Lit Bits: Oct 28, 2009

From the recent medical literature...

1. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial

Jabre P, et al. Lancet. 2009;374(9686):293-300.

Introduction
Critically ill patients often require emergency orotracheal intubation for airway control. Rapid sequence intubation with administration of a sedative and a paralytic agent is common. Etomidate is the sedative-hypnotic drug that is most often used in rapid sequence intubation, but its use has been challenged because it can cause a reversible adrenal insufficiency by dose-dependent inhibition of 11β-hydroxylase.

Several studies have suggested an association between the use of etomidate and the occurrence of adrenal insufficiency and increased morbidity in critically ill or injured patients, particularly in those with sepsis. Because adrenal insufficiency when a patient is critically ill can increase the risk of death, several investigators have advised against the use of etomidate, even as a single bolus.9 However, no causal link has been established between its use and an increase in morbidity and mortality.

Etomidate's haemodynamic tolerance, even in patients with shock, and the excellent intubation conditions provided have to be weighed against potential adverse effects, including adrenal insufficiency. A possible alternative to etomidate is ketamine, which is not known to inhibit the adrenal axis. The aim of this randomised controlled study was to compare early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients.

Abstract
BACKGROUND: Critically ill patients often require emergency intubation. The use of etomidate as the sedative agent in this context has been challenged because it might cause a reversible adrenal insufficiency, potentially associated with increased in-hospital morbidity. We compared early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients.

METHODS: In this randomised, controlled, single-blind trial, 655 patients who needed sedation for emergency intubation were prospectively enrolled from 12 emergency medical services or emergency departments and 65 intensive care units in France. Patients were randomly assigned by a computerised random-number generator list to receive 0.3 mg/kg of etomidate (n=328) or 2 mg/kg of ketamine (n=327) for intubation. Only the emergency physician enrolling patients was aware of group assignment. The primary endpoint was the maximum score of the sequential organ failure assessment during the first 3 days in the intensive care unit. We excluded from the analysis patients who died before reaching the hospital or those discharged from the intensive care unit before 3 days (modified intention to treat). This trial is registered with ClinicalTrials.gov, number NCT00440102.

FINDINGS: 234 patients were analysed in the etomidate group and 235 in the ketamine group. The mean maximum SOFA score between the two groups did not differ significantly (10.3 [SD 3.7] for etomidate vs 9.6 [3.9] for ketamine; mean difference 0.7 [95% CI 0.0-1.4], p=0.056). Intubation conditions did not differ significantly between the two groups (median intubation difficulty score 1 [IQR 0-3] in both groups; p=0.70). The percentage of patients with adrenal insufficiency was significantly higher in the etomidate group than in the ketamine group (OR 6.7, 3.5-12.7). We recorded no serious adverse events with either study drug.

INTERPRETATION: Our results show that ketamine is a safe and valuable alternative to etomidate for endotracheal intubation in critically ill patients, and should be considered in those with sepsis.

FUNDING: French Ministry of Health.

Discussion
Our study shows that one etomidate bolus is not associated with a significant increase in morbidity or mortality compared with ketamine in patients admitted to the intensive care unit. The maximum SOFA score did not differ significantly between the two drugs in the subgroup of patients having sepsis or trauma. However, for the subgroup of septic patients (n=76), the small number of patients might account for the absence of significant difference. The mortality rate at day 28 in this subgroup did not differ between the treatment groups.

An association between the administration of etomidate and an increased mortality of patients with sepsis has been suggested previously. In a retrospective study of children with meningococcal sepsis or shock, mortality rate was 30% in patients who received etomidate versus 12% in those who did not, but the difference was not significant (OR 3•1 [95% CI 0•3–79•3]). In a post-hoc analysis of the Corticus study undertaken in patients with severe sepsis, the 28-day mortality rate was significantly higher in patients who received etomidate than in those who did not (p=0•03). The investigators, however, did not draw any cause and effect conclusion, presumably because of the lack of randomisation to sedative agents.

By contrast with the substantial increase in mortality reported by Ledingham and Watts, etomidate did not affect outcome in trauma patients in our study. This discrepancy between the two studies is probably related to the duration of etomidate administration: one bolus in our study versus prolonged sedation in Ledingham and Watts' study. Hildreth and co-workers reported increased use of blood products, ventilator days, and days in intensive care in trauma patients randomly assigned to etomidate (n=18) versus midazolam (n=12), but reported no difference in mortality. However, interpretation of this study is difficult because half of the eligible patients were excluded, with 11 of 31 patients having received etomidate.

Although adrenal axis dysfunction arises to some extent after etomidate use for rapid sequence intubation, the effect of such adrenal suppression on patients' outcome remains debated. Studies have reported increased mortality in non-responders to the adrenocorticotropin hormone stimulation test and in patients with adrenal insufficiency. One bolus of etomidate decreases cortisol secretion, which contributed to the increased morbidity and mortality reported in several studies. However, these findings have not been confirmed by other investigators. Clearly, the results of these studies could be biased owing to the presence of multiple confounding factors.

Our study confirms the finding of others that etomidate affects the adrenal axis: according to our criteria, more than four-fifths of etomidate recipients had adrenal insufficiency and were non-responders to the adrenocorticotropin hormone stimulation test. About half of patients given ketamine also had adrenal insufficiency, which emphasises that critical illness per se affects adrenal function. In one study, more than 30% of non-responders had not been exposed to etomidate, and in another, 51% of patients with septic shock who had not received etomidate were non-responders. Indeed, multiple mechanisms could account for adrenal insufficiency in critically ill patients. Adrenal insufficiency is probably associated with increased mortality in critically ill patients, including those with sepsis; however, whether the adrenal axis suppression and mortality are the result of some underlying process, or whether the adrenal axis suppression causes death, has never been established. Among established independent predictors of low cortisol response to adrenocorticotropin hormone stimulation are a low pH or bicarbonate and platelet count, disease severity, and organ failure. Fentanyl or sufentanil infusion can also modify cortisol concentrations. However, these factors should not affect the results of our study since both patient groups received the same type of continuous sedation (fentanyl or sufentanil combined with midazolam).

Etomidate is the sedative-hypnotic drug most often used by emergency physicians for rapid sequence intubation, and is the drug of choice for patients who are haemodynamically unstable. Use of ketamine instead of etomidate might have drawn attention to potential adverse effects of the use of ketamine during the intubation procedure. The most common side-effects of ketamine are psychodysleptic effects, but they could not be observed because, unlike in an operating theatre, patients are not awakened until several hours after intubation. We noted no difference between the sedative drugs tested in our study on the ease of intubation, probably because intubation conditions depend mostly on the muscle relaxant effects of succinylcholine. Accordingly, Sivilotti and Ducharme reported no significant difference in the overall successful intubation in a comparison of three hypnotic drugs.

With regard to the strengths and limitations of our study, we have confirmed the appropriateness of the choice of the maximum SOFA score as the primary endpoint. There is an established relation between the maximum SOFA score and Δ-SOFA score (from maximum to admission) and mortality in patients who are critically ill. Moreover, measurement of the SOFA score has good reliability and accuracy among intensivists. These scores have shown its usefulness in the assessment of in-hospital morbidity in seriously ill patients.

However, our study might not have had sufficient power to show a significant increase in morbidity related to the use of etomidate in patients with sepsis. Our failure to enroll and analyse a larger number of patients with sepsis could have led to a type-II error for this group. A future study should be based on patients with sepsis only, since the controversy regarding the use of etomidate focuses on these patients. We felt that patients admitted with trauma were important to study as well because of suggestions from recent reports that etomidate might be harmful to this group of patients. In conclusion, our results show that ketamine is a safe and valuable alternative to etomidate for intubation in critically ill patients, particularly in septic patients.

2. Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients

Chang AM, et al. Amer J Emerg Med. 2009;27:916-921.

Objective
Guidelines recommend treating patients with a new or presumed new left bundle-branch block (LBBB) similar to those with an acute ST-segment elevation myocardial infarction. It is often unclear which emergency department (ED) patients with potentially ischemic symptoms actually have an acute myocardial infarction (AMI), even in the setting of LBBB. Our null hypothesis was that in ED patients with potential AMI, the presence of a new or presumed new LBBB would not predict an increased likelihood of AMI.

Methods
This was an observational cohort study. Patients older than 30 years who presented with chest pain or other ischemic equivalent and had an electrocardiogram (ECG) to evaluate potential acute coronary syndrome (ACS) were enrolled. Data collected include demographics, history, ECG, and cardiac markers. Electrocardiograms were classified according to the standardized guidelines, including LBBB not known to be old (new or presumed new LBBB), LBBB known to be old, or no LBBB. The hospital course was followed, and 30-day follow-up was performed on all patients. Our main outcome was AMI.

Results
There were 7937 visits (mean age, 54.3 ± 15 years, 57% female, 68% black): 55 had new or presumed new LBBB, 136 had old LBBB, and 7746 had no LBBB. The rate of AMI was not significantly different between the 3 groups (7.3% vs 5.2% vs 6.1%; P = .75). Revascularization (7.8% vs old 5.2% vs 4.3%; P = .04) and coronary artery disease were more common in patients with new or presumed new LBBB (19.2% vs 11.9% vs 10.1%; P = .0004).

Conclusions
Despite guideline recommendations that patients with potential ACS and new or presumed new LBBB should be treated similar to STEMI, ED patients with a new or presumed new LBBB are not at increased risk of AMI. In fact, the presence of LBBB, whether new or old, did not predict AMI. Caution should be used in applying recommendations derived from patients with definite AMI to ED patients with potential ACS that may or may not be sustaining an AMI.

3. Recent-onset A Fibbers in the ED: Cardiovert?

Stead LG, et al. Rhythm Control With Electrocardioversion for Atrial Fibrillation and Flutter. Ann Emerg Med. 2009;54:745-747.

This review provides little evidence on which emergency physicians can base decisions about patients with acute atrial fibrillation. Because the majority of symptomatic patients encountered in the ED have atrial fibrillation of less than 48 hours’ duration and the risk of stroke and other complications in such patients is low, current practice remains cardioversion (electrical or medical) as soon as possible. In older patients with sustained atrial fibrillation, referral for cardioversion may be warranted for quality of life considerations; however, stroke prevention must be an integral
component of pre- and postcardioversion management to reduce the risk of embolic stroke.

Full-text (free): http://download.journals.elsevierhealth.com/pdfs/journals/0196-0644/PIIS0196064408020866.pdf

4. Arranging Follow-up Appointments for your Discharged Patients

Vinson DR, Patel PB. Facilitating follow-up after emergency care using an appointment assignment system. J Healthcare Quality. 2009; 31:18-24.

Many emergency department patients require urgent follow-up in primary care. The most effective way to help patients obtain their needed after-visit care is to secure the appointment on their behalf prior to their departure from the ED. This study describes the development, implementation, and outcomes of an appointment assignment system that facilitates patient follow-up at two community hospitals in an integrated healthcare system. This patient-centered system resulted in a high rate of compliance and a very low rate of unscheduled ED recidivism. Improving access in this manner will likely strengthen the continuum of care, improve quality, and increase patient satisfaction.

Full-text (free) available from the authors: drvinson@ucdavis.edu

5. Sleep-Deprived Attending Surgeons Have Higher Rates of Procedural Complications

Kathleen Louden. October 19, 2009 (Chicago, Illinois) — Attending surgeons who perform daytime surgical procedures within 6 hours of finishing an overnight shift have a nearly 3-fold higher rate of provider-related complications than when their opportunity for sleep between procedures exceeds 6 hours, a new study finds. The study was published in the October 14 issue of the Journal of the American Medical Association.

Until now, little was known about the effects of long work shifts and limited sleep opportunity on the performance of attending physicians, said lead author Jeffrey Rothschild, MD, MPH, a surgeon at Brigham and Women's Hospital and an assistant professor of medicine at Harvard Medical School in Boston, Massachusetts.

"Attendings who perform emergency overnight procedures . . . often perform elective procedures the next day," said Dr. Rothschild, who presented the results at a media briefing held to release new research on surgical care.

"Our data suggest that attending physicians, like residents and nurses, may be at increased risk of making errors when sleep-deprived or working extended shifts," he said.

The authors studied the outcomes of 919 "postnighttime" procedures performed by 86 attending surgeons over an 8-year period. The definition of a postnighttime procedure was one performed in the operating room the day after at least 1 operative case between midnight and 6 am. Dr. Rothschild's team compared outcomes of postnighttime procedures with those of 3552 control procedures, which were the same or similar procedures performed by the same 86 surgeons when they had not worked the previous night, within 12 months of the other procedures. Of the 86 surgeons, 32 were general surgeons. Their mean length of experience was 14 years.

Working Late Does Not Increase Next-Day Complications

Dr. Rothschild and colleagues found that the overall rate of complications — intraoperative adverse events likely attributable to the surgeon — did not significantly differ between postnighttime and control procedures. The complication rate was 7.5% in the postnighttime group and 7.8% in the control group. Likewise, the duration of the extended work shift did not have a statistically significant effect on the complication rate.

It was only when the investigators looked at the data by length of sleep opportunity — the time between the end of the last overnight case and the beginning of the first case later that day — that they observed a significant difference in the frequency of complications. When surgeons in the postnighttime group got 6 hours or less of sleep opportunity, there was a 2.7-fold increase in the rate of complications, compared with a longer time between shifts in the same group, Dr. Rothschild said. The difference between that 8.5% complication rate and the 3.1% rate for surgeons whose sleep opportunity was more than 6 hours was significant (P = .03), the authors write.

Actual sleep time was likely to be far shorter than sleep opportunity, owing to the need to change clothes and travel home, Dr. Rothschild noted.

Most of the complications that occurred were preventable, the authors report. The most frequent complications for both groups, according to Dr. Rothschild, were organ injury, bleeding, and infections.

Based on their findings, he said that "a limitless work week for attending physicians is not optimal for patient care."

Self-Regulation Needed

Unlike resident physicians, attending physicians in the United States have no restrictions on the number of hours they can work. Dr. Rothschild did not think that attendings' work hours would become federally regulated. Instead, he recommended strategies that surgeons can take to reduce complications due to fatigue.

"Surgeons can try to avoid scheduling elective surgeries the day after they take emergency call, or at least when risks are high for the elective procedure. And, if possible, they should use back-up personnel to assist when they are fatigued."

A limitation of the study, according to Dr. Rothschild, is that the investigators did not know the surgeons' sleep practices the night before control procedures. "Some physicians could have worked overnight at other hospitals," he explained. Also, the findings might not apply to nonteaching hospitals, he observed.

Although the study included data from only 1 center, it raised the profile of a common problem, said Phil Fontanarosa, MD, MBA, executive deputy editor of JAMA. "More awareness is needed about this problem among attending physicians, because all the focus [of fatigue contributing to medical errors] has been on residents," Dr. Fontanarosa told Medscape General Surgery.

JAMA. 2009;302:1565-1572.

6. Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment: U.S. Preventive Services Task Force Says “Don’t Bother”

Ann Intern Med. 2009;151:474-482.

The U.S. Preventive Services Task Force (USPSTF) has issued a recommendation statement on the use of 9 nontraditional risk factors (high-sensitivity C-reactive protein [CRP], ankle–brachial index, leukocyte count, fasting blood glucose level, periodontal disease, carotid intima–media thickness, coronary artery calcification on electron-beam computed tomography, homocysteine level, and lipoprotein[a] level) in assessing coronary heart disease (CHD) risk in asymptomatic persons. It concludes that the current evidence is insufficient to assess the balance of benefits and harms of using these nontraditional risk factors to screen asymptomatic men and women with no history of CHD to prevent CHD events (I statement).

Full-text (free): http://www.annals.org/cgi/content/full/151/7/474

7. Psychosocial Stress: Bad for your Heart

Milani RV, et al. Amer J Med. 2009;122:931-938.

Background
Exercise training reduces mortality in patients with coronary artery disease. Behavioral characteristics, including depression, hostility, and overall psychosocial stress, have been shown to be independent risk factors for recurrent myocardial infarction and death in these patients. Exercise training can reduce these high-risk behaviors, but it remains uncertain as to what extent the health benefits of exercise training can be attributed to improving these behaviors.

Methods
We evaluated the impact of exercise training during cardiac rehabilitation on mortality in 53 patients with coronary artery disease with high levels of psychosocial stress and in 469 patients with coronary artery disease with low levels of psychosocial stress and compared them with 27 control patients with high psychosocial stress who did not undergo formal cardiac rehabilitation and exercise training.

Results
Mortality was approximately 4-fold greater in patients with high psychosocial stress than in those with low psychosocial stress (22% vs 5%; P = .003). Exercise training decreased the prevalence of psychosocial stress from 10% to 4% (P less than .0001) and similarly improved peak oxygen uptake in patients with high and low psychosocial stress. Mortality in patients who improved exercise capacity by greater than 10% (high exercise change) was 60% lower than in patients who had less than 10% improvement in exercise capacity (low exercise change) (P=.009). Mortality was lower in patients with high psychosocial stress with high exercise change compared with patients with high psychosocial stress with low exercise change (0% vs 19%; P=.009). In contrast, there was no significant improvement in mortality in patients with high versus low exercise change with low psychosocial stress (4% vs 8%; P=.14).

Conclusion
Psychosocial stress is an independent risk factor for mortality in patients with coronary artery disease, and exercise training can effectively reduce its prevalence. Exercise training reduces mortality in patients with coronary artery disease, and this effect seems to be mediated in part because of the salutary effects of exercise on psychosocial stress.

Full-text: http://www.amjmed.com/article/PIIS0002934309004392/fulltext

8. Urinalysis (without culture) is not reliable to detect UTI in febrile ED infants

Reardon JM, et al. Amer J Emerg Med. 2009;27:930-932.

Objective
Urinary tract infections are a common source of serious bacterial infections in febrile infants younger than 2 years. Our objective was to compare urinalysis with urine culture in the emergency department evaluation of febrile infants.

Methods
A febrile infant registry was instituted at a tertiary care hospital treating an average of 55000 patients annually (27% children), from December 2002 to December 2003. Patients were eligible if they were younger than 3 months and had a temperature of at least 38°C or if they were between 3 and 24 months of age and had a temperature of at least 39°C. Data abstracted included age, sex, and temperature. Urinalysis (UA) and urine culture (UCx) results were obtained from electronic hospital archives.

Results
Nine hundred eighty-five patients were entered into the febrile infant registry. Male patients comprised 55%. The mean age of patients was 12.6 months; median was 12 months. Four hundred thirty-five (78% of eligible patients) had both a UA and UCx from the same specimen, and there were 45 (10.3%) positive UCx result. Females accounted for 33 (73%) of 45 positive results. The sensitivity of UA for predicting a positive UCx result was 64% (95% confidence interval [CI], 49%-78%), whereas the specificity was 91% (95% CI, 88%-94%). The positive predictive value was 46% (95% CI, 31%-53%), with a negative predictive value of 96% (95% CI, 93%-97%).

Conclusion
Urinalysis is not reliable for the detection of urinary tract infections in febrile infants when compared with urine cultures.

9. Crowding Delays Treatment and Lengthens Emergency Department Length of Stay, Even Among High-Acuity Patients

McCarthy ML, et al. Ann Emerg Med. 2009;54:492-503.e4.

Study objective
We determine the effect of crowding on emergency department (ED) waiting room, treatment, and boarding times across multiple sites and acuity groups.

Methods
This was a retrospective cohort study that included ED visit and inpatient medicine occupancy data for a 1-year period at 4 EDs. We measured crowding at 30-minute intervals throughout each patient's ED stay. We estimated the effect of crowding on waiting room time, treatment time, and boarding time separately, using discrete-time survival analysis with time-dependent crowding measures (ie, number waiting, number being treated, number boarding, and inpatient medicine occupancy rate), controlling for patient demographic and clinical characteristics.

Results
Crowding substantially delayed patients' waiting room and boarding times but not treatment time. During the day shift, when the number boarding increased from the 50th to the 90th percentile, the adjusted median waiting room time (range 26 to 70 minutes) increased by 6% to 78% (range 33 to 82 minutes), and the adjusted median boarding time (range 250 to 626 minutes) increased by 15% to 47% (range 288 to 921 minutes), depending on the site. Crowding delayed the care of high-acuity level 2 patients at all sites. During crowded periods (ie, 90%), the adjusted median waiting room times of high-acuity level 2 patients were 3% to 35% higher than during normal periods, depending on the site and crowding measure.

Conclusion
Using discrete-time survival analysis, we were able to dynamically measure crowding throughout each patient's ED visit and demonstrate its deleterious effect on the timeliness of emergency care, even for high-acuity patients.

Full-text (free): http://www.annemergmed.com/article/PIIS019606440900239X/fulltext

10. D-dimer Testing in Patients with Suspected Pulmonary Embolism and Impaired Renal Function: Still Useful

Karami-Djurabi R, et al. Amer J Med. 2009;122:1050-1053.

Background
Determination of pretest probability and D-dimer tests are the first diagnostic steps in patients with suspected pulmonary embolism, which can be ruled out when clinical probability is unlikely and D-dimer level is normal. We evaluated the utility of D-dimer testing in patients with impaired renal function.

Methods
D-dimer tests were performed in consecutive patients with suspected pulmonary embolism and an unlikely clinical probability. Creatinine levels were assessed as clinical routine. Glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula. Correlation between D-dimer level and renal function and proportions of patients with normal D-dimer in different categories of estimated glomerular filtration rate (eGFR) were assessed. Different categories of decreasing eGFR were defined as: normal renal function (eGFR over 89 mL/min), mild decrease in eGFR (eGFR 60-89 mL/min), and moderate decrease in eGFR (eGFR 30-59 mL/min).

Results
Creatinine levels were assessed in 351 of 385 patients (91%). D-dimer levels significantly increased in 3 categories of decreasing eGFR (P = .027 and P = .021 for moderate renal impairment compared with mild renal impairment and normal renal function, respectively). Normal D-dimer levels were found in 58% of patients with eGFR above 89 mL/min, in 54% with eGFR 60-89 mL/min, and in 28% with eGFR 30-59 mL/min.

Conclusions
The specificity of D-dimer testing in patients with suspected pulmonary embolism and decreased GFR is significantly decreased. Nonetheless, performing D-dimer tests is still useful because computed tomography scanning can be withheld in a significant proportion of these patients.

11. Pediatric myocarditis: presenting clinical characteristics

Durani Y, et al. Amer J Emerg Med. 2009;27:942-947.

Objective
The objective of the study was to characterize the clinical profiles of pediatric patients with acute myocarditis and dilated cardiomyopathy (DCM) before diagnosis.

Methods
A retrospective cross-sectional study was conducted to identify patients with myocarditis and DCM who presented over a 10-year span at 2 tertiary care pediatric hospitals. Patients were identified based on the International Classification of Diseases, Ninth Revision, diagnostic codes.

Results
A total of 693 charts were reviewed. Sixty-two patients were enrolled in the study. Twenty-four (39%) patients had a final diagnosis of myocarditis, and 38 (61%) had DCM. Of the 62 patients initially evaluated, 10 were diagnosed with myocarditis or DCM immediately, leaving 52 patients who required subsequent evaluation before a diagnosis was determined. Study patients had a mean age of 3.5 years, 47% were male, and 53% were female. Common primary complaints were shortness of breath, vomiting, poor feeding, upper respiratory infection (URI), and fever. Common examination findings were tachypnea, hepatomegaly, respiratory distress, fever, and abnormal lung examination result. Sixty-three percent had cardiomegaly on chest x-ray, and all had an abnormal electrocardiogram results.

Conclusions
These data suggest children with acute myocarditis and DCM most commonly present with difficulty breathing. Myocarditis and DCM may mimic other respiratory or viral illnesses, but hepatomegaly or the finding of cardiomegaly and an abnormal electrocardiogram result may help distinguish these diagnoses from other more common pediatric illnesses.

12. The Association between Transfer of ED Boarders to Inpatient Hallways and Mortality: A 4-Year Experience

Viccellio A, et al. Ann Emerg Med. 2009;54:487-491.

We posted this pre-publication abstract in our May Lit Bits, abstract #20. Since this article was published this month, the full-text is now available online for free: http://www.annemergmed.com/article/S0196-0644(09)00238-8/fulltext

13. New Analyses From ECASS 3 Support Use of tPA Up to 4.5 Hours After Stroke

Susan Jeffrey. October 20, 2009 (UPDATED October 21, 2009) — Secondary analyses of data from the third European Cooperative Acute Stroke Study (ECASS 3) trial appear to support the use of recombinant tissue plasminogen activator (rt-PA, alteplase) to treat stroke up to 4.5 hours after symptom onset in patients without exclusions for treatment, but who miss the approved time window of 0 to 3 hours.

"Almost all our additional outcome analyses strongly support the positive primary and secondary trial results of ECASS 3," the investigators, with lead author Werner Hacke, MD, PhD, professor and chairman of the Department of Neurology at Ruprecht-Karls-Universität, Germany, conclude.

Although not significant in every analysis, all additional efficacy endpoints showed "at least a clear pattern in favor of alteplase," the authors note, in particular confirming that treatment was effective in patients regardless of stroke severity.

However, Dr. Hacke told Medscape Neurology that in his view, the most critical point to make about ECASS 3, now supported by these subanalyses, is not that the time window for tPA can safely be extended to 4.5 hours.

"It is that the concept of thrombolytic therapy in acute ischemic stroke is supported now by a very straightforward, conservative, randomized clinical trial, a trial that is more than double the size of the National Institute of Neurological Disorders and Stroke trial that was positive for the 3-hour time window," he said.

Along with a collection of pooled and meta-analyses and data from a large European registry, he said, their results bolster the concept, still questioned by some, that thrombolysis as a valid therapy for stroke. "We have 2 independent randomized clinical trials that are positive with the primary outcome in favor of rtPA, so there is no reason any more to not accept this as a scientific fact," Dr. Hacke stressed.

This new report from ECASS 3 was published online October 21 and will appear in the December issue of Lancet Neurology. ECASS 3 was supported by Boehringer Ingelheim.

14. Images in EM

Traumatic Eye Swelling
http://www.annemergmed.com/article/S0196-0644(09)00365-5/fulltext

Psychotic Woman With Painful Abdominal Distension
http://www.annemergmed.com/article/S0196-0644(09)00373-4/fulltext

15. Facemasks and Hand Hygiene to Prevent Influenza Transmission in Households: A Cluster Randomized Trial

Cowling BJ, et al. Ann Intern Med. 2009;151:437-446

Few data are available on the effectiveness of nonpharmaceutical interventions for preventing influenza virus transmission. In this cluster randomized trial of 259 people with confirmed influenza virus infection and 794 household contacts, hand washing and facemasks seemed to prevent influenza virus transmission when healthy people started these measures within 36 hours of symptom onset in an infected family member. Although adherence to the interventions varied, these findings suggest that nonpharmaceutical interventions may help to mitigate pandemic and interpandemic influenza.

Abstract: http://www.annals.org/cgi/content/abstract/151/7/437

16. Validation of a Prediction Rule for the Identification of Children with Intra-abdominal Injuries After Blunt Torso Trauma

Holmes JF, et al. Ann Emerg Med. 2009;54:528-533.

Study objective
We validate the accuracy of a previously derived clinical prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma.

Methods
We conducted a prospective observational study of children with blunt torso trauma who were evaluated for intra-abdominal injury with abdominal computed tomography (CT), diagnostic laparoscopy, or laparotomy at a Level I trauma center during a 3-year period to validate a previously derived prediction rule. The emergency physician providing care documented history and physical examination findings on a standardized data collection form before knowledge of the results of diagnostic imaging. The clinical prediction rule being evaluated included 6 “high-risk” variables, the presence of any of which indicated that the child was not at low risk for intra-abdominal injury: low age-adjusted systolic blood pressure, abdominal tenderness, femur fracture, increased liver enzyme levels (serum aspartate aminotransferase concentration over 200 U/L or serum alanine aminotransferase concentration over 125 U/L), microscopic hematuria (urinalysis over 5 RBCs/high powered field), or an initial hematocrit level less than 30%.

Results
One thousand three hundred twenty-four children with blunt torso trauma were enrolled, and 1,119 (85%) patients had the variables in the decision rule documented by the emergency physician and therefore made up the study sample. The prediction rule had the following test characteristics: sensitivity=149 of 157, 94.9% (95% confidence interval [CI] 90.2% to 97.7%) and specificity=357 of 962, 37.1% (95% CI 34.0 to 40.3%). Three hundred sixty-five patients tested negative for the rule; thus, strict application would have resulted in a 33% reduction in abdominal CT scanning. Of the 8 patients with intra-abdominal injury not identified by the prediction rule, 1 underwent a laparotomy. This patient had a serosal tear and a mesenteric hematoma at laparotomy, neither of which required specific surgical intervention.

Conclusion
A clinical prediction rule consisting of 6 variables, easily available to clinicians in the ED, identifies most but not all children with intra-abdominal injury. Application of the prediction rule to this sample would have reduced the number of unnecessary abdominal CT scans performed but would have failed to identify 1 child undergoing (a nontherapeutic) laparotomy. Thus, further refinement of this prediction rule in a large, multicenter cohort is necessary before widespread implementation.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(09)00398-9/fulltext

17. Rapid Viral Testing Promising in Pediatric Emergencies

NEW YORK (Reuters Health) Oct 19 - In children with acute febrile respiratory illness, rapid viral testing techniques may save time and reduce demands on emergency department staff, according to a review published this month in the Cochrane Database of Systematic Reviews.

Nevertheless, lead investigator Dr. Quynh Doan said in a statement that "the existing evidence is not strong enough to prove that these tests help to reduce pressure on health systems, but it certainly does look promising."

Moreover, she told Reuters Health, "Rapid viral testing in a well defined context can provide physicians with very valuable information and potentially impact on management decision." However, "emphasis must be put on 'well defined context.'"

"We must remember," she added, "that only positive rapid viral testing adds any information, as these tests can only detect a specific virus -- commonly influenza -- and the absence of this virus in the sample is in no way indicative of what is causing the illness."

Dr. Doan of the British Columbia Children's Hospital in Vancouver, Canada, and colleagues studied data from 4 trials involving 759 children who underwent rapid testing and 829 who acted as controls.

Three of the studies employed influenza testing and the remaining study used a virus panel test encompassing influenza, parainfluenza, respiratory syncytial virus and adenovirus.

The team found that overall, viral testing reduced the use of chest X-rays (relative risk, 0.77) and that there was a trend toward less antibiotic usage (relative risk, 0.89) and fewer blood and urine investigations.

Dr. Doan also pointed out that "since the rate of positive rapid viral testing varied widely between 20 and 60% of tested subjects -- depending on which studies we look at -- perhaps we should be selective in the population to be tested in order to maximize its usefulness."

"In addition," she concluded, "it is important to note that all these studies were conducted before the H1N1 era. How rapid viral testing can contribute to managing the emergency department volume surges associated with the H1N1 pandemic can only be speculated."

Cochrane Database Syst Rev 2009.

18. The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics

Vaillancourt C, et al. Ann Emerg Med. 2009;54:663-671.e1

Study objective
We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting.

Methods
We conducted this prospective cohort study in 7 Canadian regions and involved alert (Glasgow Coma Scale score 15) and stable adult trauma patients at risk for neck injury. Advanced and basic care paramedics interpreted the Canadian C-Spine Rule status for all patients, who then underwent immobilization and assessment in the emergency department to determine the outcome, clinically important cervical spine injury.

Results
The 1,949 patients enrolled had these characteristics: median age 39.0 years (interquartile range 26 to 52 years), female patients 50.8%, motor vehicle crash 62.5%, fall 19.9%, admitted to the hospital 10.8%, clinically important cervical spine injury 0.6%, unimportant injury 0.3%, and internal fixation 0.3%. The paramedics classified patients for 12 important injuries with sensitivity 100% (95% confidence interval [CI] 74% to 100%) and specificity 37.7% (95% CI 36% to 40%). The κ value for paramedic interpretation of the Canadian C-Spine Rule (n=155) was 0.93 (95% CI 0.87 to 0.99). Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule.

Conclusion
This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.

Full-text (free): http://www.annemergmed.com/article/PIIS0196064409002418/fulltext

19. Serious Bacterial Infections Uncommon in Infants Who Have Experienced an Apparent Life-Threatening Event

Mittal MK, et al. Ann Emerg Med. 2009;54:523-527.

Study objective
We determine the incidence of serious bacterial infection in infants presenting to the emergency department (ED) with an apparent life-threatening event.

Methods
This was a prospective cohort study of infants younger than 12 months who were treated at an urban children's hospital ED during 1 year and who met standard criteria for an apparent life-threatening event. Sociodemographic data, presenting features, diagnostic testing, hospital course, and final diagnosis were collected. Follow-up information was obtained 4 weeks after the visit.

Results
Of the 198 infants enrolled, 44 (22.2%) had evaluation for serious bacterial infection: urine culture 36 (18%), blood culture 38 (19%) and cerebrospinal fluid culture 18 (9%). No infant (0/198; 95% confidence interval 0% to 1.8%) was found to have bacteremia, urinary tract infection, or bacterial meningitis, which was confirmed at the 4-week interview (99% ascertainment). Two infants were found to have enteroviral meningitis.

Conclusion
The incidence of serious bacterial infection in this cohort was extremely low. Infants presenting with an apparent life-threatening event need not be subjected to a full serious bacterial infection evaluation routinely.

20. Do Not Pardon the (CPR) Interruption

Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation

Wang HE, et al. Ann Emerg Med. 2009;54:645-652.e1

Emergency cardiac care guidelines emphasize treatment of cardiopulmonary arrest with continuous uninterrupted cardiopulmonary resuscitation (CPR) chest compressions. Paramedics in the United States perform endotracheal intubation on nearly all victims of out-of-hospital cardiopulmonary arrest. We quantified the frequency and duration of CPR chest compression interruptions associated with paramedic endotracheal intubation efforts during out-of-hospital cardiopulmonary arrest.

Methods
We studied adult out-of-hospital cardiopulmonary arrest treated by an urban and a rural emergency medical services agency from the Resuscitation Outcomes Consortium during November 2006 to June 2007. Cardiac monitors with compression sensors continuously recorded rescuer CPR chest compressions. A digital audio channel recorded all resuscitation events. We identified CPR interruptions related to endotracheal intubation efforts, including airway suctioning, laryngoscopy, endotracheal tube placement, confirmation and adjustment, securing the tube in place, bag-valve-mask ventilation between intubation attempts, and alternate airway insertion. We identified the number and duration of CPR interruptions associated with endotracheal intubation efforts.

Results
We included 100 of 182 out-of-hospital cardiopulmonary arrests in the analysis. The median number of endotracheal intubation–associated CPR interruption was 2 (interquartile range [IQR] 1 to 3; range 1 to 9). The median duration of the first endotracheal intubation–associated CPR interruption was 46.5 seconds (IQR 23.5 to 73 seconds; range 7 to 221 seconds); almost one third exceeded 1 minute. The median total duration of all endotracheal intubation–associated CPR interruptions was 109.5 seconds (IQR 54 to 198 seconds; range 13 to 446 seconds); one fourth exceeded 3 minutes. Endotracheal intubation–associated CPR pauses composed approximately 22.8% (IQR 12.6-36.5%; range 1.0% to 93.4%) of all CPR interruptions.

Conclusion
In this series, paramedic out-of-hospital endotracheal intubation efforts were associated with multiple and prolonged CPR interruptions.

Full-text (free): http://www.annemergmed.com/article/PIIS0196064409005344/fulltext

21. Abstracts from ACEP’s 2009 Scientific Assembly

A. ED Doctors Rarely Adjust Antibiotic Doses for Obese Patients

By Marilynn Larkin. NEW YORK (Reuters Health) Oct 07 - Emergency department physicians rarely adjust antimicrobial medication doses for obese patients, according to research reported Tuesday at the American College of Emergency Physicians annual meeting in Boston.

"We have a one-size-fits-all dose in our minds for most antibiotics, and we tend to give that dose regardless of size and other factors that should affect dosing, like age, renal function, and body mass index," study co-researcher Dr. Michael Mullins told Reuters Health.

Dr. Mullins and his colleagues, from Washington University School of Medicine, St. Louis, analyzed the rate at which their center's emergency physicians adhered to dose adjustment guidelines for selected antibiotics established by the university's antibiotic utilization review (AUR) committee.

They reviewed data for all emergency department patients treated over a 3-month period who weighed more than 100 kg, had a body mass index greater than 40 kg/m2, and were given cefazolin, cefepime, or ciprofloxacin.

Slightly more than a thousand patients met the study criteria. Overall, they were treated with 503 doses of cefepime, 293 doses of cefazolin, and 306 doses of ciprofloxacin. Thirty received more than one antibiotic.

Based on AUR guidelines, the initial dose for these patients should be 2 g IV for cefazolin or cefepime and 800 mg IV or 750 mg PO for ciprofloxacin.

These guidelines were followed for only 48 doses of cefepime (9.5%), 12 doses of cefazolin (4.1%), and 4 doses of ciprofloxacin (1.3%).

"Obesity is an epidemic in North America in particular, and unfortunately, we're seeing more people in the obese and severely obese range than we used to," Dr. Mullins observed. "I think this problem is under-recognized by emergency physicians and other specialists."

"If you give too low a dose," he cautioned, "you'll have treatment failure even if you pick the right antibiotic--and increase the likelihood that some of the bacteria you're trying to kill will form a mutation and become less sensitive to the drug."

B. Vast Increase in ED Visits for Head Injuries Seen After Natasha Richardson's Death

Fran Lowry. October 8, 2009 (Boston, Massachusetts) — Widespread media coverage of Natasha Richardson's death from a head injury on March 18, 2009 prompted a huge increase in emergency department (ED) visits, investigators reported here at the American College of Emergency Physicians 2009 Scientific Assembly.

The actress appeared well after she hit her head in a fall while skiing at Mont Tremblant, Quebec. She initially refused medical help, saying she felt fine, but died shortly afterward.

"We see this all the time in emergency rooms," Brian Walsh, MD, from Morristown Memorial Hospital in New Jersey, told Medscape Emergency Medicine. "Coverage about a certain disease, for instance meningitis deaths in young people, can cause a big bump in visits. We thought that the publicity surrounding her tragic death would do the same thing, and we wanted to quantify that."

Dr. Walsh and his colleagues compared the daily visits for head injury for the 10 days before and after March 18 in the EDs of 19 urban, suburban, and rural hospitals in New Jersey and New York. They classified patients as having head injury based on ICD9 codes.

They found that visits to the ED for head injury increased 73% (95% confidence interval, 53% - 94%; P less than .0001) for the 10 days after March 18 compared with the 10 days before. However, by March 31, the number of ED visits for head trauma was back to the pre–March 18 level.

According to Christina Campo-Ford, PA, from Morristown Memorial Hospital, who coauthored the study with Dr. Walsh, the media can cause quite a scare. "Good Morning America ran a spot a day after Natasha Richardson died about a little girl who was hit in the head with a softball and she was fine but then she went downhill. You can't show that on Good Morning America and not expect parents to bring their children in."

Pediatricians were telling concerned parents to bring their children who fell and hit their heads to the ED "just to be safe," she said. However, although the number of people who came to the ED for head trauma increased, the number of serious head injuries did not, nor did the percentage of computed tomography (CT) scans that were performed.

"We educated patients about the pros and cons of CTs and the radiation exposure risks and so on, and we did not do CTs unnecessarily," said Ms. Campo-Ford. "However, some patients insisted on having a CT, so we couldn't refuse them."

Ms. Campo-Ford believes that Ms. Richardson's death will continue to influence ED visits for head injury.

Media attention can definitely highlight issues, Debra Houry, MD, from Emory University in Atlanta, Georgia, told Medscape Emergency Medicine. "As emergency physicians, we need to make sure that we talk about injury prevention a well, such as helmet use, as this decreases the morbidity and mortality with a head injury."

Media reporting, which used headlines such as "Stand Up and Die" when reporting Ms. Richardson's death, fuels panic reactions on the part of the public, and encourages them to go to the ED even when such visits are not necessary. "The media called it "stand up and die," so why would you not come in if you hit your head," Ms. Campo-Ford noted.

Such reporting only compounds the already serious problem of ED overcrowding, said Dr. Walsh.
Physicians should educate their patients about head trauma and what symptoms to look for. But even when they do, some patients will insist on coming into the ED and having a CT scan anyway, Dr. Alexander M. Rosenau, DO, FACEP, from Lehigh Valley Hospital in Allentown, Pennsylvania, told Medscape Emergency Medicine. Dr. Rosenau is chair of the Emergency Medicine Foundation.

He pointed out how difficult it is to persuade patients that they don't need to come to the hospital after every head injury as a result of the publicity about Ms. Richardson. "A mother brought her daughter to the ED, insisting on a CT scan because the girl had fallen off her horse about 2 days prior and had hit her head. After taking a careful history and exam, we tried to reassure the mother that a CT was not necessary, but she was not convinced."

American College of Emergency Physicians 2009 Scientific Assembly. Abstract 156. Presented October 5, 2009.

C. Shorter Wait Times in the ED Mean More Patients Stay to See a Doctor

Marilynn Larkin. NEW YORK (Reuters Health) Oct 06 - Modest decreases in emergency department (ED) waiting times can have a big impact on whether a patient stays to see a doctor or leaves without being seen, investigators said Monday at the annual meeting of the American College of Emergency Physicians in Boston.

The research is based on an analysis of all visits to the George Washington Hospital ED from 2006-2008. Dr. Mehdi Sattarian and colleagues compared wait times for walk-in patients who left without being seen, either before or after nursing triage, to waiting times (from arrival to hospital bed) for people who arrived at the hospital at the same hour and stayed to see a doctor. They also recorded the total number of patients in the ED treatment area and lobby at the hour's end, and illness severity, Dr. Sattarian said at the Boston meeting.

During the study period, 187,663 patients came to the ED, 128,430 of whom were walk-ins. (The rest came by ambulance.) Of those, 5.2% left without being seen.

Further analysis revealed the proportion of walk-in patients who left without being seen fell from 5.5% in July-December 2006 to 3.5% in July-December 2008. During the same period, mean waiting times for walk-ins decreased from 61.4 to 52.6 minutes.

The drop in the number of patients who left without being seen occurred even while the total number of patients coming to the ED in a given hour increased (from 6.9 patients in 2006 to 7.5 patients in 2008), along with the number of patients left in the ED at the end of that hour (36.5 in 2006, 39.5 in 2008).

"We saw highly significant relationships between the number of people who left without being seen and both waiting times and the total number of patients in the emergency department," Dr. Sattarian told meeting attendees. In email to Reuters Health, he attributed improvements in "front-end processes" -- for example, streamlining registration and triage -- to the decreased waiting times and concomitant increase in the number of people who stayed to see a doctor.

Improving "back-end" processes -- what happens from the time a patient is seen by a doctor to the time they're either admitted or discharged -- could have "an even greater effect" on the number of people who stay to be seen by reducing the overall number of people in the ED, Dr. Sattarian observed.

Those strategies would include decreasing the amount of time it takes for seriously ill people to be moved to a hospital bed, and "improving laboratory and radiology turnaround times," he concluded.

D. Oxygen Therapy Relieves Headache Pain in the ED, Cuts Length of Stay, Drug Use

Marilyn Larkin. NEW YORK (Reuters Health) Oct 05 - Giving high-flow oxygen therapy for 15 minutes to emergency department patients with headaches provides rapid relief and reduces hospital stays, use of CT scans, and headache pharmacotherapy, according to a pilot study.

Dr. Boris Veysman of the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School reported the results on Monday at the annual meeting of the American College of Emergency Physicians in Boston.

"Very often, when a patient comes to the emergency department with one complaint being headache, they're uncomfortable and symptomatic and they have to wait for a workup before anyone can determine the cause. A diagnosis may not even be made in the emergency department," Dr. Veysman told Reuters Health. "So we approached it from a different perspective and asked, 'What if therapy were the first thing you did (for a headache) before attempting to find a cause?' And so we tried giving oxygen therapy, because it's so widespread and safe."

In the placebo-controlled study, 17 patients were randomized to 100% oxygen at 15 L/min for 15 minutes; 14 received high flow air for 15 minutes; and 17 received no intervention prior to standard treatment. Headache intensity was assessed using a 10-point visual analog scale.

Median times to relief were significantly shorter for patients treated with oxygen (40 minutes) compared with those treated with high flow air (110 minutes) or nothing (120 minutes). Median length of stay was also significantly shorter for patients treated with oxygen (57.5 minutes) than for those treated with air (210 minutes) or nothing (180 minutes).

In addition, CT scans were ordered less frequently: for four of 17 patients (24%) who received oxygen; 11 of 14 (79%) who received air; and eight of 17 (47%) who got nothing.

Medication was given to 29% of those who received oxygen, 86% of those who received air, and 82% of those who received no treatment.

Headache intensity was significantly reduced at both 15 minutes and 30 minutes after initiation of treatment, with patients treated with oxygen realizing the greatest reductions.

"It was a small study, and our results are preliminary," Dr. Veysman stressed. "But the medical community is starting to recognize that it's important to treat discomfort even when you don't know what's causing it, as long as you feel confident the treatment won't make the patient worse. In this case, we found more relief with oxygen than with placebo, although the fact that the headache goes away doesn't necessarily mean the patient can go home."

Lit Bits: Sept 21, 2009

From the recent medical literature...

1. Validated Rules May Predict Children at Very Low Risk for Brain Injury After Head Trauma

Laurie Barclay, MD. September 18, 2009 — Validated prediction rules might help identify children at very low risk for brain injury after head trauma, according to the results of a study published online September 14 in The Lancet.

"CT imaging of head-injured children has risks of radiation-induced malignancy," write Nathan Kuppermann, from University of California, Davis Medical Center in Sacramento, and colleagues from the Pediatric Emergency Care Applied Research Network. "Our aim was to identify children at very low risk for clinically important traumatic brain injuries (ciTBI) for whom CT might be unnecessary."

The study sample consisted of 42,412 patients younger than 18 years of age with Glasgow Coma Scale scores of 14 or 15 who presented at 25 North American emergency departments within 24 hours of head trauma. The investigators derived and validated age-specific prediction rules for ciTBI, defined as death from traumatic brain injury, neurosurgery, intubation for longer than 24 hours, or hospital admission for 2 or more nights.

Among children younger than 2 years of age, 8502 were in the derivation population and 2216 in the validation population, and among children 2 years of age and older, there were 25,283 and 6411, respectively. CT scans were performed in 14,969 children (35.3%); 376 children (0.9%) were diagnosed with ciTBIs and 60 (0.1%) underwent neurosurgery.

For children younger than 2 years, the prediction rule was normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 seconds, nonsevere injury mechanism, no palpable skull fracture, and acting normally according to the parents. In the validation population, this rule had a negative predictive value for ciTBI of 1176/1176 (100.0%; 95% confidence interval [CI], 99.7 - 100.0) and a sensitivity of 25/25 (100%; 95% CI, 86.3 - 100·0). This low-risk group consisted of 167 (24.1%) of 694 CT-imaged patients younger than 2 years of age.

For children 2 years of age and older, the prediction rule was normal mental status, no loss of consciousness, no vomiting, nonsevere injury mechanism, no signs of basilar skull fracture, and no severe headache. This rule had a negative predictive value of 3798/3800 (99.95%; 95% CI, 99.81 - 99.99) and a sensitivity of 61/63 (96.8%; 95% CI, 89.·0 - 99.6). Of 2223 CT-imaged patients 2 years of age and older, 446 (20.1%) were in this low-risk group.

"Neither rule missed neurosurgery in validation populations," the study authors write. "These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated."

Using these prediction rules, CT scans and the attendant radiation exposure could be eliminated in 1 in 4 children younger than 2 years and in 1 in 5 children older than 2 years presenting with head trauma.

Limitations of this study include lack of CT scans on all patients and lack of assessment of long-term neurocognitive outcomes.

"Application of these rules could limit CT use, protecting children from unnecessary radiation risks," the study authors conclude. "Furthermore, these rules provide the necessary data to assist clinicians and families in CT decision making after head trauma."

In an accompanying Comment, Patricia C. Parkin, MD, and Jonathon L. Maguire, MD, from the Hospital for Sick Children, University of Toronto Faculty of Medicine in Ontario, note that decision aids offer structured presentations of options and outcomes.

"Many decisions, even in acute-care settings, are sensitive to patients' values and preferences," Drs. Parkin and Maguire write. "Perhaps as this field moves forward to assessment of the effect of the rules on physicians' behavior and clinical outcomes (impact analysis), clinicians and investigators might consider involving patients in the decision-making process. Then, when asking the question 'should my head-injured child have a CT scan?', parents can weigh the probability of a clinically important traumatic brain injury with the probability of harm from ionizing radiation from the CT scan."

The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services, funded this study. The study authors and editorialists have disclosed no relevant financial relationships.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19758692

2. Multitasking Muddles the Mind?

By Constance Holden. ScienceNOW Daily News. 25 August 2009

Bad news for people who like to text their BFFs while surfing the Web for some new shoes and watching the latest episode of Project Runway. Scientists who've conducted what they say is the first-ever study of chronic multitaskers found that cognitive performance declines when people try to pay attention to many media channels at once.

Although media multitasking has become more and more prevalent, no one knows how chronic media immersion affects cognitive functioning. So a team headed by psychologist Eyal Ophir of Stanford University in Palo Alto, California, identified 19 "heavy media multitaskers" (HMMs) and 22 "light media multitaskers" (LMMs) among a group of students based on how often they reported simultaneously using media such as television, cell phones, computer games, and videos.

The researchers then gave subjects in the two groups tests to see how well they could sift relevant information from the environment, filter out irrelevant information in their memories, and quickly switch between cognitive tasks. One filtering test, for example, required viewers to note changes in red rectangles while ignoring changes in blue rectangles in the same pictures. In the task-switching experiment, participants were presented with images of paired numbers and letters and had to switch back and forth between classifying the numbers as even or odd and classifying the letters as vowels or consonants.

The HMMs did worse than the LMMs across the board. Surprisingly, says co-author and sociologist Clifford Nass, "They're bad at every cognitive control task necessary for multitasking." They were more easily distracted by irrelevant stimuli, and although their memories were no worse than those of the LMMs, they had more difficulty in selecting stored information that was relevant to the task at hand. In one filtering test, for example, the LMMs took 323 milliseconds to discern the correct answer, but the HMMs averaged 400 milliseconds.

Nass says the study has a disturbing implication in an age when more and more people are simultaneously working on a computer, listening to music, surfing the Web, texting, or talking on the phone: Access to more information tools is not necessarily making people more efficient in their intellectual chores. Also disconcerting, he notes, is that "people who chronically multitask believe they're good at it." The findings are reported this week in the Proceedings of the National Academy of Sciences.

Daphne Bavelier, a cognitive scientist at the University of Rochester in New York state, says the research presents a puzzle about the brain's ability to learn from experience. Bavelier has discovered that people who play action video games get better at the kind of task-switching those games require. In contrast, Bavelier says, the poor performance of multitaskers in the new study suggests that more experience doesn't always translate to improved performance.

It's still not clear, however, that multitasking really scrambles the brain. It's also possible that people with poor filtering and attentional abilities are more prone to multitasking to begin with. Anthony Wagner, a psychologist in the Stanford group, says he suspects that constant jumping among different media offers instant rewards that reinforce "exploratory" behavior at the expense of the ability to concentrate on a particular task.

Want more on how the brain works? See John Medina, Brain Rules: 12 Principles for Surviving and Thriving at Work, Home, and School (Seattle: Pear Press, 2008). Amazon See also the book’s webpage

3. Opioids May Be Unnecessary Adjuncts to Proposal

Randomized Clinical Trial of Propofol With and Without Alfentanil for Deep Procedural Sedation in the Emergency Department

Miner JR, et al. Acad Emerg Med. 2009;16:825–834.

Objectives: The objectives were to compare the efficacy, occurrence of adverse events, and recovery duration of propofol with and without alfentanil for use in procedural sedation in the emergency department (ED).

Methods: This was a randomized nonblinded prospective trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were given intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients received 1 mg/kg propofol either with or without a supplemental dose of 10 μg/kg alfentanil for deep procedural sedation. Doses, vital signs, nasal end-tidal CO2 (ETCO2), pulse oximetry, and bispectral electroencephalographic (EEG) analysis scores were recorded. Subclinical respiratory depression was defined as a change in ETCO2 of greater than 10 mmHg, an oxygen saturation of less than 92% at any time, or an absent ETCO2 waveform at any time. Clinical events related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure or had recall of the procedure.

Results: A total of 150 patients were enrolled; 146 underwent sedation and were included in the analysis. Seventy-four patients received propofol, and 71 received propofol with alfentanil. No clinically significant complications were noted. Subclinical respiratory depression was seen in 24/74 patients in the propofol group and 30/71 patients in the propofol/alfentanil group (effect size = 9.8%, 95% CI = –5.8% to 25.5%). Clinical signs of respiratory depression included an increase in supplemental oxygen use in 25 of the 74 propofol patients and 31 of the 71 propofol/alfentanil patients (effect size 9.9%, 95% CI = –5.9% to 25.7%), the use of bag-valve mask apparatus in seven patients in the propofol group and 12 in the propofol/alfentanil group (effect size = 5.6%, 95% CI = –3.5% to 18.4%), airway repositioning in 13 propofol patients and 20 propofol/alfentanil patients (effect size = 10.6%, 95% CI = –3.0% to 24.2%), and stimulation to induce breathing in 11 propofol patients and 20 propofol/alfentanil patients (effect size = 13.3%, 95% CI = 0.1% to 26.5%). The total time of the procedure was longer for the alfentanil/propofol group (median = 11 minutes, range = 5–22 minutes) than for the propofol group (median = 9 minutes, range = 1 to 43 minutes; effect size = 1.93 minutes, 95% CI = 0.73 to 2.58, p = 0.02). Pain during the procedure was reported by 10 of the 74 patients in the propofol group and 7 of the 71 patients in the propofol/alfentanil group (effect size = 4.5%, 95% CI = –6.8% to 14.1%). Recall of some part of the procedure was reported by 12 patients in the propofol group and 9 in the propofol/alfentanil group (effect size = 3.5%, 95% CI = –7.9% to 15.0%). All procedures were successfully completed.

Conclusions: The use of supplemental alfentanil with propofol for procedural sedation did not result in a difference in reported pain or recall immediately after the procedure. There was an increase in the proportion of patients who required stimulation to induce respiration during the procedure in patients who received propofol with supplemental alfentanil. The addition of supplemental opioid to procedural sedation with propofol does not appear beneficial.

4. Most Mistakes in the Emergency Department Caused by Human Error

Fran Lowry. September 17, 2009 — Most of the mistakes in the emergency department (ED) that have the potential to compromise patient safety are caused by human error, according to a study published online September 18 in BMC Emergency Medicine.

"[EDs] are challenging hospital settings with regard to patient safety. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety," Marleen Smits, MD, from the Netherlands Institute for Health Services Research, Utrecht, and colleagues write. "This can only be achieved if interventions tackle the dominant underlying causes."

The aim of this study was to examine the nature and causes of unintended events in EDs and the relationship between type of event and causal factor structure.

The study evaluated medical errors in the EDs of 10 hospitals in the Netherlands (1 university hospital, 3 tertiary teaching hospitals, and 6 general hospitals) for 8 to 10 weeks. ED staff members were asked to report all unintended events, no matter how trivial or commonplace, that could have harmed or did harm a patient.

A total of 522 events were reported, ranging from 46 to 71 per ED, for an average of 52 reports. Most of the reports (85%) were made by nurses; resident physicians or consultants reported 13% of the unintended events, and clerical staff reported 2%. The reporter was directly involved in 83% of the unintended events. Most occurred during daytime hours (44%); 34% occurred during evening and night, and for 22% of the unintended events, the time of occurrence was unknown or unspecified by the reporter.

Most errors occurred during medical examinations or lab tests (36%). More than half of the unintended events (56%) had consequences for the patient, and in 45% of these instances, the patient suffered some inconvenience, such as prolonged waiting time. One third of patients received suboptimal care, such as a delay in starting antibiotic treatment. The consequences of error were more severe in the 8% of patients who required an extra intervention, the 6% of patients who suffered pain, and the 3% of patients who suffered a physical injury, Dr. Smits and colleagues write.

Most root causes of error were human (60%), followed by organizational (25%) and technical (11%) causes. Nearly half of the root causes could be attributed to other departments either in or outside of the hospital.

In citing limitations to their study, the investigators note that, because the reporting was not anonymous, it is possible that certain mistakes were underreported. "This may have biased the results towards the reporting of less significant events, events without consequences for the patient, and errors originating in other departments, because these are 'safer' to report."

In addition, most errors were reported by nurses, and therefore the study results give information about events that are mainly related to nursing care and less to care by residents and specialists in the ED.

Although the majority of errors had no consequences for the patient or resulted in only minor inconveniences, their accumulated effect on patient well-being is likely to be large, the authors write. They conclude: "Event reporting gives insight into diverse unintended events. The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments."

Dr. Smits and colleagues have disclosed no relevant financial relationships.

BMC Emerg Med. 2009;9:16 http://www.biomedcentral.com/1471-227X/9/16/abstract

5. More Disturbing News About Prehospital Trauma Intubation

Prehospital intubation failed in 31% of trauma patients in a large urban trauma system.

Cobas MA, et al. Anesth Analg 2009 Aug; 109:489.

BACKGROUND: Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI.

METHODS: A prospective observational study was conducted evaluating trauma patients who had emergency prehospital airway management and were admitted during the period between August 2003 and June 2006. The PHI was considered a failure if the initial assessment determined improper placement of the endotracheal tube or if alternative airway management devices were used as a rescue measure after intubation was attempted.

RESULTS: One-thousand-three-hundred-twenty patients had emergency airway interventions performed by an anesthesiologist upon arrival at the trauma center. Of those, 203 had been initially intubated in the field by emergency medical services personnel, with 74 of 203 (36%) surviving to discharge. When evaluating the success of the intubation, 63 of 203 (31%) met the criteria for failed PHI, all of them requiring intubation, with only 18 of 63 (29%) surviving to discharge. These patients had rescue airway management provided either via Combitube® (n = 28), Laryngeal Mask Airway® (n = 6), or a cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not. Several other variables, including age, gender, weight, mechanism of injury, presence of facial injuries, and emergency medical services were not correlated with an increased incidence of failed intubations.

CONCLUSION: This prospective study showed a 31% incidence of failed PHI in a large metropolitan trauma center. We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.

6. Intervention for Non–ST-Segment-Elevation Acute Coronary Syndromes: What Difference Does a Day Make?

Interventions performed immediately or deferred to the next working day resulted in similar outcomes.

The advantages of invasive over conservative strategies for managing non–ST-segment-elevation acute coronary syndromes (NSTEACS) are established, but the optimal timing of intervention is undetermined. To find out whether immediate catheterization compared with delayed intervention reduces incident MI, investigators in France randomized 352 patients hospitalized for NSTEACS to undergo interventional treatment either immediately upon admission or on the next working day (8–60 hours after enrollment).

Median time from randomization to sheath insertion was 70 minutes in the immediate-intervention group and 21 hours in the delayed-intervention group. The primary endpoint, peak troponin level during hospitalization, did not differ significantly between the two strategies (median peak levels, 2.1 ng/mL and 1.7 ng/mL in the immediate- and delayed-intervention groups, respectively). The rate of the composite of death, MI, and urgent revascularization at 1 month also did not differ significantly between the two groups (13.7% and 10.2%, respectively). However, median hospital stay was significantly shorter with the immediate strategy than with the delayed strategy (55 hours vs. 77 hours).

Comment: These findings suggest that in patients with non–ST-segment-elevation acute coronary syndromes, immediate versus delayed intervention does not result in increased MI rates, as defined by peak troponin levels. Accordingly, rapid or urgent intervention appears to be appropriate in unstable patients, whereas logistical and cost concerns may factor into decisions about whether to defer intervention in stable patients.

— Beat J. Meyer, MD. Published in Journal Watch Cardiology September 16, 2009. Citation:
Montalescot G et al. Immediate vs delayed intervention for acute coronary syndromes: A randomized clinical trial. JAMA 2009 Sep 2; 302:947. http://www.ncbi.nlm.nih.gov/pubmed/19724041

7. Useful Clinical Aphorisms to Practice By

“Clinical aphorisms that have proved useful for me during more than 30 years of inpatient and outpatient attending at 4 US medical schools”

Alpert JS. Amer J Med. 2009;122:700-701;789-790.

Rule 1: Common things occur commonly. I make this point continuously to medical students and residents. Sometimes young clinicians will suggest an unusual diagnosis for a patient with the hope of being the only doctor to make the correct diagnosis. More experienced clinicians believe the correct diagnosis is usually something common. For example, consider a patient with an enlarged spleen. In North America, splenomegaly rarely results from entities such as primary lymphoma of the spleen or malaria. Rather, splenomegaly is often caused by portal hypertension or mononucleosis. One of my first, and best, residents during my internship told me “If it looks like a horse, whinnies like a horse, and smells like a horse, don't expect a zebra to appear” (Stone N, MD, personal communication, 1970).

Rule 2: Common sense occurs uncommonly. This aphorism is usually attributed to Voltaire. Over the years, I have seen many violations of this important rule in clinical medicine. Physicians should exercise common sense before ordering tests or performing therapeutic interventions. Examples abound in support of this rule. Recently, I saw a 60-year-old diabetic woman in my office. She had been admitted to our hospital several weeks earlier with a single bout of rest angina. Her cardiac catheterization revealed modest coronary arterial stenoses, and she was placed on medical therapy with brand name medications by another cardiologist: a statin, an angiotensin receptor blocker, and clopidogrel. Subsequently, I first saw her in my office. At that time, she and her family told me that they had paid more than $500 for 1 month's supply of the medicines that had been prescribed in the hospital. I quickly altered her regimen to include generic forms of a statin and an angiotensin-converting enzyme inhibitor, as well as 325 mg of aspirin. These new generic prescriptions would cost the patient less than $20 per month. Common sense should have been used earlier by the inpatient attending physician simply by informing the patient that generic brands cost less than brand name pharmaceuticals. As noted by Harvey Cushing (1869-1939), “Three-fifths of the practice of medicine depends on common sense, knowledge of people and of human reactions.” I would add knowledge of the patient's ability to pay for the medicines prescribed.

Rule 3: The less a procedure is indicated the more likely that its use will be accompanied by complications. This rule advises clinicians to ensure that every procedure or test ordered has a reasonable probability of altering patient management. An example of this aphorism in practice involved a healthy 55-year-old man without coronary heart disease risk factors. He became anxious when a neighbor had an acute myocardial infarction. His doctor suggested that he undergo a coronary calcium computed tomography scan. This test revealed modest coronary calcifications. The patient became more anxious when he heard the results of his computed tomography scan, and he convinced his physician that he needed a coronary angiogram. The angiogram was unremarkable, but the catheterization resulted in a large groin hematoma and pseudoaneurysm that required vascular surgical repair. If I had been involved in this patient's initial care, reassurance or, at most, a Bruce protocol electrocardiographically monitored exercise test, would have been my approach.

Rule 4: Listen between the lines.
Rule 5: Seven minutes is an inadequate amount of time to spend on a patient visit.
Rule 6: Practicing good medicine requires a triad of equal doses of hard work, kindness, and honesty.
Rule 7: No individual has a monopoly on truth.
Rule 8: Obtaining informed consent from a patient for a procedure can help or hurt the patient.
Rule 9: Physician, heal thyself.
Rule 10: Respect your fellow health care workers; they are your most important clinical asset.
Rule 11: Admission to an intensive care unit in a tertiary care hospital can be a harrowing experience for the patient.
Rule 12: True, true, and unrelated.
Rule 13: The enemy of good is perfect.
Rule 14: Physician error is often the result of overconfidence.
Rule 15: It is a privilege to practice medicine.

Full-texts (free): http://www.amjmed.com/article/S0002-9343(09)00223-X/fulltext
http://www.amjmed.com/article/S0002-9343(09)00222-8/fulltext

8. Switch to Part D Limits Access to Psychiatric Medications, Increases ED Use

Caroline Cassels. September 9, 2009 — The switch from Medicaid drug coverage to Medicare Part D has restricted access to psychiatric medications and contributed to a subsequent high rate of emergency room visits among patients with mental health disorders, new research suggests.

A study conducted at Harvard Medical School in Boston, Massachusetts, shows that since January 2006, when the switch occurred, 44% of psychiatric patients reported difficulties in accessing medications. In addition, the likelihood of visiting an emergency department was significantly higher for psychiatric patients who experienced a medication access problem than for those who did not (odds ratio, 1.75; mean P = .003).

"We were surprised by the high rate of reports of access problems — 44% of patients reported some type of access issue, and that's a pretty large number, even allowing for the fact that it is a relatively new initiative and you would expect a certain amount of miscommunication and confusion," lead author Haiden Huskamp, PhD, told Medscape Psychiatry.

The study is published in the September issue of Psychiatric Services.

Utilization Management

It is estimated that approximately one third of individuals dually eligible for Medicare and Medicaid benefits have a mental disorder. For these individuals, said Dr. Huskamp, pharmacotherapy is a key element of their treatment.

The authors point out that "dual eligibles" received coverage for prescription drugs through the Medicaid program in which patients paid little or none of the cost of their medications

However, under the Medicare Prescription Drug Improvement and Modernization Act of 2003, drug coverage for this population was shifted from Medicaid to the new Medicare Part D program, and all of these individuals were randomly assigned to a private Part D plan with associated premiums and other utilization management tools including prior authorization and stepped care.

"The creation of Part D represented an important switch for dually eligible patients. Now instead of getting their drugs from Medicaid, patients had to get their medications through private Part D plans, which had different coverage policies and restrictions," said Dr. Huskamp.

Dr. Huskamp added her group was particularly concerned about the potential effect of this policy change on the dually eligible psychiatric population.

"This is a particularly vulnerable population, and there was some concern that switching to a Part D plan that may have restrictions on the medications they were taking could have implications for the quality of care they received. So we wanted to look and see what was happening in this particular group," said Dr. Huskamp.

Drugs Not Covered or Approved

For the study, the researchers randomly sampled psychiatrists from the American Medical Association's Physicians Masterfile who reported on experiences of 1 dually eligible patient in the 9 to 12 months after Part D implementation.

Each psychiatrist was randomly assigned 1 of 21 start days and times to report on the next dually eligible patients treated during the psychiatrist's last typical work week. Information on patients' sociodemographics, treatment setting, diagnosis, clinical characteristics, and ability to access medication was gathered.

The researchers also obtained information on emergency department visits related to participants' psychiatric illness, as well as any psychiatric hospitalizations since January 1, 2006. A total of 908 patients were included in the final study sample. Of these 57% were women and 62% were between 41 and 64 years old. Almost two thirds had a diagnosis of either schizophrenia or bipolar disorder.

Overall, 400 individuals (44%) had some type of problem accessing their medications. Investigators found that 318 individuals (35%) were unable to access clinically indicated refills or new prescriptions because the drugs were not covered or approved.

In addition, 170 individuals (19%) were stable on a clinically desired or indicated medication but switched to a different drug because refills were not covered or approved, and 200 participants (22%) had problems accessing medications because of copayments.

Compared with a matched sample of dually eligible patients whose medication access was not disrupted, those with difficulty accessing their medication were more likely to incur a visit to the hospital emergency department related to their psychiatric illness.

It may be, said Dr. Huskamp, that switching from Medicaid to Part D had some unanticipated and unintended negative effects including the possibility of negative clinical outcomes, as indicated by a high rate of emergency room visits and increased health costs for non-drug-related health services.

"I think our study provides a red flag that some attention needs to be devoted to this issue. We need to examine the Part D data (which are currently not publicly available) so we can take a detailed look at utilization patterns and health outcomes for this population," said Dr. Huskamp.

"Certainly emergency department use is an indicator that things are not going well for patients, but having more concrete measures would be helpful to get a clearer understanding of how this policy change has affected patients' mental health status and functioning," she added.

Psychiatr Serv. 2009;60:1169–1174. http://www.ncbi.nlm.nih.gov/pubmed/19723730

9. Aspiration vs. Chest Tube for Spontaneous Pneumothorax: No Difference in Outcome

NEW YORK (Reuters Health) Sep 10 - For primary spontaneous pneumothorax in adults, percutaneous aspiration and standard chest tube drainage have similar outcomes, according to an abstract of a report from the Cochrane Database of Systematic Reviews.

The abstract appears in the September issue of the Annals of Emergency Medicine, in the journal's Evidence-Based Emergency Medicine section.

"The management of primary spontaneous pneumothorax is controversial, with bodies such as the American College of Chest Physicians recommending formal chest tube drainage for patients requiring intervention, (and) the British Thoracic Society recommending simple percutaneous aspiration as the primary management strategy," section editor Dr. John W. Hafner, of the University of Illinois College of Medicine at Peoria, told Reuters Health.

The abstract is based on a Cochrane Review titled "Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults," written in 2007 by Abel Wakai and colleagues. That report reviewed studies published through 2006.

Of 1735 reports of randomized trials initially identified by the researchers as potentially relevant, only one, involving 60 patients, met all the criteria for study design and quality.

In this one trial, there was no significant difference in the immediate success rate for simple percutaneous aspiration compared with intercostal chest tube drainage (relative risk (RR)=0.93).

Similarly, there were no significant differences between the two approaches in rates of early failure at 1 week (RR=1.12), 1-year success (RR=1.02), length of hospital stay (mean group difference, 1.09 days), or pleurodesis by thoracoscopic talc poudrage within a year (RR=0.95).

Simple percutaneous aspiration did reduce patients' number of hospitalizations (RR=0.52).

"Widespread use of simple percutaneous aspiration (for) primary spontaneous pneumothorax could limit more invasive chest tube placement that requires hospitalization and increased healthcare costs," Dr. Hafner said.

"Unfortunately," he added, "due to the small size of the single study in the review, the general application of these results remains in question and requires further study with a larger study sample."

Ann Emerg Med 2009;54:458-460.

10. FDA Adds Boxed Warning to Injectable Promethazine

September 16, 2009 — The US Food and Drug Administration (FDA) is requiring manufacturers of the injectable form of promethazine hydrochloride to add a boxed warning to the drug's labeling that highlights the risk of serious tissue injury if the drug is administered incorrectly.

"Intravenous administration of promethazine can cause severe tissue injury, including gangrene, requiring fasciotomy, skin graft, and/or amputation," according to information for healthcare professionals posted on the FDA Web site. In addition, "Severe tissue injury can occur from perivascular extravasation, unintentional intra-arterial injection, and intraneuronal or perineuronal infiltration."

The preferred route of administration is deep intramuscular injection. Subcutaneous and intra-arterial injection are contraindicated.

Based on these known risks, the FDA advises clinicians to “effectively communicate” the risk of severe tissue injury to the patient when promethazine is administered intravenously.

In an alert sent today from MedWatch, the FDA's safety information and adverse event reporting program, the FDA also advises healthcare professionals to monitor patients who have received promethazine via contraindicated routes of administration for signs and symptoms of potential tissue injury, including burning or pain at the site of injection, phlebitis, swelling, and blistering. And if a patient complains of pain during injection, administration should cease immediately.

The FDA is also requiring a revision in the Dosage and Administration section of the drug's labeling to highlight "specific recommendations for the maximum concentration (25 mg/mL) and rate of administration (25 mg/min) when intravenous administration of promethazine is required." The 50 mg/mL is for deep intramuscular injection only, and the intravenous line should be checked to ensure it is properly functioning with a rate of 25 mg per minute.

Promethazine hydrochloride injection, USP, first introduced to the market in 1956, is approved for a variety of uses including allergic reactions, sedation, motion sickness, nausea and vomiting associated with anesthesia and surgery, and as an adjunct to analgesics for control of postoperative pain.

Current prescribing information for promethazine does contain information on the risk of tissue injury, but it was not highlighted in a boxed warning.

More information can be found on the FDA Web site. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm182500.htm

11. Antivirals Slightly Shorten Duration of Seasonal Flu in Children

Treatment was well tolerated and slightly reduced transmission to household contacts.

Children may shed influenza virus longer than adults and are a main source of spread to household contacts. To examine the effect of antiviral treatment in children, researchers performed a meta-analysis of seven randomized controlled trials of neuraminidase inhibitors for outpatient treatment of seasonal influenza and postexposure prophylaxis in children aged 12 years or younger.

Two trials evaluated outpatient treatment with oseltamivir and two with zanamivir within 36 or 48 hours of onset of influenza-like symptoms. In a total of 1766 children (1243 with confirmed and 523 with suspected influenza), treatment reduced median time to symptom resolution, return to normal activities, or both by 0.5 to 1.5 days; reductions were statistically significant in one oseltamivir trial and one zanamivir trial. Recovery was significantly faster in children with confirmed influenza than in those with suspected influenza.

Three trials evaluated 10-day courses of oseltamivir (1 trial) or zanamivir (2 trials) for postexposure prophylaxis in 863 children. Treatment was associated with an 8% decrease in the incidence of symptomatic influenza (number needed to treat to prevent 1 additional case, 13). Compliance was high — 97% of children took more than 8 of the 10 doses of zanamivir and 90% took all 10 doses of oseltamivir. Both drugs were well tolerated; however, the incidence of vomiting was 5% higher with oseltamivir than with placebo. No deaths were reported.

Comment: This meta-analysis suggests that neuraminidase inhibitors are well tolerated in children and that they slightly reduce symptom duration and household transmission of seasonal influenza. Whether these data apply to the 2009 influenza A (H1N1) virus pandemic is not clear. Given that H1N1 disease has been mild so far in otherwise healthy children older than age 5 years, neuraminidase inhibitors cannot be recommended for routine outpatient treatment in low-risk children older than 5 years with uncomplicated suspected 2009 H1N1 influenza (JW Pediatr Adolesc Med Aug 21 2009).

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine September 4, 2009. Citation: Shun-Shin M et al. Neuraminidase inhibitors for treatment and prophylaxis of influenza in children: Systematic review and meta-analysis of randomised controlled trials. BMJ 2009 Aug 10; 339:b3172. (http://dx.doi.org/10.1136/bmj.b3172)

12. Combined Corticosteroid and Antiviral Treatment for Bells Palsy: Two Big Reviews

A. A Systematic Review and Meta-analysis

de Almeida JR, et al. JAMA. 2009;302:985-993.

Context: New evidence has emerged regarding the use of corticosteroids and antiviral agents in Bell palsy.

Objective: To estimate the association of corticosteroids and antiviral agents with the risk of unsatisfactory facial recovery in patients with Bell palsy.

Data Sources: The search included MEDLINE, EMBASE, CENTRAL, PsychInfo, CINAHL, Web of Science, PAPERSFIRST, PROCEEDINGSFIRST, and PROQUEST to identify studies up to March 1, 2009.

Study Selection and Data Extraction: Eligible studies were randomized controlled trials comparing treatment with either corticosteroids or antiviral agents with a control and measuring at least 1 of the following outcomes: unsatisfactory facial recovery (4 months), unsatisfactory short-term recovery (6 weeks to 4 months), synkinesis and autonomic dysfunction, or adverse effects. Two reviewers extracted data on study characteristics, methods, and outcomes. Disagreement was resolved by consensus.

Results: Eighteen trials involving 2786 patients were eligible. Regression analysis identified a synergistic effect when corticosteroids and antiviral agents were administered in combination compared with alone (odds ratio for interaction term, 0.54 [95% confidence interval {CI}, 0.35-0.83]; P = .004). Meta-analysis using a random-effects model showed corticosteroids alone were associated with a reduced risk of unsatisfactory recovery (relative risk [RR], 0.69 [95% CI, 0.55-0.87]; P = .001) (number needed to treat to benefit 1 person, 11 [95% CI, 8-25]), a reduced risk of synkinesis and autonomic dysfunction (RR, 0.48 [95% CI, 0.36-0.65]; P less than .001) (number needed to treat to benefit 1 person, 7 [95% CI, 6-10]), and no increase in adverse effects. Antiviral agents alone were not associated with a reduced risk of unsatisfactory recovery (RR, 1.14 [95% CI, 0.80-1.62]; P = .48). When combined with antiviral agents, corticosteroids were associated with greater benefit (RR, 0.48 [95% CI, 0.29-0.79]; P = .004) than antiviral agents alone. When combined with corticosteroids, antiviral agents were associated with greater risk reduction of borderline significance compared with corticosteroids alone (RR, 0.75 [95% CI, 0.56-1.00]; P = .05).

Conclusions: In Bell palsy, corticosteroids are associated with a reduced risk of unsatisfactory recovery. Antiviral agents, when administered with corticosteroids, may be associated with additional benefit.

B. The benefits of steroids versus steroids plus antivirals for treatment of Bell’s palsy: a meta-analysis

Quant EC, et al. BMJ 2009;339:b3354

Objective: To determine whether steroids plus antivirals provide a better degree of facial muscle recovery in patients with Bell’s palsy than steroids alone.
Design Meta-analysis.

Data sources: PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for studies published in all languages from 1984 to January 2009. Additional studies were identified from cited references.

Selection criteria: Randomised controlled trials that compared steroids with the combination of steroids and antivirals for the treatment of Bell’s palsy were included in this study. At least one month of follow-up and a primary end point of at least partial facial muscle recovery, as defined by a House-Brackmann grade of at least 2 (complete palsy is designated a grade of 6) or an equivalent score on an alternative recognised scoring system, were required.

Review methods: Two authors independently reviewed studies for methodological quality, treatment regimens, duration of symptoms before treatment, length of follow-up, and outcomes. Odds ratios with 95% confidence intervals were calculated and pooled using a random effects model.

Results: Six trials were included, a total of 1145 patients; 574 patients received steroids alone and 571 patients received steroids and antivirals. The pooled odds ratio for facial muscle recovery showed no benefit of steroids plus antivirals compared with steroids alone (odds ratio 1.50, 95% confidence interval 0.83 to 2.69; P=0.18). A one study removed analysis showed that the highest quality studies had the greatest effect on the lack of difference between study arms shown by the odds ratio. Subgroup analyses assessing causes of heterogeneity defined a priori (time from symptom onset to treatment, length of follow-up, and type of antiviral studied) showed no benefit of antivirals in addition to that provided by steroids.

Conclusions: Antivirals did not provide an added benefit in achieving at least partial facial muscle recovery compared with steroids alone in patients with Bell’s palsy. This study does not, therefore, support the routine use of antivirals in Bell’s palsy. Future studies should use improved herpes virus diagnostics and newer antivirals to assess whether combination therapy benefits patients with more severe facial paralysis at study entry.

Full-text (free): http://www.bmj.com/cgi/content/full/339/sep07_1/b3354

13. Rapid Urine Chlamydia Test for Males Is Highly Sensitive

When tested on first-void urine samples, a new rapid chlamydia test had a sensitivity of 82%.

Nadala E-C et al. BMJ 2009 Jul 28; 339:b2655.

Conclusions: The performance of the new Chlamydia Rapid Test with first void male urine samples indicates that it would be an effective diagnostic tool for chlamydial infection in men. The availability of test results within an hour allows for immediate treatment and contact tracing, potentially reducing the risks of persistent infection and onward transmission. The test could also provide a simple and reliable alternative to nucleic acid amplification assays for testing of male urine in chlamydial screening programmes in high prevalence settings.

Full-text (free): http://www.bmj.com/cgi/content/full/339/jul28_2/b2655

14. Time to Abandon the "Shotgun Approach" to Syncope Evaluation

Many unnecessary and costly tests are obtained to evaluate elders with syncope.

Syncope is common, challenging, and expensive; it accounts for 1% to 3% of all U.S. emergency department visits and about 6% of inpatient admissions, with an estimated annual healthcare cost of US$2.5 billion. Most causes of syncope are benign, but the diagnostic challenge is to identify those that are life-threatening, particularly cardiovascular causes. Despite thorough and costly work-ups, syncope etiology remains undetermined in 40% of patients after their initial evaluations.

Researchers at Yale University performed a retrospective cohort study in 2106 consecutive older patients (age, 65) who were admitted with syncope. The investigators reviewed how often various diagnostic tests were ordered and how often such results helped to establish the etiology of syncope or affected diagnosis and management. They calculated the cost per test that affected diagnosis or management and whether use of the San Francisco Syncope Rule (SFSR; Ann Emerg Med 2004; 43:224) resulted in improved cost efficiency or diagnostic yield.

Postural blood pressure measurement (i.e., orthostatics), performed in only 38% of cases, affected diagnosis and management in about 25% of patients and identified syncope etiology in 15% to 21% of syncopal episodes; it returned the highest diagnostic yield and was the most cost-effective test ($17–$21). Cardiac enzymes, head computed tomography (CT) scans, carotid ultrasound (US), and electroencephalography (EEG) had little effect on diagnosis or management (less than 5%); rarely helped determine syncope etiology (less than 2%); and were among the least cost-effective tests: EEG ($33,000), head CT ($25,000), cardiac enzymes ($22,000), and carotid US ($20,000). Use of the SFSR led to higher diagnostic yield and better cost-effectiveness for most cardiac tests.

Comment: These findings underscore the importance of prioritizing diagnostic testing based on an initial standard evaluation, which should include a complete history and physical examination (including orthostatic blood pressure measurements and an electrocardiogram). Neurological tests (i.e., head magnetic resonance imaging or CT, EEG, and carotid US) shouldn't be performed, unless a neurological disease or event is suspected, based on the initial evaluation.

I am confident that the results of this study could be replicated in a variety of clinical settings. Although "shot gunning" multiple tests might reassure patients that they are getting the best care money can buy, we must take more financial stewardship of our resources, follow evidence-based guidelines, and be willing to live with some diagnostic uncertainty. Our healthcare system and economy can no longer support indiscriminate ordering of tests. More studies should be designed to evaluate cost-effectiveness, and those results should be incorporated into clinical guidelines.

— Aaron J. Calderon, MD, FACP. Published in Journal Watch Hospital Medicine August 31, 2009. Citation: Mendu ML et al. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med. 2009;169:1299. http://www.ncbi.nlm.nih.gov/pubmed/19636031

15. Unenhanced CT May Assist in Diagnosis of Children with Flank Pain

Laurie Barclay, MD. September 14, 2009 — Unenhanced computed tomography (UCT) plays an important role in diagnosing children with flank pain, according to the results of a retrospective study reported in the September issue of Pediatrics.

"Urolithiasis can cause acute abdominal or flank pain, and its incidence is increasing," write Andre C. Persaud, MD, from Akron Children's Hospital in Akron, Ohio, and colleagues. "With increases in the use of UCT for diagnosis, additional predictors that can aid clinicians in management are needed....The objective of this study was to identify factors that predict the presence of urolithiasis detected with...UCT in children."

Between January 2002 and December 2005, a total of 339 eligible patients younger than 21 years presented to the emergency department at Akron Children's Hospital and underwent UCT of the abdomen. Mean age of those with positive results on UCT for urolithiasis was 14.4 years; 72 patients (66%) were girls. A standardized form was used to abstract data regarding demographics, clinical presentation, diagnosis, treatment, and disposition. Factors associated with urolithiasis were identified with use of univariate and logistic regression analyses.

UCT detected 110 cases of urolithiasis in 95 individual patients. Initial urinalysis results were negative for blood in 17 cases of urolithiasis (15%). Of the 110 stones detected, 57 (51.8%) were ureteral, 26 (23.6%) were renal, and 4 (3.6%) were in the bladder. Among children in whom UCT did not reveal a stone, UCT did lead to potentially significant, alternative diagnoses in 23 children (10%).

Positive predictors of urolithiasis were a history of urolithiasis, a history of nausea and vomiting, flank pain on examination, and more than 2 red blood cells per high-power field seen on urine microscopic examination. Factors inversely associated with urolithiasis on UCT scans were a history of fever or dysuria and costovertebral angle tenderness on physical examination.

"UCT plays an important role in the diagnostic evaluation of children with flank pain," the study authors write. "Approximately 15% of children with urolithiasis do not have hematuria."

Limitations of this study include retrospective design, data limited to the information reported in the electronic charts, and UCT results interpreted by a single radiologist without set guidelines.

"A history of urolithiasis, nausea and vomiting, flank pain on examination, and hematuria are positively associated with urolithiasis in children," the study authors conclude. "Fever, dysuria, and costovertebral angle tenderness are inversely associated with urolithiasis....The relative cost and potential radiation risks of UCT must be balanced against its high sensitivity in depicting calculi, rapid results, and ability to reveal alternate pathologic conditions."

The study authors have disclosed no relevant financial relationships.

Pediatrics. 2009;124:888-894. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19661055

16. More Details on Corticosteroids for Bacterial Meningitis

This meta-analysis of published randomized, placebo-controlled trials suggests that the adjunctive administration of corticosteroids is beneficial in the treatment of adolescents and adults with acute bacterial meningitis in patient populations similar to those seen in high-income countries and in areas with a low prevalence of human immunodeficiency virus infection.

Assiri AM et al. Mayo Clin Proc 2009 May; 84:403.
Abstract: http://www.mayoclinicproceedings.com/content/84/5/403.abstract

17. "Spin" Not Uncommon in Negative RCTs, Study Shows

Shelley Wood. September 14, 2009 (Vancouver, British Columbia) — French researchers who set out to classify, then quantify the amount of "spin" in publications of negative randomized controlled trials say that the language used in and around the numbers themselves may frequently serve to sugar-coat negative results. Dr Isabelle Boutron (University Paris Descartes, France), who presented the results of the study during the 2009 International Congress on Peer Review and Biomedical Publication, said "spin" in reports of negative randomized controlled trials is by no means rare.

In randomized controlled trials, the "data should speak for themselves," she said during her presentation. The problem, however, is that scientists are rarely neutral about the results of their trial and consciously or unconsciously may try to portray their findings in a rosier light, often in the hopes of expediting publication, advancing their own careers, or even profiting financially. The aim of Boutron et al's study was to get a sense of just how often scientists may be "spinning" their findings, with spin defined as presenting or discussing the results in such a way as to convince the reader that an experimental treatment is beneficial, despite a nonstatistically significant difference for the primary end point.

Boutron and colleagues searched all two-arm randomized controlled trials indexed in PubMed in December 2006, ultimately identifying a total of 72 negative randomized controlled trials. They also developed a scoring system for identifying spin, based on linguistic choices and on instances when authors put particular emphasis on statistically significant results outside the primary end point (including within-group comparisons, subgroup analyses, and secondary outcomes), or interpreted results as demonstrating "comparable effectiveness" or "equivalence." Two independent reviewers then scored the papers, and reached a consensus for individual components of each of the papers.

Overall, evidence of spin was present in 18% of study titles, rising to 29% in the results, 43% in the discussions, and 50% in the conclusions. More than 40% of publications had spin in at least two of the three sections of the main text. Taking a closer look at the conclusions specifically, Boutron et al found that 33% of abstracts contained a "high level" of spin, defined as no acknowledgement of the negative primary outcome, no expression of uncertainty, and no recommendation to study the issue further in another trial. By contrast, a high level of spin was slightly less common in the conclusions of the full article.

Speaking with heartwire, Boutron emphasized that she hopes her work can ultimately be used to help authors write more objectively, and to also assist editors, reviewers, and readers.

"I think we should be reading articles differently," she said. "We should be really careful about the way people present and conclude their articles. And for academics, they should be very careful about the way they write articles. I often work with principle investigators in writing their articles, and I always need to calm them down, because they believe that their treatments work and they try to frame the results in a specific way."

An initial hurdle, she added, is for journal editors to think more critically about the discussion and conclusion sections of articles. "Sometimes the trials are very good and they have very straightforward ways of reporting their results and methods, but the interpretation of the results will be wrong. . . . This is an area where people aren't focusing too much; they're not looking at the discussion, they are looking at the results, and whether the statistical methods were well done, did they do the randomization correctly, etc. But for the discussion and interpretation, probably because it's subjective, people are afraid to look at it. . . . I think the journals need to take a tougher stand."

18. Comparison of GlideScope Video Laryngoscopy Versus Direct Laryngoscopy Intubation in the ED

Platts-Mills TF, et al. Acad Emerg Med. 2009;16:866–871.

Objectives: The first-attempt success rate of intubation was compared using GlideScope video laryngoscopy and direct laryngoscopy in an emergency department (ED).

Methods: A prospective observational study was conducted of adult patients undergoing intubation in the ED of a Level 1 trauma center with an emergency medicine residency program. Patients were consecutively enrolled between August 2006 and February 2008. Data collected included indication for intubation, patient characteristics, device used, initial oxygen saturation, and resident postgraduate year. The primary outcome measure was success with first attempt. Secondary outcome measures included time to successful intubation, intubation failure, and lowest oxygen saturation levels. An attempt was defined as the introduction of the laryngoscope into the mouth. Failure was defined as an esophageal intubation, changing to a different device or physician, or inability to place the endotracheal tube after three attempts.

Results: A total of 280 patients were enrolled, of whom video laryngoscopy was used for the initial intubation attempt in 63 (22%) and direct laryngoscopy was used in 217 (78%). Reasons for intubation included altered mental status (64%), respiratory distress (47%), facial trauma (9%), and immobilization for imaging (9%). Overall, 233 (83%) intubations were successful on the first attempt, 26 (9%) failures occurred, and one patient received a cricothyrotomy. The first-attempt success rate was 51 of 63 (81%, 95% confidence interval [CI] = 70% to 89%) for video laryngoscopy versus 182 of 217 (84%, 95% CI = 79% to 88%) for direct laryngoscopy (p = 0.59). Median time to successful intubation was 42 seconds (range, 13 to 350 seconds) for video laryngoscopy versus 30 seconds (range, 11 to 600 seconds) for direct laryngoscopy (p less than 0.01).

Conclusions: Rates of successful intubation on first attempt were not significantly different between video and direct laryngoscopy. However, intubation using video laryngoscopy required significantly more time to complete.

19. Images in EM

Adult Female With Weakness and Chills
http://www.annemergmed.com/article/S0196-0644(09)00054-7/fulltext

20. US Clinicians Underrecognize Abdominal Migraine in Children

Daniel M. Keller, PhD. September 14, 2009 (Philadelphia, Pennsylvania) — Abdominal migraine may represent up to 15% of pediatric gastrointestinal patients who experience idiopathic recurrent abdominal pain, if results presented here at the 14th International Headache Congress are representative.

Although the condition is well recognized in Europe, it is underdiagnosed in the United States, according to investigator Donald Lewis, MD, professor and chairman of the Department of Pediatrics at Eastern Virginia Medical School and senior vice president for academic affairs at Children's Hospital of the King's Daughters in Norfolk, Virginia.

Children with recurrent abdominal pain use significant amounts of healthcare resources, he said, and the condition can lead to dysfunction and disability that may interfere with school, family, and social activities.

Dr. Lewis told Medscape Neurology that abdominal migraine is classified as one of the period syndromes of childhood that are precursors to migraine. "If you track those kids [for] long through adolescence, most of them grow up to have migraine," he said.

Belly Pain a Cardinal Feature

Dr. Lewis, a pediatric neurologist, explained that abdominal migraine is characterized by episodes of moderate to severe midline, periumbilical, or poorly localized pain lasting for 1 to 72 hours with nausea, anorexia, pallor, and occasionally headache. "But headache is not one of the cardinal features. It's episodes of belly pain," he emphasized. The condition was included in the 2004 International Classification of Headache Disorders and recognized by the 2006 Rome III criteria for functional gastrointestinal disorders as a well-defined type of recurrent abdominal pain.

Through chart reviews, Dr. Lewis and colleagues assessed patients with recurrent abdominal pain in the hospital's pediatric gastroenterology clinic to define the proportion of patients who might fulfill the International Classification of Headache Disorders 2004 criteria for abdominal migraine. Eligible subjects were girls (41%) or boys (59%) who were 1 to 21 years old and who did not have a known diagnosis of causes of chronic abdominal pain. Of an initial cohort of 600 children, 458 met the inclusion criteria. Twenty children (4.4%) met the International Classification of Headache Disorders 2004 diagnostic criteria, with an additional 11% having probable abdominal migraine (documentation lacking for 1 or more diagnostic criterion).

"So we have this large subset of children who are languishing with a vague diagnosis in [gastrointestinal] clinics who most likely have abdominal migraine," Dr. Lewis said. Making the correct diagnosis of abdominal migraine means the spectrum of migraine medications will become available to these children, he added.

Migraine prophylactic medications and acute treatments for migraine attacks are available and efficacious for abdominal migraine. Because the study was solely demographic, it did not test medication efficacy, but Dr. Lewis said the European literature has documented the efficacy of these treatments.

He speculated that abdominal migraine is underrecognized in the United States because physicians have not been taught about it. The message about the existence of the condition is especially relevant to pediatric gastroenterologists and general pediatricians. Dr. Lewis suggested that pediatricians might better refer such patients to pediatric neurologists instead of to gastroenterologists. Informed families, too, may alert their physicians if their child has recurring symptoms consistent with a diagnosis of abdominal migraine, especially if a parent, particularly the mother, has a migraine condition, as migraine is often inherited.

Background of Episodic Abdominal Pain

Brian McGeeney, MD, MPH, assistant professor of neurology at Boston University, Massachusetts, who was not involved in the study, told Medscape Neurology that in his clinical experience with adults, abdominal migraine is a real entity. "They seem to have a background of episodic abdominal pain in childhood more than one would expect by chance," he said.

"Posters like this should really heighten the awareness of this unusual syndrome to adult neurologists as well as pediatricians." Knowing a patient's childhood history of abdominal symptoms may be one more clue in the diagnosis of adult migraine.

Although abdominal migraine may be a precursor to and temporally linked with later migraine, for Dr. McGeeney, a strong indication that abdominal migraine is really a form of migraine is that it often responds to a broad range of migraine prophylactic medications.

14th International Headache Congress: Abstract PO222. Presented Saturday, September 12, 2009.

Lit Bits: Aug 21, 2009

From the recent medical literature...

1. Fever in a Vaccinated Child? Hold the Blood Cultures

Routine blood cultures are not necessary for febrile children older than 3 months.

During the past decade, children have received routine vaccinations against Haemophilus influenzae type b and pneumococcus, and, as a result, the rate of serious bacterial infections (SBIs) caused by these organisms has plummeted. This change mandates review of the approach to evaluation and treatment of febrile children. These authors studied 68 infants younger than 3 months with either home or emergency department temperatures 100.4°F and 917 children aged 3 to 24 months with ED temperatures 102.3°F who presented to the ED of a tertiary care center in San Diego in 2003. Children younger than 3 months underwent an extensive standardized work-up, and older children underwent testing based on physician discretion.

Overall, 129 children (13%) had 132 cases of SBI (82 cases of pneumonia, 45 of urinary tract infection, and 5 of bacteremia). No white blood cell (WBC) count cutoff predicted SBI. However, the subset of children younger than 3 months was too small to adequately assess the accuracy of WBC counts in this age group. Nonpathogenic bacteria were identified in 4.9% of the 690 blood cultures obtained.

Comment: With the widespread use of the pneumococcal and H. influenzae type b vaccines, most serious bacterial illnesses in children now are either pneumonia or urinary tract infections. Most febrile children older than 3 months have viral syndromes, and routine blood cultures are not suggested by any guideline. However, this small study suggests that bacteremia does occur, infrequently. Clinicians should continue to exercise judgment about when to obtain blood cultures and complete blood cell counts, remembering that children are more susceptible than adults to bacteremia and that blood cultures should not be routinely obtained for febrile vaccinated children older than 3 months (JW Emerg Med Apr 17 2009).

— Diane M. Birnbaumer, MD, FACEP. Published in Journal Watch Emergency Medicine August 14, 2009. Citation: Rudinsky SL et al. Serious bacterial infections in febrile infants in the post–pneumococcal conjugate vaccine era. Acad Emerg Med 2009;16:585.

2. Door-to-Balloon Times Improve, But Other Aspects of AMI Care Lag Behind

August 12, 2009 (Durham, North Carolina) — Hospitals that offer PCI for AMI have improved their door-to-balloon times, but they have not been as successful at improving other care performance measures, such as referring patients for cardiac rehabilitation or counseling them to stop smoking, investigators report in the August 10/24, 2009 issue of the Archives of Internal Medicine.

Hospitals need to pay attention to all aspects of the care they provide their AMI patients and not focus solely on shortening door-to-balloon times, lead author Dr Tracy Y Wang (Duke Clinical Research Institute, Durham, NC) told heartwire. "Door-to-balloon time is a great quality metric, but it's only one of several. This study highlights the fact that we're doing great at one thing, but it doesn't mean that we can neglect everything else. We need to focus on the whole process of care, rather than just focus on that one particular aspect of quality improvement."

Commenting on this study for heartwire, Dr Paul W Armstrong (University of Alberta, Edmonton) said, "The authors have provided readers with a useful reminder that outcomes of STEMI patients are influenced by a host of things, not all of which were measured in this study, and that a single metric or preoccupation with door-to-balloon times may be misleading."

Everything in Between, and Thereafter

Wang and colleagues analyzed 101 hospitals participating in the American Heart Association Get With the Guidelines program and correlated door-to-balloon time improvement from 2005 to 2007 with changes in the composite Centers for Medicare and Medicaid Services/Joint Commission on Accreditation of Healthcare Organizations (CMS/JCAHO) core measure performance and in-hospital mortality.

The CMS/JCAHO core measures include aspirin at admission and discharge, beta-blocker use at admission and discharge, ACE inhibitors and angiotensin-receptor blocker use at discharge if ejection fraction is less than 40%, time to fibrinolysis of less than 30 minutes, and smoking-cessation counseling.

Wang and her group also evaluated each hospital's performance of American College of Cardiology/American Heart Association (ACC/AHA) guideline-recommended performance measures, which included in-hospital low-density-lipoprotein assessment, lipid-lowering therapy use at discharge, clopidogrel use at discharge, cardiac rehabilitation referral, and dietary and weight management counseling for patients with a body-mass index greater than 25 kg/m2.

A total of 43 678 patients were treated for AMI between 2005 and 2007. Over this time, mean door-to-balloon times decreased from 101 minutes to 87 minutes (p less than 0.001). The hospitals, which included teaching hospitals and surgical facilities, were more likely to show a greater improvement in door-to-balloon time if they were smaller, nonteaching, and had higher door-to-balloon times to begin with.

The composite CMS/JCAHO scores improved significantly between early and late periods, increasing from a mean of 93.4% to 96.4% (p less than 0.001), and the composite ACC/AHA scores also improved, from 82.0% to 84.2% (p less than 0.001).

However, there was no significant correlation between improved door-to-balloon times and CMS/JCAHO or ACC/AHA scores, even after multivariable adjustment for differences in patient characteristics.

In-hospital mortality was 5.1% in the early period and 4.7% in the later period (p=0.09), but there was no significant association between improvements in door-to-balloon times and changes in mortality. However, in a secondary analysis, there was a suggestion of reduced mortality in the hospitals that improved both door-to-balloon time and CMS/JCAHO performance.

"If you improved only one measure alone, you wouldn't impact mortality very much, but if you improved both door-to-balloon time and the other care process measures, you would see a significant impact on mortality," commented Wang.

Shaving off 14 Minutes a "Modest" Improvement

To heartwire, Armstrong pointed out that the study is missing key information, including the overall time from symptom onset to actual achievement of effective myocardial perfusion.

"Speedy reperfusion is much more likely to affect outcome when patients present within the first two to three hours, than later when they are at the 'flat portion' of the time-efficacy curve," Armstrong said. "The overall improvement in door-to-balloon times was quite modest, 14 minutes, from 101 to 87 minutes, and this means that nearly half of all the patients were still beyond guideline recommendations of 90 minutes. Since we do not know where in time these patients are within the 12-hour window of the study, and other key information is missing, we can only affirm that we need to do better in shortening the overall time from when patients start having symptoms to when they are effectively reperfused with whatever strategy is employed and combine it with attention to the many other components of care that affect outcome."

3. Probiotic Effects on Cold and Influenza-Like Symptom Incidence and Duration in Children

Leyer GJ, et al. Pediatrics 2009;124:e172-e179.

OBJECTIVE: Probiotic consumption effects on cold and influenza-like symptom incidence and duration were evaluated in healthy children during the winter season.

METHODS: In this double-blind, placebo-controlled study, 326 eligible children (3–5 years of age) were assigned randomly to receive placebo (N = 104), Lactobacillus acidophilus NCFM (N = 110), or L acidophilus NCFM in combination with Bifidobacterium animalis subsp lactis Bi-07 (N = 112). Children were treated twice daily for 6 months.

RESULTS: Relative to the placebo group, single and combination probiotics reduced fever incidence by 53.0% (P = .0085) and 72.7% (P = .0009), coughing incidence by 41.4% (P = .027) and 62.1% (P = .005), and rhinorrhea incidence by 28.2% (P = .68) and 58.8% (P = .03), respectively. Fever, coughing, and rhinorrhea duration was decreased significantly, relative to placebo, by 32% (single strain; P = .0023) and 48% (strain combination; P less than .001). Antibiotic use incidence was reduced, relative to placebo, by 68.4% (single strain; P = .0002) and 84.2% (strain combination; P less than .0001). Subjects receiving probiotic products had significant reductions in days absent from group child care, by 31.8% (single strain; P = .002) and 27.7% (strain combination; P less than .001), compared with subjects receiving placebo treatment.

CONCLUSION: Daily dietary probiotic supplementation for 6 months was a safe effective way to reduce fever, rhinorrhea, and cough incidence and duration and antibiotic prescription incidence, as well as the number of missed school days attributable to illness, for children 3 to 5 years of age.

4. A Regional System of Stroke Care Provides Thrombolytic Outcomes Comparable With the NINDS Stroke Trial

LaMonte MP, et al. Ann Emerg Med. 2009;54:319-327.

Study objective
Administration of tissue plasminogen activator (tPA) for acute ischemic stroke remains controversial in community practice. Well-organized hierarchic systems of acute stroke care have been proposed to link community hospitals to comprehensive stroke centers. We report safety and functional outcomes in patients treated with tPA in our regional emergency stroke network and compare them with results reported from the trial conducted by the National Institute of Neurological Disorders and Stroke (NINDS).

Methods
Through a statewide communications and transport network, our brain attack center gives emergency medicine staff in the state and surrounding area immediate access to stroke specialists. The team provides consultation about the administration of tPA for ischemic stroke, using the NINDS protocol. Consultations, treatment, and outcomes are documented in our database.

Results
From 1996 to 2005, the brain attack center completed 2,670 consultations and diagnosed 1,788 patients with ischemic stroke. Two hundred forty patients (9% of all consultations; 13.4% of those with acute ischemic stroke) received tPA. Percentages of patients with symptomatic intracranial hemorrhage and 3-month modified Rankin scale scores less than or equal to 1, compared with those in the NINDS trial, were as follows: 3.3% versus 6.4% and 53% versus 43% (P=.04). Mortality rates were 13% (network) versus 17% (NINDS).

Conclusion
During a 9-year period, an emergency medicine network with stroke consultants achieved patient outcomes comparable to those reported from the NINDS trial. These results indicate that the NINDS tPA protocol is applicable to community practice, with the support of a university-based brain attack center.

Full-text (free!): http://www.annemergmed.com/article/PIIS0196064408017861/fulltext

5. Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular Outcomes

Chandra A, et al. Acad Emerg Med. 2009;16:740–748.

Objectives: The value of unstructured physician estimate of risk for disease processes, other than acute coronary syndrome (ACS), has been demonstrated. The authors sought to evaluate the predictive value of unstructured physician estimate of risk for ACS in emergency department (ED) patients without obvious initial evidence of a cardiac event.

Methods: This was a post hoc secondary analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospectively collected multicenter data registry of patients over the age of 18 years presenting to the ED with symptoms of ACS between 1999 and 2001. In this registry, following patient history, physical exam, and electrocardiogram (ECG), the unstructured treating physician estimate of risk was recorded. A 30-day follow-up and a medical record review were used to determine rates of adverse cardiac events, death, myocardial infarction (MI), or revascularization procedure. The analysis included all patients with nondiagnostic ECG changes, normal initial biomarkers, and a non-MI initial impression from the registry and excluded those without complete data or who were lost to follow-up. Data were stratified by unstructured physician risk estimate: noncardiac, low risk, high risk, or unstable angina.

Results: Of 15,608 unique patients in the registry, 10,145 met inclusion/exclusion criteria. Patients were defined as having unstable angina in 6.0% of cases; high risk, 23.5% of cases; low risk, 44.2%; and noncardiac, 26.3% of cases. Adverse cardiac event rates had an inverse relationship, decreasing from 22.0% (95% confidence interval [CI] = 18.8% to 25.6%) for unstable angina, 10.2% (95% CI = 9.0% to 11.5%) for those stratified as high risk, 2.2% (95% CI = 1.8% to 2.6%) for low risk, and to 1.8% (95% CI = 1.4% to 2.4%) for noncardiac. The relative risk (RR) of an adverse cardiac event for those with an initial label of unstable angina compared to those with a low-risk designation was 10.2 (95% CI = 8.0 to 13.0). The RR of an event for those with a high-risk initial impression compared to those with a low-risk initial impression was 4.7 (95% CI = 3.8 to 5.9). The risk of an event among those with a low-risk initial impression was the same as for those with a noncardiac initial impression (RR = 0.83, 95% CI = 0.6 to 1.2).

Conclusions: In ED patients without obvious initial evidence of a cardiac event, unstructured emergency physician (EP) estimate of risk correlates with adverse cardiac outcomes.

6. Ruling Out Abdominal Organ Injury in Children with Blunt Trauma

A new clinical score identified nearly all children with abdominal organ injury after trauma.

History and physical exam provide limited information for detecting intra-abdominal injury in children with blunt abdominal trauma. A reliable method for identifying children who require abdominal computed tomography (CT) would decrease radiation and contrast exposure and improve efficiency of care. In a prospective observational study, these authors used clinical data for 147 consecutive children with blunt abdominal trauma who were admitted to a Swedish tertiary care hospital to develop a decision rule for excluding intra-abdominal organ injuries.

All patients underwent extensive laboratory testing and abdominal ultrasound for assessment of renal artery Doppler flow by a radiologist; patients with abnormal laboratory or ultrasound findings underwent abdominal CT. The Blunt Abdominal Trauma in Children (BATiC) score assigns points as follows:

•4 points for an abnormal Doppler evaluation of the renal arteries on abdominal ultrasound

•2 points each for abdominal pain, signs of peritoneal irritation on physical exam, hemodynamic instability, aspartate aminotransferase (AST) over 60 IU/L, and alanine aminotransferase (ALT) over 25 IU/L

•1 point each for peripheral white blood cell count over 9.5 g/L, lactate dehydrogenase above 330 IU/L, lipase over 30 IU/L, and creatinine over 50 µg/L

Overall, 31 patients (21%) were diagnosed with abdominal organ injury. A BATiC score 7 had a 97% negative predictive value for abdominal organ injury. Two patients with scores 7 had injuries (1 splenic, 1 renal) that were detected by CT performed to evaluate persistent abdominal pain 24 hours after admission; neither required intervention.

Comment: The BATiC score is a promising clinical decision rule. If the method is validated in large prospective multicenter studies, its use could decrease exposure to contrast CT and increase detection of abdominal organ injuries in children with blunt abdominal trauma. Larger studies in other settings would also help determine which children with blunt abdominal trauma are eligible for use of the rule. Fine-tuning might eliminate colinear predictors, such as AST and ALT, and nonspecific indicators, such as the peripheral white blood cell count.

— Daniel J. Pallin, MD, MPH. Published in Journal Watch Emergency Medicine July 17, 2009. Citation: Karam O et al. Blunt abdominal trauma in children: A score to predict the absence of organ injury. J Pediatr 2009 Jun; 154:912

7. Correlation of sonographic measurements of the internal jugular vein with central venous pressure

Donahue SP, et al. Amer J Emerg Med. 2009;27:851-855.

Determination of volume status is crucial in treating acutely ill patients. This study examined bedside ultrasonography of the internal jugular vein (IJV) to predict central venous pressure (CVP).

Ultrasonography was performed on 34 nonventilated patients with monitored CVPs. The IJV was measured during the respiratory cycle and with the patient in different positions. Mean IJV diameter in patients with CVP less than 10 cm H2O was 7.0 mm (95% confidence interval [CI], 5.7-8.3) vs 12.5 mm (95% CI, 11.2-13.8) in patients with CVP of 10 cm H2O and greater. Measurement of end expiratory diameter with the patient supine had the highest correlation coefficient: 0.82 (95% CI). There was strong agreement among ultrasonographers: correlation coefficient, 0.92 (95% CI).

This pilot study shows promise that ultrasonography of the IJV can be a noninvasive tool to predict CVP. Measurement of end expiratory diameter in supine patients exhibited a high correlation to CVP.

8. A Feasibility Study of the Sensitivity of Emergency Physician Dysphagia Screening in Acute Stroke Patients

Turner-Lawrence DE, et al. Ann Emerg Med. 2009;54:344-348.e1.

Study objective
To determine the sensitivity of dysphagia screening by emergency physicians on acute stroke patients.

Methods
To develop a 2-tiered dysphagia screen and performed it on a convenience sample of acute stroke patients. Tier 1 examined voice quality, swallowing complaints, facial asymmetry, and aphasia. Tier 2 involved a water swallow test, with evaluation for swallowing difficulty, voice quality compromise, and pulse oximetry desaturation (2% or more). We classified patients passing both tiers as “low risk” and compared the screen's sensitivity to a formal assessment by speech language pathologists. To assess reproducibility, we performed 2 consecutive, blinded ED screens on a convenience sample of 32 patients.

Results
During 16 months, we enrolled a convenience sample of 103 patients, excluding 19 patients from data analysis for lack of a stroke discharge diagnosis (n=11), an incomplete speech language pathologist evaluation within 24 hours (n=7), or pneumonia on emergency department (ED) chest radiography (n=1). Of the 84 remaining patients, speech language pathologists identified dysphagia in 48. The sensitivity of the ED dysphagia screen was 96% (95% confidence interval [CI] 85% to 99%), with a negative likelihood ratio of 0.08 (95% CI 0.02 to 0.3). Reproducibility testing yielded a kappa for the overall screen result of 0.9 (95% CI 0.9-1.0) and a simple agreement of 97%.

Conclusion
Preliminary data on the sensitivity and reliability of our ED dysphagia screening tool are promising. The simple screen provides an easy way for emergency physicians to identify acute stroke patients eligible for early oral medications and nutrition. Further validation and refinement of our screen are needed before its widespread adoption.

9. Antibiotic Use in Children with Otitis Media Increases Risk for Recurrence

Another reason to wait and see

Clinicians often prescribe antibiotics for treatment of uncomplicated acute otitis media (AOM) in children despite lack of evidence for improved outcomes. To examine the effects of antibiotic treatment on recurrence of AOM, investigators in the Netherlands surveyed parents of 240 children (age range, 6 months to 2 years) about 3 years after the children had participated in a multicenter, randomized, double-blind trial of amoxicillin (40 mg/kg/day in 3 doses) or placebo for treatment of AOM (JW Emerg Med Apr 1 2000). Seventy percent of parents returned questionnaires.

Parents reported at least one episode of AOM since the 6-month posttreatment follow-up visit significantly more often in the amoxicillin group than in the placebo group (63% vs. 43%). Even after adjustment for confounding factors, children in the amoxicillin group had 2.5 times the risk for recurrence. In sensitivity analysis among children who were not prescribed antibiotics during the 6 months after randomized treatment, the adjusted odds ratio for recurrence was 4.4. Ear, nose, and throat surgery was less likely in the amoxicillin group (21% vs. 30%). The authors note that wide confidence intervals limit interpretation of the results and caution that the findings cannot be generalized to children with underlying disease or who live in underresourced conditions.

Comment: One more nail in the coffin for antibiotic use in simple otitis media! This practice increases risk for colonization with resistant pathogens and recurrent infections in individual children and contributes to antibiotic resistance in the general population. In uncomplicated cases, reassure parents that resolution without antibiotics is the rule, not the exception, and try a "wait-and-see prescription," rather than immediately starting unnecessary antibiotics.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine August 7, 2009. Citation: Bezáková N et al. Recurrence up to 3.5 years after antibiotic treatment of acute otitis media in very young Dutch children: Survey of trial participants. BMJ 2009 Jun 30; 338:b2525. (http://dx.doi.org/10.1136/bmj.b2525)

10. Who’s Likely to Have a Problem with Ketamine?

A. Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department: An Individual-Patient Data Meta-analysis of 8,282 Children

Green SM, et al. Ann Emerg Med. 2009;54:158-168.e4

Study objective
Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events.

Methods
We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events.

Results
In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose ≥2.5 mg/kg or total dose ≥5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class ≥3), and the choice of intravenous versus intramuscular route.

Conclusion
Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Full-text (free): http://www.annemergmed.com/article/PIIS0196064408020842/fulltext

B. Predictors of Emesis and Recovery Agitation With Emergency Department Ketamine Sedation: An Individual-Patient Data Meta-Analysis of 8,282 Children

Study objective
Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies.

Methods
We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events.

Results
In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of 2.5 mg/kg or more or a total dose of 5.0 mg/kg or more), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (less than 3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation.

Conclusion
Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.

11. Patient Satisfaction as a Function of Emergency Department Previsit Expectations

Toma G, et al. Ann Emerg Med. 2009;54:360-367.e6.

Study objectives
This study measures the effect of meeting emergency department (ED) patients' expectations for diagnostic and therapeutic interventions on patient satisfaction.

Methods
This was a cross-sectional study of consecutive patients during block enrollment periods surveyed at the beginning and end of their ED visits. On arrival patients or their surrogates were surveyed about the specific interventions they expected during their visit. After completion of ED care, they were surveyed about their level of satisfaction with the entire encounter, assessment of their provider's interpersonal skills, impression of time spent waiting in the ED, and perceived waiting time. Satisfaction was assessed with categorical responses. The degree of concordance of interventions expected and interventions provided was analyzed to determine their effect on overall ED visit satisfaction.

Results
Nine hundred eighty-seven patients presented during enrollment periods, 821 met inclusion criteria, and complete data were collected on 504 patient encounters. Twenty-nine percent had no previsit expectations of diagnostic or therapeutic interventions, 24% had a single reported expectation, 47% had multiple intervention expectations. After adjusting for potential confounders, we could not demonstrate a relationship between fulfillment of expectations and satisfaction. We did find a very strong relationship between highly ranked provider interpersonal skills and ED satisfaction (probability ratio of being “very satisfied” 8.6; 95% confidence interval 4.7 to 15.6). Other factors associated with high ED encounter satisfaction were adequate explanations for waiting times and perception of total time in the ED.

Conclusion
Overall satisfaction was strongly correlated with patient's assessment of the physician's interpersonal skills and was not correlated with whether the physician had met expectations about diagnostic and therapeutic interventions.

Full-text (free!): http://www.annemergmed.com/article/S0196-0644(09)00104-8/fulltext

12. Optimal Depth of Chest Compressions in Children

Following the American Heart Association recommendation for compression to a depth of one third to one half of chest thickness could lead to overcompression in children.

Braga MS, et al. Pediatrics 2009;124:e69-e74.

OBJECTIVE: Pediatric consensus-driven cardiopulmonary resuscitation guidelines target chest compression (CC) depths of one third to one half anterior-posterior (AP) chest depth. Estimates for this target as assessed by computed tomography (CT) measurements of internal and external AP chest dimensions could direct future pediatric cardiopulmonary resuscitation guidelines.

METHODS: A total of 280 consecutive chest CT scans in permuted blocks of 20 for each of 14 age divisions between 0 and 8 years were reconstructed and analyzed. External and internal AP depths were measured at midsternum, and residual chest depth was calculated at simulated one-third and one-half AP compressions.

RESULTS: After a simulated compression calculation, one-half external AP depth CC would result in residual internal depth of less than 10 mm for 94% (263 of 280) of children 3 months to 8 years. For a one-third external AP CC, only 0.4% (1 of 280) of children 3 months to 8 years had a calculated residual internal chest depth less than 10 mm.

CONCLUSIONS: By using CT reconstruction estimates of chest dimensions across the developmental spectrum from 0 to 8 years of age, we demonstrated that a simulated CC targeting approximately one-third external AP chest depth seems radiographically appropriate for children aged 3 months to 8 years, whereas simulated CC targeting approximately one-half external AP chest depth seems radiographically to be too deep, resulting in residual internal chest depth of less than 10 mm for most patients of this age.

13. A comparison of the palatability of flavored oral contrasts

Arya R, et al. Amer J Emerg Med. 2009;27:847-850.

Objective
The aim of this study was to compare the taste of computed tomography (CT) oral contrast diluted with various flavored drinks.

Methods
We performed a prospective, blinded, controlled trial in healthy adult volunteers. Subjects were assigned to ingest four 250-mL aliquots of oral contrast media diluted in water, Crystal Light Lemonade (Kraft Food, Northfield, Ill), Tropical Punch Kool-Aid (Kraft Food), and Tropicana orange juice (Pepsi Bottling Company, Sommers, NY) in random order; and the taste of the solution was measured with a 100-mm visual analogue scale and 5-point Likert scale from very worst to best. Between-group comparison of the taste scores was performed with repeated-measures analysis of variance and pairwise t tests. The study had 80% power to detect an effect size 0.75 SDs.

Results
There were 23 subjects; mean (SD) age was 33 (7.7) and 30% were female. The mean (SD) taste scores were water 12 (5), lemonade 37 (21), Kool-Aid 44 (20), and orange juice 40 (20) (P less than .05). The proportion of subjects completely ingesting the contrast in water (65%) was significantly less than that with other 3 study solutions (100% each, P less than .001).

Conclusions
Dilution of oral contrast media with lemonade, fruit punch, or orange juice is tastier than with water. The choice of the specific juice used to dilute the oral contrast should be individualized based on patient preferences and availability.

14. Rebound Symptoms After Stopping PPIs

The findings are pertinent for patients who take PPIs unnecessarily.

Reimer C, et al. Gastroenterol 2009;137:80-87.e1.

Background & Aims
Rebound acid hypersecretion (RAHS) has been demonstrated after 8 weeks of treatment with a proton-pump inhibitor (PPI). If RAHS induces acid-related symptoms, this might lead to PPI dependency and thus have important implications.

…Conclusions
PPI therapy for 8 weeks induces acid-related symptoms in healthy volunteers after withdrawal. This study indicates unrecognized aspects of PPI withdrawal and supports the hypothesis that RAHS has clinical implications.

Full-text (free): http://www.gastrojournal.org/article/PIIS0016508509005228/fulltext

15. Urine dipstick useless to rule out rhabdomyolysis in patients with suspected heat injury

Young SE, et al. Amer J Emerg Med. 2009;27:875-877.

Background
Heat injury is a common, potentially life-threatening medical condition. In austere or mass-casualty conditions an easy to use, sensitive screening test could be a valuable tool to care providers and evacuation planners.

Objective
The objective of the study was to determine if a simple urine dipstick test for blood is sensitive for detection of rhabdomyolysis in the suspected heat injury patient.

Material and Methods
A convenience sample of patients presenting to a military community hospital Emergency Department during summer months with a presenting complaint consistent with suspected heat injury had urine dipstick testing performed for blood and compared with the results of formal urinalysis and serum creatine kinase.

Results
60 patients were enrolled in the study, seven had creatine kinase levels greater than 1000U/L, 14 had levels greater than 500U/L, and 26 had levels greater than 250 U/L. Using 1000U/L, urine dipstick testing had a sensitivity of 14% and a specificity of 85%.

Conclusions
Urine dipstick testing for blood is not a useful screening test for rhabdomyolysis in patients suspected to have significant heat injury.

16. Clinical and ECG Effects of Escitalopram (aka Lexapro) Overdose

Van Gorpab F, et al. Ann Emerg Med. 2009;54:404-408.

Study objective
We investigate the clinical effects of escitalopram overdose and determine the risk of QT prolongation and serotonin toxicity.

Methods
A review of escitalopram overdoses to a clinical toxicology unit was undertaken. Patient demographics, details of the ingestion, clinical effects, including evidence of serotonin toxicity, complications (arrhythmias and seizures), ICU admission, and length of stay were obtained. QT and QRS intervals were manually measured on ECGs by using a standardized approach. In a subgroup of 34 prospectively recruited patients, escitalopram was detected in blood from 33 patients. Medians and interquartile ranges (IQR) were reported, and QT versus pulse rate was plotted on a QT nomogram to investigate QT prolongation.

Results
Median ingested dose in the 79 presentations was 140 mg (IQR 75 to 260 mg; range 20 to 560 mg), and escitalopram was the only drug ingested or all coingested drugs were nontoxic in 46 cases. Median length of stay for patients receiving clinically important coingestants was 19 hours (IQR 9 to 33 hours) compared with that of patients receiving escitalopram alone (median 12 hours; IQR 7 to 19 hours). Serotonin toxicity occurred in 7 of the 46 escitalopram-alone ingestions (15%) but in only 1 of the 33 patients coingesting other medications. Common features were inducible clonus and hyperreflexia. Central nervous system depression and ICU admission were rare in escitalopram-alone overdoses compared with those in cases with sedative coingestants. Bradycardia (pulse rate below 60 beats/min) occurred in 11 cases (14%) and an abnormal QT–HR pair in 11 (14%), which was associated with normal or slow pulse rates. There were no deaths, seizures, or arrhythmias.

Conclusion
Major manifestations of escitalopram overdose were serotonin toxicity, QT prolongation, and bradycardia. The study suggests a potential for cardiac arrhythmias in escitalopram overdose.

17. Facebook requests can be dilemma for physicians

Physicians with Facebook pages may have patients who ask to be accepted as a "friend" on the social network site. The request can create a dilemma; the physician doesn't want to be rude and refuse, but also may be wary about giving a patient access to personal information. As one physician wrote in the New England Journal of Medicine, the debate over crossing personal-professional boundaries has taken a different shape in a new medium.

Sachin H. Jain. Practicing Medicine in the Age of Facebook. N Engl J Med. 2009;361:649-651.

Full-text (free!): http://content.nejm.org/cgi/content/full/361/7/649

18. Is Chest CT Overused in Children After Blunt Trauma?

Neither chest x-rays nor CT scout films missed findings in patients who needed immediate surgery.

Markel TA et al. J Trauma 2009;67:23.

Background: There is a growing concern that computed tomography (CT) is being unnecessarily overused for the evaluation of pediatric patients. The purpose of this study was to analyze the trends and utility of chest CT use compared with chest X-ray (CXR) for the evaluation of children with blunt chest trauma.

Methods: A 4-year retrospective review was performed for pediatric patients who underwent chest CT within 24 hours of sustaining blunt trauma at a Level-I trauma center. Trends in the use of CT and CXR were documented, and results of radiology reports were analyzed and compared with clinical outcomes.

Results: Three hundred thirty-three children, mean age 11 years, had chest CTs, increasing from 5.5% in 2001-2002 to 10.5% in 2004-2005 (p less than 0.001). Conversely, in those children who underwent chest CT, the rate of initial CXR use decreased from 84% to 56% during the same period (p less than 0.001). Twenty percent of chest CTs had significant positive findings. Six patients underwent emergency surgery for cardiac or arterial injuries, and all demonstrated abnormal findings on CXR or CT scout imaging. When compared with the CT, only 5% of initial CXRs falsely reported normal findings that may have altered management.

Conclusions: CT use in children has increased rapidly for the initial evaluation of chest trauma, whereas CXR use has decreased. Despite this trend, CXR remains an acceptable screening tool to analyze which patients may require CT evaluation. A multidisciplinary approach is warranted to develop guidelines that standardize the use of CT and thereby decreases unnecessary radiation exposure to pediatric patients.

19. Emergency physicians report infrequent use of α-blockade for the treatment of ureteral stones

Chan CW, et al. Amer J Emerg Med. 2009;27:776-778.

We sought to determine how frequently tamsulosin is used by emergency physicians (EPs) for the treatment of patients with ureteral stones, and examine factors influencing its use.

Basic Procedures
We distributed online and paper surveys to 240 EPs in five states in the United States. Surveys asked the length of time in practice, the type of hospital setting, and the self-reported frequency of tamsulosin use by quartile.

Findings
A total of 103 EPs (43%) responded to the survey. The majority (60%, 95% CI 51% to 69%) reported the use of tamsulosin in fewer than 25% of patients presenting with ureteral stones, and many (27%, 95% CI 20% to 36%) had not heard of the use of tamsulosin for urinary-stone passage. Practice in a county hospital was associated with infrequent tamsulosin use (p=.02).

Conclusions
Despite evidence that alpha-blockade may be beneficial (see below) to patients presenting to the emergency department with ureteral stones, this approach is still used inconsistently by EPs.

20. Tamsulosin Unhelpful for Ureteral Stones in the ED: A Randomized, Controlled Trial

Ferre RM, Ann Emerg Med. 2009;54:432-439.e2.

Study objective
The α-adrenergic antagonist tamsulosin hydrochloride has become an increasingly common adjunct in the treatment of ureteral calculi; however, its efficacy in a general emergency department (ED) population has not been investigated.

Methods
We conducted a randomized, controlled trial of adult ED patients with distal ureteral calculi diagnosed by computed tomography scan. Patients were randomized to receive either a 10-day course of ibuprofen and oxycodone plus tamsulosin or ibuprofen and oxycodone alone. The primary outcome measure was successful spontaneous ureteral stone expulsion at 14 days. Secondary outcomes included time to stone passage, self-reported pain scores, number of colicky pain episodes, unscheduled return ED/primary care visits, number of days of missed work/usual function, amount of analgesic used, and adverse events.

Results
Eighty subjects were enrolled in the study, with 77 completing the trial. Mean stone size was 3.6 mm (95% confidence interval [CI] 3.4 to 3.9). Successful spontaneous stone expulsion at 14 days was similar between the groups, with 27 (77.1%) subjects in the tamsulosin group and 24 (64.9%) subjects in the standard therapy group reporting spontaneous stone passage, a difference of 12% (95% CI –8.4% to 32.8%). At 2-, 5-, and 14-day follow-up, there were no clinically important (or statistically significant) differences between the groups for any secondary outcome measure. No adverse events were reported in either group.

Conclusion
In this cohort of adult ED patients with distal ureteral calculi, treatment with tamsulosin did not substantially improve any of the studied outcome measures compared with treatment with ibuprofen and oxycodone alone.

21. Is female sex associated with ED delays to diagnosis of appendicitis in the computed tomography era?

Donlan SM, et al. Amer J Emerg Med. 2009;27:856-858.

Background
Historically, females had delays to definitive diagnosis of appendicitis when compared to males. In this current millennium, appendicitis is now most commonly diagnosed by computed tomography (CT) in the emergency department (ED) rather than at surgery.

Objective
The aim of the study was to assess if female gender is still associated with delays to diagnosis of appendicitis in the CT era.

Methods
A retrospective cohort analysis of adult patients with appendicitis at a university teaching hospital ED was conducted. Inclusion criteria was age of more than 18 years and an International Classification of Diseases, Ninth Revision (ICD-9), diagnosis of appendicitis. Patients were excluded from analysis if they were pregnant, no CT scan was obtained in the ED, or had incomplete outcome data.

Results
One hundred thirty-seven patients met inclusion criteria; 65 female, 72 males. Time from triage to CT order was 138 minutes in females and 95 minutes in males (P = .0012). Time from initial physician evaluation to CT order was 45 minutes in females and 28 minutes in males (P = .0012). Nonclassic symptoms were more common in females and pelvic evaluation did not delay the CT order.

Conclusion
Female gender is still associated with delays to CT acquisition and diagnosis of appendicitis.

Lit Bits: July 31, 2009

From the recent medical literature...

1. Radiographic Pneumonia Uncommon in Children With Wheezing

Laurie Barclay, MD. July 10, 2009 — Because radiographic pneumonia in children with wheezing but without fever is uncommon, the routine use of chest radiography in these children should be discouraged, according to the results of a prospective cohort study reported in the July issue of Pediatrics.

"The diagnosis of pneumonia in children with wheezing can be difficult, because the clinical history and auscultatory findings may be difficult to distinguish from those for children without pneumonia," write Bonnie Mathews, MD, from Children's Hospital Boston and Harvard Medical School in Boston, Massachusetts, and colleagues. "Limited data exist regarding predictors of pneumonia among children with wheezing. The goal was to identify factors associated with radiographically confirmed pneumonia among children with wheezing in the emergency department (ED) setting."

The study sample consisted of 526 individuals not older than 21 years who were seen in the ED, who had wheezing on clinical examination, and who underwent chest radiography because of possible pneumonia. Before learning the chest radiograph results, treating physicians obtained a medical history and performed and recorded a physical examination. Two blinded radiologists independently read the chest radiographs.

Among the included patients, median age was 1.9 years (interquartile range, 0.7 - 4.5 years), 47% had a history of wheezing, 36% were hospitalized, and 4.9% (95% confidence interval [CI], 3.3% - 7.3%) had radiographic pneumonia. Children with wheezing who were afebrile, defined as a temperature of less than 38°C, had a very low rate of pneumonia (2.2%; 95% CI, 1.0% - 4.7%).

Factors linked to an increased risk for radiographic pneumonia were a history of fever at home (positive likelihood ratio [LR], 1.39; 95% CI, 1.13 - 1.70), a history of abdominal pain (positive LR, 2.85; 95% CI, 1.08 - 7.54), triage temperature of 38°C or higher (positive LR, 2.03; 95% CI, 1.34 - 3.07), maximal temperature in the ED of 38°C or higher (positive LR, 1.92; 95% CI, 1.48 - 2.49), and triage oxygen saturation of less than 92% (positive LR, 3.06; 95% CI, 1.15 - 8.16).

Limitations of this study include time constraints, preventing enrollment of all eligible children; reliance on blinded radiologist review; and chest radiographs ordered at the discretion of the physicians caring for the patients, which may have introduced selection bias. The findings are not generalizable to all children with wheezing, and the rate of pneumonia may have been overestimated.

"Radiographic pneumonia among children with wheezing is uncommon," the study authors write. "Historical and clinical factors may be used to determine the need for chest radiography for wheezing children. The routine use of chest radiography for children with wheezing but without fever should be discouraged."

The study authors have disclosed no relevant financial relationships.

Pediatrics. 2009;124:e29-e36.

2. Epilepsy Misdiagnosis Still a Key Reason Behind Long Delays to Identification of Long-QT Syndrome

Shelley Wood. July 31, 2009 (Auckland, New Zealand) — Children and young adults with long-QT syndrome may face long delays before their condition is properly diagnosed, especially if their seizures are misdiagnosed as epilepsy, a new review suggests. Researchers in New Zealand, who published their findings in the July 2009 issue of the Annals of Emergency Medicine, found that the median delay to diagnosis in their series of patients was almost two and a half years, but in some patients lasted more than 20 years.

According to study authors, led by Dr Judith M MacCormick (Starship Children's Hospital, Auckland, New Zealand), mortality in long-QT syndrome is greater than 20% within the first year of a first syncopal event, then rises to nearly 50% after five years. Those numbers, drawn from natural history studies, underscore the importance of making the right diagnosis as swiftly as possible. But as previously reported by heartwire , long-QT is frequently misdiagnosed as epilepsy, particularly in children and young adults, with awareness of the misdiagnosis dating back a quarter century. Since long-QT is also a heritable condition, swift diagnosis could also lead to prevention of sudden death in family members.

"Appropriate intervention can significantly reduce mortality and morbidity, making prompt diagnosis essential," MacCormick and colleagues write.

For their study, they reviewed all cases of long-QT in the New Zealand Cardiac Inherited Disease Registry, identifying 31 people carrying the genetic mutations associated long-QT syndrome. Of these patients, 13 experienced delays ranging from two months to 23 years (median delay 2.4 years) after their first syncope or seizure. If the patient was initially labeled epileptic, the delay to diagnosis was more likely to be longer, a median of 9.75 years (ranging from 7.6 to 20.7 years). During these delays, four sudden unexplained deaths occurred in young relatives of the 31 probands.

Of note, ECGs were not infrequently requested--in 10 of 13 patients--but errors in interpreting the results were common. "Our case series suggests that even when ECGs are undertaken as part of the assessment for syncope and seizure, interpretation is often suboptimal," the authors conclude. This observation is consistent with other recent work suggesting fewer than 40% of noncardiologists and fewer than 50% of cardiologists were able to calculate a QTc interval correctly, they add.

"Our findings show that delayed recognition of long-QT syndrome is still common, with 39% of the patients experiencing delay between initial presentation and diagnosis. Although the results and conclusions of this review are based on a New Zealand cohort, they are likely to be applicable to a wider population, including the United States."

Hoof Beats? Think Zebras

Speaking with heartwire , cardiologist Dr Silvia Priori (University of Pavia, Italy), who was not involved in the study, explained that while misdiagnosis is a known phenomenon in long-QT-syndrome patients, the problem persists in part because of a communication breakdown between the neurologist, the cardiologist, and the patient and his or her family. "This is something that definitely we have known and discussed for some time, but maybe we have not worked out how to best establish this communication with the neurologists," she admitted.

Part of the problem is that many of the patients are just children, in whom a diagnosis of epilepsy seems far more likely that a heart condition.

"The issue in the long-QT community is that in the patient with repeated syncope, especially children, the primary referral is to the neurologist, and epidemiologically this makes sense." The problem, she continued, is that it is not always explained to the family that regardless of the neurological findings, "the appropriate evaluation of syncope and seizure is to see a neurologist and then to see a cardiologist. An ECG should not be denied these patients."

Priori also pointed out that, complicating matters, there are rare but important associations between long-QT and epilepsy.

"If a patient with long-QT has had a cardiac arrest or prolonged hypoxia to the brain, they may have epilepsy as a consequence of brain damage," she noted. "There is also some evidence that, especially, the long-QT type 2 patients may have a form of long-QT that may actually lead to epilepsy. They are not strong data, and it's not very common, but when you talk to people who see a lot of long-QT patients, you find that each of us will have seen one or two families where [several family members] have long-QT and epilepsy together. This is a link that maybe goes beyond coincidence."

3. Randomized, Controlled Trial of Antibiotics in the Management of Community-Acquired Skin Abscesses in the Pediatric Patient

Duong M, et al. Ann Emerg Med. 2009; in press as of July

Study objective
Emergency department visits for skin and soft tissue infections are increasing with the discovery of community-acquired methicillin-resistant Staphylococcus aureus. Whether abscesses treated surgically also require antibiotics is controversial. There are no published pediatric randomized controlled trials evaluating the need for antibiotics in skin abscess management. We determine the benefits of antibiotics in surgically managed pediatric skin abscesses.

Methods
This was a double-blind, randomized, controlled trial. Pediatric patients were randomized to receive 10 days of placebo or trimethoprim-sulfamethoxazole after incision and draining. Follow-up consisted of a visit/call at 10 to 14 days and a call at 90 days. Primary outcome was treatment failure at the 10-day follow-up. Secondary outcome was new lesion development at the 10- and 90-day follow-ups. Noninferiority of placebo relative to trimethoprim-sulfamethoxazole for primary and secondary outcomes was assessed.

Results
One hundred sixty-one patients were enrolled, with 12 lost to follow-up. The failure rates were 5.26% (n=4/76) and 4.11% (n=3/73) in the placebo and antibiotic groups, respectively, yielding a difference of 1.15, with a 1-sided 95% confidence interval (CI) (1.15% to 6.8%). Noninferiority was established with an equivalence threshold of 7%. New lesions occurred at the 10-day follow-up: 19 on placebo (26.4%) and 9 on antibiotics (12.9%), yielding a difference of 13.5, with 95% 1-sided CI (13.5% to 24.3%). At the 3-month follow-up, 15 of 52 (28.8%) in the placebo group and 13 of 46 (28.3%) in the antibiotic group developed new lesions. The difference was 0.58, with 95% 1-sided CI (0.5% to 15.6%).

Conclusion
Antibiotics are not required for pediatric skin abscess resolution. Antibiotics may help prevent new lesions in the short term, but further studies are required.

4. Immature WBCs in CSF Do Not Indicate Bacterial Meningitis

In this retrospective study, band forms in CSF of children with meningitis did not predict bacterial etiology.

Meningitis is defined as a cerebrospinal fluid (CSF) white blood cell (WBC) count 10x106/L. Although leukocytosis resulting from any etiology begins with release of immature WBCs ("bands") from the bone marrow, many physicians believe that band forms indicate bacterial infection. To assess whether presence and number of CSF bands predict bacterial etiology, researchers conducted a retrospective chart review of all cases of meningitis diagnosed at eight U.S. pediatric emergency departments from 2001 through 2004. Children who required hospital admission for other reasons and those who were pretreated with antibiotics were excluded.

Of 1116 eligible children, 4% had bacterial meningitis. In multivariate analysis, neither the absolute CSF band count nor the proportion of CSF WBCs accounted for by bands independently predicted bacterial meningitis. The authors noted that CSF and peripheral blood band counts varied widely from center to center and deemed that the variation resulted from interrater variability, rather than clinical reality.

Comment: This study adds to other evidence that band counts are subjective and useless. The authors conclude that "the detection of CSF bands does not seem to be useful for decision making regarding the cause of CSF pleocytosis." At Children’s Hospital Boston, our lab stopped reporting band counts in peripheral blood a few years ago. I hope they’ll do the same with CSF samples. Your lab should, too.

— Daniel J. Pallin, MD, MPH. Published in Journal Watch Emergency Medicine July 10, 2009.
Citation: Kanegaye JT et al. Diagnostic value of immature neutrophils (bands) in the cerebrospinal fluid of children with cerebrospinal fluid pleocytosis. Pediatrics 2009 Jun; 123:e967.

5. Randomized Clinical Trial Comparing a Patient-Driven Titration Protocol of Intravenous Hydromorphone With Traditional Physician-Driven Management of Emergency Department Patients With Acute Severe Pain

Chang AK, et al. Ann Emerg Med. 2009;54:221-225.

Study objective
We test the null hypothesis that the “1+1” hydromorphone patient-driven protocol is clinically and statistically equivalent in safety and efficacy to that of traditional physician-driven administration of opioids for emergency department (ED) treatment of acute severe pain.

Methods
This was a prospective randomized clinical trial of nonelderly adults presenting to an urban academic ED with acute pain of sufficient severity to warrant intravenous (IV) opioids in the judgment of the attending physician. Patients randomized to the 1+1 hydromorphone patient-driven protocol received 1 mg IV hydromorphone followed by a second 1-mg dose 15 minutes later if the patient responded affirmatively to the question, “Do you want more pain medication?” Patients in the physician-driven group received any IV opioid in the dose chosen by the ED attending physician, with any additional analgesia provided at the discretion of that physician. The primary outcome was the difference in improvement in pain between the 2 groups at 60 minutes, as measured by a validated and reproducible numeric rating scale. Secondary outcomes included incidence of oxygen desaturation, hypoventilation, hypotension, bradycardia, nausea, vomiting, pruritus, and use of naloxone.

Results
The mean decrease in numeric rating scale pain scores for the 1+1 hydromorphone patient-driven group was 5.6 versus 4.5 in the physician-driven group. The difference of 1.1 numeric rating scale units (95% confidence interval 0.3 to 1.9) was statistically significant but fell 0.2 numeric rating scale units short of the 1.3 numeric rating scale unit threshold required to attain clinically significant efficacy. Safety profiles were similarly satisfactory in both groups. Ninety-four percent of the 1+1 hydromorphone patient-driven group achieved adequate analgesia (as defined by the patient) within 60 minutes of protocol initiation.

Conclusion
The 1+1 hydromorphone patient-driven protocol is statistically superior and at least as clinically efficacious and safe as traditional physician-driven treatment of ED patients with acute severe pain. More than 9 of 10 patients randomized to the study protocol achieved satisfactory pain control, as defined by the patient, within an hour or less.

6. Lidocaine Reduces Pain and Anxiety From Peripheral IV Cannula Insertion

Anthony J. Brown, MD. July 31, 2009 — Injected buffered lidocaine or lidocaine cream can reduce the pain and anxiety associated with intravenous cannula insertion, according to study findings reported in the August issue of the Annals of Emergency Medicine. Between the two, injected lidocaine is more effective in alleviating pain.

Many patients who present to the emergency department require placement of a peripheral IV line, which frequently causes pain and anxiety, Dr. Candace McNaughton, from Vanderbilt University, Nashville, Tennessee, and colleagues note.

Most IV placements in the ER are done without local anesthesia, the researchers point out. This may be due to "time constraints, difficulty with their application, perceived ineffectiveness, a belief that use of local anesthesia makes it more difficult to place IVs, or a belief by healthcare providers that the pain of IV insertion is insignificant."

Research has shown that both the pain and anxiety of IV insertion can be reduced by pretreatment with local anesthetics, but the best method was unclear.

Anesthetic creams are often used to reduce pain during IV insertion. However, in a busy ER setting, their usefulness is limited due to their delayed onset of action, the authors note. By contrast, injected anesthetics have a more rapid onset, but require an additional needle stick.

In a randomized, crossover study, Dr. McNaughton's team compared pain and anxiety in 70 medical students or nurses who had IVs placed after pretreatment with injected buffered lidocaine, lidocaine cream, or no analgesia. A 10-point numeric rating scale was used to assess pain, anxiety, and treatment preference immediately following IV insertion.

The median pain scores with lidocaine cream and injected, buffered lidocaine were 3 and 1, respectively. Without analgesia, the pain was much worse with a median score of 7.

Similarly, the median anxiety score with both lidocaine treatments was 2 compared with a score of 4 without analgesia.

The pretreatment method had no bearing on the likelihood of success, the report indicates, and most of the IV placement attempts were successful.

When surveyed, 70% of the subjects indicated that they would always request injected, buffered lidocaine for themselves and for their patients undergoing IV insertion. Lidocaine cream was the preferred treatment for 26% of subjects and no analgesia for 4%.

Ann Emerg Med. 2009;54:214-220. Abstract: http://www.annemergmed.com/article/S0196-0644(08)02182-3/abstract

7. Use of a Urine Dipstick and Brief Clinical Questionnaire to Predict an Abnormal Serum Creatinine in the Emergency Department

Firestone DN, et al. Acad Emerg Med. 2009;16:699-703.

Objectives: Prior data demonstrated that a urine dipstick used alone was a sensitive predictor of abnormal creatinine, but not sufficiently enough to forego screening of serum creatinine prior to administration of contrast for diagnostic studies. The authors hypothesized that a brief historical questionnaire coupled with a urine dipstick would have high sensitivity for renal dysfunction, potentially eliminating the need for a serum creatinine prior to contrast administration.

Methods: This was a prospective study of a convenience sample of patients at two academic tertiary-care emergency departments (EDs) during 2006–2007. Subjects included patients who had both a serum creatinine result reported by the laboratory and a urine dipstick result reported in the medical record. Data included triage vital signs, basic demographic data, 14 medical history items, dipstick urinalysis, and serum creatinine results. The main outcome measure was an abnormal serum creatinine, defined as greater than 1.5 mg/dL.

Results: Complete data sets were collected on 1,354 patient visits. Of these, there were 161 (12%) with a serum creatinine of greater than1.5 mg/dL. Logistic regression analysis identified the following independent predictors associated with elevated creatinine: age greater than 60 years, known renal insufficiency, diabetes, hypertension, diuretic use, vomiting, and proteinuria. Nearly all patients with abnormal creatinine (98%) had at least one of these seven predictors. A decision tool combining these predictors would have identified 158 of 161 patients with an abnormal creatinine (sensitivity, 98.1%; 95% confidence interval [CI] = 95.8% to 99.9%) and a specificity of 21.2% (95% CI = 18.8% to 23.2%).

Conclusions: The absence of six historical factors and absence of proteinuria can be safely used to identify patients who are unlikely to have an abnormal creatinine.

8. Ketamine and Etomidate: Good Choices for RSI in Critically Ill Patients

Mortality rates were similar in patients who received single doses of etomidate or ketamine.

Despite etomidate’s hemodynamic benefits, some clinicians have challenged its use for rapid sequence intubation (RSI) in critically ill patients, citing concerns about adrenal insufficiency (JW Emerg Med Feb 1 2008). In a prospective trial, researchers compared outcomes in 469 adult patients who were randomized to receive a single intravenous bolus of etomidate (0.3 mg/kg) or ketamine (2.0 mg/kg) for induction during RSI at 65 intensive care units (ICUs) and 12 emergency departments or prehospital systems in France. All patients received IV succinylcholine (1 mg/kg) immediately after the trial medication and continuous sedation with midazolam (0.1 mg/kg/hour) combined with fentanyl or sufentanil after tube placement was confirmed.

Final diagnoses were categorized as trauma (22%), sepsis (16%), or other (including stroke, overdose, cardiogenic shock, and acute respiratory failure; 62%). Adrenal insufficiency occurred in significantly more etomidate recipients than ketamine recipients (86% vs. 48%; odds ratio, 6.7). However, no significant differences were noted between groups in maximum sequential organ failure assessment (SOFA) scores during the first 3 days in the ICU (the primary outcome), intubation conditions, various measures of catecholamine use, or 28-day mortality. No drug-related adverse outcomes were reported with either agent. The authors conclude that "ketamine is a safe and valuable alternative to etomidate for intubation in critically ill patients, particularly in septic patients." Editorialists suggest that successful intubation depends on a solid knowledge of pharmacology but do not recommend one agent over the other.

Comment: This elegant and ambitious study demonstrated measurable adrenal suppression but no evidence of adverse outcome related to a single bolus of etomidate for RSI in patients with various types of shock. Adrenal axis suppression is common in critically ill patients; in fact, about half the patients who received ketamine had adrenal insufficiency in this study. The authors note that only 16% of study patients had septic shock, and they call for a larger randomized study that includes more patients with sepsis. Clinicians should choose induction drugs based on individual patient parameters and personal familiarity and not be dissuaded from using either etomidate or ketamine based on concerns that are not supported by evidence.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine July 2, 2009.
Citation: Jabre P et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: A multicentre randomised controlled trial. Lancet 2009 Jul 1; [e-pub ahead of print].

9. CT Scans May Not Be Helpful for Most Young Children With Emergent Headache

Laurie Barclay, MD. July 29, 2009 — Computed tomographic (CT) scans seldom lead to diagnosis or contribute to immediate management of young children presenting to the emergency department with headache but normal neurologic examination findings and nonworrying history, according to the results of a study reported in the July issue of Pediatrics.

"Neuroimaging because of recurrent childhood headaches has limited value; especially in the setting of normal physical examination," write Tarannum M. Lateef, MD, from George Washington University School of Medicine and Children's National Medical Center in Washington, DC, and colleagues. "The risk of radiation exposure from CT scans is highest in the youngest age group. This study addresses the diagnostic utility of CT scans, in an ED [emergency department] setting, for children less than 6 years of age."

The investigators evaluated the records of 364 children aged 2 to 5 years seen between July 1, 2003, and June 30, 2006, in a large urban emergency department for evaluation of headache. Patients with headaches secondary to clearly apparent causes such as ventriculoperitoneal shunts, known brain tumor, or acute illnesses including viral syndromes, fever, probable meningitis, or trauma were identified based on initial history and examination findings. For the remaining patients, headache history, neurologic findings, results of laboratory and neuroimaging tests, discharge diagnosis, and disposition were reviewed.

Among 306 children (84%) with secondary headaches identified from initial history and physical examination, acute febrile illnesses, and viral respiratory tract syndromes were thought to be responsible for the headaches in 72%.

CT scans were performed in 16 (28%) of the 58 children (16% of the total study sample) with no evident central nervous system disease or systemic illness diagnosed at presentation. In 15 (94%) of these 16 patients, CT scans did not facilitate diagnosis or management. Only 1 scan result was abnormal, revealing a brainstem glioma, but this patient had abnormal findings on neurologic examination when first evaluated in the emergency department. Family history was not documented in 59% of children who were thought to have primary headaches.

"For young children presenting to the ED with headache but normal neurologic examination findings and nonworrying history, CT scans seldom lead to diagnosis or contribute to immediate management," the study authors write. "A family history often is contributory and should be part of the evaluation of young children with headache in the ED. CT imaging poses risk (which is greatest for the youngest children), is expensive, and usually is without benefit."

Limitations of this study include retrospective design, lack of complete follow-up monitoring, and analysis limited to information in clinical records. Most children studied did not have a documented family history or a thorough headache history.

"Studies such as this one can contribute to recognition of medical interventions for which indications need rethinking," the study authors conclude.

Pediatrics. 2009;124:e12-e17

10. Images in EM

Female Infant With Fever and Rash
http://www.annemergmed.com/article/S0196-0644(09)00040-7/fulltext

Infant Male With Blood-Colored Stools
http://www.annemergmed.com/article/S0196-0644(09)00035-3/fulltext

Female With Right Lower Quadrant Abdominal Pain
http://www.annemergmed.com/article/S0196-0644(09)00003-1/fulltext

11. Procedural Sedation and Analgesia Outcomes in Children After Discharge From the Emergency Department: Ketamine Versus Fentanyl/Midazolam

McQueen A, et al. Ann Emerg Med. 2009;54:191-197.e4

Study objective
Although the safety and efficacy of procedural sedation and analgesia in the pediatric emergency department (ED) has been established, the prevalence of adverse events after discharge has not been well studied. We compare the postdischarge incidence of adverse behavioral events and vomiting and hypothesize that ketamine would be associated with increased adverse behaviors.

Methods
We conducted a prospective observational study of postdischarge behavioral changes and vomiting after sedation with ketamine, ketamine/midazolam, or fentanyl/midazolam. Families were administered a Post Hospital Behavior Questionnaire (PHBQ), with higher scores indicating more adverse behaviors (anxiety, sleep disturbances). We used linear and logistic regression to model PHBQ scores and logistic regression to model vomiting risk adjusting for age, sex, procedure, length of procedure, and parental presence as potential confounders.

Results
Seven hundred eighty-six children were enrolled and 554 children (61% boys; mean age 7.5±4.5 years) were contacted. The prevalence of postdischarge vomiting was 18%, but the prevalence of adverse behavioral changes was low. When adjusted for potential confounders, the odds of a higher PHBQ score increased among patients receiving fentanyl/midazolam (fentanyl/midazolam odds ratio [OR] 2.6, 95% confidence interval [CI] 1.08 to 6.03, P=.03; ketamine OR 1.7, 95% CI 0.84 to 3.57; ketamine/midazolam OR 0.5, 95% CI 0.26 to 1.07).

Conclusion
Procedural sedation and analgesia in the ED is well tolerated. Though postdischarge vomiting occurs with some frequency, there is a low prevalence of adverse behavioral events after discharge. The use of fentanyl/midazolam was associated with higher adverse behavioral scores.

12. Ultrasound Before CT in Patients with Acute Abdominal Pain

A diagnostic strategy of ultrasound followed by CT only if ultrasound results are nondiagnostic optimizes sensitivity while minimizing radiation exposure.

Early diagnostic computed tomography (CT) in patients with acute abdominal pain increases detection of serious diagnoses but is time-consuming and costly and can increase risk for future cancers from radiation exposure (JW Emerg Med Apr 24 2009). To identify an optimal imaging strategy, researchers prospectively collected data for 1021 hemodynamically stable, nonpregnant adult patients (mean age, 47; 55% female) with nontraumatic acute abdominal pain (duration, 2 hours to 5 days) who presented to six emergency departments in the Netherlands. All patients were evaluated by a radiologist with a structured imaging protocol consisting of plain x-rays (upright chest and supine abdomen), ultrasonography, and CT.

At 6 months, an expert physician panel determined the final diagnosis and classified it as urgent (requiring treatment within 24 hours; 65% of patients) or nonurgent. The most common urgent final diagnosis was acute appendicitis (28%), followed by acute diverticulitis (12%). Investigators compared the sensitivity and specificity of 11 diagnostic imaging strategies for detecting conditions classified as urgent. Clinical diagnosis was highly sensitive (88%) but nonspecific, with and without the addition of plain x-rays (specificity, 43% and 41%, respectively). Ultrasound reduced the rate of false-positive urgent diagnoses, but its sensitivity was only 70%. CT had a sensitivity of 89%. Sensitivity was highest (94%) with a conditional strategy of using CT only after nondiagnostic ultrasound; only half the patients would have required CT with this strategy.

Comment: This elegant study provides strong evidence for use of a strategy that optimizes sensitivity while minimizing radiation exposure for evaluation of acute abdominal pain in nonpregnant adults: ultrasound first, followed by CT only if ultrasound results are negative or inconclusive. Of note, intravenous contrast alone was used for CT; thus, CT studies need not be delayed for administration of oral contrast. As shown in many prior studies, plain radiographs are essentially useless, except perhaps to confirm a diagnosis of acute bowel obstruction.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine July 24, 2009. Citation: Laméris W et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: Diagnostic accuracy study. BMJ 2009 Jun 26; 338:b2431. (http://dx.doi.org/10.1136/bmj.b2431)

13. Comparison of the 20-Hour Intravenous and 72-Hour Oral Acetylcysteine Protocols for the Treatment of Acute Acetaminophen Poisoning

Yarema MC, et al. Ann Emerg Med. 2009; in press.

Study objective
To compare outcomes after acute acetaminophen poisoning in 2 large cohorts of patients treated with either the 20-hour intravenous or 72-hour oral acetylcysteine protocol.

Methods
We conducted a retrospective cohort study with historical control comparing patients treated with one of 2 acetylcysteine regimens. Data for the 20-hour group were obtained from a medical record review of patients on whom the 20-hour intravenous protocol was initiated in Canadian hospitals from 1980 to 2005. The 72-hour group consisted of a historical cohort of patients treated in US hospitals with the 72-hour oral protocol from 1976 to 1985. The primary outcome was hepatotoxicity (aminotransferase levels over 1,000 IU/L).

Results
Of the 4,048 patients analyzed, 2,086 were in the 20-hour group and 1,962 were in the 72-hour group. The incidence of hepatotoxicity was 13.9% in the 20-hour group and 15.8% in the 72-hour group (–1.9% absolute difference; 95% confidence interval [CI] -4.2 to 0.3). The relative risk of hepatotoxicity was lower in the 20-hour group when acetylcysteine was initiated within 12 hours of ingestion. The relative risk was lower in the 72-hour group when acetylcysteine was initiated later than 18 hours after ingestion. There was no significant risk difference between groups when acetylcysteine treatment was started 12 to 18 hours after ingestion. One patient in the 20-hour group received a liver transplant and died because of acetaminophen toxicity compared with no liver transplants and 3 deaths in the 72-hour group. Anaphylactoid reactions to intravenous acetylcysteine were reported in 148 of 2,086 patients (7.1%; 95% CI 6.1% to 8.3%). This study is limited by comparison of 2 separate data sets from different countries and study years.

Conclusion
The risk of hepatotoxicity differed between the 20-hour and 72-hour protocols according to the time to initiation of acetylcysteine. It favored the 20-hour protocol for patients presenting early and favored the 72-hour protocol for patients presenting late after acute acetaminophen overdose.

14. Corticosteroids Might Be Beneficial in Severe Sepsis and Septic Shock

Reanalysis of data supports prolonged low-dose treatment in adults.

Annane D, et al. JAMA. 2009;301(22):2362-2375.

Context: The benefit of corticosteroids in severe sepsis and septic shock remains controversial.

Objective: We examined the benefits and risks of corticosteroid treatment in severe sepsis and septic shock and the influence of dose and duration.

Data Sources: We searched the CENTRAL, MEDLINE, EMBASE, and LILACS (through March 2009) databases as well as reference lists of articles and proceedings of major meetings, and we contacted trial authors.

Study Selection: Randomized and quasi-randomized trials of corticosteroids vs placebo or supportive treatment in adult patients with severe sepsis/septic shock per the American College of Chest Physicians/Society of Critical Care Medicine consensus definition were included.

Results: We identified 17 randomized trials (n = 2138) and 3 quasi-randomized trials (n = 246) that had acceptable methodological quality to pool in a meta-analysis. Twenty-eight-day mortality for treated vs control patients was 388/1099 (35.3%) vs 400/1039 (38.5%) in randomized trials (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.71-1.00; P=.05; I2=53% by random-effects model) and 28/121 (23.1%) vs 24/125 (19.2%) in quasi-randomized trials (RR, 1.05, 95% CI, 0.69-1.58; P = .83). In 12 trials investigating prolonged low-dose corticosteroid treatment, 28-day mortality for treated vs control patients was 236/629 (37.5%) vs 264/599 (44%) (RR, 0.84; 95% CI, 0.72-0.97; P = .02). This treatment increased 28-day shock reversal (6 trials; 322/481 [66.9%] vs 276/471 [58.6%]; RR, 1.12; 95% CI, 1.02-1.23; P = .02; I2 = 4%) and reduced intensive care unit length of stay by 4.49 days (8 trials; 95% CI, –7.04 to –1.94; P less than .001; I2 = 0%) without increasing the risk of gastroduodenal bleeding (13 trials; 65/800 [8.1%] vs 56/764 [7.3%]; P = .50; I2 = 0%), superinfection (14 trials; 184/998 [18.4%] vs 170/950 [17.9%]; P = .92; I2 = 8%), or neuromuscular weakness (3 trials; 4/407 [1%] vs 7/404 [1.7%]; P = .58; I2 = 30%). Corticosteroids increased the risk of hyperglycemia (9 trials; 363/703 [51.6%] vs 308/670 [46%]; P less than .001; I2 = 0%) and hypernatremia (3 trials; 127/404 [31.4%] vs 77/401 [19.2%]; P less than .001; I2 = 0%).

Conclusions: Corticosteroid therapy has been used in varied doses for sepsis and related syndromes for more than 50 years, with no clear benefit on mortality. Since 1998, studies have consistently used prolonged low-dose corticosteroid therapy, and analysis of this subgroup suggests a beneficial drug effect on short-term mortality.

15. New CDC Recommendation: All Children Should Receive Annual Seasonal Flu Vaccines

Martha Kerr. July 24, 2009 — The US Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, is changing its recommendation for annual seasonal influenza vaccination for children aged 6 months to 18 years to a "full recommendation," Anne Schuchat, MD, director of the CDC's National Center for Immunization and Respiratory Diseases, announced today.

In addition, the CDC is advising a seasonal flu vaccine for anyone who feels they need one.

"While we are focusing a lot of attention on the 2009 H1N1 influenza virus, we do expect seasonal strains to emerge, and we are issuing updates of which strains to expect," Dr. Schuchat said. These include the A-H1N1, A-H3N2, and B strains, "which are available in this year's vaccine," she noted. "This past year's recommendations encouraged annual vaccination [of children].... This year, [the CDC] is no longer just advising vaccination whenever feasible but is [issuing] a full-out recommendation" of the seasonal flu vaccine.

Only about 40% of the US population received a flu vaccine last year. The CDC is recommending and emphasizing "an intensification of use" of the vaccine.

The CDC has specifically recommended that healthcare workers be immunized, as well as that campers at sleepover summer camps and attendees of military academies where there have been notable outbreaks of influenza receive the flu vaccine and antiviral agents, but only if appropriate.

"I don't think antiviral prophylaxis is a good idea," Dr. Schuchat said, noting that oseltamivir-resistant influenza strains have been reported.

Dr. Schuchat said that the latest laboratory-confirmed case count for the H1N1 influenza virus is 43,771 cases and 302 deaths, "but this is the last time we will be reporting cases in this way." Instead, the CDC will have a FluView Weekly Surveillance Report, updated every Friday, on its Web site.

The National Institutes of Health announced yesterday that clinical trials will begin as early as next week of 2 H1N1 influenza vaccine candidates in adults, either alone or in conjunction with the seasonal flu vaccine and, if safe, in children.

Sanofi Aventis and CSL Biotherapies, manufacturers of the 2 candidate vaccines, told a US Food and Drug Administration (FDA) advisory committee yesterday that they expect to have a vaccine available by October. Dr. Schuchat said that she is concerned that the flu season could be well underway by that time, because the school year begins within weeks in many areas.

The virus is unpredictable, she said, "skipping entire communities, while hitting others really hard." In addition, the virus can cause a wide spectrum of illness, from mild symptoms to respiratory arrest and neurological problems, including seizures. "That is why we are taking the virus so seriously." H1N1 often affects young, apparently healthy individuals, as well as those at high risk, and it could affect more than 40% of the population.

"We are preparing for the worst-case scenario of 60% of the population being affected," Dr. Schuchat said. "The value of worst-case scenario planning is that it allows for continuity planning."

The FDA's Advisory Committee on Immunization Practices is set to meet July 29 to propose H1N1 vaccine recommendations. Children aged 0 to 4 years will likely be the top priority, followed by school-age children, healthcare workers, pregnant women, and adults with chronic diseases.

Today, the FDA announced it had issued an emergency use authorization for a third diagnostic test for the 2009 H1N1 influenza virus because a public health emergency involving H1N1 was declared on April 26, 2009. It is the Focus Diagnostics Influenza H1N1 (2009) Real-Time Reverse Transcription Polymerase Chain Reaction diagnostic test.

The emergency use authorization allows Focus Diagnostics to distribute the test to laboratories certified under the Clinical Laboratory Improvement Amendments to perform high-complexity tests. This test is intended for use in the detection of the 2009 H1N1 influenza virus in patients with symptoms of respiratory infection.

The test does not indicate the stage of infection, nor does a negative result preclude influenza virus infection, FDA officials emphasize.

16. Ultrasonographically Guided Peripheral Intravenous Cannulation in Emergency Department Patients With Difficult Intravenous Access: A Randomized Trial

Stein J, et al. Ann Emerg Med. 2009;54:33-40.

Study objective
We seek to compare ultrasonographically guided peripheral intravenous access to a non–ultrasonographically guided method in a randomized trial of emergency department patients with difficult intravenous access.

Methods
A prospective cohort of patients with difficult intravenous access was established. Patients were randomized to 2 groups: (1) intravenous access obtained through an ultrasonographically guided technique or (2) intravenous access obtained through non–ultrasonographically guided methods. Outcomes measured were number of attempts after enrollment, time to cannulation from enrollment, and patient satisfaction. Groups were compared with nonparametric analysis.

Results
Fifty-nine patients were randomized. Twenty-eight patients were randomized to the ultrasonography group and 31 to the no ultrasonography group. A median of 2 further intravenous attempts was required in each group before successful cannulation, corresponding to a difference of 0 attempts (95% confidence interval [CI] 0 to 1 attempts). Time to cannulation showed a median of 39 minutes in the ultrasonography group compared with 26 minutes for the no ultrasonography group, giving a median increase of 13 minutes for the ultrasonographically guided group (95% CI –5 to 28 minutes). Patients in the ultrasonography group had a median Likert satisfaction score of 8 compared with 7 for the no ultrasonography group, giving a median increase of 1 on this scale in the ultrasonography group (95% CI 0 to 2).

Conclusion
Ultrasonographically guided peripheral intravenous cannulation did not decrease the number of attempts or the time to successful catheterization, nor did it improve patient satisfaction compared with the group that did not use ultrasonography. Superiority of ultrasonographically guided peripheral intravenous cannulation is not supported by this study.

17. Nearly One Fifth of Emergency Department Visits Are by the Uninsured

Martha Kerr. July 15, 2009 — US Department of Health and Human Services (HHS) Secretary Kathleen Sebelius released new data today from the Nationwide Emergency Department Sample, the largest all-payer emergency department (ED) database in the country, showing that a disproportionate number of visits were made by uninsured or low-income patients.

There were nearly 120 million ED visits in 2006, according to the HHS's Agency for Healthcare Research and Quality (AHRQ). Nearly one fifth were made by patients without health insurance, Secretary Sebelius said, and one fifth were made by residents of rural areas. One third of ED visits were made by low-income patients.

"Our healthcare system has forced too many uninsured, rural, and low-income Americans to depend on the emergency room for the care they need," Secretary Sebelius said in an HHS release announcing the new findings. "We cannot wait for reform that gives all Americans the high-quality, affordable care they need and helps prevent illnesses from turning into emergencies."

The Nationwide Emergency Department Sample contains 26 million records from ED visits to approximately 1000 community hospitals nationwide, or approximately 20% of all US EDs.

The sample shows national estimates on the number of ED visits to all community hospitals by region, urban vs rural location, teaching status, ownership, and trauma designation. It also contains data on the acute management of patients, including the reason for the visit, the treatments they received, visit outcome (admission, discharge, or transfer to another hospital; death in the ED; or leaving the ED against medical advice). Charges for the visit and who was billed were also recorded.

AHRQ also released the 2007 Nationwide Inpatient Sample today, which is the largest database on hospital care in the United States. HHS officials say it "...provides users with an in-depth look at why patients were hospitalized, the treatments and procedures they received, and what happened to them at discharge. Researchers can use the Nationwide Inpatient Sample to examine trend data as far back as 1988."

The 2007 Nationwide Inpatient Sample contains discharge data from 8 million hospital stays at more than 1000 community hospitals.

18. First-Degree Atrioventricular Block Not as Benign as Previously Thought

Long-term risk for atrial fibrillation, pacemaker placement, and all-cause mortality rose roughly 1.5- to 3-fold.

Cheng S, et al. JAMA. 2009;301(24):2571-2577.

Context: Prolongation of the electrocardiographic PR interval, known as first-degree atrioventricular block when the PR interval exceeds 200 milliseconds, is frequently encountered in clinical practice.

Objective: To determine the clinical significance of PR prolongation in ambulatory individuals.

Design, Setting, and Participants: Prospective, community-based cohort including 7575 individuals from the Framingham Heart Study (mean age, 47 years; 54% women) who underwent routine 12-lead electrocardiography. The study cohort underwent prospective follow-up through 2007 from baseline examinations in 1968-1974. Multivariable-adjusted Cox proportional hazards models were used to examine the associations of PR interval with the incidence of arrhythmic events and death.

Main Outcome Measures: Incident atrial fibrillation (AF), pacemaker implantation, and all-cause mortality.

Results: During follow-up, 481 participants developed AF, 124 required pacemaker implantation, and 1739 died. At the baseline examination, 124 individuals had PR intervals longer than 200 milliseconds. For those with PR intervals longer than 200 milliseconds compared with those with PR intervals of 200 milliseconds or shorter, incidence rates per 10 000 person-years were 140 (95% confidence interval [CI], 95-208) vs 36 (95% CI, 32-39) for AF, 59 (95% CI, 40-87) vs 6 (95% CI, 5-7) for pacemaker implantation, and 334 (95% CI, 260-428) vs 129 (95% CI, 123-135) for all-cause mortality. Corresponding absolute risk increases were 1.04% (AF), 0.53% (pacemaker implantation), and 2.05% (all-cause mortality) per year. In multivariable analyses, each 20-millisecond increment in PR was associated with an adjusted hazard ratio (HR) of 1.11 (95% CI, 1.02-1.22; P = .02) for AF, 1.22 (95% CI, 1.14-1.30; P less than.001) for pacemaker implantation, and 1.08 (95% CI, 1.02-1.13; P = .005) for all-cause mortality. Individuals with first-degree atrioventricular block had a 2-fold adjusted risk of AF (HR, 2.06; 95% CI, 1.36-3.12; P less than .001), 3-fold adjusted risk of pacemaker implantation (HR, 2.89; 95% CI, 1.83-4.57; P less than .001), and 1.4-fold adjusted risk of all-cause mortality (HR, 1.44, 95% CI, 1.09-1.91; P = .01).

Conclusion: Prolongation of the PR interval is associated with increased risks of AF, pacemaker implantation, and all-cause mortality.

19. Ibuprofen Provides Analgesia Equivalent to Acetaminophen–Codeine in the Treatment of Acute Pain in Children with Extremity Injuries: A Randomized Clinical Trial

Friday JH, et al. Acad Emerg Med. 2009;16:711-716.

Objectives: This study compared the analgesic effectiveness of acetaminophen–codeine with that of ibuprofen for children with acute traumatic extremity pain, with the hypothesis that the two medications would demonstrate equivalent reduction in pain scores in an emergency department (ED) setting.

Methods: This was a randomized, double-blinded equivalence trial. Pediatric ED patients 5 to 17 years of age with acute traumatic extremity pain received acetaminophen–codeine (1 mg/kg as codeine, maximum 60 mg) or ibuprofen (10 mg/kg, maximum 400 mg). The patients provided Color Analog Scale (CAS) pain scores at baseline and at 20, 40, and 60 minutes after medication administration. The primary outcome measured was the difference in changes in pain score at 40 minutes, compared to a previously described minimal clinically significant change in pain score of 2 cm. The difference was defined as (change in ibuprofen CAS score from baseline) – (change in acetaminophen–codeine CAS score from baseline); negative values thus favor the ibuprofen group. Additional outcomes included need for rescue medication and adverse effects.

Results: The 32 acetaminophen–codeine and the 34 ibuprofen recipients in our convenience sample had indistinguishable pain scores at baseline. The intergroup differences in pain score change at 20 minutes (−0.6, 95% confidence interval [CI] = −1.5 to 0.3), 40 minutes (−0.4, 95% CI = −1.4 to 0.6), and 60 minutes (0.2, 95% CI = −0.8 to 1.2) were all less than 2 cm. Adverse effects were minimal: vomiting (one patient after acetaminophen–codeine), nausea (one patient after ibuprofen), and pruritus (one after acetaminophen–codeine). The three patients in each group who received rescue medications all had radiographically demonstrated fractures or dislocations.

Conclusions: This study found similar performance of acetaminophen–codeine and ibuprofen in analgesic effectiveness among ED patients aged 5–17 years with acute traumatic extremity pain. Both drugs provided measurable analgesia. Patients tolerated them well, with few treatment failures and minimal adverse effects.

20. Refining the Indications for ERCP in Biliary Pancreatitis

Among patients with severe pancreatitis, only those with cholestasis (bilirubin over 2.3 mg/dL [40 μmol/L] and/or dilated common bile duct) benefited from early ERCP.

van Santvoort HC et al. Ann Surg 2009;250:68-75.

Abstract: http://journals.lww.com/annalsofsurgery/Abstract/2009/07000/Early_Endoscopic_Retrograde.12.aspx

21. Risk of Thromboembolism Varies, Depending on Category of Immobility in Outpatients

Beam DM, et al. Ann Emerg Med. 2009;54:147-152.

Study objective
Immobility predisposes to venous thromboembolism, but this risk may vary, depending on the underlying cause of immobility.

Methods
This was a prospective, longitudinal outcome study of self-presenting emergency department (ED) patients who were from 12 hospitals and had suspected venous thromboembolism. Using explicit written criteria, clinicians recorded clinical features of each patient in the ED by using a Web-based data form. The form required one of 6 types of immobility: no immobility, general or whole-body immobility greater than 48 hours, limb (orthopedic) immobility, travel greater than 8 hours causing immobility within the previous 7 days, neurologic paralysis, or other immobility not listed above. Patients were followed for 45 days for outcome of venous thromboembolism, which required positive imaging results and clinical plan to treat. Odds ratios (ORs) were derived from logistic regression including 12 covariates.

Results
From 7,940 patients enrolled, 545 of 7,940 (6.9%) were diagnosed with venous thromboembolism (354 pulmonary embolism, 72 deep venous thrombosis, 119 pulmonary embolism and deep venous thrombosis). Risk of venous thromboembolism varied, depending on immobility type: limb (OR=2.24; 95% confidence interval [CI] 1.40 to 3.60), general (OR=1.76; 95% CI 1.26 to 2.44), other (OR=1.97; 95% CI 1.25 to 3.09), neurologic (OR=2.23; 95% CI 1.01 to 4.92), and travel (OR=1.19; 95% CI 0.85 to 1.67). Other significant risk factors from multivariate analysis included age greater than 50 years (OR =1.5; 95% CI 1.25 to 1.82), unilateral leg swelling (OR=2.68; 95% CI 2.13 to 3.37), previous venous thromboembolism (OR=2.99; 95% CI 2.41 to 3.71), active malignancy (OR=2.23; 95% CI 1.69 to 2.95), and recent surgery (OR=2.12; 95% CI 1.61 to 2.81).

Conclusion
In a large cohort of symptomatic ED patients, risk of venous thromboembolism was substantially increased by presence of limb, whole-body, or neurologic immobility but not by travel greater than 8 hours. These data show the importance of clarifying the cause of immobility in risk assessment of venous thromboembolism.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(08)01975-6/fulltext