By GINA KOLATA
Published: January 11, 2009
For years, doctors thought they had done their jobs if patients came out of an intensive care unit alive.
Now, though, researchers say they are alarmed by what they are finding as they track patients for months or years after an I.C.U. stay. Patients, even young ones, can be weak for years. Some have difficulty thinking and concentrating or have post-traumatic stress disorder and terrible memories of nightmares they had while heavily sedated.
While patients may be suffering lingering effects from illnesses that landed them in the I.C.U., researchers are increasingly convinced that spending days, weeks or months on life support in the units can elicit unexpected, long-lasting effects.
So now some I.C.U.’s are trying what seems like a radical solution: reducing sedation levels and getting patients up and walking even though they are gravely ill, complete with feeding tubes, intravenous lines and tethers to ventilators.
Even a few days in an I.C.U. can be physically devastating immediately afterward, said Dr. Naeem Ali of Ohio State University. In a recent study, he and colleagues at three other universities reported that 25 percent of patients who had spent at least five days on ventilators could not use their arms to raise themselves to sitting positions. Many could not push back against a researcher’s hand.
“We had a handful of patients who essentially looked paralyzed,” Dr. Ali said.
Researchers say the questions about how and why an I.C.U. stay can be so devastating — and new efforts to bring a marked change to the experience — are of increasing importance because, as the population ages, more people are being admitted to the units. And, with medical advances, more patients are surviving.
“We had thought these patients just heal up,” said Dr. Peter Morris of Wake Forest University Baptist Medical Center. “But now so many of these reports from different universities say they are not really O.K..”
Every I.C.U. doctor seems to have a story of a patient who illustrated the problem in an unforgettable way.
For Dr. Morris, the moment of truth came when he visited a young woman he had recently discharged from his intensive care unit. She was in a regular hospital room, lying in bed, a tray of food on the table beside her, the food still covered with a plastic lid.
“I said, ‘How are you doing? Are you hungry?’ ” Dr. Morris asked. “She said, ‘I’m very hungry.’ ” But, she explained, she was too weak to lift the lid from the tray and could not feed herself. She could barely move her wrists off the bed.
“A light bulb went off,” Dr. Morris said.
For Dr. Dale Needham, who runs the critical care physical medicine and rehabilitation program at Johns Hopkins, the moments of truth are coming from a study he has begun, following patients for five years after they leave the hospital. Many had a hard time regaining their strength, and some were never the same after their I.C.U. stay.
Now, Dr. Needham said, instead of declaring success when a patient leaves an I.C.U. alive, he and others have a new set of challenges.
“We are asking ourselves, what can we do on Day 1 to get you out of the hospital and back to work sooner, without problems with weakness, mood and thinking? What can we do for you?”
Robert Ford, a high school lacrosse player in Salisbury, Md., went from healthy to desperately ill with pneumonia the night before his prom. He recovered remarkably quickly, spending just six days on a mechanical ventilator in the I.C.U.
That was in April 2007. Now, his mother, Jacalyn Ford, said her son “doesn’t have the concentration or the patience he used to have.” When she looks at him today, she said, “I see a totally different personality.”
Dr. Needham, who recently evaluated the young man, said his strength and exercise capacity were below average for his age. Given his history as an athlete, they should have been above the mean. As much as Rob wants to play lacrosse again, he does not have the strength or stamina.
It remains difficult to tease out which disabilities come from the illness as opposed to the I.C.U. stay, but scientists are beginning to worry about the effects of simply being in an intensive care unit, on a mechanical ventilator that pushes oxygen under pressure in and out of the lungs, receiving doses of sedatives, narcotics and anesthetics high enough to make even healthy people stop breathing on their own. They have been particularly surprised by how quickly patients had lost strength. Now, it looks like what was lost may not completely come back, even years later.
“We are in the infancy of trying to figure this out,” Dr. Morris said.
Most patients who spend time in an I.C.U. lose significant weight.
Some are like one of Dr. Morris’s recent patients, Michelle Rhynes, 35. Ms. Rhynes, who lives in Winston-Salem, N.C., was confined to her bed for four days with bronchial pneumonia, burning with fever. At 2 a.m. on the fifth day, she collapsed when she tried to get up.
“I asked a friend to call an ambulance,” she said. “When I got to the hospital, I couldn’t breathe.”
She spent a month in the I.C.U., breathing with the aid of a mechanical ventilator, a feeding tube in her stomach. Ms. Rhynes, who stood 5-foot-6, experienced a loss in weight to 95 pounds from 140 pounds.
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Or they are like Gary English, one of Dr. Needham’s patients. He lives in Baltimore, has chronic obstructive pulmonary disease and spent two months in Hopkins on a mechanical ventilator. When he got out, Mr. English, 57, who is 5-foot-9, said he weighed 78 pounds. A year later he weighs 110.
Dr. O. Joseph Bienvenu, a psychiatrist at Johns Hopkins, worries about post-traumatic stress disorder. While many remember nothing of their time in an I.C.U., others cannot forget horrifying hallucinations. The experiences are all the more terrifying because patients cannot talk with mechanical ventilator tubes in their throats. Their illnesses may produce delirium, but so may the drugs used in sedation, Dr. Bienvenu said.
“One man told me he saw children’s faces that were blacked out and blood running down the walls,” Dr. Bienvenu said. “He thought he’d been kidnapped and tortured. One woman said she saw her husband and a nurse talking, and she thought they were plotting to kill her.”
When Dr. John Kress, director of the medical I.C.U. at the University of Chicago, began focusing on lasting effects of an intensive care unit stay, he wondered whether the sedatives keeping patients comfortable might actually be making them worse.
So his group tried an experiment, waking patients briefly every day by turning off their infusion of sedatives.
Not everyone approved. “People were concerned about waking patients every day, that that might put patients in a state of fear and dread and anxiety,” he said.
But, he added, “we found, to the contrary, that patients actually did better” and even had a significantly lower rate of post-traumatic stress disorder, which is manifested by such things as mood disorders, anxiety, difficulty concentrating, shortness of temper and frightening memories. It is not clear why there was less post-traumatic stress but, Dr. Kress said, “My opinion is that maintaining some awareness of reality is better for your psyche.”
That led him and his colleague Dr. William Schweickert to ask: What if the patients could actually sit up in their beds or in a chair or even walk, despite their life-support lines and tubes? They would need help from nurses, and physical and occupational therapists, but would it be possible? And, if so, would it help them or set back their recovery?
Others, including Dr. Needham, Dr. Morris and Ramona O. Hopkins, a professor of psychology and neuroscience at Brigham Young University, had the same idea and found they could get patients up and walking.
Dr. Needham said, “I meet some doctors and nurses who just shake their heads.” But, he tells them, “What you think is impossible actually happens in my I.C.U.” And, he said, “Patients like it.”
Dr. Morris found in a pilot study that the patients also seem to recover faster, spending less time in intensive care and the hospital.
But some, like Dr. Ali, who favor the idea, say it is not always feasible. “We don’t always have the right staff,” he said, explaining that it takes a team of nurses and physical and mechanical ventilatory therapists to walk intensive-care patients safely. And, he added, patients who are resting and sedated need less oxygen, which may make it safer to stay in bed.
“Our biased impression is that mobilization is helpful,” Dr. Needham said. “A typical patient may not even be able to walk when they leave the I.C.U. or even the hospital. When we see them walk in the I.C.U., we believe that has to be better.”
But, Dr. Morris said, the proof may come in clinical trials that he, Dr. Needham and others plan to do. And, he added, considering how patients fare, even when they are helped to walk while they are in the I.C.U., “there’s lots of room for improvement.”
Tuesday, January 13, 2009
Monday, January 12, 2009
Peanut Butter Recalled as Salmonella Search Continues
Ohio distributor issues recall of King Nut brand after Minn. officials find bacteria in one container; almost 400 Americans in 42 states have been sickened
Sunday, January 11, 2009
SUNDAY, Jan. 11 (HealthDay News) -- An Ohio peanut butter distributor issued a voluntary recall Saturday for two brands of peanut butter after health officials in Minnesota on Friday said they had found salmonella bacteria in a tub of peanut butter that is distributed to schools and hospitals.
The recall, and the Minnesota report, could be the breakthrough in the search for the source of a salmonella outbreak that has struck in 42 states so far.
Officials from the Minnesota Department of Health and the Minnesota Department of Agriculture issued a product warning Friday after preliminary laboratory testing indicated the presence of salmonella in a container of creamy peanut butter from King Nut, according to published reports.
Late Saturday, King Nut Companies of Solon, Ohio, announced it had issued a recall of all peanut butter distributed under its label and manufactured by Peanut Corporation of America, of Lynchburg, Va. The company also recalled its distribution of Parnell's Pride peanut butter, which is also made by Peanut Corporation, according to a prepared statement by King Nut.
King Nut, in its statement, said it took the action after salmonella was found in an open five-pound tub of King Nut peanut butter.
King Nut distributes peanut butter through food service accounts and does not sell it directly to consumers, the statement said.
The statement added, "King Nut does not supply any of the ingredients for the peanut butter distributed under its label. All other King Nut products are safe and not included in this voluntary recall."
"We are very sorry this happened," said Martin Kanan, president and chief executive officer of King Nut Companies. "We are taking immediate and voluntary action because the health and safety of those who use our products is always our highest priority."
King Nut customers are asked to take all King Nut peanut butter and Parnell's Pride peanut butter out of distribution immediately.
Peanut Corporation of America issued its own statement on its Web site late Saturday, confirming "the salmonella was found in an open container of King Nut peanut butter at a nursing facility" in Minnesota.
The statement added, however, that the finding "leaves open the possibility of cross-contamination from another source. PCA is working with the U.S. Food and Drug Administration, the Centers for Disease Control and Prevention, and other agencies to determine whether the current illness outbreak could be at all related to products made in the PCA facility."
The recall and the potential link to the multi-state outbreak come two years after ConAgra recalled its Peter Pan brand peanut butter, which had been linked to at least 625 salmonella cases in 47 states.
U.S. health officials had formed a task force last week to seek the source of the latest outbreak, which began last fall and so far has sickened 399 Americans, according to the latest numbers issued Friday by the CDC.
The strain of salmonella has been identified as Salmonella Typhimurium, the most common of the more than 2,500 types of salmonella bacteria in the United States. It's often found in uncooked eggs and meats, said officials with the CDC, who have been investigating the outbreak for several weeks.
"Cases are continuing to occur, and it is an ongoing investigation," Dr. Rajal Mody, a CDC Epidemic Intelligence Service officer, said earlier Friday. "The first people began getting ill in September, but it usually takes several weeks before enough cases have been reported to start noticing a possible outbreak."
Mody said he suspects a food item, possibly produce or a prepared packaged food.
"When you look at the distribution of cases, it does suggest that it could be a mass-distributed food," he said. "This outbreak is on the larger side, but there have been larger outbreaks."
Reports of people sickened have occurred between Sept. 3 and Dec. 29, 2008, with most illnesses starting after Oct. 1. About 18 percent of those who fell ill were hospitalized. Mody said he couldn't estimate when the outbreak might end, or how many people might eventually become infected with the germ.
Salmonella is typically transmitted through foods that are contaminated with animal feces, Mody said. As part of the investigation, federal health officials are interviewing infected people to see if there were common elements in their diet, he said.
Mody said most reported cases of salmonella occur in children. In the current outbreak, victims have ranged in age from less than 1 year to 103, he said.
An estimated 40,000 cases of salmonella infection are reported each year in the United States, but those are only the reported cases, Mody said. "Those are only the cases that are severe enough to have a person go to a doctor. It's been estimated that the actual number of total salmonella cases could be 30 times or more as great," he said.
Mody said there probably have been many unreported cases in the current outbreak. "If someone has mild symptoms, they might not seek health care," he said.
Most people infected with salmonella develop diarrhea, fever, and abdominal cramps within 12 to 72 hours after contact with the germ. Infections typically clear up in five to seven days, Mody said. "They often don't require any treatment other than making sure you take enough fluids," he said.
But, severe infections can occur, particularly in infants, the elderly, and people with weakened immune systems. In severe cases, the salmonella infection can spread from the intestines to the bloodstream and other parts of the body, causing death unless antibiotics are administered, according to the CDC.
A salmonella outbreak that began last April eventually sickened almost 1,400 Americans, sending nearly 300 of them to hospitals. The outbreak of Salmonella Saintpaul was later traced to jalapeno and serrano peppers imported from Mexico.
HealthDay
Sunday, January 11, 2009
SUNDAY, Jan. 11 (HealthDay News) -- An Ohio peanut butter distributor issued a voluntary recall Saturday for two brands of peanut butter after health officials in Minnesota on Friday said they had found salmonella bacteria in a tub of peanut butter that is distributed to schools and hospitals.
The recall, and the Minnesota report, could be the breakthrough in the search for the source of a salmonella outbreak that has struck in 42 states so far.
Officials from the Minnesota Department of Health and the Minnesota Department of Agriculture issued a product warning Friday after preliminary laboratory testing indicated the presence of salmonella in a container of creamy peanut butter from King Nut, according to published reports.
Late Saturday, King Nut Companies of Solon, Ohio, announced it had issued a recall of all peanut butter distributed under its label and manufactured by Peanut Corporation of America, of Lynchburg, Va. The company also recalled its distribution of Parnell's Pride peanut butter, which is also made by Peanut Corporation, according to a prepared statement by King Nut.
King Nut, in its statement, said it took the action after salmonella was found in an open five-pound tub of King Nut peanut butter.
King Nut distributes peanut butter through food service accounts and does not sell it directly to consumers, the statement said.
The statement added, "King Nut does not supply any of the ingredients for the peanut butter distributed under its label. All other King Nut products are safe and not included in this voluntary recall."
"We are very sorry this happened," said Martin Kanan, president and chief executive officer of King Nut Companies. "We are taking immediate and voluntary action because the health and safety of those who use our products is always our highest priority."
King Nut customers are asked to take all King Nut peanut butter and Parnell's Pride peanut butter out of distribution immediately.
Peanut Corporation of America issued its own statement on its Web site late Saturday, confirming "the salmonella was found in an open container of King Nut peanut butter at a nursing facility" in Minnesota.
The statement added, however, that the finding "leaves open the possibility of cross-contamination from another source. PCA is working with the U.S. Food and Drug Administration, the Centers for Disease Control and Prevention, and other agencies to determine whether the current illness outbreak could be at all related to products made in the PCA facility."
The recall and the potential link to the multi-state outbreak come two years after ConAgra recalled its Peter Pan brand peanut butter, which had been linked to at least 625 salmonella cases in 47 states.
U.S. health officials had formed a task force last week to seek the source of the latest outbreak, which began last fall and so far has sickened 399 Americans, according to the latest numbers issued Friday by the CDC.
The strain of salmonella has been identified as Salmonella Typhimurium, the most common of the more than 2,500 types of salmonella bacteria in the United States. It's often found in uncooked eggs and meats, said officials with the CDC, who have been investigating the outbreak for several weeks.
"Cases are continuing to occur, and it is an ongoing investigation," Dr. Rajal Mody, a CDC Epidemic Intelligence Service officer, said earlier Friday. "The first people began getting ill in September, but it usually takes several weeks before enough cases have been reported to start noticing a possible outbreak."
Mody said he suspects a food item, possibly produce or a prepared packaged food.
"When you look at the distribution of cases, it does suggest that it could be a mass-distributed food," he said. "This outbreak is on the larger side, but there have been larger outbreaks."
Reports of people sickened have occurred between Sept. 3 and Dec. 29, 2008, with most illnesses starting after Oct. 1. About 18 percent of those who fell ill were hospitalized. Mody said he couldn't estimate when the outbreak might end, or how many people might eventually become infected with the germ.
Salmonella is typically transmitted through foods that are contaminated with animal feces, Mody said. As part of the investigation, federal health officials are interviewing infected people to see if there were common elements in their diet, he said.
Mody said most reported cases of salmonella occur in children. In the current outbreak, victims have ranged in age from less than 1 year to 103, he said.
An estimated 40,000 cases of salmonella infection are reported each year in the United States, but those are only the reported cases, Mody said. "Those are only the cases that are severe enough to have a person go to a doctor. It's been estimated that the actual number of total salmonella cases could be 30 times or more as great," he said.
Mody said there probably have been many unreported cases in the current outbreak. "If someone has mild symptoms, they might not seek health care," he said.
Most people infected with salmonella develop diarrhea, fever, and abdominal cramps within 12 to 72 hours after contact with the germ. Infections typically clear up in five to seven days, Mody said. "They often don't require any treatment other than making sure you take enough fluids," he said.
But, severe infections can occur, particularly in infants, the elderly, and people with weakened immune systems. In severe cases, the salmonella infection can spread from the intestines to the bloodstream and other parts of the body, causing death unless antibiotics are administered, according to the CDC.
A salmonella outbreak that began last April eventually sickened almost 1,400 Americans, sending nearly 300 of them to hospitals. The outbreak of Salmonella Saintpaul was later traced to jalapeno and serrano peppers imported from Mexico.
HealthDay
Patterns: Trying to Avoid a Cold? Go Back to Bed
By NICHOLAS BAKALAR
Published: January 12, 2009
There is no cure for the common cold, but in an experiment that deliberately infected volunteers with a virus, researchers have shown that getting less sleep can substantially increase the risk of catching one.
Sleep Habits and Susceptibility to the Common Cold (Archives of Internal Medicine)For 14 days, the researchers monitored and recorded the sleep time of 153 healthy men and women ages 21 to 55. They also scored their sleep efficiency, the percentage of time in bed spent asleep.
Then they dripped a solution containing a rhinovirus into their noses and monitored their health for five days. Almost all subjects became infected, and more than a third had cold symptoms.
The study, led by Sheldon Cohen of Carnegie Mellon University, was published Monday in The Archives of Internal Medicine.
After controlling for age, body mass index, race, smoking and other factors, researchers found that those who got less than seven hours of sleep a night were almost three times as likely to have clinical symptoms as those who got eight or more.
Those with a sleep efficiency score of 85 percent or less were more than five times as likely to be infected as those with higher efficiency.
“Even people who lost as little as 2 to 8 percent of their eight hours’ normal sleep were at four times the risk for having symptoms, “ Dr. Cohen said. “The poorer your efficiency and the less time you sleep, the more likely you are to be infected.”
Published: January 12, 2009
There is no cure for the common cold, but in an experiment that deliberately infected volunteers with a virus, researchers have shown that getting less sleep can substantially increase the risk of catching one.
Sleep Habits and Susceptibility to the Common Cold (Archives of Internal Medicine)For 14 days, the researchers monitored and recorded the sleep time of 153 healthy men and women ages 21 to 55. They also scored their sleep efficiency, the percentage of time in bed spent asleep.
Then they dripped a solution containing a rhinovirus into their noses and monitored their health for five days. Almost all subjects became infected, and more than a third had cold symptoms.
The study, led by Sheldon Cohen of Carnegie Mellon University, was published Monday in The Archives of Internal Medicine.
After controlling for age, body mass index, race, smoking and other factors, researchers found that those who got less than seven hours of sleep a night were almost three times as likely to have clinical symptoms as those who got eight or more.
Those with a sleep efficiency score of 85 percent or less were more than five times as likely to be infected as those with higher efficiency.
“Even people who lost as little as 2 to 8 percent of their eight hours’ normal sleep were at four times the risk for having symptoms, “ Dr. Cohen said. “The poorer your efficiency and the less time you sleep, the more likely you are to be infected.”
Thursday, January 8, 2009
U.S. Flu Shows Resistance to Flu Drug, CDC Says
By Maggie Fox
WASHINGTON (Reuters) Dec 19 - A common strain of influenza circulating in the United States this winter is resistant to Tamiflu, the most popular drug used to treat it, federal health officials said on Friday.
The situation poses little danger, according to the U.S. Centers for Disease Control and Prevention, because Tamiflu is only used in a minority of cases. It advised doctors to use rival drug Relenza or rimantadine, an older drug.
Forty nine out of 50 samples tested resist the drug, although they can still be treated with other flu medications, the CDC said in a special advisory to doctors.
"It is still very early in the season. There is very little influenza out there," CDC Director Dr. Julie Gerberding told reporters in a telephone briefing.
"This is probably actually not going to affect very many people because we don't use a lot of antiviral drugs in our country," Gerberding said. "Most people with influenza don't get any treatment."
In a normal flu season, three strains of flu circulate called H1N1, H3N2 and influenza B. Flu kills about 36,000 Americans in an average year.
It is the H1N1 strain that is turning up resistant samples, Gerberding said, and comes mostly from Hawaii, Massachusetts and Texas, the states with the most cases of influenza.
Last year, just under 11 percent of the H1N1 samples tested were resistant to Tamiflu. Gerberding said she did not think the virus had evolved, but that the strain that happened to pop up was also resistant to the drug.
"We can't predict whether or not these strains will end up being the most important strains in this year's flu season. This particular H1N1 could fizzle out," Gerberding said.
Tamiflu, known generically as oseltamivir and made by Roche AG and Gilead Sciences Inc., can both prevent and treat flu if taken quickly enough.
A similar drug is Relenza, or zanamivir, made by GlaxoSmithKline under license from Australia's Biota Inc.
The U.S. national stockpile of antivirals is about 80 percent Tamiflu and 20 percent zanamivir, according to the Health and Human Services Department. The CDC's Dr. Tim Uyeki said this season's development illustrated the need to keep a diversified array of drugs on hand.
"But zanamivir... is not approved for those less than 7 years old," Uyeki said. People with asthma are also advised not to use the drug, which is inhaled.
Gerberding noted that this year's flu vaccine matched the three strains circulating so far very well. The CDC says there is still time for Americans to get a flu shot, as the season usually peaks in February.
The CDC and the U.N. World Health Organization are concerned about the threat of a new and deadly strain of flu developing that would sweep the world. That is one reason to keep a stockpile of antivirals handy, CDC says, although this year's flu season appears to be mild.
(Editing by Alan Elsner and Will Dunham)
WASHINGTON (Reuters) Dec 19 - A common strain of influenza circulating in the United States this winter is resistant to Tamiflu, the most popular drug used to treat it, federal health officials said on Friday.
The situation poses little danger, according to the U.S. Centers for Disease Control and Prevention, because Tamiflu is only used in a minority of cases. It advised doctors to use rival drug Relenza or rimantadine, an older drug.
Forty nine out of 50 samples tested resist the drug, although they can still be treated with other flu medications, the CDC said in a special advisory to doctors.
"It is still very early in the season. There is very little influenza out there," CDC Director Dr. Julie Gerberding told reporters in a telephone briefing.
"This is probably actually not going to affect very many people because we don't use a lot of antiviral drugs in our country," Gerberding said. "Most people with influenza don't get any treatment."
In a normal flu season, three strains of flu circulate called H1N1, H3N2 and influenza B. Flu kills about 36,000 Americans in an average year.
It is the H1N1 strain that is turning up resistant samples, Gerberding said, and comes mostly from Hawaii, Massachusetts and Texas, the states with the most cases of influenza.
Last year, just under 11 percent of the H1N1 samples tested were resistant to Tamiflu. Gerberding said she did not think the virus had evolved, but that the strain that happened to pop up was also resistant to the drug.
"We can't predict whether or not these strains will end up being the most important strains in this year's flu season. This particular H1N1 could fizzle out," Gerberding said.
Tamiflu, known generically as oseltamivir and made by Roche AG and Gilead Sciences Inc., can both prevent and treat flu if taken quickly enough.
A similar drug is Relenza, or zanamivir, made by GlaxoSmithKline under license from Australia's Biota Inc.
The U.S. national stockpile of antivirals is about 80 percent Tamiflu and 20 percent zanamivir, according to the Health and Human Services Department. The CDC's Dr. Tim Uyeki said this season's development illustrated the need to keep a diversified array of drugs on hand.
"But zanamivir... is not approved for those less than 7 years old," Uyeki said. People with asthma are also advised not to use the drug, which is inhaled.
Gerberding noted that this year's flu vaccine matched the three strains circulating so far very well. The CDC says there is still time for Americans to get a flu shot, as the season usually peaks in February.
The CDC and the U.N. World Health Organization are concerned about the threat of a new and deadly strain of flu developing that would sweep the world. That is one reason to keep a stockpile of antivirals handy, CDC says, although this year's flu season appears to be mild.
(Editing by Alan Elsner and Will Dunham)
Early Elective C-Sections Produce Complications
Babies delivered at 37 weeks have double the troubles of those born at 39 weeks
WEDNESDAY, Jan. 7 (HealthDay News) -- Women having an elective repeat C-section should wait until they're at least 39 weeks into their pregnancy to have the baby, if there are no medical issues with the mother or baby, a new study found.
Delivering just two weeks earlier doubles the risk that the baby will have problems, such as trouble breathing, infection and low blood sugar, according to the study.
The findings buttress recommendations from the American College of Obstetricians and Gynecologists (ACOG).
"About 36 percent of women were delivered prior to 39 weeks, electively by Caesarean," said the study's lead author, Dr. Alan T.N. Tita, an assistant professor of obstetrics and gynecology and an epidemiologist at the University of Alabama at Birmingham. "These early deliveries were associated with adverse outcomes. There was a two-fold increase in morbidity in those delivered at 37 weeks compared to women delivered at 39 weeks."
Results of the study are published in the Jan. 8 issue of the New England Journal of Medicine.
Once a woman has had a Caesarean delivery, she and her doctor may decide to perform an "elective" C-section for subsequent births. The recommendation is that any such delivery should occur at 39 weeks or later if there are no medical concerns for the mother or baby. If a woman wants to deliver before 39 weeks, ACOG recommends that amniocentesis be performed to assess lung maturity in the baby.
The new study included 13,258 women who underwent elective repeat Caesarean deliveries at one of 19 U.S. academic medical centers. All of the sites are part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Maternal-Fetal Medicine Units Network.
Of the elective C-sections, 35.8 percent were performed before 39 weeks of gestation, with 6.3 percent done at 37 weeks and 29.5 percent at 38 weeks, the study found.
Babies born at 37 weeks had twice the rate of certain complications, such as needing to be placed on a mechanical ventilator, newborn sepsis (a blood infection) and low blood sugar. Babies delivered at 38 weeks had a 1.5 times higher rate of complications, according to the study.
Dr. Peter Bernstein, a maternal-fetal medicine specialist at Montefiore Medical Center and Albert Einstein College of Medicine in New York City, said he was not surprised by the increase in complications for deliveries before 39 weeks. "The bigger surprise to me was that nearly 36 percent of elective procedures were done before the 39th week," Bernstein said.
"The institutions that participate in this network are big academic centers," he said. "In the academic world, these are among the top institutions, and that more than one-third apparently aren't following ACOG guidelines is a surprise."
Both Tita and Bernstein said that early deliveries are probably due to both mothers and doctors. "There's an interplay between patient desires and physician willingness to accommodate patients," Tita said.
Bernstein said that women often prefer their own doctor for the delivery and not another doctor in the practice, which can lead to scheduled deliveries. And, he added, when you try to accommodate both the mother's and the doctor's schedule, it's easy to see how things get pushed back a week or more.
But he added a caution. "We have to not fool around with this," he said. "The baby may not be ready. This study's findings underline that the ACOG guidelines are appropriate."
Tita added, "In the absence of complications, it's probably optimal to wait until 39 weeks to undergo elective Caesarean."
WEDNESDAY, Jan. 7 (HealthDay News) -- Women having an elective repeat C-section should wait until they're at least 39 weeks into their pregnancy to have the baby, if there are no medical issues with the mother or baby, a new study found.
Delivering just two weeks earlier doubles the risk that the baby will have problems, such as trouble breathing, infection and low blood sugar, according to the study.
The findings buttress recommendations from the American College of Obstetricians and Gynecologists (ACOG).
"About 36 percent of women were delivered prior to 39 weeks, electively by Caesarean," said the study's lead author, Dr. Alan T.N. Tita, an assistant professor of obstetrics and gynecology and an epidemiologist at the University of Alabama at Birmingham. "These early deliveries were associated with adverse outcomes. There was a two-fold increase in morbidity in those delivered at 37 weeks compared to women delivered at 39 weeks."
Results of the study are published in the Jan. 8 issue of the New England Journal of Medicine.
Once a woman has had a Caesarean delivery, she and her doctor may decide to perform an "elective" C-section for subsequent births. The recommendation is that any such delivery should occur at 39 weeks or later if there are no medical concerns for the mother or baby. If a woman wants to deliver before 39 weeks, ACOG recommends that amniocentesis be performed to assess lung maturity in the baby.
The new study included 13,258 women who underwent elective repeat Caesarean deliveries at one of 19 U.S. academic medical centers. All of the sites are part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Maternal-Fetal Medicine Units Network.
Of the elective C-sections, 35.8 percent were performed before 39 weeks of gestation, with 6.3 percent done at 37 weeks and 29.5 percent at 38 weeks, the study found.
Babies born at 37 weeks had twice the rate of certain complications, such as needing to be placed on a mechanical ventilator, newborn sepsis (a blood infection) and low blood sugar. Babies delivered at 38 weeks had a 1.5 times higher rate of complications, according to the study.
Dr. Peter Bernstein, a maternal-fetal medicine specialist at Montefiore Medical Center and Albert Einstein College of Medicine in New York City, said he was not surprised by the increase in complications for deliveries before 39 weeks. "The bigger surprise to me was that nearly 36 percent of elective procedures were done before the 39th week," Bernstein said.
"The institutions that participate in this network are big academic centers," he said. "In the academic world, these are among the top institutions, and that more than one-third apparently aren't following ACOG guidelines is a surprise."
Both Tita and Bernstein said that early deliveries are probably due to both mothers and doctors. "There's an interplay between patient desires and physician willingness to accommodate patients," Tita said.
Bernstein said that women often prefer their own doctor for the delivery and not another doctor in the practice, which can lead to scheduled deliveries. And, he added, when you try to accommodate both the mother's and the doctor's schedule, it's easy to see how things get pushed back a week or more.
But he added a caution. "We have to not fool around with this," he said. "The baby may not be ready. This study's findings underline that the ACOG guidelines are appropriate."
Tita added, "In the absence of complications, it's probably optimal to wait until 39 weeks to undergo elective Caesarean."
Economic Blues Trickle Down to Physicians
Robert Lowes
Information from Industry
December 28, 2008 — Although most physicians are not losing their jobs or homes, they're nonetheless feeling the repercussions of the recession that began in December 2007 and deepened during the financial crisis in the fall of 2008. Symptoms large and small abound of a financial slump in medicine:
Fifty-six percent of hospitals told the American Hospital Association in November that physicians were seeking more financial support, ranging from reimbursement for on-call duty to outright employment.
Roughly 1 in 2 physicians plan to attend fewer continuing medical education conferences in 2009 that require overnight travel, according to a September survey by the publication Medical Meetings.
Some physicians may be receiving fewer holiday gifts, a sure sign of belt tightening among patients. Internist Sheree Lipkis, MD, in Glenview, Illinois, has noticed a decline in such gifts from previous years from her patients. "Some of them have lost their jobs," Dr. Lipkis told Medscape Medical News.
Physicians like Dr. Lipkis might expect that rising unemployment and curtailed consumer spending would reduce patient volume, but that's not a universal pattern. To be sure, elective surgery has tailed off. Six in 10 plastic surgeons, for example, report a decrease in cosmetic procedures during the first 8 months of 2008, according to the American Society of Plastic Surgeons. Yet most primary-care physicians interviewed by Medscape Medical News say they haven't slowed down. "Patient numbers are stable," said internist C. B. Dehlin, DO, in Lansing, Michigan. "Maybe we're just caring for the 90% of Michiganders that have jobs."
Patients Postponing Care, Skipping Tests and Treatments
Full schedules for primary-care physicians may be misleading, though. Thirty-six percent of Americans are postponing needed care, while another 30% are skipping tests and treatments outright, according to a survey in October 2008 by the Henry J. Kaiser Family Foundation, and both categories are up 7 percentage points since April 2008. However, with many primary-care physicians ordinarily drowning in patients, reduced demand may simply translate into a shorter waiting time for an appointment slot as opposed to an open slot.
Also, the payment cycles of commercial insurers may have temporarily softened the effect of the recession for physicians who enjoyed crowded waiting rooms in late 2008. By that time, many if not most insured patients had met their annual deductible, motivating them to load up on needed care before year's end while it was less expensive. Dr. Lipkis said that's the reason why the last few months of 2008 were busier than usual for her. Come January 2009, the prospect of shouldering the entire cost of an office visit or procedure may discourage insured patients from making an appointment.
If patients — insured or not — do book an appointment, there's also the possibility that they may not pay up afterward. The Kaiser Family Foundation found that one third of Americans were struggling to pay their medical bills in fall 2008, up from one quarter in 2006. Not surprisingly, a St. Louis collection agency called Account Resolution has seen the dollar volume of delinquent accounts received from physicians increase by roughly 25% in the last half of 2008, says company president James Hill, Jr. "These trends are happening all across the country," Mr. Hill said. And they only stand to worsen with unemployment expected to hit 8.3% by the end of 2009, according to financial research firm Standard & Poor's.
One component of the current recession — the credit crunch — has made it harder for some physicians to borrow money to start a practice or expand an existing one. "Automatic loans for anyone with a medical degree are a thing of the past," practice management consultant Michael LaPenna in Kentwood, Michigan, told Medscape Medical News. Besides requiring physicians to put up security for term loans, cautious banks are asking physicians with an existing line of credit to prove that they have enough accounts receivable to justify the amount of money made available.
Bolstered Medicaid, Medicare Spending May Help
Prognosticators such as Standard and Poor's expect the recession to last well into 2009. How physicians fare will depend partly on the success of federal bailout efforts enacted under the Bush administration — bankrolling banks to loosen up credit, for example — as well as the economic stimulants that President-elect Barack Obama has said he will administer. Mr. Obama has contemplated pouring billions of dollars into state Medicaid programs that have experienced budget cuts in the face of higher demand (the Kaiser Family Foundation estimates that every 1% increase in unemployment adds 1 million people to Medicaid and the State Children's Health Insurance Program). For many physicians, bolstered Medicaid spending could mean the difference between poor compensation versus none at all.
The American College of Physicians (ACP) is asking the federal government to be just as generous with Medicare. It is recommending that for 18 months, Congress fund a 10% bonus for all Medicare services performed by primary-care physicians. "Without funding to stabilize primary-care practices, many will go under and have to close" in light of the credit crunch, investment losses, slower collections, and uncompensated care, the ACP states in a letter to the incoming Obama administration.
While everybody, it seems, is waiting for federal largesse, physicians can act on their own to cope with the forlorn economy. For starters, tune up your billing and collection operation. With patients losing insurance coverage or switching to a spouse's policy after a job loss, it's imperative to verify insurance eligibility and benefits at the front desk so you know whom to bill, said practice management consultant Mr. LaPenna. Collecting copays and patient balances at the front desk is another must for the sake of maximizing revenue. If patients are short on money, offer them an installment plan. It can be as simple as keeping their credit card number on file — with the patient's authorization — and automatically charging it over a set number of months.
Improve Marketing to Current and New Patients
Practices with openings in their schedules should try to make it easier for patients to make appointments, suggested Hobie Collins, a practice management consultant with the Medical Group Management Association in Louisville, Kentucky. Extended weekday hours, for example, cater to employed patients who might find it hard to come in otherwise. "Eliminate as many barriers as you can," said Mr. Collins.
Stepped up marketing can also help fill up the waiting room. Target your existing patients first, advises practice management consultant Jeff Denning in La Jolla, California. "Go through your charts and see who's overdue for preventive or follow-up care, and give them a call," Mr. Denning said. A practice Web site may help a surgical specialist attract new cases.
Cost control is an indispensable virtue during a recession. "Remember the motto from the Great Depression," Mr. LaPenna said. "Use it up, wear it out, make it do, or do without." To achieve the right economy of scale, Mr. LaPenna said, physicians may have to go beyond mere downsizing and consider merging with another practice.
How drastic the solution needs to be, of course, depends on the length and severity of the recession. Dr. Lipkis, for one, will be watching how many tins of popcorn and bottles of wine she receives from patients when the winter holidays come around in 2009. In the meantime, she's giving thanks.
Dr. Lipkis said: "We remind our staff during stressful days how lucky we are to have jobs and be financially afloat."
Information from Industry
December 28, 2008 — Although most physicians are not losing their jobs or homes, they're nonetheless feeling the repercussions of the recession that began in December 2007 and deepened during the financial crisis in the fall of 2008. Symptoms large and small abound of a financial slump in medicine:
Fifty-six percent of hospitals told the American Hospital Association in November that physicians were seeking more financial support, ranging from reimbursement for on-call duty to outright employment.
Roughly 1 in 2 physicians plan to attend fewer continuing medical education conferences in 2009 that require overnight travel, according to a September survey by the publication Medical Meetings.
Some physicians may be receiving fewer holiday gifts, a sure sign of belt tightening among patients. Internist Sheree Lipkis, MD, in Glenview, Illinois, has noticed a decline in such gifts from previous years from her patients. "Some of them have lost their jobs," Dr. Lipkis told Medscape Medical News.
Physicians like Dr. Lipkis might expect that rising unemployment and curtailed consumer spending would reduce patient volume, but that's not a universal pattern. To be sure, elective surgery has tailed off. Six in 10 plastic surgeons, for example, report a decrease in cosmetic procedures during the first 8 months of 2008, according to the American Society of Plastic Surgeons. Yet most primary-care physicians interviewed by Medscape Medical News say they haven't slowed down. "Patient numbers are stable," said internist C. B. Dehlin, DO, in Lansing, Michigan. "Maybe we're just caring for the 90% of Michiganders that have jobs."
Patients Postponing Care, Skipping Tests and Treatments
Full schedules for primary-care physicians may be misleading, though. Thirty-six percent of Americans are postponing needed care, while another 30% are skipping tests and treatments outright, according to a survey in October 2008 by the Henry J. Kaiser Family Foundation, and both categories are up 7 percentage points since April 2008. However, with many primary-care physicians ordinarily drowning in patients, reduced demand may simply translate into a shorter waiting time for an appointment slot as opposed to an open slot.
Also, the payment cycles of commercial insurers may have temporarily softened the effect of the recession for physicians who enjoyed crowded waiting rooms in late 2008. By that time, many if not most insured patients had met their annual deductible, motivating them to load up on needed care before year's end while it was less expensive. Dr. Lipkis said that's the reason why the last few months of 2008 were busier than usual for her. Come January 2009, the prospect of shouldering the entire cost of an office visit or procedure may discourage insured patients from making an appointment.
If patients — insured or not — do book an appointment, there's also the possibility that they may not pay up afterward. The Kaiser Family Foundation found that one third of Americans were struggling to pay their medical bills in fall 2008, up from one quarter in 2006. Not surprisingly, a St. Louis collection agency called Account Resolution has seen the dollar volume of delinquent accounts received from physicians increase by roughly 25% in the last half of 2008, says company president James Hill, Jr. "These trends are happening all across the country," Mr. Hill said. And they only stand to worsen with unemployment expected to hit 8.3% by the end of 2009, according to financial research firm Standard & Poor's.
One component of the current recession — the credit crunch — has made it harder for some physicians to borrow money to start a practice or expand an existing one. "Automatic loans for anyone with a medical degree are a thing of the past," practice management consultant Michael LaPenna in Kentwood, Michigan, told Medscape Medical News. Besides requiring physicians to put up security for term loans, cautious banks are asking physicians with an existing line of credit to prove that they have enough accounts receivable to justify the amount of money made available.
Bolstered Medicaid, Medicare Spending May Help
Prognosticators such as Standard and Poor's expect the recession to last well into 2009. How physicians fare will depend partly on the success of federal bailout efforts enacted under the Bush administration — bankrolling banks to loosen up credit, for example — as well as the economic stimulants that President-elect Barack Obama has said he will administer. Mr. Obama has contemplated pouring billions of dollars into state Medicaid programs that have experienced budget cuts in the face of higher demand (the Kaiser Family Foundation estimates that every 1% increase in unemployment adds 1 million people to Medicaid and the State Children's Health Insurance Program). For many physicians, bolstered Medicaid spending could mean the difference between poor compensation versus none at all.
The American College of Physicians (ACP) is asking the federal government to be just as generous with Medicare. It is recommending that for 18 months, Congress fund a 10% bonus for all Medicare services performed by primary-care physicians. "Without funding to stabilize primary-care practices, many will go under and have to close" in light of the credit crunch, investment losses, slower collections, and uncompensated care, the ACP states in a letter to the incoming Obama administration.
While everybody, it seems, is waiting for federal largesse, physicians can act on their own to cope with the forlorn economy. For starters, tune up your billing and collection operation. With patients losing insurance coverage or switching to a spouse's policy after a job loss, it's imperative to verify insurance eligibility and benefits at the front desk so you know whom to bill, said practice management consultant Mr. LaPenna. Collecting copays and patient balances at the front desk is another must for the sake of maximizing revenue. If patients are short on money, offer them an installment plan. It can be as simple as keeping their credit card number on file — with the patient's authorization — and automatically charging it over a set number of months.
Improve Marketing to Current and New Patients
Practices with openings in their schedules should try to make it easier for patients to make appointments, suggested Hobie Collins, a practice management consultant with the Medical Group Management Association in Louisville, Kentucky. Extended weekday hours, for example, cater to employed patients who might find it hard to come in otherwise. "Eliminate as many barriers as you can," said Mr. Collins.
Stepped up marketing can also help fill up the waiting room. Target your existing patients first, advises practice management consultant Jeff Denning in La Jolla, California. "Go through your charts and see who's overdue for preventive or follow-up care, and give them a call," Mr. Denning said. A practice Web site may help a surgical specialist attract new cases.
Cost control is an indispensable virtue during a recession. "Remember the motto from the Great Depression," Mr. LaPenna said. "Use it up, wear it out, make it do, or do without." To achieve the right economy of scale, Mr. LaPenna said, physicians may have to go beyond mere downsizing and consider merging with another practice.
How drastic the solution needs to be, of course, depends on the length and severity of the recession. Dr. Lipkis, for one, will be watching how many tins of popcorn and bottles of wine she receives from patients when the winter holidays come around in 2009. In the meantime, she's giving thanks.
Dr. Lipkis said: "We remind our staff during stressful days how lucky we are to have jobs and be financially afloat."
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