Concern about Copper’s Effectiveness in Preventing Hospital-Acquired Infections

As public knowledge about the benefits of antimicrobial copper touch surfaces in healthcare facilities continues to grow, questions about this tool naturally arise. Can this copper surface really continuously kill up to 83% of bacteria it comes in contact with? Can it really reduce patient infections by more than half? Can this metal really keep people safer? The answer is “yes,” as has been reported in the Journal of Infection Control, in Hospital Epidemiology, and in the Journal of Clinical Microbiology.

In his “Letter to the Editor (“Concern about Copper’s Effectiveness in Preventing Hospital-Acquired Infections,” November 2013), Dr. Rod Duraski voices cautions about human sensitivity to copper—noting that implanted copper-nickel alloy devices have the potential for severe allergic reactions; however, implanted devices are not part of the EPA-approved products list of antimicrobial copper and, therefore, are not being proposed for use in the fight against hospital infections. Although some patients might experience sensitivity to jewelry, zippers, or buttons, if made from nickel-containing copper alloys, these reactions will be the result of prolonged skin contact, and when removed, the sensitivity will dissipate. The touch-surface components proposed in Karen Appold’s story, “Copper,” (September 2013) come into very brief and intermittent contact with the skin. And, sensitivities are not life-threatening; hospital-acquired infections are.

In fact, three of the four major coin denominations (nickel, dime, quarter) are made from copper-nickel alloys. If these metals are suitable for the everyday exposure we all experience with coinage, they are just as safe when it comes to touch surface components in hospitals. In many instances, the benefits of copper outweigh the relative risk of a rash caused by nickel sensitivity.

Like any surface, copper alloys should be cleaned regularly—especially in hospitals. Copper alloys are compatible with all hospital grade cleaners and disinfectants when the cleaners are used according to manufacturer label instructions. But more importantly, the antimicrobial effect of this metal is not inhibited if the surfaces tarnish. In 2005, a study (www.antimicrobialcopper.com/media/69850/infectious_disease.pdf) found tarnish to be a non-issue when researchers tested the bacterial load on three separate copper alloys, all of which had developed tarnish over time. Additionally, manufacturers are offering components made from tarnish-resistant alloys.

—Harold Michels, PhD, senior vice president of technology and technical services, Copper Development Association, Inc.

Correction: April 4, 2014

A version of this article appeared in print in the April 2014 issue of The Hospitalist. Changes have since been made to the online article per the request of the author.

Concern about Copper’s Effectiveness in Preventing Hospital-Acquired Infections

As public knowledge about the benefits of antimicrobial copper touch surfaces in healthcare facilities continues to grow, questions about this tool naturally arise. Can this copper surface really continuously kill up to 83% of bacteria it comes in contact with? Can it really reduce patient infections by more than half? Can this metal really keep people safer? The answer is “yes,” as has been reported in the Journal of Infection Control, in Hospital Epidemiology, and in the Journal of Clinical Microbiology.

In his “Letter to the Editor (“Concern about Copper’s Effectiveness in Preventing Hospital-Acquired Infections,” November 2013), Dr. Rod Duraski voices cautions about human sensitivity to copper—noting that implanted copper-nickel alloy devices have the potential for severe allergic reactions; however, implanted devices are not part of the EPA-approved products list of antimicrobial copper and, therefore, are not being proposed for use in the fight against hospital infections. Although some patients might experience sensitivity to jewelry, zippers, or buttons, if made from nickel-containing copper alloys, these reactions will be the result of prolonged skin contact, and when removed, the sensitivity will dissipate. The touch-surface components proposed in Karen Appold’s story, “Copper,” (September 2013) come into very brief and intermittent contact with the skin. And, sensitivities are not life-threatening; hospital-acquired infections are.

In fact, three of the four major coin denominations (nickel, dime, quarter) are made from copper-nickel alloys. If these metals are suitable for the everyday exposure we all experience with coinage, they are just as safe when it comes to touch surface components in hospitals. In many instances, the benefits of copper outweigh the relative risk of a rash caused by nickel sensitivity.

Like any surface, copper alloys should be cleaned regularly—especially in hospitals. Copper alloys are compatible with all hospital grade cleaners and disinfectants when the cleaners are used according to manufacturer label instructions. But more importantly, the antimicrobial effect of this metal is not inhibited if the surfaces tarnish. In 2005, a study (www.antimicrobialcopper.com/media/69850/infectious_disease.pdf) found tarnish to be a non-issue when researchers tested the bacterial load on three separate copper alloys, all of which had developed tarnish over time. Additionally, manufacturers are offering components made from tarnish-resistant alloys.

—Harold Michels, PhD, senior vice president of technology and technical services, Copper Development Association, Inc.

Correction: April 4, 2014

A version of this article appeared in print in the April 2014 issue of The Hospitalist. Changes have since been made to the online article per the request of the author.

Concern about Copper’s Effectiveness in Preventing Hospital-Acquired Infections

As public knowledge about the benefits of antimicrobial copper touch surfaces in healthcare facilities continues to grow, questions about this tool naturally arise. Can this copper surface really continuously kill up to 83% of bacteria it comes in contact with? Can it really reduce patient infections by more than half? Can this metal really keep people safer? The answer is “yes,” as has been reported in the Journal of Infection Control, in Hospital Epidemiology, and in the Journal of Clinical Microbiology.

In his “Letter to the Editor (“Concern about Copper’s Effectiveness in Preventing Hospital-Acquired Infections,” November 2013), Dr. Rod Duraski voices cautions about human sensitivity to copper—noting that implanted copper-nickel alloy devices have the potential for severe allergic reactions; however, implanted devices are not part of the EPA-approved products list of antimicrobial copper and, therefore, are not being proposed for use in the fight against hospital infections. Although some patients might experience sensitivity to jewelry, zippers, or buttons, if made from nickel-containing copper alloys, these reactions will be the result of prolonged skin contact, and when removed, the sensitivity will dissipate. The touch-surface components proposed in Karen Appold’s story, “Copper,” (September 2013) come into very brief and intermittent contact with the skin. And, sensitivities are not life-threatening; hospital-acquired infections are.

In fact, three of the four major coin denominations (nickel, dime, quarter) are made from copper-nickel alloys. If these metals are suitable for the everyday exposure we all experience with coinage, they are just as safe when it comes to touch surface components in hospitals. In many instances, the benefits of copper outweigh the relative risk of a rash caused by nickel sensitivity.

Like any surface, copper alloys should be cleaned regularly—especially in hospitals. Copper alloys are compatible with all hospital grade cleaners and disinfectants when the cleaners are used according to manufacturer label instructions. But more importantly, the antimicrobial effect of this metal is not inhibited if the surfaces tarnish. In 2005, a study (www.antimicrobialcopper.com/media/69850/infectious_disease.pdf) found tarnish to be a non-issue when researchers tested the bacterial load on three separate copper alloys, all of which had developed tarnish over time. Additionally, manufacturers are offering components made from tarnish-resistant alloys.

—Harold Michels, PhD, senior vice president of technology and technical services, Copper Development Association, Inc.

Correction: April 4, 2014

A version of this article appeared in print in the April 2014 issue of The Hospitalist. Changes have since been made to the online article per the request of the author.

A new rule issued by the Centers for Medicare & Medicaid Services (CMS) is at the center of controversy fueled by competing interests and lack of clarity. And, for the fourth time since the two-midnight rule was introduced in the 2014 Hospital Inpatient Prospective Payment System, its implementation has been delayed. Hospitals and providers have until March 31, 2015, before auditors begin scrutinizing patient admission statuses for reimbursement determination.

The rule requires Medicare and Medicaid patients spending fewer than two midnights receiving hospital care to be classified as outpatient or under observation. Patients spending more than two midnights will be considered inpatient. Only physicians can make the determination, and the clock begins ticking the moment care begins.

The rule also cuts hospital inpatient reimbursement by 0.2%, because CMS believes the number of inpatient admissions will increase.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.”

–Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association

The rule pits private Medicare auditors (Medicare Administrative Contractors, MACs, and Recovery Audit Contractors, RACs), who have a financial stake in denying inpatient claims, against hospitals and physicians. It does little to clear confusion for patients when it comes time for them to pay their bills.

Patients generally are unaware whether they’ve been admitted or are under observation. But observation status leaves them on the hook for any skilled nursing care they receive following discharge and for the costs of routine maintenance drugs hospitals give them for chronic conditions.

Beneficiaries also are not eligible for Medicare Part A skilled nursing care coverage if they were an inpatient for fewer than 72 hours, and observation days do not count toward the three-day requirement. The two-midnight rule adds another “layer” to the equation, says Bradley Flansbaum, DO, MPH, FACP, a hospitalist and clinical assistant professor of medicine at NYU School of Medicine in New York City.

At the same time, hospitals now face penalties for patients readmitted within 30 days of discharge for a similar episode of care. Observation status offers a measure of protection in the event patients return.

The number of observation patients increased 69% between 2006 and 2011, according to federal data cited by Kaiser Health News, and the number of observation patients staying more than 48 hours increased from 3% to 8% during this same period.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed,” says Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.

“We feel time should not be the only factor taken into account,” Hiatt Kim adds. “It should be a decision a physician reaches based on a patient’s condition.”

Good Intentions

The rule states that hospital stays fewer than two midnights are generally medically inappropriate for inpatient designation. The services provided are not at issue, but CMS believes those administered during a short stay could be provided on a less expensive outpatient basis.

Dr. Flansbaum, a member of SHM’s Public Policy Committee, says the language of medical necessity that designates status is unclear, though CMS has given physicians the benefit of the doubt.

“We are looking for clear signals from providers for how we determine when someone is appropriately inpatient and when they’re observation,” he explains.

Although medical needs can be quantified, there are often other, nonmedical factors that put patients at risk and influence when and whether a patient is admitted. Physicians routinely weigh these factors on behalf of their patients.

“Risk isn’t necessarily implied by just a dangerous blood value,” Dr. Flansbaum says. “If something is not right in the transition zone or in the community, I think those [factors] need to be taken into account.”

Physicians are being given “a lot of latitude” in CMS’ new rule, he notes.

Clarification

In recent clarification, CMS highlighted exceptions to the rule. If “unforeseen circumstances” shorten the anticipated stay of someone initially deemed inpatient—transfer to another hospital, death, or clinical improvement in fewer than two midnights, for example—CMS can advise auditors to approve the inpatient claim.

Additionally, CMS will maintain a list of services considered “inpatient only,” regardless of stay duration.

But creating a list of every medically necessary service is an “administrative black hole,” says Dr. Flansbaum, though he believes that with enough time and clarity, compliance with the two-midnight rule is possible.

Kelly April Tyrrell is a freelance writer in Wilmington, Del.

A new rule issued by the Centers for Medicare & Medicaid Services (CMS) is at the center of controversy fueled by competing interests and lack of clarity. And, for the fourth time since the two-midnight rule was introduced in the 2014 Hospital Inpatient Prospective Payment System, its implementation has been delayed. Hospitals and providers have until March 31, 2015, before auditors begin scrutinizing patient admission statuses for reimbursement determination.

The rule requires Medicare and Medicaid patients spending fewer than two midnights receiving hospital care to be classified as outpatient or under observation. Patients spending more than two midnights will be considered inpatient. Only physicians can make the determination, and the clock begins ticking the moment care begins.

The rule also cuts hospital inpatient reimbursement by 0.2%, because CMS believes the number of inpatient admissions will increase.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.”

–Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association

The rule pits private Medicare auditors (Medicare Administrative Contractors, MACs, and Recovery Audit Contractors, RACs), who have a financial stake in denying inpatient claims, against hospitals and physicians. It does little to clear confusion for patients when it comes time for them to pay their bills.

Patients generally are unaware whether they’ve been admitted or are under observation. But observation status leaves them on the hook for any skilled nursing care they receive following discharge and for the costs of routine maintenance drugs hospitals give them for chronic conditions.

Beneficiaries also are not eligible for Medicare Part A skilled nursing care coverage if they were an inpatient for fewer than 72 hours, and observation days do not count toward the three-day requirement. The two-midnight rule adds another “layer” to the equation, says Bradley Flansbaum, DO, MPH, FACP, a hospitalist and clinical assistant professor of medicine at NYU School of Medicine in New York City.

At the same time, hospitals now face penalties for patients readmitted within 30 days of discharge for a similar episode of care. Observation status offers a measure of protection in the event patients return.

The number of observation patients increased 69% between 2006 and 2011, according to federal data cited by Kaiser Health News, and the number of observation patients staying more than 48 hours increased from 3% to 8% during this same period.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed,” says Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.

“We feel time should not be the only factor taken into account,” Hiatt Kim adds. “It should be a decision a physician reaches based on a patient’s condition.”

Good Intentions

The rule states that hospital stays fewer than two midnights are generally medically inappropriate for inpatient designation. The services provided are not at issue, but CMS believes those administered during a short stay could be provided on a less expensive outpatient basis.

Dr. Flansbaum, a member of SHM’s Public Policy Committee, says the language of medical necessity that designates status is unclear, though CMS has given physicians the benefit of the doubt.

“We are looking for clear signals from providers for how we determine when someone is appropriately inpatient and when they’re observation,” he explains.

Although medical needs can be quantified, there are often other, nonmedical factors that put patients at risk and influence when and whether a patient is admitted. Physicians routinely weigh these factors on behalf of their patients.

“Risk isn’t necessarily implied by just a dangerous blood value,” Dr. Flansbaum says. “If something is not right in the transition zone or in the community, I think those [factors] need to be taken into account.”

Physicians are being given “a lot of latitude” in CMS’ new rule, he notes.

Clarification

In recent clarification, CMS highlighted exceptions to the rule. If “unforeseen circumstances” shorten the anticipated stay of someone initially deemed inpatient—transfer to another hospital, death, or clinical improvement in fewer than two midnights, for example—CMS can advise auditors to approve the inpatient claim.

Additionally, CMS will maintain a list of services considered “inpatient only,” regardless of stay duration.

But creating a list of every medically necessary service is an “administrative black hole,” says Dr. Flansbaum, though he believes that with enough time and clarity, compliance with the two-midnight rule is possible.

Kelly April Tyrrell is a freelance writer in Wilmington, Del.

A new rule issued by the Centers for Medicare & Medicaid Services (CMS) is at the center of controversy fueled by competing interests and lack of clarity. And, for the fourth time since the two-midnight rule was introduced in the 2014 Hospital Inpatient Prospective Payment System, its implementation has been delayed. Hospitals and providers have until March 31, 2015, before auditors begin scrutinizing patient admission statuses for reimbursement determination.

The rule requires Medicare and Medicaid patients spending fewer than two midnights receiving hospital care to be classified as outpatient or under observation. Patients spending more than two midnights will be considered inpatient. Only physicians can make the determination, and the clock begins ticking the moment care begins.

The rule also cuts hospital inpatient reimbursement by 0.2%, because CMS believes the number of inpatient admissions will increase.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.”

–Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association

The rule pits private Medicare auditors (Medicare Administrative Contractors, MACs, and Recovery Audit Contractors, RACs), who have a financial stake in denying inpatient claims, against hospitals and physicians. It does little to clear confusion for patients when it comes time for them to pay their bills.

Patients generally are unaware whether they’ve been admitted or are under observation. But observation status leaves them on the hook for any skilled nursing care they receive following discharge and for the costs of routine maintenance drugs hospitals give them for chronic conditions.

Beneficiaries also are not eligible for Medicare Part A skilled nursing care coverage if they were an inpatient for fewer than 72 hours, and observation days do not count toward the three-day requirement. The two-midnight rule adds another “layer” to the equation, says Bradley Flansbaum, DO, MPH, FACP, a hospitalist and clinical assistant professor of medicine at NYU School of Medicine in New York City.

At the same time, hospitals now face penalties for patients readmitted within 30 days of discharge for a similar episode of care. Observation status offers a measure of protection in the event patients return.

The number of observation patients increased 69% between 2006 and 2011, according to federal data cited by Kaiser Health News, and the number of observation patients staying more than 48 hours increased from 3% to 8% during this same period.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed,” says Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.

“We feel time should not be the only factor taken into account,” Hiatt Kim adds. “It should be a decision a physician reaches based on a patient’s condition.”

Good Intentions

The rule states that hospital stays fewer than two midnights are generally medically inappropriate for inpatient designation. The services provided are not at issue, but CMS believes those administered during a short stay could be provided on a less expensive outpatient basis.

Dr. Flansbaum, a member of SHM’s Public Policy Committee, says the language of medical necessity that designates status is unclear, though CMS has given physicians the benefit of the doubt.

“We are looking for clear signals from providers for how we determine when someone is appropriately inpatient and when they’re observation,” he explains.

Although medical needs can be quantified, there are often other, nonmedical factors that put patients at risk and influence when and whether a patient is admitted. Physicians routinely weigh these factors on behalf of their patients.

“Risk isn’t necessarily implied by just a dangerous blood value,” Dr. Flansbaum says. “If something is not right in the transition zone or in the community, I think those [factors] need to be taken into account.”

Physicians are being given “a lot of latitude” in CMS’ new rule, he notes.

Clarification

In recent clarification, CMS highlighted exceptions to the rule. If “unforeseen circumstances” shorten the anticipated stay of someone initially deemed inpatient—transfer to another hospital, death, or clinical improvement in fewer than two midnights, for example—CMS can advise auditors to approve the inpatient claim.

Additionally, CMS will maintain a list of services considered “inpatient only,” regardless of stay duration.

But creating a list of every medically necessary service is an “administrative black hole,” says Dr. Flansbaum, though he believes that with enough time and clarity, compliance with the two-midnight rule is possible.

Kelly April Tyrrell is a freelance writer in Wilmington, Del.

click for large version

Steve Narang, MD, a pediatrician, hospitalist, and the then-CMO at Banner Health’s Cardon Children’s Medical Center in Phoenix, was attending a leadership summit where all of Banner’s top officials were gathered. It was his third day in his new job.

Banner’s President, Peter Fine, gave a presentation in the future of healthcare and asked for questions. Dr. Narang stepped up to the microphone, asked a question, and made remarks about how the organization needed to ready itself for the changing landscape. Kathy Bollinger, president of the Arizona West Region of Banner, was struck by those remarks. Less than two years later, she made Dr. Narang the CEO at Arizona’s largest teaching hospital, Good Samaritan Medical Center.

His hospitalist background was an important ingredient in the kind of leader Dr. Narang has become, she says.

“The correlation is that hospitalists are leading teams; they are quarterbacking care,” Bollinger adds. “A good hospitalist brings the team together.”

Physicians with a background in hospital medicine are no strangers to C-suite level positions at hospitals. In April, Brian Harte, MD, SFHM, was named president of South Pointe Hospital in Warrenville Heights, Ohio, a center within the Cleveland Clinic system. In January, Patrick Cawley, MD, MBA, MHM, a former SHM president, was named CEO at the Medical University of South Carolina Medical Center in Charleston.

Other recent C-suite arrivals include Nasim Afsar, MD, SFHM, an SHM board member who is associate CMO at UCLA Hospitals in Los Angeles, and Patrick Torcson, MD, MMM, FACP, SFHM, another SHM board member, vice president, and chief integration officer at St. Tammany Parish Hospital in Covington, La.

Although their paths to the C-suite have differed, each agrees that their experience in hospital medicine gave them the knowledge of the system that was required to begin an ascent to the highest levels of leadership. Just as important, or maybe more so, their exposure to the inner workings of a hospital awakened within them a desire to see the system function better. And the necessity of working with all types of healthcare providers within the complicated hospital setting helped them recognize—or at least get others to recognize—their potential for leadership, and helped hone the teamwork skills that are vital in top administrative roles.

They also say that, when they were starting out, they never aspired to high leadership positions. Rather, it was simply following their own interests that ultimately led them there.

By the time Dr. Narang stepped up to the microphone that day in Phoenix, he had more than a dozen years under his belt working as a hospitalist for a children’s hospital and as part of a group that created a pediatric hospitalist company in Louisiana.

And that work helped lay the foundation for him, he says.

“Being a hospitalist was a key strength of my background,” Dr. Narang explains. “Hospitalists are so well-positioned…to get truly at the intersection of operations and find value in a complex puzzle. Hospitalists are able to do that.

“At the end of the day, it’s about leadership. And I learned that from day one as a hospitalist.”

His confidence and sense of the big picture were not lost on Bollinger that day at the leadership summit.

“I thought that took a fair amount of courage,” she says, “on Day 3, to stand up to the mic and have [a] specific conversation with the president of the company. In my mind, he was very enlightened. His comments were very enlightened.”

Firm Foundation

Robert Zipper, MD, MMM, SFHM, chair of SHM’s Leadership Committee, and CMO of Sound Physicians’ West Region, says it’s probably not realistic for a hospitalist to vault up immediately to a chief executive officer position. Pursuing lower-level leadership roles would be a good starting point for hospitalists with C-suite aspirations, he says.

“For those just starting out, I would recommend that they seek out opportunities to lead or be a part of managing change in their hospitals. The right opportunities should feel like a bit of a stretch, but not overwhelming. This might be work in quality, medical staff leadership, etc.,” Dr. Zipper says.

For hospitalists with leadership experience, CMO and vice president of medical affairs have the closest translation, he adds. He also says jobs like chief informatics officer and roles in quality improvement are highly suitable for hospitalists.

According to the 2011 Cejka Executive Search Physician Executive Compensation Survey, a survey of the American College of Physician Executives’ membership of physicians in management, the median salary of physicians in CEO positions was $393,152. That figure was $343,334 for CMO and $307,500 for chief quality and patient safety officer. The median for all physician executive positions was $305,000. Compensation was typically higher in academic medical centers and lower for hospitals and multi-specialty groups.

Hospitalists in executive positions had a 2011 median income of $275,000, according to the survey.

The survey also showed a wide range of compensation, typically dependent on the size of the institution. Some hospitalist leaders with more than 75% of their full-time-equivalent hours worked clinically “might actually take a small pay cut to make a move,” Dr. Zipper says.

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Natural Progression

The hospitalist executives interviewed, for the most part, were emphatic that C-suite level leadership was not something that they imagined for themselves when they began their medical careers.

“In 2007, I could never imagine doing anything less than 100 percent clinical hospitalist work,” UCLA Hospitals’ Dr. Afsar says. “But once I started working and doing my hospitalist job day in and day out, I realized that there were many aspects of our care where I knew we could do better.”

Dr. Harte, president of South Pointe Hospital in Cleveland, says he never really thought about hospital administration as a career ambition. But, “opportunities presented themselves.”

Dr. Torcson says he was so firmly disinterested in administrative positions that when he was asked to join the Medical Executive Committee at his hospital, his first thought was “no way … I’m a doctor, not an administrator.” But after talking to some senior colleagues about it, they reminded him that he was basically obliged to say “yes.” And it ended up being a crucial component in his ascent through the ranks.

Dr. Narang imagined having a career that impacted value fairly early on, after making observations during his pediatric residency. But even he was surprised when he got the call to be CEO, after less than two years on the job.

Now, in retrospect, they all see their years working as a rank-and-file hospitalist as formative.

As a leader in a hospital, you have to be good at recruiting physicians, retaining them and developing them professionally, Dr. Harte says. That requires having clinical credibility, being a decent mentor, being a good role model, and “wearing your integrity on your sleeve.”

“I think one of the things that makes hospitalists fairly natural fits for the hospital leadership positions is that a hospital is a very complicated environment,” Dr. Harte notes. “You have pockets of enormous expertise that sometimes function like silos.

“Being a hospitalist actually trains you well for those things. By nature of what we do, we tend to be folks who do multi-disciplinary rounds. We can sit around a table or walk rounds with nurses, case managers, physical therapists, respiratory therapists, and the like, and actually develop a plan of care that recognizes the expertise of the other individuals within that group. That is a very good incubator for that kind of thinking.”

Hospital leaders also have to know how everything works together within the hospital.

“Hospital medicine has this overlap with that domain as it is,” Dr. Harte continues. “We work in hospitals. It is not such a stretch then, to think that we could be running a hospital.”

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Golden Opportunity

Dr. Torcson says the opportunities to lead in the hospital setting abound. A former internist, he says hospitalists are primed to “improve quality and service at the hospital level because of the system-based approach to hospital care.”

Dealing with incomplete information and uncertainty are important challenges for hospital leaders, something Dr. Afsar says are daily hurdles for hospitalists.

“By nature when you’re a hospitalist, you are a problem solver,” she says. “You don’t shy away from problems that you don’t understand.”

That problem-solver outlook is what prompted Neil Martin, MD, chief of neurosurgery at UCLA, to ask Dr. Afsar to join a quality improvement program within the department—first as a participant and then as its leader.

“She was always one of the most active and vocal and solution-oriented people on the committees that I was participating in,” Dr. Martin says. “She was not the kind of person who would describe all of the problems and leave it at that. But, rather, [she] would help identify problems and then propose solutions and then help follow through to implement solutions.”

Hospitalist C-suiters describe days dominated by meetings with executive teams, staff, and individual physicians or groups. Meetings are a necessity, as executives are tasked with crafting a vision, constantly assessing progress, and refining the approach when necessary.

Continuing at least some clinical work is important, Dr. Harte says. It depends on the organization, but he says he sees benefits that help him in his administrative duties.

“It changes the dynamic of the interaction with some of the naysayers on the medical staff,” he says. “That’s still something that I enjoy doing. I think it’s important for me, it’s important for the credibility of my job, and particularly for the organization that I work at.”

A lot of C-suiters sought out formal training in administrative areas—though not necessarily an MBA—once they realized they had an interest in administration.

Dr. Torcson says getting a master’s in medical management degree was “absolutely invaluable.”

“It was obvious to me that I had some needs to develop some additional competencies and capabilities, a different skill set than I gained in medical school and residency,” he says. “The same skill set that makes one a successful or quality physician isn’t necessarily the same skill set that you need to be an effective manager or administrator.”

Dr. Afsar completed an advanced quality improvement training program at Intermountain Healthcare, and Dr. Narang received a master’s in healthcare management from Harvard.

Dr. Harte, who does not have an advanced management degree, says that at some institutions, such as Cleveland Clinic, you can learn on the job the non-clinical areas needed to be a top leader in a hospital, including finance and strategy.

Dr. Zipper says a related degree can be a big leg up.

“If one is specifically looking to enter the C-suite, an advanced business or management degree will make that barrier a lot lower,” he says. Whether that degree is a master’s in business administration, healthcare administration, medical management, or a similar degree doesn’t seem to matter much, he adds.

When she was looking for a new CEO for Good Samaritan Medical Center, Bollinger says that she preferred to hire a physician. That candidate, she says, had to have certain leadership qualities, including the ability to create a suitable vision, curiosity, an “executive presence,” and a “tolerance of ambiguity.”

As it turns out, the value of having a physician CEO has been “probably three times what I anticipated,” she says.

If you’re a hospitalist and have an interest in rising up the leadership ladder, getting involved and getting exposure to areas of interest is where it begins.

“I would say go for it,” Dr. Afsar says. “Raising your hand and being willing to take on responsibility are kind of the first steps in getting involved. I think it’s just as much making sure that you’re the right fit for that type of work, as it is to excel and do well. Not everyone, I think, will thrive and enjoy this type of work. So I think having the opportunity to get exposed to it and see if it’s something that you enjoy is a critical piece.”

Tom Collins is a freelance writer in Florida.

click for large version

Steve Narang, MD, a pediatrician, hospitalist, and the then-CMO at Banner Health’s Cardon Children’s Medical Center in Phoenix, was attending a leadership summit where all of Banner’s top officials were gathered. It was his third day in his new job.

Banner’s President, Peter Fine, gave a presentation in the future of healthcare and asked for questions. Dr. Narang stepped up to the microphone, asked a question, and made remarks about how the organization needed to ready itself for the changing landscape. Kathy Bollinger, president of the Arizona West Region of Banner, was struck by those remarks. Less than two years later, she made Dr. Narang the CEO at Arizona’s largest teaching hospital, Good Samaritan Medical Center.

His hospitalist background was an important ingredient in the kind of leader Dr. Narang has become, she says.

“The correlation is that hospitalists are leading teams; they are quarterbacking care,” Bollinger adds. “A good hospitalist brings the team together.”

Physicians with a background in hospital medicine are no strangers to C-suite level positions at hospitals. In April, Brian Harte, MD, SFHM, was named president of South Pointe Hospital in Warrenville Heights, Ohio, a center within the Cleveland Clinic system. In January, Patrick Cawley, MD, MBA, MHM, a former SHM president, was named CEO at the Medical University of South Carolina Medical Center in Charleston.

Other recent C-suite arrivals include Nasim Afsar, MD, SFHM, an SHM board member who is associate CMO at UCLA Hospitals in Los Angeles, and Patrick Torcson, MD, MMM, FACP, SFHM, another SHM board member, vice president, and chief integration officer at St. Tammany Parish Hospital in Covington, La.

Although their paths to the C-suite have differed, each agrees that their experience in hospital medicine gave them the knowledge of the system that was required to begin an ascent to the highest levels of leadership. Just as important, or maybe more so, their exposure to the inner workings of a hospital awakened within them a desire to see the system function better. And the necessity of working with all types of healthcare providers within the complicated hospital setting helped them recognize—or at least get others to recognize—their potential for leadership, and helped hone the teamwork skills that are vital in top administrative roles.

They also say that, when they were starting out, they never aspired to high leadership positions. Rather, it was simply following their own interests that ultimately led them there.

By the time Dr. Narang stepped up to the microphone that day in Phoenix, he had more than a dozen years under his belt working as a hospitalist for a children’s hospital and as part of a group that created a pediatric hospitalist company in Louisiana.

And that work helped lay the foundation for him, he says.

“Being a hospitalist was a key strength of my background,” Dr. Narang explains. “Hospitalists are so well-positioned…to get truly at the intersection of operations and find value in a complex puzzle. Hospitalists are able to do that.

“At the end of the day, it’s about leadership. And I learned that from day one as a hospitalist.”

His confidence and sense of the big picture were not lost on Bollinger that day at the leadership summit.

“I thought that took a fair amount of courage,” she says, “on Day 3, to stand up to the mic and have [a] specific conversation with the president of the company. In my mind, he was very enlightened. His comments were very enlightened.”

Firm Foundation

Robert Zipper, MD, MMM, SFHM, chair of SHM’s Leadership Committee, and CMO of Sound Physicians’ West Region, says it’s probably not realistic for a hospitalist to vault up immediately to a chief executive officer position. Pursuing lower-level leadership roles would be a good starting point for hospitalists with C-suite aspirations, he says.

“For those just starting out, I would recommend that they seek out opportunities to lead or be a part of managing change in their hospitals. The right opportunities should feel like a bit of a stretch, but not overwhelming. This might be work in quality, medical staff leadership, etc.,” Dr. Zipper says.

For hospitalists with leadership experience, CMO and vice president of medical affairs have the closest translation, he adds. He also says jobs like chief informatics officer and roles in quality improvement are highly suitable for hospitalists.

According to the 2011 Cejka Executive Search Physician Executive Compensation Survey, a survey of the American College of Physician Executives’ membership of physicians in management, the median salary of physicians in CEO positions was $393,152. That figure was $343,334 for CMO and $307,500 for chief quality and patient safety officer. The median for all physician executive positions was $305,000. Compensation was typically higher in academic medical centers and lower for hospitals and multi-specialty groups.

Hospitalists in executive positions had a 2011 median income of $275,000, according to the survey.

The survey also showed a wide range of compensation, typically dependent on the size of the institution. Some hospitalist leaders with more than 75% of their full-time-equivalent hours worked clinically “might actually take a small pay cut to make a move,” Dr. Zipper says.

click for large version

Natural Progression

The hospitalist executives interviewed, for the most part, were emphatic that C-suite level leadership was not something that they imagined for themselves when they began their medical careers.

“In 2007, I could never imagine doing anything less than 100 percent clinical hospitalist work,” UCLA Hospitals’ Dr. Afsar says. “But once I started working and doing my hospitalist job day in and day out, I realized that there were many aspects of our care where I knew we could do better.”

Dr. Harte, president of South Pointe Hospital in Cleveland, says he never really thought about hospital administration as a career ambition. But, “opportunities presented themselves.”

Dr. Torcson says he was so firmly disinterested in administrative positions that when he was asked to join the Medical Executive Committee at his hospital, his first thought was “no way … I’m a doctor, not an administrator.” But after talking to some senior colleagues about it, they reminded him that he was basically obliged to say “yes.” And it ended up being a crucial component in his ascent through the ranks.

Dr. Narang imagined having a career that impacted value fairly early on, after making observations during his pediatric residency. But even he was surprised when he got the call to be CEO, after less than two years on the job.

Now, in retrospect, they all see their years working as a rank-and-file hospitalist as formative.

As a leader in a hospital, you have to be good at recruiting physicians, retaining them and developing them professionally, Dr. Harte says. That requires having clinical credibility, being a decent mentor, being a good role model, and “wearing your integrity on your sleeve.”

“I think one of the things that makes hospitalists fairly natural fits for the hospital leadership positions is that a hospital is a very complicated environment,” Dr. Harte notes. “You have pockets of enormous expertise that sometimes function like silos.

“Being a hospitalist actually trains you well for those things. By nature of what we do, we tend to be folks who do multi-disciplinary rounds. We can sit around a table or walk rounds with nurses, case managers, physical therapists, respiratory therapists, and the like, and actually develop a plan of care that recognizes the expertise of the other individuals within that group. That is a very good incubator for that kind of thinking.”

Hospital leaders also have to know how everything works together within the hospital.

“Hospital medicine has this overlap with that domain as it is,” Dr. Harte continues. “We work in hospitals. It is not such a stretch then, to think that we could be running a hospital.”

click for large version

Golden Opportunity

Dr. Torcson says the opportunities to lead in the hospital setting abound. A former internist, he says hospitalists are primed to “improve quality and service at the hospital level because of the system-based approach to hospital care.”

Dealing with incomplete information and uncertainty are important challenges for hospital leaders, something Dr. Afsar says are daily hurdles for hospitalists.

“By nature when you’re a hospitalist, you are a problem solver,” she says. “You don’t shy away from problems that you don’t understand.”

That problem-solver outlook is what prompted Neil Martin, MD, chief of neurosurgery at UCLA, to ask Dr. Afsar to join a quality improvement program within the department—first as a participant and then as its leader.

“She was always one of the most active and vocal and solution-oriented people on the committees that I was participating in,” Dr. Martin says. “She was not the kind of person who would describe all of the problems and leave it at that. But, rather, [she] would help identify problems and then propose solutions and then help follow through to implement solutions.”

Hospitalist C-suiters describe days dominated by meetings with executive teams, staff, and individual physicians or groups. Meetings are a necessity, as executives are tasked with crafting a vision, constantly assessing progress, and refining the approach when necessary.

Continuing at least some clinical work is important, Dr. Harte says. It depends on the organization, but he says he sees benefits that help him in his administrative duties.

“It changes the dynamic of the interaction with some of the naysayers on the medical staff,” he says. “That’s still something that I enjoy doing. I think it’s important for me, it’s important for the credibility of my job, and particularly for the organization that I work at.”

A lot of C-suiters sought out formal training in administrative areas—though not necessarily an MBA—once they realized they had an interest in administration.

Dr. Torcson says getting a master’s in medical management degree was “absolutely invaluable.”

“It was obvious to me that I had some needs to develop some additional competencies and capabilities, a different skill set than I gained in medical school and residency,” he says. “The same skill set that makes one a successful or quality physician isn’t necessarily the same skill set that you need to be an effective manager or administrator.”

Dr. Afsar completed an advanced quality improvement training program at Intermountain Healthcare, and Dr. Narang received a master’s in healthcare management from Harvard.

Dr. Harte, who does not have an advanced management degree, says that at some institutions, such as Cleveland Clinic, you can learn on the job the non-clinical areas needed to be a top leader in a hospital, including finance and strategy.

Dr. Zipper says a related degree can be a big leg up.

“If one is specifically looking to enter the C-suite, an advanced business or management degree will make that barrier a lot lower,” he says. Whether that degree is a master’s in business administration, healthcare administration, medical management, or a similar degree doesn’t seem to matter much, he adds.

When she was looking for a new CEO for Good Samaritan Medical Center, Bollinger says that she preferred to hire a physician. That candidate, she says, had to have certain leadership qualities, including the ability to create a suitable vision, curiosity, an “executive presence,” and a “tolerance of ambiguity.”

As it turns out, the value of having a physician CEO has been “probably three times what I anticipated,” she says.

If you’re a hospitalist and have an interest in rising up the leadership ladder, getting involved and getting exposure to areas of interest is where it begins.

“I would say go for it,” Dr. Afsar says. “Raising your hand and being willing to take on responsibility are kind of the first steps in getting involved. I think it’s just as much making sure that you’re the right fit for that type of work, as it is to excel and do well. Not everyone, I think, will thrive and enjoy this type of work. So I think having the opportunity to get exposed to it and see if it’s something that you enjoy is a critical piece.”

Tom Collins is a freelance writer in Florida.

click for large version

Steve Narang, MD, a pediatrician, hospitalist, and the then-CMO at Banner Health’s Cardon Children’s Medical Center in Phoenix, was attending a leadership summit where all of Banner’s top officials were gathered. It was his third day in his new job.

Banner’s President, Peter Fine, gave a presentation in the future of healthcare and asked for questions. Dr. Narang stepped up to the microphone, asked a question, and made remarks about how the organization needed to ready itself for the changing landscape. Kathy Bollinger, president of the Arizona West Region of Banner, was struck by those remarks. Less than two years later, she made Dr. Narang the CEO at Arizona’s largest teaching hospital, Good Samaritan Medical Center.

His hospitalist background was an important ingredient in the kind of leader Dr. Narang has become, she says.

“The correlation is that hospitalists are leading teams; they are quarterbacking care,” Bollinger adds. “A good hospitalist brings the team together.”

Physicians with a background in hospital medicine are no strangers to C-suite level positions at hospitals. In April, Brian Harte, MD, SFHM, was named president of South Pointe Hospital in Warrenville Heights, Ohio, a center within the Cleveland Clinic system. In January, Patrick Cawley, MD, MBA, MHM, a former SHM president, was named CEO at the Medical University of South Carolina Medical Center in Charleston.

Other recent C-suite arrivals include Nasim Afsar, MD, SFHM, an SHM board member who is associate CMO at UCLA Hospitals in Los Angeles, and Patrick Torcson, MD, MMM, FACP, SFHM, another SHM board member, vice president, and chief integration officer at St. Tammany Parish Hospital in Covington, La.

Although their paths to the C-suite have differed, each agrees that their experience in hospital medicine gave them the knowledge of the system that was required to begin an ascent to the highest levels of leadership. Just as important, or maybe more so, their exposure to the inner workings of a hospital awakened within them a desire to see the system function better. And the necessity of working with all types of healthcare providers within the complicated hospital setting helped them recognize—or at least get others to recognize—their potential for leadership, and helped hone the teamwork skills that are vital in top administrative roles.

They also say that, when they were starting out, they never aspired to high leadership positions. Rather, it was simply following their own interests that ultimately led them there.

By the time Dr. Narang stepped up to the microphone that day in Phoenix, he had more than a dozen years under his belt working as a hospitalist for a children’s hospital and as part of a group that created a pediatric hospitalist company in Louisiana.

And that work helped lay the foundation for him, he says.

“Being a hospitalist was a key strength of my background,” Dr. Narang explains. “Hospitalists are so well-positioned…to get truly at the intersection of operations and find value in a complex puzzle. Hospitalists are able to do that.

“At the end of the day, it’s about leadership. And I learned that from day one as a hospitalist.”

His confidence and sense of the big picture were not lost on Bollinger that day at the leadership summit.

“I thought that took a fair amount of courage,” she says, “on Day 3, to stand up to the mic and have [a] specific conversation with the president of the company. In my mind, he was very enlightened. His comments were very enlightened.”

Firm Foundation

Robert Zipper, MD, MMM, SFHM, chair of SHM’s Leadership Committee, and CMO of Sound Physicians’ West Region, says it’s probably not realistic for a hospitalist to vault up immediately to a chief executive officer position. Pursuing lower-level leadership roles would be a good starting point for hospitalists with C-suite aspirations, he says.

“For those just starting out, I would recommend that they seek out opportunities to lead or be a part of managing change in their hospitals. The right opportunities should feel like a bit of a stretch, but not overwhelming. This might be work in quality, medical staff leadership, etc.,” Dr. Zipper says.

For hospitalists with leadership experience, CMO and vice president of medical affairs have the closest translation, he adds. He also says jobs like chief informatics officer and roles in quality improvement are highly suitable for hospitalists.

According to the 2011 Cejka Executive Search Physician Executive Compensation Survey, a survey of the American College of Physician Executives’ membership of physicians in management, the median salary of physicians in CEO positions was $393,152. That figure was $343,334 for CMO and $307,500 for chief quality and patient safety officer. The median for all physician executive positions was $305,000. Compensation was typically higher in academic medical centers and lower for hospitals and multi-specialty groups.

Hospitalists in executive positions had a 2011 median income of $275,000, according to the survey.

The survey also showed a wide range of compensation, typically dependent on the size of the institution. Some hospitalist leaders with more than 75% of their full-time-equivalent hours worked clinically “might actually take a small pay cut to make a move,” Dr. Zipper says.

click for large version

Natural Progression

The hospitalist executives interviewed, for the most part, were emphatic that C-suite level leadership was not something that they imagined for themselves when they began their medical careers.

“In 2007, I could never imagine doing anything less than 100 percent clinical hospitalist work,” UCLA Hospitals’ Dr. Afsar says. “But once I started working and doing my hospitalist job day in and day out, I realized that there were many aspects of our care where I knew we could do better.”

Dr. Harte, president of South Pointe Hospital in Cleveland, says he never really thought about hospital administration as a career ambition. But, “opportunities presented themselves.”

Dr. Torcson says he was so firmly disinterested in administrative positions that when he was asked to join the Medical Executive Committee at his hospital, his first thought was “no way … I’m a doctor, not an administrator.” But after talking to some senior colleagues about it, they reminded him that he was basically obliged to say “yes.” And it ended up being a crucial component in his ascent through the ranks.

Dr. Narang imagined having a career that impacted value fairly early on, after making observations during his pediatric residency. But even he was surprised when he got the call to be CEO, after less than two years on the job.

Now, in retrospect, they all see their years working as a rank-and-file hospitalist as formative.

As a leader in a hospital, you have to be good at recruiting physicians, retaining them and developing them professionally, Dr. Harte says. That requires having clinical credibility, being a decent mentor, being a good role model, and “wearing your integrity on your sleeve.”

“I think one of the things that makes hospitalists fairly natural fits for the hospital leadership positions is that a hospital is a very complicated environment,” Dr. Harte notes. “You have pockets of enormous expertise that sometimes function like silos.

“Being a hospitalist actually trains you well for those things. By nature of what we do, we tend to be folks who do multi-disciplinary rounds. We can sit around a table or walk rounds with nurses, case managers, physical therapists, respiratory therapists, and the like, and actually develop a plan of care that recognizes the expertise of the other individuals within that group. That is a very good incubator for that kind of thinking.”

Hospital leaders also have to know how everything works together within the hospital.

“Hospital medicine has this overlap with that domain as it is,” Dr. Harte continues. “We work in hospitals. It is not such a stretch then, to think that we could be running a hospital.”

click for large version

Golden Opportunity

Dr. Torcson says the opportunities to lead in the hospital setting abound. A former internist, he says hospitalists are primed to “improve quality and service at the hospital level because of the system-based approach to hospital care.”

Dealing with incomplete information and uncertainty are important challenges for hospital leaders, something Dr. Afsar says are daily hurdles for hospitalists.

“By nature when you’re a hospitalist, you are a problem solver,” she says. “You don’t shy away from problems that you don’t understand.”

That problem-solver outlook is what prompted Neil Martin, MD, chief of neurosurgery at UCLA, to ask Dr. Afsar to join a quality improvement program within the department—first as a participant and then as its leader.

“She was always one of the most active and vocal and solution-oriented people on the committees that I was participating in,” Dr. Martin says. “She was not the kind of person who would describe all of the problems and leave it at that. But, rather, [she] would help identify problems and then propose solutions and then help follow through to implement solutions.”

Hospitalist C-suiters describe days dominated by meetings with executive teams, staff, and individual physicians or groups. Meetings are a necessity, as executives are tasked with crafting a vision, constantly assessing progress, and refining the approach when necessary.

Continuing at least some clinical work is important, Dr. Harte says. It depends on the organization, but he says he sees benefits that help him in his administrative duties.

“It changes the dynamic of the interaction with some of the naysayers on the medical staff,” he says. “That’s still something that I enjoy doing. I think it’s important for me, it’s important for the credibility of my job, and particularly for the organization that I work at.”

A lot of C-suiters sought out formal training in administrative areas—though not necessarily an MBA—once they realized they had an interest in administration.

Dr. Torcson says getting a master’s in medical management degree was “absolutely invaluable.”

“It was obvious to me that I had some needs to develop some additional competencies and capabilities, a different skill set than I gained in medical school and residency,” he says. “The same skill set that makes one a successful or quality physician isn’t necessarily the same skill set that you need to be an effective manager or administrator.”

Dr. Afsar completed an advanced quality improvement training program at Intermountain Healthcare, and Dr. Narang received a master’s in healthcare management from Harvard.

Dr. Harte, who does not have an advanced management degree, says that at some institutions, such as Cleveland Clinic, you can learn on the job the non-clinical areas needed to be a top leader in a hospital, including finance and strategy.

Dr. Zipper says a related degree can be a big leg up.

“If one is specifically looking to enter the C-suite, an advanced business or management degree will make that barrier a lot lower,” he says. Whether that degree is a master’s in business administration, healthcare administration, medical management, or a similar degree doesn’t seem to matter much, he adds.

When she was looking for a new CEO for Good Samaritan Medical Center, Bollinger says that she preferred to hire a physician. That candidate, she says, had to have certain leadership qualities, including the ability to create a suitable vision, curiosity, an “executive presence,” and a “tolerance of ambiguity.”

As it turns out, the value of having a physician CEO has been “probably three times what I anticipated,” she says.

If you’re a hospitalist and have an interest in rising up the leadership ladder, getting involved and getting exposure to areas of interest is where it begins.

“I would say go for it,” Dr. Afsar says. “Raising your hand and being willing to take on responsibility are kind of the first steps in getting involved. I think it’s just as much making sure that you’re the right fit for that type of work, as it is to excel and do well. Not everyone, I think, will thrive and enjoy this type of work. So I think having the opportunity to get exposed to it and see if it’s something that you enjoy is a critical piece.”

Tom Collins is a freelance writer in Florida.

Last week I saw a 35-year-old man for follow-up on a positive rapid plasma reagin (RPR). He thought he had syphilis, but he had never had any syphilis symptoms, so I suspected the RPR was a false positive. Because I seldom encounter this situation, it was time for some “point of care” research. I checked an online reference and found that the fluorescent treponemal antibody absorption (FTA-ABS) test is highly sensitive and would be sufficient to rule out syphilis. The good news: His subsequent FTA-ABS was negative. But the situation left me wondering why the FTA-ABS had not been done automatically after the positive RPR.

The question, “What is the best test to rule in or rule out X?” comes up frequently for family physicians (FPs), and sometimes we are uncertain about ordering the best test and interpreting the results correctly. According to a recent national survey sponsored by the Centers for Disease Control and Prevention¹—for which I was privileged to be the principal investigator—1768 FPs and general internists reported ordering diagnostic laboratory tests for an average of 31.4% of their patients per week. They were uncertain about the right test to order for 14.7% of these patients and uncertain about interpreting the results for 8.3%. That might not seem like a lot, but with more than 500 million primary care patient visits per year in the United States, this potentially affects 23 million patients each year.

In our EMR, 90% of the lab report details things I don't need to know to get to the 10% I do need, I have to scroll to click.We asked about problems with test ordering, too. I don’t think you will be surprised that physicians reported insurance company restrictions and costs to patients were the main barriers. They also reported difficulty with the variety of names for the same tests, which I certainly noticed when I moved from Cleveland Clinic to University of Illinois at Chicago. Not getting test results in a timely manner was a big problem, too, as was confusing report formats. In our electronic medical record, 90% of the lab report details things I don’t need to know and to get to the 10% I do need, I have to scroll or click.

In this issue, Tessier et al illustrate ways to avoid common lab testing pitfalls. I would argue that in addition to helpful articles like this one, we also need better electronic tools to help guide us when uncertain. Then again, the phone is still good technology; when in doubt, pick it up and call your lab.

Last week I saw a 35-year-old man for follow-up on a positive rapid plasma reagin (RPR). He thought he had syphilis, but he had never had any syphilis symptoms, so I suspected the RPR was a false positive. Because I seldom encounter this situation, it was time for some “point of care” research. I checked an online reference and found that the fluorescent treponemal antibody absorption (FTA-ABS) test is highly sensitive and would be sufficient to rule out syphilis. The good news: His subsequent FTA-ABS was negative. But the situation left me wondering why the FTA-ABS had not been done automatically after the positive RPR.

The question, “What is the best test to rule in or rule out X?” comes up frequently for family physicians (FPs), and sometimes we are uncertain about ordering the best test and interpreting the results correctly. According to a recent national survey sponsored by the Centers for Disease Control and Prevention¹—for which I was privileged to be the principal investigator—1768 FPs and general internists reported ordering diagnostic laboratory tests for an average of 31.4% of their patients per week. They were uncertain about the right test to order for 14.7% of these patients and uncertain about interpreting the results for 8.3%. That might not seem like a lot, but with more than 500 million primary care patient visits per year in the United States, this potentially affects 23 million patients each year.

In our EMR, 90% of the lab report details things I don't need to know to get to the 10% I do need, I have to scroll to click.We asked about problems with test ordering, too. I don’t think you will be surprised that physicians reported insurance company restrictions and costs to patients were the main barriers. They also reported difficulty with the variety of names for the same tests, which I certainly noticed when I moved from Cleveland Clinic to University of Illinois at Chicago. Not getting test results in a timely manner was a big problem, too, as was confusing report formats. In our electronic medical record, 90% of the lab report details things I don’t need to know and to get to the 10% I do need, I have to scroll or click.

In this issue, Tessier et al illustrate ways to avoid common lab testing pitfalls. I would argue that in addition to helpful articles like this one, we also need better electronic tools to help guide us when uncertain. Then again, the phone is still good technology; when in doubt, pick it up and call your lab.

Last week I saw a 35-year-old man for follow-up on a positive rapid plasma reagin (RPR). He thought he had syphilis, but he had never had any syphilis symptoms, so I suspected the RPR was a false positive. Because I seldom encounter this situation, it was time for some “point of care” research. I checked an online reference and found that the fluorescent treponemal antibody absorption (FTA-ABS) test is highly sensitive and would be sufficient to rule out syphilis. The good news: His subsequent FTA-ABS was negative. But the situation left me wondering why the FTA-ABS had not been done automatically after the positive RPR.

The question, “What is the best test to rule in or rule out X?” comes up frequently for family physicians (FPs), and sometimes we are uncertain about ordering the best test and interpreting the results correctly. According to a recent national survey sponsored by the Centers for Disease Control and Prevention¹—for which I was privileged to be the principal investigator—1768 FPs and general internists reported ordering diagnostic laboratory tests for an average of 31.4% of their patients per week. They were uncertain about the right test to order for 14.7% of these patients and uncertain about interpreting the results for 8.3%. That might not seem like a lot, but with more than 500 million primary care patient visits per year in the United States, this potentially affects 23 million patients each year.

In our EMR, 90% of the lab report details things I don't need to know to get to the 10% I do need, I have to scroll to click.We asked about problems with test ordering, too. I don’t think you will be surprised that physicians reported insurance company restrictions and costs to patients were the main barriers. They also reported difficulty with the variety of names for the same tests, which I certainly noticed when I moved from Cleveland Clinic to University of Illinois at Chicago. Not getting test results in a timely manner was a big problem, too, as was confusing report formats. In our electronic medical record, 90% of the lab report details things I don’t need to know and to get to the 10% I do need, I have to scroll or click.

In this issue, Tessier et al illustrate ways to avoid common lab testing pitfalls. I would argue that in addition to helpful articles like this one, we also need better electronic tools to help guide us when uncertain. Then again, the phone is still good technology; when in doubt, pick it up and call your lab.

We were happy to learn in “Time to routinely screen for intimate partner violence?” (PURLs. J Fam Pract. 2013;62:90-92) that the US Preventive Services Task Force (USPSTF) agrees with the Institute of Medicine (IOM) that all women of childbearing age should be screened for intimate partner violence (IPV).¹ Although the USPSTF recommendation comes 2 years after that of the IOM, it is truly better late than never.

Two populations with known IPV issues require special consideration: lesbian, gay, bisexual, transgender (LGBT) patients and heterosexual men. The rate of IPV is higher in the LGBT population than in heterosexual men and women cohabitating with their partners.² Despite high rates of IPV within the LGBT population, women in this group frequently are overlooked for IPV screening.²

We must remember to screen men in heterosexual relationships, as well. In 2000, the National Violence Against Women survey found that 7% of men reported having experienced IPV in their lifetime.² Given this data, we believe that all patients ages 14 years and older—regardless of gender or sexual orientation—should be screened for IPV. This would be a much-needed step towards addressing a major public health problem.

Barbara McMillan-Persaud, MD
Kyra P. Clark, MD
Riba Kelsey-Harris, MD
Folashade Omole, MD, FAAFP
Atlanta, Ga

We were happy to learn in “Time to routinely screen for intimate partner violence?” (PURLs. J Fam Pract. 2013;62:90-92) that the US Preventive Services Task Force (USPSTF) agrees with the Institute of Medicine (IOM) that all women of childbearing age should be screened for intimate partner violence (IPV).¹ Although the USPSTF recommendation comes 2 years after that of the IOM, it is truly better late than never.

Two populations with known IPV issues require special consideration: lesbian, gay, bisexual, transgender (LGBT) patients and heterosexual men. The rate of IPV is higher in the LGBT population than in heterosexual men and women cohabitating with their partners.² Despite high rates of IPV within the LGBT population, women in this group frequently are overlooked for IPV screening.²

We must remember to screen men in heterosexual relationships, as well. In 2000, the National Violence Against Women survey found that 7% of men reported having experienced IPV in their lifetime.² Given this data, we believe that all patients ages 14 years and older—regardless of gender or sexual orientation—should be screened for IPV. This would be a much-needed step towards addressing a major public health problem.

Barbara McMillan-Persaud, MD
Kyra P. Clark, MD
Riba Kelsey-Harris, MD
Folashade Omole, MD, FAAFP
Atlanta, Ga

We were happy to learn in “Time to routinely screen for intimate partner violence?” (PURLs. J Fam Pract. 2013;62:90-92) that the US Preventive Services Task Force (USPSTF) agrees with the Institute of Medicine (IOM) that all women of childbearing age should be screened for intimate partner violence (IPV).¹ Although the USPSTF recommendation comes 2 years after that of the IOM, it is truly better late than never.

Two populations with known IPV issues require special consideration: lesbian, gay, bisexual, transgender (LGBT) patients and heterosexual men. The rate of IPV is higher in the LGBT population than in heterosexual men and women cohabitating with their partners.² Despite high rates of IPV within the LGBT population, women in this group frequently are overlooked for IPV screening.²

We must remember to screen men in heterosexual relationships, as well. In 2000, the National Violence Against Women survey found that 7% of men reported having experienced IPV in their lifetime.² Given this data, we believe that all patients ages 14 years and older—regardless of gender or sexual orientation—should be screened for IPV. This would be a much-needed step towards addressing a major public health problem.

Barbara McMillan-Persaud, MD
Kyra P. Clark, MD
Riba Kelsey-Harris, MD
Folashade Omole, MD, FAAFP
Atlanta, Ga

THE CASE

A previously healthy 35-year-old man with a one-week history of left-sided neck pain and fever as high as 104°F sought care at our emergency department. He was given a diagnosis of viral pharyngitis and discharged. He returned the next day and indicated that he was now experiencing drenching night sweats and weakness.

The patient was anxious, but not distressed. His temperature was 100.1°F; blood pressure, 113/65 mm Hg; heart rate, 150 beats per minute; respiratory rate, 18 breaths per minute; and oxygen saturation, 95% on room air. Head and neck examination revealed bilateral cervical lymphadenopathy with pronounced tenderness on the left side of his neck. Oral exam revealed dry mucous membranes, halitosis, and bilateral tonsillar enlargement without exudate. The cardiopulmonary exam was within normal limits. Lab tests showed a white blood cell (WBC) count of 5.9 x 109/L. An ultrasound of the neck revealed thrombosis in the left submandibular branch of the left internal jugular vein (IJV) (FIGURE 1).

The next day, the patient remained febrile (102.8°F) and developed rigors, diarrhea, pleuritic chest pain, and an elevated WBC count (14.5). A blood culture grew gramnegative rods. The patient was started on piperacillin/tazobactam, and doxycycline was added to treat possible tick-borne infections. Computed tomography (CT) scans of the chest showed the presence of septic pulmonary emboli and small bilateral pleural effusions (FIGURE 2).

THE DIAGNOSIS

We made a diagnosis of Lemierre’s syndrome because our patient met all 4 criteria for the condition:^1,2
• a recent oropharyngeal infection
• clinical or radiological evidence of IJV thrombosis
• isolation of anaerobic pathogens (mainly Fusobacterium necrophorum)
• evidence of at least one septic focus, most commonly in the lungs.

We changed the patient’s antibiotic therapy to intravenous (IV) meropenem. His WBC and fever improved, and on Day 10 he was discharged to complete a 28-day course of IV meropenem via a peripherally inserted central catheter.

DISCUSSION

Lemierre’s—A “forgotten” condition that’s making a comeback

In 1936, French microbiologist Andrew Lemierre formally characterized the syndrome in a review of 20 patients who had sepsis, metastatic pulmonary lesions, and isolation of Bacillus funduliformis (now known as F necrophorum).^1,2 Other organisms that have been identified in this syndrome include Fusobacterium nucleatum, Candida, Staphylococcus, and Streptococcus.²

Before the antibiotic era, Lemierre’s syndrome was common and often fatal. But with the introduction of penicillin in the 1940s, the incidence of the syndrome dropped, and it eventually became known as “the forgotten disease.”² Since the 1990s, however, there has been a marked resurgence of Lemierre’s syndrome.³ The incidence of Lemierre’s syndrome today is 0.6 to 2.3 cases per 1 million people per year, with a mortality rate of up to 18%.^3,4

This resurgence of Lemierre’s syndrome has been linked to the restricted use of antibiotics for throat infections.3 (One study found the number of prescriptions written for antibiotics decreased by 23% from 1992 to 2000.⁵) Other factors cited for the increased incidence of Lemierre’s syndrome include improved identification of anaerobic organisms, more effective blood culture methods, and an increased awareness of this syndrome among clinical microbiologists.⁶

Diagnosis requires a high degree of suspicion

Lemierre’s syndrome typically occurs in healthy young adults. Pharyngitis is the most common initial symptom, occurring in 87% of patients.² This is followed by a fever (102.2°F - 105.8°F) usually 4 to 5 days after the onset of sore throat.³ Other common symptoms include chills, dysphagia, dyspnea, chest pain, hemoptysis, cervical neck discomfort, arthralgia, malaise, and night sweats.² Following suppurative thrombophlebitis of the IJV, infection spreads to other organ systems. Pulmonary involvement is the most common site (97% of cases).³ Other complications of this syndrome are listed in the TABLE.³

The differential includes mononucleosis

The differential diagnosis encompasses several common illnesses, including mononucleosis, Group A streptococcal pharyngitis, and peritonsillar abscess. However, while patients with these conditions might have a fever and an elevated WBC count, they typically would not have the pleuritic chest pain that is characteristic of Lemierre’s syndrome. In addition, while patients with peritonsillar abscess would have tonsillar exudates, patients with Lemierre’s syndrome would not likely have them.

Influenza is also part of the differential, although focal neck pain usually isn’t a finding in patients who have the flu.

Once other common illnesses have been ruled out, it’s important to have a high index of suspicion for Lemierre’s syndrome because the oropharyngeal infection may resolve by the time of presentation, and there may be few findings on physical exam.⁷ Therefore, suspect Lemierre’s if a patient comes in with neck pain and/or pleuritic chest pain and has a recent history of oropharyngeal infection and fever.

CT scan of the neck and chest with contrast is the optimal diagnostic modality because it allows physicians to visualize the IJV⁸ and detect pulmonary emboli.⁹ Doppler ultrasound also can be used to diagnose IJV thrombosis. Ultrasound findings would reveal an echogenic focus within a dilated IJV or a complex mass of cystic and solid components.¹⁰

Many case reports have demonstrated that complete recovery is possible without anticoagulation.Prompt antibiotic treatment is essential

Patients with Lemierre’s syndrome require prompt and appropriate antimicrobial therapy. Researchers have reported mortality rates of 25% among patients who received delayed antibiotic therapy, compared with rates of up to 18% with prompt therapy.³ Metronidazole is the most commonly prescribed antibiotic.⁸ When combined with ceftriaxone, it provides coverage for both F necrophorum and streptococci, a common copathogen. Monotherapy with a carbapenem antibiotic, clindamycin, ampicillin/sulbactam, or antipseudomonal penicillin also are appropriate options.⁵ Antimicrobial treatment for 3 to 6 weeks is recommended because relapses have been noted in patients treated for less than 2 weeks.¹¹

Anticoagulation is controversial.² Proponents of anticoagulation to treat Lemierre’s syndrome believe it may prevent formation of septic emboli and could expedite recovery.^4,12 Others believe that clots associated with Lemierre’s syndrome dissolve on their own and that anticoagulation may increase the likelihood of septic emboli.¹³ Many case reports, including this one, have demonstrated that complete recovery is possible without anticoagulation.^10,13-15 Anticoagulation therapy can be considered for patients with Lemierre’s syndrome in the absence of any contraindications such as gastrointestinal or intracranial bleeding.

THE TAKEAWAY

Suspect Lemierre’s syndrome when a patient complains of neck pain, high fever, rigors, dry cough, and pleuritic chest pain and mentions a sore throat that he or she had in the pretceding 7 days. Diagnosis can be confirmed by radiological findings and blood cultures positive for F. necrophorum. Patients with Lemierre’s syndrome should be promptly treated with antibiotics; evidence for anticoagulation is inconclusive.

THE CASE

A previously healthy 35-year-old man with a one-week history of left-sided neck pain and fever as high as 104°F sought care at our emergency department. He was given a diagnosis of viral pharyngitis and discharged. He returned the next day and indicated that he was now experiencing drenching night sweats and weakness.

The patient was anxious, but not distressed. His temperature was 100.1°F; blood pressure, 113/65 mm Hg; heart rate, 150 beats per minute; respiratory rate, 18 breaths per minute; and oxygen saturation, 95% on room air. Head and neck examination revealed bilateral cervical lymphadenopathy with pronounced tenderness on the left side of his neck. Oral exam revealed dry mucous membranes, halitosis, and bilateral tonsillar enlargement without exudate. The cardiopulmonary exam was within normal limits. Lab tests showed a white blood cell (WBC) count of 5.9 x 109/L. An ultrasound of the neck revealed thrombosis in the left submandibular branch of the left internal jugular vein (IJV) (FIGURE 1).

The next day, the patient remained febrile (102.8°F) and developed rigors, diarrhea, pleuritic chest pain, and an elevated WBC count (14.5). A blood culture grew gramnegative rods. The patient was started on piperacillin/tazobactam, and doxycycline was added to treat possible tick-borne infections. Computed tomography (CT) scans of the chest showed the presence of septic pulmonary emboli and small bilateral pleural effusions (FIGURE 2).

THE DIAGNOSIS

We made a diagnosis of Lemierre’s syndrome because our patient met all 4 criteria for the condition:^1,2
• a recent oropharyngeal infection
• clinical or radiological evidence of IJV thrombosis
• isolation of anaerobic pathogens (mainly Fusobacterium necrophorum)
• evidence of at least one septic focus, most commonly in the lungs.

We changed the patient’s antibiotic therapy to intravenous (IV) meropenem. His WBC and fever improved, and on Day 10 he was discharged to complete a 28-day course of IV meropenem via a peripherally inserted central catheter.

DISCUSSION

Lemierre’s—A “forgotten” condition that’s making a comeback

In 1936, French microbiologist Andrew Lemierre formally characterized the syndrome in a review of 20 patients who had sepsis, metastatic pulmonary lesions, and isolation of Bacillus funduliformis (now known as F necrophorum).^1,2 Other organisms that have been identified in this syndrome include Fusobacterium nucleatum, Candida, Staphylococcus, and Streptococcus.²

Before the antibiotic era, Lemierre’s syndrome was common and often fatal. But with the introduction of penicillin in the 1940s, the incidence of the syndrome dropped, and it eventually became known as “the forgotten disease.”² Since the 1990s, however, there has been a marked resurgence of Lemierre’s syndrome.³ The incidence of Lemierre’s syndrome today is 0.6 to 2.3 cases per 1 million people per year, with a mortality rate of up to 18%.^3,4

This resurgence of Lemierre’s syndrome has been linked to the restricted use of antibiotics for throat infections.3 (One study found the number of prescriptions written for antibiotics decreased by 23% from 1992 to 2000.⁵) Other factors cited for the increased incidence of Lemierre’s syndrome include improved identification of anaerobic organisms, more effective blood culture methods, and an increased awareness of this syndrome among clinical microbiologists.⁶

Diagnosis requires a high degree of suspicion

Lemierre’s syndrome typically occurs in healthy young adults. Pharyngitis is the most common initial symptom, occurring in 87% of patients.² This is followed by a fever (102.2°F - 105.8°F) usually 4 to 5 days after the onset of sore throat.³ Other common symptoms include chills, dysphagia, dyspnea, chest pain, hemoptysis, cervical neck discomfort, arthralgia, malaise, and night sweats.² Following suppurative thrombophlebitis of the IJV, infection spreads to other organ systems. Pulmonary involvement is the most common site (97% of cases).³ Other complications of this syndrome are listed in the TABLE.³

The differential includes mononucleosis

The differential diagnosis encompasses several common illnesses, including mononucleosis, Group A streptococcal pharyngitis, and peritonsillar abscess. However, while patients with these conditions might have a fever and an elevated WBC count, they typically would not have the pleuritic chest pain that is characteristic of Lemierre’s syndrome. In addition, while patients with peritonsillar abscess would have tonsillar exudates, patients with Lemierre’s syndrome would not likely have them.

Influenza is also part of the differential, although focal neck pain usually isn’t a finding in patients who have the flu.

Once other common illnesses have been ruled out, it’s important to have a high index of suspicion for Lemierre’s syndrome because the oropharyngeal infection may resolve by the time of presentation, and there may be few findings on physical exam.⁷ Therefore, suspect Lemierre’s if a patient comes in with neck pain and/or pleuritic chest pain and has a recent history of oropharyngeal infection and fever.

CT scan of the neck and chest with contrast is the optimal diagnostic modality because it allows physicians to visualize the IJV⁸ and detect pulmonary emboli.⁹ Doppler ultrasound also can be used to diagnose IJV thrombosis. Ultrasound findings would reveal an echogenic focus within a dilated IJV or a complex mass of cystic and solid components.¹⁰

Many case reports have demonstrated that complete recovery is possible without anticoagulation.Prompt antibiotic treatment is essential

Patients with Lemierre’s syndrome require prompt and appropriate antimicrobial therapy. Researchers have reported mortality rates of 25% among patients who received delayed antibiotic therapy, compared with rates of up to 18% with prompt therapy.³ Metronidazole is the most commonly prescribed antibiotic.⁸ When combined with ceftriaxone, it provides coverage for both F necrophorum and streptococci, a common copathogen. Monotherapy with a carbapenem antibiotic, clindamycin, ampicillin/sulbactam, or antipseudomonal penicillin also are appropriate options.⁵ Antimicrobial treatment for 3 to 6 weeks is recommended because relapses have been noted in patients treated for less than 2 weeks.¹¹

Anticoagulation is controversial.² Proponents of anticoagulation to treat Lemierre’s syndrome believe it may prevent formation of septic emboli and could expedite recovery.^4,12 Others believe that clots associated with Lemierre’s syndrome dissolve on their own and that anticoagulation may increase the likelihood of septic emboli.¹³ Many case reports, including this one, have demonstrated that complete recovery is possible without anticoagulation.^10,13-15 Anticoagulation therapy can be considered for patients with Lemierre’s syndrome in the absence of any contraindications such as gastrointestinal or intracranial bleeding.

THE TAKEAWAY

Suspect Lemierre’s syndrome when a patient complains of neck pain, high fever, rigors, dry cough, and pleuritic chest pain and mentions a sore throat that he or she had in the pretceding 7 days. Diagnosis can be confirmed by radiological findings and blood cultures positive for F. necrophorum. Patients with Lemierre’s syndrome should be promptly treated with antibiotics; evidence for anticoagulation is inconclusive.

THE CASE

A previously healthy 35-year-old man with a one-week history of left-sided neck pain and fever as high as 104°F sought care at our emergency department. He was given a diagnosis of viral pharyngitis and discharged. He returned the next day and indicated that he was now experiencing drenching night sweats and weakness.

The patient was anxious, but not distressed. His temperature was 100.1°F; blood pressure, 113/65 mm Hg; heart rate, 150 beats per minute; respiratory rate, 18 breaths per minute; and oxygen saturation, 95% on room air. Head and neck examination revealed bilateral cervical lymphadenopathy with pronounced tenderness on the left side of his neck. Oral exam revealed dry mucous membranes, halitosis, and bilateral tonsillar enlargement without exudate. The cardiopulmonary exam was within normal limits. Lab tests showed a white blood cell (WBC) count of 5.9 x 109/L. An ultrasound of the neck revealed thrombosis in the left submandibular branch of the left internal jugular vein (IJV) (FIGURE 1).

The next day, the patient remained febrile (102.8°F) and developed rigors, diarrhea, pleuritic chest pain, and an elevated WBC count (14.5). A blood culture grew gramnegative rods. The patient was started on piperacillin/tazobactam, and doxycycline was added to treat possible tick-borne infections. Computed tomography (CT) scans of the chest showed the presence of septic pulmonary emboli and small bilateral pleural effusions (FIGURE 2).

THE DIAGNOSIS

We made a diagnosis of Lemierre’s syndrome because our patient met all 4 criteria for the condition:^1,2
• a recent oropharyngeal infection
• clinical or radiological evidence of IJV thrombosis
• isolation of anaerobic pathogens (mainly Fusobacterium necrophorum)
• evidence of at least one septic focus, most commonly in the lungs.

We changed the patient’s antibiotic therapy to intravenous (IV) meropenem. His WBC and fever improved, and on Day 10 he was discharged to complete a 28-day course of IV meropenem via a peripherally inserted central catheter.

DISCUSSION

Lemierre’s—A “forgotten” condition that’s making a comeback

In 1936, French microbiologist Andrew Lemierre formally characterized the syndrome in a review of 20 patients who had sepsis, metastatic pulmonary lesions, and isolation of Bacillus funduliformis (now known as F necrophorum).^1,2 Other organisms that have been identified in this syndrome include Fusobacterium nucleatum, Candida, Staphylococcus, and Streptococcus.²

Before the antibiotic era, Lemierre’s syndrome was common and often fatal. But with the introduction of penicillin in the 1940s, the incidence of the syndrome dropped, and it eventually became known as “the forgotten disease.”² Since the 1990s, however, there has been a marked resurgence of Lemierre’s syndrome.³ The incidence of Lemierre’s syndrome today is 0.6 to 2.3 cases per 1 million people per year, with a mortality rate of up to 18%.^3,4

This resurgence of Lemierre’s syndrome has been linked to the restricted use of antibiotics for throat infections.3 (One study found the number of prescriptions written for antibiotics decreased by 23% from 1992 to 2000.⁵) Other factors cited for the increased incidence of Lemierre’s syndrome include improved identification of anaerobic organisms, more effective blood culture methods, and an increased awareness of this syndrome among clinical microbiologists.⁶

Diagnosis requires a high degree of suspicion

Lemierre’s syndrome typically occurs in healthy young adults. Pharyngitis is the most common initial symptom, occurring in 87% of patients.² This is followed by a fever (102.2°F - 105.8°F) usually 4 to 5 days after the onset of sore throat.³ Other common symptoms include chills, dysphagia, dyspnea, chest pain, hemoptysis, cervical neck discomfort, arthralgia, malaise, and night sweats.² Following suppurative thrombophlebitis of the IJV, infection spreads to other organ systems. Pulmonary involvement is the most common site (97% of cases).³ Other complications of this syndrome are listed in the TABLE.³

The differential includes mononucleosis

The differential diagnosis encompasses several common illnesses, including mononucleosis, Group A streptococcal pharyngitis, and peritonsillar abscess. However, while patients with these conditions might have a fever and an elevated WBC count, they typically would not have the pleuritic chest pain that is characteristic of Lemierre’s syndrome. In addition, while patients with peritonsillar abscess would have tonsillar exudates, patients with Lemierre’s syndrome would not likely have them.

Influenza is also part of the differential, although focal neck pain usually isn’t a finding in patients who have the flu.

Once other common illnesses have been ruled out, it’s important to have a high index of suspicion for Lemierre’s syndrome because the oropharyngeal infection may resolve by the time of presentation, and there may be few findings on physical exam.⁷ Therefore, suspect Lemierre’s if a patient comes in with neck pain and/or pleuritic chest pain and has a recent history of oropharyngeal infection and fever.

CT scan of the neck and chest with contrast is the optimal diagnostic modality because it allows physicians to visualize the IJV⁸ and detect pulmonary emboli.⁹ Doppler ultrasound also can be used to diagnose IJV thrombosis. Ultrasound findings would reveal an echogenic focus within a dilated IJV or a complex mass of cystic and solid components.¹⁰

Many case reports have demonstrated that complete recovery is possible without anticoagulation.Prompt antibiotic treatment is essential

Patients with Lemierre’s syndrome require prompt and appropriate antimicrobial therapy. Researchers have reported mortality rates of 25% among patients who received delayed antibiotic therapy, compared with rates of up to 18% with prompt therapy.³ Metronidazole is the most commonly prescribed antibiotic.⁸ When combined with ceftriaxone, it provides coverage for both F necrophorum and streptococci, a common copathogen. Monotherapy with a carbapenem antibiotic, clindamycin, ampicillin/sulbactam, or antipseudomonal penicillin also are appropriate options.⁵ Antimicrobial treatment for 3 to 6 weeks is recommended because relapses have been noted in patients treated for less than 2 weeks.¹¹

Anticoagulation is controversial.² Proponents of anticoagulation to treat Lemierre’s syndrome believe it may prevent formation of septic emboli and could expedite recovery.^4,12 Others believe that clots associated with Lemierre’s syndrome dissolve on their own and that anticoagulation may increase the likelihood of septic emboli.¹³ Many case reports, including this one, have demonstrated that complete recovery is possible without anticoagulation.^10,13-15 Anticoagulation therapy can be considered for patients with Lemierre’s syndrome in the absence of any contraindications such as gastrointestinal or intracranial bleeding.

THE TAKEAWAY

Suspect Lemierre’s syndrome when a patient complains of neck pain, high fever, rigors, dry cough, and pleuritic chest pain and mentions a sore throat that he or she had in the pretceding 7 days. Diagnosis can be confirmed by radiological findings and blood cultures positive for F. necrophorum. Patients with Lemierre’s syndrome should be promptly treated with antibiotics; evidence for anticoagulation is inconclusive.

ABSTRACT

Purpose Little is known about patients who present a written list during a medical consultation. In this preliminary study, we sought to examine and characterize patients who use a prepared list.

Methods The design was an open observational case-controlled study that took place at 2 urban primary care clinics. We enrolled patients consecutively as they arrived with a written list for consultation. Consecutive patients presenting without a list served as the control group. Physician interviews and completed questionnaires provided demographic and medical characteristics of this group and explanations for list preparation.

Results Fifty-four patients presented with a list and were compared with controls. Statistically, patients arriving with a list were significantly more likely to be older and retired, and less likely to be salaried workers or housewives. These patients had more chronic diseases and consumed more long-term medications. They had a greater number of doctor visits in the past year compared with controls, and perceived an increase in memory loss. There were no differences between the groups in terms of psychiatric disease or personality disorders.

Conclusions Aside from certain demographic and health characteristics, patients who use written lists do not differ substantially from those who don’t. They have no discernible ill intention, and the list serves as a memory aid to make the most of the visit.

Nonverbal communication is a significant part of the physician-patient encounter, in part revealing clues to underlying attitudes and emotions or indicating whether one agrees or disagrees with expressed statements.¹ Nonverbal communication exhibited by both doctor and patient strongly influences how each participant perceives the encounter and helps determine how the physician-patient relationship will develop.^2-4

Patients, for example, are affected by the amount of physician eye contact and computer use. Less eye contact and greater attention to the computer tend to lower patients’ opinions of the consultation.^1,5 These and other behaviors may contribute to the finding that 30% to 80% of patients feel their expectations are not met in routine primary care visits.⁶

Physicians, despite attempts to remain nonjudgmental, can be affected by a patient’s demeanor on entering the consulting room. Subtle prejudices may be evoked by age, gender, ethnicity, manner of dress, tone of voice, mannerisms, cell phone interruptions, and the like.^7,8 Negative reactions can create barriers to good communication. Awareness of them may be the first step to preventing or removing hindrances to meaningful dialogue.⁹

Patients who present lists at office visits tend to be older, have a number of chronic disorders, and think they have memory loss.One aspect of a patient’s presentation that may be viewed negatively is possession of a list. But this need not be the case. The list, if viewed as a patient-initiated agenda, can lead to a gratifying encounter for both patient and physician. In fact, there is reason to believe that a list representing a set agenda at the start of a visit may enhance patient satisfaction without increasing visit length.¹⁰ In fact, the Agency for Healthcare Research and Quality (AHRQ) advises patients to “Write down your questions before your visit. List the most important ones first to make sure they get asked and answered.”¹¹

To learn more about the people who arrive at a consultation with a written list, we conducted a study at 2 clinics in Clalit Health Services—Southern District (CHS-SD), which we designed to focus on answering the following questions:
1. Do patients with lists have a unique sociodemographic profile?
2. Do they present with specific medical ailments but have a high frequency of psychiatric disorders?
3. What are the underlying motives leading to list use?

METHODS

Design

This was an open observational case-controlled study, approved by the institutional review board and the clinical research board of the Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Setting

We conducted our study at 2 urban primary care clinics serving a population of 7000 people of diverse ages, 10% of whom are recent immigrants.

Selection of participants

We consecutively recruited patients who carried a list to use during the consultation. After obtaining patients’ informed consent to participate in the study, we asked them to spend the time necessary to disclose requested information. We excluded those who were not fluent in the language of their physicians.

Intervention

Family physicians at the participating clinics distributed a questionnaire to patients arriving with a written list, then conducted guided interviews. We defined “list use” as the patient’s choice to refer to a list as an agenda for that visit, whether to remind one’s self to cover all complaints, to accurately describe symptoms, to request medication prescriptions, or to ask about test results.

First, through interview or questionnaire, we gathered standard sociodemographic data. Second, we focused on general health issues, chronic medical disorders, psychiatric disorders, chronic medication consumption, and number of visits. We derived this information from computerized medical records. Third, through the questionnaire, we inquired about the reason patients used a list, and asked patients to subjectively rate their memory and give the general reasons for their visit.

The control group consisted of patients recruited consecutively at arbitrary points in time until its size matched that of the study group. These patients volunteered information to the same line of inquiry. Some members of the groups chose to complete the questionnaires in writing without the physician’s assistance.

Statistical analysis

We processed results using SPSS software. We applied the x2 test for statistical interpretation and set statistical significance at P<.05.

RESULTS

Twenty-five men and twenty-nine women ages 21 to 82 years of age comprised the group of patients presenting with a list. All patients who met inclusion criteria agreed to cooperate. TABLE 1 summarizes the sociodemographic data. The control group consisted of 30 men and 22 women ages 20 to 86 years of age.

There was no statistically meaningful difference in gender ratio between the groups. In the study and control groups, respectively, the average number of children of each subject was 4.1 and 3.5, years of formal education were 10.8 and 10.6, and years since immigration were 40.5 and 37.8 (P=.42). Marital status and average household income were also similar in both groups.

Statistically significant findings with the study group were relatively older ages and likelihood to be pensioners. The study group included fewer employed individuals and fewer housewives (P<.001). They also were more likely to have more than 3 chronic diseases (48.1% vs. 9.6%; P<.001) and took more long-term medications, including benzodiazepines (TABLE 2). They had a greater number of doctor visits in the past year compared with controls and reported a perceived increase in memory loss (TABLE 3). There were no significant differences between the groups in psychiatric or personality disorders, as determined by surveying patients’ electronic records.

Psychiatric disorders are no more common among list users than nonlist users. The reasons most commonly given for using a list indicated a desire to completely satisfy the objectives of the visit. Most of the individuals decided to prepare a list on their own initiative without persuasion from any external source.

DISCUSSION

In an survey of 216 family physicians and internists at the University of Wisconsin, >60% of respondents said their patients bring in lists very often or sometimes.¹¹ This figure seems much higher than would be found in our country (Israel). However, the practice is certainly common; although the actual frequency is unknown.

Other published observations about list use. Middleton et al¹² studied the effects of planned use of agenda forms, completed by patients and handed to physicians at the outset of a primary care visit. The written agenda significantly increased the number of problems identified in each consultation. Patient satisfaction increased and deepened the doctor-patient relationship. However, the duration of consultations also increased.

A commentary by Schrager et al¹¹ acknowledges that lists are dreaded by some physicians. Particularly if the expectation is for a patient to present with a single complaint, the appearance of a list may be an unwelcome surprise, suggesting a collection of separate complaints. And compulsive and somatizing patients can raise a series of overwhelming issues that encumber a short visit. But the commentary points out that, in general, fear of a list is unfounded, and that acceptance without prejudging can lead to a constructive outcome.

A number of researchers have examined the relationship between negative physician attitudes and certain patient attributes such as sociodemographic characteristics or a persistent emotional component to their ailments.¹³ Katz¹⁴ reported that patients who generated the most frustration were those who demanded a cure, those who added unrelated complaints at the end of the visit, malingerers, and those who refused to accept responsibility for their own maladies. List users, we believe, should not be lumped in with this group automatically.

One way for patients to become more involved in their care is to bring a list of questions to each visit, as advised by AHRQ.In our study, patients with lists did request more frequent consultations. However, this correlated closely with a heavier burden of disease. Using patient-centered communication to set the agenda for the visit and address the entirety of patients’ concerns has been shown to improve not only patient satisfaction but also adherence to treatment recommendations.^15,16 One way for patients to become more involved in their care is to bring a list of questions to each visit, as advised by AHRQ.

What our study revealed about list users. Our results show that those who made use of a list were older than the ones who did not, more likely to be pensioners, and less likely to be employed or be housewives. They had more chronic diseases, were receiving more medications including benzodiazepines, and had a significantly higher rate of medical appointments than did the controls. Psychiatric diagnoses were no more common among the list users, and reasons given for list use were congruent with aging and an increased burden of disease and medication. We could not discern the exact contribution of each independent factor of advanced age or disease burden. This would be an interesting issue to address in more elaborate research, as would be the actual frequency of list use.

The fact that the study group consumed more benzodiazepine medications may hint that its members suffer from greater levels of anxiety of depression. Limitations of our study. The weaknesses of our study include its questionable generalizability and the possibility that a number of list bearers may not have been recruited due to time constraints on patients or physicians. Randomization could have been improved if we had selected the controls consecutively after selecting the study patients, and not at a separate time. We did not time the length of the consultations, something that should be done in future studies.

The fact that the study group consumed more benzodiazepine medications may hint that its members suffer from greater levels of anxiety or depression. Nevertheless, we assumed that such conditions were likely of modest intensity since they were not included in the medical records.

Large-scale research could yield far more trustworthy results by adjusting for age, country of origin, and disease burden.

CORRESPONDENCE
Sody Naimer, MD, Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, POB 653, Beer-Sheva 84105, Israel; [email protected]

Acknowledgement
The authors thank Dr. Joseph Herman and Mrs. Barbra Schipper for their assistance in preparing this manuscript.

ABSTRACT

Purpose Little is known about patients who present a written list during a medical consultation. In this preliminary study, we sought to examine and characterize patients who use a prepared list.

Methods The design was an open observational case-controlled study that took place at 2 urban primary care clinics. We enrolled patients consecutively as they arrived with a written list for consultation. Consecutive patients presenting without a list served as the control group. Physician interviews and completed questionnaires provided demographic and medical characteristics of this group and explanations for list preparation.

Results Fifty-four patients presented with a list and were compared with controls. Statistically, patients arriving with a list were significantly more likely to be older and retired, and less likely to be salaried workers or housewives. These patients had more chronic diseases and consumed more long-term medications. They had a greater number of doctor visits in the past year compared with controls, and perceived an increase in memory loss. There were no differences between the groups in terms of psychiatric disease or personality disorders.

Conclusions Aside from certain demographic and health characteristics, patients who use written lists do not differ substantially from those who don’t. They have no discernible ill intention, and the list serves as a memory aid to make the most of the visit.

Nonverbal communication is a significant part of the physician-patient encounter, in part revealing clues to underlying attitudes and emotions or indicating whether one agrees or disagrees with expressed statements.¹ Nonverbal communication exhibited by both doctor and patient strongly influences how each participant perceives the encounter and helps determine how the physician-patient relationship will develop.^2-4

Patients, for example, are affected by the amount of physician eye contact and computer use. Less eye contact and greater attention to the computer tend to lower patients’ opinions of the consultation.^1,5 These and other behaviors may contribute to the finding that 30% to 80% of patients feel their expectations are not met in routine primary care visits.⁶

Physicians, despite attempts to remain nonjudgmental, can be affected by a patient’s demeanor on entering the consulting room. Subtle prejudices may be evoked by age, gender, ethnicity, manner of dress, tone of voice, mannerisms, cell phone interruptions, and the like.^7,8 Negative reactions can create barriers to good communication. Awareness of them may be the first step to preventing or removing hindrances to meaningful dialogue.⁹

Patients who present lists at office visits tend to be older, have a number of chronic disorders, and think they have memory loss.One aspect of a patient’s presentation that may be viewed negatively is possession of a list. But this need not be the case. The list, if viewed as a patient-initiated agenda, can lead to a gratifying encounter for both patient and physician. In fact, there is reason to believe that a list representing a set agenda at the start of a visit may enhance patient satisfaction without increasing visit length.¹⁰ In fact, the Agency for Healthcare Research and Quality (AHRQ) advises patients to “Write down your questions before your visit. List the most important ones first to make sure they get asked and answered.”¹¹

To learn more about the people who arrive at a consultation with a written list, we conducted a study at 2 clinics in Clalit Health Services—Southern District (CHS-SD), which we designed to focus on answering the following questions:
1. Do patients with lists have a unique sociodemographic profile?
2. Do they present with specific medical ailments but have a high frequency of psychiatric disorders?
3. What are the underlying motives leading to list use?

METHODS

Design

This was an open observational case-controlled study, approved by the institutional review board and the clinical research board of the Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Setting

We conducted our study at 2 urban primary care clinics serving a population of 7000 people of diverse ages, 10% of whom are recent immigrants.

Selection of participants

We consecutively recruited patients who carried a list to use during the consultation. After obtaining patients’ informed consent to participate in the study, we asked them to spend the time necessary to disclose requested information. We excluded those who were not fluent in the language of their physicians.

Intervention

Family physicians at the participating clinics distributed a questionnaire to patients arriving with a written list, then conducted guided interviews. We defined “list use” as the patient’s choice to refer to a list as an agenda for that visit, whether to remind one’s self to cover all complaints, to accurately describe symptoms, to request medication prescriptions, or to ask about test results.

First, through interview or questionnaire, we gathered standard sociodemographic data. Second, we focused on general health issues, chronic medical disorders, psychiatric disorders, chronic medication consumption, and number of visits. We derived this information from computerized medical records. Third, through the questionnaire, we inquired about the reason patients used a list, and asked patients to subjectively rate their memory and give the general reasons for their visit.

The control group consisted of patients recruited consecutively at arbitrary points in time until its size matched that of the study group. These patients volunteered information to the same line of inquiry. Some members of the groups chose to complete the questionnaires in writing without the physician’s assistance.

Statistical analysis

We processed results using SPSS software. We applied the x2 test for statistical interpretation and set statistical significance at P<.05.

RESULTS

Twenty-five men and twenty-nine women ages 21 to 82 years of age comprised the group of patients presenting with a list. All patients who met inclusion criteria agreed to cooperate. TABLE 1 summarizes the sociodemographic data. The control group consisted of 30 men and 22 women ages 20 to 86 years of age.

There was no statistically meaningful difference in gender ratio between the groups. In the study and control groups, respectively, the average number of children of each subject was 4.1 and 3.5, years of formal education were 10.8 and 10.6, and years since immigration were 40.5 and 37.8 (P=.42). Marital status and average household income were also similar in both groups.

Statistically significant findings with the study group were relatively older ages and likelihood to be pensioners. The study group included fewer employed individuals and fewer housewives (P<.001). They also were more likely to have more than 3 chronic diseases (48.1% vs. 9.6%; P<.001) and took more long-term medications, including benzodiazepines (TABLE 2). They had a greater number of doctor visits in the past year compared with controls and reported a perceived increase in memory loss (TABLE 3). There were no significant differences between the groups in psychiatric or personality disorders, as determined by surveying patients’ electronic records.

Psychiatric disorders are no more common among list users than nonlist users. The reasons most commonly given for using a list indicated a desire to completely satisfy the objectives of the visit. Most of the individuals decided to prepare a list on their own initiative without persuasion from any external source.

DISCUSSION

In an survey of 216 family physicians and internists at the University of Wisconsin, >60% of respondents said their patients bring in lists very often or sometimes.¹¹ This figure seems much higher than would be found in our country (Israel). However, the practice is certainly common; although the actual frequency is unknown.

Other published observations about list use. Middleton et al¹² studied the effects of planned use of agenda forms, completed by patients and handed to physicians at the outset of a primary care visit. The written agenda significantly increased the number of problems identified in each consultation. Patient satisfaction increased and deepened the doctor-patient relationship. However, the duration of consultations also increased.

A commentary by Schrager et al¹¹ acknowledges that lists are dreaded by some physicians. Particularly if the expectation is for a patient to present with a single complaint, the appearance of a list may be an unwelcome surprise, suggesting a collection of separate complaints. And compulsive and somatizing patients can raise a series of overwhelming issues that encumber a short visit. But the commentary points out that, in general, fear of a list is unfounded, and that acceptance without prejudging can lead to a constructive outcome.

A number of researchers have examined the relationship between negative physician attitudes and certain patient attributes such as sociodemographic characteristics or a persistent emotional component to their ailments.¹³ Katz¹⁴ reported that patients who generated the most frustration were those who demanded a cure, those who added unrelated complaints at the end of the visit, malingerers, and those who refused to accept responsibility for their own maladies. List users, we believe, should not be lumped in with this group automatically.

One way for patients to become more involved in their care is to bring a list of questions to each visit, as advised by AHRQ.In our study, patients with lists did request more frequent consultations. However, this correlated closely with a heavier burden of disease. Using patient-centered communication to set the agenda for the visit and address the entirety of patients’ concerns has been shown to improve not only patient satisfaction but also adherence to treatment recommendations.^15,16 One way for patients to become more involved in their care is to bring a list of questions to each visit, as advised by AHRQ.

What our study revealed about list users. Our results show that those who made use of a list were older than the ones who did not, more likely to be pensioners, and less likely to be employed or be housewives. They had more chronic diseases, were receiving more medications including benzodiazepines, and had a significantly higher rate of medical appointments than did the controls. Psychiatric diagnoses were no more common among the list users, and reasons given for list use were congruent with aging and an increased burden of disease and medication. We could not discern the exact contribution of each independent factor of advanced age or disease burden. This would be an interesting issue to address in more elaborate research, as would be the actual frequency of list use.

The fact that the study group consumed more benzodiazepine medications may hint that its members suffer from greater levels of anxiety of depression. Limitations of our study. The weaknesses of our study include its questionable generalizability and the possibility that a number of list bearers may not have been recruited due to time constraints on patients or physicians. Randomization could have been improved if we had selected the controls consecutively after selecting the study patients, and not at a separate time. We did not time the length of the consultations, something that should be done in future studies.

The fact that the study group consumed more benzodiazepine medications may hint that its members suffer from greater levels of anxiety or depression. Nevertheless, we assumed that such conditions were likely of modest intensity since they were not included in the medical records.

Large-scale research could yield far more trustworthy results by adjusting for age, country of origin, and disease burden.

CORRESPONDENCE
Sody Naimer, MD, Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, POB 653, Beer-Sheva 84105, Israel; [email protected]

Acknowledgement
The authors thank Dr. Joseph Herman and Mrs. Barbra Schipper for their assistance in preparing this manuscript.

ABSTRACT

Purpose Little is known about patients who present a written list during a medical consultation. In this preliminary study, we sought to examine and characterize patients who use a prepared list.

Methods The design was an open observational case-controlled study that took place at 2 urban primary care clinics. We enrolled patients consecutively as they arrived with a written list for consultation. Consecutive patients presenting without a list served as the control group. Physician interviews and completed questionnaires provided demographic and medical characteristics of this group and explanations for list preparation.

Results Fifty-four patients presented with a list and were compared with controls. Statistically, patients arriving with a list were significantly more likely to be older and retired, and less likely to be salaried workers or housewives. These patients had more chronic diseases and consumed more long-term medications. They had a greater number of doctor visits in the past year compared with controls, and perceived an increase in memory loss. There were no differences between the groups in terms of psychiatric disease or personality disorders.

Conclusions Aside from certain demographic and health characteristics, patients who use written lists do not differ substantially from those who don’t. They have no discernible ill intention, and the list serves as a memory aid to make the most of the visit.

Nonverbal communication is a significant part of the physician-patient encounter, in part revealing clues to underlying attitudes and emotions or indicating whether one agrees or disagrees with expressed statements.¹ Nonverbal communication exhibited by both doctor and patient strongly influences how each participant perceives the encounter and helps determine how the physician-patient relationship will develop.^2-4

Patients, for example, are affected by the amount of physician eye contact and computer use. Less eye contact and greater attention to the computer tend to lower patients’ opinions of the consultation.^1,5 These and other behaviors may contribute to the finding that 30% to 80% of patients feel their expectations are not met in routine primary care visits.⁶

Physicians, despite attempts to remain nonjudgmental, can be affected by a patient’s demeanor on entering the consulting room. Subtle prejudices may be evoked by age, gender, ethnicity, manner of dress, tone of voice, mannerisms, cell phone interruptions, and the like.^7,8 Negative reactions can create barriers to good communication. Awareness of them may be the first step to preventing or removing hindrances to meaningful dialogue.⁹

Patients who present lists at office visits tend to be older, have a number of chronic disorders, and think they have memory loss.One aspect of a patient’s presentation that may be viewed negatively is possession of a list. But this need not be the case. The list, if viewed as a patient-initiated agenda, can lead to a gratifying encounter for both patient and physician. In fact, there is reason to believe that a list representing a set agenda at the start of a visit may enhance patient satisfaction without increasing visit length.¹⁰ In fact, the Agency for Healthcare Research and Quality (AHRQ) advises patients to “Write down your questions before your visit. List the most important ones first to make sure they get asked and answered.”¹¹

To learn more about the people who arrive at a consultation with a written list, we conducted a study at 2 clinics in Clalit Health Services—Southern District (CHS-SD), which we designed to focus on answering the following questions:
1. Do patients with lists have a unique sociodemographic profile?
2. Do they present with specific medical ailments but have a high frequency of psychiatric disorders?
3. What are the underlying motives leading to list use?

METHODS

Design

This was an open observational case-controlled study, approved by the institutional review board and the clinical research board of the Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Setting

We conducted our study at 2 urban primary care clinics serving a population of 7000 people of diverse ages, 10% of whom are recent immigrants.

Selection of participants

We consecutively recruited patients who carried a list to use during the consultation. After obtaining patients’ informed consent to participate in the study, we asked them to spend the time necessary to disclose requested information. We excluded those who were not fluent in the language of their physicians.

Intervention

Family physicians at the participating clinics distributed a questionnaire to patients arriving with a written list, then conducted guided interviews. We defined “list use” as the patient’s choice to refer to a list as an agenda for that visit, whether to remind one’s self to cover all complaints, to accurately describe symptoms, to request medication prescriptions, or to ask about test results.

First, through interview or questionnaire, we gathered standard sociodemographic data. Second, we focused on general health issues, chronic medical disorders, psychiatric disorders, chronic medication consumption, and number of visits. We derived this information from computerized medical records. Third, through the questionnaire, we inquired about the reason patients used a list, and asked patients to subjectively rate their memory and give the general reasons for their visit.

The control group consisted of patients recruited consecutively at arbitrary points in time until its size matched that of the study group. These patients volunteered information to the same line of inquiry. Some members of the groups chose to complete the questionnaires in writing without the physician’s assistance.

Statistical analysis

We processed results using SPSS software. We applied the x2 test for statistical interpretation and set statistical significance at P<.05.

RESULTS

Twenty-five men and twenty-nine women ages 21 to 82 years of age comprised the group of patients presenting with a list. All patients who met inclusion criteria agreed to cooperate. TABLE 1 summarizes the sociodemographic data. The control group consisted of 30 men and 22 women ages 20 to 86 years of age.

There was no statistically meaningful difference in gender ratio between the groups. In the study and control groups, respectively, the average number of children of each subject was 4.1 and 3.5, years of formal education were 10.8 and 10.6, and years since immigration were 40.5 and 37.8 (P=.42). Marital status and average household income were also similar in both groups.

Statistically significant findings with the study group were relatively older ages and likelihood to be pensioners. The study group included fewer employed individuals and fewer housewives (P<.001). They also were more likely to have more than 3 chronic diseases (48.1% vs. 9.6%; P<.001) and took more long-term medications, including benzodiazepines (TABLE 2). They had a greater number of doctor visits in the past year compared with controls and reported a perceived increase in memory loss (TABLE 3). There were no significant differences between the groups in psychiatric or personality disorders, as determined by surveying patients’ electronic records.

Psychiatric disorders are no more common among list users than nonlist users. The reasons most commonly given for using a list indicated a desire to completely satisfy the objectives of the visit. Most of the individuals decided to prepare a list on their own initiative without persuasion from any external source.

DISCUSSION

In an survey of 216 family physicians and internists at the University of Wisconsin, >60% of respondents said their patients bring in lists very often or sometimes.¹¹ This figure seems much higher than would be found in our country (Israel). However, the practice is certainly common; although the actual frequency is unknown.

Other published observations about list use. Middleton et al¹² studied the effects of planned use of agenda forms, completed by patients and handed to physicians at the outset of a primary care visit. The written agenda significantly increased the number of problems identified in each consultation. Patient satisfaction increased and deepened the doctor-patient relationship. However, the duration of consultations also increased.

A commentary by Schrager et al¹¹ acknowledges that lists are dreaded by some physicians. Particularly if the expectation is for a patient to present with a single complaint, the appearance of a list may be an unwelcome surprise, suggesting a collection of separate complaints. And compulsive and somatizing patients can raise a series of overwhelming issues that encumber a short visit. But the commentary points out that, in general, fear of a list is unfounded, and that acceptance without prejudging can lead to a constructive outcome.

A number of researchers have examined the relationship between negative physician attitudes and certain patient attributes such as sociodemographic characteristics or a persistent emotional component to their ailments.¹³ Katz¹⁴ reported that patients who generated the most frustration were those who demanded a cure, those who added unrelated complaints at the end of the visit, malingerers, and those who refused to accept responsibility for their own maladies. List users, we believe, should not be lumped in with this group automatically.

One way for patients to become more involved in their care is to bring a list of questions to each visit, as advised by AHRQ.In our study, patients with lists did request more frequent consultations. However, this correlated closely with a heavier burden of disease. Using patient-centered communication to set the agenda for the visit and address the entirety of patients’ concerns has been shown to improve not only patient satisfaction but also adherence to treatment recommendations.^15,16 One way for patients to become more involved in their care is to bring a list of questions to each visit, as advised by AHRQ.

What our study revealed about list users. Our results show that those who made use of a list were older than the ones who did not, more likely to be pensioners, and less likely to be employed or be housewives. They had more chronic diseases, were receiving more medications including benzodiazepines, and had a significantly higher rate of medical appointments than did the controls. Psychiatric diagnoses were no more common among the list users, and reasons given for list use were congruent with aging and an increased burden of disease and medication. We could not discern the exact contribution of each independent factor of advanced age or disease burden. This would be an interesting issue to address in more elaborate research, as would be the actual frequency of list use.

The fact that the study group consumed more benzodiazepine medications may hint that its members suffer from greater levels of anxiety of depression. Limitations of our study. The weaknesses of our study include its questionable generalizability and the possibility that a number of list bearers may not have been recruited due to time constraints on patients or physicians. Randomization could have been improved if we had selected the controls consecutively after selecting the study patients, and not at a separate time. We did not time the length of the consultations, something that should be done in future studies.

The fact that the study group consumed more benzodiazepine medications may hint that its members suffer from greater levels of anxiety or depression. Nevertheless, we assumed that such conditions were likely of modest intensity since they were not included in the medical records.

Large-scale research could yield far more trustworthy results by adjusting for age, country of origin, and disease burden.

CORRESPONDENCE
Sody Naimer, MD, Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, POB 653, Beer-Sheva 84105, Israel; [email protected]

Acknowledgement
The authors thank Dr. Joseph Herman and Mrs. Barbra Schipper for their assistance in preparing this manuscript.

Little evidence suggests that most complementary or alternative medicine therapies treat the symptoms of multiple sclerosis (MS), according to an American Academy of Neurology guideline published March 25 in Neurology. Oral cannabis and oral medical marijuana spray, however, may ease patients’ reported symptoms of spasticity, pain related to spasticity, and frequent urination in MS. Not enough evidence is available to show whether smoking marijuana helps treat MS symptoms, according to the guideline. The authors concluded that magnetic therapy is probably effective for fatigue and probably ineffective for depression. Fish oil is probably ineffective for relapses, disability, fatigue, MRI lesions, and quality of life, according to the guideline. In addition, evidence indicates that ginkgo biloba is ineffective for cognition and possibly effective for fatigue, said the authors.

People who develop diabetes and high blood pressure in middle age are more likely to have brain cell loss and problems with memory and thinking skills than people who never have diabetes or high blood pressure or who develop them in old age, according to a study published online ahead of print March 19 in Neurology. Investigators evaluated the thinking and memory skills of 1,437 people (average age, 80), conducted brain scans, and reviewed participants’ medical records to determine whether the latter had been diagnosed with diabetes or high blood pressure in middle age or later. Midlife diabetes was associated with subcortical infarctions, reduced hippocampal volume, reduced whole brain volume, and prevalent mild cognitive impairment. Midlife hypertension was associated with infarctions and white matter hyperintensity volume.

Each 15-minute decrease in treatment delay may provide a patient an average equivalent of one month of additional disability-free life, according to a study published online ahead of print March 13 in Stroke. Researchers examined observational prospective data for 2,258 consecutive stroke patients treated with IV thrombolysis to determine distributions of age, sex, stroke severity, onset-to-treatment times, and three-month modified Rankin Scale score in daily clinical practice. The investigators found that for every one-minute reduction in onset-to-treatment time, patients gained an average 1.8 days of healthy life. Although all patients benefited from faster treatment, younger patients with longer life expectancies gained a little more than older patients. Women gained slightly more than men throughout their longer lifetimes. The awareness of the importance of speed could promote practice change, said the authors.

The FDA has approved extended-release Qudexy XR (topiramate) capsules as initial monotherapy in patients 10 or older with partial-onset seizures or primary generalized tonic-clonic seizures. The drug also received approval as adjunctive therapy in patients age 2 or older with partial-onset seizures, primary generalized tonic-clonic seizures, and seizures associated with Lennox–Gastaut syndrome. In a randomized, double-blind, placebo-controlled study, the drug demonstrated favorable safety and tolerability in patients with refractory partial-onset seizures. The extended-release formulation was associated with a significantly greater median percent reduction from baseline in seizure frequency, compared with placebo (39.5% vs 21.7%) after 11 weeks of treatment. Upsher-Smith Laboratories, headquartered in Maple Grove, Minnesota, manufactures the drug and expects it to be available during the second quarter of 2014.

The FDA has approved the Cefaly medical device as a preventive treatment for migraine headaches. The product is the first transcutaneous electrical nerve stimulation device specifically authorized for use before the onset of pain. The product is a small, portable, battery-powered unit resembling a plastic headband worn across the forehead once per day for 20 minutes. The device applies an electric current to the skin and underlying tissues to stimulate branches of the trigeminal nerve. In a study including 67 participants, patients who used Cefaly had significantly fewer days with migraines per month and used less migraine attack medication, compared with patients who used a placebo device. STX-Med, which is headquartered in Herstal, Liege, Belgium, manufactures the device, which is indicated for patients 18 and older.

Children with autism who are fed infant formula containing soy protein rather than milk protein may have a higher rate of seizures, according to research published March 12 in PLOS One. Researchers analyzed medical record data for 1,949 children with autism, including information on infant formula use, seizure incidence, the specific type of seizure exhibited, and IQ. Soy-based formula was given in 17.5% of the study population. About 13% of the subjects were female. The researchers found a 2.6-fold higher rate of febrile seizures (4.2% vs 1.6%), a 2.1-fold higher rate of epilepsy comorbidity (3.6% vs 1.7%), and a fourfold higher rate of simple partial seizures (1.2% vs 0.3%) in the children with autism who were fed soy-based formula. No statistically significant associations were found with other outcomes.

For patients with Alzheimer’s disease, levels of markers of neuronal injury in the spinal fluid may decrease as symptoms of memory loss and mental decline appear, according to research published March 5 in Science Translational Medicine. Investigators studied data from the Dominantly Inherited Alzheimer’s Network, which includes participants from families with genetic mutations that cause rare inherited forms of Alzheimer’s disease. The group examined levels of tau, p-tau, and visinin-like protein-1 (VILIP-1). Asymptomatic mutation carriers had elevated concentrations of CSF tau, p-tau181, and VILIP-1 10 to 20 years before their estimated age at symptom onset and before cognitive deficits were detected. The concentrations of CSF biomarkers of neuronal injury or death decreased after their estimated age at symptom onset, suggesting a slowing of acute neurodegenerative processes with symptomatic disease progression.

Men with poor cardiovascular fitness or a low IQ at age 18 are more likely to develop dementia before age 60, investigators reported online ahead of print March 6 in Brain. The researchers conducted a population-based cohort study of more than 1.1 million Swedish male conscripts (age 18) who underwent conscription exams between 1968 and 2005. Participants were followed for as long as 42 years. In fully adjusted models, low cardiovascular fitness and cognitive performance at age 18 were associated with increased risk for future early-onset dementia and mild cognitive impairment, compared with high cardiovascular fitness and cognitive performance. Poor performance on cardiovascular fitness and cognitive tests was associated with a greater-than-sevenfold and a greater than eightfold increased risk of early-onset dementia and early-onset mild cognitive impairment, respectively.

A test that detects low levels of prion protein in the blood may accurately screen for infection with the agent responsible for variant Creutzfeldt-Jakob disease (vCJD), according to a study published online ahead of print March 3 in JAMA Neurology. Researchers performed the test on samples from national blood collection and prion disease centers in the US and the UK. The samples were taken from healthy donors, patients with nonprion neurodegenerative disease, patients in whom a prion disease diagnosis was likely, and patients with confirmed vCJD. The assay’s specificity was confirmed as 100% in a healthy UK cohort. No potentially cross-reactive blood samples from patients with nonprion neurodegenerative diseases tested positive. Two patients with sporadic CJD tested positive. The authors’ previous sensitivity estimate was reconfirmed but not refined.

The FDA has approved Neuraceq (florbetaben F18 injection) for PET imaging of the brain to estimate beta-amyloid neuritic plaque density in adults with cognitive impairment who are being evaluated for Alzheimer’s disease and other causes of cognitive decline. The approval is based on safety data from 872 patients who participated in global clinical trials, and on three studies that examined images from adults with a range of cognitive function. Images were analyzed from 82 subjects with postmortem confirmation of the presence or absence of beta-amyloid neuritic plaques. Correlation of the visual PET interpretation with histopathology in these 82 brains demonstrated that Neuraceq (Piramal Imaging; Boston) accurately detects moderate to frequent beta-amyloid neuritic plaques in the brain.

A combination of human umbilical cord blood cells (hUCBs) and granulocyte colony stimulating factor (G-CSF) may provide more benefit for patients with traumatic brain injury (TBI) than either therapy alone, according to research published March 12 in PLOS One. Adult rats underwent moderate TBI and, seven days later, were treated with saline alone, G-CSF and saline, hUCB and saline, or hUCB and G-CSF. The rats treated with saline exhibited widespread neuroinflammation, impaired endogenous neurogenesis, and severe hippocampal cell loss. hUCB monotherapy suppressed neuroinflammation, nearly normalized neurogenesis, and reduced hippocampal cell loss, compared with saline alone. G-CSF monotherapy produced partial and short-lived benefits characterized by low levels of neuroinflammation, modest neurogenesis, and moderate reduction of hippocampal cell loss. Combined therapy robustly dampened neuroinflammation, enhanced endogenous neurogenesis, and reduced hippocampal cell loss.

The ability to learn new information may be significantly poorer among patients with Parkinson’s disease than among healthy individuals, according to research published online ahead of print February 24 in Movement Disorders. Investigators examined 27 patients with Parkinson’s disease without dementia and 27 age-, gender-, and education-matched healthy controls with a neuropsychologic test battery designed to assess new learning and memory. The researchers found a significant difference in the groups’ ability to learn a list of 10 semantically related words. Once the groups were equated on learning abilities, the investigators found no significant difference between patients with Parkinson’s disease and controls in recall or recognition of the newly learned material. The memory deficit in nondemented patients with Parkinson’s disease largely results from a deficit in learning new information, said the authors.

Chronic sleep loss may lead to irreversible physical damage to and loss of brain cells, according to research published March 19 in the Journal of Neuroscience. Investigators examined mice following periods of normal rest, short wakefulness, or extended wakefulness to model shift workers’ typical sleep patterns. In response to short-term sleep loss, locus coeruleus neurons upregulated the sirtuin type 3 (SirT3) protein, which protects neurons from metabolic injury. After several days of shift worker sleep patterns, locus coeruleus neurons in the mice had reduced SirT3 and increased cell death. In addition, oxidative stress and acetylation of mitochondrial proteins increased. The mice lost 25% of their locus coeruleus neurons. “This is the first report that sleep loss can actually result in a loss of neurons,” said the authors.

—Erik Greb

Little evidence suggests that most complementary or alternative medicine therapies treat the symptoms of multiple sclerosis (MS), according to an American Academy of Neurology guideline published March 25 in Neurology. Oral cannabis and oral medical marijuana spray, however, may ease patients’ reported symptoms of spasticity, pain related to spasticity, and frequent urination in MS. Not enough evidence is available to show whether smoking marijuana helps treat MS symptoms, according to the guideline. The authors concluded that magnetic therapy is probably effective for fatigue and probably ineffective for depression. Fish oil is probably ineffective for relapses, disability, fatigue, MRI lesions, and quality of life, according to the guideline. In addition, evidence indicates that ginkgo biloba is ineffective for cognition and possibly effective for fatigue, said the authors.

People who develop diabetes and high blood pressure in middle age are more likely to have brain cell loss and problems with memory and thinking skills than people who never have diabetes or high blood pressure or who develop them in old age, according to a study published online ahead of print March 19 in Neurology. Investigators evaluated the thinking and memory skills of 1,437 people (average age, 80), conducted brain scans, and reviewed participants’ medical records to determine whether the latter had been diagnosed with diabetes or high blood pressure in middle age or later. Midlife diabetes was associated with subcortical infarctions, reduced hippocampal volume, reduced whole brain volume, and prevalent mild cognitive impairment. Midlife hypertension was associated with infarctions and white matter hyperintensity volume.

Each 15-minute decrease in treatment delay may provide a patient an average equivalent of one month of additional disability-free life, according to a study published online ahead of print March 13 in Stroke. Researchers examined observational prospective data for 2,258 consecutive stroke patients treated with IV thrombolysis to determine distributions of age, sex, stroke severity, onset-to-treatment times, and three-month modified Rankin Scale score in daily clinical practice. The investigators found that for every one-minute reduction in onset-to-treatment time, patients gained an average 1.8 days of healthy life. Although all patients benefited from faster treatment, younger patients with longer life expectancies gained a little more than older patients. Women gained slightly more than men throughout their longer lifetimes. The awareness of the importance of speed could promote practice change, said the authors.

The FDA has approved extended-release Qudexy XR (topiramate) capsules as initial monotherapy in patients 10 or older with partial-onset seizures or primary generalized tonic-clonic seizures. The drug also received approval as adjunctive therapy in patients age 2 or older with partial-onset seizures, primary generalized tonic-clonic seizures, and seizures associated with Lennox–Gastaut syndrome. In a randomized, double-blind, placebo-controlled study, the drug demonstrated favorable safety and tolerability in patients with refractory partial-onset seizures. The extended-release formulation was associated with a significantly greater median percent reduction from baseline in seizure frequency, compared with placebo (39.5% vs 21.7%) after 11 weeks of treatment. Upsher-Smith Laboratories, headquartered in Maple Grove, Minnesota, manufactures the drug and expects it to be available during the second quarter of 2014.

The FDA has approved the Cefaly medical device as a preventive treatment for migraine headaches. The product is the first transcutaneous electrical nerve stimulation device specifically authorized for use before the onset of pain. The product is a small, portable, battery-powered unit resembling a plastic headband worn across the forehead once per day for 20 minutes. The device applies an electric current to the skin and underlying tissues to stimulate branches of the trigeminal nerve. In a study including 67 participants, patients who used Cefaly had significantly fewer days with migraines per month and used less migraine attack medication, compared with patients who used a placebo device. STX-Med, which is headquartered in Herstal, Liege, Belgium, manufactures the device, which is indicated for patients 18 and older.

Children with autism who are fed infant formula containing soy protein rather than milk protein may have a higher rate of seizures, according to research published March 12 in PLOS One. Researchers analyzed medical record data for 1,949 children with autism, including information on infant formula use, seizure incidence, the specific type of seizure exhibited, and IQ. Soy-based formula was given in 17.5% of the study population. About 13% of the subjects were female. The researchers found a 2.6-fold higher rate of febrile seizures (4.2% vs 1.6%), a 2.1-fold higher rate of epilepsy comorbidity (3.6% vs 1.7%), and a fourfold higher rate of simple partial seizures (1.2% vs 0.3%) in the children with autism who were fed soy-based formula. No statistically significant associations were found with other outcomes.

For patients with Alzheimer’s disease, levels of markers of neuronal injury in the spinal fluid may decrease as symptoms of memory loss and mental decline appear, according to research published March 5 in Science Translational Medicine. Investigators studied data from the Dominantly Inherited Alzheimer’s Network, which includes participants from families with genetic mutations that cause rare inherited forms of Alzheimer’s disease. The group examined levels of tau, p-tau, and visinin-like protein-1 (VILIP-1). Asymptomatic mutation carriers had elevated concentrations of CSF tau, p-tau181, and VILIP-1 10 to 20 years before their estimated age at symptom onset and before cognitive deficits were detected. The concentrations of CSF biomarkers of neuronal injury or death decreased after their estimated age at symptom onset, suggesting a slowing of acute neurodegenerative processes with symptomatic disease progression.

Men with poor cardiovascular fitness or a low IQ at age 18 are more likely to develop dementia before age 60, investigators reported online ahead of print March 6 in Brain. The researchers conducted a population-based cohort study of more than 1.1 million Swedish male conscripts (age 18) who underwent conscription exams between 1968 and 2005. Participants were followed for as long as 42 years. In fully adjusted models, low cardiovascular fitness and cognitive performance at age 18 were associated with increased risk for future early-onset dementia and mild cognitive impairment, compared with high cardiovascular fitness and cognitive performance. Poor performance on cardiovascular fitness and cognitive tests was associated with a greater-than-sevenfold and a greater than eightfold increased risk of early-onset dementia and early-onset mild cognitive impairment, respectively.

A test that detects low levels of prion protein in the blood may accurately screen for infection with the agent responsible for variant Creutzfeldt-Jakob disease (vCJD), according to a study published online ahead of print March 3 in JAMA Neurology. Researchers performed the test on samples from national blood collection and prion disease centers in the US and the UK. The samples were taken from healthy donors, patients with nonprion neurodegenerative disease, patients in whom a prion disease diagnosis was likely, and patients with confirmed vCJD. The assay’s specificity was confirmed as 100% in a healthy UK cohort. No potentially cross-reactive blood samples from patients with nonprion neurodegenerative diseases tested positive. Two patients with sporadic CJD tested positive. The authors’ previous sensitivity estimate was reconfirmed but not refined.

The FDA has approved Neuraceq (florbetaben F18 injection) for PET imaging of the brain to estimate beta-amyloid neuritic plaque density in adults with cognitive impairment who are being evaluated for Alzheimer’s disease and other causes of cognitive decline. The approval is based on safety data from 872 patients who participated in global clinical trials, and on three studies that examined images from adults with a range of cognitive function. Images were analyzed from 82 subjects with postmortem confirmation of the presence or absence of beta-amyloid neuritic plaques. Correlation of the visual PET interpretation with histopathology in these 82 brains demonstrated that Neuraceq (Piramal Imaging; Boston) accurately detects moderate to frequent beta-amyloid neuritic plaques in the brain.

A combination of human umbilical cord blood cells (hUCBs) and granulocyte colony stimulating factor (G-CSF) may provide more benefit for patients with traumatic brain injury (TBI) than either therapy alone, according to research published March 12 in PLOS One. Adult rats underwent moderate TBI and, seven days later, were treated with saline alone, G-CSF and saline, hUCB and saline, or hUCB and G-CSF. The rats treated with saline exhibited widespread neuroinflammation, impaired endogenous neurogenesis, and severe hippocampal cell loss. hUCB monotherapy suppressed neuroinflammation, nearly normalized neurogenesis, and reduced hippocampal cell loss, compared with saline alone. G-CSF monotherapy produced partial and short-lived benefits characterized by low levels of neuroinflammation, modest neurogenesis, and moderate reduction of hippocampal cell loss. Combined therapy robustly dampened neuroinflammation, enhanced endogenous neurogenesis, and reduced hippocampal cell loss.

The ability to learn new information may be significantly poorer among patients with Parkinson’s disease than among healthy individuals, according to research published online ahead of print February 24 in Movement Disorders. Investigators examined 27 patients with Parkinson’s disease without dementia and 27 age-, gender-, and education-matched healthy controls with a neuropsychologic test battery designed to assess new learning and memory. The researchers found a significant difference in the groups’ ability to learn a list of 10 semantically related words. Once the groups were equated on learning abilities, the investigators found no significant difference between patients with Parkinson’s disease and controls in recall or recognition of the newly learned material. The memory deficit in nondemented patients with Parkinson’s disease largely results from a deficit in learning new information, said the authors.

Chronic sleep loss may lead to irreversible physical damage to and loss of brain cells, according to research published March 19 in the Journal of Neuroscience. Investigators examined mice following periods of normal rest, short wakefulness, or extended wakefulness to model shift workers’ typical sleep patterns. In response to short-term sleep loss, locus coeruleus neurons upregulated the sirtuin type 3 (SirT3) protein, which protects neurons from metabolic injury. After several days of shift worker sleep patterns, locus coeruleus neurons in the mice had reduced SirT3 and increased cell death. In addition, oxidative stress and acetylation of mitochondrial proteins increased. The mice lost 25% of their locus coeruleus neurons. “This is the first report that sleep loss can actually result in a loss of neurons,” said the authors.

—Erik Greb

Little evidence suggests that most complementary or alternative medicine therapies treat the symptoms of multiple sclerosis (MS), according to an American Academy of Neurology guideline published March 25 in Neurology. Oral cannabis and oral medical marijuana spray, however, may ease patients’ reported symptoms of spasticity, pain related to spasticity, and frequent urination in MS. Not enough evidence is available to show whether smoking marijuana helps treat MS symptoms, according to the guideline. The authors concluded that magnetic therapy is probably effective for fatigue and probably ineffective for depression. Fish oil is probably ineffective for relapses, disability, fatigue, MRI lesions, and quality of life, according to the guideline. In addition, evidence indicates that ginkgo biloba is ineffective for cognition and possibly effective for fatigue, said the authors.

People who develop diabetes and high blood pressure in middle age are more likely to have brain cell loss and problems with memory and thinking skills than people who never have diabetes or high blood pressure or who develop them in old age, according to a study published online ahead of print March 19 in Neurology. Investigators evaluated the thinking and memory skills of 1,437 people (average age, 80), conducted brain scans, and reviewed participants’ medical records to determine whether the latter had been diagnosed with diabetes or high blood pressure in middle age or later. Midlife diabetes was associated with subcortical infarctions, reduced hippocampal volume, reduced whole brain volume, and prevalent mild cognitive impairment. Midlife hypertension was associated with infarctions and white matter hyperintensity volume.

Each 15-minute decrease in treatment delay may provide a patient an average equivalent of one month of additional disability-free life, according to a study published online ahead of print March 13 in Stroke. Researchers examined observational prospective data for 2,258 consecutive stroke patients treated with IV thrombolysis to determine distributions of age, sex, stroke severity, onset-to-treatment times, and three-month modified Rankin Scale score in daily clinical practice. The investigators found that for every one-minute reduction in onset-to-treatment time, patients gained an average 1.8 days of healthy life. Although all patients benefited from faster treatment, younger patients with longer life expectancies gained a little more than older patients. Women gained slightly more than men throughout their longer lifetimes. The awareness of the importance of speed could promote practice change, said the authors.

The FDA has approved extended-release Qudexy XR (topiramate) capsules as initial monotherapy in patients 10 or older with partial-onset seizures or primary generalized tonic-clonic seizures. The drug also received approval as adjunctive therapy in patients age 2 or older with partial-onset seizures, primary generalized tonic-clonic seizures, and seizures associated with Lennox–Gastaut syndrome. In a randomized, double-blind, placebo-controlled study, the drug demonstrated favorable safety and tolerability in patients with refractory partial-onset seizures. The extended-release formulation was associated with a significantly greater median percent reduction from baseline in seizure frequency, compared with placebo (39.5% vs 21.7%) after 11 weeks of treatment. Upsher-Smith Laboratories, headquartered in Maple Grove, Minnesota, manufactures the drug and expects it to be available during the second quarter of 2014.

The FDA has approved the Cefaly medical device as a preventive treatment for migraine headaches. The product is the first transcutaneous electrical nerve stimulation device specifically authorized for use before the onset of pain. The product is a small, portable, battery-powered unit resembling a plastic headband worn across the forehead once per day for 20 minutes. The device applies an electric current to the skin and underlying tissues to stimulate branches of the trigeminal nerve. In a study including 67 participants, patients who used Cefaly had significantly fewer days with migraines per month and used less migraine attack medication, compared with patients who used a placebo device. STX-Med, which is headquartered in Herstal, Liege, Belgium, manufactures the device, which is indicated for patients 18 and older.

Children with autism who are fed infant formula containing soy protein rather than milk protein may have a higher rate of seizures, according to research published March 12 in PLOS One. Researchers analyzed medical record data for 1,949 children with autism, including information on infant formula use, seizure incidence, the specific type of seizure exhibited, and IQ. Soy-based formula was given in 17.5% of the study population. About 13% of the subjects were female. The researchers found a 2.6-fold higher rate of febrile seizures (4.2% vs 1.6%), a 2.1-fold higher rate of epilepsy comorbidity (3.6% vs 1.7%), and a fourfold higher rate of simple partial seizures (1.2% vs 0.3%) in the children with autism who were fed soy-based formula. No statistically significant associations were found with other outcomes.

For patients with Alzheimer’s disease, levels of markers of neuronal injury in the spinal fluid may decrease as symptoms of memory loss and mental decline appear, according to research published March 5 in Science Translational Medicine. Investigators studied data from the Dominantly Inherited Alzheimer’s Network, which includes participants from families with genetic mutations that cause rare inherited forms of Alzheimer’s disease. The group examined levels of tau, p-tau, and visinin-like protein-1 (VILIP-1). Asymptomatic mutation carriers had elevated concentrations of CSF tau, p-tau181, and VILIP-1 10 to 20 years before their estimated age at symptom onset and before cognitive deficits were detected. The concentrations of CSF biomarkers of neuronal injury or death decreased after their estimated age at symptom onset, suggesting a slowing of acute neurodegenerative processes with symptomatic disease progression.

Men with poor cardiovascular fitness or a low IQ at age 18 are more likely to develop dementia before age 60, investigators reported online ahead of print March 6 in Brain. The researchers conducted a population-based cohort study of more than 1.1 million Swedish male conscripts (age 18) who underwent conscription exams between 1968 and 2005. Participants were followed for as long as 42 years. In fully adjusted models, low cardiovascular fitness and cognitive performance at age 18 were associated with increased risk for future early-onset dementia and mild cognitive impairment, compared with high cardiovascular fitness and cognitive performance. Poor performance on cardiovascular fitness and cognitive tests was associated with a greater-than-sevenfold and a greater than eightfold increased risk of early-onset dementia and early-onset mild cognitive impairment, respectively.

A test that detects low levels of prion protein in the blood may accurately screen for infection with the agent responsible for variant Creutzfeldt-Jakob disease (vCJD), according to a study published online ahead of print March 3 in JAMA Neurology. Researchers performed the test on samples from national blood collection and prion disease centers in the US and the UK. The samples were taken from healthy donors, patients with nonprion neurodegenerative disease, patients in whom a prion disease diagnosis was likely, and patients with confirmed vCJD. The assay’s specificity was confirmed as 100% in a healthy UK cohort. No potentially cross-reactive blood samples from patients with nonprion neurodegenerative diseases tested positive. Two patients with sporadic CJD tested positive. The authors’ previous sensitivity estimate was reconfirmed but not refined.

The FDA has approved Neuraceq (florbetaben F18 injection) for PET imaging of the brain to estimate beta-amyloid neuritic plaque density in adults with cognitive impairment who are being evaluated for Alzheimer’s disease and other causes of cognitive decline. The approval is based on safety data from 872 patients who participated in global clinical trials, and on three studies that examined images from adults with a range of cognitive function. Images were analyzed from 82 subjects with postmortem confirmation of the presence or absence of beta-amyloid neuritic plaques. Correlation of the visual PET interpretation with histopathology in these 82 brains demonstrated that Neuraceq (Piramal Imaging; Boston) accurately detects moderate to frequent beta-amyloid neuritic plaques in the brain.

A combination of human umbilical cord blood cells (hUCBs) and granulocyte colony stimulating factor (G-CSF) may provide more benefit for patients with traumatic brain injury (TBI) than either therapy alone, according to research published March 12 in PLOS One. Adult rats underwent moderate TBI and, seven days later, were treated with saline alone, G-CSF and saline, hUCB and saline, or hUCB and G-CSF. The rats treated with saline exhibited widespread neuroinflammation, impaired endogenous neurogenesis, and severe hippocampal cell loss. hUCB monotherapy suppressed neuroinflammation, nearly normalized neurogenesis, and reduced hippocampal cell loss, compared with saline alone. G-CSF monotherapy produced partial and short-lived benefits characterized by low levels of neuroinflammation, modest neurogenesis, and moderate reduction of hippocampal cell loss. Combined therapy robustly dampened neuroinflammation, enhanced endogenous neurogenesis, and reduced hippocampal cell loss.

The ability to learn new information may be significantly poorer among patients with Parkinson’s disease than among healthy individuals, according to research published online ahead of print February 24 in Movement Disorders. Investigators examined 27 patients with Parkinson’s disease without dementia and 27 age-, gender-, and education-matched healthy controls with a neuropsychologic test battery designed to assess new learning and memory. The researchers found a significant difference in the groups’ ability to learn a list of 10 semantically related words. Once the groups were equated on learning abilities, the investigators found no significant difference between patients with Parkinson’s disease and controls in recall or recognition of the newly learned material. The memory deficit in nondemented patients with Parkinson’s disease largely results from a deficit in learning new information, said the authors.

Chronic sleep loss may lead to irreversible physical damage to and loss of brain cells, according to research published March 19 in the Journal of Neuroscience. Investigators examined mice following periods of normal rest, short wakefulness, or extended wakefulness to model shift workers’ typical sleep patterns. In response to short-term sleep loss, locus coeruleus neurons upregulated the sirtuin type 3 (SirT3) protein, which protects neurons from metabolic injury. After several days of shift worker sleep patterns, locus coeruleus neurons in the mice had reduced SirT3 and increased cell death. In addition, oxidative stress and acetylation of mitochondrial proteins increased. The mice lost 25% of their locus coeruleus neurons. “This is the first report that sleep loss can actually result in a loss of neurons,” said the authors.

—Erik Greb