Which imaging modality is best for suspected stroke?

Patients exhibiting stroke symptoms should have brain imaging immediately within 3 hours of symptom onset (strength of recommendation [SOR]: A, based on systematic review). In the first 3 hours after a suspected cerebrovascular accident (CVA), noncontrast head computerized tomography (CT) is the gold standard for diagnosis of acute hemorrhagic stroke (SOR: C, based on expert panel consensus). However, the sensitivity for hemorrhage declines steeply 8 to 10 days after the event. Eligibility guidelines for acute thrombolytic therapy are currently based on use of CT to rule out acute hemorrhagic stroke. Magnetic resonance imaging (MRI) may be equally accurate in diagnosing an acute hemorrhagic stroke if completed within 90 minutes of presentation for patients whose symptoms began fewer than 6 hours earlier (SOR: B, based on a single high-quality cohort study). MRI is more sensitive than CT for ischemic stroke in the first 24 hours of symptoms (SOR: B, based on systematic review of low-quality studies with consistent findings) and is more sensitive than CT in the diagnosis of hemorrhagic or ischemic stroke greater than 1 week after symptom onset (SOR: B, based on 1 high-quality prospective cohort study)

Are there Enough Doctors in My Community? People's Perception of Local Physician Supply

Purpose. To assess how closely people's perception of local physician supply relates to physician-to-population ratio, and identify what other factors are associated with this perception. Method. Adults (n=4,879) from 150 Southern rural counties completed telephone surveys November 2002-July 2003. Response to a question about perception of adequacy of local physician supply was analyzed with bivariate and multivariate methods assessing strength of association between this perception and actual physician-to-population ratio, individual characteristics, county characteristics, and perceptions about and experience with health care. Results. Respondents more likely to feel there were enough physicians in their area include those who were less likely to state: doctors should be used as a last resort (OR 2.0,p < .001 ), their travel time to care was less than 30 minutes (OR 1.52,p <.001), cost of care was not a problem for them (OR 1.45,p <.001), they were satisfied with the care they had received (OR 1.67,p=.023) and confident in the skills of their physician (OR 1.39, p=.006). Respondents in areas with higher physician-to-population ratios, who were over 65, White, male, and in good health were also more likely agree there were enough local doctors. In our model most variance in opinion about physician supply was explained by perceptions and experience variables, followed by individual characteristic variables, physician-to-population ratio, and county-level variables. Conclusions. People with positive perceptions about and experiences with health care are more likely to perceive that there are not enough physicians in their community. This perception was more strongly associated with perception of adequacy of physician supply than other variables, including physician-to-population ratio.Master of Public Healt

Preferences Versus Practice: Life-Sustaining Treatments in Last Months of Life in Long-Term Care

To determine the prevalence and correlates of decisions made about life-sustaining treatments among residents in long-term care settings, including how often decisions were honored and characteristics associated with decisions not being followed

The End-of-Life Experience in Long-Term Care: Five Themes Identified From Focus Groups With Residents, Family Members, and Staff

This study was designed to examine the end-of-life (EOL) experience in long-term care (LTC) based on input from key stakeholders

Advance Care Planning in Nursing Homes and Assisted Living Communities

To determine the prevalence and characteristics of advance care planning (ACP) among persons dying in long-term care (LTC) facilities, and to examine the relationship between respondent, facility, decedent, and family characteristics and ACP

Preferences Versus Practice: Life-Sustaining Treatments in Last Months of Life in Long-Term Care

PURPOSE: To determine the prevalence and correlates of decisions made about life-sustaining treatments among residents in long-term care settings, including how often decisions were honored and characteristics associated with decisions not being followed. DESIGN AND METHODS: Retrospective interviews with one family caregiver and one facility staff member for each of 327 decedents who received end-of-life care in 27 nursing homes (NHs) and 85 residential care/assisted living (RC/AL) settings in four states were analyzed with respect to decedent demographics, facility characteristics, prevalence of decisions made about medical interventions, proportion of residents whose decisions were heeded, and characteristics associated with decisions not being heeded. RESULTS: Most family caregivers reported making a decision with a physician about resuscitation (89.1%), inserting a feeding tube (82.1%), administering antibiotics (64.3%), and hospital transfer (83.7%). Reported care was inconsistent with decisions made in five of seven (71.4%) of resuscitations, one of seven feeding tube insertions (14.3%), 15 of 78 antibiotics courses (19.2%), and 26 of 87 hospital transfers (29.9%). Decedents who received antibiotics contrary to their wishes were older (mean age 92 versus 85, p= 0.014). More than half (53.8%) of decedents who had care discordant with their wishes about hospitalization lived in a NH compared to 32.8% of those whose decision were concordant (p=0.034). IMPLICATIONS: Most respondents reported decision-making with a doctor about life-sustaining treatments, but those decisions were not consistently heeded. Being older and living in a NH were risk factors for decisions not being heeded

Effect of the Inpatient General Medicine Rotation on Student Pursuit of a Generalist Career

BACKGROUND: Entry into general internal medicine (GIM) has declined. The effect of the inpatient general medicine rotation on medical student career choices is uncertain. OBJECTIVE: To assess the effect of student satisfaction with the inpatient general medicine rotation on pursuit of a career in GIM. DESIGN: Multicenter cohort study. PARTICIPANTS: Third-year medical students between July 2001 and June 2003. MEASUREMENTS: End-of-internal medicine clerkship survey assessed satisfaction with the rotation using a 5-point Likert scale. Pursuit of a career in GIM defined as: (1) response of “Very Likely” or “Certain” to the question “How likely are you to pursue a career in GIM?”; and (2) entry into an internal medicine residency using institutional match data. RESULTS: Four hundred and two of 751 (54%) students responded. Of the student respondents, 307 (75%) matched in the 2 years following their rotations. Twenty-eight percent (87) of those that matched chose an internal medicine residency. Of these, 8% (25/307) were pursuing a career in GIM. Adjusting for site and preclerkship interest, overall satisfaction with the rotation predicted pursuit of a career in GIM (odds ratio [OR] 3.91, P<.001). Although satisfaction with individual items did not predict pursuit of a generalist career, factor analysis revealed 3 components of satisfaction (attending, resident, and teaching). Adjusting for preclerkship interest, 2 factors (attending and teaching) were associated with student pursuit of a career in GIM (P<.01). CONCLUSIONS: Increased satisfaction with the inpatient general medicine rotation promotes pursuit of a career in GIM