The data could have big financial implications for health-care providers.

Last week, the U.S. Department of Health and Human Services (HHS) released information from more than 4,600 hospitals on its Hospital Compare Web site, which falls under the aegis of the Centers for Medicare & Medicaid Services (CMS).

“This new update to CMS’s Hospital Compare feature will help patients and their families better compare quality at America’s hospitals,” said HHS Secretary Kathleen Sebelius, as quoted in a department news release. “And thanks to this new update this year, for the first time, Medicare patients can see how efficiently facilities use certain types of imaging equipment and keep them safe from exposure to potentially harmful radiation that may not be necessary.”

Though the information is aimed at consumers, it’s not that easy to find on the site (here’s the download page), nor is it easy to read. However, it’s already having repercussions.

Based on advance word about the data, some hospitals have already started curtailing their use of double CT scans (one with a contrast agent, one without) of the chest and abdomen. CMS says a double scan is recommended for only a small number of conditions. But Health News Florida reported that, according to the data, some Florida hospitals perform the scans on more than half their patients, thus exposing them to a double dose of radiation.

“Certainly some of these scans are unnecessary,” said Barry M. Straube, MD, chief medical officer at CMS.

The Chicago Tribune reported that some Chicago-area hospitals had revised their policies to reduce double scans. Florida hospitals were also examining their procedures. However, some critics complained that the report was a pretty blunt instrument. An Illinois Hospital Association executive, for example, pointed out that the data merely describe how many scans a hospital performed, not whether they were medically justified or influenced by such factors as referrals from other hospitals.

The mammography data also raised questions. For example, Health News Florida reported that the data categorize most Florida hospital outpatient departments as performing either too many mammograms or too few. CMS says hospitals with mammogram recall rates (the percentage of mammography recipients who have a follow-up mammogram or ultrasound within 45 days) of greater than 14 percent may be performing too many follow-ups, and those with rates of less than 8 percent may be performing too few.

“I don’t know where they came up with those numbers,” David Ansell, MD, told the Tribune. Dr. Ansell is chief medical officer at Rush University Medical Center and president of the Metropolitan Chicago Breast Cancer Task Force. He suggested that different ways of evaluating mammography rates, such as determining how many cancers were detected per thousand women screened, would be more meaningful.

He and other critics had better make their cases now. Starting in October 2012, the government plans to use the Hospital Compare data to adjust payments for hospitals.

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Two radiology technicians have sued Bozeman Deaconess Hospital in Bozeman, Montana. They claim that, while working in a darkroom at the hospital, they were exposed to unsafe levels of X-ray film developing chemicals.

Court documents say one of the women began working at the hospital in 2000 and the other in 2007. Both women say that within a short time, they began experiencing fatigue, headaches, and other symptoms. In the court documents, they say they were exposed to “unhealthy and toxic levels of Glutaraldehyde and other harmful chemical gases associated with developing X-ray film.”

The documents claim that on May 20, 2009, maintenance workers discovered that the ventilation fan in the darkroom was not plugged in and had never operated. In the documents, the women say that because of the “dangerous chemicals” in the unventilated room, they suffered damages including “physical injuries, medical expenses, lost earning capacity, lost wages, pain and suffering, mental, physical and emotional distress, loss of established course of life, loss of household services and other injuries.”

According to the federal Occupational Health and Safety Administration (OSHA), glutaraldehyde is used in X-ray developing solutions as a hardening agent to shorten film drying time. The OSHA publication Best Practices for the Safe Use of Glutaraldehyde in Health Care says, “The most serious adverse health effect documented among employees exposed to glutaraldehyde vapor is occupational asthma, a chronic condition characterized by bronchial hyperresponsiveness.” There are no mandatory federal exposure limits, but the National Institute for Occupational Safety and Health recommends a maximum exposure limit of 0.2 parts per million.

The hospital responded: “Bozeman Deaconess Hospital voluntarily requested an on-site safety consultation in June 2009 by the Montana Occupational Safety and Health Bureau. The State of Montana’s representative reported that ‘[n]o hazards were found during the visit to Bozeman Deaconess Hospital’ in the area in question.”

The hospital said it would defend itself against the suit but declined to elaborate, citing its policy not to comment in detail regarding pending litigation.

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So concludes a group of German researchers who undertook “a selective literature review on recent technical innovations in the field of WB-MRI and the clinical uses of this new method, with particular emphasis on diagnostic imaging in oncology.” Their findings appear in the current issue of Deutsches Ärzteblatt International.

Here are some specific uses the researchers examined, along with their conclusions:

• Tumor screening. Because it does not involve ionizing radiation, WB-MRI may have some potential for screening of general, asymptomatic populations—but its time has not yet come, because of the low percentage of patients in which tumors were detected (less than 2%) and the lack of proven cost-effectiveness.
• Tumor staging. WB-MRI appears particularly effective in TNM staging of patients with gastrointestinal tumors, breast cancer, or malignant melanoma (diagnostic accuracy of 91%). It seems less effective in detecting lymph node or lung metastases or the staging of pulmonary tumors.
• Multiple myeloma and other bone-marrow diseases. Because of its good bone-marrow contrast, WB-MRI may be the best choice for detecting plasma cell neoplasms, particularly in early stages of the disease.
• Rheumatic diseases. MRI provides especially useful information in the early stages of rheumatic joint disease. Because rheumatoid arthritis can affect the whole body, WB-MRI might find early manifestations of this disease.
• Diabetes. “WB-MRI seems suitable for early diagnosis of secondary complications and for potentially more effective treatment planning in patients with diabetes mellitus, who have a high prevalence of cardiovascular diseases.”
• Benign bone tumors. Patients with multiple cartilaginous exostoses face considerable risk that the tumors will transform from benign to cancerous. WB-MRI can be particularly helpful in these cases because osteochondromas often occur in many different areas of the body and because many patients are young and thus would be at higher risk from repeated radiation exposure.

Technical advances now allow WB-MRI to be completed in less than an hour without loss of image quality. It seems likely that we’ve just started exploring its usefulness.

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“Asthma is a major health problem affecting 300 million people worldwide,” said Sumit Gupta, MBBS, a postgraduate student at the university. Dr. Gupta and colleagues at the Institute for Lung Health and Radiology Department at Glenfield Hospital in Leicester have been studying the use of CT in relation to severe asthma.

“Approximately half a million people in UK suffer from severe asthma and are, as a consequence, at increased risk of asthma attacks, hospitalization, and death, and often have severely impaired quality of life,” Dr. Gupta said. “Structural changes that occur in airways of asthmatic individuals remain difficult to quantify and monitor. Computed tomography scans have now emerged as a noninvasive research tool to assess these airway structural changes.”

Dr. Gupta and his colleagues have been looking at airway thickness, as measured by CT. Thicker airway walls are associated with worsening of lung function and inflammation of the airways. A novel therapy that suppressed airway inflammation resulted in reductions in both airway-wall thickness and asthma attacks among patients with severe asthma.

Chris Brightling, honorary consultant at the Institute for Lung Health and leader of this study, said, “Ability to objectively quantify different structural changes in asthma using CT may assist in differentiating various disease sub-types and help deliver personalized health care.”

Preliminary results of the study are scheduled to be presented June 24 at the University of Leicester’s Festival of Postgraduate Research. A university news release about the study didn’t address the risks of radiation exposure from the CT scans. However, patients with severe asthma obviously are more immediately concerned with being able to breathe than with radiation side effects that are not likely to manifest themselves for years, if at all.

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Crayfish—also known as crawdads and, particularly in the South, crawfish or mudbugs—commonly carry a parasite called Paragonimus kellicotti. A thorough cooking kills the half-inch oval worms. But if infected crayfish are eaten raw, the worms can travel from a person’s intestine to the lungs or to the brain, where they can cause severe headaches and vision problems. They can even migrate to just under the skin, where they appear as small, moving nodules.

Doctors at Washington University School of Medicine in St. Louis have diagnosed six cases of Paragonimus infection in the past three years, including three since September.

“The infection, called paragonimiasis, is very rare, so it’s extremely unusual to see this many cases in one medical center in a relatively short period of time,” said Washington University infectious diseases specialist Gary Weil, MD. Weil, professor of medicine and of molecular microbiology, treated some of the patients. “We’re almost certain there are other people out there with the infection who haven’t been diagnosed. That’s why we want to get the word out.”

Crayfish are freshwater creatures that resemble miniature lobsters. Boiled crayfish are considered a delicacy, especially in Louisiana. The Washington University doctors didn’t address the question of why anyone would eat them raw. Evidently some people do—though not many, because the disease is so unusual that most of the six Washington University patients had received multiple treatments for pneumonia and had undergone invasive procedures before being correctly diagnosed.

Paragonimiasis is seldom fatal and can be treated with praziquantel taken orally three times a day for just two days. All six Washington University patients recovered completely, including one man who had temporarily lost his vision because the parasites had invaded his brain.

To diagnose it, “you have to be a bit of a detective and be open to all the clues,” said Washington University infectious diseases specialist Thomas Bailey, MD, professor of medicine. Bailey diagnosed and treated the first case at the School of Medicine.

Infected patients show elevated levels of eosinophil white blood cells, and X-rays show excess fluid around the lungs and sometimes the heart.

In addition to alerting medical personnel, the Washington University doctors have a message for the public: “do not eat raw crayfish.”

Excellent advice. Boiled, however, they’re delicious. Here’s a recipe. Hurry, though; the season has just about ended.

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So, during the summer after his sophomore year in high school, he carried out a research project on the necessity and cost effectiveness of repeated chest X-rays in children who are dependent on home mechanical ventilation (HMV). On Monday, he presented his findings at the American Thoracic Society Annual Conference in New Orleans.

Kun turned 18 in April and will graduate from La Salle High School in Pasadena, California, later this month. It’s really true, he said, as quoted in the May 2010 edition of the ATS News electronic newsletter, that: “I used to be one of those kids who played video games all day.”

When he decided that there had to be more to life, he consulted his mother, Sheila Kun, a pulmonary registered nurse at Children’s Hospital Los Angeles. She, in turn, introduced her son to her mentor, Thomas G. Keens, MD, a pediatric pulmonologist at the hospital and professor of pediatrics, physiology, and biophysics at the University of Southern California’s Keck School of Medicine. Said young Kun:

Dr. Keens showed me a whole new world. He told me to go out every day and do something useful.

Kun figured it might be useful to examine the effects of repeated X-rays on HMV children admitted to the hospital for pneumonia. He used the hospital database to analyze records of 28 HMV patients ranging in age from 8 months to 16 years. He checked the number of chest X-rays they received and whether the results of those X-rays affected the patients’ treatment plans.

“These kids are often admitted to the hospital with pneumonia during viral winter seasons,” Kun said. “During their hospital course, chest X-rays are frequently used to assess their lung condition, but we do not know how often they should be used or whether they are helpful in prompting changes in treatment.”

Kun found that the 28 patients received an average of five chest X-rays per hospitalization, but that two-thirds of those X-rays did not result in any change in therapy within 24 hours. Nor were the majority of discharges contingent on X-ray findings.

“It’s interesting to note that some European physicians only use X-rays if they think something is going wrong, but here in the United States, X-rays are used to follow a patient’s progress,” Kun said. “Based on this observation, we can speculate that lowering the frequency of chest X-rays could be beneficial to patients, as they are not the sole predictors of how a respiratory patient’s treatment course should be changed.”

Kun will attend the University of California at Davis in the fall. He’s undecided about his career, but thinks he might pursue his interest in how economics and the practice of medicine intersect. “With health-care reform,” he said, “it will be increasingly important to review costs and benefits.”

Smart kid.

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Cryptococcus gattii, an airborne fungus normally seen only in tropical and subtropical regions, mysteriously showed up in 1999 on Canada’s Vancouver Island. Nobody knows how it got there or why it’s thriving in a temperate climate. So far, it has killed 19 of 218 known victims (8.7 percent) in the province of British Columbia. Since 2004, it has been reported in Washington and Oregon as well.

A study published on April 22 in the journal PLoS Pathogens reported that a new, highly virulent strain has appeared in Oregon, where it has killed 6 of 21 known victims—a frightening mortality rate of more than 28 percent. Even scarier is the fact that, though fungal infections typically strike people with weakened immune systems, most Cryptococcus gattii victims have been otherwise healthy.

The study warns that the disease is likely to spread into Northern California and possibly beyond. Edmond Byrnes, one of the study’s co-authors, told National Geographic:

The alarming thing is that it’s occurring in this region, it’s affecting healthy people, and geographically it’s been expanding.

The infection begins when the fungal spores, found on and near trees, are inhaled. The fungus starts to grow in the lungs, creating pulmonary nodules or opacities. An estimated 20 percent of victims develop meningitis. The disease has also been found in a variety of domestic and wild animals, even dolphins.

There is some good news. The disease seems to infect only a tiny percentage of those who are exposed to it. It cannot spread from person to person, and it can be treated with antibiotics, although treatment often must continue for months.

As with most diseases, early diagnosis greatly improves the prognosis. However, Cryptococcus gattii can lurk undetected in the body for a long time. From the point of infection it takes an average of six months for symptoms to appear. The symptoms vary, but often include coughing and shortness of breath, night sweats, fever and chills, headache, chest pain, neck pain and stiffness, weight loss, light sensitivity and decreased alertness.

The PLoS Pathogens article points out that even those outside the Pacific Northwest should be on the alert for this infection:

The potential dangers of travel-associated risks should be noted, as a growing number of cases attributable to travel within the Pacific NW region have been documented.

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The CDC, in 2007, made changes to the treatment and screening protocol of potential immigrants. They required more testing, in their native countries, for those who showed signs of TB, and they sought six months or more of treatment for actual TB patients and insured that they were infection free before immigrating. More changes included the screening of people under the age of 15 who had not yet been tested.

Actual US numbers last year recorded 11,540 cases, as opposed to 12,904 in 2008, or 3.8 cases in 100,000 people, as opposed to 4.2 for 2008. Sixty percent of the patients were legal and illegal immigrants from Vietnam, India, Mexico and the Philippines.

Though numbers of TB patients have been decreasing annually, and significantly since the 1800s when one out of every seven died from it, they have only done so at about 4% a year. Because of the recent larger ratio, record keepers have looked at other possible scenarios, such as under-diagnosis and fewer treatments overall, and have rejected them. They considered the latest budget cuts in local health departments, which might have indicated a determining factor, for instance, but that would have made sense only if case numbers had gone up.

“This is provisional data and still needs to be scrutinized,” said Michael Leonard, MD, an infectious diseases specialist from Emory University. Still, “more aggressive measures to identify and stop the spread of TB may be paying off,” Carla Winston, PhD, CDC epidemiologist and lead author of the report, said.

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“The case certainly seems compelling for use of lung scintigraphy to diagnose PE in patients with clear chest X-rays, especially in women of childbearing age,” wrote C. Richard Goldfarb, MD, in a review of an article in Radiology Today.

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Using data from CT scans and pulmonary function tests performed on 27 patients, researchers in France compared bronchial measurements in 15 men and women with asthma to those of 12 healthy people. The team used special software to compute lumen area (LA), total area (TA), and wall area (WA). Compared to their healthier counterparts, the people with asthma had signficantly lower LA, TA, and WA and higher WA/LA and WA/TA ratios from the fourth generation bronchus and downward.

“It would be interesting to see if there is any reversal in these changes depending upon pharmacologic therapy,” says Vineet R. Jain, MD, who reviewed the study.

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