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The diagnostic imaging of patients presenting with right lower quadrant pain and suspected appendicitis may be organized according to age and gender and to the presence or absence of “classic” signs and symptoms of acute appendicitis. Among adult patients presenting with clinical signs of acute appendicitis, the sensitivity and specificity of CT are greater than those of ultrasound, with improved performance when CT is performed with intravenous contrast. The use of rectal contrast has been associated with decreased time in the emergency department. Computed tomography has also been shown to reduce cost and negative appendectomy rates. Both CT and ultrasound are also effective in the identification of causes of right lower quadrant pain unrelated to appendicitis. Among pediatric patients, the sensitivity and specificity of graded-compression ultrasound can approach those of CT, without the use of ionizing radiation. Performing MRI after inconclusive ultrasound in pregnant patients has been associated with sensitivity and specificity of 80% to 86% and 97% to 99%, respectively. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to an article on salaried general practitioners (GP).

Objective: Physicians' fears of being sued may lead to defensive medical practices, such as ordering nonindicated medical imaging. We investigated the association between states' medical malpractice tort reforms and neurologic imaging rates for patients seen in the emergency department with mild head trauma., Methods: We assessed neurologic imaging among a national sample of 8588 women residing in 10 US states evaluated in an emergency setting for head injury between January 1, 1992, and December 31, 2001. We assessed the odds of imaging as it varied by the enactment of medical liability reform laws., Results: The medical liability reform laws were significantly associated with the likelihood of imaging. States with laws that limited monetary damages (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.40-0.99), mandated periodic award payments (OR, 0.64; 95% CI, 0.43-0.97), or specified collateral source offset rules (OR, 0.62; 95% CI, 0.40-0.96) had an approximately 40% lower odds of imaging, whereas states that had laws that limited attorney's contingency fees had significantly higher odds of imaging (OR, 1.5; 95% CI, 0.99-2.4), compared to states without these laws. When we used a summation of the number of laws in place, the greater the number of laws, the lower the odds of imaging. In the multivariate analysis, after adjusting for individual and community factors, the total number of laws remained significantly associated with the odds of imaging, and the effect of the individual laws was attenuated, but not eliminated., Conclusion: The tort reforms we examined were associated with the propensity to obtain neurologic imaging. If these results are confirmed in larger studies, tort reform might mitigate defensive medical practices., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Tobacco-related mortality is one of the biggest killers in American medicine. Evidence suggests that if adolescents can be kept tobacco-free, most will never start using tobacco. Therefore, tobacco control policies directed at the youth population could provide an effective method for sustaining long-term reductions in smoking in all segments of the population. Many forms of tobacco control policies have been implemented including restrictive laws, public campaigns, and taxation duties; there has been disagreement over which is most effective. We investigate the efficacy of various methods of tobacco control in youth and present a review of the published evidence. Econometric data for both youth access restrictions and environmental tobacco smoke restrictions afford ambiguous results. Results vary in a continuum from a moderate negative effect toward, ironically, a marginal positive effect on smoking. While information dissemination policies may be somewhat effective on the onset, they are limited in their effect and eventually diminish over time. We conclude that increases in price affect teen smoking to a great degree. Most estimates show that for a 10 percent increase in prices, which could be implemented by a tax per pack, a 15 percent decrease in cigarettes consumed could be accomplished. Taxation policies are an effective means of preventative medicine.

Virtually all smoking begins in our population's youth and remains as a habit into those smokers' elder years. If we desire to halt smoking in its infancy, we should seek to deter and induce cessation in the youth years. It has been cited that taxation is an effective means to deter smoking at all ages, particularly efficacious in the youth population. This paper explores the merits of this method of preventative medicine, and intends to investigate differences between the price elasticity of cigarette demand between various cohorts, particularly the adult versus the youth population. We use a two-variable log-log, ordinary least-squares econometric regression to determine the extent that price alterations have on participation rates and quantity smoked. Our results show that youth are quite responsive to price increases showing a decrease of 14 percent prevalence in smoking for a 10 percent increase in price; whereas, the adult population is relatively less responsive to such price changes, exhibiting nearly a 2 percent decrease in prevalence for a 10 percent increase in price. We conclude that taxation is an effective means of socially-enacted preventative medicine in deterring youth smoking.