March 2008

Medical-Intelligence

A Monthly Review of Recent Articles of Interest
by Marc D. Schwartz, MD

Table of Contents
Avoid In-Hospital Lung Clots
Survive an In-Hospital Cardiac Arrest
Medical Progress in In-Hospital Treatment
Oral Contraceptives Reduce Ovarian Cancer Risk
All That Glitters...
I’m Tired and I Wanna Go Home...from Tanzania
Quick Takes

Live Long and Prosper - Chapter One
Avoid In-Hospital Lung Clots
Blood clots of the lung are the most common preventable cause of in-hospital death. Medication and other measures to prevent it lower the risk by over half in medical patients and three quarters in general surgical patients. A recent study found that, among at-risk patients in the United States, only half of medical patients and three quarters of surgical patients received preventative medical and other treatment recommended by the American College of Chest Physicians. If you are hospitalized, check with your doctor to find out if you are “at risk for pulmonary embolism” and if you are getting the prophylactic treatment recommended

Live Long and Prosper - Chapter Two
Survive an In-Hospital Cardiac Arrest
In a study of outcomes of patients who had a pulseless cardiac arrest while in the hospital, it was found that all major outcomes, including survival and neurological damage, were less positive for those whose arrest occurred at night, between 11 PM and 7 AM. Some of the many known characteristics of nights in hospitals are lower staffing levels, less expertise of personnel on duty, less staff oversight, and less stringent patient monitoring practices. You can’t choose when to have a cardiac arrest, but it may be helpful to prepare a family member or friend to come to the hospital ASAP if you have do one at night. If your hospital allows it, they can camp out at your bedside and do their best to make sure you’re getting all the care you need. JAMA Feb 20, 2008 299:785

Medical Progress in In-Hospital Treatment
And while we’re discussing things in-hospital, let me introduce the Hospitalist, the new medical specialist who focuses only on treating in-patients. You may be disappointed to learn that substituting hospitalists for patients’ own doctors does not reduce the death rate or readmission rate. So far, studies suggest that its main benefit is reducing the length of stay.

Oral Contraceptives Reduce Ovarian Cancer Risk
Women who used oral contraceptives (OC’s) were found to have 25% less risk of ovarian cancer than those who did not take them. The longer a woman used them, the greater the protection, and benefits were observed up to 29 years after cessation. The editorialist of Lancet, where this study was published, argues that the decline in ovarian cancer resulting from the use of OC’s outweighs the small increase in risk for other cancers.

All That Glitters...
It appears that a quarter of patients taking aspirin do not get its anti-clotting benefit. In a group of 3,000 patients with established cardiovascular disease, adverse cardiovascular events occurred more often in aspirin resistant patients (40%) than in aspirin sensitive patients (15%). At the present time, it is not known which commercial laboratory test is best for determining aspirin resistance nor which anti-clotting drug to take instead of aspirin. (Herbals and vitamins are of little help.) You may want to ask your doctor to keep you up to date on progress with this issue. I’ll let you know if I hear of any news about this.

I’m Tired and I Wanna Go Home...from Tanzania
While many private health insurance plans reimburse for emergency medical expenses overseas, and some cover “medical evacuation” — moving sick or injured travelers to the nearest adequate hospital — almost no health insurance policies pay to bring travelers back home to the United States. And that can be the most expensive part of a health crisis abroad. An air ambulance from London to New York can cost $40,000; from Hong Kong, it can cost up to $100,000.

When shopping for overseas hospitalization insurance, it is important to understand the terminology. Typically, ‘evacuation’ means getting to the nearest medically appropriate hospital; ‘medical repatriation’ means getting you from there back home. Medical repatriation and can be bought for three months ($190 a person), six months ($290) or 12 months ($490).

The details of plans vary. Some cover additional expenses that might be incurred in a medical emergency overseas, like the cost of flying a relative to your bedside or the return home of your children or traveling companion. American Express Platinum members already have medical repatriation benefits. In June, AARP will begin offering the service to its members.

If you’re abroad, need hospitalization, haven’t planned ahead for a medical emergency, and don’t have the cash on hand to pay for it, there may still be a way home. The United States government may lend you the money. In 2006, the Overseas Citizens Services of the State Department issued 843 repatriation loans totaling a little over $1 million. (Once you get home, your passport is no longer valid until you pay the loan.) The office can also provide logistical support, translation services and medical referrals. To reach the office from overseas, call 202-501-4444, or contact the nearest embassy or consulate.

Quick Takes
People regularly taking anti-inflammatories like Motrin, Advil, etc. can cut their chances of having upper GI bleeding or ulcers in half by taking a proton-pump inhibitor like Prevacid or Prilosec (or generics).

A web based calculator for predicting the risk of hip fracture is available at hipcalculator.fhcrc.org.