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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_445"
                     title="Physician Charged in Michael Jackson Death"
                     score="0.013"
                     href="http://www.medpagetoday.com/EmergencyMedicine/EmergencyMedicine/tb/18368?impressionId=1265813268871"
                     
      &lt;p&gt;Conrad Robert Murray, MD, the physician attending Michael Jackson when the pop singer died of cardiac arrest last June, has been charged with involuntary manslaughter in Los Angeles.&lt;/p&gt;
&lt;p&gt;Murray was to be arraigned this afternoon. If convicted, he could receive a maximum prison term of four years.&lt;/p&gt;
&lt;p&gt;According to the L.A. County District Attorney&apos;s office, Murray &quot;did unlawfully, and without malice, kill Michael Joseph Jackson . . . in the commission of an unlawful act, not amounting to a felony; and in the commission of a lawful act which might have produced death, in an unlawful manner, and without due caution and circumspection.&quot;&lt;/p&gt;
&lt;p&gt;Witnesses said Murray was with Jackson when the 50-year-old singer collapsed at his rented home in Beverly Hills. Murray tried to revive Jackson there with CPR, then accompanied him to a hospital. Jackson was pronounced dead at the hospital without regaining consciousness.&lt;/p&gt;
&lt;p&gt;Subsequent statements from investigators indicated that Murry had injected Jackson with the anesthetic agent propofol earlier that day, apparently to help Jackson sleep.&lt;/p&gt;
&lt;p&gt;The singer had long complained of insomnia, according to news reports.&lt;/p&gt;
&lt;p&gt;After an autopsy, the Los Angeles county coroner&apos;s office &lt;a href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/15736&quot; mce_href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/15736&quot; target=&quot;_blank&quot;&gt;ruled in August&lt;/a&gt; that Jackson died of an overdose involving multiple drugs, including propofol and lorazepam (Ativan). Other drugs found in his system included midazolam, diazepam, lidocaine, and ephedrine.&lt;/p&gt;
&lt;p&gt;News reports indicated that other physicians besides Murray had prescribed drugs for Jackson. In addition to insomnia, the singer was believed to suffer from chronic pain related to burns suffered during the filming of a television commercial years earlier.&lt;/p&gt;
&lt;p&gt;The Reuters news service reported that Murray had told investigators he was not the first physician to give propofol to Jackson.&lt;/p&gt;
&lt;p&gt;In numerous public statements, Murray has maintained his innocence of wrongdoing.&lt;/p&gt;
&lt;p&gt;When Jackson died, he was about two weeks from beginning a series of 50 concerts in London, his first major performance effort in a decade. The posthumous concert film &quot;This Is It&quot; was filmed during rehearsals for the series.&lt;/p&gt;
&lt;p&gt;Although paparazzi photographs released in the months prior to his death portrayed the singer looking frail and gaunt  --  one showed him in a wheelchair  --  he appeared healthy in the film.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_439"
                     title="Heart Often Affected in Churg-Strauss (CME/CE)"
                     score="0.013"
                     href="http://www.medpagetoday.com/Rheumatology/GeneralRheumatology/tb/18353?impressionId=1265813268871"
                     
      &lt;p&gt;Cardiac involvement is common in patients with Churg-Strauss syndrome, even when their vasculitis is in clinical remission, a Dutch study found.&lt;/p&gt;
&lt;p&gt;Cardiac MRI detected abnormalities in 62% of patients with this rare, systemic disorder but in only 3% of matched controls (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), according to Robert M. Dennert, MD, of Maastricht University in the Netherlands, and colleagues.&lt;/p&gt;
&lt;p&gt;Yet only 26% of the patients had clinical symptoms suggesting cardiac involvement, the researchers reported in February&apos;s &lt;em&gt;Arthritis &amp;amp; Rheumatism.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;Cardiac involvement is an important predictor of poor outcome in Churg-Strauss syndrome, with approximately half of the associated mortality being heart-related. Myocardial damage typically results from eosinophilic infiltration and granuloma formation.&lt;/p&gt;
&lt;p&gt;However, the cardiac manifestations are often subclinical. They remain undiagnosed, and the exact incidence is unclear.&lt;/p&gt;
&lt;p&gt;So Dennert and colleagues enrolled 32 patients with confirmed Churg-Strauss syndrome who were in complete clinical remission, performing detailed imaging assessments to determine the frequency and extent of heart involvement.&lt;/p&gt;
&lt;p&gt;About two-thirds were men. The mean age was 61 years, and disease duration was slightly over six years.&lt;/p&gt;
&lt;p&gt;A total of 41% had antineutrophil cytoplasmic antibodies (ANCA), and most were on maintenance steroids or immunosuppressants.&lt;/p&gt;
&lt;p&gt;On EKG, major abnormalities (atrial fibrillation and conduction disturbances) were detected in only 13% of patients. Minor abnormalities such as T wave abnormalities were seen in 50% of patients and in one control subject.&lt;/p&gt;
&lt;p&gt;Echocardiography identified abnormalities in 50% of patients and in 3% of controls (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001). These included wall motion and valvular abnormalities, pericardial effusion, and pulmonary hypertension.&lt;/p&gt;
&lt;p&gt;In the 62% of patients whose MRIs revealed abnormalities, findings included fibrosis, inflammation, wall motion and valvular abnormalities, pericardial effusion, and obliterated right ventricle.&lt;/p&gt;
&lt;p&gt;Previous reports had suggested that ANCA positivity in Churg-Strauss syndrome was more often associated with renal disease and peripheral neuropathy, while ANCA negativity was associated with fever and heart involvement.&lt;/p&gt;
&lt;p&gt;In this cohort, 74% of ANCA-negative patients had cardiac involvement, and in 64%, these were wall motion disturbances.&lt;/p&gt;
&lt;p&gt;In comparison, only 23% of ANCA-positive patients had heart involvement.&lt;/p&gt;
&lt;p&gt;Defects were identified with echocardiography or MRI in 88% of patients who had clinical symptoms, and in all who had major EKG abnormalities.&lt;/p&gt;
&lt;p&gt;But in the absence of symptoms and even with a normal EKG, abnormalities could still be detected on echocardiography or MRI in almost 40% of patients, according to the investigators.&lt;/p&gt;
&lt;p&gt;&quot;We therefore recommend that the evaluation for cardiac involvement in patients with [Churg-Strauss syndrome] should include not only detailed history of cardiac symptoms and EKG, but also imaging with echocardiography or cardiac MRI,&quot; they stated.&lt;/p&gt;
&lt;p&gt;The high prevalence of heart abnormalities could not be attributed to concomitant heart disease such as coronary artery disease or hypertension, because the prevalence of these diseases among patients was comparable to that in controls.&lt;/p&gt;
&lt;p&gt;Churg-Strauss syndrome typically develops in three phases, beginning with asthma, followed by peripheral and tissue eosinophilia accompanied by pulmonary infiltrates, and finally the systemic small-vessel vasculitis.&lt;/p&gt;
&lt;p&gt;During this late phase the vasculitic lesions in the coronary vessels and myocardium can lead to myocardial infarction, heart failure, and cardiac tamponade.&lt;/p&gt;
&lt;p&gt;Studies have shown that long-term treatment with immunosuppressive drugs can improve survival and resolve the cardiac abnormalities, so early diagnosis is needed.&lt;/p&gt;
&lt;p&gt;The authors acknowledged that their study was cross-sectional, and that a longitudinal study could have provided more detailed data.&lt;/p&gt;
&lt;p&gt;Nonetheless, the study revealed a high incidence of cardiac involvement, which was often unrecognized, and they concluded that a multidisciplinary approach to management therefore should include a cardiologist.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the Netherlands Heart Foundation and the Dutch Organization for Scientific Research.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_380"
                     title="AMA Opens Site for Physicians Looking to Help Haiti"
                     score="0.011"
                     href="http://www.medpagetoday.com/EmergencyMedicine/EmergencyMedicine/tb/18271?impressionId=1265813268871"
                     
      &lt;p&gt;The AMA has launched a &lt;a href=&quot;http://www.ama-assn.org/go/haiti-volunteer&quot; mce_href=&quot;http://www.ama-assn.org/go/haiti-volunteer&quot; target=&quot;_blank&quot; title=&quot;AMA&amp;#8200;Haiti&amp;#8200;volunteer&amp;#8200;site&quot;&gt;Web site &lt;/a&gt;to help coordinate healthcare professionals who want to volunteer for the medical relief effort in Haiti.&lt;/p&gt;
&lt;p&gt;The site hosts a registry where volunteers can enter their names and contact information, credentials, and other relevant language and disaster relief skills.&lt;/p&gt;
&lt;p&gt;The registry will be used for aid to Haiti and in future disasters that may require volunteer physician support, the AMA said in a statement.&lt;/p&gt;
&lt;p&gt;The AMA site also contains a free online training program that offers potential volunteers insight into the clinical and public healthcare skills necessary to aid in the relief effort.&lt;/p&gt;
&lt;p&gt;The page was created at a time when the number of hospitalizations and new patients has started to decline, AMA president J. James Rohack, MD, noted, but &quot;the need for continued medical assistance is still significant.&quot;&lt;/p&gt;
&lt;p&gt;&quot;I encourage physicians to consider how they can help with this effort,&quot; he declared.&lt;/p&gt;
&lt;p&gt;Some observers have criticized the large volume of doctors swarming to the disaster-stricken nation, claiming the additional burden placed on already limited food, water, and housing resources comes at a time when engineers have not yet rebuilt the necessary housing and plumbing outlets.&lt;/p&gt;
&lt;p&gt;The Web site itself cautioned would-be volunteers that Haiti is still in desperate condition. &quot;Physicians must be prepared to provide care in a physically challenging, austere, resource-constrained environment. It is imperative that those involved in the relief effort be self-sufficient and are able to work independently,&quot; the site warned.&lt;/p&gt;
&lt;p&gt;The AMA publishes the journal &lt;em&gt;Disaster Medicine and Public Health Preparedness&lt;/em&gt;, which it said would serve as a valuable resource to potential volunteers.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_471"
                     title="Early Pregnancy Determines Late Outcomes (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18405?impressionId=1265813268871"
                     
      &lt;p&gt;Growth of the fetus during the first trimester  --  when essential organ development is completed  --  lays the foundation for important outcomes in pregnancy and early childhood, Dutch researchers found.&lt;/p&gt;
&lt;p&gt;Restricted first-trimester growth appeared to more than double the risk of preterm birth, low birth weight, and small size for gestational age at birth in a prospective study led by Vincent W.V. Jaddoe, MD, PhD, of Erasmus Medical Center in Rotterdam.&lt;/p&gt;
&lt;p&gt;Infants who didn&apos;t grow as much as expected during the first trimester also showed accelerated &quot;catch-up&quot; growth up to their second birthday  --  a well-established risk factor for later metabolic and cardiovascular disease.&lt;/p&gt;
&lt;p&gt;&quot;It could be that growth as early as in the first trimester of pregnancy is associated with disease in adulthood, although longer follow-up studies are necessary to examine this relationship,&quot; the researchers wrote in the Feb. 10 &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;This and prior studies suggest that women at high risk of problems late in pregnancy could be identifiable in the first trimester, with the potential for trials of screening and early intervention, according to an accompanying editorial by Gordon C.S. Smith, MD, PhD, of the University of Cambridge, England.&lt;/p&gt;
&lt;p&gt;The challenge, Smith wrote, will be to &quot;produce robust screening tests with acceptable levels of detection and prediction, and to identify interventions that are effective in improving outcome when a pregnancy has been identified as high risk.&quot;&lt;/p&gt;
&lt;p&gt;The researchers&apos; population-based, prospective Generation R Study included 1,631 pregnant women in Rotterdam with a known and reliable first day of their last menstrual period and a regular menstrual cycle.&lt;/p&gt;
&lt;p&gt;Fetal crown-to-rump length, measured by ultrasound between the gestational age of 10 weeks 0 days and 13&lt;/p&gt;
&lt;p&gt;weeks 6 days, is typically used to determine gestational age. But in this study it served as the main parameter of first-trimester fetal growth.&lt;/p&gt;
&lt;p&gt;Predictors of restricted fetal growth in multivariate analyses included the following (given as standard deviation growth score): &lt;ul&gt; &lt;li&gt;Younger maternal age (0.10 per 4.68-year standard deviation increase, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) &lt;/li&gt; &lt;li&gt;Higher maternal diastolic blood pressure (&amp;#8722;0.05 per 9.52-mm Hg standard deviation increase, &lt;em&gt;P&lt;/em&gt;=0.03) &lt;/li&gt; &lt;li&gt;Higher hematocrit level (&amp;#8722;0.07 per 2.50% standard deviation increase, &lt;em&gt;P&lt;/em&gt;=0.02) &lt;/li&gt; &lt;li&gt;Smoking (&amp;#8722;0.13, &lt;em&gt;P&lt;/em&gt;=0.03)&lt;/li&gt; &lt;li&gt;Folic acid supplement use (0.17, &lt;em&gt;P&lt;/em&gt;=0.03) &lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;After adjustment for multiple testing, only hematocrit and maternal age remained significant factors, but smoking and nonoptimal use of folic acid supplements together produced a significant reduction in first-trimester fetal growth (SD score &amp;#8722;0.52, 95% CI &amp;#8722;0.78 to &amp;#8722;0.25, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for interaction).&lt;/p&gt;
&lt;p&gt;Higher hematocrit levels may indicate lower circulating plasma volume. That in turn could lead to suboptimal placental perfusion, the researchers suggested as a possible explanation for the importance of this factor.&lt;/p&gt;
&lt;p&gt;The impact on pregnancy outcomes was significant for all adverse birth outcomes assessed. Compared with normal first-trimester fetal growth, growth restriction was associated with the following risks: &lt;ul&gt; &lt;li&gt;2.12-fold higher adjusted odds of preterm birth before 37 weeks&apos; gestation (4.0% versus 7.2%, &lt;em&gt;P&lt;/em&gt;=0.006).&lt;/li&gt; &lt;li&gt;2.42-fold higher adjusted odds of low birth weight, defined as less than 2,500 g or 5 lb 8 oz (3.5% versus 7.5%, &lt;em&gt;P&lt;/em&gt;=0.001).&lt;/li&gt; &lt;li&gt;2.64-fold higher adjusted odds of being small for gestational age at birth, defined as in the lowest 20% (4.0% versus 10.6%, &lt;em&gt;P&lt;/em&gt;=0.001). &lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Independent of birth weight, fetal growth restriction in the first trimester accelerated postnatal growth until age 2 years (0.139 standard deviation score increase over two years per standard deviation fetal-crown-to-rump length decrease, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Even though they included only women with reliable menstrual cycles, the authors noted, misclassification of gestational age might still have been an issue, depending on timing of ovulation and implantation.&lt;/p&gt;
&lt;p&gt;&quot;Further studies are needed to assess the associations of first-trimester growth variation on the risks of disease in later childhood and adulthood,&quot; they concluded.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The first phase of the Generation R Study was financially supported by the Erasmus Medical Center, the Erasmus University Rotterdam, and the Netherlands Organization for Health Research.&lt;/p&gt;&lt;p&gt;Jaddoe reported receipt of funding from the Netherlands Organization for Health Research.&lt;/p&gt;&lt;p&gt;The researchers reported no conflicts of interest.&lt;/p&gt;&lt;p&gt;Smith reported having been a member of preterm labor advisory boards for GlaxoSmithKline. He also reported funding from Cambridge National Institute for Health Research Biomedical Research Centre, Cambridge University Hospitals, NHS Foundation Trust.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_470"
                     title="For-Profit Hospitals Most Likely to Overtreat Dementia Patients (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Geriatrics/Dementia/tb/18402?impressionId=1265813268871"
                     
      Tube-feeding patients with advanced dementia  --  a practice whose effectiveness has been questioned by two widely cited literature reviews  --  is most common in larger hospitals and those run for profit, researchers said.&lt;br&gt;
&lt;br&gt;The odds of a feeding-tube insertion in a hospitalized patient with advanced dementia were about 50% greater when the hospital was larger than 310 beds than in facilities with 100 beds or less, and it was 33% more common in for-profit versus government-owned facilities, reported Joan M. Teno, MD, of Brown University in Providence, R.I., and colleagues.&lt;br&gt;
&lt;br&gt;Hospitals that frequently admitted elderly patients in the last six months of life to their ICUs  --  signifying a pattern of aggressive end-of-life care  --  were also substantially more likely to use tube feeding, the researchers wrote in the Feb. 10 &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;At some 12% of the 2,797 acute-care hospitals included in the analysis, which covered an eight-year period ending in 2007, feeding tubes were never used in patients with advanced dementia.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;In others, however, such patients were intubated for feeding at rates of up to 38.9 per 100 hospitalizations.&lt;/p&gt;
&lt;p&gt;Teno and colleagues suggested that many of these insertions reflect overtreatment. They cited previous research showing that tube feeding &quot;does not improve survival, prevent aspiration pneumonia, heal or prevent decubitus ulcers, or improve other clinical outcomes.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Feeding tube insertion in persons with advanced cognitive impairment demonstrates a disconnect with the existing evidence of their effectiveness,&quot; Teno and colleagues commented. &quot;Many experts have expressed concerns regarding the overuse of feeding tubes.&quot;&lt;/p&gt;
&lt;p&gt;They called for more research into the decision-making processes that produce such variations among hospitals and interventions to reduce unnecessary insertions and those that conflict with patients&apos; preferences.&lt;/p&gt;
&lt;p&gt;Teno and colleagues analyzed data on some 163,000 patients included in the U.S. Nursing Home Minimum Data Set whose records indicated an age greater than 65, advanced cognitive impairment, lack of prior tube feeding, and an acute-care hospitalization from 2000 to 2007.&lt;/p&gt;
&lt;p&gt;They also had data on the size and business structure of the hospitals to which patients were admitted.&lt;/p&gt;
&lt;p&gt;The researchers found the following adjusted odds ratios for hospital characteristics associated with feeding tube insertions: &lt;ul&gt; &lt;li&gt;Business model: 1.33 (95% CI 1.21 to 1.46) for for-profit versus government owned.&lt;/li&gt; &lt;li&gt;Size: 1.48 (95% CI 1.35 to 1.63) for more than 310 beds versus less than 101 beds.&lt;/li&gt; &lt;li&gt;ICU use in failing elderly patients: 2.60 (95% CI 2.20 to 3.06) for highest decile of ICU care in the last six months of life versus the lowest decile.&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The adjustments included age, gender, race and ethnicity, medical history, degree of cognitive impairment, advanced care directives, and durable power of attorney.&lt;/p&gt;
&lt;p&gt;The differences were much greater before the adjustments. For example, the raw data showed a rate of 8.0 feeding tube insertions per 100 hospitalizations at large facilities compared with 4.3 per 100 in small hospitals.&lt;/p&gt;
&lt;p&gt;Similarly, hospitals with the most aggressive ICU use in elderly patients had an insertion rate of 10.1 per 100 hospitalizations, while those with the lowest ICU use in such patients had a mean rate of 2.9 per 100.&lt;/p&gt;
&lt;p&gt;Teno and colleagues also found that some other hospital factors  --  such as the ratio of specialists to general medicine physicians and the use of hospice services  --  did not significantly predict feeding tube use.&lt;/p&gt;
&lt;p&gt;On the other hand, indicators of advanced care planning were significantly associated with reduced feeding tube insertions, although perhaps not as much as would be expected.&lt;/p&gt;
&lt;p&gt;Expressed as adjusted odds ratios, the rate reductions were: &lt;ul&gt; &lt;li&gt;Living will: 0.75 (95% CI 0.70 to 0.79)&lt;/li&gt; &lt;li&gt;Durable power of attorney: 0.88 (95% CI 0.84 to 0.91)&lt;/li&gt; &lt;li&gt;DNR orders: 0.65 (95% CI 0.62 to 0.67)&lt;/li&gt; &lt;li&gt;Orders to forgo artificial hydration and nutrition: 0.73 (95% CI 0.67 to 0.80)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;&quot;These results raise more questions than answers,&quot; Teno and colleagues noted in calling for additional research into the reasons for the trends they identified.&lt;/p&gt;
&lt;p&gt;&quot;Future research to examine these reported variations should focus on decision making for feeding tube insertion in hospitalized nursing home residents with dementia. Additionally, the role that hospitals and nursing homes have in advance care planning is critically important,&quot; they wrote, noting that advanced care planning is often neglected in nursing homes.&lt;/p&gt;
&lt;p&gt;Teno and colleagues noted some limitations to the study, notably the reliance on administrative records for most data, as well as the lack of information on physician counseling and patient preferences beyond the orders recorded in the database.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The National Institute on Aging funded the study.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>
