Reuters Health

NEW YORK - CT scans identify all clinically significant cervical spine injuries in intoxicated patients with blunt trauma, according to a new study.

"I don't think any of the results were particularly surprising to any of us who regularly do trauma care, but what I do think is remarkable about them is that they dispel several long-held myths about the c-spine, intoxicated patients, and the clearance process," Dr. Matthew J. Martin from Legacy Emanuel Medical Center, Portland, Oregon told Reuters Health.

"I think it again confirms that modern CT scan is highly reliable for identifying significant c-spine injuries, but also that the majority of so called 'intoxicated' patients are examinable enough to determine whether the collar can be removed (when combined with the CT scan)," he said.

Up to half of trauma patients are intoxicated, making clearance of the cervical spine a commonly encountered dilemma with both medical and medicolegal implications. Most guidelines indicate that the cervical spine should not be cleared in such patients, resulting in prolonged immobilization or additional imaging even in the face of a normal CT scan.

Dr. Martin's team examined cervical spine clearance practices for intoxicated trauma patients, examined the reliability of cervical spine CT scans for identifying clinically significant injuries (CSIs), and looked for CSIs that might have been missed by CT scans.

Among 1,429 patients who had an alcohol or drug screen performed, 44.2% were intoxicated, the researchers report in JAMA Surgery, online June 15.

Cervical spine injuries were identified in 11.3% of the sober group, 8.1% of the alcohol-intoxicated group, and 12.0% of the drug-intoxicated group.

CT scans yielded negative predictive values of 99.2% for all injuries and 99.8% for unstable injuries. There were five false-negative CT scans, including four central cord syndromes without associated fractures and one potentially unstable injury in a drug-intoxicated patient who presented with clear quadriplegia on examination.

Half of the intoxicated patients were admitted with continued cervical spine immobilization only on the basis of their intoxication. There were no missed CSIs in this group, and all patients were discharged without evidence of an injury or neurologic deficit. They underwent cervical spine immobilization for an average of 15.1 hours, about four times the average time to cervical spine clearance among sober patients (3.7 hours).

"The finding of how long we are keeping these patients in a c-collar based solely on intoxication should raise some eyebrows, and identifies an easy target for process improvement," Dr. Martin said.

"Cervical collars and immobilization are not therapeutic for the vast majority of c-spine injuries; they are really only to prevent inadvertent motion of an unstable c-spine injury," Dr. Martin said. "This is exceedingly rare in a patient who presents with no gross motor deficit, and a high quality CT scan will identify these unstable injuries very reliably. In addition, there are multiple adverse effects of prolonged immobilization, and even of getting an MRI."

"When these are factored in, I think the risk:benefit analysis falls squarely on the side of early clearance based on CT scan," he concluded.

"A key point is that this should be done by experts who are familiar with not only the global concept (the collar can be removed with a negative CT scan), but also the finer points where you could potentially cause harm, or where you should not remove the collar," Dr. Martin added. "This is where a very clear written protocol comes into play and reduces variation or errors that could cause patient harm."

"The results of this study suggest that it is unnecessary to delay cervical spine clearance until intoxicated patients are sober or until magnetic resonance imaging is performed," write Dr. Olubode A. Olufajo and Dr. Ali Salim from Brigham and Women's Hospital, Boston, in a related editorial. "However, caution must be taken in making conclusions based on these data."

"Although the authors conducted the study at an institution with high-quality CT technology and well-trained radiologists, they still recorded a false-negative CT report consistent with a misread," they note. "With the higher potential for this nature of error in lower-resourced settings, it becomes important to compare the costs and benefits of early removal of cervical collars."

They wonder, "With our knowledge that intoxicated patients form up to half of the population of trauma patients, is it really safe to risk irreversible injuries in 1% of the population to save a few hours in cervical clearance times?"

Dr. Stephen Asha from the University of New South Wales in Sydney, Australia, who has reported on various aspects of cervical spine imaging, told Reuters Health by email, "I think this study confirms what clinical experience as well as much of the more recent studies on cervical spine CT scanning tells us, which is that if there is nothing abnormal detected on a new generation, multi-slice CT, then the neck can be cleared."

"Of course there were a few missed injuries, but this needs to be put into context: no one just does a test in isolation, it is always combined with a clinical assessment, and a consideration the mechanism of injury," said Dr. Asha, who was not involved in the new work. "In this case there were five injuries not apparent on the CT scan, but all had obvious spinal cord injury on clinical examination before the CT was done, so these injuries were never going to be missed in a real clinical setting."

"MRI use should be carefully considered because the problem with MRI is that it can be over-sensitive, demonstrating abnormal signal suggesting ligamentous injury in patient who simply have a ligamentous 'strain,'" Dr. Asha explained. "The false-positive results then lead to further periods of inappropriate immobilization and testing, with the accompanying costs, inconvenience, and complications."

"In patients in whom the clinical assessment raises no concerns for injury, then a normal CT should herald the end of investigations," he said. "MRI should be reserved for those where the clinical assessment is abnormal or where the CT is abnormal and further evaluation for ligamentous or spinal injury is required."

Dr. Asha concluded, "If the clinical exam is not concerning and the CT is normal, then clear the neck."

SOURCE: http://bit.ly/28MxHxA and http://bit.ly/28MxHO5

JAMA Surg 2016.

NEW YORK - CT scans identify all clinically significant cervical spine injuries in intoxicated patients with blunt trauma, according to a new study.

"I don't think any of the results were particularly surprising to any of us who regularly do trauma care, but what I do think is remarkable about them is that they dispel several long-held myths about the c-spine, intoxicated patients, and the clearance process," Dr. Matthew J. Martin from Legacy Emanuel Medical Center, Portland, Oregon told Reuters Health.

"I think it again confirms that modern CT scan is highly reliable for identifying significant c-spine injuries, but also that the majority of so called 'intoxicated' patients are examinable enough to determine whether the collar can be removed (when combined with the CT scan)," he said.

Up to half of trauma patients are intoxicated, making clearance of the cervical spine a commonly encountered dilemma with both medical and medicolegal implications. Most guidelines indicate that the cervical spine should not be cleared in such patients, resulting in prolonged immobilization or additional imaging even in the face of a normal CT scan.

Dr. Martin's team examined cervical spine clearance practices for intoxicated trauma patients, examined the reliability of cervical spine CT scans for identifying clinically significant injuries (CSIs), and looked for CSIs that might have been missed by CT scans.

Among 1,429 patients who had an alcohol or drug screen performed, 44.2% were intoxicated, the researchers report in JAMA Surgery, online June 15.

Cervical spine injuries were identified in 11.3% of the sober group, 8.1% of the alcohol-intoxicated group, and 12.0% of the drug-intoxicated group.

CT scans yielded negative predictive values of 99.2% for all injuries and 99.8% for unstable injuries. There were five false-negative CT scans, including four central cord syndromes without associated fractures and one potentially unstable injury in a drug-intoxicated patient who presented with clear quadriplegia on examination.

Half of the intoxicated patients were admitted with continued cervical spine immobilization only on the basis of their intoxication. There were no missed CSIs in this group, and all patients were discharged without evidence of an injury or neurologic deficit. They underwent cervical spine immobilization for an average of 15.1 hours, about four times the average time to cervical spine clearance among sober patients (3.7 hours).

"The finding of how long we are keeping these patients in a c-collar based solely on intoxication should raise some eyebrows, and identifies an easy target for process improvement," Dr. Martin said.

"Cervical collars and immobilization are not therapeutic for the vast majority of c-spine injuries; they are really only to prevent inadvertent motion of an unstable c-spine injury," Dr. Martin said. "This is exceedingly rare in a patient who presents with no gross motor deficit, and a high quality CT scan will identify these unstable injuries very reliably. In addition, there are multiple adverse effects of prolonged immobilization, and even of getting an MRI."

"When these are factored in, I think the risk:benefit analysis falls squarely on the side of early clearance based on CT scan," he concluded.

"A key point is that this should be done by experts who are familiar with not only the global concept (the collar can be removed with a negative CT scan), but also the finer points where you could potentially cause harm, or where you should not remove the collar," Dr. Martin added. "This is where a very clear written protocol comes into play and reduces variation or errors that could cause patient harm."

"The results of this study suggest that it is unnecessary to delay cervical spine clearance until intoxicated patients are sober or until magnetic resonance imaging is performed," write Dr. Olubode A. Olufajo and Dr. Ali Salim from Brigham and Women's Hospital, Boston, in a related editorial. "However, caution must be taken in making conclusions based on these data."

"Although the authors conducted the study at an institution with high-quality CT technology and well-trained radiologists, they still recorded a false-negative CT report consistent with a misread," they note. "With the higher potential for this nature of error in lower-resourced settings, it becomes important to compare the costs and benefits of early removal of cervical collars."

They wonder, "With our knowledge that intoxicated patients form up to half of the population of trauma patients, is it really safe to risk irreversible injuries in 1% of the population to save a few hours in cervical clearance times?"

Dr. Stephen Asha from the University of New South Wales in Sydney, Australia, who has reported on various aspects of cervical spine imaging, told Reuters Health by email, "I think this study confirms what clinical experience as well as much of the more recent studies on cervical spine CT scanning tells us, which is that if there is nothing abnormal detected on a new generation, multi-slice CT, then the neck can be cleared."

"Of course there were a few missed injuries, but this needs to be put into context: no one just does a test in isolation, it is always combined with a clinical assessment, and a consideration the mechanism of injury," said Dr. Asha, who was not involved in the new work. "In this case there were five injuries not apparent on the CT scan, but all had obvious spinal cord injury on clinical examination before the CT was done, so these injuries were never going to be missed in a real clinical setting."

"MRI use should be carefully considered because the problem with MRI is that it can be over-sensitive, demonstrating abnormal signal suggesting ligamentous injury in patient who simply have a ligamentous 'strain,'" Dr. Asha explained. "The false-positive results then lead to further periods of inappropriate immobilization and testing, with the accompanying costs, inconvenience, and complications."

"In patients in whom the clinical assessment raises no concerns for injury, then a normal CT should herald the end of investigations," he said. "MRI should be reserved for those where the clinical assessment is abnormal or where the CT is abnormal and further evaluation for ligamentous or spinal injury is required."

Dr. Asha concluded, "If the clinical exam is not concerning and the CT is normal, then clear the neck."

SOURCE: http://bit.ly/28MxHxA and http://bit.ly/28MxHO5

JAMA Surg 2016.

NEW YORK - CT scans identify all clinically significant cervical spine injuries in intoxicated patients with blunt trauma, according to a new study.

"I don't think any of the results were particularly surprising to any of us who regularly do trauma care, but what I do think is remarkable about them is that they dispel several long-held myths about the c-spine, intoxicated patients, and the clearance process," Dr. Matthew J. Martin from Legacy Emanuel Medical Center, Portland, Oregon told Reuters Health.

"I think it again confirms that modern CT scan is highly reliable for identifying significant c-spine injuries, but also that the majority of so called 'intoxicated' patients are examinable enough to determine whether the collar can be removed (when combined with the CT scan)," he said.

Up to half of trauma patients are intoxicated, making clearance of the cervical spine a commonly encountered dilemma with both medical and medicolegal implications. Most guidelines indicate that the cervical spine should not be cleared in such patients, resulting in prolonged immobilization or additional imaging even in the face of a normal CT scan.

Dr. Martin's team examined cervical spine clearance practices for intoxicated trauma patients, examined the reliability of cervical spine CT scans for identifying clinically significant injuries (CSIs), and looked for CSIs that might have been missed by CT scans.

Among 1,429 patients who had an alcohol or drug screen performed, 44.2% were intoxicated, the researchers report in JAMA Surgery, online June 15.

Cervical spine injuries were identified in 11.3% of the sober group, 8.1% of the alcohol-intoxicated group, and 12.0% of the drug-intoxicated group.

CT scans yielded negative predictive values of 99.2% for all injuries and 99.8% for unstable injuries. There were five false-negative CT scans, including four central cord syndromes without associated fractures and one potentially unstable injury in a drug-intoxicated patient who presented with clear quadriplegia on examination.

Half of the intoxicated patients were admitted with continued cervical spine immobilization only on the basis of their intoxication. There were no missed CSIs in this group, and all patients were discharged without evidence of an injury or neurologic deficit. They underwent cervical spine immobilization for an average of 15.1 hours, about four times the average time to cervical spine clearance among sober patients (3.7 hours).

"The finding of how long we are keeping these patients in a c-collar based solely on intoxication should raise some eyebrows, and identifies an easy target for process improvement," Dr. Martin said.

"Cervical collars and immobilization are not therapeutic for the vast majority of c-spine injuries; they are really only to prevent inadvertent motion of an unstable c-spine injury," Dr. Martin said. "This is exceedingly rare in a patient who presents with no gross motor deficit, and a high quality CT scan will identify these unstable injuries very reliably. In addition, there are multiple adverse effects of prolonged immobilization, and even of getting an MRI."

"When these are factored in, I think the risk:benefit analysis falls squarely on the side of early clearance based on CT scan," he concluded.

"A key point is that this should be done by experts who are familiar with not only the global concept (the collar can be removed with a negative CT scan), but also the finer points where you could potentially cause harm, or where you should not remove the collar," Dr. Martin added. "This is where a very clear written protocol comes into play and reduces variation or errors that could cause patient harm."

"The results of this study suggest that it is unnecessary to delay cervical spine clearance until intoxicated patients are sober or until magnetic resonance imaging is performed," write Dr. Olubode A. Olufajo and Dr. Ali Salim from Brigham and Women's Hospital, Boston, in a related editorial. "However, caution must be taken in making conclusions based on these data."

"Although the authors conducted the study at an institution with high-quality CT technology and well-trained radiologists, they still recorded a false-negative CT report consistent with a misread," they note. "With the higher potential for this nature of error in lower-resourced settings, it becomes important to compare the costs and benefits of early removal of cervical collars."

They wonder, "With our knowledge that intoxicated patients form up to half of the population of trauma patients, is it really safe to risk irreversible injuries in 1% of the population to save a few hours in cervical clearance times?"

Dr. Stephen Asha from the University of New South Wales in Sydney, Australia, who has reported on various aspects of cervical spine imaging, told Reuters Health by email, "I think this study confirms what clinical experience as well as much of the more recent studies on cervical spine CT scanning tells us, which is that if there is nothing abnormal detected on a new generation, multi-slice CT, then the neck can be cleared."

"Of course there were a few missed injuries, but this needs to be put into context: no one just does a test in isolation, it is always combined with a clinical assessment, and a consideration the mechanism of injury," said Dr. Asha, who was not involved in the new work. "In this case there were five injuries not apparent on the CT scan, but all had obvious spinal cord injury on clinical examination before the CT was done, so these injuries were never going to be missed in a real clinical setting."

"MRI use should be carefully considered because the problem with MRI is that it can be over-sensitive, demonstrating abnormal signal suggesting ligamentous injury in patient who simply have a ligamentous 'strain,'" Dr. Asha explained. "The false-positive results then lead to further periods of inappropriate immobilization and testing, with the accompanying costs, inconvenience, and complications."

"In patients in whom the clinical assessment raises no concerns for injury, then a normal CT should herald the end of investigations," he said. "MRI should be reserved for those where the clinical assessment is abnormal or where the CT is abnormal and further evaluation for ligamentous or spinal injury is required."

Dr. Asha concluded, "If the clinical exam is not concerning and the CT is normal, then clear the neck."

SOURCE: http://bit.ly/28MxHxA and http://bit.ly/28MxHO5

JAMA Surg 2016.

WASHINGTON—The U.S. federal program that pays elderly Americans' hospital bills will exhaust reserves in 2028, two years sooner than last year's estimate, trustees of the program said on Wednesday.

In their annual financial review, the trustees also said that the combined Social Security and disability trust fund reserves are estimated to run out in 2034, the same projection as last year.

The Medicare program's trust fund for hospital care is still scheduled to have sufficient funding 11 years longer than the estimate given before the Affordable Care Act was passed, the trustees said.

They put the shortening of the timeline down to changes in estimates of income and cost, particularly in the near term.

A depletion in funds available for Medicare and Social Security does not mean the programs would suddenly stop. At the current rate of payroll tax collections, Medicare would be able to cover 87 percent of costs in 2028. This would fall to 79 percent by 2043 and then gradually increase.

Social Security would be able to pay about three-quarters of scheduled benefits from 2034 to 2090, the trustees said.

WASHINGTON—The U.S. federal program that pays elderly Americans' hospital bills will exhaust reserves in 2028, two years sooner than last year's estimate, trustees of the program said on Wednesday.

In their annual financial review, the trustees also said that the combined Social Security and disability trust fund reserves are estimated to run out in 2034, the same projection as last year.

The Medicare program's trust fund for hospital care is still scheduled to have sufficient funding 11 years longer than the estimate given before the Affordable Care Act was passed, the trustees said.

They put the shortening of the timeline down to changes in estimates of income and cost, particularly in the near term.

A depletion in funds available for Medicare and Social Security does not mean the programs would suddenly stop. At the current rate of payroll tax collections, Medicare would be able to cover 87 percent of costs in 2028. This would fall to 79 percent by 2043 and then gradually increase.

Social Security would be able to pay about three-quarters of scheduled benefits from 2034 to 2090, the trustees said.

WASHINGTON—The U.S. federal program that pays elderly Americans' hospital bills will exhaust reserves in 2028, two years sooner than last year's estimate, trustees of the program said on Wednesday.

In their annual financial review, the trustees also said that the combined Social Security and disability trust fund reserves are estimated to run out in 2034, the same projection as last year.

The Medicare program's trust fund for hospital care is still scheduled to have sufficient funding 11 years longer than the estimate given before the Affordable Care Act was passed, the trustees said.

They put the shortening of the timeline down to changes in estimates of income and cost, particularly in the near term.

A depletion in funds available for Medicare and Social Security does not mean the programs would suddenly stop. At the current rate of payroll tax collections, Medicare would be able to cover 87 percent of costs in 2028. This would fall to 79 percent by 2043 and then gradually increase.

Social Security would be able to pay about three-quarters of scheduled benefits from 2034 to 2090, the trustees said.

(Reuters Health) - Patients in the emergency room who don't speak English well are slightly more likely to return within days, suggesting their care the first time was not as good as it could have been, researchers say.

In a study in one New York hospital, about 4 percent of English speakers made an unplanned return to the ER within three days, compared to 5 percent of people with limited English.

Low use of professional translators may partly explain the disparity in care, the researchers report in the Annals of Emergency Medicine.

"There's a necessary but not sufficient step to providing care for people with low English proficiency . . . having a good interpreter or healthcare provider who can speak to them in their language," said Dr. Elizabeth Jacobs of the University of Wisconsin-Madison, who was not part of the new study.

The study team, led by Dr. Ka Ming Ngai of the Icahn School of Medicine at Mount Sinai in New York, analyzed 2012 data from the Mount Sinai emergency department. More than 32,000 adult patients and 45,000 ER visits were included. The study did not include patients with psychiatric or substance-related

complaints, those who were nonverbal or had altered mental status, and those with a history of frequent ER visits.

Almost 3,000 patients had limited English proficiency, and in about half of cases someone served as an interpreter. Usually, this was a family member or an ER staff member. Only 527 visits in this group, 24 percent, involved a professional interpreter.

More than a quarter of patients were admitted to the hospital and 1,380 patients had an unplanned return to the ER within three days.

After accounting for age, sex, insurance, race, ethnicity, triage category and other health problems, having limited English proficiency was not tied to greater risk of being admitted to the hospital.

But those with limited English proficiency were about 24 percent more likely to return to the ER unexpectedly.

Ngai told Reuters Health by email that he has been studying the problem of language barriers for the past six years and over time has seen some improvements.

"New medical students are now routinely educated to use interpreter phones during their clinical simulation . . .however, there are still many barriers including access to interpreters and interpreter phones, time constraints, and (doctors) trying to 'get by' with their own language skills," he said.

Ngai said regulatory bodies require hospitals to make language services available. In New York State, for example, upon a request to the hospital administration by the patient, the patient's family or representative, or the provider of medical care, hospitals must provide translation services in inpatient and outpatient settings within 20 minutes and in emergency settings with 10 minutes.

Most New York Hospitals use an interpreter phone service, he said.

Patients who struggle to speak the local language are "a really important population to study and think about how we can improve their care," Jacobs said.

A 5 percent rather than 4 percent rate of return to the ER is not a large difference, but that could be due to the large number of patients excluded from the study, and because there was no validated measure of English proficiency, Jacobs said.

"That might be why we didn't see large differences, if some people considered low English proficiency actually spoke English well, or were getting good interpretive services," she said. "If you took them out, the difference might be larger."

Patients who do not speak English may struggle in other areas of the health system more than at the ER, she added.

But even having an interpreter at the hospital won't help patients deal with insurance providers, she noted.

"There are contextual issues that you may not be able to fully adequately address unless you can understand the nuances," Jacobs said.

"When dealing with immigrant population, it is almost always more than 'just' language," Ngai agreed. There can be cultural issues, too.

In addition, people with low English proficiency may also be less able to take days off of work, and to agree to be admitted to the hospital when necessary, than others, Jacobs said.

We've made tremendous progress in assuring interpreters are more available," in person, over the phone or by video, Jacobs said.

But, she said, "we are very imperfect at getting patients the services they need. It's important for providers to be educated on these issues and to understand how to access these services."

It would be ideal to try to match patients with providers by language and culture, but in the meantime, "language is a good start," Ngai said.

(Reuters Health) - Patients in the emergency room who don't speak English well are slightly more likely to return within days, suggesting their care the first time was not as good as it could have been, researchers say.

In a study in one New York hospital, about 4 percent of English speakers made an unplanned return to the ER within three days, compared to 5 percent of people with limited English.

Low use of professional translators may partly explain the disparity in care, the researchers report in the Annals of Emergency Medicine.

"There's a necessary but not sufficient step to providing care for people with low English proficiency . . . having a good interpreter or healthcare provider who can speak to them in their language," said Dr. Elizabeth Jacobs of the University of Wisconsin-Madison, who was not part of the new study.

The study team, led by Dr. Ka Ming Ngai of the Icahn School of Medicine at Mount Sinai in New York, analyzed 2012 data from the Mount Sinai emergency department. More than 32,000 adult patients and 45,000 ER visits were included. The study did not include patients with psychiatric or substance-related

complaints, those who were nonverbal or had altered mental status, and those with a history of frequent ER visits.

Almost 3,000 patients had limited English proficiency, and in about half of cases someone served as an interpreter. Usually, this was a family member or an ER staff member. Only 527 visits in this group, 24 percent, involved a professional interpreter.

More than a quarter of patients were admitted to the hospital and 1,380 patients had an unplanned return to the ER within three days.

After accounting for age, sex, insurance, race, ethnicity, triage category and other health problems, having limited English proficiency was not tied to greater risk of being admitted to the hospital.

But those with limited English proficiency were about 24 percent more likely to return to the ER unexpectedly.

Ngai told Reuters Health by email that he has been studying the problem of language barriers for the past six years and over time has seen some improvements.

"New medical students are now routinely educated to use interpreter phones during their clinical simulation . . .however, there are still many barriers including access to interpreters and interpreter phones, time constraints, and (doctors) trying to 'get by' with their own language skills," he said.

Ngai said regulatory bodies require hospitals to make language services available. In New York State, for example, upon a request to the hospital administration by the patient, the patient's family or representative, or the provider of medical care, hospitals must provide translation services in inpatient and outpatient settings within 20 minutes and in emergency settings with 10 minutes.

Most New York Hospitals use an interpreter phone service, he said.

Patients who struggle to speak the local language are "a really important population to study and think about how we can improve their care," Jacobs said.

A 5 percent rather than 4 percent rate of return to the ER is not a large difference, but that could be due to the large number of patients excluded from the study, and because there was no validated measure of English proficiency, Jacobs said.

"That might be why we didn't see large differences, if some people considered low English proficiency actually spoke English well, or were getting good interpretive services," she said. "If you took them out, the difference might be larger."

Patients who do not speak English may struggle in other areas of the health system more than at the ER, she added.

But even having an interpreter at the hospital won't help patients deal with insurance providers, she noted.

"There are contextual issues that you may not be able to fully adequately address unless you can understand the nuances," Jacobs said.

"When dealing with immigrant population, it is almost always more than 'just' language," Ngai agreed. There can be cultural issues, too.

In addition, people with low English proficiency may also be less able to take days off of work, and to agree to be admitted to the hospital when necessary, than others, Jacobs said.

We've made tremendous progress in assuring interpreters are more available," in person, over the phone or by video, Jacobs said.

But, she said, "we are very imperfect at getting patients the services they need. It's important for providers to be educated on these issues and to understand how to access these services."

It would be ideal to try to match patients with providers by language and culture, but in the meantime, "language is a good start," Ngai said.

(Reuters Health) - Patients in the emergency room who don't speak English well are slightly more likely to return within days, suggesting their care the first time was not as good as it could have been, researchers say.

In a study in one New York hospital, about 4 percent of English speakers made an unplanned return to the ER within three days, compared to 5 percent of people with limited English.

Low use of professional translators may partly explain the disparity in care, the researchers report in the Annals of Emergency Medicine.

"There's a necessary but not sufficient step to providing care for people with low English proficiency . . . having a good interpreter or healthcare provider who can speak to them in their language," said Dr. Elizabeth Jacobs of the University of Wisconsin-Madison, who was not part of the new study.

The study team, led by Dr. Ka Ming Ngai of the Icahn School of Medicine at Mount Sinai in New York, analyzed 2012 data from the Mount Sinai emergency department. More than 32,000 adult patients and 45,000 ER visits were included. The study did not include patients with psychiatric or substance-related

complaints, those who were nonverbal or had altered mental status, and those with a history of frequent ER visits.

Almost 3,000 patients had limited English proficiency, and in about half of cases someone served as an interpreter. Usually, this was a family member or an ER staff member. Only 527 visits in this group, 24 percent, involved a professional interpreter.

More than a quarter of patients were admitted to the hospital and 1,380 patients had an unplanned return to the ER within three days.

After accounting for age, sex, insurance, race, ethnicity, triage category and other health problems, having limited English proficiency was not tied to greater risk of being admitted to the hospital.

But those with limited English proficiency were about 24 percent more likely to return to the ER unexpectedly.

Ngai told Reuters Health by email that he has been studying the problem of language barriers for the past six years and over time has seen some improvements.

"New medical students are now routinely educated to use interpreter phones during their clinical simulation . . .however, there are still many barriers including access to interpreters and interpreter phones, time constraints, and (doctors) trying to 'get by' with their own language skills," he said.

Ngai said regulatory bodies require hospitals to make language services available. In New York State, for example, upon a request to the hospital administration by the patient, the patient's family or representative, or the provider of medical care, hospitals must provide translation services in inpatient and outpatient settings within 20 minutes and in emergency settings with 10 minutes.

Most New York Hospitals use an interpreter phone service, he said.

Patients who struggle to speak the local language are "a really important population to study and think about how we can improve their care," Jacobs said.

A 5 percent rather than 4 percent rate of return to the ER is not a large difference, but that could be due to the large number of patients excluded from the study, and because there was no validated measure of English proficiency, Jacobs said.

"That might be why we didn't see large differences, if some people considered low English proficiency actually spoke English well, or were getting good interpretive services," she said. "If you took them out, the difference might be larger."

Patients who do not speak English may struggle in other areas of the health system more than at the ER, she added.

But even having an interpreter at the hospital won't help patients deal with insurance providers, she noted.

"There are contextual issues that you may not be able to fully adequately address unless you can understand the nuances," Jacobs said.

"When dealing with immigrant population, it is almost always more than 'just' language," Ngai agreed. There can be cultural issues, too.

In addition, people with low English proficiency may also be less able to take days off of work, and to agree to be admitted to the hospital when necessary, than others, Jacobs said.

We've made tremendous progress in assuring interpreters are more available," in person, over the phone or by video, Jacobs said.

But, she said, "we are very imperfect at getting patients the services they need. It's important for providers to be educated on these issues and to understand how to access these services."

It would be ideal to try to match patients with providers by language and culture, but in the meantime, "language is a good start," Ngai said.

NEW YORK (Reuters Health) - Higher-volume hospitals do better in treatment of obstructive hypertrophic cardiomyopathy (HCM), but more efforts are needed to direct patients to these centers, according to New York-based researchers.

In an April 27 online paper in JAMA Cardiology, they note that recommendations are that the treatments, septal myectomy (SM) and alcohol septal ablation (ASA), be performed only by experienced operators with dedicated HCM clinical programs.

"Our study demonstrates that a significant number of cases of septal myectomy and alcohol septal ablation are not being performed at centers of excellence despite the guideline," Dr. Luke K. Kim, of Weill Cornell Medical College, told Reuters Health by email.

Dr. Kim and colleagues investigated compliance and its influence on outcome by examining nationwide data from 2003 to 2009 on 6,386 patients who underwent SM and 4,862 who had ASA. During this period almost 60% of institutions performed 10 or fewer SM procedures. The corresponding proportion for ASAs was 67%.

The incidence of in-hospital death after SM was significantly lower in hospitals in the highest volume tertile (3.8%) than those in the middle (9.6%) and lowest tertiles (15.6%). Corresponding proportions for ASA were 0.6%, 0.8% and 2.3%. There was a similar pattern for acute renal failure after ASA (2.4%, 7.6% and 6.2%).

After adjustment, being in the lowest tertile of SM volume was an independent predictor of in-hospital all-cause mortality (odds ratio, 3.11) and bleeding (OR, 3.77). However, being in the lowest volume for ASA was not independently associated with an increased risk of adverse post-procedural events.

In addition, hospitalization at a high-volume center was associated with a shorter stay and lower costs for both procedures.

However, over the study period, wrote the investigators, "Most centers that provide septal reduction therapy performed few SM and ASA procedures" and were "below the threshold recommended."

In particular, they concluded "Low SM volume was associated with worse outcomes, including higher mortality, longer length of stay, and higher costs. More efforts are needed to encourage referral of patients to centers of excellence for septal reduction therapy."

Commenting on the findings by email, Dr. Steve R. Ommen, coauthor of an accompanying invited opinion, told Reuters Health that "patients deserve to be offered the best care and outcomes possible and that appears to be possible only at centers with focused expertise in the management of HCM. Simply being a high-volume facility does not translate into achieving the safety nor the success observed at expert centers."

Dr. Ommen of the Mayo Clinic, Rochester, Minnesota, added that "Success takes a comprehensive understanding of the underlying HCM disease process. That is really the main take-home message from my point of view."

The other really astonishing finding," he concluded, "was that the median number of procedures performed was only one per year per hospital in the study."

The Michael Wolk Heart Foundation and the New York Cardiac Center supported this research. Two coauthors reported disclosures.

NEW YORK (Reuters Health) - Higher-volume hospitals do better in treatment of obstructive hypertrophic cardiomyopathy (HCM), but more efforts are needed to direct patients to these centers, according to New York-based researchers.

In an April 27 online paper in JAMA Cardiology, they note that recommendations are that the treatments, septal myectomy (SM) and alcohol septal ablation (ASA), be performed only by experienced operators with dedicated HCM clinical programs.

"Our study demonstrates that a significant number of cases of septal myectomy and alcohol septal ablation are not being performed at centers of excellence despite the guideline," Dr. Luke K. Kim, of Weill Cornell Medical College, told Reuters Health by email.

Dr. Kim and colleagues investigated compliance and its influence on outcome by examining nationwide data from 2003 to 2009 on 6,386 patients who underwent SM and 4,862 who had ASA. During this period almost 60% of institutions performed 10 or fewer SM procedures. The corresponding proportion for ASAs was 67%.

The incidence of in-hospital death after SM was significantly lower in hospitals in the highest volume tertile (3.8%) than those in the middle (9.6%) and lowest tertiles (15.6%). Corresponding proportions for ASA were 0.6%, 0.8% and 2.3%. There was a similar pattern for acute renal failure after ASA (2.4%, 7.6% and 6.2%).

After adjustment, being in the lowest tertile of SM volume was an independent predictor of in-hospital all-cause mortality (odds ratio, 3.11) and bleeding (OR, 3.77). However, being in the lowest volume for ASA was not independently associated with an increased risk of adverse post-procedural events.

In addition, hospitalization at a high-volume center was associated with a shorter stay and lower costs for both procedures.

However, over the study period, wrote the investigators, "Most centers that provide septal reduction therapy performed few SM and ASA procedures" and were "below the threshold recommended."

In particular, they concluded "Low SM volume was associated with worse outcomes, including higher mortality, longer length of stay, and higher costs. More efforts are needed to encourage referral of patients to centers of excellence for septal reduction therapy."

Commenting on the findings by email, Dr. Steve R. Ommen, coauthor of an accompanying invited opinion, told Reuters Health that "patients deserve to be offered the best care and outcomes possible and that appears to be possible only at centers with focused expertise in the management of HCM. Simply being a high-volume facility does not translate into achieving the safety nor the success observed at expert centers."

Dr. Ommen of the Mayo Clinic, Rochester, Minnesota, added that "Success takes a comprehensive understanding of the underlying HCM disease process. That is really the main take-home message from my point of view."

The other really astonishing finding," he concluded, "was that the median number of procedures performed was only one per year per hospital in the study."

The Michael Wolk Heart Foundation and the New York Cardiac Center supported this research. Two coauthors reported disclosures.

NEW YORK (Reuters Health) - Higher-volume hospitals do better in treatment of obstructive hypertrophic cardiomyopathy (HCM), but more efforts are needed to direct patients to these centers, according to New York-based researchers.

In an April 27 online paper in JAMA Cardiology, they note that recommendations are that the treatments, septal myectomy (SM) and alcohol septal ablation (ASA), be performed only by experienced operators with dedicated HCM clinical programs.

"Our study demonstrates that a significant number of cases of septal myectomy and alcohol septal ablation are not being performed at centers of excellence despite the guideline," Dr. Luke K. Kim, of Weill Cornell Medical College, told Reuters Health by email.

Dr. Kim and colleagues investigated compliance and its influence on outcome by examining nationwide data from 2003 to 2009 on 6,386 patients who underwent SM and 4,862 who had ASA. During this period almost 60% of institutions performed 10 or fewer SM procedures. The corresponding proportion for ASAs was 67%.

The incidence of in-hospital death after SM was significantly lower in hospitals in the highest volume tertile (3.8%) than those in the middle (9.6%) and lowest tertiles (15.6%). Corresponding proportions for ASA were 0.6%, 0.8% and 2.3%. There was a similar pattern for acute renal failure after ASA (2.4%, 7.6% and 6.2%).

After adjustment, being in the lowest tertile of SM volume was an independent predictor of in-hospital all-cause mortality (odds ratio, 3.11) and bleeding (OR, 3.77). However, being in the lowest volume for ASA was not independently associated with an increased risk of adverse post-procedural events.

In addition, hospitalization at a high-volume center was associated with a shorter stay and lower costs for both procedures.

However, over the study period, wrote the investigators, "Most centers that provide septal reduction therapy performed few SM and ASA procedures" and were "below the threshold recommended."

In particular, they concluded "Low SM volume was associated with worse outcomes, including higher mortality, longer length of stay, and higher costs. More efforts are needed to encourage referral of patients to centers of excellence for septal reduction therapy."

Commenting on the findings by email, Dr. Steve R. Ommen, coauthor of an accompanying invited opinion, told Reuters Health that "patients deserve to be offered the best care and outcomes possible and that appears to be possible only at centers with focused expertise in the management of HCM. Simply being a high-volume facility does not translate into achieving the safety nor the success observed at expert centers."

Dr. Ommen of the Mayo Clinic, Rochester, Minnesota, added that "Success takes a comprehensive understanding of the underlying HCM disease process. That is really the main take-home message from my point of view."

The other really astonishing finding," he concluded, "was that the median number of procedures performed was only one per year per hospital in the study."

The Michael Wolk Heart Foundation and the New York Cardiac Center supported this research. Two coauthors reported disclosures.

NEW YORK (Reuters Health) - Implanted cardioverter-defibrillators (ICDs) carry a high risk of long-term complications, especially for younger patients, women, and blacks, researchers report.

Early implantation-related risks such as device malfunction are well known, but longer-term risks -- especially beyond the first year after implantation -- are poorly defined, Dr. Isuru Ranasinghe of Queen Elizabeth Hospital in South Australia and colleagues observed in an article online May 2 in Annals of

Internal Medicine.

"Knowing the long-term risks is important for patients to make an informed choice, because (implantation) is a lifelong treatment," Dr. Ranasinghe told Reuters Health by email.  "Moreover, more than two-thirds of patients who receive an ICD for prevention of future events never require treatment from the ICD, although they continue to be at risk for device-related harms."

To investigate, the researchers analyzed data from the American College of Cardiology Foundation's National Cardiovascular Data Registry ICD Registry and Medicare claims to assess the long-term nonfatal risks for ICD-related complications among 114,484 patients at 1,437 U.S. centers with first-time implantations.

Implanted devices included single-chamber ICDs (19.8% of patients); dual-chamber ICDs (41.3%), and cardiac resynchronization therapy with a defibrillator (CRT-D; 38.9%).

During a median follow-up of 2.7 years, 40,072 patients died, representing 12.6 deaths per 100 patient years of followup. After accounting for the deaths, "there were 6.1 ICD-related complications per 100 patient years where the patient required an acute hospitalization or a reoperation," Dr. Ranasinghe said.

"In addition, there were 3.9 device reoperations per 100 patient years for reasons other than complications. Typically performed to replace the ICD battery, these reoperations are somewhat expected with time. Nevertheless, these surgical procedures are important for patients, as they carry a risk of patient harm," he observed.

Those more likely to experience long-term complications were women (16% higher risk), blacks (14% higher risk), and patients ages 65-69 at implantation (55% higher risk compared with those 85 and older) -- findings that require further investigation, according to Dr. Ranasinghe.

"Patients were 38% more likely to experience a complication if they had the more complex CRT-D compared with a simpler (single-chamber) device. A patient with a CRT-D device was also four times more likely to require a reoperation for reasons other than complications compared with a single-chamber ICD during the study period," he said.

Dr Ranasinghe added, "The rate of complications is substantial and higher than previously reported. The continued occurrence of complications long after the initial implantation indicates the need for vigilance and ongoing surveillance of ICD-related complications."

"There is considerable debate as to the added benefit of more complex devices compared with simpler single-chamber ICDs. Where possible, using a simpler device may reduce the risk of ICD-related harm," he said.

Dr. Paul J. Hauptman of Saint Louis University School of Medicine in Missouri, told Reuters Health by email, "The study adds to a rich literature that highlights the need for clinicians and patients to carefully consider the potential risks and benefits of implantable defibrillators and CRT devices."

"Although (this was) not a primary focus of the paper, I was struck by the 35% mortality at a median of 2.7 years (in addition to a significant ICD-related complication rate)," said Dr. Hauptman, who has done work in this area. "By linking registry and Medicare data, the authors succeed in providing meaningful insight into what happens to real patients in the real world. We would be abrogating our role as physicians if we ignore analyses like this one."

The study was funded by the American College of Cardiology Foundation's National Cardiovascular Data Registry and other organizations. Five coauthors reported disclosures.

NEW YORK (Reuters Health) - Implanted cardioverter-defibrillators (ICDs) carry a high risk of long-term complications, especially for younger patients, women, and blacks, researchers report.

Early implantation-related risks such as device malfunction are well known, but longer-term risks -- especially beyond the first year after implantation -- are poorly defined, Dr. Isuru Ranasinghe of Queen Elizabeth Hospital in South Australia and colleagues observed in an article online May 2 in Annals of

Internal Medicine.

"Knowing the long-term risks is important for patients to make an informed choice, because (implantation) is a lifelong treatment," Dr. Ranasinghe told Reuters Health by email.  "Moreover, more than two-thirds of patients who receive an ICD for prevention of future events never require treatment from the ICD, although they continue to be at risk for device-related harms."

To investigate, the researchers analyzed data from the American College of Cardiology Foundation's National Cardiovascular Data Registry ICD Registry and Medicare claims to assess the long-term nonfatal risks for ICD-related complications among 114,484 patients at 1,437 U.S. centers with first-time implantations.

Implanted devices included single-chamber ICDs (19.8% of patients); dual-chamber ICDs (41.3%), and cardiac resynchronization therapy with a defibrillator (CRT-D; 38.9%).

During a median follow-up of 2.7 years, 40,072 patients died, representing 12.6 deaths per 100 patient years of followup. After accounting for the deaths, "there were 6.1 ICD-related complications per 100 patient years where the patient required an acute hospitalization or a reoperation," Dr. Ranasinghe said.

"In addition, there were 3.9 device reoperations per 100 patient years for reasons other than complications. Typically performed to replace the ICD battery, these reoperations are somewhat expected with time. Nevertheless, these surgical procedures are important for patients, as they carry a risk of patient harm," he observed.

Those more likely to experience long-term complications were women (16% higher risk), blacks (14% higher risk), and patients ages 65-69 at implantation (55% higher risk compared with those 85 and older) -- findings that require further investigation, according to Dr. Ranasinghe.

"Patients were 38% more likely to experience a complication if they had the more complex CRT-D compared with a simpler (single-chamber) device. A patient with a CRT-D device was also four times more likely to require a reoperation for reasons other than complications compared with a single-chamber ICD during the study period," he said.

Dr Ranasinghe added, "The rate of complications is substantial and higher than previously reported. The continued occurrence of complications long after the initial implantation indicates the need for vigilance and ongoing surveillance of ICD-related complications."

"There is considerable debate as to the added benefit of more complex devices compared with simpler single-chamber ICDs. Where possible, using a simpler device may reduce the risk of ICD-related harm," he said.

Dr. Paul J. Hauptman of Saint Louis University School of Medicine in Missouri, told Reuters Health by email, "The study adds to a rich literature that highlights the need for clinicians and patients to carefully consider the potential risks and benefits of implantable defibrillators and CRT devices."

"Although (this was) not a primary focus of the paper, I was struck by the 35% mortality at a median of 2.7 years (in addition to a significant ICD-related complication rate)," said Dr. Hauptman, who has done work in this area. "By linking registry and Medicare data, the authors succeed in providing meaningful insight into what happens to real patients in the real world. We would be abrogating our role as physicians if we ignore analyses like this one."

The study was funded by the American College of Cardiology Foundation's National Cardiovascular Data Registry and other organizations. Five coauthors reported disclosures.

NEW YORK (Reuters Health) - Implanted cardioverter-defibrillators (ICDs) carry a high risk of long-term complications, especially for younger patients, women, and blacks, researchers report.

Early implantation-related risks such as device malfunction are well known, but longer-term risks -- especially beyond the first year after implantation -- are poorly defined, Dr. Isuru Ranasinghe of Queen Elizabeth Hospital in South Australia and colleagues observed in an article online May 2 in Annals of

Internal Medicine.

"Knowing the long-term risks is important for patients to make an informed choice, because (implantation) is a lifelong treatment," Dr. Ranasinghe told Reuters Health by email.  "Moreover, more than two-thirds of patients who receive an ICD for prevention of future events never require treatment from the ICD, although they continue to be at risk for device-related harms."

To investigate, the researchers analyzed data from the American College of Cardiology Foundation's National Cardiovascular Data Registry ICD Registry and Medicare claims to assess the long-term nonfatal risks for ICD-related complications among 114,484 patients at 1,437 U.S. centers with first-time implantations.

Implanted devices included single-chamber ICDs (19.8% of patients); dual-chamber ICDs (41.3%), and cardiac resynchronization therapy with a defibrillator (CRT-D; 38.9%).

During a median follow-up of 2.7 years, 40,072 patients died, representing 12.6 deaths per 100 patient years of followup. After accounting for the deaths, "there were 6.1 ICD-related complications per 100 patient years where the patient required an acute hospitalization or a reoperation," Dr. Ranasinghe said.

"In addition, there were 3.9 device reoperations per 100 patient years for reasons other than complications. Typically performed to replace the ICD battery, these reoperations are somewhat expected with time. Nevertheless, these surgical procedures are important for patients, as they carry a risk of patient harm," he observed.

Those more likely to experience long-term complications were women (16% higher risk), blacks (14% higher risk), and patients ages 65-69 at implantation (55% higher risk compared with those 85 and older) -- findings that require further investigation, according to Dr. Ranasinghe.

"Patients were 38% more likely to experience a complication if they had the more complex CRT-D compared with a simpler (single-chamber) device. A patient with a CRT-D device was also four times more likely to require a reoperation for reasons other than complications compared with a single-chamber ICD during the study period," he said.

Dr Ranasinghe added, "The rate of complications is substantial and higher than previously reported. The continued occurrence of complications long after the initial implantation indicates the need for vigilance and ongoing surveillance of ICD-related complications."

"There is considerable debate as to the added benefit of more complex devices compared with simpler single-chamber ICDs. Where possible, using a simpler device may reduce the risk of ICD-related harm," he said.

Dr. Paul J. Hauptman of Saint Louis University School of Medicine in Missouri, told Reuters Health by email, "The study adds to a rich literature that highlights the need for clinicians and patients to carefully consider the potential risks and benefits of implantable defibrillators and CRT devices."

"Although (this was) not a primary focus of the paper, I was struck by the 35% mortality at a median of 2.7 years (in addition to a significant ICD-related complication rate)," said Dr. Hauptman, who has done work in this area. "By linking registry and Medicare data, the authors succeed in providing meaningful insight into what happens to real patients in the real world. We would be abrogating our role as physicians if we ignore analyses like this one."

The study was funded by the American College of Cardiology Foundation's National Cardiovascular Data Registry and other organizations. Five coauthors reported disclosures.

NEW YORK (Reuters Health) - Lipid-lowering therapy, consisting almost entirely of statins, substantially lowered the risk of cardiovascular disease (CVD) and cardiovascular death in individuals with type 1 diabetes without a history of CVD, according to a new study.

Among more than 24,000 Swedish patients with type 1 diabetes, over a mean follow-up of six years, primary prevention with lipid-lowering therapy (LLT) reduced the incidence of cardiovascular death, all-cause death, stroke, coronary heart disease, and acute myocardial infarction.

The risk of cardiovascular death was reduced by 40%, while the reductions for acute MI and coronary heart disease were 22% and 15%, respectively, according to an article online on April 18 in Diabetes Care.

In email to Reuters Health, corresponding author Dr. Christel Hero, of the Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden, emphasized that "individuals with type 1 diabetes are at enhanced risk for CVD compared to the general population."

The study encompassed 24,230 individuals with type 1 diabetes (mean age 39.4 years): 5,387 treated with lipid-lowering medication and 18,843 untreated. In 97% of cases, LLT was with statins.

Hazard ratios for treated versus untreated participants were significant for all outcomes: cardiovascular death, 0.60; all-cause death, 0.56; fatal/nonfatal stroke, 0.56; fatal/nonfatal acute myocardial infarction, 0.78; and fatal/nonfatal coronary heart disease 0.85. Hazard ratios in a one-to-one matched cohort with 4,025 treated and 4,025 untreated individuals were significant only for all-cause death (0.74).

"Our study shows convincing effects of LLT in preventing all cardiovascular endpoints, even if the effect on reducing cardiovascular morbidity, except for stroke, was lesser than the effect on cardiovascular death and all-cause death," the authors wrote.

This study, Dr. Urman said, supports the idea that essentially all type 1 diabetics should be taking statins (absent any contraindications).

NEW YORK (Reuters Health) - Lipid-lowering therapy, consisting almost entirely of statins, substantially lowered the risk of cardiovascular disease (CVD) and cardiovascular death in individuals with type 1 diabetes without a history of CVD, according to a new study.

Among more than 24,000 Swedish patients with type 1 diabetes, over a mean follow-up of six years, primary prevention with lipid-lowering therapy (LLT) reduced the incidence of cardiovascular death, all-cause death, stroke, coronary heart disease, and acute myocardial infarction.

The risk of cardiovascular death was reduced by 40%, while the reductions for acute MI and coronary heart disease were 22% and 15%, respectively, according to an article online on April 18 in Diabetes Care.

In email to Reuters Health, corresponding author Dr. Christel Hero, of the Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden, emphasized that "individuals with type 1 diabetes are at enhanced risk for CVD compared to the general population."

The study encompassed 24,230 individuals with type 1 diabetes (mean age 39.4 years): 5,387 treated with lipid-lowering medication and 18,843 untreated. In 97% of cases, LLT was with statins.

Hazard ratios for treated versus untreated participants were significant for all outcomes: cardiovascular death, 0.60; all-cause death, 0.56; fatal/nonfatal stroke, 0.56; fatal/nonfatal acute myocardial infarction, 0.78; and fatal/nonfatal coronary heart disease 0.85. Hazard ratios in a one-to-one matched cohort with 4,025 treated and 4,025 untreated individuals were significant only for all-cause death (0.74).

"Our study shows convincing effects of LLT in preventing all cardiovascular endpoints, even if the effect on reducing cardiovascular morbidity, except for stroke, was lesser than the effect on cardiovascular death and all-cause death," the authors wrote.

This study, Dr. Urman said, supports the idea that essentially all type 1 diabetics should be taking statins (absent any contraindications).

NEW YORK (Reuters Health) - Lipid-lowering therapy, consisting almost entirely of statins, substantially lowered the risk of cardiovascular disease (CVD) and cardiovascular death in individuals with type 1 diabetes without a history of CVD, according to a new study.

Among more than 24,000 Swedish patients with type 1 diabetes, over a mean follow-up of six years, primary prevention with lipid-lowering therapy (LLT) reduced the incidence of cardiovascular death, all-cause death, stroke, coronary heart disease, and acute myocardial infarction.

The risk of cardiovascular death was reduced by 40%, while the reductions for acute MI and coronary heart disease were 22% and 15%, respectively, according to an article online on April 18 in Diabetes Care.

In email to Reuters Health, corresponding author Dr. Christel Hero, of the Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden, emphasized that "individuals with type 1 diabetes are at enhanced risk for CVD compared to the general population."

The study encompassed 24,230 individuals with type 1 diabetes (mean age 39.4 years): 5,387 treated with lipid-lowering medication and 18,843 untreated. In 97% of cases, LLT was with statins.

Hazard ratios for treated versus untreated participants were significant for all outcomes: cardiovascular death, 0.60; all-cause death, 0.56; fatal/nonfatal stroke, 0.56; fatal/nonfatal acute myocardial infarction, 0.78; and fatal/nonfatal coronary heart disease 0.85. Hazard ratios in a one-to-one matched cohort with 4,025 treated and 4,025 untreated individuals were significant only for all-cause death (0.74).

"Our study shows convincing effects of LLT in preventing all cardiovascular endpoints, even if the effect on reducing cardiovascular morbidity, except for stroke, was lesser than the effect on cardiovascular death and all-cause death," the authors wrote.

This study, Dr. Urman said, supports the idea that essentially all type 1 diabetics should be taking statins (absent any contraindications).

NEW YORK (Reuters Health) - Certain metal-on-metal (MoM) hip replacement devices implanted after 2006 have an "unacceptably high" revision rate, due mainly to manufacturing problems, according to a new study.

"Although the use of MoM hip devices has declined dramatically in the past five years, hundreds of thousands remain in situ, with the long-term future uncertain," Dr. David Langton, of University Hospital of North Tees in Stockton, UK, and colleagues wrote in an article online April 29 in BMJ Open.

To determine risk factors for revision in patients implanted with the commonly used DePuy Pinnacle MoM hip prostheses, the researchers identified all patients at the Stockton-based hospital who were implanted with a 36 mm MoM Pinnacle hip in conjunction with an S-ROM or Corail uncemented stem. They then identified only patients with components that had been implanted by either of the two senior authors of the study, Dr. Raj Logishetty or Dr. Antoni Viral Francis Nargol.

Implantations were performed from 2003-2009 and patients were monitored yearly. From 2007-2011, as awareness of the risk of adverse reactions to metal debris (ARMD) from MoMs increased, the hospital offered patients who developed symptoms blood metal ion testing and as-needed ultrasound scanning. From 2011 onward, given the widespread problems reported with MoMs, the hospital recalled all Pinnacle MoM patients for examination.

A total of 489 MoM Pinnacle hips had been implanted into 243 women and 191 men. Of these, 352 patients attended the MoM recall clinics and 64 died during the study period (mean

followup, about 7.5 years). For the purposes of survival analyses, those who did not attend the recall clinics were assumed to have well-functioning prostheses.

A total of 71 hips were revised -- an "unacceptably high" rate, according to the authors. All but one were carried out for ARMD, with one revision for a loose cup. Prosthetic survival rate for the cohort as a whole was 83.6% at nine years.

In 53 revisions (75%), "copious amounts" of fluid were found, and in 32 (45%), it was noted to be under pressure or had fistulated through the capsule. No abnormal fluid was identified at revision in only one case.

The researchers noted obvious damage to the abductor musculature in 38 cases. They documented a moderate-to-severe aseptic lymphocyte-dominated vasculitis-associated lesion on examination of retrieved tissues in 36 cases (51%). In 13 cases (19%), they found metallosis with no identified lymphocytic infiltration.

The majority of explanted devices showed signs of taper junction failure. A significant number of devices were found to be manufactured out of their specifications -- a finding that was confirmed by an analysis of a wider data set from the Northern Retrieval Registry.

Risk factors for revision were bilateral MoM prostheses, smaller Pinnacle liners, and implantation in 2006 or later. Women were found to be at greater risk of early device failure. However, shell sizes and bearing diameters confounded the analyses, and liner size and/or earlier year of liner manufacture were determined to be greater threats to prosthetic survival than gender. The authors suggest that this analysis be repeated with input from an additional registry.

Dr. Langton, who is involved in litigation related to the Pinnacle device, told Reuters Health by email, "We have essentially shown that one of the major health care/orthopedic product manufacturers sold a product to surgeons and health care systems on the basis (that it was a) technologically advanced precision-engineered device, and it wasn't precision-engineered."

He added, "the product was produced in the same factories as (DePuy's) other failed product, the ASR, which was . . . marketed on the same premise."

Mindy Tinsley, senior director, Communications and Public Affairs at DePuy Synthes Franchise, refuted the study findings. "We stand behind the strong record of safety and effectiveness of the (Pinnacle) ULTAMET Metal-on-Metal," she told Reuters Health by email.

She added that "there are no manufacturing problems" with the device and noted that DePuy "questions the validity of the . . . paper given significant flaws in how it was conducted." According to Tinsley, "measurements taken following an accepted international standard at the DePuy UK manufacturing facility" showed the device liners "were manufactured within specification."

Dr. Mark W. Hungerford, director of Joint Replacement and Reconstruction at Mercy Medical Center in Baltimore, told Reuters Health by phone, "One study does not make or break anything in science. There have been issues in the field about MoM and early failure rates or not. That's a serious issue being looked at by a lot of people. This is one more study showing a problem, but it's not a definitive one."

With respect to patients, "the obligation is no different than for any orthopedic device," said Dr. Hungerford, who has not used the Pinnacle device. "All can fail, all need to be monitored for failure on a regular basis, and if problems arise, they need to be dealt with."

The authors reported no funding. Dr. Langton, Dr. Nargol, and coauthors Dr. Thomas Joyce and Dr. Nick Cooke are retained experts for plaintiffs in ongoing MoM litigation. Dr. Langton and Dr. Nargol have worked with the U.S. Department of Justice in litigation involving DePuy.

NEW YORK (Reuters Health) - Certain metal-on-metal (MoM) hip replacement devices implanted after 2006 have an "unacceptably high" revision rate, due mainly to manufacturing problems, according to a new study.

"Although the use of MoM hip devices has declined dramatically in the past five years, hundreds of thousands remain in situ, with the long-term future uncertain," Dr. David Langton, of University Hospital of North Tees in Stockton, UK, and colleagues wrote in an article online April 29 in BMJ Open.

To determine risk factors for revision in patients implanted with the commonly used DePuy Pinnacle MoM hip prostheses, the researchers identified all patients at the Stockton-based hospital who were implanted with a 36 mm MoM Pinnacle hip in conjunction with an S-ROM or Corail uncemented stem. They then identified only patients with components that had been implanted by either of the two senior authors of the study, Dr. Raj Logishetty or Dr. Antoni Viral Francis Nargol.

Implantations were performed from 2003-2009 and patients were monitored yearly. From 2007-2011, as awareness of the risk of adverse reactions to metal debris (ARMD) from MoMs increased, the hospital offered patients who developed symptoms blood metal ion testing and as-needed ultrasound scanning. From 2011 onward, given the widespread problems reported with MoMs, the hospital recalled all Pinnacle MoM patients for examination.

A total of 489 MoM Pinnacle hips had been implanted into 243 women and 191 men. Of these, 352 patients attended the MoM recall clinics and 64 died during the study period (mean

followup, about 7.5 years). For the purposes of survival analyses, those who did not attend the recall clinics were assumed to have well-functioning prostheses.

A total of 71 hips were revised -- an "unacceptably high" rate, according to the authors. All but one were carried out for ARMD, with one revision for a loose cup. Prosthetic survival rate for the cohort as a whole was 83.6% at nine years.

In 53 revisions (75%), "copious amounts" of fluid were found, and in 32 (45%), it was noted to be under pressure or had fistulated through the capsule. No abnormal fluid was identified at revision in only one case.

The researchers noted obvious damage to the abductor musculature in 38 cases. They documented a moderate-to-severe aseptic lymphocyte-dominated vasculitis-associated lesion on examination of retrieved tissues in 36 cases (51%). In 13 cases (19%), they found metallosis with no identified lymphocytic infiltration.

The majority of explanted devices showed signs of taper junction failure. A significant number of devices were found to be manufactured out of their specifications -- a finding that was confirmed by an analysis of a wider data set from the Northern Retrieval Registry.

Risk factors for revision were bilateral MoM prostheses, smaller Pinnacle liners, and implantation in 2006 or later. Women were found to be at greater risk of early device failure. However, shell sizes and bearing diameters confounded the analyses, and liner size and/or earlier year of liner manufacture were determined to be greater threats to prosthetic survival than gender. The authors suggest that this analysis be repeated with input from an additional registry.

Dr. Langton, who is involved in litigation related to the Pinnacle device, told Reuters Health by email, "We have essentially shown that one of the major health care/orthopedic product manufacturers sold a product to surgeons and health care systems on the basis (that it was a) technologically advanced precision-engineered device, and it wasn't precision-engineered."

He added, "the product was produced in the same factories as (DePuy's) other failed product, the ASR, which was . . . marketed on the same premise."

Mindy Tinsley, senior director, Communications and Public Affairs at DePuy Synthes Franchise, refuted the study findings. "We stand behind the strong record of safety and effectiveness of the (Pinnacle) ULTAMET Metal-on-Metal," she told Reuters Health by email.

She added that "there are no manufacturing problems" with the device and noted that DePuy "questions the validity of the . . . paper given significant flaws in how it was conducted." According to Tinsley, "measurements taken following an accepted international standard at the DePuy UK manufacturing facility" showed the device liners "were manufactured within specification."

Dr. Mark W. Hungerford, director of Joint Replacement and Reconstruction at Mercy Medical Center in Baltimore, told Reuters Health by phone, "One study does not make or break anything in science. There have been issues in the field about MoM and early failure rates or not. That's a serious issue being looked at by a lot of people. This is one more study showing a problem, but it's not a definitive one."

With respect to patients, "the obligation is no different than for any orthopedic device," said Dr. Hungerford, who has not used the Pinnacle device. "All can fail, all need to be monitored for failure on a regular basis, and if problems arise, they need to be dealt with."

The authors reported no funding. Dr. Langton, Dr. Nargol, and coauthors Dr. Thomas Joyce and Dr. Nick Cooke are retained experts for plaintiffs in ongoing MoM litigation. Dr. Langton and Dr. Nargol have worked with the U.S. Department of Justice in litigation involving DePuy.

NEW YORK (Reuters Health) - Certain metal-on-metal (MoM) hip replacement devices implanted after 2006 have an "unacceptably high" revision rate, due mainly to manufacturing problems, according to a new study.

"Although the use of MoM hip devices has declined dramatically in the past five years, hundreds of thousands remain in situ, with the long-term future uncertain," Dr. David Langton, of University Hospital of North Tees in Stockton, UK, and colleagues wrote in an article online April 29 in BMJ Open.

To determine risk factors for revision in patients implanted with the commonly used DePuy Pinnacle MoM hip prostheses, the researchers identified all patients at the Stockton-based hospital who were implanted with a 36 mm MoM Pinnacle hip in conjunction with an S-ROM or Corail uncemented stem. They then identified only patients with components that had been implanted by either of the two senior authors of the study, Dr. Raj Logishetty or Dr. Antoni Viral Francis Nargol.

Implantations were performed from 2003-2009 and patients were monitored yearly. From 2007-2011, as awareness of the risk of adverse reactions to metal debris (ARMD) from MoMs increased, the hospital offered patients who developed symptoms blood metal ion testing and as-needed ultrasound scanning. From 2011 onward, given the widespread problems reported with MoMs, the hospital recalled all Pinnacle MoM patients for examination.

A total of 489 MoM Pinnacle hips had been implanted into 243 women and 191 men. Of these, 352 patients attended the MoM recall clinics and 64 died during the study period (mean

followup, about 7.5 years). For the purposes of survival analyses, those who did not attend the recall clinics were assumed to have well-functioning prostheses.

A total of 71 hips were revised -- an "unacceptably high" rate, according to the authors. All but one were carried out for ARMD, with one revision for a loose cup. Prosthetic survival rate for the cohort as a whole was 83.6% at nine years.

In 53 revisions (75%), "copious amounts" of fluid were found, and in 32 (45%), it was noted to be under pressure or had fistulated through the capsule. No abnormal fluid was identified at revision in only one case.

The researchers noted obvious damage to the abductor musculature in 38 cases. They documented a moderate-to-severe aseptic lymphocyte-dominated vasculitis-associated lesion on examination of retrieved tissues in 36 cases (51%). In 13 cases (19%), they found metallosis with no identified lymphocytic infiltration.

The majority of explanted devices showed signs of taper junction failure. A significant number of devices were found to be manufactured out of their specifications -- a finding that was confirmed by an analysis of a wider data set from the Northern Retrieval Registry.

Risk factors for revision were bilateral MoM prostheses, smaller Pinnacle liners, and implantation in 2006 or later. Women were found to be at greater risk of early device failure. However, shell sizes and bearing diameters confounded the analyses, and liner size and/or earlier year of liner manufacture were determined to be greater threats to prosthetic survival than gender. The authors suggest that this analysis be repeated with input from an additional registry.

Dr. Langton, who is involved in litigation related to the Pinnacle device, told Reuters Health by email, "We have essentially shown that one of the major health care/orthopedic product manufacturers sold a product to surgeons and health care systems on the basis (that it was a) technologically advanced precision-engineered device, and it wasn't precision-engineered."

He added, "the product was produced in the same factories as (DePuy's) other failed product, the ASR, which was . . . marketed on the same premise."

Mindy Tinsley, senior director, Communications and Public Affairs at DePuy Synthes Franchise, refuted the study findings. "We stand behind the strong record of safety and effectiveness of the (Pinnacle) ULTAMET Metal-on-Metal," she told Reuters Health by email.

She added that "there are no manufacturing problems" with the device and noted that DePuy "questions the validity of the . . . paper given significant flaws in how it was conducted." According to Tinsley, "measurements taken following an accepted international standard at the DePuy UK manufacturing facility" showed the device liners "were manufactured within specification."

Dr. Mark W. Hungerford, director of Joint Replacement and Reconstruction at Mercy Medical Center in Baltimore, told Reuters Health by phone, "One study does not make or break anything in science. There have been issues in the field about MoM and early failure rates or not. That's a serious issue being looked at by a lot of people. This is one more study showing a problem, but it's not a definitive one."

With respect to patients, "the obligation is no different than for any orthopedic device," said Dr. Hungerford, who has not used the Pinnacle device. "All can fail, all need to be monitored for failure on a regular basis, and if problems arise, they need to be dealt with."

The authors reported no funding. Dr. Langton, Dr. Nargol, and coauthors Dr. Thomas Joyce and Dr. Nick Cooke are retained experts for plaintiffs in ongoing MoM litigation. Dr. Langton and Dr. Nargol have worked with the U.S. Department of Justice in litigation involving DePuy.

The Centers for Medicare and Medicaid Services has been letting patients grade their hospital experiences, and those "patient experience scores" may give some insight into a hospital's health outcomes, a new study suggests.

Some people have been concerned that patient experience isn't the most important factor to measure, said coauthor Dr. Ashish K. Jha, of the Harvard T. H. Chan School of Public Health in Boston.

"Medicare has been putting a lot of data out for a long time, but the broad consensus has been it's very hard for consumers to use this info," Jha told Reuters Health by phone. "CMS responded by giving out star ratings that consumers can understand easily."

The five-star rating system is based on patients' answers to 27 questions about a recent hospital stay. Questions cover communication with nurses and doctors, the responsiveness of hospital staff, the hospital's cleanliness and quietness, pain management, communication about medicines, discharge

information, and would they recommend the hospital.

The survey is administered to a random sample of adult patients between 48 hours and six weeks after hospital discharge. Consumers can compare their local hospitals online.

For the new study, the researchers compared the CMS patient-experience ratings at more than 3,000 hospitals in October 2015 to data from those hospitals on death or readmission within 30 days of discharge.

Patients in the study had been hospitalized for myocardial infarction, pneumonia or heart failure.

Of the 3,000 hospitals, 125 had five stars, more than 2,000 had three or four stars, 623 had two stars, and 76 had only one star.

Four and five-star hospitals tended to be small rural nonteaching hospitals in the Midwest.

Five-star hospitals had the lowest average patient death rate, 9.8 percent over the 30 days following discharge, while four three and two-star hospitals all had just over 10 percent mortality rates and one-star hospitals had an average 11.2 percent mortality rate, as reported in a research letter online April 10 in JAMA Internal Medicine.

Five-star hospitals also readmitted less than 20 percent of patients over the next month, while other hospitals all readmitted at least that many.

The data only included Medicare patients, who are older andmay not have the same results as younger patients, and there was not much difference between two, three and four-star hospitals, the authors note.

"If you use the star rating you're more likely to end up at a high quality hospital," Jha said. "But I wouldn't use only the star rating to choose a hospital."

"I don't think these data are enough to by themselves to suggest that (patients) should use the star rating as a single guide to choose an institution," agreed Dr. Joshua J. Fenton of the University of California, Davis, who was not part of the new study.

No large hospitals had five stars, and more than half of the five-star facilities didn't have an intensive care unit, Fenton told Reuters Health by phone.

"I can say from practicing in a rural hospital for a few years and we did not have an ICU, when we hospitalized someone with pneumonia or congestive heart failure, we would certainly not have kept them there if we thought it was likely there would be a complication," he said.

Smaller rural hospitals "select" less acute patients, he said. The authors of the new study tried to account for that, but it may still have affected the results.

The Centers for Medicare and Medicaid Services has been letting patients grade their hospital experiences, and those "patient experience scores" may give some insight into a hospital's health outcomes, a new study suggests.

Some people have been concerned that patient experience isn't the most important factor to measure, said coauthor Dr. Ashish K. Jha, of the Harvard T. H. Chan School of Public Health in Boston.

"Medicare has been putting a lot of data out for a long time, but the broad consensus has been it's very hard for consumers to use this info," Jha told Reuters Health by phone. "CMS responded by giving out star ratings that consumers can understand easily."

The five-star rating system is based on patients' answers to 27 questions about a recent hospital stay. Questions cover communication with nurses and doctors, the responsiveness of hospital staff, the hospital's cleanliness and quietness, pain management, communication about medicines, discharge

information, and would they recommend the hospital.

The survey is administered to a random sample of adult patients between 48 hours and six weeks after hospital discharge. Consumers can compare their local hospitals online.

For the new study, the researchers compared the CMS patient-experience ratings at more than 3,000 hospitals in October 2015 to data from those hospitals on death or readmission within 30 days of discharge.

Patients in the study had been hospitalized for myocardial infarction, pneumonia or heart failure.

Of the 3,000 hospitals, 125 had five stars, more than 2,000 had three or four stars, 623 had two stars, and 76 had only one star.

Four and five-star hospitals tended to be small rural nonteaching hospitals in the Midwest.

Five-star hospitals had the lowest average patient death rate, 9.8 percent over the 30 days following discharge, while four three and two-star hospitals all had just over 10 percent mortality rates and one-star hospitals had an average 11.2 percent mortality rate, as reported in a research letter online April 10 in JAMA Internal Medicine.

Five-star hospitals also readmitted less than 20 percent of patients over the next month, while other hospitals all readmitted at least that many.

The data only included Medicare patients, who are older andmay not have the same results as younger patients, and there was not much difference between two, three and four-star hospitals, the authors note.

"If you use the star rating you're more likely to end up at a high quality hospital," Jha said. "But I wouldn't use only the star rating to choose a hospital."

"I don't think these data are enough to by themselves to suggest that (patients) should use the star rating as a single guide to choose an institution," agreed Dr. Joshua J. Fenton of the University of California, Davis, who was not part of the new study.

No large hospitals had five stars, and more than half of the five-star facilities didn't have an intensive care unit, Fenton told Reuters Health by phone.

"I can say from practicing in a rural hospital for a few years and we did not have an ICU, when we hospitalized someone with pneumonia or congestive heart failure, we would certainly not have kept them there if we thought it was likely there would be a complication," he said.

Smaller rural hospitals "select" less acute patients, he said. The authors of the new study tried to account for that, but it may still have affected the results.

The Centers for Medicare and Medicaid Services has been letting patients grade their hospital experiences, and those "patient experience scores" may give some insight into a hospital's health outcomes, a new study suggests.

Some people have been concerned that patient experience isn't the most important factor to measure, said coauthor Dr. Ashish K. Jha, of the Harvard T. H. Chan School of Public Health in Boston.

"Medicare has been putting a lot of data out for a long time, but the broad consensus has been it's very hard for consumers to use this info," Jha told Reuters Health by phone. "CMS responded by giving out star ratings that consumers can understand easily."

The five-star rating system is based on patients' answers to 27 questions about a recent hospital stay. Questions cover communication with nurses and doctors, the responsiveness of hospital staff, the hospital's cleanliness and quietness, pain management, communication about medicines, discharge

information, and would they recommend the hospital.

The survey is administered to a random sample of adult patients between 48 hours and six weeks after hospital discharge. Consumers can compare their local hospitals online.

For the new study, the researchers compared the CMS patient-experience ratings at more than 3,000 hospitals in October 2015 to data from those hospitals on death or readmission within 30 days of discharge.

Patients in the study had been hospitalized for myocardial infarction, pneumonia or heart failure.

Of the 3,000 hospitals, 125 had five stars, more than 2,000 had three or four stars, 623 had two stars, and 76 had only one star.

Four and five-star hospitals tended to be small rural nonteaching hospitals in the Midwest.

Five-star hospitals had the lowest average patient death rate, 9.8 percent over the 30 days following discharge, while four three and two-star hospitals all had just over 10 percent mortality rates and one-star hospitals had an average 11.2 percent mortality rate, as reported in a research letter online April 10 in JAMA Internal Medicine.

Five-star hospitals also readmitted less than 20 percent of patients over the next month, while other hospitals all readmitted at least that many.

The data only included Medicare patients, who are older andmay not have the same results as younger patients, and there was not much difference between two, three and four-star hospitals, the authors note.

"If you use the star rating you're more likely to end up at a high quality hospital," Jha said. "But I wouldn't use only the star rating to choose a hospital."

"I don't think these data are enough to by themselves to suggest that (patients) should use the star rating as a single guide to choose an institution," agreed Dr. Joshua J. Fenton of the University of California, Davis, who was not part of the new study.

No large hospitals had five stars, and more than half of the five-star facilities didn't have an intensive care unit, Fenton told Reuters Health by phone.

"I can say from practicing in a rural hospital for a few years and we did not have an ICU, when we hospitalized someone with pneumonia or congestive heart failure, we would certainly not have kept them there if we thought it was likely there would be a complication," he said.

Smaller rural hospitals "select" less acute patients, he said. The authors of the new study tried to account for that, but it may still have affected the results.

(Reuters Health) - Patients assigned a "nonurgent" status on arrival in the emergency room might still be sick enough to be hospitalized, a new study shows.

Patients deemed by triage nurses to be "nonurgent" often receive diagnostic services and procedures, and some are even admitted to critical care units, researchers found.

Triage was never intended to completely rule out severe illness, only to give patients an estimate of how long they may have to wait to see a doctor, the researchers note.

Dr. Renee Y. Hsia of the University of California, San Francisco and colleagues used a national survey of patient visits to the emergency department (E.D.) between 2009 and 2011, with triage scores assigned by a nurse when the patient arrived. The scores range from one to five, with one through three including immediate, emergency and urgent patients, and four and five being semi-urgent and nonurgent.

They used data on almost 60,000 observations of patients age 18 to 64 collected between 2009 and 2011, which represented 240 million E.D. visits. More than 90 percent had a score of one to

four and were deemed "urgent" visits, while about eight percent had a score of five and were "nonurgent."

Almost half of nonurgent visits involved diagnostic scans, imaging or blood tests, and a third involved procedures like splinting or giving intravenous fluids. For urgent visits, about three-quarters involved diagnostics and half involved procedures.

About four of every 100 non-urgent visits resulted in hospital admission, as reported in JAMA Internal Medicine.

Backache, acute upper respiratory infections, soft-tissue inflammation, and acute sore throat were among the 10 most common diagnoses for both urgent and non-urgent patients.

"Triage is normally done at the very beginning of the visit, usually by a triage nurse," Hsia told Reuters Health by email. "Triaging patients is an extremely difficult task, since patients are what we (as providers) call 'undifferentiated,' since there has not been time to do a full history and physical, and nurses have limited information upon which to base their determination."

"We should not expect triage categorization to be perfect, and one of the goals of this paper is to show that, indeed, triage is not," Hsia said.

Many states have policies that patients with Medicaid insurance who present to the E.D. for "non-urgent" visits will be charged a co-payment, which may keep people from seeking

needed care, even though the triage system is not perfect, she said.

"It is important that we do not blame the patient for going to the E.D. if there were no alternatives that were available in a timely manner," Hsia said.

"Our study cannot distinguish the reasons behind why we found such a high proportion of visits that received diagnostic services or procedures," she said.

Some of the procedures may not have needed to happen in an E.D. setting, but since the patients presented there, they were treated, Hsia added.

(Reuters Health) - Patients assigned a "nonurgent" status on arrival in the emergency room might still be sick enough to be hospitalized, a new study shows.

Patients deemed by triage nurses to be "nonurgent" often receive diagnostic services and procedures, and some are even admitted to critical care units, researchers found.

Triage was never intended to completely rule out severe illness, only to give patients an estimate of how long they may have to wait to see a doctor, the researchers note.

Dr. Renee Y. Hsia of the University of California, San Francisco and colleagues used a national survey of patient visits to the emergency department (E.D.) between 2009 and 2011, with triage scores assigned by a nurse when the patient arrived. The scores range from one to five, with one through three including immediate, emergency and urgent patients, and four and five being semi-urgent and nonurgent.

They used data on almost 60,000 observations of patients age 18 to 64 collected between 2009 and 2011, which represented 240 million E.D. visits. More than 90 percent had a score of one to

four and were deemed "urgent" visits, while about eight percent had a score of five and were "nonurgent."

Almost half of nonurgent visits involved diagnostic scans, imaging or blood tests, and a third involved procedures like splinting or giving intravenous fluids. For urgent visits, about three-quarters involved diagnostics and half involved procedures.

About four of every 100 non-urgent visits resulted in hospital admission, as reported in JAMA Internal Medicine.

Backache, acute upper respiratory infections, soft-tissue inflammation, and acute sore throat were among the 10 most common diagnoses for both urgent and non-urgent patients.

"Triage is normally done at the very beginning of the visit, usually by a triage nurse," Hsia told Reuters Health by email. "Triaging patients is an extremely difficult task, since patients are what we (as providers) call 'undifferentiated,' since there has not been time to do a full history and physical, and nurses have limited information upon which to base their determination."

"We should not expect triage categorization to be perfect, and one of the goals of this paper is to show that, indeed, triage is not," Hsia said.

Many states have policies that patients with Medicaid insurance who present to the E.D. for "non-urgent" visits will be charged a co-payment, which may keep people from seeking

needed care, even though the triage system is not perfect, she said.

"It is important that we do not blame the patient for going to the E.D. if there were no alternatives that were available in a timely manner," Hsia said.

"Our study cannot distinguish the reasons behind why we found such a high proportion of visits that received diagnostic services or procedures," she said.

Some of the procedures may not have needed to happen in an E.D. setting, but since the patients presented there, they were treated, Hsia added.

(Reuters Health) - Patients assigned a "nonurgent" status on arrival in the emergency room might still be sick enough to be hospitalized, a new study shows.

Patients deemed by triage nurses to be "nonurgent" often receive diagnostic services and procedures, and some are even admitted to critical care units, researchers found.

Triage was never intended to completely rule out severe illness, only to give patients an estimate of how long they may have to wait to see a doctor, the researchers note.

Dr. Renee Y. Hsia of the University of California, San Francisco and colleagues used a national survey of patient visits to the emergency department (E.D.) between 2009 and 2011, with triage scores assigned by a nurse when the patient arrived. The scores range from one to five, with one through three including immediate, emergency and urgent patients, and four and five being semi-urgent and nonurgent.

They used data on almost 60,000 observations of patients age 18 to 64 collected between 2009 and 2011, which represented 240 million E.D. visits. More than 90 percent had a score of one to

four and were deemed "urgent" visits, while about eight percent had a score of five and were "nonurgent."

Almost half of nonurgent visits involved diagnostic scans, imaging or blood tests, and a third involved procedures like splinting or giving intravenous fluids. For urgent visits, about three-quarters involved diagnostics and half involved procedures.

About four of every 100 non-urgent visits resulted in hospital admission, as reported in JAMA Internal Medicine.

Backache, acute upper respiratory infections, soft-tissue inflammation, and acute sore throat were among the 10 most common diagnoses for both urgent and non-urgent patients.

"Triage is normally done at the very beginning of the visit, usually by a triage nurse," Hsia told Reuters Health by email. "Triaging patients is an extremely difficult task, since patients are what we (as providers) call 'undifferentiated,' since there has not been time to do a full history and physical, and nurses have limited information upon which to base their determination."

"We should not expect triage categorization to be perfect, and one of the goals of this paper is to show that, indeed, triage is not," Hsia said.

Many states have policies that patients with Medicaid insurance who present to the E.D. for "non-urgent" visits will be charged a co-payment, which may keep people from seeking

needed care, even though the triage system is not perfect, she said.

"It is important that we do not blame the patient for going to the E.D. if there were no alternatives that were available in a timely manner," Hsia said.

"Our study cannot distinguish the reasons behind why we found such a high proportion of visits that received diagnostic services or procedures," she said.

Some of the procedures may not have needed to happen in an E.D. setting, but since the patients presented there, they were treated, Hsia added.

NEW YORK (Reuters Health) - Among medically treated patients with acute coronary syndrome (ACS), prior clopidogrel therapy appears to be associated with more cardiovascular events, researchers have found.

As Dr. Chee Tang Chin told Reuters Health by email, "We found that among patients who were admitted for an acute coronary syndrome and did not undergo coronary revascularization, those patients who were already taking clopidogrel were at a higher risk for a subsequent

cardiovascular event, as compared to patients not taking clopidogrel on admission."

The study, a prespecified subanalysis of the TRILOGY ACS trial, was published online March 30 in Heart.

Of almost 9,000 patients, 73% first received clopidogrel in-hospital within 72 hours of presentation and daily until randomization to clopidogrel versus prasugrel (plus aspirin). The remaining 27% were taking clopidogrel prior to admission and continued daily clopidogrel therapy until the date of randomization.

Over 30 months, those with prior clopidogrel use had a significantly higher frequency of cardiovascular death, MI and stroke (20.8% vs. 18.3%, p=0.002). There was no significant  difference in the frequency of bleeding events.

Dr. Chin pointed out that in the prior users, "This excess risk was largely accounted for by the higher burden of high-risk co-morbidities among this group, such as diabetes and prior

cardiovascular disease. However, consistent with the overall TRILOGY-ACS results, the use of a more potent antiplatelet agent such as prasugrel did not modify this risk."

"These results," Dr. Chin concluded, "are important as they imply that among ACS patients treated only medically, strategies beyond platelet inhibition need to be considered for further optimizing outcomes."

NEW YORK (Reuters Health) - Among medically treated patients with acute coronary syndrome (ACS), prior clopidogrel therapy appears to be associated with more cardiovascular events, researchers have found.

As Dr. Chee Tang Chin told Reuters Health by email, "We found that among patients who were admitted for an acute coronary syndrome and did not undergo coronary revascularization, those patients who were already taking clopidogrel were at a higher risk for a subsequent

cardiovascular event, as compared to patients not taking clopidogrel on admission."

The study, a prespecified subanalysis of the TRILOGY ACS trial, was published online March 30 in Heart.

Of almost 9,000 patients, 73% first received clopidogrel in-hospital within 72 hours of presentation and daily until randomization to clopidogrel versus prasugrel (plus aspirin). The remaining 27% were taking clopidogrel prior to admission and continued daily clopidogrel therapy until the date of randomization.

Over 30 months, those with prior clopidogrel use had a significantly higher frequency of cardiovascular death, MI and stroke (20.8% vs. 18.3%, p=0.002). There was no significant  difference in the frequency of bleeding events.

Dr. Chin pointed out that in the prior users, "This excess risk was largely accounted for by the higher burden of high-risk co-morbidities among this group, such as diabetes and prior

cardiovascular disease. However, consistent with the overall TRILOGY-ACS results, the use of a more potent antiplatelet agent such as prasugrel did not modify this risk."

"These results," Dr. Chin concluded, "are important as they imply that among ACS patients treated only medically, strategies beyond platelet inhibition need to be considered for further optimizing outcomes."

NEW YORK (Reuters Health) - Among medically treated patients with acute coronary syndrome (ACS), prior clopidogrel therapy appears to be associated with more cardiovascular events, researchers have found.

As Dr. Chee Tang Chin told Reuters Health by email, "We found that among patients who were admitted for an acute coronary syndrome and did not undergo coronary revascularization, those patients who were already taking clopidogrel were at a higher risk for a subsequent

cardiovascular event, as compared to patients not taking clopidogrel on admission."

The study, a prespecified subanalysis of the TRILOGY ACS trial, was published online March 30 in Heart.

Of almost 9,000 patients, 73% first received clopidogrel in-hospital within 72 hours of presentation and daily until randomization to clopidogrel versus prasugrel (plus aspirin). The remaining 27% were taking clopidogrel prior to admission and continued daily clopidogrel therapy until the date of randomization.

Over 30 months, those with prior clopidogrel use had a significantly higher frequency of cardiovascular death, MI and stroke (20.8% vs. 18.3%, p=0.002). There was no significant  difference in the frequency of bleeding events.

Dr. Chin pointed out that in the prior users, "This excess risk was largely accounted for by the higher burden of high-risk co-morbidities among this group, such as diabetes and prior

cardiovascular disease. However, consistent with the overall TRILOGY-ACS results, the use of a more potent antiplatelet agent such as prasugrel did not modify this risk."

"These results," Dr. Chin concluded, "are important as they imply that among ACS patients treated only medically, strategies beyond platelet inhibition need to be considered for further optimizing outcomes."