Ryan is a 15-year-old transmale patient (natal sex female who identifies as male and prefers male pronouns, he/him/his) who presents to the emergency department (ED) with suicidal thoughts that have increased with his period this month. His father explains to the registration staff that Ryan is transgender and while his legal name is still Rachel, he prefers to be addressed as Ryan and uses male pronouns. The registration person passes this on to the nurse who will be caring for Ryan. While in the ED, Ryan is frequently referred to by his birth name, Rachel, and female pronouns by various staff members. Dad corrects them, and staff are responsive to his feedback, but the continued misgendering increases Ryan’s suicidality to the point that dad considers leaving the ED.

Nakeia is a 2-month-old infant female brought to the clinic by her parents Shayla and Marie, who are a married lesbian couple. When the doctor walks in, she introduces herself to Shayla and when she sees Marie, she says, “It’s so nice that your mother came with you to the appointment today.” Marie is taken aback and wonders if they should search for another pediatrician who has experience working with LGB couples.

The two cases above are fictional cases created from a collection of experiences shared by patients and families that have presented to our clinics. While unintentional, the assumptions of staff and providers resulted in distress for the patient and families being cared for. What could have been done differently?

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are less likely to access health care than are their non-LGBTQ peers for a variety of reasons. Perceived discrimination within the health care system, and health care providers’ lack of awareness and knowledge of LGBTQ specific health issues are factors that lead to decreased use of health care services.¹ In a 2009 survey of LGBT adults, 56% of LGB respondents and 70% of transgender and gender nonconforming respondents reported experiencing at least one incident of discrimination in the health care setting.² The Institute of Medicine (IOM), the Association of American Medical Colleges (AAMC), and the Joint Commission recommend specific training of health care providers on issues of LGBTQ health as one way of addressing these barriers.^2,3,4 Despite these recommendations, many providers report that they are not adequately trained to provide care for LGBT patients.¹

A number of resources are available to help health care providers and staff increase their competency in caring for LGBTQ patients and families. The National LGBT Health Education Center is one easy-to-use resource that has information on disparities in the LGBT community and strategies that can be implemented in practice to address these disparities. These strategies are not expensive to implement, but do require time, effort, and dedication from staff and providers to provide best quality care to all patients. Below are a few suggestions to create an inclusive health care environment adapted from the center’s guide on creating inclusive health care environments for LGBT people⁵:

All staff receive training on culturally affirming care for LGBT people.

• Training on terminology, health disparities, and how to avoid assumptions and stereotypes is important for all staff members. A positive or negative encounter with one staff member can set the tone for the whole visit.

• Respectful, nonjudgmental communication can help patients and families feel safe and comfortable and increases the likelihood that they remain engaged in care.

Processes and forms reflect the diversity of LGBT people and their relationships.

• Preferred names/pronouns. Many transgender patients have insurance cards and legal documents that do not reflect their current identity. Having a process where preferred names and pronouns can be recorded in the chart and easily communicated to other staff members is important. It is equally important that staff members are trained to recognize and use this information.

• Relationship questions. All staff members should ask the relationship of people accompanying patients to visits and not assume relationships.

• Sexual history questions. When asking or collecting information about sexual history, do not assume heterosexuality.

All patients receive routine sexual health histories.

• A confidential sexual health history should be part of the comprehensive history for all adolescent patients.

• Discussions should be broad, not only focusing on sexual behaviors and risks, but also addressing attraction, readiness for sex, health of relationships, sexual satisfaction, and history of trauma or abuse.

• Ask open-ended and inclusive questions, such as “Are you in a relationship?” “Are you attracted to men, women, both, neither?”

• Ask patients and parents if they have any concerns about gender identity. This offers an opportunity for patients and parents to discuss these issues.

•  Avoid assumptions by asking these questions of all patients.

Clinical care and services incorporate LGBT health care needs.

LGBTQ youth in general have the same health and wellness needs as those of all patients. There are, however, health disparities that exist in this community related to stigma and minority stress. Clinicians should be aware of these disparities so they can provide targeted, individualized care.

• Gay men, bisexual men, and transgender women face higher rates of HIV and STIs. Culturally responsive prevention and testing is important, including availability of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) therapy for HIV as appropriate.

• Smoking and substance use rates are higher in LGBTQ youth; assessing for this and providing appropriate support is important.

• LGBTQ youth are at higher risk of depression, anxiety, suicidality, and bullying. Assessing for family and social support is important as these can be protective. Connecting parents and youth to support groups can be helpful.

• Transgender youth may require specialized services including counseling, psychiatric services, pubertal suppression, and cross-sex hormone therapy. Knowledge of where patients can be appropriately referred is important.

The physical environment welcomes and includes LGBT people.

Studies have shown that many LGBTQ youth and parents look for signs or clues that a clinic or facility is welcoming or safe. Below are some easy ways to communicate openness through the physical space.

• Signs and brochures. Prominently display clinic or institutional nondiscrimination policies. LGBT-friendly symbols such as the rainbow flag or safe zone signs can be displayed on placards, bulletin boards, or staff badges.

• Reading materials. Brochures, magazines and décor that contain images of couples and families should include same-sex couples and LGBT families. Reading materials should include topics relevant to the LGBTQ patients. Information about local LGBTQ resources should be available.

• Restrooms. Transgender and gender nonconforming youth often experience anxiety using public restrooms in part due to fear of harassment. Health care spaces should have policies that allow patients to use restrooms based on their gender identity rather than birth sex. If possible, it is helpful to provide access to single occupancy unisex restrooms.

Creating a space that is safe, welcoming, and respectful of LGBTQ patients and families is one way to begin addressing the health disparities that exist in this community. Below are resources to help your clinic or institution become one of these spaces.

1. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (National Academies Press: Washington, 2011).

2. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV (New York: Lambda Legal, 2010).

3. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Non-Conforming, or born with DSD: A Resource for Medical Educators. (AAMC: Washington, 2014).

4. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. (The Joint Commission: Oak Brook, Ill. 2011)

5. Ten Things: Creating Inclusive Health Care Environments for LGBT People. National LGBT Health Education Center (www.lgbthealtheducation.org).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Ryan is a 15-year-old transmale patient (natal sex female who identifies as male and prefers male pronouns, he/him/his) who presents to the emergency department (ED) with suicidal thoughts that have increased with his period this month. His father explains to the registration staff that Ryan is transgender and while his legal name is still Rachel, he prefers to be addressed as Ryan and uses male pronouns. The registration person passes this on to the nurse who will be caring for Ryan. While in the ED, Ryan is frequently referred to by his birth name, Rachel, and female pronouns by various staff members. Dad corrects them, and staff are responsive to his feedback, but the continued misgendering increases Ryan’s suicidality to the point that dad considers leaving the ED.

Nakeia is a 2-month-old infant female brought to the clinic by her parents Shayla and Marie, who are a married lesbian couple. When the doctor walks in, she introduces herself to Shayla and when she sees Marie, she says, “It’s so nice that your mother came with you to the appointment today.” Marie is taken aback and wonders if they should search for another pediatrician who has experience working with LGB couples.

The two cases above are fictional cases created from a collection of experiences shared by patients and families that have presented to our clinics. While unintentional, the assumptions of staff and providers resulted in distress for the patient and families being cared for. What could have been done differently?

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are less likely to access health care than are their non-LGBTQ peers for a variety of reasons. Perceived discrimination within the health care system, and health care providers’ lack of awareness and knowledge of LGBTQ specific health issues are factors that lead to decreased use of health care services.¹ In a 2009 survey of LGBT adults, 56% of LGB respondents and 70% of transgender and gender nonconforming respondents reported experiencing at least one incident of discrimination in the health care setting.² The Institute of Medicine (IOM), the Association of American Medical Colleges (AAMC), and the Joint Commission recommend specific training of health care providers on issues of LGBTQ health as one way of addressing these barriers.^2,3,4 Despite these recommendations, many providers report that they are not adequately trained to provide care for LGBT patients.¹

A number of resources are available to help health care providers and staff increase their competency in caring for LGBTQ patients and families. The National LGBT Health Education Center is one easy-to-use resource that has information on disparities in the LGBT community and strategies that can be implemented in practice to address these disparities. These strategies are not expensive to implement, but do require time, effort, and dedication from staff and providers to provide best quality care to all patients. Below are a few suggestions to create an inclusive health care environment adapted from the center’s guide on creating inclusive health care environments for LGBT people⁵:

All staff receive training on culturally affirming care for LGBT people.

• Training on terminology, health disparities, and how to avoid assumptions and stereotypes is important for all staff members. A positive or negative encounter with one staff member can set the tone for the whole visit.

• Respectful, nonjudgmental communication can help patients and families feel safe and comfortable and increases the likelihood that they remain engaged in care.

Processes and forms reflect the diversity of LGBT people and their relationships.

• Preferred names/pronouns. Many transgender patients have insurance cards and legal documents that do not reflect their current identity. Having a process where preferred names and pronouns can be recorded in the chart and easily communicated to other staff members is important. It is equally important that staff members are trained to recognize and use this information.

• Relationship questions. All staff members should ask the relationship of people accompanying patients to visits and not assume relationships.

• Sexual history questions. When asking or collecting information about sexual history, do not assume heterosexuality.

All patients receive routine sexual health histories.

• A confidential sexual health history should be part of the comprehensive history for all adolescent patients.

• Discussions should be broad, not only focusing on sexual behaviors and risks, but also addressing attraction, readiness for sex, health of relationships, sexual satisfaction, and history of trauma or abuse.

• Ask open-ended and inclusive questions, such as “Are you in a relationship?” “Are you attracted to men, women, both, neither?”

• Ask patients and parents if they have any concerns about gender identity. This offers an opportunity for patients and parents to discuss these issues.

•  Avoid assumptions by asking these questions of all patients.

Clinical care and services incorporate LGBT health care needs.

LGBTQ youth in general have the same health and wellness needs as those of all patients. There are, however, health disparities that exist in this community related to stigma and minority stress. Clinicians should be aware of these disparities so they can provide targeted, individualized care.

• Gay men, bisexual men, and transgender women face higher rates of HIV and STIs. Culturally responsive prevention and testing is important, including availability of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) therapy for HIV as appropriate.

• Smoking and substance use rates are higher in LGBTQ youth; assessing for this and providing appropriate support is important.

• LGBTQ youth are at higher risk of depression, anxiety, suicidality, and bullying. Assessing for family and social support is important as these can be protective. Connecting parents and youth to support groups can be helpful.

• Transgender youth may require specialized services including counseling, psychiatric services, pubertal suppression, and cross-sex hormone therapy. Knowledge of where patients can be appropriately referred is important.

The physical environment welcomes and includes LGBT people.

Studies have shown that many LGBTQ youth and parents look for signs or clues that a clinic or facility is welcoming or safe. Below are some easy ways to communicate openness through the physical space.

• Signs and brochures. Prominently display clinic or institutional nondiscrimination policies. LGBT-friendly symbols such as the rainbow flag or safe zone signs can be displayed on placards, bulletin boards, or staff badges.

• Reading materials. Brochures, magazines and décor that contain images of couples and families should include same-sex couples and LGBT families. Reading materials should include topics relevant to the LGBTQ patients. Information about local LGBTQ resources should be available.

• Restrooms. Transgender and gender nonconforming youth often experience anxiety using public restrooms in part due to fear of harassment. Health care spaces should have policies that allow patients to use restrooms based on their gender identity rather than birth sex. If possible, it is helpful to provide access to single occupancy unisex restrooms.

Creating a space that is safe, welcoming, and respectful of LGBTQ patients and families is one way to begin addressing the health disparities that exist in this community. Below are resources to help your clinic or institution become one of these spaces.

1. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (National Academies Press: Washington, 2011).

2. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV (New York: Lambda Legal, 2010).

3. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Non-Conforming, or born with DSD: A Resource for Medical Educators. (AAMC: Washington, 2014).

4. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. (The Joint Commission: Oak Brook, Ill. 2011)

5. Ten Things: Creating Inclusive Health Care Environments for LGBT People. National LGBT Health Education Center (www.lgbthealtheducation.org).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Ryan is a 15-year-old transmale patient (natal sex female who identifies as male and prefers male pronouns, he/him/his) who presents to the emergency department (ED) with suicidal thoughts that have increased with his period this month. His father explains to the registration staff that Ryan is transgender and while his legal name is still Rachel, he prefers to be addressed as Ryan and uses male pronouns. The registration person passes this on to the nurse who will be caring for Ryan. While in the ED, Ryan is frequently referred to by his birth name, Rachel, and female pronouns by various staff members. Dad corrects them, and staff are responsive to his feedback, but the continued misgendering increases Ryan’s suicidality to the point that dad considers leaving the ED.

Nakeia is a 2-month-old infant female brought to the clinic by her parents Shayla and Marie, who are a married lesbian couple. When the doctor walks in, she introduces herself to Shayla and when she sees Marie, she says, “It’s so nice that your mother came with you to the appointment today.” Marie is taken aback and wonders if they should search for another pediatrician who has experience working with LGB couples.

The two cases above are fictional cases created from a collection of experiences shared by patients and families that have presented to our clinics. While unintentional, the assumptions of staff and providers resulted in distress for the patient and families being cared for. What could have been done differently?

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are less likely to access health care than are their non-LGBTQ peers for a variety of reasons. Perceived discrimination within the health care system, and health care providers’ lack of awareness and knowledge of LGBTQ specific health issues are factors that lead to decreased use of health care services.¹ In a 2009 survey of LGBT adults, 56% of LGB respondents and 70% of transgender and gender nonconforming respondents reported experiencing at least one incident of discrimination in the health care setting.² The Institute of Medicine (IOM), the Association of American Medical Colleges (AAMC), and the Joint Commission recommend specific training of health care providers on issues of LGBTQ health as one way of addressing these barriers.^2,3,4 Despite these recommendations, many providers report that they are not adequately trained to provide care for LGBT patients.¹

A number of resources are available to help health care providers and staff increase their competency in caring for LGBTQ patients and families. The National LGBT Health Education Center is one easy-to-use resource that has information on disparities in the LGBT community and strategies that can be implemented in practice to address these disparities. These strategies are not expensive to implement, but do require time, effort, and dedication from staff and providers to provide best quality care to all patients. Below are a few suggestions to create an inclusive health care environment adapted from the center’s guide on creating inclusive health care environments for LGBT people⁵:

All staff receive training on culturally affirming care for LGBT people.

• Training on terminology, health disparities, and how to avoid assumptions and stereotypes is important for all staff members. A positive or negative encounter with one staff member can set the tone for the whole visit.

• Respectful, nonjudgmental communication can help patients and families feel safe and comfortable and increases the likelihood that they remain engaged in care.

Processes and forms reflect the diversity of LGBT people and their relationships.

• Preferred names/pronouns. Many transgender patients have insurance cards and legal documents that do not reflect their current identity. Having a process where preferred names and pronouns can be recorded in the chart and easily communicated to other staff members is important. It is equally important that staff members are trained to recognize and use this information.

• Relationship questions. All staff members should ask the relationship of people accompanying patients to visits and not assume relationships.

• Sexual history questions. When asking or collecting information about sexual history, do not assume heterosexuality.

All patients receive routine sexual health histories.

• A confidential sexual health history should be part of the comprehensive history for all adolescent patients.

• Discussions should be broad, not only focusing on sexual behaviors and risks, but also addressing attraction, readiness for sex, health of relationships, sexual satisfaction, and history of trauma or abuse.

• Ask open-ended and inclusive questions, such as “Are you in a relationship?” “Are you attracted to men, women, both, neither?”

• Ask patients and parents if they have any concerns about gender identity. This offers an opportunity for patients and parents to discuss these issues.

•  Avoid assumptions by asking these questions of all patients.

Clinical care and services incorporate LGBT health care needs.

LGBTQ youth in general have the same health and wellness needs as those of all patients. There are, however, health disparities that exist in this community related to stigma and minority stress. Clinicians should be aware of these disparities so they can provide targeted, individualized care.

• Gay men, bisexual men, and transgender women face higher rates of HIV and STIs. Culturally responsive prevention and testing is important, including availability of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) therapy for HIV as appropriate.

• Smoking and substance use rates are higher in LGBTQ youth; assessing for this and providing appropriate support is important.

• LGBTQ youth are at higher risk of depression, anxiety, suicidality, and bullying. Assessing for family and social support is important as these can be protective. Connecting parents and youth to support groups can be helpful.

• Transgender youth may require specialized services including counseling, psychiatric services, pubertal suppression, and cross-sex hormone therapy. Knowledge of where patients can be appropriately referred is important.

The physical environment welcomes and includes LGBT people.

Studies have shown that many LGBTQ youth and parents look for signs or clues that a clinic or facility is welcoming or safe. Below are some easy ways to communicate openness through the physical space.

• Signs and brochures. Prominently display clinic or institutional nondiscrimination policies. LGBT-friendly symbols such as the rainbow flag or safe zone signs can be displayed on placards, bulletin boards, or staff badges.

• Reading materials. Brochures, magazines and décor that contain images of couples and families should include same-sex couples and LGBT families. Reading materials should include topics relevant to the LGBTQ patients. Information about local LGBTQ resources should be available.

• Restrooms. Transgender and gender nonconforming youth often experience anxiety using public restrooms in part due to fear of harassment. Health care spaces should have policies that allow patients to use restrooms based on their gender identity rather than birth sex. If possible, it is helpful to provide access to single occupancy unisex restrooms.

Creating a space that is safe, welcoming, and respectful of LGBTQ patients and families is one way to begin addressing the health disparities that exist in this community. Below are resources to help your clinic or institution become one of these spaces.

1. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (National Academies Press: Washington, 2011).

2. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV (New York: Lambda Legal, 2010).

3. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Non-Conforming, or born with DSD: A Resource for Medical Educators. (AAMC: Washington, 2014).

4. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. (The Joint Commission: Oak Brook, Ill. 2011)

5. Ten Things: Creating Inclusive Health Care Environments for LGBT People. National LGBT Health Education Center (www.lgbthealtheducation.org).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Q1: ANSWER: E

Critique

Different types of meat have different risks of resulting in meat impaction in patients with predisposing esophageal factors. The ranking order is as follows: Beef more than pork more than turkey more than chicken more than fish.

Reference

1. Gasiorowska, A. et al. Gasteroenterol Hepatol. 2009;5:269-79.

Q1: ANSWER: E

Critique

Different types of meat have different risks of resulting in meat impaction in patients with predisposing esophageal factors. The ranking order is as follows: Beef more than pork more than turkey more than chicken more than fish.

Reference

1. Gasiorowska, A. et al. Gasteroenterol Hepatol. 2009;5:269-79.

Q1: ANSWER: E

Critique

Different types of meat have different risks of resulting in meat impaction in patients with predisposing esophageal factors. The ranking order is as follows: Beef more than pork more than turkey more than chicken more than fish.

Reference

1. Gasiorowska, A. et al. Gasteroenterol Hepatol. 2009;5:269-79.

Echocardiograms were done, but who was reading them?

A 67-YEAR-OLD MAN had been under the care of his primary care physician for aortic stenosis. The physician was aware of this diagnosis and did periodic echocardiograms to monitor the patient’s heart. The patient was sent to a cardiologist for additional care. Over the next year and a half, the decedent’s condition worsened, and he died of heart failure.

PLAINTIFF’S CLAIM The defendants deviated from the standard of care in not reading the echocardiograms. If they had, they could have treated him and extended his life.

THE DEFENSE The cardiologist said it was not up to him to read the echocardiogram. The primary care physician acknowledged that he deviated from the standard of care.

VERDICT $3 million Connecticut verdict.

Don't assume the specialist has taken charge; verify or manage the patient yourself.

COMMENT This is a clear case of failure to take responsibility. I suspect the failure was based on the assumption by both physicians that the other physician was monitoring the patient’s status.

This happened to me with a patient who gradually drifted into acute heart failure while I assumed the nephrologist was managing his diuretics. A phone call and more furosemide would have prevented that hospital admission. (Luckily, my patient recovered uneventfully.)

Don’t assume the specialist has taken charge; verify or manage the patient yourself.

Third call to help line finally leads to office visit, but it’s too late

A 42-YEAR-OLD WOMAN called a phone help line and told a nurse that she had a fever, chills, sore throat, and severe chest pain. The next day she called again and spoke with a nurse who routed her call to a physician. The physician diagnosed the woman with influenza during their 4-minute conversation. She called again the next day and was told to come in for examination. The woman did so and was admitted. One day later, she died of sepsis secondary to pneumonia.

PLAINTIFF’S CLAIM The standard of care required immediate examination by the time of the second call.

THE DEFENSE The plaintiff did not actually report chest pain until the second call, and she contracted an unusually fast-acting strain of pneumonia.

VERDICT $3.5 million California arbitration award.

COMMENT Delayed diagnosis is one of the main reasons family physicians are successfully sued. Management of this patient may have been reasonable the first day. The second call should have prompted a same day visit or instructions to go to the emergency department or at least an urgent care facility. The third call was too late.

Echocardiograms were done, but who was reading them?

A 67-YEAR-OLD MAN had been under the care of his primary care physician for aortic stenosis. The physician was aware of this diagnosis and did periodic echocardiograms to monitor the patient’s heart. The patient was sent to a cardiologist for additional care. Over the next year and a half, the decedent’s condition worsened, and he died of heart failure.

PLAINTIFF’S CLAIM The defendants deviated from the standard of care in not reading the echocardiograms. If they had, they could have treated him and extended his life.

THE DEFENSE The cardiologist said it was not up to him to read the echocardiogram. The primary care physician acknowledged that he deviated from the standard of care.

VERDICT $3 million Connecticut verdict.

Don't assume the specialist has taken charge; verify or manage the patient yourself.

COMMENT This is a clear case of failure to take responsibility. I suspect the failure was based on the assumption by both physicians that the other physician was monitoring the patient’s status.

This happened to me with a patient who gradually drifted into acute heart failure while I assumed the nephrologist was managing his diuretics. A phone call and more furosemide would have prevented that hospital admission. (Luckily, my patient recovered uneventfully.)

Don’t assume the specialist has taken charge; verify or manage the patient yourself.

Third call to help line finally leads to office visit, but it’s too late

A 42-YEAR-OLD WOMAN called a phone help line and told a nurse that she had a fever, chills, sore throat, and severe chest pain. The next day she called again and spoke with a nurse who routed her call to a physician. The physician diagnosed the woman with influenza during their 4-minute conversation. She called again the next day and was told to come in for examination. The woman did so and was admitted. One day later, she died of sepsis secondary to pneumonia.

PLAINTIFF’S CLAIM The standard of care required immediate examination by the time of the second call.

THE DEFENSE The plaintiff did not actually report chest pain until the second call, and she contracted an unusually fast-acting strain of pneumonia.

VERDICT $3.5 million California arbitration award.

COMMENT Delayed diagnosis is one of the main reasons family physicians are successfully sued. Management of this patient may have been reasonable the first day. The second call should have prompted a same day visit or instructions to go to the emergency department or at least an urgent care facility. The third call was too late.

Echocardiograms were done, but who was reading them?

A 67-YEAR-OLD MAN had been under the care of his primary care physician for aortic stenosis. The physician was aware of this diagnosis and did periodic echocardiograms to monitor the patient’s heart. The patient was sent to a cardiologist for additional care. Over the next year and a half, the decedent’s condition worsened, and he died of heart failure.

PLAINTIFF’S CLAIM The defendants deviated from the standard of care in not reading the echocardiograms. If they had, they could have treated him and extended his life.

THE DEFENSE The cardiologist said it was not up to him to read the echocardiogram. The primary care physician acknowledged that he deviated from the standard of care.

VERDICT $3 million Connecticut verdict.

Don't assume the specialist has taken charge; verify or manage the patient yourself.

COMMENT This is a clear case of failure to take responsibility. I suspect the failure was based on the assumption by both physicians that the other physician was monitoring the patient’s status.

This happened to me with a patient who gradually drifted into acute heart failure while I assumed the nephrologist was managing his diuretics. A phone call and more furosemide would have prevented that hospital admission. (Luckily, my patient recovered uneventfully.)

Don’t assume the specialist has taken charge; verify or manage the patient yourself.

Third call to help line finally leads to office visit, but it’s too late

A 42-YEAR-OLD WOMAN called a phone help line and told a nurse that she had a fever, chills, sore throat, and severe chest pain. The next day she called again and spoke with a nurse who routed her call to a physician. The physician diagnosed the woman with influenza during their 4-minute conversation. She called again the next day and was told to come in for examination. The woman did so and was admitted. One day later, she died of sepsis secondary to pneumonia.

PLAINTIFF’S CLAIM The standard of care required immediate examination by the time of the second call.

THE DEFENSE The plaintiff did not actually report chest pain until the second call, and she contracted an unusually fast-acting strain of pneumonia.

VERDICT $3.5 million California arbitration award.

COMMENT Delayed diagnosis is one of the main reasons family physicians are successfully sued. Management of this patient may have been reasonable the first day. The second call should have prompted a same day visit or instructions to go to the emergency department or at least an urgent care facility. The third call was too late.

I stumbled upon an absolutely brilliant TED talk about how we need to forget about the “pecking order” within workplaces and how we need to focus on team social connectedness as a strategy to enhance teamwork and productivity.1 I found the analogy in the presenter’s talk so incredibly poignant for the work we do every day in hospital medicine. As we work to solve incredibly challenging problems daily, we do so among continuously changing and highly charged teams. How can we create our teams to be the most effective and productive to serve the greater good?

The speaker, Margaret Heffernan, is an entrepreneur and former CEO of five companies. She tells a story about a study performed by an evolutionary biologist by the name of William Muir of Purdue University in West Lafayette, Ind.2 Muir undertook a series of studies evaluating the social order and productivity of chickens (as measured by egg production) and the team characteristics that make chickens more or less productive. After watching flocks of chickens for several generations, he picked out the most productive chickens and put them all together in a “super flock.” He then watched their productivity over the next several generations and compared their productivity to those in the regular flock.

What he found was that the regular flock became more productive and most of the members of the super flock were dead!

The most productive members of the super flock had essentially pecked the other members to death. He surmised that the only reason the super chickens were initially productive was by suppressing the productivity of the original flock members. The chickens in the regular flock that were initially less aggressive (and less productive) over time sustained fewer injuries and were able to be more productive in the absence of super chickens. The energy that the animals had previously invested in negative behaviors (pecking, injuries, and healing) was redirected into positive behaviors (making eggs).

Muir and his team have gone on to research a tool to predict social aggressiveness and social agreeableness in individual animals. Those high on the socially agreeable scales (and low on the socially aggressive scales) are more valuable for producing highly effective teams of agricultural animals by enhancing group dynamics, social interactions, and actual productivity.

Backward Thinking

Heffernan argues that we have run most businesses (hospitals included) and many societies (at least capitalistic ones) in the super chicken model. In this model, we view leadership as a trait to be individually owned and perfected, and we think that leaders are supposed to have all the answers. In order to determine our leaders, we charge highly competent people to compete against one another as if in a talent contest. It has long been thought that to be successful as teams, we should recruit the best and brightest, pit them against on another, and see who wins, then promote the winner, put them in charge of everything, and give them all the resources they could want or need to be a super chicken.

But this model inevitably suppresses the remainder of the flock and leads to aggression and waste.

In many scenarios in our hospitals, physicians view themselves as and act like super chickens; we try to be the hardest working, the brightest, and the most powerful. How many times have we heard of or witnessed circumstances where a physician suppresses the candor or opinion from other disciplines on the care team? I think we all know physicians (ourselves included) who demand the role of decision maker and ignore the opinions or needs of the remainder of the team, including patients or their family.

Alternatives

So if we should not be subscribing to the super chicken theory, then what type of leadership structures should we be subscribing to within medical teams to produce the best outcomes for ourselves and for our patients and their families?

A study performed by MIT scientists gives us some insight. Researchers found that when random groups of people are given very difficult problems to solve (e.g., think about diagnostic dilemmas or very difficult patients), certain group attributes made it more likely that the group would be successful in solving these difficult problems. The groups that were most effective were not those with a few people with extremely high IQs or with the highest collective IQ. The teams that were most effective and able to solve difficult problems were those that showed high degrees of social sensitivity among members (i.e., empathy). The highest-performing teams gave roughly equal time to each member (e.g., think about physicians, pharmacists, social workers, case managers, consultants on a typical medical team). They also found the highest-performing teams had more women in them. (I feel so redeemed!)

In summary, what they learned from these experiments was that the most successful teams were more socially connected and more highly attuned and sensitive to one another. This is not to say that highly successful teams were leaderless. There is absolutely a vital role that leaders play in such teams. In Jim Collins’ famous book Good to Great, in studying leadership and teams, he did not find the best leaders were super chickens who autocratically made unilateral decisions. Instead, he found the best leaders function more like facilitators, having the humility and skill to draw out shared solutions from large participatory teams.3 Doesn’t this sound like how a hospitalist should run multidisciplinary rounds?

The other major attribute that the MIT researchers noticed about highly functional teams is that each and every member of the team was extremely willing and able to give and receive help. They found that teams with high mutual understanding and trust were more likely to seamlessly—and almost effortlessly—give and receive help from one another. They ended up acting as one another’s social support network. If any team member was confronted by a difficult problem or situation, each felt confident that it could be easily solved with the collective skill and wisdom of the team.

As a result of such research, some companies have developed and implemented strategies to enhance such social capital, such as synchronizing coffee breaks and disallowing coffee mugs at individual desks. These companies consider it a vital strategic mission to ensure that team members get to know and understand one another and that they serve as a social support network at work. They believe that it is reliance and interdependency that ensures trust and enhances productivity.

So what really matters is the mortar, not just the bricks.

HM Takeaway

For hospital medicine teams, what we need to do is accept that teams work best when every member has a voice and is valued. When others look to us (usually seen as team leaders) to make all the decisions (as if we are super chickens), we need to empower our team members to make decisions with us.

We need to actively work toward this model of being a team leader, break any cycles of dependency that we have set up, and produce better outcomes.

We need to avoid acting like super chickens and appreciate and empower a true team effort.

We need to stop accepting that management and promotions occur by talent contests that pit employees against one another and insist that rivalry at every level has to be replaced by social capital and social connectedness.

Only then will our leadership result in creating effective and productive bricks and mortar. TH

References

1. Heffernan M. Margaret Heffernan: why it’s time to forget the pecking order at work. TED Talks. June 16, 2015. Available at: https://www.youtube.com/watch?v=Vyn_xLrtZaY&feature=youtu.be.
2. Steeves SA. Scientists find method to pick non-competitive animals, improve production. Available at: https://news.uns.purdue.edu/x/2007a/070212MuirSelection.html.
3. Collins J. Good to Great. New York, N.Y.: HarperBusiness; 2011.

I stumbled upon an absolutely brilliant TED talk about how we need to forget about the “pecking order” within workplaces and how we need to focus on team social connectedness as a strategy to enhance teamwork and productivity.1 I found the analogy in the presenter’s talk so incredibly poignant for the work we do every day in hospital medicine. As we work to solve incredibly challenging problems daily, we do so among continuously changing and highly charged teams. How can we create our teams to be the most effective and productive to serve the greater good?

The speaker, Margaret Heffernan, is an entrepreneur and former CEO of five companies. She tells a story about a study performed by an evolutionary biologist by the name of William Muir of Purdue University in West Lafayette, Ind.2 Muir undertook a series of studies evaluating the social order and productivity of chickens (as measured by egg production) and the team characteristics that make chickens more or less productive. After watching flocks of chickens for several generations, he picked out the most productive chickens and put them all together in a “super flock.” He then watched their productivity over the next several generations and compared their productivity to those in the regular flock.

What he found was that the regular flock became more productive and most of the members of the super flock were dead!

The most productive members of the super flock had essentially pecked the other members to death. He surmised that the only reason the super chickens were initially productive was by suppressing the productivity of the original flock members. The chickens in the regular flock that were initially less aggressive (and less productive) over time sustained fewer injuries and were able to be more productive in the absence of super chickens. The energy that the animals had previously invested in negative behaviors (pecking, injuries, and healing) was redirected into positive behaviors (making eggs).

Muir and his team have gone on to research a tool to predict social aggressiveness and social agreeableness in individual animals. Those high on the socially agreeable scales (and low on the socially aggressive scales) are more valuable for producing highly effective teams of agricultural animals by enhancing group dynamics, social interactions, and actual productivity.

Backward Thinking

Heffernan argues that we have run most businesses (hospitals included) and many societies (at least capitalistic ones) in the super chicken model. In this model, we view leadership as a trait to be individually owned and perfected, and we think that leaders are supposed to have all the answers. In order to determine our leaders, we charge highly competent people to compete against one another as if in a talent contest. It has long been thought that to be successful as teams, we should recruit the best and brightest, pit them against on another, and see who wins, then promote the winner, put them in charge of everything, and give them all the resources they could want or need to be a super chicken.

But this model inevitably suppresses the remainder of the flock and leads to aggression and waste.

In many scenarios in our hospitals, physicians view themselves as and act like super chickens; we try to be the hardest working, the brightest, and the most powerful. How many times have we heard of or witnessed circumstances where a physician suppresses the candor or opinion from other disciplines on the care team? I think we all know physicians (ourselves included) who demand the role of decision maker and ignore the opinions or needs of the remainder of the team, including patients or their family.

Alternatives

So if we should not be subscribing to the super chicken theory, then what type of leadership structures should we be subscribing to within medical teams to produce the best outcomes for ourselves and for our patients and their families?

A study performed by MIT scientists gives us some insight. Researchers found that when random groups of people are given very difficult problems to solve (e.g., think about diagnostic dilemmas or very difficult patients), certain group attributes made it more likely that the group would be successful in solving these difficult problems. The groups that were most effective were not those with a few people with extremely high IQs or with the highest collective IQ. The teams that were most effective and able to solve difficult problems were those that showed high degrees of social sensitivity among members (i.e., empathy). The highest-performing teams gave roughly equal time to each member (e.g., think about physicians, pharmacists, social workers, case managers, consultants on a typical medical team). They also found the highest-performing teams had more women in them. (I feel so redeemed!)

In summary, what they learned from these experiments was that the most successful teams were more socially connected and more highly attuned and sensitive to one another. This is not to say that highly successful teams were leaderless. There is absolutely a vital role that leaders play in such teams. In Jim Collins’ famous book Good to Great, in studying leadership and teams, he did not find the best leaders were super chickens who autocratically made unilateral decisions. Instead, he found the best leaders function more like facilitators, having the humility and skill to draw out shared solutions from large participatory teams.3 Doesn’t this sound like how a hospitalist should run multidisciplinary rounds?

The other major attribute that the MIT researchers noticed about highly functional teams is that each and every member of the team was extremely willing and able to give and receive help. They found that teams with high mutual understanding and trust were more likely to seamlessly—and almost effortlessly—give and receive help from one another. They ended up acting as one another’s social support network. If any team member was confronted by a difficult problem or situation, each felt confident that it could be easily solved with the collective skill and wisdom of the team.

As a result of such research, some companies have developed and implemented strategies to enhance such social capital, such as synchronizing coffee breaks and disallowing coffee mugs at individual desks. These companies consider it a vital strategic mission to ensure that team members get to know and understand one another and that they serve as a social support network at work. They believe that it is reliance and interdependency that ensures trust and enhances productivity.

So what really matters is the mortar, not just the bricks.

HM Takeaway

For hospital medicine teams, what we need to do is accept that teams work best when every member has a voice and is valued. When others look to us (usually seen as team leaders) to make all the decisions (as if we are super chickens), we need to empower our team members to make decisions with us.

We need to actively work toward this model of being a team leader, break any cycles of dependency that we have set up, and produce better outcomes.

We need to avoid acting like super chickens and appreciate and empower a true team effort.

We need to stop accepting that management and promotions occur by talent contests that pit employees against one another and insist that rivalry at every level has to be replaced by social capital and social connectedness.

Only then will our leadership result in creating effective and productive bricks and mortar. TH

References

1. Heffernan M. Margaret Heffernan: why it’s time to forget the pecking order at work. TED Talks. June 16, 2015. Available at: https://www.youtube.com/watch?v=Vyn_xLrtZaY&feature=youtu.be.
2. Steeves SA. Scientists find method to pick non-competitive animals, improve production. Available at: https://news.uns.purdue.edu/x/2007a/070212MuirSelection.html.
3. Collins J. Good to Great. New York, N.Y.: HarperBusiness; 2011.

I stumbled upon an absolutely brilliant TED talk about how we need to forget about the “pecking order” within workplaces and how we need to focus on team social connectedness as a strategy to enhance teamwork and productivity.1 I found the analogy in the presenter’s talk so incredibly poignant for the work we do every day in hospital medicine. As we work to solve incredibly challenging problems daily, we do so among continuously changing and highly charged teams. How can we create our teams to be the most effective and productive to serve the greater good?

The speaker, Margaret Heffernan, is an entrepreneur and former CEO of five companies. She tells a story about a study performed by an evolutionary biologist by the name of William Muir of Purdue University in West Lafayette, Ind.2 Muir undertook a series of studies evaluating the social order and productivity of chickens (as measured by egg production) and the team characteristics that make chickens more or less productive. After watching flocks of chickens for several generations, he picked out the most productive chickens and put them all together in a “super flock.” He then watched their productivity over the next several generations and compared their productivity to those in the regular flock.

What he found was that the regular flock became more productive and most of the members of the super flock were dead!

The most productive members of the super flock had essentially pecked the other members to death. He surmised that the only reason the super chickens were initially productive was by suppressing the productivity of the original flock members. The chickens in the regular flock that were initially less aggressive (and less productive) over time sustained fewer injuries and were able to be more productive in the absence of super chickens. The energy that the animals had previously invested in negative behaviors (pecking, injuries, and healing) was redirected into positive behaviors (making eggs).

Muir and his team have gone on to research a tool to predict social aggressiveness and social agreeableness in individual animals. Those high on the socially agreeable scales (and low on the socially aggressive scales) are more valuable for producing highly effective teams of agricultural animals by enhancing group dynamics, social interactions, and actual productivity.

Backward Thinking

Heffernan argues that we have run most businesses (hospitals included) and many societies (at least capitalistic ones) in the super chicken model. In this model, we view leadership as a trait to be individually owned and perfected, and we think that leaders are supposed to have all the answers. In order to determine our leaders, we charge highly competent people to compete against one another as if in a talent contest. It has long been thought that to be successful as teams, we should recruit the best and brightest, pit them against on another, and see who wins, then promote the winner, put them in charge of everything, and give them all the resources they could want or need to be a super chicken.

But this model inevitably suppresses the remainder of the flock and leads to aggression and waste.

In many scenarios in our hospitals, physicians view themselves as and act like super chickens; we try to be the hardest working, the brightest, and the most powerful. How many times have we heard of or witnessed circumstances where a physician suppresses the candor or opinion from other disciplines on the care team? I think we all know physicians (ourselves included) who demand the role of decision maker and ignore the opinions or needs of the remainder of the team, including patients or their family.

Alternatives

So if we should not be subscribing to the super chicken theory, then what type of leadership structures should we be subscribing to within medical teams to produce the best outcomes for ourselves and for our patients and their families?

A study performed by MIT scientists gives us some insight. Researchers found that when random groups of people are given very difficult problems to solve (e.g., think about diagnostic dilemmas or very difficult patients), certain group attributes made it more likely that the group would be successful in solving these difficult problems. The groups that were most effective were not those with a few people with extremely high IQs or with the highest collective IQ. The teams that were most effective and able to solve difficult problems were those that showed high degrees of social sensitivity among members (i.e., empathy). The highest-performing teams gave roughly equal time to each member (e.g., think about physicians, pharmacists, social workers, case managers, consultants on a typical medical team). They also found the highest-performing teams had more women in them. (I feel so redeemed!)

In summary, what they learned from these experiments was that the most successful teams were more socially connected and more highly attuned and sensitive to one another. This is not to say that highly successful teams were leaderless. There is absolutely a vital role that leaders play in such teams. In Jim Collins’ famous book Good to Great, in studying leadership and teams, he did not find the best leaders were super chickens who autocratically made unilateral decisions. Instead, he found the best leaders function more like facilitators, having the humility and skill to draw out shared solutions from large participatory teams.3 Doesn’t this sound like how a hospitalist should run multidisciplinary rounds?

The other major attribute that the MIT researchers noticed about highly functional teams is that each and every member of the team was extremely willing and able to give and receive help. They found that teams with high mutual understanding and trust were more likely to seamlessly—and almost effortlessly—give and receive help from one another. They ended up acting as one another’s social support network. If any team member was confronted by a difficult problem or situation, each felt confident that it could be easily solved with the collective skill and wisdom of the team.

As a result of such research, some companies have developed and implemented strategies to enhance such social capital, such as synchronizing coffee breaks and disallowing coffee mugs at individual desks. These companies consider it a vital strategic mission to ensure that team members get to know and understand one another and that they serve as a social support network at work. They believe that it is reliance and interdependency that ensures trust and enhances productivity.

So what really matters is the mortar, not just the bricks.

HM Takeaway

For hospital medicine teams, what we need to do is accept that teams work best when every member has a voice and is valued. When others look to us (usually seen as team leaders) to make all the decisions (as if we are super chickens), we need to empower our team members to make decisions with us.

We need to actively work toward this model of being a team leader, break any cycles of dependency that we have set up, and produce better outcomes.

We need to avoid acting like super chickens and appreciate and empower a true team effort.

We need to stop accepting that management and promotions occur by talent contests that pit employees against one another and insist that rivalry at every level has to be replaced by social capital and social connectedness.

Only then will our leadership result in creating effective and productive bricks and mortar. TH

References

1. Heffernan M. Margaret Heffernan: why it’s time to forget the pecking order at work. TED Talks. June 16, 2015. Available at: https://www.youtube.com/watch?v=Vyn_xLrtZaY&feature=youtu.be.
2. Steeves SA. Scientists find method to pick non-competitive animals, improve production. Available at: https://news.uns.purdue.edu/x/2007a/070212MuirSelection.html.
3. Collins J. Good to Great. New York, N.Y.: HarperBusiness; 2011.

(Reuters Health) - The proportion of older Americans taking at least five medications or supplements went up in a recent study.

The increase in people using multiple medications - known as polypharmacy - paralleled an increase in the number of older Americans at risk for major drug interactions, researchers found.

"That's a concern from a public health standpoint, because it's getting worse," said Dima Qato, the study's lead author from the University of Illinois at Chicago.

Qato and her colleagues previously reported that polypharmacy is common among older Americans. More than half were taking prescription and nonprescription medications between 2005 and 2006.

There have been a lot of changes in U.S. regulations and the pharmacy market since that time, however. Some of those changes include new and less expensive generic drugs and the implementation of Medicare Part D, which is the prescription component of the government-run health insurance program for the elderly or disabled.

To evaluate the change in polypharmacy over time, the researchers compared the 2005-2006 results to data collected from 2010-2011.

Participants in the study were between the ages of 62 and 85 and were living at home. The researchers interviewed 2,351 people in 2005-2006 and 2,206 in 2010-2011.

Overall, about 67 percent were taking five or more medications or supplements in 2010-2011, up from about 53 percent in 2005-2006.

Use of cholesterol-lowering statins rose from about 34 percent to about 46 percent, the researchers reported in JAMA Internal Medicine. The proportion of people taking blood-thinning medications also increased, from about 33 percent to 43 percent, and use of omega-3 fish oil pills rose from about 5 percent to about 19 percent.

Along with the increase in polypharmacy, the researchers found the risk of major drug interactions nearly doubled, going from about 8 percent to about 15 percent.

"I think we have to keep in mind that while it's important to improve access to medications, we need to make sure they're used safely," said Qato.

On one hand, the new results can be seen as positive, said Dr. Michael Steinman, a gerontologist at the University of California, San Francisco.

We're treating more people with medications that could potentially help them," he said. "But when people have four or five chronic conditions, medications quickly balloon to a large number."

It's important to ensure clear communication between everyone involved in a patient's care, including the patient, said Steinman, who wrote an editorial accompanying the new study.

"You can get rid of problems and excess medications by talking with your doctors," he said.

A separate study reported in the same issue of the journal found that nearly 42 percent of adults did not tell their doctors about the use of complementary or alternative medicine, which includes - among other things - supplements, herbs, homeopathy, special diets and acupuncture.

Many patients said they didn't tell their doctors about these alternative medicines because they weren't asked or because their doctors didn't need to know that information, write Judy Juo and Pamela Jo Johnson, of the University of Minnesota in Minneapolis.

"If a person is talking with their doctor about the medications they're using, they should be talking about all the medications they're using," said Steinman.

(Reuters Health) - The proportion of older Americans taking at least five medications or supplements went up in a recent study.

The increase in people using multiple medications - known as polypharmacy - paralleled an increase in the number of older Americans at risk for major drug interactions, researchers found.

"That's a concern from a public health standpoint, because it's getting worse," said Dima Qato, the study's lead author from the University of Illinois at Chicago.

Qato and her colleagues previously reported that polypharmacy is common among older Americans. More than half were taking prescription and nonprescription medications between 2005 and 2006.

There have been a lot of changes in U.S. regulations and the pharmacy market since that time, however. Some of those changes include new and less expensive generic drugs and the implementation of Medicare Part D, which is the prescription component of the government-run health insurance program for the elderly or disabled.

To evaluate the change in polypharmacy over time, the researchers compared the 2005-2006 results to data collected from 2010-2011.

Participants in the study were between the ages of 62 and 85 and were living at home. The researchers interviewed 2,351 people in 2005-2006 and 2,206 in 2010-2011.

Overall, about 67 percent were taking five or more medications or supplements in 2010-2011, up from about 53 percent in 2005-2006.

Use of cholesterol-lowering statins rose from about 34 percent to about 46 percent, the researchers reported in JAMA Internal Medicine. The proportion of people taking blood-thinning medications also increased, from about 33 percent to 43 percent, and use of omega-3 fish oil pills rose from about 5 percent to about 19 percent.

Along with the increase in polypharmacy, the researchers found the risk of major drug interactions nearly doubled, going from about 8 percent to about 15 percent.

"I think we have to keep in mind that while it's important to improve access to medications, we need to make sure they're used safely," said Qato.

On one hand, the new results can be seen as positive, said Dr. Michael Steinman, a gerontologist at the University of California, San Francisco.

We're treating more people with medications that could potentially help them," he said. "But when people have four or five chronic conditions, medications quickly balloon to a large number."

It's important to ensure clear communication between everyone involved in a patient's care, including the patient, said Steinman, who wrote an editorial accompanying the new study.

"You can get rid of problems and excess medications by talking with your doctors," he said.

A separate study reported in the same issue of the journal found that nearly 42 percent of adults did not tell their doctors about the use of complementary or alternative medicine, which includes - among other things - supplements, herbs, homeopathy, special diets and acupuncture.

Many patients said they didn't tell their doctors about these alternative medicines because they weren't asked or because their doctors didn't need to know that information, write Judy Juo and Pamela Jo Johnson, of the University of Minnesota in Minneapolis.

"If a person is talking with their doctor about the medications they're using, they should be talking about all the medications they're using," said Steinman.

(Reuters Health) - The proportion of older Americans taking at least five medications or supplements went up in a recent study.

The increase in people using multiple medications - known as polypharmacy - paralleled an increase in the number of older Americans at risk for major drug interactions, researchers found.

"That's a concern from a public health standpoint, because it's getting worse," said Dima Qato, the study's lead author from the University of Illinois at Chicago.

Qato and her colleagues previously reported that polypharmacy is common among older Americans. More than half were taking prescription and nonprescription medications between 2005 and 2006.

There have been a lot of changes in U.S. regulations and the pharmacy market since that time, however. Some of those changes include new and less expensive generic drugs and the implementation of Medicare Part D, which is the prescription component of the government-run health insurance program for the elderly or disabled.

To evaluate the change in polypharmacy over time, the researchers compared the 2005-2006 results to data collected from 2010-2011.

Participants in the study were between the ages of 62 and 85 and were living at home. The researchers interviewed 2,351 people in 2005-2006 and 2,206 in 2010-2011.

Overall, about 67 percent were taking five or more medications or supplements in 2010-2011, up from about 53 percent in 2005-2006.

Use of cholesterol-lowering statins rose from about 34 percent to about 46 percent, the researchers reported in JAMA Internal Medicine. The proportion of people taking blood-thinning medications also increased, from about 33 percent to 43 percent, and use of omega-3 fish oil pills rose from about 5 percent to about 19 percent.

Along with the increase in polypharmacy, the researchers found the risk of major drug interactions nearly doubled, going from about 8 percent to about 15 percent.

"I think we have to keep in mind that while it's important to improve access to medications, we need to make sure they're used safely," said Qato.

On one hand, the new results can be seen as positive, said Dr. Michael Steinman, a gerontologist at the University of California, San Francisco.

We're treating more people with medications that could potentially help them," he said. "But when people have four or five chronic conditions, medications quickly balloon to a large number."

It's important to ensure clear communication between everyone involved in a patient's care, including the patient, said Steinman, who wrote an editorial accompanying the new study.

"You can get rid of problems and excess medications by talking with your doctors," he said.

A separate study reported in the same issue of the journal found that nearly 42 percent of adults did not tell their doctors about the use of complementary or alternative medicine, which includes - among other things - supplements, herbs, homeopathy, special diets and acupuncture.

Many patients said they didn't tell their doctors about these alternative medicines because they weren't asked or because their doctors didn't need to know that information, write Judy Juo and Pamela Jo Johnson, of the University of Minnesota in Minneapolis.

"If a person is talking with their doctor about the medications they're using, they should be talking about all the medications they're using," said Steinman.

Photo by Sage Ross

Researchers believe a new tool could help physicians predict the risks and benefits of extended dual antiplatelet therapy (DAPT) in patients who have undergone percutaneous coronary intervention (PCI).

The team said the tool, known as the DAPT Score, exhibited “modest accuracy” for determining which patients were at high risk for late ischemic events and would therefore benefit most from longer-term DAPT therapy.

The DAPT Score also proved somewhat accurate for identifying patients who were at high risk of late bleeding events and might be harmed by continuing DAPT for more than a year after PCI.

Still, the researchers said the scoring system requires further validation and prospective evaluation to assess its potential effects on patient care.

Robert W. Yeh, MD, of Beth Israel Deaconess Medical Center in Boston, Massachusetts, and his colleagues reported these results in JAMA.

“Dual antiplatelet therapy is standard for patients following coronary stent procedures, but we haven’t had good tools to help us determine how long we should be treating individual patients,” Dr Yeh said.

So he and his colleagues set out to identify factors that would predict whether the expected benefit of reduced ischemia would outweigh the expected increase in bleeding associated with continuing DAPT for more than a year after PCI.

The team used 11,648 patients treated on the DAPT study to create the DAPT Score. Patients in this trial had a drug-eluting stent placed, then received 12 months of open-label thienopyridine plus aspirin. After that, they were randomized to 18 months of continued thienopyridine plus aspirin or placebo plus aspirin.

The DAPT Score was designed to distinguish ischemic and bleeding risk 12 to 30 months after PCI. Patients are given a numerical score (-2 to 10) based on certain risk factors. They receive:

• 1 point each for myocardial infarction at presentation, prior myocardial infarction or PCI, diabetes, stent diameter less than 3 mm, smoking, and paclitaxel-eluting stent
• 2 points each for history of congestive heart failure/low ejection fraction and vein graft intervention
• −1 point for age 65 to younger than 75
• −2 points for age 75 or older.

The researchers validated the DAPT Score in 8136 patients from the PROTECT trial. In this trial, researchers assessed the effect of DAPT on the incidence of stent thrombosis at 3 years in patients randomized to receive the Endeavor zotarolimus-eluting stent or the Cypher sirolimus-eluting stent.

After stent placement, patients were assigned to receive aspirin indefinitely and clopidogrel/ticlopidine for at least 3 months and up to 12 months.

Results in DAPT cohort

In the DAPT cohort, ischemia occurred in 348 patients (3.0%), and bleeding occurred in 215 (1.8%).

The researchers said the derivation cohort models predicting ischemia and bleeding had moderate discrimination, with c statistics of 0.70 and 0.68, respectively. After bootstrap internal validation, optimism-corrected c statistics were 0.68 and 0.66, respectively.

The researchers also compared patients with high DAPT scores (≥2 points) to those with lower scores (<2). As expected, continued DAPT was associated with larger reductions in ischemia and smaller increases in bleeding in the high-score group (n=5917) than in the low-score group (n=5731).

In the high-score group, the incidence of ischemia was 2.7% for continued DAPT and 5.7% for placebo plus aspirin (P<0.001). In the low-score group, the incidence was 1.7% for continued DAPT and 2.3% for placebo plus aspirin (P=0.07; interaction P<0.001).

In the high-score group, the incidence of bleeding was 1.8% for continued DAPT and 1.4% for placebo plus aspirin (P=0.26). In the low-score group, the incidence was 3.0% for continued DAPT and 1.4% for placebo plus aspirin (P<0.001; interaction P=0.02).

Results in PROTECT cohort

In the PROTECT cohort, ischemia occurred in 79 patients (1.0%) and bleeding in 37 patients (0.5%). Again, the models predicting ischemia and bleeding had moderate discrimination, with c statistics of 0.64 for both outcomes.

The rate of ischemia from 12 through 30 months after PCI was greater among the high-score patients (n=2848) than the low-score patients (n=5288). The rates were 1.5% and 0.7%, respectively. The hazard ratio was 2.01 (P=0.002).

Rates of moderate or severe bleeding were not significantly different by DAPT Score. The rates were 0.4% in the high-score patients and 0.5% in the low-score patients. The hazard ratio was 0.69 (P=0.31).

The researchers said that, based on these results, use of the DAPT Score should be cautious pending further validation.

“We haven’t prospectively validated the use of the score, and it’s only applicable to patients similar to those who were randomized in the DAPT study, so we still need to be cautious,” Dr Yeh said. “Nevertheless, we think it represents a significant step forward in understanding benefits and risks of treatment.”

Photo by Sage Ross

Researchers believe a new tool could help physicians predict the risks and benefits of extended dual antiplatelet therapy (DAPT) in patients who have undergone percutaneous coronary intervention (PCI).

The team said the tool, known as the DAPT Score, exhibited “modest accuracy” for determining which patients were at high risk for late ischemic events and would therefore benefit most from longer-term DAPT therapy.

The DAPT Score also proved somewhat accurate for identifying patients who were at high risk of late bleeding events and might be harmed by continuing DAPT for more than a year after PCI.

Still, the researchers said the scoring system requires further validation and prospective evaluation to assess its potential effects on patient care.

Robert W. Yeh, MD, of Beth Israel Deaconess Medical Center in Boston, Massachusetts, and his colleagues reported these results in JAMA.

“Dual antiplatelet therapy is standard for patients following coronary stent procedures, but we haven’t had good tools to help us determine how long we should be treating individual patients,” Dr Yeh said.

So he and his colleagues set out to identify factors that would predict whether the expected benefit of reduced ischemia would outweigh the expected increase in bleeding associated with continuing DAPT for more than a year after PCI.

The team used 11,648 patients treated on the DAPT study to create the DAPT Score. Patients in this trial had a drug-eluting stent placed, then received 12 months of open-label thienopyridine plus aspirin. After that, they were randomized to 18 months of continued thienopyridine plus aspirin or placebo plus aspirin.

The DAPT Score was designed to distinguish ischemic and bleeding risk 12 to 30 months after PCI. Patients are given a numerical score (-2 to 10) based on certain risk factors. They receive:

• 1 point each for myocardial infarction at presentation, prior myocardial infarction or PCI, diabetes, stent diameter less than 3 mm, smoking, and paclitaxel-eluting stent
• 2 points each for history of congestive heart failure/low ejection fraction and vein graft intervention
• −1 point for age 65 to younger than 75
• −2 points for age 75 or older.

The researchers validated the DAPT Score in 8136 patients from the PROTECT trial. In this trial, researchers assessed the effect of DAPT on the incidence of stent thrombosis at 3 years in patients randomized to receive the Endeavor zotarolimus-eluting stent or the Cypher sirolimus-eluting stent.

After stent placement, patients were assigned to receive aspirin indefinitely and clopidogrel/ticlopidine for at least 3 months and up to 12 months.

Results in DAPT cohort

In the DAPT cohort, ischemia occurred in 348 patients (3.0%), and bleeding occurred in 215 (1.8%).

The researchers said the derivation cohort models predicting ischemia and bleeding had moderate discrimination, with c statistics of 0.70 and 0.68, respectively. After bootstrap internal validation, optimism-corrected c statistics were 0.68 and 0.66, respectively.

The researchers also compared patients with high DAPT scores (≥2 points) to those with lower scores (<2). As expected, continued DAPT was associated with larger reductions in ischemia and smaller increases in bleeding in the high-score group (n=5917) than in the low-score group (n=5731).

In the high-score group, the incidence of ischemia was 2.7% for continued DAPT and 5.7% for placebo plus aspirin (P<0.001). In the low-score group, the incidence was 1.7% for continued DAPT and 2.3% for placebo plus aspirin (P=0.07; interaction P<0.001).

In the high-score group, the incidence of bleeding was 1.8% for continued DAPT and 1.4% for placebo plus aspirin (P=0.26). In the low-score group, the incidence was 3.0% for continued DAPT and 1.4% for placebo plus aspirin (P<0.001; interaction P=0.02).

Results in PROTECT cohort

In the PROTECT cohort, ischemia occurred in 79 patients (1.0%) and bleeding in 37 patients (0.5%). Again, the models predicting ischemia and bleeding had moderate discrimination, with c statistics of 0.64 for both outcomes.

The rate of ischemia from 12 through 30 months after PCI was greater among the high-score patients (n=2848) than the low-score patients (n=5288). The rates were 1.5% and 0.7%, respectively. The hazard ratio was 2.01 (P=0.002).

Rates of moderate or severe bleeding were not significantly different by DAPT Score. The rates were 0.4% in the high-score patients and 0.5% in the low-score patients. The hazard ratio was 0.69 (P=0.31).

The researchers said that, based on these results, use of the DAPT Score should be cautious pending further validation.

“We haven’t prospectively validated the use of the score, and it’s only applicable to patients similar to those who were randomized in the DAPT study, so we still need to be cautious,” Dr Yeh said. “Nevertheless, we think it represents a significant step forward in understanding benefits and risks of treatment.”

Photo by Sage Ross

Researchers believe a new tool could help physicians predict the risks and benefits of extended dual antiplatelet therapy (DAPT) in patients who have undergone percutaneous coronary intervention (PCI).

The team said the tool, known as the DAPT Score, exhibited “modest accuracy” for determining which patients were at high risk for late ischemic events and would therefore benefit most from longer-term DAPT therapy.

The DAPT Score also proved somewhat accurate for identifying patients who were at high risk of late bleeding events and might be harmed by continuing DAPT for more than a year after PCI.

Still, the researchers said the scoring system requires further validation and prospective evaluation to assess its potential effects on patient care.

Robert W. Yeh, MD, of Beth Israel Deaconess Medical Center in Boston, Massachusetts, and his colleagues reported these results in JAMA.

“Dual antiplatelet therapy is standard for patients following coronary stent procedures, but we haven’t had good tools to help us determine how long we should be treating individual patients,” Dr Yeh said.

So he and his colleagues set out to identify factors that would predict whether the expected benefit of reduced ischemia would outweigh the expected increase in bleeding associated with continuing DAPT for more than a year after PCI.

The team used 11,648 patients treated on the DAPT study to create the DAPT Score. Patients in this trial had a drug-eluting stent placed, then received 12 months of open-label thienopyridine plus aspirin. After that, they were randomized to 18 months of continued thienopyridine plus aspirin or placebo plus aspirin.

The DAPT Score was designed to distinguish ischemic and bleeding risk 12 to 30 months after PCI. Patients are given a numerical score (-2 to 10) based on certain risk factors. They receive:

• 1 point each for myocardial infarction at presentation, prior myocardial infarction or PCI, diabetes, stent diameter less than 3 mm, smoking, and paclitaxel-eluting stent
• 2 points each for history of congestive heart failure/low ejection fraction and vein graft intervention
• −1 point for age 65 to younger than 75
• −2 points for age 75 or older.

The researchers validated the DAPT Score in 8136 patients from the PROTECT trial. In this trial, researchers assessed the effect of DAPT on the incidence of stent thrombosis at 3 years in patients randomized to receive the Endeavor zotarolimus-eluting stent or the Cypher sirolimus-eluting stent.

After stent placement, patients were assigned to receive aspirin indefinitely and clopidogrel/ticlopidine for at least 3 months and up to 12 months.

Results in DAPT cohort

In the DAPT cohort, ischemia occurred in 348 patients (3.0%), and bleeding occurred in 215 (1.8%).

The researchers said the derivation cohort models predicting ischemia and bleeding had moderate discrimination, with c statistics of 0.70 and 0.68, respectively. After bootstrap internal validation, optimism-corrected c statistics were 0.68 and 0.66, respectively.

The researchers also compared patients with high DAPT scores (≥2 points) to those with lower scores (<2). As expected, continued DAPT was associated with larger reductions in ischemia and smaller increases in bleeding in the high-score group (n=5917) than in the low-score group (n=5731).

In the high-score group, the incidence of ischemia was 2.7% for continued DAPT and 5.7% for placebo plus aspirin (P<0.001). In the low-score group, the incidence was 1.7% for continued DAPT and 2.3% for placebo plus aspirin (P=0.07; interaction P<0.001).

In the high-score group, the incidence of bleeding was 1.8% for continued DAPT and 1.4% for placebo plus aspirin (P=0.26). In the low-score group, the incidence was 3.0% for continued DAPT and 1.4% for placebo plus aspirin (P<0.001; interaction P=0.02).

Results in PROTECT cohort

In the PROTECT cohort, ischemia occurred in 79 patients (1.0%) and bleeding in 37 patients (0.5%). Again, the models predicting ischemia and bleeding had moderate discrimination, with c statistics of 0.64 for both outcomes.

The rate of ischemia from 12 through 30 months after PCI was greater among the high-score patients (n=2848) than the low-score patients (n=5288). The rates were 1.5% and 0.7%, respectively. The hazard ratio was 2.01 (P=0.002).

Rates of moderate or severe bleeding were not significantly different by DAPT Score. The rates were 0.4% in the high-score patients and 0.5% in the low-score patients. The hazard ratio was 0.69 (P=0.31).

The researchers said that, based on these results, use of the DAPT Score should be cautious pending further validation.

“We haven’t prospectively validated the use of the score, and it’s only applicable to patients similar to those who were randomized in the DAPT study, so we still need to be cautious,” Dr Yeh said. “Nevertheless, we think it represents a significant step forward in understanding benefits and risks of treatment.”

PET scan

Image by Jens Langner

A PET probe known as [¹⁸F]CFA could be used to aid the treatment of leukemias and other cancers, according to research published in PNAS.

Investigators say [¹⁸F]CFA can detect the activity of deoxycytidine kinase (dCK) in humans more effectively than existing probes.

dCK is a rate-limiting enzyme in the cytosolic deoxyribonucleoside salvage pathway and is considered an important therapeutic and PET-imaging target in certain cancers.

Research has shown that dCK is highly expressed in acute leukemia cells and activated lymphocytes. And the enzyme plays an integral role in allowing drugs such as clofarabine, cytarabine, and fludarabine to treat certain leukemias.

“This enzyme is essential for the therapeutic activity of an entire class of anticancer drugs and even for some antiviral drugs,” said study author Caius Radu, MD, of the University of California, Los Angeles.

“It can take an inactive drug and activate it. If you trick a cancer cell or virus to activate the drug, it would be toxic for the cancer cell or viral genome.”

Until recently, PET technology was only able to clearly detect dCK in mice due to the metabolic instability of the available probes and cross-reactivity with a dCK-related enzyme in humans.

However, Dr Radu and his colleagues showed that [¹⁸F]CFA can clearly detect dCK in humans.

The team found that [¹⁸F]CFA accumulation in leukemia cells correlated with dCK expression, and they were able to inhibit [¹⁸F]CFA accumulation with a dCK inhibitor.

Experiments with [¹⁸F]CFA PET/CT in humans showed probe accumulation in tissues with high dCK expression, such as hematopoietic bone marrow and secondary lymphoid organs.

“We are able to clearly see tissues, including tumor tissues, with high dCK activity that we haven’t seen before in humans using any of the other probes previously developed for this enzyme,” Dr Radu said.

He added that, since activated immune cells increase their expression of dCK, [¹⁸F]CFA could also be used to monitor the effectiveness of immunotherapeutic interventions.

The investigators hope to begin clinical trials with [¹⁸F]CFA in the near future.

Dr Radu and his team invented [¹⁸F]CFA and its analogs, which were patented by the University of California and have been licensed to Sofie Biosciences, a company founded by Dr Radu and his team. The University of California also patented additional intellectual property for small-molecule dCK inhibitors.

PET scan

Image by Jens Langner

A PET probe known as [¹⁸F]CFA could be used to aid the treatment of leukemias and other cancers, according to research published in PNAS.

Investigators say [¹⁸F]CFA can detect the activity of deoxycytidine kinase (dCK) in humans more effectively than existing probes.

dCK is a rate-limiting enzyme in the cytosolic deoxyribonucleoside salvage pathway and is considered an important therapeutic and PET-imaging target in certain cancers.

Research has shown that dCK is highly expressed in acute leukemia cells and activated lymphocytes. And the enzyme plays an integral role in allowing drugs such as clofarabine, cytarabine, and fludarabine to treat certain leukemias.

“This enzyme is essential for the therapeutic activity of an entire class of anticancer drugs and even for some antiviral drugs,” said study author Caius Radu, MD, of the University of California, Los Angeles.

“It can take an inactive drug and activate it. If you trick a cancer cell or virus to activate the drug, it would be toxic for the cancer cell or viral genome.”

Until recently, PET technology was only able to clearly detect dCK in mice due to the metabolic instability of the available probes and cross-reactivity with a dCK-related enzyme in humans.

However, Dr Radu and his colleagues showed that [¹⁸F]CFA can clearly detect dCK in humans.

The team found that [¹⁸F]CFA accumulation in leukemia cells correlated with dCK expression, and they were able to inhibit [¹⁸F]CFA accumulation with a dCK inhibitor.

Experiments with [¹⁸F]CFA PET/CT in humans showed probe accumulation in tissues with high dCK expression, such as hematopoietic bone marrow and secondary lymphoid organs.

“We are able to clearly see tissues, including tumor tissues, with high dCK activity that we haven’t seen before in humans using any of the other probes previously developed for this enzyme,” Dr Radu said.

He added that, since activated immune cells increase their expression of dCK, [¹⁸F]CFA could also be used to monitor the effectiveness of immunotherapeutic interventions.

The investigators hope to begin clinical trials with [¹⁸F]CFA in the near future.

Dr Radu and his team invented [¹⁸F]CFA and its analogs, which were patented by the University of California and have been licensed to Sofie Biosciences, a company founded by Dr Radu and his team. The University of California also patented additional intellectual property for small-molecule dCK inhibitors.

PET scan

Image by Jens Langner

A PET probe known as [¹⁸F]CFA could be used to aid the treatment of leukemias and other cancers, according to research published in PNAS.

Investigators say [¹⁸F]CFA can detect the activity of deoxycytidine kinase (dCK) in humans more effectively than existing probes.

dCK is a rate-limiting enzyme in the cytosolic deoxyribonucleoside salvage pathway and is considered an important therapeutic and PET-imaging target in certain cancers.

Research has shown that dCK is highly expressed in acute leukemia cells and activated lymphocytes. And the enzyme plays an integral role in allowing drugs such as clofarabine, cytarabine, and fludarabine to treat certain leukemias.

“This enzyme is essential for the therapeutic activity of an entire class of anticancer drugs and even for some antiviral drugs,” said study author Caius Radu, MD, of the University of California, Los Angeles.

“It can take an inactive drug and activate it. If you trick a cancer cell or virus to activate the drug, it would be toxic for the cancer cell or viral genome.”

Until recently, PET technology was only able to clearly detect dCK in mice due to the metabolic instability of the available probes and cross-reactivity with a dCK-related enzyme in humans.

However, Dr Radu and his colleagues showed that [¹⁸F]CFA can clearly detect dCK in humans.

The team found that [¹⁸F]CFA accumulation in leukemia cells correlated with dCK expression, and they were able to inhibit [¹⁸F]CFA accumulation with a dCK inhibitor.

Experiments with [¹⁸F]CFA PET/CT in humans showed probe accumulation in tissues with high dCK expression, such as hematopoietic bone marrow and secondary lymphoid organs.

“We are able to clearly see tissues, including tumor tissues, with high dCK activity that we haven’t seen before in humans using any of the other probes previously developed for this enzyme,” Dr Radu said.

He added that, since activated immune cells increase their expression of dCK, [¹⁸F]CFA could also be used to monitor the effectiveness of immunotherapeutic interventions.

The investigators hope to begin clinical trials with [¹⁸F]CFA in the near future.

Dr Radu and his team invented [¹⁸F]CFA and its analogs, which were patented by the University of California and have been licensed to Sofie Biosciences, a company founded by Dr Radu and his team. The University of California also patented additional intellectual property for small-molecule dCK inhibitors.

Blood culture positive for

Staphylococcus infection

Photo by Bill Branson

The US Food and Drug Administration (FDA) has granted 510(k) clearance for a blood culture panel that detects sepsis caused by methicillin-resistant Staphylococcus aureus (MRSA) and other Staphylococcus species.

The Staph ID/R Blood Culture Panel is a product of Great Basin Scientific, Inc.

It is an automated, DNA multiplex assay used to identify Staphylococcus species directly from positive blood cultures in about 2 hours.

The panel also detects the mecA gene, a drug-resistance marker that confers resistance to methicillin and other beta-­lactams and creates MRSA.

In addition, the Staph ID/R Blood Culture Panel identifies coagulase-negative staphylococci.

According to the US Centers for Disease Control and Prevention, 20% to 50% of all positive blood cultures are likely false positives due to contamination caused by coagulase-negative staphylococci, many of which are part of the normal flora of human skin and are not dangerous.

The Staph ID/R Blood Culture Panel is run on the Great Basin Analyzer. The company says the assay requires less than a minute of hands-­on time and no results interpretation due to electronic results reporting.

Blood culture positive for

Staphylococcus infection

Photo by Bill Branson

The US Food and Drug Administration (FDA) has granted 510(k) clearance for a blood culture panel that detects sepsis caused by methicillin-resistant Staphylococcus aureus (MRSA) and other Staphylococcus species.

The Staph ID/R Blood Culture Panel is a product of Great Basin Scientific, Inc.

It is an automated, DNA multiplex assay used to identify Staphylococcus species directly from positive blood cultures in about 2 hours.

The panel also detects the mecA gene, a drug-resistance marker that confers resistance to methicillin and other beta-­lactams and creates MRSA.

In addition, the Staph ID/R Blood Culture Panel identifies coagulase-negative staphylococci.

According to the US Centers for Disease Control and Prevention, 20% to 50% of all positive blood cultures are likely false positives due to contamination caused by coagulase-negative staphylococci, many of which are part of the normal flora of human skin and are not dangerous.

The Staph ID/R Blood Culture Panel is run on the Great Basin Analyzer. The company says the assay requires less than a minute of hands-­on time and no results interpretation due to electronic results reporting.

Blood culture positive for

Staphylococcus infection

Photo by Bill Branson

The US Food and Drug Administration (FDA) has granted 510(k) clearance for a blood culture panel that detects sepsis caused by methicillin-resistant Staphylococcus aureus (MRSA) and other Staphylococcus species.

The Staph ID/R Blood Culture Panel is a product of Great Basin Scientific, Inc.

It is an automated, DNA multiplex assay used to identify Staphylococcus species directly from positive blood cultures in about 2 hours.

The panel also detects the mecA gene, a drug-resistance marker that confers resistance to methicillin and other beta-­lactams and creates MRSA.

In addition, the Staph ID/R Blood Culture Panel identifies coagulase-negative staphylococci.

According to the US Centers for Disease Control and Prevention, 20% to 50% of all positive blood cultures are likely false positives due to contamination caused by coagulase-negative staphylococci, many of which are part of the normal flora of human skin and are not dangerous.

The Staph ID/R Blood Culture Panel is run on the Great Basin Analyzer. The company says the assay requires less than a minute of hands-­on time and no results interpretation due to electronic results reporting.

Blood samples

Photo by Graham Colm

A comparison of commercially available blood tests has revealed more variability than expected, according to researchers.

The group compared basic blood tests run by commercial laboratories and found the testing service, type of test, and time of collection all influenced the accuracy of results.

Given that these tests can be used for disease diagnosis or to determine whether a patient’s medication is working, the researchers said this study highlights the importance of knowing the accuracy and variability of blood test results.

“While most of the variability we found was within clinically accepted ranges, there were several cases where inaccurate results would have led to incorrect medical decisions,” said Joel Dudley, PhD, of the Icahn School of Medicine at Mount Sinai in New York, New York.

“We hope this study will inspire the biomedical community to take a critical look at all testing variables to ensure that lab results are as robust and reproducible as possible.”

Dr Dudley and his colleagues described this study in the Journal of Clinical Investigation.

The researchers collected peripheral blood samples from 60 healthy adults at 4 separate time points within a 6.5-hour window. The samples were collected in Phoenix, Arizona, at an ambulatory clinic and at retail outlets with point-of-care services.

The team collected 14 samples per subject and used those samples to compare 22 common clinical lab tests conducted at 3 commercial labs. One lab, Theranos, offered blood tests obtained from a finger prick, and the other 2, Quest and LabCorp, required standard venipuncture draws.

More than half of the test results showed significant differences between test providers. Of the 22 tests, 15 (68%) showed significant variability between labs (P<0.002).

Triglyceride levels and red blood cell counts were among the most consistent results, while white blood cell counts and overall cholesterol levels were among the most variable.

Test results from Theranos were flagged by Theranos as abnormal 1.6 times more often than tests from LabCorp or Quest (P<0.0001). The percentages for measurements outside their normal range were 8.3% for LabCorp, 7.5% for Quest, and 12.2% for Theranos.

In addition, the researchers noted that, although they controlled subjects’ eating and physical activity, data from blood samples collected earlier in the day were sometimes significantly different from samples taken from the same subjects later in the day.

There were significant difference between measurements collected at time points 1 and 2 vs time points 3 and 4 for 13 of the 22 tests (P<0.002).

“These testing disparities occurred despite rigorous laboratory certification and proficiency standards designed to ensure consistency,” said study author Eric Schadt, PhD, of Mount Sinai.

“Our results suggest the need for greater transparency in lab technologies and procedures, as well as a much more thorough investigation of biological mechanisms that may contribute to more dynamic levels than we currently understand.”

Blood samples

Photo by Graham Colm

A comparison of commercially available blood tests has revealed more variability than expected, according to researchers.

The group compared basic blood tests run by commercial laboratories and found the testing service, type of test, and time of collection all influenced the accuracy of results.

Given that these tests can be used for disease diagnosis or to determine whether a patient’s medication is working, the researchers said this study highlights the importance of knowing the accuracy and variability of blood test results.

“While most of the variability we found was within clinically accepted ranges, there were several cases where inaccurate results would have led to incorrect medical decisions,” said Joel Dudley, PhD, of the Icahn School of Medicine at Mount Sinai in New York, New York.

“We hope this study will inspire the biomedical community to take a critical look at all testing variables to ensure that lab results are as robust and reproducible as possible.”

Dr Dudley and his colleagues described this study in the Journal of Clinical Investigation.

The researchers collected peripheral blood samples from 60 healthy adults at 4 separate time points within a 6.5-hour window. The samples were collected in Phoenix, Arizona, at an ambulatory clinic and at retail outlets with point-of-care services.

The team collected 14 samples per subject and used those samples to compare 22 common clinical lab tests conducted at 3 commercial labs. One lab, Theranos, offered blood tests obtained from a finger prick, and the other 2, Quest and LabCorp, required standard venipuncture draws.

More than half of the test results showed significant differences between test providers. Of the 22 tests, 15 (68%) showed significant variability between labs (P<0.002).

Triglyceride levels and red blood cell counts were among the most consistent results, while white blood cell counts and overall cholesterol levels were among the most variable.

Test results from Theranos were flagged by Theranos as abnormal 1.6 times more often than tests from LabCorp or Quest (P<0.0001). The percentages for measurements outside their normal range were 8.3% for LabCorp, 7.5% for Quest, and 12.2% for Theranos.

In addition, the researchers noted that, although they controlled subjects’ eating and physical activity, data from blood samples collected earlier in the day were sometimes significantly different from samples taken from the same subjects later in the day.

There were significant difference between measurements collected at time points 1 and 2 vs time points 3 and 4 for 13 of the 22 tests (P<0.002).

“These testing disparities occurred despite rigorous laboratory certification and proficiency standards designed to ensure consistency,” said study author Eric Schadt, PhD, of Mount Sinai.

“Our results suggest the need for greater transparency in lab technologies and procedures, as well as a much more thorough investigation of biological mechanisms that may contribute to more dynamic levels than we currently understand.”

Blood samples

Photo by Graham Colm

A comparison of commercially available blood tests has revealed more variability than expected, according to researchers.

The group compared basic blood tests run by commercial laboratories and found the testing service, type of test, and time of collection all influenced the accuracy of results.

Given that these tests can be used for disease diagnosis or to determine whether a patient’s medication is working, the researchers said this study highlights the importance of knowing the accuracy and variability of blood test results.

“While most of the variability we found was within clinically accepted ranges, there were several cases where inaccurate results would have led to incorrect medical decisions,” said Joel Dudley, PhD, of the Icahn School of Medicine at Mount Sinai in New York, New York.

“We hope this study will inspire the biomedical community to take a critical look at all testing variables to ensure that lab results are as robust and reproducible as possible.”

Dr Dudley and his colleagues described this study in the Journal of Clinical Investigation.

The researchers collected peripheral blood samples from 60 healthy adults at 4 separate time points within a 6.5-hour window. The samples were collected in Phoenix, Arizona, at an ambulatory clinic and at retail outlets with point-of-care services.

The team collected 14 samples per subject and used those samples to compare 22 common clinical lab tests conducted at 3 commercial labs. One lab, Theranos, offered blood tests obtained from a finger prick, and the other 2, Quest and LabCorp, required standard venipuncture draws.

More than half of the test results showed significant differences between test providers. Of the 22 tests, 15 (68%) showed significant variability between labs (P<0.002).

Triglyceride levels and red blood cell counts were among the most consistent results, while white blood cell counts and overall cholesterol levels were among the most variable.

Test results from Theranos were flagged by Theranos as abnormal 1.6 times more often than tests from LabCorp or Quest (P<0.0001). The percentages for measurements outside their normal range were 8.3% for LabCorp, 7.5% for Quest, and 12.2% for Theranos.

In addition, the researchers noted that, although they controlled subjects’ eating and physical activity, data from blood samples collected earlier in the day were sometimes significantly different from samples taken from the same subjects later in the day.

There were significant difference between measurements collected at time points 1 and 2 vs time points 3 and 4 for 13 of the 22 tests (P<0.002).

“These testing disparities occurred despite rigorous laboratory certification and proficiency standards designed to ensure consistency,” said study author Eric Schadt, PhD, of Mount Sinai.

“Our results suggest the need for greater transparency in lab technologies and procedures, as well as a much more thorough investigation of biological mechanisms that may contribute to more dynamic levels than we currently understand.”

THE CASE

A 45-year-old airman presented to our medical group with acute onset of sharp, positional left lateral chest wall pain that he’d had for 2 days. The pain began after an extreme core body workout. Treatment with ibuprofen 800 mg and local electrical stimulation one day prior provided no benefit. The patient reported the pain to be a 6 out of 10 when still and a 9 to 10 when sitting for more than a few minutes, turning, or taking a medium to deep breath. The patient felt “dangerously distracted by the pain” while driving in for his appointment.

We noted focal left lower lateral intercostal muscle tenderness without trigger point-like thickness or spasm. The patient also had restricted inspiration, secondary to the severe pain, and decreased left lower field breath sounds. His vital signs were normal, as was his cardiac exam.

THE DIAGNOSIS

While awaiting a chest x-ray, the patient was offered and opted to try acupuncture for pain relief. (We have medical acupuncturists on staff.) Analgesics had already been used, but had provided little relief.

We identified 4 acupuncture sites in the ear: 2 were battlefield acupuncture (BFA) points (more on this in a bit) and 2 points were deemed active by a skin conductance point finder (a handheld device that assesses changes in electrical skin resistance at auricular acupuncture points). The left ear points that were treated included the cingulate gyrus (intertragic notch), Shen Men (triangular fossa), and chest and abdomen regional points (antihelix) (FIGURE 1).

Within 15 minutes, the patient reported significant pain relief and was able to inspire deeply without pain. The patient also underwent a chest x-ray, which revealed atelectasis of the left lower lobe (FIGURE 2A) caused by pain-induced hypoventilation.

Because the patient’s pain was so well controlled, he returned to work immediately after the appointment. At the end of his shift 6 hours later he returned, unscheduled, to report pain at a level of one out of 10 and said he was able to breathe normally. In addition, lung auscultation was normal and a repeat chest x-ray revealed that the atelectasis had almost completely resolved (FIGURE 2B). This occurred without medication or other therapy. The pain did not return.

DISCUSSION

Although acupuncture is over 2000 years old, it has been largely disregarded in the United States due to a lack of mainstream evidence supporting its efficacy. Research is hindered by significant variation in approach between providers, the difficulties inherent to blinding patients and providers to treatment vs placebo, and poor insurance coverage and reimbursement.

Acupuncture research is burgeoning. A 2012 meta-analysis concluded that patients receiving acupuncture had less pain than those receiving sham or no acupuncture for several pain conditions. Specifically, scores for back and neck pain, osteoarthritis, and chronic headache were 0.23, 0.16, and 0.15 standard deviations (SDs), respectively, lower for patients receiving acupuncture than for those who got sham acupuncture. The effect sizes for acupuncture patients compared to no acupuncture controls were 0.55, 0.57, and 0.42 respectively (all P<.001).¹

Several theories explain how auricular acupuncture may work. Paul Nogier, MD, noted that the ear is composed of ectodermal, mesodermal, and endodermal tissues, and mapped the “inverted fetus” homunculus in the ear, which corresponds to specific body points.² Functional magnetic resonance imaging has demonstrated increased brain activity in the cingulate gyrus and thalamic regions in response to a painful stimulus, as well as attenuation of this activity after the placement of needles in corresponding auricular cingulate gyrus and thalamus points.³ In addition, research has confirmed that acupuncture raises serum and cerebrospinal levels of endorphins and enkephalins.⁴

Less than 15 minutes after needle placement, our patient reported significant pain relief and was able to inspire deeply without pain.

Battlefield acupuncture (BFA) was developed by Richard Niemtzow, MD, and has been used for acute injuries in the front lines of battle as well as for many health conditions. BFA treats pain using a sequence of 5 predetermined auricular acupuncture points.⁵ Onset and duration of pain relief vary depending on the location and nature of the pathology. We’ve noted that BFA for chronic pain has a shorter duration of benefit and is more likely to need to be repeated.

One randomized pilot study involving 87 patients presenting to the emergency room blinded emergency health care providers to the inclusion of the first 2 BFA points in their otherwise usual care of acute pain patients. Participants in the acupuncture group experienced a 23% reduction in pain before discharge compared to no change in the standard care group (P<.0005).⁶

Our patient. We inserted semi-permanent needles with a needle length of 2 mm into 4 locations on the ear. (These needles can remain in the ear for several days and fall out on their own or they may be removed by pulling the stud ends.) As noted earlier, our patient reported pain relief within 15 minutes and was pain free by the next day.

THE TAKEAWAY

Research confirms that acupuncture raises serum and cerebrospinal levels of endorphins and enkephalins.

Auricular acupuncture can treat acute and chronic pain. As proof, the BFA technique is widely used by health care providers throughout the US military and Department of Veterans Affairs. In this case, the immediate pain relief and x-ray documentation of atelectasis resolution within 6 hours of treatment provide support that auricular acupuncture was beneficial in reversing the cause of this atelectasis, which was pain-induced hypoventilation.

While the acute pain control observed with this patient is not unusual in our experience, what is unusual is the rare visual confirmation of the striking degree of pain reduction possible with auricular acupuncture.

THE CASE

A 45-year-old airman presented to our medical group with acute onset of sharp, positional left lateral chest wall pain that he’d had for 2 days. The pain began after an extreme core body workout. Treatment with ibuprofen 800 mg and local electrical stimulation one day prior provided no benefit. The patient reported the pain to be a 6 out of 10 when still and a 9 to 10 when sitting for more than a few minutes, turning, or taking a medium to deep breath. The patient felt “dangerously distracted by the pain” while driving in for his appointment.

We noted focal left lower lateral intercostal muscle tenderness without trigger point-like thickness or spasm. The patient also had restricted inspiration, secondary to the severe pain, and decreased left lower field breath sounds. His vital signs were normal, as was his cardiac exam.

THE DIAGNOSIS

While awaiting a chest x-ray, the patient was offered and opted to try acupuncture for pain relief. (We have medical acupuncturists on staff.) Analgesics had already been used, but had provided little relief.

We identified 4 acupuncture sites in the ear: 2 were battlefield acupuncture (BFA) points (more on this in a bit) and 2 points were deemed active by a skin conductance point finder (a handheld device that assesses changes in electrical skin resistance at auricular acupuncture points). The left ear points that were treated included the cingulate gyrus (intertragic notch), Shen Men (triangular fossa), and chest and abdomen regional points (antihelix) (FIGURE 1).

Within 15 minutes, the patient reported significant pain relief and was able to inspire deeply without pain. The patient also underwent a chest x-ray, which revealed atelectasis of the left lower lobe (FIGURE 2A) caused by pain-induced hypoventilation.

Because the patient’s pain was so well controlled, he returned to work immediately after the appointment. At the end of his shift 6 hours later he returned, unscheduled, to report pain at a level of one out of 10 and said he was able to breathe normally. In addition, lung auscultation was normal and a repeat chest x-ray revealed that the atelectasis had almost completely resolved (FIGURE 2B). This occurred without medication or other therapy. The pain did not return.

DISCUSSION

Although acupuncture is over 2000 years old, it has been largely disregarded in the United States due to a lack of mainstream evidence supporting its efficacy. Research is hindered by significant variation in approach between providers, the difficulties inherent to blinding patients and providers to treatment vs placebo, and poor insurance coverage and reimbursement.

Acupuncture research is burgeoning. A 2012 meta-analysis concluded that patients receiving acupuncture had less pain than those receiving sham or no acupuncture for several pain conditions. Specifically, scores for back and neck pain, osteoarthritis, and chronic headache were 0.23, 0.16, and 0.15 standard deviations (SDs), respectively, lower for patients receiving acupuncture than for those who got sham acupuncture. The effect sizes for acupuncture patients compared to no acupuncture controls were 0.55, 0.57, and 0.42 respectively (all P<.001).¹

Several theories explain how auricular acupuncture may work. Paul Nogier, MD, noted that the ear is composed of ectodermal, mesodermal, and endodermal tissues, and mapped the “inverted fetus” homunculus in the ear, which corresponds to specific body points.² Functional magnetic resonance imaging has demonstrated increased brain activity in the cingulate gyrus and thalamic regions in response to a painful stimulus, as well as attenuation of this activity after the placement of needles in corresponding auricular cingulate gyrus and thalamus points.³ In addition, research has confirmed that acupuncture raises serum and cerebrospinal levels of endorphins and enkephalins.⁴

Less than 15 minutes after needle placement, our patient reported significant pain relief and was able to inspire deeply without pain.

Battlefield acupuncture (BFA) was developed by Richard Niemtzow, MD, and has been used for acute injuries in the front lines of battle as well as for many health conditions. BFA treats pain using a sequence of 5 predetermined auricular acupuncture points.⁵ Onset and duration of pain relief vary depending on the location and nature of the pathology. We’ve noted that BFA for chronic pain has a shorter duration of benefit and is more likely to need to be repeated.

One randomized pilot study involving 87 patients presenting to the emergency room blinded emergency health care providers to the inclusion of the first 2 BFA points in their otherwise usual care of acute pain patients. Participants in the acupuncture group experienced a 23% reduction in pain before discharge compared to no change in the standard care group (P<.0005).⁶

Our patient. We inserted semi-permanent needles with a needle length of 2 mm into 4 locations on the ear. (These needles can remain in the ear for several days and fall out on their own or they may be removed by pulling the stud ends.) As noted earlier, our patient reported pain relief within 15 minutes and was pain free by the next day.

THE TAKEAWAY

Research confirms that acupuncture raises serum and cerebrospinal levels of endorphins and enkephalins.

Auricular acupuncture can treat acute and chronic pain. As proof, the BFA technique is widely used by health care providers throughout the US military and Department of Veterans Affairs. In this case, the immediate pain relief and x-ray documentation of atelectasis resolution within 6 hours of treatment provide support that auricular acupuncture was beneficial in reversing the cause of this atelectasis, which was pain-induced hypoventilation.

While the acute pain control observed with this patient is not unusual in our experience, what is unusual is the rare visual confirmation of the striking degree of pain reduction possible with auricular acupuncture.

THE CASE

A 45-year-old airman presented to our medical group with acute onset of sharp, positional left lateral chest wall pain that he’d had for 2 days. The pain began after an extreme core body workout. Treatment with ibuprofen 800 mg and local electrical stimulation one day prior provided no benefit. The patient reported the pain to be a 6 out of 10 when still and a 9 to 10 when sitting for more than a few minutes, turning, or taking a medium to deep breath. The patient felt “dangerously distracted by the pain” while driving in for his appointment.

We noted focal left lower lateral intercostal muscle tenderness without trigger point-like thickness or spasm. The patient also had restricted inspiration, secondary to the severe pain, and decreased left lower field breath sounds. His vital signs were normal, as was his cardiac exam.

THE DIAGNOSIS

While awaiting a chest x-ray, the patient was offered and opted to try acupuncture for pain relief. (We have medical acupuncturists on staff.) Analgesics had already been used, but had provided little relief.

We identified 4 acupuncture sites in the ear: 2 were battlefield acupuncture (BFA) points (more on this in a bit) and 2 points were deemed active by a skin conductance point finder (a handheld device that assesses changes in electrical skin resistance at auricular acupuncture points). The left ear points that were treated included the cingulate gyrus (intertragic notch), Shen Men (triangular fossa), and chest and abdomen regional points (antihelix) (FIGURE 1).

Within 15 minutes, the patient reported significant pain relief and was able to inspire deeply without pain. The patient also underwent a chest x-ray, which revealed atelectasis of the left lower lobe (FIGURE 2A) caused by pain-induced hypoventilation.

Because the patient’s pain was so well controlled, he returned to work immediately after the appointment. At the end of his shift 6 hours later he returned, unscheduled, to report pain at a level of one out of 10 and said he was able to breathe normally. In addition, lung auscultation was normal and a repeat chest x-ray revealed that the atelectasis had almost completely resolved (FIGURE 2B). This occurred without medication or other therapy. The pain did not return.

DISCUSSION

Although acupuncture is over 2000 years old, it has been largely disregarded in the United States due to a lack of mainstream evidence supporting its efficacy. Research is hindered by significant variation in approach between providers, the difficulties inherent to blinding patients and providers to treatment vs placebo, and poor insurance coverage and reimbursement.

Acupuncture research is burgeoning. A 2012 meta-analysis concluded that patients receiving acupuncture had less pain than those receiving sham or no acupuncture for several pain conditions. Specifically, scores for back and neck pain, osteoarthritis, and chronic headache were 0.23, 0.16, and 0.15 standard deviations (SDs), respectively, lower for patients receiving acupuncture than for those who got sham acupuncture. The effect sizes for acupuncture patients compared to no acupuncture controls were 0.55, 0.57, and 0.42 respectively (all P<.001).¹

Several theories explain how auricular acupuncture may work. Paul Nogier, MD, noted that the ear is composed of ectodermal, mesodermal, and endodermal tissues, and mapped the “inverted fetus” homunculus in the ear, which corresponds to specific body points.² Functional magnetic resonance imaging has demonstrated increased brain activity in the cingulate gyrus and thalamic regions in response to a painful stimulus, as well as attenuation of this activity after the placement of needles in corresponding auricular cingulate gyrus and thalamus points.³ In addition, research has confirmed that acupuncture raises serum and cerebrospinal levels of endorphins and enkephalins.⁴

Less than 15 minutes after needle placement, our patient reported significant pain relief and was able to inspire deeply without pain.

Battlefield acupuncture (BFA) was developed by Richard Niemtzow, MD, and has been used for acute injuries in the front lines of battle as well as for many health conditions. BFA treats pain using a sequence of 5 predetermined auricular acupuncture points.⁵ Onset and duration of pain relief vary depending on the location and nature of the pathology. We’ve noted that BFA for chronic pain has a shorter duration of benefit and is more likely to need to be repeated.

One randomized pilot study involving 87 patients presenting to the emergency room blinded emergency health care providers to the inclusion of the first 2 BFA points in their otherwise usual care of acute pain patients. Participants in the acupuncture group experienced a 23% reduction in pain before discharge compared to no change in the standard care group (P<.0005).⁶

Our patient. We inserted semi-permanent needles with a needle length of 2 mm into 4 locations on the ear. (These needles can remain in the ear for several days and fall out on their own or they may be removed by pulling the stud ends.) As noted earlier, our patient reported pain relief within 15 minutes and was pain free by the next day.

THE TAKEAWAY

Research confirms that acupuncture raises serum and cerebrospinal levels of endorphins and enkephalins.

Auricular acupuncture can treat acute and chronic pain. As proof, the BFA technique is widely used by health care providers throughout the US military and Department of Veterans Affairs. In this case, the immediate pain relief and x-ray documentation of atelectasis resolution within 6 hours of treatment provide support that auricular acupuncture was beneficial in reversing the cause of this atelectasis, which was pain-induced hypoventilation.

While the acute pain control observed with this patient is not unusual in our experience, what is unusual is the rare visual confirmation of the striking degree of pain reduction possible with auricular acupuncture.