Hospital Room Lighting May Worsen Your Mood and Pain.


Story at-a-glance

  • Hospital patients are exposed to insufficient levels of light, disrupting both their circadian rhythms and sleep cycles
  • Light-deprived patients had fragmented and low levels of sleep, and those with the lowest exposures to light during the day reported more depressed mood and fatigue
  • Inadequate bright-light exposure has a far-reaching impact on your most critical bodily functions, including your ability to heal
  • Exposure to night-time light may also hinder the production of the hormone melatonin, which is very important for immune health
  • If you or a loved one is confined to a hospital room, move to areas with brighter natural light as much as possible, or bring in some full-spectrum light bulbs, and wear an eye mask at night to block night-time artificial light exposures

Hopefully you have never spent much time in a hospital, but if you have you likely experienced frequent disruptions to your sleep.

Aside from the beeping machines and nightly checks from hospital staff, your room was probably dimly lit with artificial light both day and night — a major impediment to proper sleep and well-being.

As a new study in the Journal of Advanced Nursing1 revealed, the lighting in many hospital rooms may be so bad that it actually worsens patients’ sleep, mood and pain levels.

Hospital-Room Lighting May Lead to Disrupted Sleep Cycles, Increased Pain and Fatigue

The study found that, on average, hospital patients in the study were exposed to about 105 lux (a measure of light emission) daily. This is a very low level of light; for comparison, an office would generally provide about 500 lux and being outdoors on a sunny day could provide 100,000 lux.2

The rooms were so dimly lit that many hospital patients had trouble sleeping. Your body requires a minimum of 1,500 lux for 15 minutes a day just to maintain a normal sleep-wake cycle, but ideally it should be closer to 4,000 for healthful sleep.3

Not surprisingly, the researchers found that the patients’ sleep time was “fragmented and low,” with most averaging just four hours of sleep a night.

Those with the lowest exposures to light during the day also reported more depressed mood and fatigue than those exposed to more light. The researchers noted:4 “Low light exposure significantly predicted fatigue and total mood disturbance.”

Why You Need Exposure to Bright Light During the Day

When full-spectrum light enters your eyes, it not only goes to your visual centers enabling you to see, it also goes to your brain’s hypothalamus where it affects your entire body.

Your hypothalamus controls body temperature, hunger and thirst, water balance and blood pressure. Additionally, it controls your body’s master gland, the pituitary, which secretes many essential hormones, including those that influence your mood.

Exposure to full-spectrum lighting is actually one effective therapy used for treating depression, infection, and much more – so it’s not surprising that hospital patients deprived of such exposures had poorer moods and fatigue.

Studies have also shown that poor lighting in the workplace triggers headaches, stress, fatigue and strained watery eyes, not to mention inferior work production.

Conversely, companies that have switched to full-spectrum lights report improved employee morale, greater productivity, reduced errors and decreased absenteeism. Some experts even believe that “malillumination” is to light what malnutrition is to food.

In a hospital setting, this has serious ramifications, as patients are already under profound stress due to illness and may be further stressed by a lack of natural bright light.

Your ‘body clock’ is also housed in tiny centers located in your hypothalamus, controlling your body’s circadian rhythm. This light-sensitive rhythm is dependent on Mother Nature, with its natural cycles of light and darkness, to function optimally.

Consequently, anything that disrupts these rhythms, like inadequate sunlight exposure to your body (including your eyes), has a far-reaching impact on your body’s ability to function and, certainly, also on its ability to heal.

Nighttime Light Exposure is Also Detrimental

While the featured study didn’t focus specifically on hospital patients’ nighttime light exposures, they’re likely to be significant. Most hospital room doors remain ajar all night, allowing artificial light from the hall to flood the room. There are also lights on medical equipment and monitors, and if your room is not private you may also be exposed to light from a roommates’ television or bathroom trips.

This is important because just as your body requires bright-light exposure during the day, it requires pitch-blackness at night to function optimally – which is all the more critical in the case of a hospital stay when bodily self-healing is most needed.

When you turn on a light at night, you immediately send your brain misinformation about the light-dark cycle. The only thing your brain interprets light to be is day. Believing daytime has arrived, your biological clock instructs your pineal gland to immediately cease its production of the hormone melatonin – a significant blow to your health, especially if you’re ill, as melatonin produces a number of health benefits in terms of your immune system. It’s a powerful antioxidant and free radical scavenger that helps combat inflammation.

In fact, melatonin is so integral to your immune system that a lack of it causes your thymus gland, a critically important part of your immune system, to atrophy.5 In addition, melatonin helps you fall asleep and bestows a feeling of overall comfort and well being, and it has proven to have an impressive array of anti-cancer benefits.6 So unnaturally suppressing this essential hormone is the last thing that a recovering hospital patient needs.

If a Loved One is In the Hospital, Let the Daylight Shine In

The best way to get exposure to healthy full-spectrum light is to do it the way nature intended, by going out in the sun with your bare skin – and ‘bare’ eyes — exposed on a regular basis. If you or a loved one is confined to a hospital room, however, the next best option is to move to areas with brighter natural light as much as possible, or alternatively bring in some full-spectrum light bulbs.

At night, the opposite holds true. You should turn off lights as much as possible, keep the door closed and close the blinds on the window. Wearing an eye mask is another simple trick that can help to keep unwanted light exposures to a minimum if you’re spending the night in a hospital. Taken together, these are simple ways to boost mood and improve sleep and fatigue levels among hospitalized patients.

The Other Major Risk of Spending Time in a Hospital

No matter how important it is, poor lighting may be the least of your worries if you find yourself hospitalized, as once you’re hospitalized you’re immediately at risk for medical errors, which is actually a leading cause of death in the US. According to the most recent research7 into the cost of medical mistakes in terms of lives lost, 210,000 Americans are killed by preventable hospital errors each year.

When deaths related to diagnostic errors, errors of omission, and failure to follow guidelines are included, the number skyrockets to an estimated 440,000 preventable hospital deaths each year!

One of the best safeguards is to have someone there with you. Dr. Andrew Saul has written an entire book on the issue of safeguarding your health while hospitalized. Frequently, you’re going to be relatively debilitated, especially post-op when you’re under the influence of anesthesia, and you won’t have the opportunity to see clearly the types of processes that are going on.

For every medication given in the hospital, ask, “What is this medication? What is it for? What’s the dose?” Take notes. Ask questions. Building a relationship with the nurses can go a long way. Also, when they realize they’re going to be questioned, they’re more likely to go through that extra step of due diligence to make sure they’re getting it right—that’s human nature. Of course, knowing how to prevent disease so you can avoid hospitals in the first place is clearly your best bet. One of the best strategies on that end is to optimize your diet. You can get up to speed on that by reviewing my comprehensive Nutrition Plan.

It’s Important for Virtually Everyone to Optimize Light Exposure: 5 Top Tips

Getting back to the issue of lighting, this isn’t only an issue for hospital patients. Virtually everyone requires exposure to bright light during the day and darkness at night for optimal health. Toward that end, here are my top tips to optimize your light exposure on a daily (and nightly) basis:

1.    Get some sun in the morning, if possible. Your circadian system needs bright light to reset itself. Ten to 15 minutes of morning sunlight will send a strong message to your internal clock that day has arrived, making it less likely to be confused by weaker light signals during the night. More sunlight exposure is required as you age.

2.    Make sure you get BRIGHT sun exposure regularly. Remember, your pineal gland produces melatonin roughly in approximation to the contrast of bright sun exposure in the day and complete darkness at night. If you work indoors, make a point to get outdoors during your breaks.

3.    Avoid watching TV or using your computer in the evening, at least an hour or so before going to bed.These devices emit blue light, which tricks your brain into thinking it’s still daytime. Normally your brain starts secreting melatonin between 9 and 10 pm, and these devices emit light that may stifle that process.

4.    Sleep in complete darkness, or as close to it as possible. Even the slightest bit of light in your bedroom can disrupt your biological clock and your pineal gland’s melatonin production. This means that even the tiny glow from your clock radio could be interfering with your sleep, so cover your alarm clock up at night or get rid of it altogether. You may want to cover your windows with drapes or blackout shades, or wear an eye mask while you sleep.

5.    Install a low-wattage yellow, orange or red light bulb if you need a source of light for navigation at night.Light in these bandwidths does not shut down melatonin production in the way that white and blue bandwidth light does. Salt lamps are handy for this purpose.

 

 

 

 

Candy Crush Saga: The Science Behind Our Addiction.


A year after the game’s mobile launch, we still can’t stop playing. The app’s designer and psychology experts weigh in on exactly what makes it so irresistible

If you haven’t heard of Candy Crush, it’s the mobile game that’s so addictive, players say they have left their children stranded at school, abandoned housework and even injured themselves as they try to reach new levels of the game.

Candy Crush

Candy Crush has been played 151 billion times since it launched as an app on mobile devices exactly year ago. And it’s the first game to ever be No. 1 on iOS, Android and Facebook at the same time. Candy Crush’s creator, King, a Stockholm-based company, says 1 in every 23 Facebook users plays it. And while Candy Crush is free, the in-game purchases that some players choose to make add up. Think Gaming, which releases gaming analytics, estimates that it takes in $875,382 per day. (By comparison, another insanely popular mobile game, Angry Birds, takes in an estimated $6,381 daily.)

All that adds up to some seriously distracted users. A survey by Ask Your Target Market polled 1,000 players and found that 32% of them ignored friends or family to play the game, 28% played during work, 10% got into arguments with significant others over how long they played, and 30% said they were “addicted.”

But there are lots of amusing games out there, so what’s so addictive about this one?

We asked Tommy Palm, one of the game’s designers, what the King team did to get us hooked. We also called a few psychology experts and players to understand the backstory on why their tactics worked so well. Here are the nine reasons they say Candy Crush is so irresistible:

1. It Makes You Wait

Perhaps the most genius element of Candy Crush is its ability to make you long for it. You get five chances (lives) to line up the requisite number of candy icons. Once you run out of lives, you have to wait in 30-minute increments to continue play. Or, if you’re impatient, you can pay to get back in the game — which is why it’s bringing in so much revenue. “You can’t just play all the time. You run out of lives,” says Andy Jarc, 22, one of the few players to reach level 440 in the game. “So the fact that they kind of constrain you — the whole mantra, ‘You always want what you can’t have.’ I can’t have more lives and I want them.”

“I think it makes the game more fun long term,” says designer Palm. “If you have a game that consumes a lot of mental bandwidth, you will continue playing it without noticing that you’re hungry or need to go to the bathroom. But then you binge and eventually you stop playing. It’s much better from an entertainment point of view to create a more balanced experience where you have natural breaks.”

2. We’re All Suckers for Sweet Talk

You flick four candies in a row, and they zap away. Candies above begin to cascade down, making even more matches. At the end words pop up on your screen, accompanied by a voice that says “Sweet” or “Delicious.” This feedback is essential for player immersion. “Positive rewards are the main reason people become addicted to things,” says Dr. Kimberly Young, a pioneering expert on Internet and gaming addiction who treats those addicted to the cyberworld. “When you play the game, you feel better about yourself.”

3. You Can Play With One Hand 

According to Palm, the icons and setup were created so players could multitask. You can play Candy Crush while carrying a drink, toting a purse or bag, clinging to a subway pole, or hiding your phone under the table. That’s a huge advantage and makes this game perfect for a train ride, a distraction while you’re waiting to see a doctor, or something to get you through boring meetings. Plus, you can play offline as well — so even if you’re stuck in a tunnel, you can be “crushing.”

4. There’s Always More

According to Palm, the Candy Crush team updates the game constantly and creates new levels every two weeks. Right now there are 544 levels. “Just three years ago, a game with 30 levels would be astonishing,” King says. “And now with this game, it has raised the bar with how much content a mobile game should and will have.”

Plus, on any single level, there’s no way to fail. If you run out of options on a board — and that happens once in a blue moon — the board immediately resets. You never get stuck. You can’t lose. “I believe this is part of the reinforcing pattern which keeps you playing,” says Dr. Dinah Miller, a psychiatrist who has written about the addicting elements of another popular game, Angry Birds. The game only ends when you’ve run out of your allotted number of moves “and you can end that frustration by buying your way out.”

5. You Don’t Have to Pay – but if You Want to, It’s Easy

King reports that of all the players on its last level — 544 — more than 60% of them didn’t pay a cent to buy extra lives or chances to get there. But if you want to pay, it’s easy. Connected to Facebook or the app store? Just click to pay.

6. It Taps Into Our Inner Child

“Many people have had a very positive feeling about candy since they were kids,” says Palm. “And it makes for a really nice visual game board with a lot of color and interesting shapes.” In fact, when you play you feel as if you’re transported into an entire Candy Land experience. The game pieces are candy, and the homepage for the game looks like the traditional Candy Land board, with your Facebook friends’ pictures displayed as pieces on that board, sitting at whatever level they’re stuck on.

7. It’s Social

Social games — any game that allows you to connect with your friends through a social-media platform like Facebook — have taken off. Whether it’s Words With Friends, Kingdoms of Camelot or Candy Crush, the ability to play with, or compete against, friends is irresistible. “Look, nobody’s coming to me because they have a clinical addiction to Candy Crush,” says Young. “It’s more of a social addiction, if you will.”

8. It’s an Escape

“When you read the research about gaming,” Young says, “you’re often looking at people who are distracting themselves from something in their lives.” The relaxing exercise of lining up candies to the tune of upbeat music is a perfect stress reliever.

9.  It Grows on You

This isn’t your average “line up three” game. “I started playing, and at first I was like whatever, it’s just bejeweled,” says Jarc. “But as I played more and more, it became addicting.”

King’s high-level of attentiveness toward updating gameplay has made it better quality than most casual games that are out there. When players took to Facebook to express their frustration with level 65 — notoriously one of the hardest levels in the game — King went into the game and altered the level to make it easier (though not too easy) multiple times.

 

 

Playing Pop and Rock Music Boosts Performance of Solar Cells.


Playing pop and rock music improves the performance of solar cells, according to new research from scientists at Queen Mary University of London and Imperial College London.

The high frequencies and pitch found in pop and rock music cause vibrations that enhanced energy generation in solar cells containing a cluster of ‘nanorods’, leading to a 40 per cent increase in efficiency of the solar cells.

The study has implications for improving energy generation from sunlight, particularly for the development of new, lower cost, printed solar cells.

The researchers grew billions of tiny rods (nanorods) made from zinc oxide, then covered them with an active polymer to form a device that converts sunlight into electricity.

Using the special properties of the zinc oxide material, the team was able to show that sound levels as low as 75 decibels (equivalent to a typical roadside noise or a printer in an office) could significantly improve the solar cell performance.

“After investigating systems for converting vibrations into electricity this is a really exciting development that shows a similar set of physical properties can also enhance the performance of a photovoltaic,” said Dr Steve Dunn, Reader in Nanoscale Materials from Queen Mary’s School of Engineering and Materials Science and co-author of the paper.

Scientists had previously shown that applying pressure or strain to zinc oxide materials could result in voltage outputs, known as the piezoelectric effect. However, the effect of these piezoelectric voltages on solar cell efficiency had not received significant attention before.

“We thought the soundwaves, which produce random fluctuations, would cancel each other out and so didn’t expect to see any significant overall effect on the power output,” said James Durrant, Professor of Photochemistry at Imperial College London, who co-led the study.

“We tried playing music instead of dull flat sounds, as this helped us explore the effect of different pitches. The biggest difference we found was when we played pop music rather than classical, which we now realise is because our acoustic solar cells respond best to the higher pitched sounds present in pop music,” he concluded.

The discovery could be used to power devices that are exposed to acoustic vibrations, such as air conditioning units or within cars and other vehicles.

Co-author Dr Joe Briscoe also from Queen Mary’s School of Engineering and Materials Science, commented: “The whole device extremely simple and inexpensive to produce as the zinc oxide was grown using a simple, chemical solution technique and the polymer was also deposited from a solution.”

Dr Dunn added: “The work highlights the benefits of collaboration to develop new and interesting systems and scientific understanding.”

Home Test for Pharyngitis May Reduce Unneeded Strep Cultures.


A patient-driven approach to streptococcal pharyngitis diagnosis using a new home test score might save on unnecessary physician visits, cultures, and treatment, according to a retrospective cohort study published online November 4 in the Annals of Internal Medicine. However, some experts are skeptical of the home score algorithm and of its potential cost-savings.

“Globally, group A streptococcal (GAS) pharyngitis affects hundreds of millions of persons each year,” write Andrew M. Fine, MD, MPH, from the Division of Emergency Medicine-Main 1, Boston Children’s Hospital in Massachusetts, and colleagues. “In the United States, more than 12 million persons make outpatient visits for pharyngitis; however, clinicians cannot differentiate GAS pharyngitis from other causes of acute pharyngitis (for example, viral) on the basis of a physical examination of the oropharynx.”

Most cases of sore throat are viral, rather than bacterial, and therefore are self-limiting and transient even without antibiotic treatment. To classify risk for GAS pharyngitis and guide management of adults with acute pharyngitis, the American College of Physicians and Centers for Disease Control and Prevention recommend use of clinical scores to identify low-risk patients. According to consensus guidelines, such patients should not be tested or treated for GAS pharyngitis.

The goal of this study was to help patients decide when to visit a clinician for evaluation of sore throat. The study sample consisted of 71,776 patients at least 15 years of age who were evaluated for pharyngitis from September 2006 to December 2008 at one of a national chain of retail health clinics.

Using information from patient-reported clinical variables, as well as local incidence of GAS pharyngitis, the investigators created a score and compared it with the Centor score and other traditional scores, using information from clinicians’ assessments. Clinical variables in the new score were fever, absence of cough, and age.

The investigators estimated outcomes if patients who were at least 15 years of age with sore throat did not visit a clinician when the new score indicated less than 10% likelihood of GAS pharyngitis, compared with being managed by clinicians following guidelines using the Centor score. The researchers suggest that following this strategy would avoid 230,000 clinician visits in the United States each year, and that 8500 patients with GAS pharyngitis who would have received antibiotics under clinician management would not receive antibiotics.

A limitation of this approach is current lack of availability of real-time information about the local incidence of GAS pharyngitis, which is needed to calculate the new score. Study limitations include retrospective design and reliance on self-report of symptoms.

“A patient-driven approach to pharyngitis diagnosis that uses this new score could save hundreds of thousands of visits annually by identifying patients at home who are unlikely to require testing or treatment,” the authors write.

Experts Question Limitations and Cost-Savings of the New Score

In an accompanying editorial, Edward L. Kaplan, MD, MMC, from the Department of Pediatrics, University of Minnesota Medical School in Minneapolis, warns of limitations of the new home score. These include overly broad age range, as GAS pharyngitis is rare in persons older than 50 years, and the assumption that GAS pharyngitis has even prevalence across communities.

Dr. Kaplan recommends stratification by age categories and notes that uncomplicated GAS pharyngitis has not been reportable to health departments for several decades in most states, making incidence difficult to determine. Other limitations include failure to account for potential effects of the decisions made by the multiple clinicians from more than 70 clinics attended by patients in this sample, and lack of differentiation of true GAS infection from upper respiratory tract “carriers” among adults.

“Until we have a proven cost-effective vaccine to protect against Streptococcus pyogenes, we cannot expect the magnitude of this medical and public health issue to decrease,” Dr. Kaplan writes. “Even if a cost-effective vaccine is developed, how it may affect true infections and the carrier state in children may be entirely different in adults. Fine and colleagues have proposed an interim approach, but there are surely others.”

In a second editorial, Robert M. Centor, MD, from the University of Alabama at Birmingham in Huntsville, questions the potential cost-savings if the new score were widely used. Alternative strategies to improve treatment and reduce costs include clinical assessment that eliminates testing for patients at low risk, as well as the use of generic antibiotics for those with GAS pharyngitis. He also warns that all guidelines and recommendations for GAS pharyngitis apply only to patients who have had symptoms for fewer than 3 days.

“If symptoms persist or worsen, then the patient no longer has acute pharyngitis; therefore, we should use a different diagnostic and therapeutic approach,” he writes.

Other questions posed by Dr. Centor include whether patients would actually download and use such a test before deciding whether to seek medical care for sore throat and why many physicians, clinics, and emergency departments do not follow published guidelines recommending against antibiotic use for patients with low probability of GAS pharyngitis.

“Although the goals [of this study] are admirable, the approach does not seem practical or cost-saving,” Dr. Centor concludes. “We have more practical strategies for decreasing costs for patients with sore throat.

CLOTBUST-Hands Free.


Pilot Safety Study of a Novel Operator-Independent Ultrasound Device in Patients With Acute Ischemic Stroke

Background and Purpose—The Combined Lysis of Thrombus in Brain Ischemia With Transcranial Ultrasound and Systemic T-PA-Hands-Free (CLOTBUST-HF) study is a first-in-human, National Institutes of Health–sponsored, multicenter, open-label, pilot safety trial of tissue-type plasminogen activator (tPA) plus a novel operator-independent ultrasound device in patients with ischemic stroke caused by proximal intracranial occlusion.

Methods—All patients received standard-dose intravenous tPA, and shortly after tPA bolus, the CLOTBUST-HF device delivered 2-hour therapeutic exposure to 2-MHz pulsed-wave ultrasound. Primary outcome was occurrence of symptomatic intracerebral hemorrhage. All patients underwent pretreatment and post-treatment transcranial Doppler ultrasound or CT angiography. National Institutes of Health Stroke Scale scores were collected at 2 hours and modified Rankin scale at 90 days.

Results—Summary characteristics of all 20 enrolled patients were 60% men, mean age of 63 (SD=14) years, and median National Institutes of Health Stroke Scale of 15. Sites of pretreatment occlusion were as follows: 14 of 20 (70%) middle cerebral artery, 3 of 20 (15%) terminal internal carotid artery, and 3 of 20 (15%) vertebral artery. The median (interquartile range) time to tPA at the beginning of sonothrombolysis was 22 (13.5–29.0) minutes. All patients tolerated the entire 2 hours of insonation, and none developed symptomatic intracerebral hemorrhage. No serious adverse events were related to the study device. Rates of 2-hour recanalization were as follows: 8 of 20 (40%; 95% confidence interval, 19%–64%) complete and 2 of 20 (10%; 95% confidence interval, 1%–32%) partial. Middle cerebral artery occlusions demonstrated the greatest complete recanalization rate: 8 of 14 (57%; 95% confidence interval, 29%–82%). At 90 days, 5 of 20 (25%, 95% confidence interval, 7%–49) patients had a modified Rankin scale of 0 to 1.

Conclusions—Sonothrombolysis using a novel, operator-independent device, in combination with systemic tPA, seems safe, and recanalization rates warrant evaluation in a phase III efficacy trial.

Source: Stroke

Active Versus Passive Cooling During Neonatal Transport.


BACKGROUND AND OBJECTIVE: Therapeutic hypothermia is now the standard of care for hypoxic-ischemic encephalopathy. Treatment should be started early, and it is often necessary to transfer the infant to a regional NICU for ongoing care. There are no large studies reporting outcomes from infants cooled passively compared with active (servo-controlled) cooling during transfer. Our goal was to review data from a regional transport service, comparing both methods of cooling.

METHODS: This was a retrospective observational study of 143 infants referred to a regional NICU for ongoing therapeutic hypothermia. Of the 134 infants transferred, the first 64 were cooled passively, and 70 were subsequently cooled after purchase of a servo-controlled mattress. Key outcome measures were time to arrival at the regional unit, temperature at referral and arrival at the regional unit, and temperature stability during transfer.

RESULTS: The age cooling was started was significantly shorter in the actively cooled group (46 [0–352] minutes vs 120 [0–502] minutes; P <.01). The median (range) stabilization time (153 [60–385] minutes vs 133 [45–505] minutes; P = .04) and age at arrival at the regional unit (504 [191–924] minutes vs 452 [225–1265]) minutes; P = .01) were significantly shorter in the actively cooled group. Only 39% of infants passively cooled were within the target temperature range at arrival to the regional unit compared with 100% actively cooled.

CONCLUSIONS: Servo-controlled active cooling has been shown to improve temperature stability and is associated with a reduction in transfer time.

Source: http://pediatrics.aappublications.org

Narrow-Spectrum Antibiotics Effective for Pediatric Pneumonia.


Narrow-spectrum antibiotics have similar efficacy and cost-effectiveness as broad-spectrum antibiotics in the treatment of pediatric community-acquired pneumonia (CAP), according to the findings of a retrospective study.

Derek J Williams, MD, MPH, from Vanderbilt University School of Medicine in Nashville, Tennessee, and colleagues published their findings online October 28 in Pediatrics.

“The 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America…guideline for the management of children with [CAP] recommends narrow-spectrum antimicrobial therapy for most hospitalized children,” the authors write. “Nevertheless, few studies have directly compared the effectiveness of narrow-spectrum agents to the broader spectrum third-generation cephalosporins commonly used among hospitalized children with CAP.”

Therefore, the researchers used the Pediatric Health Information System database to assess the hospital length of stay (LOS) and associated healthcare costs of children aged 6 months to 18 years who were diagnosed with pneumonia between July 2005 and June 2011 and treated with either narrow-spectrum or broad-spectrum antibiotics. The authors excluded children with potentially severe pneumonia, those at risk for healthcare-associated infections, and those with mild disease requiring less than 2 days of hospitalization.

Narrow-spectrum therapy consisted of the exclusive use of penicillin or ampicillin, whereas broad-spectrum treatment was defined as the exclusive use of parenteral ceftriaxone or cefotaxime.

The median LOS for the entire study population (n = 15,564) was 3 days (interquartile range, 3 – 4 days), and LOS was not significantly different between the narrow-spectrum and broad-spectrum treatment groups (adjusted difference [aD], 0.12 days; P = .11), after adjustments for covariates including age, sex, and ethnicity.

Similarly, the investigators found no differences in the proportion of children requiring intensive care unit admission in the first 2 days of hospitalization (adjusted odds ratio [aOR], 0.85; 95% CI, 0.25 – 2.73) or hospital readmission within 14 days (aOR, 0.85; 95% CI, 0.45 – 1.63) were noted between the groups.

Narrow-spectrum treatment was also linked to a similar cost of hospitalization (aD, −$14.4; 95% CI, −$177.1 to $148.3) and cost per episode of illness (aD, −$18.6; 95% CI, −$194 to $156.9) as broad-spectrum therapy.

The researchers note that the limitations of the study were mostly related to its retrospective nature, including potential confounding by indication, the absence of etiologic and other clinical data, and a relative lack of objective outcome measures.

“Clinical outcomes and costs for children hospitalized with CAP are not different when empirical treatment is with narrow-spectrum compared with broad-spectrum therapy,” the authors write. “Programs promoting guideline implementation and targeting judicious antibiotic selection for CAP are needed to optimize management of childhood CAP in the United States.”

Major Bleed Risk Falls with Bivalirudin vs Heparin en Route to PCI for STEMI: EUROMAX.


The 30-day risk of death or major bleeding fell significantly in ST-elevation MI (STEMI) patients treated with bivalirudin (Angiomax, the Medicines Company) compared with heparin-based management, both initiated prior to arrival at a hospital for primary PCI, in a large randomized but open-label study[1].

The bivalirudin benefit for that composite end point in the European Ambulance Acute Coronary Syndrome Angiography(EUROMAX) trial was driven by a significant drop in major bleeding, the definition of which excluded bleeding related to CABG surgery.

The heparin-based strategy consisted of either unfractionated heparin (UFH) or the low-molecular-weight heparin enoxaparin(Lovenox, Sanofi). Both groups could receive a GP IIb/IIIa inhibitor provisionally.

EUROMAX was published today in the New England Journal of Medicine with lead author Dr Philippe Gabriel Steg (Hôpital Bichat, Paris, France) to coincide with his presentation of the trial here at TCT 2013 .

http://img.medscape.com/news/2013/ih_131030_Steg_Philippe_Gabriel_TCT2013_120x156.jpg

Dr Philippe Gabriel Steg

Bivalirudin’s 40% primary-end-point relative risk reduction included a >50% drop in risk for non-CABG major bleeding. On the other hand, the relative risk of stent thrombosis with bivalirudin was nearly threefold what was seen in the heparin group, although absolute rates were very low.

At a media briefing on the trial, Steg said the excess stent thromboses with bivalirudin were driven by events in the acute phase, within 24 hours of PCI. And, he observed, they didn’t translate into more reinfarctions or ischemia-driven revascularization.

Still, “acute stent thrombosis . . . while rarely fatal and not outweighing the advantages of bivalirudin, is the only troubling issue with bivalirudin in STEMI, and we do need strategies to reduce this complication,” according to Dr Gregg W Stone (New York-Presbyterian Hospital/Columbia University Medical Center New York, NY), the assigned discussant following Steg’s formal presentation of EUROMAX.

Shades of HORIZONS AMI

The trial’s findings are reminiscent of the HORIZONS AMI trial 30-day outcomes reported about six years ago and covered then by heartwire . That trial, Steg et al observe, preceded some important changes in STEMI management and PCI technique that likely affected bleeding risk, changes that were a part of EUROMAX. These included the expansion of radial-artery PCI access, newer antiplatelet agents, reduced GP-IIb/IIIa-inhibitor use, and progressively earlier initiation of IV anticoagulants.

In the >3600-patient HORIZONS AMI, anticoagulation wasn’t started early during transport. But both it and EUROMAX with its nearly 2200 patients saw a decreased bleeding risk and increased stent-thrombosis risk with bivalirudin compared with heparin. But in contrast to EUROMAX, the earlier trial also showed a reduced risk of cardiac death in bivalirudin patients.

The two studies taken together have more to say than either alone. “I think the results of EUROMAX will heavily impact clinical use of bivalirudin in Europe,” Steg said to heartwire . “The results are very consistent wih HORIZONS AMI, even to the point of the stent-thrombosis signal” and are “reassuring enough to embrace [bivalirudin] in the prehospital setting.” That is, he added, “If you want to. [The EUROMAX results] are not mind-blowing because we don’t see a mortality reduction. But they suggest that the benefits seen in HORIZONS AMI can be extended to the contemporary prehospital setting. “

At the media briefing, Dr Bernard Gersh (Mayo Clinic, Rochester, MN), who wasn’t involved in the trial, said, “It’s not that often that you see trials that really will change clinical practice, and I think this will.”

The Role of Prehospital Diagnosis and Treatment

Gersh also said, “I’ve never seen really anything that suggests that prehospital administration [of anticoagulants] and [STEMI] diagnosis is not beneficial.”

But whether they are achievable in the field varies by country, even within Europe. Interviewed, Steg pointed out that at most participating centers, there were no physicians in the ambulances. It does take some expertise to interpret the ECGs, unless the tracings can be transmitted to a center for remote reading. But, he said, “It’s been shown in other trials if you have good trained paramedics, they do just as well if not better than physicians.”

Also speaking at the briefing as a EUROMAX observer, Dr Philippe Généreux (NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY) said prehospital STEMI diagnosis and treatment initiation could make the most difference in countries like Canada, “where there aren’t cath labs on every corner” and it might take 45 to 60 minutes for an ambulance to reach a PCI center.

Prospects for prehospital management in the US seem more remote, observers agreed. Dr James B Hermiller, Jr (St Vincent Hospital/The Heart Center of Indiana, Indianapolis,) said at the briefing, “The barrier to this in the US is very great. It’s difficult just to  get ECGs in the field, let alone administer anticoagulants, but we need to get there because this is very important.”

The Open-Label Randomization

EUROMAX randomized patients at centers in nine European countries presenting within 12 hours of onset of symptoms from electrocardiographically defined STEMI, on an open-label basis, to the bivalirudin or heparin strategies. Treatment was initiated in the ambulance or at a non-PCI hospital with subsequent transport to a PCI center.

For the 1089 patients who received bivalirudin, the drug was started as a 0.75-mg/kg bolus followed by an infusion of 1.75 mg/kg/h continued for at least four hours after PCI. The 1109 control patients received UFH at either 100 IU/g or 60 IU/kg with a GP IIb/IIIa inhibitor or were allowed to have enoxaparin at 0.5 mg/kg. Adjuvant GP IIb/IIIa inhibitors were allowed at physicians’ discretion. All patients received aspirin plus a P2Y12 inhibitor.

Relative Risk (95% CI) for Outcomes, Bivalirudin vs Heparin Strategies for STEMI Initiated During Emergency Transport to Primary PCI

End points

RR (95% CI)

p

30-day death from any cause or non-CABG major bleedinga

0.60 (0.43–0.82)

0.001

30-day death from any cause, reinfarction, or non-CABG major bleeding

0.72 (0.54–0.96)

0.02

Non-CABG major bleeding

0.43 (0.28–0.66)

<0.001

Major bleeding (TIMI definition)

0.62 (0.32–1.20)

0.15

Severe or life-threatening bleeding (GUSTO definition)

0.61 (0.22–1.68)

0.33

Definite stent thrombosisb

2.89 (1.14–7.29)

0.02

a. Primary end point 
b. Academic Research Consortium criteria

No significant differences were seen at 30 days for the composite of death, reinfarction, ischemia-driven revascularization, or stroke, or for any stroke or ischemic stroke. A committee blinded to treatment assignment adjudicated bleeding episodes and clinical events.

As discussant, Stone pointed out that PCI via the radial artery, rather than the femoral artery, was done in only 6% of cases in HORIZONS AMI but in 47% of EUROMAX patients. Some predicted that the greater proportion of radial procedures would lead to a much lower major bleeding rate and make it hard for bivalirudin to show an effect. A EUROMAX subgroup analysis found, however, that the benefits of bivalirudin over the heparin-based strategy were consistent for different kinds of patients, including whether their PCI was by the radial or femoral routes.

“Therefore, bivalirudin is beneficial regardless of the access site, and this is because most bleeding in the STEMI and ACS setting is not access-site related,” he said. It’s the non–access-site bleeds to pose the greater threat to later outcomes. So, he said, “the advantages of bivalirudin are present in patients undergoing radial as well as femoral intervention, and radialists should pay attention to this.”

Stone said EUROMAX raises the question of whether using cangrelor (the Medicines Company) as part of the accompanying antiplatelet therapy might help prevent stent thrombosis with bivalirudin, and that’s being addressed in HORIZONS-AMI-2, which is starting soon.

Helmets Still Uncommon Among Children in Bicycle Accidents.


Only 1 in 10 children involved in a bicycle accident was wearing a helmet, a review of emergency department records in Los Angeles County shows.

“We found decreased use among older children, minority groups, and those of lower socioeconomic status,” said Veronica Sullins, MD, from Harbor-UCLA Medical Center in Torrance, California.

Bicycle-related injuries are responsible for more than 250,000 visits to the emergency department and nearly 200 deaths a year. California has the second highest number of cyclist fatalities.

The use of a bicycle helmet reduces head injuries by 63% to 88%, but a small number of children younger than 15 years wear helmets, Dr. Sullins reported.

She presented the research here at the American Academy of Pediatrics 2013 National Conference and Exhibition.

Dr. Sullins and her team reviewed information from the Trauma and Emergency Medicine Information System for patients younger than 18 years. The median age of the children was 13 years, and 64% were male.

The primary end points were the association between helmet use and age, sex, insurance status, and race or ethnicity.

Only 11% Wore Helmets

Of the 1248 children identified, 11% were wearing helmets when their injuries occurred. Of these, 13.8% were younger than 12 years and 9.8% were 12 years or older.

Helmet use was 47% more likely in the younger age group (P < .03), was 10 times more likely in white children than in children from a minority group (P < .0001), and was twice as likely in children covered by private insurance as in those covered by public or no insurance (P < .0001).

There were no differences in any of the primary end points between the helmeted and unhelmeted groups. However, “we should note that of the 9 total deaths, 8 children were not wearing helmets,” Dr. Sullins said.

On multivariable logistic regression analysis, helmet use did not increase the need for emergency surgery, mortality, or length of hospital stay, after adjustment for age, race and ethnicity, and injury severity score.

Only injury severity score increased the risk for all outcomes. For every 1-point increase in injury severity score, length of stay increased by 0.4 days (P < .0001). Private insurance decreased the length of stay.

“Overall, less than 1% of patients died, few required emergency surgery (5.9%), permanent disability was very low (0.5%), but temporary disability was high (65.4%),” she said.

On the basis of the findings, Dr. Sullins and her team recommend that middle schools, high schools, low-income communities, and minority populations in Los Angeles County be targeted for bicycle safety programs.

Targeted Education

“This study picked up some remarkable trends in the difference in helmet use across different socioeconomic groups,” said Tanzid Shams, MD, who leads the concussion and brain injury program at the Floating Hospital for Children at Tufts Medical Center in Boston. “We need to look more closely at why this disparity exists.”

He told Medscape Medical News that “we want all children to wear helmets. One effective strategy would be to develop targeted campaigns that positively reinforce healthy habits.”

“The governing bodies for sports such as skateboarding and BMX can really get behind a campaign that encourages wearing helmets anytime one is riding a bicycle. I believe that a consistent message from role models can be highly effective,” said Dr. Shams.

He noted that in addition to emphasizing the value of helmets to parents, pediatricians should stress the importance of a proper fit.

“Very frequently, I see a child wearing a helmet that is loosely dangling off the head. When purchasing a bicycle helmet, one-size-fits-all may not be the best approach. The key is to go for a snug fit that does not constrict circulation or vision,” he explained.

“Several helmet manufacturers offer adjustable inner harnesses that allow for fit adjustments as the head of the child grows,” Dr. Shams said. “This feature is a good investment in terms of protecting the child from potential head trauma.”

Report Finds ‘Culture of Resistance’ on Youth Concussion.


Young athletes in the United States face a “culture of resistance” to telling a coach or parent they might have a concussion, according to a new report from the Institute of Medicine and National Research Council. 

The 306-page report, “Sports-Related Concussions in Youth: Improving the Science, Changing the Culture,” was released during a briefing today at the National Academy of Sciences in Washington, DC.

“Even though there is an increased willingness to report a concussion, there is still the desire on the part of the athlete not to report it because they feel they are letting their teammates down; on the part of the coaches because it upsets the team they have on the field, or their own belief that, ‘I had these, I’m okay, it’s just part of the sport’; and on the part of the parents who want to see their children excel and be accepted,” said Robert Graham, MD, chair of the committee that wrote the report.

Attitude Adjustment

Efforts are needed to “change the culture,” said Dr. Graham, who is director of the National Program Office for Aligning Forces for Quality at George Washington University in Washington, DC.

Over 9 months, the committee did a comprehensive review of the literature on concussions in youth sports with athletes aged 5 to 21 years. 

“The findings of our report justify the concerns about sports concussions in young people,” said Dr. Graham. “However, there are numerous areas in which we need more and better data.  Until we have that information, we urge parents, schools, athletic departments, and the public to examine carefully what we do know, as with any decision regarding risk, so they can make more informed decisions about young athletes playing sports,” he added.

The reported number of individuals aged 19 and under treated in US emergency departments for concussions and other nonfatal sports- and recreation-related traumatic brain injuries (TBIs) increased from 150,000 in 2001 to 250,000 in 2009.

“This could possibly be due to an increase in awareness or reporting of concussions,” committee member Tracey Covassin, PhD, director of the undergraduate athletic training program at Michigan State University in East Lansing. “However, we do not know the true incidence of concussions as several concussions go unreported, as well as a lack of consistency in terminology with different studies that have reported different definitions of concussions.”

The committee found that the majority of research into concussions is at the high school and collegiate levels, with very few to no data reported below the high school level.

The committee also found a “shift” in the incidence of concussions, with more reported at the high school level than the collegiate level, Dr. Covassin said.

Football, ice hockey, lacrosse, wrestling, and soccer are associated with the highest rates of reported concussions for male athletes at the high school and college levels, while soccer, lacrosse, and basketball are associated with the highest rates of reported concussions for female athletes at these levels of play.

Limited Evidence Helmets Cut Risk

The committee found little evidence that current sports helmet designs cut the risk for concussions. 

“What the literature tells us is that diffuse brain injuries like concussion are caused by a combination of linear and rotational forces,” explained committee member Kristy Arbogast, PhD, engineering core director, Center for Injury Research and Prevention, Children’s Hospital of Philadelphia in Pennsylvania. “What we do know is that helmets reduce that linear portion. There is limited evidence that they can manage the rotational components of the impact. This is in part due to standards.”

The committee stressed, however, that properly fitted helmets, face masks, and mouth guards should still be used because they reduce the risk for other injuries.

The committee also examined the scientific literature on concussion recognition, diagnosis, and management. They found that the signs and symptoms of concussion are usually placed into 4 categories — physical, cognitive, emotional, and sleep — with patients having 1 or more symptoms from 1 or more categories. 

Most youth athletes with concussion will recover within 2 weeks of the injury, but in 10% to 20% of cases concussion symptoms persist for several weeks, months, or even years. 

Return to Play

The committee advises that a concussed athlete return to play only when he or she has recovered demonstrably and is no longer having any symptoms. An individualized treatment plan that includes physical and mental rest may be beneficial for recovery from a concussion, but current research does not suggest a standard or universal level and duration of rest needed, the committee notes.

Athletes who return to play before complete recovery are at increased risk for prolonged recovery or more serious consequences if they sustain a second concussion. “The evidence is pretty clear” on this, said committee member Arthur Maerlender, PhD, director of pediatric neuropsychological services at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire.

The literature also suggests that single and multiple concussions can lead to impairments in the areas of memory and processing speed.  However, it remains unclear whether repetitive head impacts and multiple concussions sustained in youth lead to long-term neurodegenerative disease, such as chronic traumatic encephalopathy, the committee said.

It notes, however, that surveys of retired professional athletes provide some evidence that a history of multiple concussions increases risk for depression. In a survey of more than 2500 retired professional football players, approximately 11% reported having clinical depression. “Very little” research has evaluated the relationship between concussions and suicidal thoughts and behaviors, the committee notes.

In youth sports, several organizations have called for a “hit count” to limit the amount of head contact a player receives over a given amount of time. Although this concept is “fundamentally sound,” the committee found that implementing a specific threshold for the number of impacts or the magnitude of impacts per week or per season is without scientific basis.

The committee calls for establishing a national surveillance system to accurately determine the number of sports-related concussions, identify changes in the brain following concussions in youth, conduct studies to assess the consequences and effects of concussions over a life span, and evaluate the effectiveness of sports rules and playing practices in reducing concussions.