Increase federal funding and support of disaster preparedness. “It has been 7 years since 9/11, but we have only achieved a C+” nationally, Dr. Stephen Epstein, chair of the task force and an emergency physician at Harvard Beth Israel Deaconess Medical Center in Boston, said at the press briefing. “Surely, America can do better.”

5. Increase support for the nation's health care “safety net.” “Federal policies must be enacted to reimburse hospitals for uncompensated emergency and trauma care,” the report states.

“In addition, federal and state policies must address the growing rates of uninsured adults and children in our nation,” who often end up in the care of emergency physicians.

6. Foster greater coordination of emergency services.

7. Maximize the use of information technologies to track and enhance the quality and patient safety environment, and to ensure that health care workers are properly trained.

8. Strengthen emergency departments through national reform. Ensure that emergency department reform is not left out of other national efforts.

Financial support for the report card was provided by the Emergency Medicine Foundation, by a $250,000 grant from the WellPoint Foundation, and through a $50,000 grant from the Robert Wood Johnson Foundation.

The report, which ACEP plans to reissue every 3 years, is available at www.acep.org/reportcard

“It has been 7 years since 9/11, but we have only achieved a C+” nationally on disaster preparedness, Dr. Stephen Epstein said. ©Jay Mallin

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — The United States gets a C- in support of emergency care, according to a report by the American College of Emergency Physicians.

Among the states, Massachusetts scored the highest, B, and Arkansas the lowest, D-.

After Massachusetts, the highest overall grades were received by the District of Columbia (B-), Rhode Island (B-), Maryland (B-), and Nebraska (C+). After Arkansas, the lowest overall grades went to Oregon (D), Nevada (D), New Mexico (D), and Oklahoma (D).

The report card does not measure the quality of care in individual hospitals or by individual emergency providers, but “considers the legislative and regulatory environment, the existing infrastructure, and the available workforce that constitute the emergency care system we all rely upon every day,” according to an executive summary released at a press briefing.

Two years in the making, it is the second such report issued by ACEP since 2006. Its committee, made up of 14 physicians and ACEP regional heads, drew on unpublished medical reports, as well as data from the Centers for Disease Control and Prevention, the National Highway Traffic Safety Administration, the Centers for Medicare and Medicaid Services, the American Medical Association, other physician associations, and a survey of state health officials.

The report reviewed five major categories affecting care and weighed them according to their importance to the overall delivery of emergency services: access to care (30%); the quality and patient safety environment (20%); the medical liability environment (20%); public health and injury prevention legislation (15%); and disaster preparedness (15%), a new category that was not included in the original 2006 report card.

The nation's overall C-reflects an especially low grade in the access-to-care category: a D-, according to the report. That's due primarily to the combined effect of an aging population and a simultaneous shortage of emergency departments and emergency care workers.

“While national data for hospital crowding, emergency department patient boarding, ambulance diversions, and shortages of on-call specialists are available, there is a critical lack of detailed and state-specific data related to these and other major emergency care access issues,” the report stated. “Collection and analysis of such data should be a priority for states as they work to address these issues and ensure adequate access to care.”

Nationally, the areas receiving the highest grades (C+) were in the quality and patient safety environment category, which “has benefited from extensive efforts to continually improve the quality of care provided,” according to the report, and in the disaster preparedness category.

The report card outlined eight recommendations to improve the nation's overall grade:

1. Alleviate boarding in emergency departments and hospital crowding, identified in surveys and studies as one of the top concerns of emergency physicians. It's a problem with simple, “high-impact” solutions—such as coordinating inpatient discharge times and moving patients to beds as soon as they are admitted.

2. Pass the Access to Emergency Medical Services Act, also known as the Access Act. Among other things, the proposed federal legislation calls for the CMS to collect data on boarding for the purpose of developing new standards and guidelines.

3. Enact federal and state medical liability reforms, primarily those that help retain physicians and ensure access to specialists nationwide.

4. Increase federal funding and support of disaster preparedness. “It has been 7 years since 9/11, but we have only achieved a C+” nationally, Dr. Stephen Epstein, chair of the task force and an emergency physician at Harvard Beth Israel Deaconess Medical Center in Boston, said at the press briefing. “Surely, America can do better.”

5. Increase support for the nation's health care “safety net.” “Federal policies must be enacted to reimburse hospitals for uncompensated emergency and trauma care,” the report states.

“In addition, federal and state policies must address the growing rates of uninsured adults and children in our nation,” who often end up in the care of emergency physicians.

6. Foster greater coordination of emergency services.

7. Maximize the use of information technologies to track and enhance the quality and patient safety environment, and to ensure that health care workers are properly trained.

8. Strengthen emergency departments through national reform. Ensure that emergency department reform is not left out of other national efforts.

Financial support for the report card was provided by the Emergency Medicine Foundation, by a $250,000 grant from the WellPoint Foundation, and through a $50,000 grant from the Robert Wood Johnson Foundation.

The report, which ACEP plans to reissue every 3 years, is available at www.acep.org/reportcard

“It has been 7 years since 9/11, but we have only achieved a C+” nationally on disaster preparedness, Dr. Stephen Epstein said. ©Jay Mallin

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — The United States gets a C- in support of emergency care, according to a report by the American College of Emergency Physicians.

Among the states, Massachusetts scored the highest, B, and Arkansas the lowest, D-.

After Massachusetts, the highest overall grades were received by the District of Columbia (B-), Rhode Island (B-), Maryland (B-), and Nebraska (C+). After Arkansas, the lowest overall grades went to Oregon (D), Nevada (D), New Mexico (D), and Oklahoma (D).

The report card does not measure the quality of care in individual hospitals or by individual emergency providers, but “considers the legislative and regulatory environment, the existing infrastructure, and the available workforce that constitute the emergency care system we all rely upon every day,” according to an executive summary released at a press briefing.

Two years in the making, it is the second such report issued by ACEP since 2006. Its committee, made up of 14 physicians and ACEP regional heads, drew on unpublished medical reports, as well as data from the Centers for Disease Control and Prevention, the National Highway Traffic Safety Administration, the Centers for Medicare and Medicaid Services, the American Medical Association, other physician associations, and a survey of state health officials.

The report reviewed five major categories affecting care and weighed them according to their importance to the overall delivery of emergency services: access to care (30%); the quality and patient safety environment (20%); the medical liability environment (20%); public health and injury prevention legislation (15%); and disaster preparedness (15%), a new category that was not included in the original 2006 report card.

The nation's overall C-reflects an especially low grade in the access-to-care category: a D-, according to the report. That's due primarily to the combined effect of an aging population and a simultaneous shortage of emergency departments and emergency care workers.

“While national data for hospital crowding, emergency department patient boarding, ambulance diversions, and shortages of on-call specialists are available, there is a critical lack of detailed and state-specific data related to these and other major emergency care access issues,” the report stated. “Collection and analysis of such data should be a priority for states as they work to address these issues and ensure adequate access to care.”

Nationally, the areas receiving the highest grades (C+) were in the quality and patient safety environment category, which “has benefited from extensive efforts to continually improve the quality of care provided,” according to the report, and in the disaster preparedness category.

The report card outlined eight recommendations to improve the nation's overall grade:

1. Alleviate boarding in emergency departments and hospital crowding, identified in surveys and studies as one of the top concerns of emergency physicians. It's a problem with simple, “high-impact” solutions—such as coordinating inpatient discharge times and moving patients to beds as soon as they are admitted.

2. Pass the Access to Emergency Medical Services Act, also known as the Access Act. Among other things, the proposed federal legislation calls for the CMS to collect data on boarding for the purpose of developing new standards and guidelines.

3. Enact federal and state medical liability reforms, primarily those that help retain physicians and ensure access to specialists nationwide.

4. Increase federal funding and support of disaster preparedness. “It has been 7 years since 9/11, but we have only achieved a C+” nationally, Dr. Stephen Epstein, chair of the task force and an emergency physician at Harvard Beth Israel Deaconess Medical Center in Boston, said at the press briefing. “Surely, America can do better.”

5. Increase support for the nation's health care “safety net.” “Federal policies must be enacted to reimburse hospitals for uncompensated emergency and trauma care,” the report states.

“In addition, federal and state policies must address the growing rates of uninsured adults and children in our nation,” who often end up in the care of emergency physicians.

6. Foster greater coordination of emergency services.

7. Maximize the use of information technologies to track and enhance the quality and patient safety environment, and to ensure that health care workers are properly trained.

8. Strengthen emergency departments through national reform. Ensure that emergency department reform is not left out of other national efforts.

Financial support for the report card was provided by the Emergency Medicine Foundation, by a $250,000 grant from the WellPoint Foundation, and through a $50,000 grant from the Robert Wood Johnson Foundation.

The report, which ACEP plans to reissue every 3 years, is available at www.acep.org/reportcard

“It has been 7 years since 9/11, but we have only achieved a C+” nationally on disaster preparedness, Dr. Stephen Epstein said. ©Jay Mallin

ELSEVIER GLOBAL MEDICAL NEWS

Average glucose levels at hospital admission for acute myocardial infarction predict 30-day mortality better than does diabetes history, even though the latter is routinely used as an assessment tool, according to an analysis of two large trials.

“Patients with no diabetes history with elevated in-hospital glucose levels have the same high risk for short-term death after AMI as patients with diabetes history,” the investigators wrote.

Dr. Abhinav Goya of the Emory Schools of Public Health and Medicine in Atlanta, along with an international team of investigators, conducted a post hoc analysis of two randomized, controlled trials of AMI with ST-segment elevation: the Clinical Trial of Reviparin and Metabolic Modulation in Acute Myocardial Infarction Treatment and Evaluation-Estudios Clinicos Latino America (CREATE-ECLA), and the Organization for the Assessment of Strategies for Ischemic Syndromes-6 (OASIS-6). For the analysis, the investigators looked at glucose measurements taken at hospital admission, at 6 hours post admission, and at 24 hours post admission, and took as “average in-hospital glucose” the mean of the three. They also assessed diabetes history, and then estimated the ability of these to forecast death at 30 days.

A total of 30,536 patients were analyzed. Of them, 13,100 (43%) had an average glucose of at least 144 mg/dL, the cutoff point that was used to predict risk of 30-day mortality. Of these 13,100 patients, 8,388 (64%) did not have a history of diabetes.

At 30 days, 2,808 patients had died. Average glucose predicted mortality with a highly significant odds ratio of 1.10, and this remained undiminished after adjustment for diabetes history, according to Dr. Goya, also of the Population Health Research Institute, Hamilton, Ont.

Diabetes history alone also predicted death at 30 days, with a highly significant odds ratio of 1.63; however, after adjustment for average glucose, the odds ratio fell to a nonsignificant 0.98.

Additionally, nondiabetic patients with glucose levels above 144 mg/dL had an average rate of death that nearly matched that of diabetic patients with similarly high glucose—13.2% versus 13.7%, respectively (Am. Heart J. 2009 Feb. 23 [doi:10.1016/j.ahj.2008.12.007]).

“These hyperglycemic patients with no diabetes history would have been overlooked as high risk if diabetic status alone were used for risk assessment,” the authors concluded.

“The use of in-hospital glucose levels in addition to diabetes history greatly enhances the identification of high-risk patients,” and because it is measured routinely throughout the AMI hospitalization, “elevated glucose levels should be integrated along with diabetes history into the risk stratification of AMI patients,” the authors wrote.

The CREATE-ECLA trial had no external funding; OASIS-6 was funded by Sanofi Aventis, Organon, and GlaxoSmithKline.

Average glucose levels at hospital admission for acute myocardial infarction predict 30-day mortality better than does diabetes history, even though the latter is routinely used as an assessment tool, according to an analysis of two large trials.

“Patients with no diabetes history with elevated in-hospital glucose levels have the same high risk for short-term death after AMI as patients with diabetes history,” the investigators wrote.

Dr. Abhinav Goya of the Emory Schools of Public Health and Medicine in Atlanta, along with an international team of investigators, conducted a post hoc analysis of two randomized, controlled trials of AMI with ST-segment elevation: the Clinical Trial of Reviparin and Metabolic Modulation in Acute Myocardial Infarction Treatment and Evaluation-Estudios Clinicos Latino America (CREATE-ECLA), and the Organization for the Assessment of Strategies for Ischemic Syndromes-6 (OASIS-6). For the analysis, the investigators looked at glucose measurements taken at hospital admission, at 6 hours post admission, and at 24 hours post admission, and took as “average in-hospital glucose” the mean of the three. They also assessed diabetes history, and then estimated the ability of these to forecast death at 30 days.

A total of 30,536 patients were analyzed. Of them, 13,100 (43%) had an average glucose of at least 144 mg/dL, the cutoff point that was used to predict risk of 30-day mortality. Of these 13,100 patients, 8,388 (64%) did not have a history of diabetes.

At 30 days, 2,808 patients had died. Average glucose predicted mortality with a highly significant odds ratio of 1.10, and this remained undiminished after adjustment for diabetes history, according to Dr. Goya, also of the Population Health Research Institute, Hamilton, Ont.

Diabetes history alone also predicted death at 30 days, with a highly significant odds ratio of 1.63; however, after adjustment for average glucose, the odds ratio fell to a nonsignificant 0.98.

Additionally, nondiabetic patients with glucose levels above 144 mg/dL had an average rate of death that nearly matched that of diabetic patients with similarly high glucose—13.2% versus 13.7%, respectively (Am. Heart J. 2009 Feb. 23 [doi:10.1016/j.ahj.2008.12.007]).

“These hyperglycemic patients with no diabetes history would have been overlooked as high risk if diabetic status alone were used for risk assessment,” the authors concluded.

“The use of in-hospital glucose levels in addition to diabetes history greatly enhances the identification of high-risk patients,” and because it is measured routinely throughout the AMI hospitalization, “elevated glucose levels should be integrated along with diabetes history into the risk stratification of AMI patients,” the authors wrote.

The CREATE-ECLA trial had no external funding; OASIS-6 was funded by Sanofi Aventis, Organon, and GlaxoSmithKline.

Average glucose levels at hospital admission for acute myocardial infarction predict 30-day mortality better than does diabetes history, even though the latter is routinely used as an assessment tool, according to an analysis of two large trials.

“Patients with no diabetes history with elevated in-hospital glucose levels have the same high risk for short-term death after AMI as patients with diabetes history,” the investigators wrote.

Dr. Abhinav Goya of the Emory Schools of Public Health and Medicine in Atlanta, along with an international team of investigators, conducted a post hoc analysis of two randomized, controlled trials of AMI with ST-segment elevation: the Clinical Trial of Reviparin and Metabolic Modulation in Acute Myocardial Infarction Treatment and Evaluation-Estudios Clinicos Latino America (CREATE-ECLA), and the Organization for the Assessment of Strategies for Ischemic Syndromes-6 (OASIS-6). For the analysis, the investigators looked at glucose measurements taken at hospital admission, at 6 hours post admission, and at 24 hours post admission, and took as “average in-hospital glucose” the mean of the three. They also assessed diabetes history, and then estimated the ability of these to forecast death at 30 days.

A total of 30,536 patients were analyzed. Of them, 13,100 (43%) had an average glucose of at least 144 mg/dL, the cutoff point that was used to predict risk of 30-day mortality. Of these 13,100 patients, 8,388 (64%) did not have a history of diabetes.

At 30 days, 2,808 patients had died. Average glucose predicted mortality with a highly significant odds ratio of 1.10, and this remained undiminished after adjustment for diabetes history, according to Dr. Goya, also of the Population Health Research Institute, Hamilton, Ont.

Diabetes history alone also predicted death at 30 days, with a highly significant odds ratio of 1.63; however, after adjustment for average glucose, the odds ratio fell to a nonsignificant 0.98.

Additionally, nondiabetic patients with glucose levels above 144 mg/dL had an average rate of death that nearly matched that of diabetic patients with similarly high glucose—13.2% versus 13.7%, respectively (Am. Heart J. 2009 Feb. 23 [doi:10.1016/j.ahj.2008.12.007]).

“These hyperglycemic patients with no diabetes history would have been overlooked as high risk if diabetic status alone were used for risk assessment,” the authors concluded.

“The use of in-hospital glucose levels in addition to diabetes history greatly enhances the identification of high-risk patients,” and because it is measured routinely throughout the AMI hospitalization, “elevated glucose levels should be integrated along with diabetes history into the risk stratification of AMI patients,” the authors wrote.

The CREATE-ECLA trial had no external funding; OASIS-6 was funded by Sanofi Aventis, Organon, and GlaxoSmithKline.