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Few Outpatients With Flu Prescribed Antivirals

Among patients with PCR-confirmed influenza, more receive antibiotic prescriptions

WEDNESDAY, July 23, 2014 (HealthDay News) -- Few outpatients with influenza are prescribed antivirals, while antibiotic prescribing is more frequent, according to a study published online July 16 in Clinical Infectious Diseases.

Fiona Havers, M.D., M.H.S., from the U.S. Centers for Disease Control and Prevention in Atlanta, and colleagues describe antiviral receipt among outpatients with acute respiratory illness and antibiotic receipt among patients with influenza. Data were obtained from five sites in the U.S. Influenza Vaccine Effectiveness Network Study for the 2012 to 2013 influenza season. Medical and pharmacy records were used to obtain medical history and prescription information.

The researchers found that 7.5 percent of the 6,766 patients with acute respiratory illness received an antiviral prescription. Overall, 35 percent of these patients had polymerase chain reaction-confirmed influenza; 15 percent received an antiviral prescription. Nineteen percent of the 1,021 acute respiratory infection patients at high risk for influenza complications were prescribed an antiviral medication. Of the participants with antibiotic data, 30 percent of those with PCR-confirmed influenza were prescribed one of three antibiotics and 16 percent were prescribed antiviral medications.

"Antiviral treatment was prescribed infrequently among outpatients with influenza for whom therapy would be most beneficial; in contrast, antibiotic prescribing was more frequent," the authors write. "Continued efforts to educate clinicians on appropriate antibiotic and antiviral use are essential to improve health care quality."

Several authors disclosed financial ties to the pharmaceutical industry.

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Documentation Tip of the Week: Avoid Medicare Audits


Avoid Medicare auditstips

Protect yourself and your hospital from a Medicare audit by documenting carefully and effectively. Auditors look to confirm the presence of “medical necessity.” Use strong action words like:

• Acute
• Exacerbation
• Acute or chronic
• Worsening

Remember to support your assessment and plan with a physical exam that demonstrates the findings consistent with your chosen diagnosis.


Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.


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6 Best Tips to Boost Your Documentation Process: Tip 5

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6 Best Tips to Boost Your Documentation Process: Tip 1


CDC: Many Children With Medicaid Using ER As Doctor's Office

Lead author expects the Affordable Care Act to ease the situation

THURSDAY, July 24, 2014 (HealthDay News) -- Children covered by Medicaid visit the emergency room for medical care far more often than uninsured or privately insured youngsters, and children with Medicaid are more likely than those with private insurance to visit for a reason other than a serious medical problem, according to a 2012 survey conducted by the U.S. Centers for Disease Control and Prevention.

In 2012, regardless of insurance, three-quarters of children's emergency department visits occurred at night or on weekends when doctors' offices were closed, according to a July data brief published by the National Center for Health Statistics (NCHS). About one-quarter of children with Medicaid went to an emergency room at least once that year, more than uninsured children (16 percent) or children with private insurance (13 percent). These differences held whether the patients went just once or two times or more.

True emergencies led similar proportions of Medicaid and uninsured patients to visit the emergency department -- 61 and 59 percent, respectively. A greater number of children with private insurance -- more than two-thirds -- had a serious condition steer them to the emergency room. In all, only about 10 percent of children at the emergency department for serious conditions were taken by ambulance.

Renee Gindi, Ph.D., a survey statistician at the CDC's NCHS and lead author of the report, told HealthDay that she expects the Affordable Care Act will ease the situation. "These changes in children's health insurance coverage will lead to more preventive care, having a usual source of care -- a medical home -- and that would alleviate this emergency room use," Gindi said. Because the report is based on data from 2012, the full effect of the Affordable Care Act isn't reflected, she added.

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Secukinumab Effective in Moderate-to-Severe Psoriasis

Data from two randomized trials demonstrate efficacy of secukinumab versus placebo

THURSDAY, July 10, 2014 (HealthDay News) -- For patients with moderate-to-severe plaque psoriasis, the fully human anti-interleukin-17A monoclonal antibody, secukinumab, is effective, according to research published online July 9 in the New England Journal of Medicine.

Richard G. Langley, M.D., from Dalhousie University in Halifax, Canada, and colleagues assessed secukinumab in two phase 3 trials involving patients with moderate-to-severe plaque psoriasis. The Efficacy of Response and Safety of Two Fixed Secukinumab Regimens in Psoriasis (ERASURE) trial involved 738 patients and the Full Year Investigative Examination of Secukinumab versus Etanercept Using Two Dosing Regimens to Determine Efficacy in Psoriasis (FIXTURE) study involved 1,306 patients. Patients were randomized to 300 mg or 150 mg subcutaneous secukinumab or placebo, or to etanercept in the FIXTURE study.

The researchers found that in both studies the proportion of patients who had a reduction of 75 percent or more from baseline in the psoriasis area-and-severity index score was higher with each secukinumab dose versus placebo or etanercept. The rates were 81.6 and 71.6 percent, respectively, with 300 and 150 mg of secukinumab, compared to 4.5 percent with placebo in the ERASURE study. In the FIXTURE study, the rates were 77.1 and 67.0 percent, respectively, with 300 and 150 mg of secukinumab, compared to 44.0 percent with etanercept and 4.9 percent with placebo (P < 0.001 for secukinumab doses versus comparators).

"Secukinumab was effective for psoriasis in two randomized trials, validating interleukin-17A as a therapeutic target," the authors write.

The study was funded by Novartis, the manufacturer of secukinumab.

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In Case You Missed It: Week of July 25, 2014


“In Case You Missed It” is a weekly roundup of popularicymi healthcare headlines.

Ace your meetings with these tips! Some administrators feel their entire day is filled with nothing but meetings ... click here to continue reading.

Has Patient Satisfaction Gone Too Far? — The Case for Jerks in Healthcare. "Among healthcare leaders, there has been a call to arms of sorts, which has swelled over the last five or so years, to rid medicine of, well, jerks. >> continue reading on

Discovered by Dr. Howie Mell! "The availability of concentrated caffeine powders may mean that we will be seeing more cases of significant overdose. Here are some key take-home points from the discussion - See more here:

Discovered by Dr. Michael Lozano! Physician Leadership Development Hinges on Communication. Read the entire post on

Discovered by Dr. Michael Lozano! How to End Disruptive Behavior that Compromises Patient Safety. "When faced with disruptive behavior, managers at hospitals and other healthcare facilities often will brush it under the rug. They're reluctant to ..." continue at >>

VIDEO! Dr. Al Sacchetti, along with two surprise guests, tell you what to expect when he hosts Day 3:Session 1 of  Essentials of EM 2014 in November.

For more information about EEM 2014, visit their website


Join a facility that has been chosen as one of the 100 TOP HOSPITALS in the United States three years in a row with a new rate increase just announced! We're looking for an ED physician at McAllen Medical CenterLearn more and submit your CV here!


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Meeting Planner: Schedule or ambush? Formal or Casual? Ideas for Becoming a Meeting Master


EmCare Director of Clinical Services

clinician hallway meeting Some administrators feel their entire day is filled with nothing but meetings. Physicians can feel this frustration as well and tend do not want to set established meeting times with administrators because of it. If you’re among those frustrated by “over-meeting,” you might want to consider encounters such as phone calls, hallway visits and pre-and post- meeting tags on meetings – these can be less formal and less intense than traditional meetings.

Advantages of “hallway” meetings:

  • Quick, easy and informal – they can set people at ease without anticipation of a “difficult” meeting
  • Allows for more conversations in a given day, since you can conceivably reach many more people and topics in a day. It’s “guerilla warfare,” much like an E.D. environment!
Disadvantages of “hallway” meetings:
  • Administrators might not be prepared for these encounters
  • They can be distractions to what the administrator was previously doing
  • The administrator might be distracted thinking about other projects
  • There is generally more power and meaning in an established, set, scheduled meeting with the administrator.

Advantages of an established meeting with preset agenda:

  • The administrator’s calendar has your name and topic on it, allowing for all involved to be prepared for the discussion clinical meeting
  • You are probably more likely to have the administrator’s full, undivided attention 
  • The administrator will likely be more prepared 
  • You are sending a message that you value the administrator’s time – this can be very important! 
  • You are entering into their comfort zone which may allow them to make better decisions 
  • There is probably more organization to the meeting (especially with a preset agenda). This can better demonstrate your organization skills and professionalism. 
  • It can be easier to take notes. (Watch administrators during meetings...they generally take notes, which is more difficult to do with hallway conversations or phone calls.)

Keys to success of traditional meetings:

  • First, arrive on time. Administrators usually don’t like to wait. Theygenerally also know the value of their medical staff’s time as well and will do everything in their power to show up to your meeting on time themselves.
  • The attention span of an administrator can be extremely short. Keep this in mind when determining the length of the meeting, developing the agenda and managing the agenda. 
  • Know your agenda items: prepare in advance and don’t come in five or ten minutes prior to prepare.
  • Have supporting documents and make copies for the administrator. Take notes on key questions and comments from the administrator and follow up on these items
  • Manage the meeting to end on time. If you are able to wrap up even five minutes early, you could make the administrator’s day! If you find the meeting is going to run over, wrap it up anyway with a comment like “We are running out of time and I want to value your schedule and I would like to continue this discussion prior to our next meeting. Would you like to make another appointment?” You could be met with a response such as, “No, let’s continue the conversation” or “Yes, let’s set up another time.” The administrator may not express immediate gratitude, but may have a sense of respect for your professionalism.

Once this type of meeting takes place on a regular basis, the hallway type meetings become more effective than before.

About Ken Stackhouse:

Ken StackhouseWith more than 30 years of healthcare experience, Ken Stackhouse has been a Divisional Director of Clinical Services (DDCS) for EmCare since 2007 and currently practices as an emergency department (E.D.) nurse practitioner. Prior to joining EmCare, Ken worked as Director of Patient Care and Emergency Services at Corpus Christi Medical Center in Texas and Director of Emergency Services and EMS at Baylor Regional Medical Center in Grapevine, Tex. He has also held such titles as Director of Day Surgery/Endoscopy, Trauma Coordinator, Staff Registered Nurse (R.N.) and Firefighter/Paramedic.



Survival >80 Percent After Valve-in-Valve Implantation

Finding among patients with degenerated aortic valves; worse survival for stenosis as mode of failure

FRIDAY, July 11, 2014 (HealthDay News) -- For patients with failed surgical bioprosthetic valves, one-year survival after transcatheter valve-in-valve implantation is 83.2 percent, according to a study published in the July 9 issue of the Journal of the American Medical Association.

Danny Dvir, M.D., from St. Paul's Hospital in Vancouver, Canada, and colleagues examined the survival of patients after transcatheter valve-in-valve implantation inside failed surgical bioprosthetic valves. Data were obtained from a multinational valve-in-valve registry that included 459 patients (mean age, 77.6 years) with degenerated bioprosthetic valves undergoing valve-in-valve implantation at 55 centers.

The models of bioprosthesis failure included stenosis (39.4 percent), regurgitation (30.3 percent), and combined (30.3 percent). The researchers found that 7.6 percent of patients died within one month following valve-in-valve implantation; 1.7 percent had major stroke; and 92.6 percent of surviving patients had good functional status (New York Heart Association class I/II). There was an 83.2 percent overall one-year Kaplan-Meier survival rate. One-year survival was worse for patients in the stenosis group (76.6 percent) versus the regurgitation group (91.2 percent) and the combined group (83.9 percent) (P = 0.01). One-year survival was worse for patients with small valves (74.8 percent) versus intermediate-sized valves (81.8 percent) and large valves (93.3 percent) (P = 0.001). Having small surgical bioprosthesis (≤21 mm) and baseline stenosis (versus regurgitation) were associated with mortality within one year (hazard ratios, 2.04 and 3.07, respectively).

"In this registry of patients who underwent transcatheter valve-in-valve implantation for degenerated bioprosthetic aortic valves, overall one-year survival was 83.2 percent," the authors write.

Several authors disclosed financial ties to the medical device and biotechnology industries.

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Stroke Incidence, Mortality Down From 1987 to 2011

Prospective cohort study in four U.S. communities showed decrease for blacks and whites

TUESDAY, July 15, 2014 (HealthDay News) -- From 1987 to 2011 there was a decrease in stroke incidence and mortality rates in four U.S. communities, according to a study published in the July 16 issue of the Journal of the American Medical Association.

Silvia Koton, Ph.D., from Tel Aviv University in Israel, and colleagues examined trends in stroke incidence and subsequent mortality in the Atherosclerosis Risk in Communities cohort from 1987 to 2011. The cohort study involved 14,357 participants free of stroke at baseline from four different U.S. communities.

The researchers found that 1,051 participants (7 percent) had incident stroke, including 929 with incident ischemic stroke and 140 with incident hemorrhagic stroke. Over time, stroke incidence decreased in white and black participants (age-adjusted incidence rate ratio per 10-year period, 0.76). The decrease was evident in participants aged 65 years and older (age-adjusted incidence rate ratio, 0.69), but not in those younger than 65 years (age-adjusted incidence rate ratio, 0.97). There was a similar decrease in incidence by sex. Fifty-eight percent of participants with incident stroke died through 2011. Over time there was a decrease in mortality after stroke (hazard ratio, 0.80), with the decrease mainly due to a decrease at younger than age 65 years (hazard ratio, 0.65); the decrease was similar across race and sex.

"In a multicenter cohort of black and white adults in U.S. communities, stroke incidence and mortality rates decreased from 1987 to 2011," the authors write.

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Smoking Has Negative Impact on Success of ACL Reconstruction

Negative effect on subjective and objective outcomes of anterior cruciate ligament reconstruction

THURSDAY, July 10, 2014 (HealthDay News) -- Cigarette smoking is associated with a negative impact on anterior cruciate ligament (ACL) reconstruction outcomes, according to a study published in the June 18 issue of The Journal of Bone & Joint Surgery.

Sung-Jae Kim, M.D., Ph.D., from the Yonsei University College of Medicine in South Korea, and colleagues conducted a retrospective review of 251 patients who underwent unilateral ACL reconstruction with use of bone-patellar tendon-bone autograft from January 2002 to August 2009. Preoperative values and 24-month postoperative findings were compared for nonsmokers, current smokers, and former smokers.

The researchers found that the three groups differed significantly in terms of postoperative mean side-to-side anterior knee translation (P = 0.003), mean Lysholm score (P < 0.001), and mean International Knee Documentation Committee (IKDC) subjective score (P < 0.001); there was no minimal clinically important difference seen in the difference in IKDC subjective score. Pack-years of exposure correlated with postoperative anterior translation (P = 0.015) and IKDC objective grade (odds ratio, 1.083; P = 0.002) in a dose-dependent manner. There was a significant difference for light, moderate, and heavy smokers in anterior translation (P = 0.038) and in the proportion of cases by IKDC objective grade (P = 0.013).

"Cigarette smoking appeared to have a negative effect on subjective and objective outcomes of ACL reconstruction, and heavy smokers showed greater knee instability," the authors write.

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Ecstasy Use May Lead to Posterior Spinal Artery Aneurysm

Case report describes PSA aneurysm in teen with neck stiffness, headaches after 'Ecstasy' use

MONDAY, July 7, 2014 (HealthDay News) -- Use of 3,4-methylenedioxymethamphetamine, "Ecstasy," can trigger intracranial hemorrhage, subarachnoid hemorrhage (SAH), and possibly de novo aneurysm formation and rupture, according to a case report published online July 3 in BMJ Case Reports.

Jeremiah Johnson, M.D., from the University of Miami Miller School of Medicine, and colleagues describe the case of a teenager presenting with neck stiffness, headaches, and nausea after ingesting Ecstasy.

The researchers note that a brain computed tomography (CT) was negative for SAH, but cerebral vasculitis was suggested by CT angiogram. SAH was indicated on a lumbar puncture, but a cerebral angiogram was negative. Abnormalities on the dorsal surface of the cervical spinal cord were identified on a spinal magnetic resonance angiogram, and a subsequent spinal angiogram demonstrated a left posterior spinal artery (PSA) 2 mm fusiform aneurysm. The aneurysmal portion of the PSA was excised during surgery and without postoperative neurological sequelae.

"'Ecstasy' can lead to neurovascular inflammation, intracranial hemorrhage, SAH and potentially even de novo aneurysm formation and subsequent rupture," the authors write.

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