Lit Bits by David R Vinson

Lit Bits: Jan 14, 2012

2012-01-14T08:56:00.000-08:00

From the recent medical literature...

1. Serial Changes in Highly Sensitive Troponin I Assay and Early Diagnosis of Myocardial Infarction

Keller T, et al. JAMA 2011;306(24):2684-2693.

Context: Introduction of highly sensitive troponin assays into clinical practice has substantially improved the evaluation of patients with chest pain.

Objective: To evaluate the diagnostic performance of a highly sensitive troponin I (hsTnI) assay compared with a contemporary troponin I (cTnI) assay and their serial changes in the diagnosis of acute myocardial infarction (AMI).

Design, Setting, and Patients: A total of 1818 patients with suspected acute coronary syndrome were consecutively enrolled at the chest pain units of the University Heart Center Hamburg, the University Medical Center Mainz, and the Federal Armed Forces Hospital Koblenz, all in Germany, from 2007 to 2008. Twelve biomarkers including hsTnI (level of detection, 3.4 pg/mL) and cTnI (level of detection, 10 pg/mL) were measured on admission and after 3 and 6 hours.

Main Outcome Measures: Diagnostic performance for AMI of baseline and serial changes in hsTnI and cTnI results at 3 hours after admission to the emergency department.

Results: Of the 1818 patients, 413 (22.7%) were diagnosed as having AMI. For discrimination of AMI, the area under the receiver operating characteristic (ROC) curve was 0.96 (95% CI, 0.95-0.97) for hsTnI on admission and 0.92 (95% CI, 0.90-0.94) for cTnI on admission. Both were superior to the other evaluated diagnostic biomarkers. The use of hsTnI at admission (with the diagnostic cutoff value at the 99th percentile of 30 pg/mL) had a sensitivity of 82.3% and a negative predictive value (for ruling out AMI) of 94.7%. The use of cTnI (with the diagnostic cutoff value at the 99th percentile of 32 pg/mL) at admission had a sensitivity of 79.4% and a negative predictive value of 94.0%. Using levels obtained at 3 hours after admission, the sensitivity was 98.2% and the negative predictive value was 99.4% for both hsTnI and cTnI assays. Combining the 99th percentile cutoff at admission with the serial change in troponin concentration within 3 hours, the positive predictive value (for ruling in AMI) for hsTnI increased from 75.1% at admission to 95.8% after 3 hours, and for cTnI increased from 80.9% at admission to 96.1% after 3 hours.

Conclusions: Among patients with suspected acute coronary syndrome, hsTnI or cTnI determination 3 hours after admission may facilitate early rule-out of AMI. A serial change in hsTnI or cTnI levels from admission (using the 99th percentile diagnostic cutoff value) to 3 hours after admission may facilitate an early diagnosis of AMI.

2. Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study

Subramanian P, et al. BMJ 2011;343:d7506

Introduction: A humorous anaesthetic colleague recently repeated the following popular saying while an operating table was being repaired with a mallet: “typical orthopaedic surgeon—as strong as an ox but half as bright.” Making fun of orthopaedic surgeons is a popular pastime in operating theatres throughout the country. This pursuit has recently spread to the internet; a humorous animation entitled “orthopedia vs anesthesia” had received more than half a million hits at the time of writing.1 Several comparisons of orthopaedic surgeons to primates have been published, and the medical literature contains suggestions that orthopaedic surgery requires brute force and ignorance.2 3 4

The stereotypical image of the strong but stupid orthopaedic surgeon has not been subject to scientific scrutiny. Previous studies have shown that the average hand size of orthopaedic surgeons is larger than that of general surgeons.2 3 However, a search of the worldwide scientific literature found no studies assessing the strength or intelligence of orthopaedic surgeons. In the absence of a cohort of willing oxen as a control group, and given that the phrase is popular with anaesthetists, we designed this study to compare the mean grip strength of the dominant hand and the intelligence test score of orthopaedic surgeons and anaesthetists..

Abstract: Objective: To compare the intelligence and grip strength of orthopaedic surgeons and anaesthetists.

Design: Multicentre prospective comparative study. Setting: Three UK district general hospitals in 2011.

Participants: 36 male orthopaedic surgeons and 40 male anaesthetists at consultant or specialist registrar grade.

Main outcome measures: Intelligence test score and dominant hand grip strength.

Results: Orthopaedic surgeons had a statistically significantly greater mean grip strength (47.25 (SD 6.95) kg) than anaesthetists (43.83 (7.57) kg). The mean intelligence test score of orthopaedic surgeons was also statistically significantly greater at 105.19 (10.85) compared with 98.38 (14.45) for anaesthetists.

Conclusions: Male orthopaedic surgeons have greater intelligence and grip strength than their male anaesthetic colleagues, who should find new ways to make fun of their orthopaedic friends.

Full-text (free): http://www.bmj.com/content/343/bmj.d7506

3. Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis

Singh B, et al. Ann Emerg Med. 2012; in press

Study objective: To perform a systematic review and meta-analysis to define the diagnostic performance of pulmonary embolism rule-out criteria (PERC) in deferring the need for D-dimer testing to rule out pulmonary embolism in the emergency department (ED).

Methods: We searched EMBASE, MEDLINE, Scopus, Web of Knowledge, and all the evidence-based medicine reviews that included the Cochrane Database of Systematic Reviews through August 14, 2011, and hand searched references in potentially eligible articles and conference proceedings of major emergency medicine organizations for the previous 2 years. We selected studies that reported diagnostic performance of PERC, reported original research, and were conducted in the ED, with no language restrictions. Two investigators independently identified eligible studies and extracted data. We used contingency tables to calculate sensitivity, specificity, and likelihood ratios.

Results: We found 12 qualifying cohorts (studying 13,885 patients with 1,391 pulmonary embolism diagnoses), 10 prospective and 2 retrospective, from 6 countries. Pooled sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios for 10 included studies were 0.97 (95% confidence interval [CI] 0.96 to 0.98), 0.23 (95% CI 0.22 to 0.24), 1.24 (95% CI 1.18 to 1.30), and 0.17 (95% CI 0.13 to 0.23), respectively. Significant heterogeneity was observed in specificity (I2=97.2%) and positive likelihood ratio (I2=84.2%).

Conclusion: The existing literature suggests consistently high sensitivity and low but acceptable specificity of the PERC to rule out pulmonary embolism in patients with low pretest probability.

_______________________

The related Reuters article can be found here: http://www.medscape.com/viewarticle/756136

For dissenting evidence, see, for example, Hugli O, et al. The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism. J Thromb Haemost. 2011;9:300-4. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21091866

About this study, Singh et al explain: “Two of the included studies (Hugli et al and Righini et al) report a higher frequency of missed pulmonary embolism and have raised concern about the reliability of PERC. However, their higher failure rate likely results from the higher pulmonary embolism prevalence observed in their European settings. The threshold for pulmonary embolism diagnostic imaging in the United States is substantially lower than that in Europe, presumably because of the higher litigation risk. The PERC rule was developed for use in low probability settings.”

See too Hennessey A, et al. A Patient with a Large Pulmonary Saddle Embolus Eluding Both Clinical Gestalt and Validated Decision Rules. Ann Emerg Med 2012; in press. Abstract: http://www.annemergmed.com/article/S0196-0644(11)01801-4/abstract

See also a helpful essay reviewing PE by Rick Bukata at Emergency Physicians Monthly: http://www.epmonthly.com/columns/in-my-opinion/pe-still-a-challenging-diagnosis/

4. Modest Public Health Impact of Nontargeted Human Immunodeficiency Virus Screening in 29 EDs

Kayigan Wilson d’Almeida, MD; Arch Intern Med. 2012;172(1):12-20.

Background: To lower the number of undiagnosed infections and to improve early detection, international health agencies have promoted nontargeted human immunodeficiency virus (HIV) screening in health care settings, including emergency departments (EDs). This strategy remains controversial and has yet to be tested on a large scale. We assessed the public health impact of nontargeted HIV–rapid test (RT) screening among ED patients in the metropolitan area of Paris (11.7 million inhabitants), where half of France's new HIV cases are diagnosed annually.

Methods: During a randomly assigned 6-week period for each of the 29 participating EDs, 18- to 64-year-old patients who were able to provide consent for HIV testing were offered a fingerstick whole-blood HIV RT. Main outcome measures were the number of patients tested for HIV and their characteristics vs those of the general metropolitan Paris population and the proportion of newly diagnosed HIV-positive patients among those tested and their characteristics vs those from the national HIV case surveillance.

Results: Among 138 691 visits, there were 78 411 eligible patients, 20 962 of whom (27.0%) were offered HIV RT; 13 229 (63.1%) accepted testing and 12 754 (16.3%) were tested. The ED patients' characteristics reflected the general population distribution. Eighteen patients received new HIV diagnoses (0.14%; 95% confidence interval, 0.08%-0.22%). Like national HIV case surveillance patients, they belonged to a high-risk group (n = 17), were previously tested (n = 12), and were either symptomatic or had a CD4 lymphocyte count lower than 350/µL, suggesting late-stage infections (n = 8); 12 patients were linked to care.

Conclusions: Nontargeted HIV testing in EDs was feasible but identified only a few new HIV diagnoses, often at late stages, and, unexpectedly, most patients belonged to a high-risk group. Our findings do not support the implementation of nontargeted screening of the general population in EDs.

5. Do Emergency Physicians Admit More or Fewer Patients on Busy Days?

Albrecht R, et al. J Emerg Med. 2011;41:709-712.

Background: Although the issues concerning the impact of emergency department (ED) overcrowding have been the subject of much recent concern, there are few data regarding the effect of ED census on emergency physician behavior with respect to the decision to admit patients. Admission rates might either increase or decrease on busy days, when the system and the physician are under stress.

Study Objective: The purpose of this study was to determine if ED physicians change their admitting behavior depending on ED census.

Methods: This was a retrospective review of 3 months' data (92 consecutive days, July 9–October 9, 2006) in a community ED with an annual census of approximately 70,000 patients and an emergency medicine residency program. We defined each of the 92 days to be either “busy” (over 180 patients seen), “slow” (fewer than 147 patients seen) or “medium” (147–180 patients seen). We then compared the rates of admission to the hospital on the “busy,” “medium,” and “slow” days. We also compared each attending physician's personal rates of admission on slow days to his or her rate of admission on medium or busy days. ED staffing was constant throughout the study period. All comparisons were with chi-squared.

Results: There were 14,969 patients seen in the ED during the 92 study days. On “busy” days, 20.1% of the 3400 patients were admitted to the hospital; on “medium” days, 20.6% of the 9057 patients were admitted; on “slow” days, 19.7% of the 2512 patients were admitted. There was no significant association between the level of patient volume in the ED and rate of admission (p = 0.55). When comparing each of 14 attending physicians to him- or herself, there was no significant association found between rate of admission and ED census (all p values above 0.3). All three categories of days, “busy,” “medium,” and “slow” did not differ in terms of acuity as judged by triage level distribution.

Conclusion: The likelihood of a patient's admission vs. discharge is not affected by ED patient volume. Furthermore, we found no evidence that an individual physician's admitting behavior was associated with ED patient volume.

6. Is Nasogastric Lavage Beneficial for Acute Gastrointestinal Bleeding?

The procedure increased the likelihood of early endoscopy but not better patient outcomes, such as lower mortality. The question merits prospective analysis.

Nasogastric lavage (NGL) was once a standard initial procedure for all patients with acute gastrointestinal (GI) bleeding, but its use is now under debate. Although some data suggest that patients with a bloody NGL are more likely to have severe bleeding (Gastrointest Endosc 2004; 59:172), the test's presumed benefits — confirming an upper GI source of bleeding, clearing the stomach for better endoscopic visualization, and reducing the risk for aspiration — have not been tested.

To evaluate the effects of NGL during triage on clinical outcomes, investigators conducted a retrospective database study of 632 patients from a Veterans Administration hospital. To control for confounding factors that might influence the decision to perform lavage, researchers identified 24 variables a priori that were associated with receiving NGL and used them to develop a propensity score — or likelihood of undergoing NGL — among patients with acute GI bleeding. They then matched 193 patients who received lavage and 193 who did not by propensity score and compared clinical outcomes.

Patients who underwent NGL were more likely to have an endoscopy (odds ratio, 1.71) and to receive it sooner (hazard ratio, 1.49) than other patients. Lavage did not affect mortality, length of hospital stay, or the need for transfusions or surgery. Bloody aspirates were associated with high-risk lesions at endoscopy (OR, 2.69).

The authors conclude that NGL is associated with receiving early endoscopy and might be useful in triage but does not affect clinical outcomes.

Comment: This paper will be of interest to many physicians caring for patients with upper GI bleeding and likely will be interpreted differently, depending on when they are seeing the patient and what they are trying to accomplish. One thing remains clear though — routine use of NGL in these patients is not justified. We already know that NGL cannot be used to exclude ongoing upper GI bleeding as one sixth of patients with active bleeding will have a negative NGL. Now, this study demonstrates that NGL results in no difference in a number of important clinical outcomes. However, certain targeted uses of NGL — such as to enhance visualization before endoscopy, thereby assisting in lesion identification — were not part of this study. These possible roles for NGL as an adjunctive tool to enhance endoscopy or to improve specific patient outcomes will require appropriately designed prospective studies. Until then, routine use of NGL in patients with upper GI bleeding is not indicated, but there are likely selected patients who might benefit from this intervention.

— David J. Bjorkman, MD, MSPH (HSA), SM (Epid.). Published in Journal Watch Gastroenterology December 2, 2011. Citation(s): Huang ES et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc 2011 Nov; 74:971.
Medline abstract (Free): http://www.ncbi.nlm.nih.gov/pubmed/21737077

Pallin DJ and Saltzman JR. Is nasogastric lavage in patients with acute upper GI bleeding indicated or antiquated? Gastrointest Endosc 2011 Nov; 74:981.
Medline abstract (Free): http://www.ncbi.nlm.nih.gov/pubmed/22032314

7. Emergency Medicine Top Stories of 2011 from Journal Watch

A perspective on the most important research in the field from the past year

We are pleased to provide you with our Top 10 list for 2011. In other years, we have provided two lists: one reflecting our editors' selections and one based on total number of page views. We have come to know that the latter list, while interesting, does not reflect the needs or interests of emergency medicine clinicians but rather reflects the final common pathway of a very large, heterogeneous pool of Web searches. So, we no longer will provide that list. Instead, we have selected the most important studies covered by Journal Watch Emergency Medicine in 2011. Each of these summaries is worth a read, and, in many cases, linking to the original source — the published study — is valuable.

We hope that you continue to enjoy our annual lists and our ongoing efforts to keep you informed about medical information that will affect how you think and how you practice.

Full-text (free): http://emergency-medicine.jwatch.org/cgi/content/full/2011/1230/1

8. "Wait and see" approach to the ED cardioversion of acute AF

Doyle B, et al. Emerg Med Int. 2011. Epub 2011 Nov 17.

Objective. Acute atrial fibrillation often spontaneously resolves. This study aimed to investigate the outcomes and satisfaction of an evidence-based ED protocol employing a "wait and see" approach.

Methods. A prospective observational cohort study of adult patients presenting to the Emergency Department with stable acute atrial fibrillation was performed. Patients were excluded if they were considered to be unstable, need hospitalization, or poor candidates for ED procedural sedation. Routine care was provided on the index visit, and suitable candidates were discharged and asked to return to the ED the following day for possible electrical cardioversion. Outcome measures included spontaneous reversion to sinus rhythm, success of cardioversion, length of stay, adverse event and return visits for AF within 30 days, and patient satisfaction.

Results. Thirty five patient encounters were analysed over a 21-month period. Twenty two of the 35 patients (63%) had spontaneous resolution of atrial fibrillation upon presentation for potential cardioversion. All of the remaining patients underwent successful cardioversion to normal sinus rhythm without significant adverse events recorded. No patients required hospitalization. Three patients (9%) returned to the ED within 30 days for recurrence of atrial fibrillation. All patients were reported to be "very satisfied" with this approach.

Conclusion. A "wait and see" approach to the ED electrical cardioversion of atrial fibrillation showed that almost two-thirds of patients had spontaneous resolution without requiring cardioversion or observation in the ED or hospital. All patients were successfully reverted to normal sinus rhythm and had a high degree of satisfaction.

Full-text (free): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226298/

9. Video + Direct Laryngoscopy

by Richard Levitan, MD. Emergency Physicians Monthly, December 22, 2011

While some still debate the relative merits of direct vs. video laryngoscopy, the newest set of laryngoscopes make it easy, offering the best of both worlds.

At the recent Society for Airway Management conference there was a debate on Direct Laryngoscopy (DL) vs. Video Laryngoscopy (VL). While I love imaging and the mechanical and teaching advantages of look-around-the-curve video laryngoscopes, there is beauty in the simplicity, speed, and emergency applicability of direct laryngoscopy. DL is faster and does better with fluids, bleeding, and vomitus while tube delivery is much more straightforward with hyperangulated video devices. When VL is used in large series it does not perform better overall than DL, although there are cases when DL is very hard and VL easy. Alternatively, I have had some hard or impossible VL cases where DL was a slam dunk.

It occurred to me after the conference that the debate was in some ways pointless, given the new array of DL/VL devices which make both options available to you. With hyperangulated devices like the Glidescope, McGrath Series 5, or Storz Dorges Blade video laryngoscope, the angulation of the blade prevents any direct view. If the video fails, from fluids or any other reason, there is no direct view. This is not the case with DL/VL combination devices. Intubation can be done via direct line of sight, just as a standard instrument would be used, or under video, or as a combination. In the setting of emergency airways, especially trauma airways, I think this has great value.

Currently available DL/VL devices include the Storz C-Mac, the new McGath Mac (now to be distributed by Covidien), and the Glidescope Direct Trainer…

The remainder of the text (free) here: http://www.epmonthly.com/subspecialties/technology/video--direct-laryngoscopy-/

10. Effective Antibiotic Treatment Prescribed by Emergency Physicians in Patients Admitted to the ICU with Severe Sepsis or Septic Shock: Where is the Gap?

Capp R, et al. J Emerg Med. 2011;573-580.

Background: Antibiotic selection made within the first hour of recognition of severe sepsis and septic shock has been shown to decrease mortality.

Objective: The purpose of this study was to determine what antibiotics are being prescribed and to identify factors influencing ineffective antibiotic coverage in patients with severe sepsis or septic shock. In addition, we explore an alternative method for antibiotic selection that could improve organism coverage.

Methods: This was a retrospective review of emergency department (ED) patients admitted to an intensive care unit (ICU) over a 12-month period with a culture-positive diagnosis of either severe sepsis or septic shock. Appropriate antibiotic therapy was defined as effective coverage of the offending organism based on final culture results.

Results: Of the 1400 patients admitted to the ICU, 137 patients were culture positive and met the criteria for severe sepsis or septic shock. Effective antibiotic coverage was prescribed by emergency physicians in 82% (95% confidence interval [CI] .74–.88) of cases. Of the 25 patients who received ineffective antibiotics, the majority had infections caused by resistant Gram-negative organisms. Health care-associated pneumonia guidelines were applied to all patients, regardless of the source of infection, and were 100% sensitive (95% CI .93–1) for selecting patients who had infections caused by highly resistant organisms.

Conclusion: Emergency physicians achieved 82% effective antibiotic coverage in patients with severe sepsis or septic shock. The gap seems to be in coverage of highly resistant Gram-negative organisms. An alternative approach to antibiotic prescription, utilizing a set of guidelines for community- and health care-associated infections, was found to be 100% sensitive in selecting patients who had infections caused by the more resistant organisms.

11. Ciclesonide Trumps Antibiotics for Pediatric Otitis Media

Fran Lowry, Medscsape. November 22, 2011 (Boston, Massachusetts) — The nasal corticosteroid spray ciclesonide is more effective than a broad-spectrum oral antibiotic for the treatment of children with otitis media with effusion, according to a small study presented in an oral session here at the American College of Allergy, Asthma & Immunology 2011 Annual Scientific Meeting.

A resolution of otitis media with effusion occurred after 8 days of treatment with the aqueous nasal spray, but it took 14 days for a resolution in children treated with amoxicillin and clavulanate, Safa Nsouli, MD, director of the Danville Asthma and Allergy Clinic in California, reported.

In an open-label study, Dr. Nsouli and colleagues randomized 40 atopic children, 6 to 11 years of age, with otitis media with effusion to 1 of 2 groups: 2 sprays of ciclesonide 50 µg per nostril daily (n = 20); or amoxicillin and clavulanate potassium 90 mg/kg per day in 2 divided doses every 12 hours (n = 20). Both treatments were given for a 2-week period.

The effectiveness of the 2 treatments was assessed objectively using pneumatic otoscopy, impedance tympanometry, and audiometry.

"There is a nasal obstruction that occurs with otitis media. If we eliminate the nasal obstruction with ciclesonide, we decrease the aspiration reflex of the nasopharyngeal secretions into the middle ear that occur via the eustacian tube," Dr. Nsouli told Medscape Medical News.

"We also reduce the allergic inflammatory obstruction of the eustacian tube. Ciclesonide decreases those mechanisms, which helps clear the otitis media much faster than a plain antibiotic treatment that works only on the bacteria," he said. "It's like having a clogged sink. You can try to clean the sink but it is impossible unless the sink is unplugged and drained."

In addition to resolving otitis media symptoms more rapidly, ciclesonide is a safer option, Dr. Nsouli said.

"I am sure many doctors and parents have noticed that their pediatric patients with otitis media can be on several antibiotic courses, sometimes for 6 to 8 months, with no results. They have even inserted an ear tube for drainage of the secretions. Our study shows that we can eliminate the long-term course of antibiotics," Dr. Nsouli said.

Heartening Results

Medscape Medical News invited Chitra Dinakar, MD, professor of pediatrics at the University of Missouri at Kansas City, for her views on this study.

"Studies have shown that only about 1 in 3 children with middle-ear effusion who undergo myringotomy and placement of ventilation tubes have a bacterial pathogen identified; in general, qualitative studies suggest low bacterial densities in such effusions," Dr. Dinakar noted. "Additionally, inflammatory exudates or infiltration of neutrophils in the fluid is typically not found.

Despite this, pediatricians encounter patients with "fluid in the ear" who are given multiple course of antibiotics, raising concerns about "the development of multidrug-resistant pathogens and the effects of antibiotics on a young child's natural flora and immune system," she said.

"It is heartening to note that this small open-label study showed more rapid resolution of symptoms with a nasal steroid, compared to a course of an appropriate antibiotic, at least in the short-term assessment period of 2 weeks," Dr. Dinakar said.

Dr. Nsouli has disclosed no relevant financial relationships. Dr. Dinakar reports financial relationships with AstraZeneca and GlaxoSmithKline.

American College of Allergy, Asthma & Immunology (ACAAI) 2011 Annual Scientific Meeting: Abstract 62. Presented November 6, 2011.

12. Images in Medicine

Lung Herniation after Cough-Induced Rupture of Intercostal Muscle
http://www.nejm.org/doi/full/10.1056/NEJMicm1106070

Pneumopericardium Associated with a Peptic Ulcer
http://www.nejm.org/doi/full/10.1056/NEJMicm1107529

Image Challenge: What’s This?
http://www.nejm.org/image-challenge?ci=12222011

A Head Shot
http://www.nejm.org/doi/full/10.1056/NEJMicm1009118

13. Low-dose diltiazem in atrial fibrillation with rapid ventricular response.

Lee J, et al. Am J Emerg Med. 2011 Oct;29(8):849-54.

OBJECTIVES: Diltiazem is one of the most commonly used medications to control the rapid ventricular response in atrial fibrillation (AF). The recommended starting dose is an intravenous bolus of 0.25 mg/kg over 2 minutes. To avoid hypotension, we have empirically used a lower dose of diltiazem. We compared the efficacy and safety of different doses of diltiazem in rapid AF.

METHODS: A retrospective chart review was undertaken in patients who presented to the emergency department with rapid AF. Patients were divided into 3 groups according to diltiazem dosage: low dose (≤ 0.2 mg/kg), standard dose (greater than 0.2 and ≤ 0.3 mg/kg), and high dose (more than 0.3 mg/kg). We compared the rates of therapeutic response (adequate rate control) and complications (such as hypotension). Multivariate regression analysis was used to determine the effect of diltiazem dose on the occurrence of complications.

RESULTS: A total of 180 patients were included in the analysis. There were no significant differences in the rates of therapeutic response for the low-, standard-, and high-dose groups (70.5%, 77.1%, and 77.8%; P = .605). The rates of hypotension in the low-, standard-, and high-dose groups were 18%, 34.9%, and 41.7%, respectively. After adjusting confounding variables, the rate of hypotension was significantly lower in the low-dose group in comparison with the standard-dose group (adjusted odds ratio, 0.39; 95% confidence interval, 0.16-0.94).

CONCLUSIONS: Low-dose diltiazem might be as effective as the standard dose in controlling rapid AF and reduce the risk of hypotension.

14. When balance is bias (in scientific journalism)

Trevor Jackson, magazine editor. BMJ 2011;343:d8006

Sometimes the science is strong enough for the media to come down on one side of a debate

In his 2010 BBC television series Wonders of the Solar System, the physicist Brian Cox made a remark that offended some horoscope lovers. “Despite the fact that astrology is a load of rubbish, Jupiter can in fact have a profound influence on our planet. And it’s through a force . . . gravity.” The BBC received a number of complaints, including one from a viewer who said that Cox made his comment without an “alternative opinion being allowed.” The complainant griped that the programme made no attempt to “consider such questions from the perspective of an astrologer, who draws upon a very different body of observation and knowledge built over thousands of years.” Cox later gave the BBC a statement (which it declined to issue) saying, “I apologise to the astrology community for not making myself clear. I should have said that this new age drivel is undermining the very fabric of our civilisation.”

This tale, which beautifully points up the ridiculousness of always demanding balance in science communication, is told by Steve Jones, emeritus professor of human genetics at University College London, in a report published this year. The BBC Trust commissioned Jones to review the impartiality and accuracy of the BBC’s coverage of science; and although Jones found much to praise, he expresses concern about the BBC’s guidelines on “due impartiality.” These, Jones found, had a distorting effect, creating a sense of equivalence where there was none, and privileging maverick and dissident views so that they appeared as valid as established scientific fact. (This is not to say that established facts cannot be disproved. But the onus is on the claimants to prove or disprove their case within the rigorous paradigms of modern scientific research—witness the current debates on the invariability of the speed of light.)

Jones found that BBC journalists, in their quest for objectivity and impartiality—entirely understandable aims in coverage of politics and arts—risked giving the impression in their science reporting that there were two equal sides to a story when clearly there were not. As Jones says, “There is widespread concern that [the BBC’s] reporting of science sometimes gives an unbalanced view of particular issues because of its insistence on bringing in dissident voices into what are in effect settled debates.”

The dangers of this approach are clear in journalistic coverage of subjects such as the MMR (measles, mumps, rubella) vaccine—as the BMJ has previously shown—and climate change. A 2003 study into coverage of MMR showed that the media’s insistence on giving equal weight to both the views of the anti-vaccine camp and to the overwhelming body of scientific evidence exonerating the vaccine from its alleged adverse effects made people think that scientists themselves were divided over the safety of the vaccine, when they were not. The quest for balance created what Jones and others have called “false balance,” and in the case of the MMR vaccine helped fuel a public health disaster.

The investigative journalist Nick Davies, in his 2008 book Flat Earth News—an examination of falsehood, distortion, and propaganda in the world’s media—says that the insistence on balance is one of the factors that stops journalists getting at the truth. “Neutrality requires the packaging of conflicting claims, which is precisely the opposite of truth telling. If two men go to mow a meadow and one comes back and says ‘The job’s done’ and the other comes back and says ‘We never cut a single blade of grass,’ neutrality requires the journalist to report a controversy surrounding the state of the meadow, to throw together both men’s claims and shove it out to the world with an implicit sign over the top declaring, ‘We don’t know what’s happening—you decide’.” Another seasoned UK journalist, Malcolm Dean, takes a similar line on balance in his 2011 book Democracy Under Attack, as does the Science Media Centre, in its evidence to the ongoing Leveson inquiry into media ethics. If journalists will not decide where the truth lies, this puts the onus on readers and viewers; and given that scientists are not always expert communicators, there is a real risk that the anti-science view will hold sway.

Davies’s and Dean’s position reflects that of the US academics Maxwell T Boykoff and Jules M Boykoff, who have researched the reporting of climate change. In two seminal papers, the Boykoffs identified the journalistic norm of balance—the refusal to privilege the high level consensus that anthropogenic climate change is a reality over the views of right wing mavericks and oil industry funded commentators—as one of the factors that has sown doubt and confusion among the public.

In his recent book Who Speaks for the Climate?, Maxwell Boykoff shows that the journalistic norm of balance in news reporting “has served to amplify outlier views on anthropogenic climate change, and concurrently engendered an appearance of increased uncertainty regarding anthropogenic climate science. This, in turn, has entered into an already highly contested arena where it has permeated climate policy discourse and decision-making.”

Part of the problem is that it takes time for a scientific consensus to emerge, and the media are impatient. Few scientists would nowadays argue that smoking does not cause lung cancer, that the world was created in six days, or that the earth is flat, but that wasn’t always the case. Davies shows how the oil industry began mobilising its public relations campaign against the notion of anthropogenic climate change in 1989, years before any scientific consensus could emerge on global warming.

So what is to be done? In the current climate, as media outlets have to produce ever more copy with fewer resources, the outlook is bleak. The BBC hopes that a new stipulation in its editorial guidelines—“due weight,” the recognition that, for example, minority views should not necessarily be given equal weight to the prevailing consensus12—and an online training module on the specific demands of science reporting will help. Steve Jones says he is yet to see any evidence of the difference this can make, but it is a start. Also, researchers themselves should hone their communication skills.

Meanwhile, some science journalism will continue to be weighed in the balance and found wanting.

References: http://www.bmj.com/content/343/bmj.d8006

15. Surge Reported in Energy Drink ED Visits

Laird Harrison. Medscape. November 28, 2011 — The number of emergency department visits associated with nonalcohol energy drinks is surging, according to a report from the US Substance Abuse and Mental Health Services Administration (SAMHSA).

In 2005, the agency recorded 1,128 such visits and in 2009 it recorded 13,114 such visits, with the highest number occurring in 2008 (16,055). Data are not yet available for 2010.

"Energy drinks used in excess or in combination with alcohol or drugs can pose a serious health risk," said SAMHSA administrator Pamela S. Hyde in a press release.

The agency defines energy drinks as flavored beverages containing high amounts of stimulants such as caffeine. The drinks are marketed to youth and are consumed by up to 50% of children, adolescents, and young adults.

The report, entitled Emergency Department Visits Involving Energy Drinks, is based on data from SAMHSA's 2005 to 2009 Drug Abuse Warning Network (DAWN) reports. DAWN is a public health surveillance system that monitors drug-related hospital emergency department visits reported in the United States.

The report found that in 44% of emergency department visits involving energy drinks, the drinks were taken together with other substances, such as alcohol, pharmaceuticals, and illicit drugs. This combination of energy drinks and other substances of abuse was greatest in young adults 18 to 25 years of age (52%).

The vast majority (77%) of these visits were made by people 18 to 39 years of age, and 64% were made by males, according to the report.

Energy-drink-related emergency department visits involving males were twice as likely as those involving females to include the use of alcohol (20% vs 10%) or illicit drugs (12% vs 5%).

Female visits were more likely than male visits to involve the combined use of energy drinks and pharmaceuticals (35% vs 23%).

Studies indicate that excessive caffeine intake from energy drinks can cause adverse reactions, such as arrhythmias, hypertension, and dehydration. Combining energy drinks with substances of abuse raises the risk for serious, even life-threatening, injury and for the likelihood of engaging in risky behaviors, such as driving under the influence.

The National Institute on Alcohol Abuse and Alcoholism has developed a pocket guide for healthcare professionals and others to help with screening and brief intervention for youth who might have alcohol problems, including cases involving energy drinks.

"The beverage industry, consumer groups, community coalitions, the healthcare community, teachers, parents, and others must get the word out that quick-fix energy drinks are not a solution and carry great risks, especially in combination with other substances of abuse," said Ms. Hyde.

The report (full-text, free): http://www.samhsa.gov/data/2k11/WEB_DAWN_089/WEB_DAWN_089_HTML.pdf

Pocket Guide: http://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuidePocket.pdf

16. Acetaminophen May Be Bad for Asthmatic Kids

McBride JT. Pediatrics. 2011;128;1181.

A growing number of studies have documented such a strong association between acetaminophen exposure and asthma that it is possible that much of the dramatic increase in childhood asthma over the past 30 years has been related to the use of acetaminophen. Although this possibility has been widely acknowledged, commentators have been reluctant, without a randomized clinical trial, to conclude that acetaminophen causes asthma and, with rare exception, have not recommended changes in practice. As a pediatric pulmonologist, I am entrusted with the care of many asthmatic children and, at some level, with the respiratory health of all children in my area. Given this role, I must decide when and how to act on the possibility that acetaminophen is detrimental to asthmatic children. Considering currently available data, I now recommend that any child with asthma or a family history of asthma avoid using acetaminophen.

The epidemiologic association between acetaminophen use and asthma prevalence and severity in children and adults is well established. A variety of observations suggest that acetaminophen use has contributed to the recent increase in asthma prevalence in children: (1) the strength of the association; (2) the consistency of the association across age, geography, and culture; (3) the dose-response relationship; (4) the timing of increased acetaminophen use and the asthma epidemic; (5) the relationship between per-capita sales of acetaminophen and asthma prevalence across countries; (6) the results of a double-blind trial of ibuprofen and acetaminophen for treatment of fever in asthmatic children; and (7) the biologically plausible mechanism of glutathione depletion in airway mucosa. Until future studies document the safety of this drug, children with asthma or at risk for asthma should avoid the use of acetaminophen.

Full-text in Pediatrics (free): http://pediatrics.aappublications.org/content/128/6/1181.full

New York Times Essay: http://www.nytimes.com/2011/12/20/health/evidence-mounts-linking-acetaminophen-and-asthma.html

17. Consensus Criteria Predict Futile Prehospital Trauma Resuscitation

None of 294 patients had meaningful survival, and EMS resuscitation triggered hospital costs approaching $4 million.

In 2003, the National Association of Emergency Medical Services (EMS) Physicians and the American College of Surgeons Committee on Trauma published guidelines on when to withhold or terminate prehospital resuscitation in traumatic cardiopulmonary arrest (TCPA). Using data from a level I trauma registry from 2003 through 2010, researchers studied prehospital TCPA patients aged 18 years for whom these guidelines were violated. Criteria to withhold or terminate care were (1) blunt trauma with apnea, pulselessness, and no organized electrocardiogram activity; (2) penetrating trauma with the preceding clinical presentation and no other signs of life; (3) 15 minutes of cardiopulmonary resuscitation without return of spontaneous circulation; or (4) EMS-witnessed TCPA followed by 15 minutes of unsuccessful resuscitation en route to the emergency department (ED).

Among 294 patients, mechanism of injury was blunt in 90 (31%) and penetrating in 204 (69%). Overall, 274 patients (93%) died in the ED, and 12 (4%) died during surgery. Of the 8 patients who reached the intensive care unit, 7 died in the ICU, and 1 (0.3%) survived but had a Glasgow Coma Scale score of 6 and was discharged to a long-term care facility.

Comment: The charges for hospital care for these 294 patients totaled nearly US$4 million, and the one surviving patient had a horrible outcome. These data strongly support the existing guidelines and the need to ensure that EMS personnel understand and adhere to them.

— John A. Marx, MD, FAAEM. Published in Journal Watch Emergency Medicine December 9, 2011. Citation: Mollberg NM et al. The consequences of noncompliance with guidelines for withholding or terminating resuscitation in traumatic cardiac arrest patients. J Trauma 2011 Oct; 71:997.

18. The Wait that Matters

Maa J. N Engl J Med. 2011 Jun 16;364(24):2279-81.

She was 69 years old and, with the exception of mild heart disease, was in excellent health. One day, around mid-morning, she noticed that her heartbeat was irregular and she felt slightly short of breath. Using her home blood-pressure cuff, she found that her pulse was 130. Since her blood pressure was stable, she decided to forgo a call to 911 and instead asked her husband to drive her to the local hospital — one of the most highly regarded academic medical centers on the West Coast.

After waiting about an hour to be seen, she was diagnosed with rapid atrial fibrillation around 8 o'clock on a Thursday evening. Given her age, the emergency department (ED) staff and the consulting cardiologist decided to admit her to the hospital. The medical team started giving her intravenous heparin for anticoagulation and planned to perform electrical cardioversion the following day if a transesophageal echocardiogram (TEE) confirmed the absence of an atrial thrombus.

Because no inpatient bed was available, the patient was kept in the ED overnight. The narrowness of the stretcher and the noise and bright lights of the ED hallway made it hard for her to get much sleep. The following day, shortly before noon, she was wheeled upstairs to a bed.

Early in the afternoon, the cardiologist stopped by to let her know that because her admission had been delayed, it would not be possible to complete her procedures before the end of the workday. Therefore, she would remain in the hospital receiving intravenous heparin and oral warfarin throughout the weekend and would undergo TEE and cardioversion the following Monday.

The next day, without warning, the patient sustained a massive embolic stroke…

The remainder of the essay (free): http://www.nejm.org/doi/full/10.1056/NEJMp1101882

19. How fast does the Grim Reaper walk? Receiver operating characteristics curve analysis in healthy men aged 70 and over

Stanaway FF, et al. BMJ 2011;343:d7679

Introduction

The Grim Reaper, the personification of death, is a well known mythological and literary figure. Reported characteristics include a black cloak with cowl, a scythe, and cachexia. High quality scientific research linking the Grim Reaper to mortality has been scarce, despite extensive anecdotes.

Walking speed is a commonly used objective measure of physical capability in older people, predicting survival in several cohort studies. A recent meta-analysis found that being in the lowest fourth of walking speed compared with the highest was associated with a threefold increased risk of mortality. Moreover, the association between slow walking speed and mortality seems consistent across several ethnic groups and shows a dose-response relation.8 Although the association between walking speed and mortality has been well documented, the plausible biological relation between the two remains unclear.

We assessed whether the relation between slow walking speed and mortality results from the increased likelihood of being caught by Death. By assessing this relation using receiver operating characteristics curve analysis, we hypothesised we would be able to determine the walking speed of the Grim Reaper—information of importance to public health…

Abstract

Objective: To determine the speed at which the Grim Reaper (or Death) walks.

Design: Population based prospective study.

Setting: Older community dwelling men living in Sydney, Australia.

Participants: 1705 men aged 70 or more participating in CHAMP (Concord Health and Ageing in Men Project).

Main outcome measures: Walking speed (m/s) and mortality. Receiver operating characteristics curve analysis was used to calculate the area under the curve for walking speed and determine the walking speed of the Grim Reaper. The optimal walking speed was estimated using the Youden index (sensitivity+specificity−1), a common summary measure of the receiver operating characteristics curve, and represents the maximum potential effectiveness of a marker.

Results: The mean walking speed was 0.88 (range 0.15-1.60) m/s. The highest Youden index (0.293) was observed at a walking speed of 0.82 m/s (2 miles (about 3 km) per hour), corresponding to a sensitivity of 63% and a specificity of 70% for mortality. Survival analysis showed that older men who walked faster than 0.82 m/s were 1.23 times less likely to die (95% confidence interval 1.10 to 1.37) than those who walked slower (P=0.0003). A sensitivity of 1.0 was obtained when a walking speed of 1.36 m/s (3 miles (about 5 km) per hour) or greater was used, indicating that no men with walking speeds of 1.36 m/s or greater had contact with Death.

Conclusion: The Grim Reaper’s preferred walking speed is 0.82 m/s (2 miles (about 3 km) per hour) under working conditions. As none of the men in the study with walking speeds of 1.36 m/s (3 miles (about 5 km) per hour) or greater had contact with Death, this seems to be the Grim Reaper’s most likely maximum speed; for those wishing to avoid their allotted fate, this would be the advised walking speed.

20. Corticosteroids Impart No Benefit after Single-Dose Etomidate for Intubation

Moderate-dose hydrocortisone infusion did not affect outcomes in intubated patients without septic shock who had etomidate-related adrenal insufficiency.

Some physicians have expressed concern about adrenal suppression associated with etomidate use, but is this suppression clinically relevant? Researchers in France prospectively studied 97 patients with acute medical or traumatic conditions without septic shock who underwent intubation with etomidate plus succinylcholine in the prehospital or emergency department settings. Patients were randomized to receive continuous infusions of hydrocortisone (200 mg/day) or saline for 42 hours, starting 6 hours after intubation. Postintubation sedation was maintained with a variety of sedative and analgesic agents (not etomidate). Patients received vasopressor support and insulin as required to maintain target mean arterial blood pressure of 65 to 90 mm Hg and serum glucose levels of below 10 mmol/L.

Six hours after etomidate administration, 91% of patients randomized to the hydrocortisone group and 84% randomized to the control group met criteria for adrenal insufficiency based on corticotrophin stimulation tests and serum hormonal assays. No significant differences were noted between groups in rate of decline of Sequential Organ Failure Assessment scores, duration of mechanical ventilation, length of stay in the intensive care unit, or 28-day mortality.

Comment: Hydrocortisone treatment is not without risk and does not seem to benefit the group of patients studied. Etomidate, with its stable cardiovascular profile, remains an induction agent of choice for emergency intubation, particularly in multitrauma patients with brain injury whose outcomes might be worsened by inadequate systemic blood pressure for cerebral perfusion.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine January 13, 2012. Citation: Payen JF et al. Corticosteroid after etomidate in critically ill patients: A randomized controlled trial. Crit Care Med 2012 Jan; 40:29.

Medline abstract (Free): http://www.ncbi.nlm.nih.gov/pubmed/21926601

Marik PE. Etomidate in critically ill patients: Is it safe? Crit Care Med 2012 Jan; 40:301.
Medline abstract (Free): http://www.ncbi.nlm.nih.gov/pubmed/22179348

21. How to keep those New Year’s resolutions

Psychologists have identified successful ways of meeting self-determined goals, but they may not work if you’re a perfectionist.

Harv Health Lett. 2006 Jan;31(3):1-2.

Full-text (free): http://harvardhealth.staywell.com/viewNewsletter.aspx?NLID=47&INC=yes

“Exploring Change” as a New Year’s Resolution

In preparation to making changes, I will be exploring how changes are made. (A clever deferral strategy, wouldn’t you say?)

An introduction to the psychology of decision making can be found here: “The Mechanics of Choice” by Eric Wargo. The Observer, Vol.25, No.1 January, 2012

After years of tinkering, psychological scientists are figuring out how the gears turn when we make decisions. Full-text (free): http://tinyurl.com/dx62hfj

Some Fascinating Reading for Winter 2012 on Change: Cognitive, social, and historical

Daniel Kahneman (Nobel Laureate), Thinking: Fast and Slow (New York: Farrar, Straus and Giroux, 2011). http://www.amazon.com/dp/0374275637/ Ranked by the New York Times among their top 5 best non-fiction books of 2011 http://www.nytimes.com/2011/12/11/books/10-best-books-of-2011.html

Chip Heath and Dan Heath, Switch: How to Change Things when Change is Hard (New York: Broadway Books, 2010). http://www.amazon.com/dp/0385528752/

Timothy D. Wilson, Redirect: The Surprising New Science of Psychological Change (New York: Little, Brown and Company, 2011). http://www.amazon.com/dp/0316051888/

Steven Pinker, The Better Angels of our Nature: Why Violence Has Declined (New York: Penguin Group, 2011). http://www.amazon.com/dp/0670022950/

Lit Bits: Dec 17, 2011

2011-12-17T21:07:00.000-08:00

From the recent medical literature...

1. Do Boarding and Overcrowding Have Measurable Adverse Clinical Consequences?

A. The Association between Length of ED Boarding and Mortality

Singer AJ, et al. Acad Emerg Med. 2011;18:1324-1329.

Objectives: Emergency department (ED) boarding has been associated with several negative patient-oriented outcomes, from worse satisfaction to higher inpatient mortality rates. The current study evaluates the association between length of ED boarding and outcomes. The authors expected that prolonged ED boarding of admitted patients would be associated with higher mortality rates and longer hospital lengths of stay (LOS).

Methods: This was a retrospective cohort study set at a suburban academic ED with an annual ED census of 90,000 visits. Consecutive patients admitted to the hospital from the ED and discharged between October 2005 and September 2008 were included. An electronic medical record (EMR) system was used to extract patient demographics, ED disposition (discharge, admit to floor), ED and hospital LOS, and in-hospital mortality. Boarding was defined as ED LOS 2 hours or more after decision for admission. Descriptive statistics were used to evaluate the association between length of ED boarding and hospital LOS, subsequent transfer to an intensive care unit (ICU), and mortality controlling for comorbidities.

Results: There were 41,256 admissions from the ED. Mortality generally increased with increasing boarding time, from 2.5% in patients boarded less than 2 hours to 4.5% in patients boarding 12 hours or more (p less than 0.001). Mean hospital LOS also showed an increase with boarding time (p less than 0.001), from 5.6 days (SD ± 11.4 days) for those who stayed in the ED for less than 2 hours to 8.7 days (SD ± 16.3 days) for those who boarded for more than 24 hours. The increases were still apparent after adjustment for comorbid conditions and other factors.

Conclusions: Hospital mortality and hospital LOS are associated with length of ED boarding.

B. The Association of ED Crowding and Time to Antibiotics in Febrile Neonates

Kennebeck SS, et al. Acad Emerg Med. 2011;18:1380-1385.

Objectives: The objective was to assess the relationship between emergency department (ED) crowding and timeliness of antibiotic administration to neonates presenting with fever in a pediatric ED.

Methods: This was a retrospective cohort study of febrile neonates (aged 0–30 days) evaluated for serious bacterial infections (SBIs) in a pediatric ED from January 2006 to January 2008. General linear models were used to evaluate the association of five measures of ED crowding with timeliness of antibiotic administration, controlling for patient characteristics. A secondary analysis was conducted to determine which part of the ED visit for this population was most affected by crowding.

Results: A total of 190 patients met inclusion criteria. Mean time to first antibiotic was 181.7 minutes (range = 18–397 minutes). At the time of case presentation, the number of patients waiting in the waiting area, total number of hours spent in the ED by current ED patients, number of ED patients awaiting admission, and hourly boarding time were all positively associated with longer times to antibiotic. The time from patient arrival to room placement exhibited the strongest association with measures of crowding.

Conclusions: Emergency department crowding is associated with delays in antibiotic administration to the febrile neonate despite rapid recognition of this patient population as a high-risk group. Each component of ED crowding, in terms of input, throughput, and output factors, was associated with delays. Further work is required to develop processes that foster a more rapid treatment protocol for these high-risk patients, regardless of ED crowding pressures.

C. An Empirical Assessment of Boarding and Quality of Care: Delays in Care among Chest Pain, Pneumonia, and Cellulitis Patients

Liu SW, et al. Acad Emerg Med. 2011;18:1339–1348.

Background: As hospital crowding has increased, more patients have ended up boarding in the emergency department (ED) awaiting their inpatient beds. To the best of our knowledge, no study has compared the quality of care of boarded and nonboarded patients.

Objectives: This study sought to examine whether being a boarded patient and boarding longer were associated with more delays, medication errors, and adverse events among ED patients admitted with chest pain, pneumonia, or cellulitis.

Methods: This study was a retrospective cohort design in which data collection was accomplished via medical record review from two urban teaching hospitals. Patients admitted with chest pain, pneumonia, or cellulitis between August 2004 and January 2005 were eligible for inclusion. Our outcomes measures were: 1) delays in administration of home medications, cardiac enzyme tests, partial thromboplastin time (PTT), and antibiotics; 2) medication errors; and 3) adverse events or near misses. Primary independent variables were boarded status, boarding time, and boarded time interval. Multiple logistic regression models controlling for patient, ED, and hospital characteristics were used.

Results: A total of 1,431 patient charts were included: 811 with chest pain, 387 with pneumonia, and 233 with cellulitis. Boarding time was associated with an increased odds of home medication delays (adjusted odds ratio [AOR] = 1.07, 95% confidence interval [CI] = 1.05 to 1.10), as were boarded time intervals of 12, 18, and 24 hours. Boarding time also was associated with lower odds of having a late cardiac enzyme test (AOR = 0.93, 95% CI = 0.88 to 0.97).

Conclusions: Boarding was associated with home medication delays, but fewer cardiac enzyme test delays. Boarding was not associated with delayed PTT checks, antibiotic administration, medication errors, or adverse events/near misses. These findings likely reflect the inherent resources of the ED and the inpatient units.

D. ED Crowding is Associated with Decreased Quality of Analgesia Delivery for Children with Pain Related to Acute, Isolated, Long-bone Fractures

Sills MR, et al. Acad Emerg Med. 2011;18:1330-1338.

Objectives: The authors sought to determine which quality measures of analgesia delivery are most influenced by emergency department (ED) crowding for pediatric patients with long-bone fractures.

Methods: This cross-sectional, retrospective study included patients 0–21 years seen for acute, isolated long-bone fractures, November 2007 to October 2008, at a children’s hospital ED. Nine quality measures were studied: six were based on the timeliness (1-hour receipt) and effectiveness (receipt/nonreceipt) of three fracture-related processes: pain score, any analgesic, and opioid analgesic administration. Three equity measures were also tested: language, identified primary care provider (PCP), and insurance. The primary independent variable was a crowding measure: ED occupancy. Models were adjusted for age, language, insurance, identified PCP, triage level, ambulance arrival, and time of day. The adjusted risk of each timeliness or effectiveness quality measure was measured at five percentiles of crowding and compared to the risk at the 10th and 90th percentiles. The role of equity measures as moderators of the crowding-quality models was tested.

Results: The study population included 1,229 patients. Timeliness and effectiveness quality measures showed an inverse association with crowding—an effect not moderated by equity measures. Patients were 4% to 47% less likely to receive timely care and were 3% to 17% less likely to receive effective care when each crowding measure was at the 90th than at the 10th percentile (p less than 0.05). For three of the six quality measures, quality declined steeply between the 75th and 90th crowding percentiles.

Conclusions: Crowding is associated with decreased timeliness and effectiveness, but not equity, of analgesia delivery for children with fracture-related pain.

E. Crowding Does Not Adversely Affect Time to PCI for AMI in a Community ED

Harris B, et al. Ann Emerg Med. 2012;59:13-17.

Study objective: Multiple studies have linked emergency department (ED) crowding to delays in patient care, such as treatment with antibiotics and analgesics. Multiple studies have also demonstrated the benefit of timely percutaneous coronary intervention for patients with acute ST-segment elevation myocardial infarction (STEMI). We therefore study whether increased occupancy rates in our community ED might correlate with delays in door-to-balloon time for patients with acute STEMI who are referred for emergency percutaneous coronary intervention.

Methods: This study was a single-institution prospective observational study. For every patient arriving in our ED from June 2007 through October 2009 with acute STEMI treated with percutaneous coronary intervention, we measured the ED occupancy rate on arrival and the door-to-balloon time and determined the correlation between these variables in univariate and multivariate analyses controlling for patient characteristics, occupancy rate, times to ECG and catheter laboratory activation, and the availability of the catheterization laboratory team (in-house versus on-call).

Results: During the study period, 210 patients were treated with emergency percutaneous coronary intervention in accordance with the hospital protocol. For these patients, the mean ED occupancy rate at arrival was 127% (range 28% to 214%). The mean time to balloon inflation was 65 minutes (range 25 to 142 minutes). The time to balloon inflation did not significantly change with increasing occupancy rate in univariate analysis (Spearman's correlation −0.02; 95% confidence interval −0.13 to 0.11) or in multivariate analysis, with the only significant variable being the availability of the catheterization laboratory team in house, which was associated with reduced time to balloon inflation.

Conclusion: Times to achieve emergency percutaneous coronary intervention for acute STEMI do not correlate positively with crowding as measured by the occupancy rate in our ED.

2. CHADS2 Telling in AF Patients on Oral Anticoagulants

Megan Brooks. November 22, 2011 — In patients with atrial fibrillation, higher CHADS2 score is associated with increased risk for stroke or systemic embolism, bleeding, and death, even with optimal anticoagulation with warfarin or dabigatran, according to a subgroup analysis of the RE-LY trial.

In anticoagulated patients, "the commonly used CHADS2 risk score not only predicts stroke (as it was developed for) but also mortality and major bleeding," first author Jonas Oldgren, MD, associate professor of cardiology, Uppsala Clinical Research Centre and Department of Medical Sciences, Uppsala University Hospital, Sweden, told Medscape Medical News.

The analysis was published November 15 in Annals of Internal Medicine.

Prediction Rule

CHADS2 is a simple and validated clinical prediction rule for estimating stroke risk in patients with atrial fibrillation not receiving anticoagulants, the authors note in their paper. Its value in predicting thrombotic and bleeding complications in patients receiving anticoagulant therapy is unclear.

Dr. Oldgren and colleagues used data from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial to assess thrombotic and bleeding risk according to the baseline CHADS2 score.

The study involved 18,112 patients with atrial fibrillation at risk for stroke who were randomly assigned to treatment with dabigatran (Pradaxa, Boehringer Ingelheim), 110 mg or 150 mg twice daily, or warfarin at a dose adjusted to an international normalized ratio (INR) of 2.0 to 3.0 for a median of 2 years.

The main RE-LY results, published in 2009 in the New England Journal of Medicine, showed that the rates of stroke or systemic embolism and death each decreased by 0.5% per year with dabigatran, 150 mg twice daily, compared with dose-adjusted warfarin. Rates of major bleeding did not differ, but intracranial bleeding was less common with dabigatran.

The CHADS2 risk score assigns 1 point for a history of congestive heart failure, hypertension, diabetes, or age older than 75 years and 2 points for a history of stroke or transient ischemic attack.

In the RE-LY cohort, 5775 patients had CHADS2 scores of 0 to 1, 6455 had scores of 2, and 5882 patients had scores of 3 to 6.

Even with anticoagulation, the risk for the primary outcome of stroke or systemic embolism increased with increasing CHADS2 score, the authors report.

There was also a progressive near-linear increase in the risk for other outcomes with increasing CHADS2 score, the authors report.

Regardless of CHADS2 score, "rates of stroke or systemic embolism were lower with dabigatran, 150 mg twice daily, and rates of intracranial bleeding were lower with both dabigatran doses than with warfarin treatment," Dr. Oldgren told Medscape Medical News.

These findings "extend our knowledge in important ways," write the authors of a linked commentary.

"CHADS2 scores of 3 or higher identify patients with the most to gain and the most to lose by using anticoagulant therapy," note Rebecca J. Beyth, MD, University of Florida, Gainesville, and C. Seth Landefeld, MD, University of California, San Francisco.

"Whether they receive warfarin or dabigatran, 150 mg twice daily, these patients have a 2% to 3% annual risk for stroke or systemic embolism, a nearly 5% risk for major bleeding, and a nearly 6% risk for death," they add.

Interpret Cautiously

Dr. Oldgren and colleagues caution that these subgroup analyses were not prespecified and "should be deemed exploratory."

Nonetheless, "we believe these results are valuable for clinicians in their daily practice and useful in the decision on oral anticoagulant treatment in patients with atrial fibrillation at risk for stroke," Dr. Oldgren told Medscape Medical News.

Dr. Beyth and Dr. Landefeld agree. They say these data along with other studies performed to date can help physicians choose whether to use dabigatran or warfarin.

"On the one hand, dabigatran is more effective and safer for many patients with nonvalvular atrial fibrillation, especially younger patients, patients with CHADS2 scores of 0 or 1, and those in whom the INR is not maintained within the therapeutic range at least 60% of the time," they point out.

"On the other hand, the relative benefits of warfarin and dabigatran depend on the proportion of time that the INR is maintained within the therapeutic range in patients receiving warfarin and on patients adhering to a twice-daily regimen of dabigatran," they note.

The study was funded by Boehringer Ingelheim Pharmaceuticals. A complete list of disclosures for the RE-LY investigators and editorial writers can be found on the journal's Web site.

Ann Intern Med. 2011;155:660-667, 714-715.

Abstract: http://www.annals.org/content/155/10/660.abstract

3. Acutely Injured ED Patients on Dabigatran: Problematic

Cotton BA, et al. N Engl J Med 2011; 365:2039-2040.

To the Editor:

Trauma remains the fourth leading cause of death in the United States, with 40,000 deaths annually in persons over the age of 65. U.S. trauma centers are seeing an increasing number of severely injured elderly patients,1 and hemorrhagic complications and head injuries account for a substantial proportion of these fatalities.1 Although the preinjury use of warfarin is increasing and is associated with a considerable increase in morbidity and mortality, these complications can be dramatically reduced with methods that rapidly reverse the anticoagulant effect.1 Moreover, numerous options are available to achieve warfarin reversal (e.g., vitamin K, plasma, factor VIIa, and factor concentrates).1 Warfarin reversal can also be easily monitored with readily available laboratory and point-of-care tests.

Warfarin has long been the mainstay of anticoagulation therapy in atrial fibrillation. However, dabigatran etexilate (a new oral direct thrombin inhibitor) has recently been reported to have a similar or lower bleeding risk as compared with warfarin.2,3 Unlike warfarin, dietary restrictions and frequent blood sampling to monitor the degree of anticoagulation are unnecessary with dabigatran. Enthusiasm for this agent, however, must be tempered by three notable concerns: there is no readily available means for assessing the degree of anticoagulation with dabigatran, there is no readily available reversal strategy, and life-threatening bleeding complications can occur after an injury in patients taking this drug.

Lack of a readily available method to determine the degree of anticoagulation creates a major challenge to those treating injured patients. Moreover, the irreversible coagulopathy of dabigatran is of great concern to trauma and emergency physicians. Currently, the only reversal option for dabigatran is emergency dialysis (as suggested in a single line in the package insert). The ability to perform rapid dialysis in patients with bleeding whose condition is unstable or in those with large intracranial hemorrhages will present an incredible challenge, even at level 1 trauma centers.

Recently, we have cared for several injured patients receiving dabigatran, all of whom had poor outcomes. Although the results of conventional coagulation studies were normal, the values obtained on rapid thromboelastography (rTEG) at the time of admission were grossly abnormal. Specifically, the values for activated clotting time on rTEG (normal range, 86 to 118 seconds), which correspond to the inhibition of enzymatic clotting, were markedly prolonged. Figure 1 (link below) is the tracing from a patient who fell from a standing position, deteriorated neurologically, and died shortly after emergency craniotomy. It shows that all values except activated clotting time were normal. Unfortunately, even with the aid of rTEG, supportive care is all that is available in the emergency setting.

As dabigatran and other similar therapeutic agents move into the marketplace, we urge the Food and Drug Administration to consider the generalizability of study findings and to support more pragmatic trials. As such, we strongly urge that hemorrhagic complications and death resulting from trauma be included as part of the routine surveillance of all newly approved oral anticoagulants.

Link to figure (free): http://www.nejm.org/doi/full/10.1056/NEJMc1111095

Related Medscape Article: http://www.medscape.com/viewarticle/754332

4. Elevated HCG with an Empty Uterus Does Not Always Mean Ectopic Pregnancy

Live birth can occur in women with elevated HCG and no gestational sac seen on initial transvaginal ultrasound.

Until recently, common teaching was that when serum β human chorionic gonadotropin (β-HCG) is above 1000–2000 mIU/mL — the "discriminatory zone" — a gestational sac should be seen on transvaginal ultrasound in normal intrauterine pregnancy. To test this, researchers at a Boston hospital analyzed data for 202 patients during an 11-year period who had elevated β-HCG on the same day as transvaginal ultrasound showing no intrauterine fluid collection and then had subsequent ultrasound evidence of a live intrauterine embryo or fetus.

On the day of initial scan, β-HCG levels were less than 1000 mIU/mL in 80% of patients, 1000–1499 in 9%, 1500–1999 in 6%, and above 2000 mIU/mL in 5%. None of the 9 patients with β-HCG levels above 2000 mIU/mL had fibroids or other anatomic abnormalities that would have interfered with visualization of intrauterine fluid collection. The highest initial β-HCG level in a pregnancy that culminated in a live birth was 4336 mIU/mL. Initial β-HCG levels were not associated with pregnancy outcomes.

Comment: The Society of Radiologists in Ultrasound is planning a consensus conference on early first trimester sonography in 2012, which might well end the notion of the HCG "discriminatory zone" for diagnosis of ectopic pregnancy. Nevertheless, in hemodynamically stable patients with elevated β-HCG and no gestational sac or adnexal masses suggestive of ectopic pregnancy on transvaginal ultrasound, serial β-HCG measurement and repeat ultrasound to assess for a viable fetus is a reasonable option before diagnosing ectopic pregnancy.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine December 16, 2011. Citation: Doubilet PM and Benson CB. Further evidence against the reliability of the human chorionic gonadotropin discriminatory level. J Ultrasound Med 2011 Dec; 30:1637.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22123998

5. Prevalence of Clinically Important TBI in Children with Minor Blunt Head Trauma and Isolated Severe Injury Mechanisms

Nigrovic LE, et al.for the Traumatic Brain Injury (TBI) Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). Arch Pediatr Adolesc Med. Published online December 5, 2011.

Objective: To determine the prevalence of clinically important traumatic brain injuries (TBIs) with severe injury mechanisms in children with minor blunt head trauma but with no other risk factors from the Pediatric Emergency Care Applied Research Network (PECARN) TBI prediction rules (defined as isolated severe injury mechanisms).

Design: Secondary analysis of a large prospective observational cohort study.

Setting: Twenty-five emergency departments participating in the PECARN.

Patients: Children with minor blunt head trauma and Glasgow Coma Scale scores of at least 14.

Intervention: Treating clinicians completed a structured data form that included injury mechanism (severity categories defined a priori).

Main Outcome Measures: Clinically important TBIs were defined as intracranial injuries resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for at least 2 nights. We investigated the rate of clinically important TBIs in children with either severe injury mechanisms or isolated severe injury mechanisms.

Results: Of the 42 412 patients enrolled in the overall study, 42 099 (99%) had injury mechanisms recorded, and their data were included for analysis. Of all study patients, 5869 (14%) had severe injury mechanisms, and 3302 (8%) had isolated severe injury mechanisms. Overall, 367 children had clinically important TBIs (0.9%; 95% CI, 0.8%-1.0%). Of the 1327 children younger than 2 years with isolated severe injury mechanisms, 4 (0.3%; 95% CI, 0.1%-0.8%) had clinically important TBIs, as did 12 of the 1975 children 2 years or older (0.6%; 95% CI, 0.3%-1.1%).

Conclusion: Children with isolated severe injury mechanisms are at low risk of clinically important TBI, and many do not require emergent neuroimaging.

6. Emergency Hospitalizations for Adverse Drug Events in Older Americans

Adverse drug events (ADEs) cause an estimated 100,000 emergency hospitalizations for seniors each year, yet two thirds involve just a handful of anticoagulants and diabetes medications, according to a study published in the November 24 issue of the New England Journal of Medicine.

The study, by researchers from the US Centers for Disease Control and Prevention (CDC), singles out 4 drugs and drug classes — warfarin, oral antiplatelet medications, insulins, and oral hypoglycemic agents. Alone or together, they account for 67% of emergency ADE hospitalizations of adults 65 years and older. Warfarin was implicated in 33%, lead author Daniel Budnitz, MD, MPH, director of the CDC's Medication Safety Program, and coauthors write.

Budnitz DS, et al. N Engl J Med 2011; 365:2002-2012.

Introduction: Decreasing the number of preventable rehospitalizations by 20% by the end of 2013 is a goal of the $1 billion federal initiative Partnership for Patients, and the pursuit of this goal represents an opportunity to reduce harm to patients and reduce health care costs. Adverse drug events are a direct consequence of clinical care and a key focus of the partnership.

Hospitalizations for adverse drug events are likely to increase as Americans live longer, have greater numbers of chronic conditions, and take more medications. Among adults 65 years of age or older, 40% take 5 to 9 medications and 18% take 10 or more. Age-related physiological changes, a greater degree of frailty, a larger number of coexisting conditions, and polypharmacy have been associated with an increased risk of adverse events, and older adults are nearly seven times as likely as younger persons to have adverse drug events that require hospitalization.

In a previous study, we found that medications classified as always potentially inappropriate were implicated in only 3.6% of emergency department visits for adverse drug events in older adults, whereas three medications (warfarin, insulin, and digoxin) were implicated in 33.3% of such emergency department visits. Data on the medications that most commonly cause hospitalizations for adverse drug events in the United States have been limited. Detailed and drug-specific data are needed to help focus current patient-safety efforts. We used nationally representative public health surveillance data to describe emergency hospitalizations for adverse drug events in persons 65 years of age or older and to assess the contribution of specific medications, including those identified as high-risk or inappropriate by current national health care quality measures.

Background: Adverse drug events are important preventable causes of hospitalization in older adults. However, nationally representative data on adverse drug events that result in hospitalization in this population have been limited.

Methods: We used adverse-event data from the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project (2007 through 2009) to estimate the frequency and rates of hospitalization after emergency department visits for adverse drug events in older adults and to assess the contribution of specific medications, including those identified as high-risk or potentially inappropriate by national quality measures.

Results: On the basis of 5077 cases identified in our sample, there were an estimated 99,628 emergency hospitalizations (95% confidence interval [CI], 55,531 to 143,724) for adverse drug events in U.S. adults 65 years of age or older each year from 2007 through 2009. Nearly half of these hospitalizations were among adults 80 years of age or older (48.1%; 95% CI, 44.6 to 51.6). Nearly two thirds of hospitalizations were due to unintentional overdoses (65.7%; 95% CI, 60.1 to 71.3). Four medications or medication classes were implicated alone or in combination in 67.0% (95% CI, 60.0 to 74.1) of hospitalizations: warfarin (33.3%), insulins (13.9%), oral antiplatelet agents (13.3%), and oral hypoglycemic agents (10.7%). High-risk medications were implicated in only 1.2% (95% CI, 0.7 to 1.7) of hospitalizations.

Conclusions: Most emergency hospitalizations for recognized adverse drug events in older adults resulted from a few commonly used medications, and relatively few resulted from medications typically designated as high-risk or inappropriate. Improved management of antithrombotic and antidiabetic drugs has the potential to reduce hospitalizations for adverse drug events in older adults.

Medscape Review: http://www.medscape.com/viewarticle/754138

7. Does primary stroke center certification change ED diagnosis, utilization, and disposition of patients with acute stroke?

Ballard DW, et al. Am J Emerg Med. 2011 Nov 17. [Epub ahead of print]

BACKGROUND AND PURPOSE: We examined the impact of primary stroke center (PSC) certification on emergency department (ED) use and outcomes within an integrated delivery system in which EDs underwent staggered certification.

METHODS: A retrospective cohort study of 30 461 patients seen in 17 integrated delivery system EDs with a primary diagnosis of transient ischemic attack (TIA), intracranial hemorrhage, or ischemic stroke between 2005 and 2008 was conducted. We compared ED stroke patient visits across hospitals for (1) temporal trends and (2) pre- and post-PSC certification-using logistic and linear regression models to adjust for comorbidities, patient characteristics, and calendar time, to examine major outcomes (ED throughput time, hospital admission, radiographic imaging utilization and throughput, and mortality) across certification stages.

RESULTS: There were 15 687 precertification ED visits and 11 040 postcertification visits. Primary stroke center certification was associated with significant changes in care processes associated with PSC certification process, including (1) ED throughput for patients with intracranial hemorrhage (55 minutes faster), (2) increased utilization of cranial magnetic resonance imaging for patients with ischemic stroke (odds ratio, 1.88; 95% confidence interval, 1.36-2.60), and (3) decrease in time to radiographic imaging for most modalities, including cranial computed tomography done within 6 hours of ED arrival (TIA: 12 minutes faster, ischemic stroke: 11 minutes faster), magnetic resonance imaging for patients with ischemic stroke (197 minutes faster), and carotid Doppler sonography for TIA patients (138 minutes faster). There were no significant changes in survival.

CONCLUSIONS: Stroke center certification was associated with significant changes in ED admission and radiographic utilization patterns, without measurable improvements in survival.

8. Do outcomes of near syncope really parallel those of syncope? Uh…yup.

Grossman SA, et al. Amer J Emerg Med. 2012;30:203-206.

Background: Limited information on the evaluation of emergency department (ED) patients complaining of “near syncope” exists. Multiple studies of syncope exclude near syncope claiming near syncope is poorly defined and its definition is nonuniform.

Objective: The aim of this study was to determine the incidence of critical interventions or adverse outcomes associated with near syncope and compare these outcomes with syncope.

Methods: Prospective, observational study enrolling (August 2007–October 2008) consecutive ED patients (age, ≥18 years) presenting with near syncope was conducted. Near syncope was defined as an episode in which the patient felt they might lose consciousness but did not. Critical intervention/adverse outcome was defined as hemorrhage, cardiac ischemia/intervention, alteration in antidysrhythmics, pacemaker/defibrillator placement, sepsis, stroke, death, dysrhythmia, sepsis, pulmonary embolus, or carotid stenosis. Primary outcome was an adverse outcome or critical intervention in hospital or less than 30 days. Near syncope and syncope outcomes and admission rates were compared using the χ2 test.

Results; After 1870 patients were screened, 244 met the study definition. Of the 244 patients, follow-up was achieved in 242 (99%). Emergency department hospitalization or 30-day adverse outcomes occurred in 49 (20%) of 244 compared with 68 (23%) of 293 of patients with syncope (P = .40). The most common adverse outcomes/critical interventions were hemorrhage (n = 6), bradydysrhythmia (n = 6), alteration in antidysrhythmics (n = 6), and sepsis (n = 10). Of patients with near syncope, 49% were admitted compared with 69% with syncope (P = .001).

Conclusion: Patients with near syncope are as likely those with syncope to experience critical interventions or adverse outcomes; however, near-syncope patients are less likely to be admitted. Given similar risk of adverse outcomes for near syncope and syncope, future studies are warranted to improve the treatment of ED patients with near syncope.

9. National Performance is Poor on Door-In to Door-Out Time among Patients Transferred for Primary PCI

Herrin J, et al. Arch Intern Med. 2011;171(21):1879-1886.

Background: Delays in treatment time are commonplace for patients with ST-segment elevation acute myocardial infarction who must be transferred to another hospital for percutaneous coronary intervention. Experts have recommended that door-in to door-out (DIDO) time (ie, time from arrival at the first hospital to transfer from that hospital to the percutaneous coronary intervention hospital) should not exceed 30 minutes. We sought to describe national performance in DIDO time using a new measure developed by the Centers for Medicare & Medicaid Services.

Methods: We report national median DIDO time and examine associations with patient characteristics (age, sex, race, contraindication to fibrinolytic therapy, and arrival time) and hospital characteristics (number of beds, geographic region, location [rural or urban], and number of cases reported) using a mixed effects multivariable model.

Results: Among 13 776 included patients from 1034 hospitals, only 1343 (9.7%) had a DIDO time within 30 minutes, and DIDO exceeded 90 minutes for 4267 patients (31.0%). Mean estimated times (95% CI) to transfer based on multivariable analysis were 8.9 (5.6-12.2) minutes longer for women, 9.1 (2.7-16.0) minutes longer for African Americans, 6.9 (1.6-11.9) minutes longer for patients with contraindication to fibrinolytic therapy, shorter for all age categories (except older than 75 years) relative to the category of 18 to 35 years, 15.3 (7.3-23.5) minutes longer for rural hospitals, and 14.4 (6.6-21.3) minutes longer for hospitals with 9 or fewer transfers vs 15 or more in 2009 (all P less than .001).

Conclusion: Among patients presenting to emergency departments and requiring transfer to another facility for percutaneous coronary intervention, the DIDO time rarely met the recommended 30 minutes.

10. Effect of IV ondansetron on QT interval prolongation in patients with cardiovascular disease and additional risk factors for torsades: a prospective, observational study.

Hafermann MJ, et al. Drug Healthc Patient Saf. 2011;3:53-8.

BACKGROUND: The 5-hydroxytryptamine type 3 antagonists, or setrons (eg, ondansetron), are commonly used for nausea and vomiting in the hospital setting. In 2001, droperidol was given a black box warning because it was found to prolong the QT interval and induce arrhythmias. The setrons share with droperidol the same potential proarrhythmic mechanisms, but limited data exist concerning their effects on the QT interval in individuals at high risk for torsades de pointes.

METHODS: Forty hospitalized patients admitted for heart failure or acute coronary syndromes with one or more risk factors for torsades de pointes and an order for intravenous ondansetron 4 mg were enrolled in this prospective, observational study. The QT interval corrected for heart rate (QTc) was obtained via a 12-lead electrocardiogram on admission and again 120 minutes after the first dose of ondansetron in order to determine the mean change in QTc following ondansetron exposure.

RESULTS: The mean time interval between obtaining the baseline electrocardiogram and the second electrocardiogram following ondansetron administration was 3.5 ± 2.14 hours. In the total population, the QTc interval was prolonged by 19.3 ± 18 msec (P less than 0.0001) 120 minutes after ondansetron administration. For patients with an acute coronary syndrome and those with heart failure, QTc was prolonged by 18.3 ± 20 msec (P less than 0.0001) and 20.6 ± 20 msec (P less than 0.0012), respectively. Following ondansetron exposure, 31% and 46% in the heart failure and acute coronary syndromes groups, respectively, met gender-related thresholds for a prolonged QTc.

CONCLUSION: Our study found QTc prolongation due to ondansetron administration similar to that found in previous studies. When used in patients with cardiovascular disease (eg, heart failure or acute coronary syndromes) with one or more risk factors for torsades de pointes, ondansetron may significantly increase the QTc interval for up to 120 minutes after administration. From a patient safety perspective, patients who are at high risk for torsades de pointes and receiving ondansetron should be followed via telemetry when admitted to hospital.

Full-text (free): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202761/

11. The Role of Triage Nurse Ordering on Mitigating Overcrowding in EDs: A Systematic Review

Rowe BH, et al. Acad Emerg Med. 2011;18:1349-1357.

Objectives: The objective was to examine the effectiveness of triage nurse ordering (TNO) on mitigating the effect of emergency department (ED) overcrowding.

Methods: Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, SCOPUS, Web of Science, HealthSTAR, Dissertation Abstracts, ABI/INFORM Global), controlled trial registry websites, conference proceedings, study references, experts in the field, and correspondence with authors were used to identify potentially relevant studies. Interventional studies in which TNO was used to influence ED overcrowding metrics (length of stay [LOS] and physician initial assessment [PIA]) were included in the review. Two reviewers independently assessed study eligibility and methodologic quality. Mean differences were calculated and reported with corresponding 95% confidence intervals (CIs).

Results: From more than 14,000 potentially relevant studies, 14 were included in the systematic review. Most were single-center ED studies; the overall quality was rated as weak, due to methodologic deficiencies and variable outcome reporting. TNO was associated with a 37-minute mean reduction (95% CI = −44.10 to −30.30 minutes) in the overall ED LOS in one randomized clinical trial (RCT); a 51-minute mean reduction (95% CI = −56.3 to −45.5 minutes) was observed in non-RCTs. When applied to injured subjects with suspected fractures, TNO interventions reduced ED LOS by 20 minutes (95% CI = −37.5 to −1.9 minutes) in three RCTs and by 18 minutes (95% CI = −23.2 to −13.2) in two non-RCTs. No significant reduction in PIA was observed in two RCTs.

Conclusions: Overall, TNO appears to be an effective intervention to reduce ED LOS, especially in injury and/or suspected fracture cases. The available evidence is limited by small numbers of studies, weak methodologic quality, and incomplete reporting. Future studies should focus on a better description of the contextual factors surrounding these interventions and exploring the impact of TNO on other indicators of productivity and satisfaction with health care delivery.

12. Corticosteroids Useful in Acute COPD Exacerbation Requiring Ventilatory Support

Alia I, et al. Arch Intern Med 2011;171:1939-1948.

NEW YORK (Reuters Health) Dec 01 - Patients with an acute exacerbation of chronic obstructive pulmonary disease (COPD) receiving invasive or noninvasive mechanical ventilation benefit from systemic corticosteroid therapy, a randomized controlled trial in this critically ill patient population confirms.

Compared with placebo, corticosteroid therapy cut the duration of mechanical ventilation and intensive care by one day each, although the latter effect did not reach statistical significance.

For patients initially requiring non-invasive ventilation, corticosteroids eliminated the need for rescue mechanical ventilation.

Dr. Inmaculada Alia, from Hospital Universitario de Getafe in Spain and colleagues report their study in the Archives of Internal Medicine November 28.

A commentary appearing in the journal notes that the shorter intensive care unit (ICU) stay is "certainly clinically significant."

Given the "economic burden" of acute COPD exacerbations, reducing time spent in the ICU, and the need for rescue mechanical ventilation, can lead to "substantial savings," write Dr. Andrew Shorr and Dr. Chee Chan from the Pulmonary and Critical Care Medicine Section, Washington Hospital Center and Georgetown University in Washington, D.C.

Roughly 10% of patients with acute exacerbations of COPD need mechanical ventilation. Yet studies assessing the effect of corticosteroid therapy on COPD exacerbations have excluded those requiring mechanical ventilation or admitted to the ICU because they are prone to complications associated with corticosteroids, such as infections, hyperglycemia and ICU-acquired paresis.

Dr. Alia and colleagues performed a double-blind, placebo-controlled trial in 83 patients with an acute exacerbation of COPD who were receiving invasive or non-invasive mechanical ventilation. Participants were randomly assigned to receive intravenous methylprednisolone (0.5 mg/kg every 6 hours for 72 hours, 0.5 mg/kg every 12 hours on days 4 through 6, and 0.5 mg/kg/d on days 7 through 10) or placebo.

The groups were well-matched in terms of demographics, severity of illness, reasons for COPD exacerbation, gas exchange variables and corticosteroid rescue treatment.

Receipt of corticosteroids led to a reduction in the median duration of mechanical ventilation (3 days vs. 4 days; p=0.04); a trend toward a shorter median length of ICU stay (6 days vs. 7 days; p=0.09); and a reduction in the rate of failure of noninvasive mechanical ventilation (0% vs. 37%; p=0.04).

Importantly, say the investigators, giving systemic corticosteroids to this critically ill group of patients did not appear to raise the risk of gastrointestinal bleeding, superinfections, psychiatric disorders, or acquired neuromuscular weakness.

The major complication was hyperglycemia, a well-known consequence of corticosteroid therapy. However, it had no unfavorable clinical consequences in this study, the researchers say.

Dr. Alia and colleagues acknowledge that these findings "may not have a great impact on the current clinical treatment of ICU patients with COPD exacerbations because most of them are probably treated with corticosteroids."

However, the results "do provide strong evidence of the beneficial effects of systemic corticosteroid therapy on clinically relevant outcomes in a patient population that has never previously been enrolled in a clinical trial," they say.

Drs. Shorr and Chan say the findings are "important," noting that "few researchers venture into the ICU for clinical trials. As a consequence, intensivists are often left extrapolating data from non-critically ill patients."

However, they suggest that equipoise -- the concept that there must be uncertainty as to the relative benefit of the intervention(s) under evaluation - was "at least potentially in question for the current trial."

"If clinical trials of what are considered standard treatments are to be conducted...they must be performed with full consideration of equipoise," they contend.

SOURCE: http://archinte.ama-assn.org/cgi/content/abstract/171/21/1939

13. The non-utility of routine CXR in initial evaluation of stable blunt trauma patients

Paydar S, et al. Amer J Emerg Med. 2012;30:1-4.

Background: Radiology plays an important role in evaluation of a trauma patient. Although chest radiography is recommended for initial evaluation of the trauma patient by the Advanced Trauma Life Support course, we hypothesized that precise physical examinations and history taking accurately identify those blunt trauma patients at low risk for chest injury, making routine radiographs unnecessary. Thus, this study was performed to investigate the role of chest radiography in initial evaluation of those trauma patients with normal physical examination.

Methods: In this prospective cross-sectional study, all the hemodynamically stable blunt trauma patients with negative physical examination result referred to our trauma center during a 4-month period (March-June 2009) were included. Chest radiographies were performed and reviewed for abnormalities.

Results: During the study period, 5091 blunt trauma patients referred to our center, out of which, 1008 were hemodynamically stable and had negative physical examination result. Only 1 (0.1%) patient had abnormal chest radiography that showed perihilar lymphadenopathy, unrelated to trauma.

Conclusion: Performing routine chest radiography in stable blunt trauma patients is of low clinical value. Thus, decision making for performing chest radiography in blunt trauma patients based on clinical findings would be efficacious and resource saving.

14. Images in (Emergency) Medicine

Lingual Zoster
http://www.nejm.org/doi/full/10.1056/NEJMicm1107466

A Lucent Hemithorax Not Due to Pneumothorax
http://www.nejm.org/doi/full/10.1056/NEJMicm1101918

Zoster of the Tympanic Membrane
http://www.nejm.org/doi/full/10.1056/NEJMicm1104444

Thrombosis of a Mechanical Mitral Valve
http://www.nejm.org/doi/full/10.1056/NEJMicm1100131

Internal-Carotid-Artery Dissection and Cranial-Nerve Palsies
http://www.nejm.org/doi/full/10.1056/NEJMicm1009319

Can You Name these Foot Bones?
http://www.bmj.com/content/343/bmj.d7830

Adult Female with Ocular Lens Injury
http://www.annemergmed.com/article/S0196-0644(11)00500-2/fulltext

Young Man with Stab Wound to the Neck
http://www.annemergmed.com/article/S0196-0644(11)00389-1/fulltext

Adult Female with Abdominal Pain
http://www.annemergmed.com/article/S0196-0644(11)00717-7/fulltext

15. Medscape’s Highlights of the Year

In Medicine Generally
http://www.medscape.com/features/year-in-medicine/2011

In Emergency Medicine Research in Particular
http://www.medscape.com/viewarticle/753872

16. Variables Associated with Discordance between Emergency Physician and Neurologist Diagnoses of TIA in the ED

Schrock JW, et al. Ann Emerg Med. 2012;59:19-26.

Study objective: Transient ischemic attack is a common clinical diagnosis in emergency department (ED) patients with acute neurologic complaints. Accurate diagnosis of transient ischemic attack is essential to help guide evaluation and avoid treatment delays. We seek to determine the prevalence of discordant diagnosis for patients receiving an ED diagnosis of transient ischemic attack compared with neurologist final diagnosis. Secondary goals are to evaluate the influence of atypical transient ischemic attack symptoms, the ABCD2 score, and emergency physician experience on discordant diagnoses.

Methods: We performed a retrospective cohort study evaluating all ED patients receiving a diagnosis of transient ischemic attack during a 4-year period. The emergency physician diagnosis was compared with that of the neurologist. The neurologist's final diagnosis was considered the criterion standard diagnosis. Subject demographic and clinical information was collected with a structured instrument. The following atypical symptoms present at the ED evaluation were evaluated with logistic regression: headache, tingling, involuntary movement, seeing flashing lights or wavy lines, dizziness, confusion, incontinence, and ABCD2 score of 4 or greater. Bivariate analysis was used to evaluate the influence of emergency physician experience (≤6 years versus more than 6 years) on discordant diagnosis. Odds ratios (ORs) and proportions are reported with 95% confidence intervals (CIs), interquartile range was used where appropriate.

Results: We evaluated 436 subjects, of whom 7 were excluded, allowing 429 subjects for evaluation. Of these individuals, 156 (36%; 95% CI 32% to 41%) received a discordant diagnosis. The median emergency physician time in clinical practice was 6 years (interquartile range 2 to 12 years). Features associated with a discordant transient ischemic attack diagnosis included headache (OR 2.52; 95% CI 1.59 to 3.99), involuntary movement (OR 3.19; 95% CI 1.35 to 7.54), and dizziness (OR 1.92; 95% CI 1.22 to 3.02). Incontinence, confusion, and seeing wavy lines or flashing lights were not significantly associated with a discordant diagnosis. Patients with tingling and a high ABCD2 score had an increased odds of concordant transient ischemic attack diagnosis (OR 0.54, 95% CI 0.32 to 0.92; OR 0.53, 95% CI 0.35 to 0.82, respectively).

Conclusion: Discordant diagnoses between emergency physicians and neurologists were observed in 36% of patients. The presence of headache, involuntary movement, and dizziness predicted discordant diagnoses, whereas the presence of tingling and an increased ABCD2 score predicted concordant transient ischemic attack diagnosis.

17. How Prevalent Is Pulmonary Thrombosis During Acute Chest Syndrome?

In a French study, PT occurred in 17% of ACS episodes.

Mekontso Dessap A, et al. Am J Respir Crit Care Med 2011 Nov 1; 184:1022

Rationale: The pathophysiology of acute chest syndrome (ACS) in patients with sickle cell disease is complex, and pulmonary artery thrombosis (PT) may contribute to this complication.

Objectives: To evaluate the prevalence of PT during ACS using multidetector computed tomography (MDCT).

Methods: We screened 125 consecutive patients during 144 ACS episodes. One hundred twenty-one MDCTs (in 103 consecutive patients) were included in the study.

Measurements and Main Results: Twenty MDCTs were positive for PT, determining a prevalence of 17% (95% confidence interval, 10–23%). Revised Geneva clinical probability score was similar between patients with PT and those without. D-dimer testing was very often positive (95%) during ACS. A precipitating factor for ACS was less frequently found in patients with PT as compared with those without. Patients with PT exhibited significantly higher platelet counts (517 [273–729] vs. 307 [228–412] 109/L, P less than 0.01) and lower bilirubin (28 [19–43] vs. 44 [31–71] µmol/L, P less than 0.01) levels at the onset of ACS as compared with others. In addition, patients with PT had a higher platelet count peak (537 [345–785] vs. 417 [330–555] 109/L, P = 0.048) and smaller bilirubin peak (36 [18–51] vs. 46 [32–83] µmol/L, P = 0.048) and lactate dehydrogenase peak (357 [320–704] vs. 604 [442–788] IU/L, P = 0.01) during hospital stay as compared with others.

Conclusions: PT is not a rare event in the context of ACS and seems more likely in patients with higher platelet counts and lower hemolytic rate during ACS. Patients with sickle cell disease presenting with respiratory symptoms suggestive of ACS may benefit from evaluation for PT.

18. CTA Shows Promise for Diagnosing Lower GI Bleeding

James Brice. Medscape. November 28, 2011 — Computed tomography (CT) angiography could emerge as a viable option for detecting the presence and origin of lower intestinal hemorrhage in patients who present to the emergency department.

A prospective study, conducted at La Paz University Hospital in Madrid, Spain, has established the feasibility of CT angiography in this setting. The imaging technique had 100% sensitivity (19 of 19 patients) and 96% specificity (27 of 28 patients) for diagnosing active or recent lower gastrointestinal (GI) tract bleeding in a series of 47 consecutive patients. The results of the study were published online November 14 in Radiology.

Milagros Martí, MD, and coauthors stressed the importance of quickly obtaining an accurate assessment of suspected lower GI bleeding for effective treatment. Hemorrhage can occur anywhere in the GI tract from the esophagus to the rectum, and can range from mild to massive acute bleeding. Mortality rates range from 8% to 16%, but can be as high as 40% when bleeding is severe, the authors note.

Currently, diagnosis can require a multimodal approach. Optical colonoscopy is the preferred choice for initial evaluation distal to the ligament of Treitz, but problems with staff availability during off hours, proper bowel preparation, and poor bowel visualization from obstructions caused by intraluminal blood clots make it difficult to apply. Additionally, the source of bleeding is extracolonic in about 10% of cases.

Technetium-99m red blood cell imaging is another accepted option because of its high sensitivity to moderate and severe bleeding. However, it cannot be relied upon to identify the precise source and cause of bleeding.

Conventional angiography and emergency surgery are often performed to address persistent bleeding, but physicians generally try to avoid these invasive and expensive procedures when possible.

Previous studies have suggested that CT angiography might be useful in this setting, but have been limited by their small size or retrospective nature.

In this prospective study, Dr. Martí and colleagues tested a triphasic CT protocol that ranged from the diaphragm to the inferior pubic ramus. Imaging was performed on a 64-slice scanner. Tube voltage was 120 kVp, with automatic tube current modulation to reduce dosage. Oral contrast was not used.

The investigators used a preliminary unenhanced CT scan to uncover preexisting intraluminal hyperattenuating material. The unenhanced scan helped prevent the misinterpretation of hyperattenuating material that can mimic contrast medium extravasation and result in false-positive findings, the authors explain.

Intravenous contrast material (4 mL/s) was administered before the acquisition of an arterial phase scan. It was obtained using automated bolus triggering and began when attenuation in the proximal abdominal aorta reached 150 HU. A portal venous phase scan was acquired 70 seconds after the start of contrast injection.

CT angiography identified extravasation, indicating active hemorrhage, in 14 patients. Seven patients were transferred directly to the angiography suite for possible embolization. Conventional angiography confirmed the presence and location of bleeding suggested by CT angiography in 6 of the 7 cases — 2 in the jejunum/ileum, 3 in the colon, and 1 in the rectosigmoid region. In 1 patient, CT angiography depicted active extravasation in the colon, but bleeding had stopped before angiography was performed. The researchers classified that case as a false positive.

The remaining 7 patients underwent surgery.

The authors conclude that CT angiography helped identify active bleeding and the site of bleeding in 83% of the cases (39 of 47 patients). Imaging results helped guided therapy and helped select the most appropriate hemostatic intervention. The ability to localize the point of origin of bleeding allowed targeted endovascular embolization to stanch it.

Study limitations include the small sample size from a single hospital, the lack of a control group, and the focus on patients from whom emergent colonoscopy was requested. More sophisticated multicenter trials are needed to determine if CT angiography qualifies as a front-line exam for diagnosing lower GI hemorrhage.

Radiology. Published online November 14, 2011.

Abstract: http://radiology.rsna.org/content/early/2011/11/08/radiol.11110326.abstract

19. Hospital Admission Decision for Patients with Community-Acquired Pneumonia: Variability among Physicians in an ED

Dean NC, et al. Ann Emerg Med. 2012;59:35-41.

Study objective: We examine variability among emergency physicians in rate of hospitalization for patients with pneumonia and the effect of variability on clinical outcomes.

Methods: We studied 2,069 LDS Hospital emergency department (ED) patients with community-acquired pneumonia who were aged 18 years or older during 1996 to 2006, identified by International Classification of Diseases, Ninth Revision coding and compatible chest radiographs. We extracted vital signs, laboratory and radiographic results, hospitalization, and outcomes from the electronic medical record. We defined “low severity” as PaO2/FiO2 ratio greater than or equal to 280 mm Hg, predicted mortality less than 5% by an electronic version of CURB-65 that uses continuous and weighted elements (eCURB), and less than 3 Infectious Disease Society of America-American Thoracic Society 2007 severe pneumonia minor criteria. We adjusted hospitalization decisions and outcomes for illness severity and patient demographics.

Results: Initial hospitalization rate was 58%; 10.7% of patients initially treated as outpatients were secondarily hospitalized within 7 days. Median age of admitted patients was 63 years; median eCURB predicted mortality was 2.65% (mean 6.8%) versus 46 years and 0.93% for outpatients. The 18 emergency physicians (average age 44.9 [standard deviation 7.6] years; years in practice 8.4 [standard deviation 6.9]) objectively calculated and documented illness severity in 2.7% of patients. Observed 30-day mortality for inpatients was 6.8% (outpatient mortality 0.34%) and decreased over time. Individual physician admission rates ranged from 38% to 79%, with variability not explained by illness severity, time of day, day of week, resident care in conjunction with an attending physician, or patient or physician demographics. Higher hospitalization rates were not associated with reduced mortality or fewer secondary hospital admissions.

Conclusion: We observed a 2-fold difference in pneumonia hospitalization rates among emergency physicians, unexplained by objective data

20. Treating secondary spontaneous PTX: Is a pigtail catheter sufficient?

Chen C, et al. Amer J Emerg Med. 2012;30:45-50.

Objective: The study aimed to assess the clinical efficacy of pigtail catheter drainage for patients with a first episode of secondary spontaneous pneumothorax (SSP) and different associated conditions.

Methods: We retrospectively reviewed the records of patients with SSP who received pigtail catheter drainage as their initial management between July 2002 and October 2009. A total of 168 patients were included in the analysis; 144 (86%) males and 24 (14%) females with a mean age of 60.3 ± 18.3 years (range, 17-91 years). Data regarding demographic characteristics, pneumothorax size, complications, treatments, length of hospital stay, and associated conditions were analyzed.

Results: In total, 118 (70%) patients were successfully treated with pigtail catheter drainage, and 50 (30%) patients required further management. Chronic obstructive lung disease was the most common underlying disease (57% of cases). Secondary spontaneous pneumothorax associated with infectious diseases had a higher rate of treatment failure than SSP associated with obstructive lung conditions (19/38 [50%] successful vs 78/104 [75%] successful, P = .004) and malignancy (19/38 [50%] successful vs 13/16 [81%] successful, P = .021). Moreover, patients with SSP associated with infectious diseases had a longer length of hospital stay than those with obstructive lung conditions (23.8 vs 14.5 days, P = .003) and malignancy (23.8 vs 12.1 days, P = .017). No complications were associated with pigtail catheter drainage.

Conclusions: A higher rate of treatment failure was noted in SSP patients with infectious diseases; thus, pigtail catheter drainage is appropriate as an initial management for patients with SSPs associated with obstructive lung conditions and malignancy.

21. Likelihood That a Woman with Screen-Detected Breast Cancer Has Had Her "Life Saved" by That Screening

Welch HG, et al. Arch Intern Med. 2011;171(22):2043-2046.

Background: Perhaps the most persuasive messages promoting screening mammography come from women who argue that the test "saved my life." Because other possibilities exist, we sought to determine how often lives were actually saved by mammography screening.

Methods: We created a simple method to estimate the probability that a woman with screen-detected breast cancer has had her life saved because of screening. We used DevCan, the National Cancer Institute's software for analyzing Surveillance Epidemiology and End Results (SEER) data, to estimate the 10-year risk of diagnosis and the 20-year risk of death—a time horizon long enough to capture the downstream benefits of screening. Using a range of estimates on the ability of screening mammography to reduce breast cancer mortality (relative risk reduction [RRR], 5%-25%), we estimated the risk of dying from breast cancer in the presence and absence of mammography in women of various ages (ages 40, 50, 60, and 70 years).

Results: We found that for a 50-year-old woman, the estimated risk of having a screen-detected breast cancer in the next 10 years is 1910 per 100 000. Her observed 20-year risk of breast cancer death is 990 per 100 000. Assuming that mammography has already reduced this risk by 20%, the risk of death in the absence of screening would be 1240 per 100 000, which suggests that the mortality benefit accrued to 250 per 100 000. Thus, the probability that a woman with screen-detected breast cancer avoids a breast cancer death because of mammography is 13% (250/1910). This number falls to 3% if screening mammography reduces breast cancer mortality by 5%. Similar analyses of women of different ages all yield probability estimates below 25%.

Conclusions: Most women with screen-detected breast cancer have not had their life saved by screening. They are instead either diagnosed early (with no effect on their mortality) or overdiagnosed.

Lit Bits: Nov 26, 2011

2011-11-26T10:09:00.000-08:00

From the recent medical literature...

1. Number of Coronary Heart Disease Risk Factors and Mortality in Patients with First MI

Risk of fatal heart attack higher without warning signs

One in seven patients who did not display risk factors suggestive of heart disease died after experiencing a heart attack compared with 1 in 28 with five risk factors, according to a study in the Journal of the American Medical Association. The survival of patients with more risk factors might be due to medications they took, researchers said. The findings were based on data from a national registry of nearly 550,000 first-time heart attack cases from 1994 to 2006

Canto JG, et al. JAMA 2011; 306(19):2120-2127.

Context: Few studies have examined the association between the number of coronary heart disease risk factors and outcomes of acute myocardial infarction in community practice.

Objective: To determine the association between the number of coronary heart disease risk factors in patients with first myocardial infarction and hospital mortality.

Design: Observational study from the National Registry of Myocardial Infarction, 1994-2006.

Patients: We examined the presence and absence of 5 major traditional coronary heart disease risk factors (hypertension, smoking, dyslipidemia, diabetes, and family history of coronary heart disease) and hospital mortality among 542 008 patients with first myocardial infarction and without prior cardiovascular disease.

Main Outcome Measure: All-cause in-hospital mortality.

Results: A majority (85.6%) of patients who presented with initial myocardial infarction had at least 1 of the 5 coronary heart disease risk factors, and 14.4% had none of the 5 risk factors. Age varied inversely with the number of coronary heart disease risk factors, from a mean age of 71.5 years with 0 risk factors to 56.7 years with 5 risk factors (P for trend less than .001). The total number of in-hospital deaths for all causes was 50 788. Unadjusted in-hospital mortality rates were 14.9%, 10.9%, 7.9%, 5.3%, 4.2%, and 3.6% for patients with 0, 1, 2, 3, 4, and 5 risk factors, respectively. After adjusting for age and other clinical factors, there was an inverse association between the number of coronary heart disease risk factors and hospital mortality adjusted odds ratio (1.54; 95% CI, 1.23-1.94) among individuals with 0 vs 5 risk factors. This association was consistent among several age strata and important patient subgroups.

Conclusion: Among patients with incident acute myocardial infarction without prior cardiovascular disease, in-hospital mortality was inversely related to the number of coronary heart disease risk factors.

2. Children with Normal CT after Blunt Head Injury Are at Low Risk for Neurological Complications

No neurosurgical interventions were required in children with blunt head injury who had GCS scores of 14 or 15 and normal head CT scans in the emergency department.

In a planned secondary analysis of a prospective observational cohort study from PECARN (the Pediatric Emergency Care Applied Research Network), investigators evaluated the frequency of neurological complications in children (age, below 18 years) with blunt head trauma (isolated or multisystem trauma), initial Glasgow Coma Scale (GCS) scores of 14 or 15, and normal emergency department head computed tomography (CT) scans. CT scans were performed at the discretion of the treating provider. Patients discharged to home were followed up at 1 week by telephone survey (capture rate, 79%); morgue and medical records were reviewed for patients with incomplete surveys.

Of 13,543 patients (mean age, 8.9 years; 20% below 2 years) who met inclusion criteria during the 2-year study period, 2485 (18%) were hospitalized. Among hospitalized patients, 137 (6%) underwent subsequent neuroimaging, and 16 (0.6%) had abnormal findings. Among discharged patients, 197 (2%) underwent subsequent neuroimaging, and 5 (0.05%) had abnormal findings. No patient in either group required neurosurgical intervention.

Comment: Children with blunt head injury who have normal GCS scores and head CT scans can be safely discharged home with postconcussive follow-up care instructions regarding signs of deterioration and outpatient follow-up before resuming physical activities, such as sports.

— Katherine Bakes, MD. Published in Journal Watch Emergency Medicine November 4, 2011

Citation: Holmes JF et al. Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation? Ann Emerg Med 2011 Oct; 58:315.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21683474

3. Cardioversion of acute AF in the short observation unit in Italy: comparison of a protocol focused on electrical cardioversion with simple antiarrhythmic treatment

Cristoni L, et al. Emerg Med J 2011;28:932-937

Background: Direct current cardioversion (DCC) has been shown to be effective for the management of atrial fibrillation (AF) in the emergency department (ED). Pharmacological cardioversion was compared with a strategy including DCC on patients with uncomplicated, recent-onset (within 48 h) AF managed in a short observation unit (SOU).

Methods: A prospective observational study was undertaken over a period of 13 months in two institutions. A DCC-centred protocol was applied to 171 AF cases in a hospital (DCC-cohort) and pharmacological cardioversion to 151 AF cases in another hospital (P-cohort). Patients remaining in AF after 24 h were admitted. The outcomes were rate of discharge in sinus rhythm, length of stay in the ED-SOU, rate of hospitalisation and complications of treatment. Data collected were analysed according to Student t test and χ2 statistics.

Results: Discharge in sinus rhythm was achieved in 159/171 cases in the DCC-cohort and 77/151 cases in the P-cohort (93% vs 51%; number needed to treat (NNT) 2.4; 95% CI 2.0 to 3.1, p less than 0.001), whereas mean length of stay was 7+7 h in the DCC-cohort and 9+6 h in the P-cohort (p=0.43). Eleven cases from the DCC-cohort and 67 from the P-cohort were admitted (admission rate 6% vs 44%; NNT 2.6; 95% CI 2.2 to 3.5, p less than 0.001). Three short-term complications occurred in the DCC-cohort and five in the P-cohort (2% vs 3%, p=0.59). Two strokes were registered in the DCC-cohort during 6-month follow-up (p undefined).

Conclusions: Electrical cardioversion of recent-onset AF in the SOU is safe, effective and reduces hospitalisations. Further studies are needed to identify the most cost-effective strategy for the management of AF patients in emergency settings.

Cf a U.S. ED study with similar results without employing an obs unit: Managing ED Patients with Recent-onset AF. J Emerg Med. 2010 Jul 15. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/20634022

4. Broken Toe? Forget the Follow-up

by Kevin Klauer, DO, Emergency Physicians Monthly, November 10, 2011

Want to save the healthcare system time and money? Forget the follow-up and make the emergency department the last stop for a range of simple injuries. First up: broken toes.

Definitive management? Aren’t we capable of finishing anything we start? In a different place, in a different time, in a world where common sense outweighs defensive medicine, we should be the last stop for certain conditions.

Toe fractures are an excellent place to start. Let’s assume that complications are expected with toe fractures. How bad could they be? Even if there is a non-union, you have nine others! Clearly, many patients cannot receive definitive management in the ED, either due to the need for specialized care (i.e., complex fracture management), assessment for response to treatment (i.e., community acquired pneumonia or cellulitis) or the need for further diagnostic evaluation (i.e., low risk chest or undifferentiated abdominal pain). In contrast to a toe, chest pain patients only have one heart, and that organ trumps a toe any day.

I have no idea how many toe fractures are seen annually in U.S. EDs. However, I would venture to guess it’s more than a baker’s dozen. Thus, the impact for providing more efficient and cost-effective care by providing definitive management for toe fractures is likely to be substantial. About a year and a half ago, I dropped a trailer hitch on my right 5th toe. I knew upon impact it was broken. I’m not a swearing man. However, I consulted the socially unacceptable thesaurus on that one. It hurt. It swelled, and it wasn’t back to normal for about 5 weeks, but I didn’t seek medical attention for it. In my “N” of one, the outcome has been good and the cost of care was $0.00. Not withstanding the lack of value of radiographic evaluation, buddy taping and buying a post-op shoe, follow-up care wouldn’t have changed the outcome.

Not only is definitive management of toe fractures a reasonable consideration, with respect to incorporating cost-saving strategies for healthcare reform, using less diagnostics makes sense also. So, what are we worried about? Sure. It’s broken. So, the reflex is to order an x-ray. However, when you already know it’s broken and you won’t do anything different with the test you’re considering ordering, just say no. In my opinion, too many radiographs are ordered due to culture and not used to improve care. Most patients want an answer, not a test. So, if you can give them a definitive answer without order a radiograph, you both might be happier.

Although there is much data on this topic, let’s just discuss one contemporary article by Van Vliet-Koppert…

The remainder of the essay is here: http://www.epmonthly.com/subspecialties/management/broken-toe-forget-the-follow-up/

5. Relationship between Pain Severity and Outcomes in Patients Presenting with Potential ACS

Edwards M, et al. Ann Emerg Med. 2011;58:501-507.

Study objective: Although lay people often assume that severe pain is more commonly associated with worse outcomes, the relationship between pain severity and outcome for patients presenting with potential acute coronary syndrome has not been well described. We hypothesize that pain severity will not be associated with acute myocardial infarction or 30-day cardiovascular complications.

Methods: We conducted a secondary analysis of a prospective cohort study of patients presenting to the emergency department (ED) with potential acute coronary syndrome. Trained research assistants collected data, including demographics, medical history, symptoms, hospital course, and 30-day outcomes (record review and telephone). Pain score on arrival (0 to 10) was abstracted from nurses' triage documentation in the electronic record. Severe pain was defined as 9 or 10. The main outcomes were the prevalence of acute myocardial infarction during index visit and composite of death, acute myocardial infarction, revascularization including percutaneous coronary intervention, or coronary bypass artery grafting at 30 days. Multivariable modeling was prespecified to adjust for age, race, sex, pain duration, thrombolysis in myocardial infarction (TIMI) score, and mode of arrival. Data are presented as relative risk (RR) with 95% confidence intervals (CI).

Results: Patients (3,306) had pain documented (mean age 51.0 years; SD 12.6 years; 57% women; 66% black). Follow-up was 93%. By 30 days, 34 patients had died, 105 patients underwent revascularization (94 percutaneous coronary intervention, 14 coronary bypass artery grafting), and 111 patients experienced acute myocardial infarction. There was not a relationship between severe pain and acute myocardial infarction (RR 1.28; 95% CI 0.93 to 1.76) or 30-day composite outcome (1.19; 95% CI 0.91 to 1.56). After adjusting for potential confounding variables, we found that the prevalence of inhospital acute myocardial infarction was related to TIMI score (adjusted relative risk [aRR] 2.00; 95% CI 1.05 to 3.80), male sex (aRR 1.48; 95% CI 1.00 to 2.18), and arrival by emergency medical services (EMS) (aRR 1.73; 95% CI 1.13 to 2.63) but not age (aRR 1.42; 95% CI 0.68 to 2.95), white race (aRR 1.25; 95% CI 0.85 to 1.86), pain duration greater than 1 hour (aRR 1.36; 95% CI 0.89 to 2.07), or severe pain (aRR 1.43; 95% CI 0.91 to 2.22). Thirty-day composite outcome was related to male sex (aRR 1.53; 95% CI 1.16 to 2.01), white race (aRR 1.43; 95% CI 1.09 to 1.87), and higher TIMI score (aRR 2.24; 95% CI 1.39 to 3.60) but was not related to age (aRR 1.26; 95% CI 0.75 to 2.11), pain duration greater than 1 hour (aRR 0.8; 95% CI 0.60 to 1.06), EMS arrival (aRR 1.23; 95% CI 0.96 to 1.60), or severe pain (aRR 1.39; 95% CI 0.95 to 1.97).

Conclusion: For patients who present to the ED with potential acute coronary syndrome, severe pain is not related to likelihood of acute myocardial infarction at presentation or death, acute myocardial infarction or revascularization within 30 days.

6. Lytics for Acute CVA

A. Stroke Mimics and Intravenous Thrombolysis

Artto V, et al. Ann Emerg Med. 2011; in press.

Study objective: The necessity for rapid administration of intravenous thrombolysis in patients with acute ischemic stroke may lead to treatment of patients with conditions mimicking stroke. We analyze stroke patients treated with intravenous thrombolysis in our center to characterize cases classified as stroke mimics.

Methods: We identified and reviewed all cases with a diagnosis other than ischemic stroke in our large-scale single-center stroke thrombolysis registry. We compared these stroke mimics with patients with neuroimaging-negative and neuroimaging-positive ischemic stroke results.

Results: Among 985 consecutive intravenous thrombolysis–treated patients, we found 14 stroke mimics (1.4%; 95% confidence interval 0.8% to 2.4%), 694 (70.5%) patients with neuroimaging-positive ischemic stroke results, and 275 (27.9%) patients with neuroimaging-negative ischemic stroke results. Stroke mimics were younger than patients with neuroimaging-negative or -positive ischemic stroke results. Compared with patients with neuroimaging-positive ischemic stroke results, stroke mimics had less severe symptoms at baseline and better 3-month outcome. No differences appeared in medical history or clinical features between stroke mimics and patients with neuroimaging-negative ischemic stroke results. None of the stroke mimics developed symptomatic intracerebral hemorrhage compared with 63 (9.1%) among patients with neuroimaging-positive ischemic stroke results and 6 (2.2%) among patients with neuroimaging-negative ischemic stroke results.

Conclusion: Stroke mimics were infrequent among intravenous thrombolysis–treated stroke patients in this cohort, and their treatment did not lead to harmful complications.

B. Patients with Diabetes and Prior Stroke Benefit from Thrombolytic Therapy for Treatment of Acute Stroke

This finding will expand eligibility for thrombolysis in the U.S.

Concomitant diabetes mellitus and prior stroke is thought to potentially mitigate the benefits of thrombolytic therapy for acute stroke. In Europe, concomitant diabetes and prior stroke is considered a contraindication to thrombolytic therapy, whereas in the U.S., it is considered a contraindication only for patients who present in the expanded treatment window (3–4.5 hours).

Researchers used registry data to assess the effect of diabetes and prior stroke on outcomes (adjusted 90-day modified Rankin Scale score) in patients who received tissue plasminogen activator (TPA) for acute stroke (data from the Safe Implementation of Thrombolysis in Stroke–International Stroke Thrombolysis Register) and control patients who did not (data from the Virtual International Stroke Trials Archive). Analyses were controlled for the following confounding patient variables: National Institutes of Health Stroke Scale score, age, and comorbidities.

Of 29,500 patients, 19% had diabetes, 17% had prior stroke, and 6% had both. Among patients with diabetes, prior stroke, or both, those who received TPA had significantly better outcomes than those who did not receive TPA. Among patients who received TPA, those with diabetes, prior stroke, or both had similar outcomes to those with neither diabetes nor prior stroke.

Comment: This large study does not support excluding patients with diabetes mellitus, prior stroke, or both from consideration for thrombolytic therapy for treatment of acute stroke. This finding will expand eligibility for thrombolytic therapy.

— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine November 18, 2011. Citation: Mishra NK et al. Thrombolysis outcomes in acute ischemic stroke patients with prior stroke and diabetes mellitus. Neurology 2011 Nov 22; 77:1866.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22094479

7. Patterns and Predictors of Short-Term Death after ED Discharge

Gelareh Z. Gabayan GZ, et al. Ann Emerg Med. 2011;58:551-558.e2.

Study objective: The emergency department (ED) is an inherently high-risk setting. Early death after an ED evaluation is a rare and devastating outcome; understanding it can potentially help improve patient care and outcomes. Using administrative data from an integrated health system, we describe characteristics and predictors of patients who experienced 7-day death after ED discharge.

Methods: Administrative data from 12 hospitals were used to identify death after discharge in adults aged 18 year or older within 7 days of ED presentation from January 1, 2007, to December 31, 2008. Patients who were nonmembers of the health system, in hospice care, or treated at out-of-network EDs were excluded. Predictors of 7-day postdischarge death were identified with multivariable logistic regression.

Results; The study cohort contained a total of 475,829 members, with 728,312 discharges from Kaiser Permanente Southern California EDs in 2007 and 2008. Death within 7 days of discharge occurred in 357 cases (0.05%). Increasing age, male sex, and number of preexisting comorbidities were associated with increased risk of death. The top 3 primary discharge diagnoses predictive of 7-day death after discharge included noninfectious lung disease (odds ratio [OR] 7.1; 95% confidence interval [CI] 2.9 to 17.4), renal disease (OR 5.6; 95% CI 2.2 to 14.2), and ischemic heart disease (OR 3.8; 95% CI 1.0 to 13.6).

Conclusion; Our study suggests that 50 in 100,000 patients in the United States die within 7 days of discharge from an ED. To our knowledge, our study is the first to identify potentially “high-risk” discharge diagnoses in patients who experience a short-term death after discharge.

8. What Do We Do With a Positive Troponin Test?

Amal Mattu, MD. Medscape Emerg Med. Posted: 10/28/2011

Introduction

A physician recently emailed me with a question (paraphrasing): "Our lab recently switched over to using the new high-sensitivity troponin test and we're confused. What do we do with a positive troponin (TN) test?"

A handful of years ago, I suppose my gut response to someone asking what to do with a positive TN test would have been to tell that person to do more continuing medical education before seeing any more patients. My belief now, however, has become one of complete empathy with this physician and his colleagues. It seems that we all are having a tough time figuring this out, including our own cardiologists. The most recent high-profile article pertaining to the high-sensitivity (HS)-TN test has prompted another flurry of emails, questions, and uncertainty. Here's a quick summary and then some further thoughts about the article, TN testing, and evaluating patients with possible acute coronary syndromes.

Rapid Exclusion of Acute Myocardial Infarction in Patients With Undetectable Troponin Using a High-Sensitivity Assay

Body R, Carley S, McDowell G, et al. J Am Coll Cardiol. 2011;58:1332-1339

Study Summary

The study authors evaluated 703 patients presenting with chest pain to a large hospital's emergency department (ED) in the United Kingdom. A total of 130 (18.5%) patients were diagnosed with acute myocardial infarction (AMI) using standard, accepted criteria for diagnosis with TN testing, which incorporates a serial rise (or fall) of TN. Serial testing in this case meant that the researchers obtained a TN level (a HS-TN-T assay was used in this study) at the time of presentation and a second level at 12 hours after the onset of symptoms. Nearly half (46%) of the patients presented within 3 hours of symptom onset, so the study did incorporate many early presenters.

The study authors found that of 130 patients diagnosed with AMI, 100% had an elevated HS-TN level at the time of presentation (95% confidence interval was 95.1%-100%). In other words, no patients who presented initially with a negative HS-TN level had a positive HS-TN on serial testing. The study authors suggested that this HS-TN level would obviate the need for serial testing and therefore allow early discharge of these patients from the ED. Sounds great! No more serial TN testing is needed, and we can now make dispositions after only 1 blood test and, at least slightly, decrease ED crowding. Right?

Viewpoint

Before we even begin to address the limitations associated with the study and its conclusions, let's first try to agree on a few things:

• Nothing in medicine is 100%: Nothing is 100% positive, 100% negative, or 100% accurate. Well, death is 100% certain, but not much else. Just like every other study in history that claimed 100% accuracy, subsequent attempts to validate this study will demonstrate numbers less than 100%.

• What we do in emergency medicine is not to rule in or rule out diseases, but we risk stratify everything. For example, if you see a patient with chest pain who has an ECG with ST-segment elevation in the anterior leads and ST-depression in the inferior leads, it risk stratifies that patient to a higher likelihood of AMI, but it doesn't definitely rule in AMI. In fact, the accuracy of such an ECG for AMI is only ~90%. Similarly, if a patient with chest pain has a normal ECG, it risk stratifies that patient to a lower likelihood of AMI but doesn't rule it out.

• This same concept of risk stratification applies to TN testing. A negative TN risk stratifies a patient to a lower likelihood of AMI but not to 0%. Also, a positive TN risk stratifies a patient to a higher likelihood of AMI, but not to 100%. This last point is critically important to remember: Positive TNs are markers of myocardial injury, but AMI is only one cause of myocardial injury. There are numerous other causes of positive TN: cardiac trauma, congestive heart failure, aortic valve disease, dysrhythmias (tachy- or brady-), rhabdomyolysis, pulmonary embolism, acute neurologic disease (including stroke and subarachnoid hemorrhage), inflammatory diseases of the heart (pericarditis, myocarditis), infiltrative diseases of the heart, sepsis, toxins, and so on.[1] In fact, many cardiologists already think that the current TN tests are too sensitive!

• The fact that there are so many causes of positive TNs is the exact reason why the international universal definition of AMI[1] incorporates serial TN testing rather than relying on an isolated positive TN. True atherosclerosis-related AMI produces a rise and fall of TNs, whereas the majority of other causes of positive TN do not produce this typical sequence of levels.

•It's important to remember that our mandate in the ED -- at least in the United States -- is not to simply evaluate patients for AMI. We also need to evaluate patients for acute coronary syndrome. Elevated levels of TN are helpful for diagnosing myocardial injury, but they are nearly worthless for diagnosing ischemia (ie, unstable angina). Therefore, what we currently have in TN is a test that, when positive, doesn't rule in acute coronary syndrome and when negative doesn't rule out acute coronary syndrome.

Putting history and ECG aside, let's focus on just the TN. How exactly are we supposed to use TN testing? First, it's important that we all change our mind-set such that we don't think of TNs as a test to rule in or rule out disease. They are only useful at risk stratifying the disease and making decisions that are based on that risk. If the TN is positive, you and your consulting cardiologists might consider cardiac catheterization or instead consider performing serial testing to distinguish between the typical rise of true AMI vs the "smoldering" elevation that is often seen in the other conditions. On the other hand, if the TN is negative, it simply risk stratifies patients to a lower likelihood of acute coronary syndrome (but not zero). Essentially, negative TNs indicate that a patient is now stable for a provocative test; they do not exclude acute coronary syndrome. The current national American College of Cardiology/American Heart Association (ACC/AHA)[2,3] and American College of Emergency Physicians (ACEP)[4] guidelines allow us to discontinue the ACS workup only after a negative provocative test; they do not allow us to discontinue the workup after negative TNs.

The remainder of the article can be found here: http://www.medscape.com/viewarticle/752166

9. Low yield of ED MRI for suspected epidural abscess

El Sayed M, et al. Amer J Emerg Med. 2011;978-982.

Purpose: The aim of this study was to estimate the yield of emergency department (ED) magnetic resonance imaging (MRI) in detecting spinal epidural abscess (SEA) and to identify clinical factors predicting positive MRI results.

Basic Procedure: We examined a cohort of patients who underwent MRI to rule out SEA, followed by a nested case-control comparison of those with positive results and a sample with negative results. A positive result was defined as osteomyelitis, discitis, or SEA. Predictor variables included temperature, presenting complaint, drug abuse status, history of SEA or back surgery, midline back tenderness, neurologic deficit, MRI level, mean white blood cell count, erythrocyte sedimentation rate, and C-reactive protein level.

Main Findings: Fourteen of the 120 available MRIs were excluded; 7 (6.6%) of the remaining 106 were positive. Temperature was 1.1°C higher in cases than controls (95% CI, 0.6-1.7).

Conclusion: Emergency department MRI for suspected SEA has a low yield. Clinical guidelines are needed to improve efficiency.

10. Rapid (60 mL/kg) versus standard (20 mL/kg) intravenous rehydration in paediatric gastroenteritis: pragmatic blinded randomised clinical trial

Freedman SB, et al. BMJ 2011;343:bmj.d6976

Introduction

Gastroenteritis remains a disease of major importance in public health. Although oral rehydration is appropriate for most children, many receive prolonged intravenous rehydration, which contributes to overcrowding in the emergency department. Given the safety of replacing fluid deficits over 24 hours in haemodynamically stable children, traditional teaching and the National Patient Safety Agency have advocated such an approach. Experts have noted, however, that there is a disparity between the slow restoration regimens recommended and the rapid rehydration regimens used by clinicians treating dehydration. The latter has the potential to reduce a child’s level of agitation and clinical signs of dehydration, in addition to enhancing alertness and appetite. These potential benefits might enable clinicians to achieve earlier rehydration with subsequent reductions in length of stay and costs. A review of rapid intravenous rehydration studies concluded that evidence of efficacy is lacking. Thus gastroenteritis treatment guidelines aimed at developed countries, where severe dehydration is uncommon, rarely provide a detailed rapid rehydration strategy.

Because of its potential benefits, and despite a paucity of evidence, rapid intravenous rehydration has gradually become incorporated into clinical practice9 and is recommended in a leading textbook of emergency medicine. This procedure, however, is not without risks. A recent study of fluid bolus resuscitation in febrile African children had to be stopped early because of increased mortality in the bolus group. Moreover, advocates for rapid intravenous rehydration4 suggest that serum should be routinely tested to enable the detection of severe hyponatraemia or hypernatraemia, which necessitates specific therapeutic approaches to reduce the risk of central pontine myelinolysis and cerebral oedema, respectively. As only 30% of academic paediatric emergency medicine physicians routinely check electrolytes in the United States, the widespread use of rapid intravenous rehydration might place children at unnecessary risk. Given the established safety of standard rehydration in haemodynamically stable children, the lack of evidence of benefit, and the potential complications that might arise with the widespread use of rapid intravenous rehydration, a rigorous evaluation of this more aggressive approach is needed.

We carried out a pragmatic randomised, blinded, comparative effectiveness trial among haemodynamically stable children in whom oral rehydration had failed and who were deemed to require intravenous rehydration. Our primary objective was to determine whether treatment with rapid intravenous rehydration resulted in a clinically important increase in the number of children achieving rehydration compared with standard treatment.

Abstract

Objective: To determine if rapid rather than standard intravenous rehydration results in improved hydration and clinical outcomes when administered to children with gastroenteritis.

Design: Single centre, two arm, parallel randomised pragmatic controlled trial. Blocked randomisation stratified by site. Participants, caregivers, outcome assessors, investigators, and statisticians were blinded to the treatment assignment.

Setting: Paediatric emergency department in a tertiary care centre in Toronto, Canada.

Participants: 226 children aged 3 months to 11 years; complete follow-up was obtained on 223 (99%). Eligible children were aged over 90 days, had a diagnosis of dehydration secondary to gastroenteritis, had not responded to oral rehydration, and had been prescribed intravenous rehydration. Children were excluded if they weighed less than 5 kg or more than 33 kg, required fluid restriction, had a suspected surgical condition, or had an insurmountable language barrier. Children were also excluded if they had a history of a chronic systemic disease, abdominal surgery, bilious or bloody vomit, hypotension, or hypoglycaemia or hyperglycaemia.

Interventions: Rapid (60 mL/kg) or standard (20 mL/kg) rehydration with 0.9% saline over an hour; subsequent fluids administered according to protocol.

Main outcome measures: Primary outcome: clinical rehydration, assessed with a validated scale, two hours after the start of treatment. Secondary outcomes: prolonged treatment, mean clinical dehydration scores over the four hour study period, time to discharge, repeat visits to emergency department, adequate oral intake, and physician’s comfort with discharge. Data from all randomised patients were included in an intention to treat analysis.

Results: 114 patients were randomised to rapid rehydration and 112 to standard. One child was withdrawn because of severe hyponatraemia at baseline. There was no evidence of a difference between the rapid and standard rehydration groups in the proportions of participants who were rehydrated at two hours (41/114 (36%) v 33/112 (30%); difference 6.5% (95% confidence interval −5.7% to 18.7%; P=0.32). The results did not change after adjustment for weight, baseline dehydration score, and baseline pH (odds ratio 1.8, 0.90 to 3.5; P=0.10). The rates of prolonged treatment were similar (52% rapid v 43% standard; difference 8.9%, 21% to −5%; P=0.19). Although dehydration scores were similar throughout the study period (P=0.96), the median time to discharge was longer in the rapid group (6.3 v 5.0 hours; P=0.03).

Conclusions: There are no relevant clinical benefits from the administration of rapid rather than standard intravenous rehydration to haemodynamically stable children deemed to require intravenous rehydration.

Full-text: http://www.bmj.com/content/343/bmj.d6976

11. Febrile Infants Aged 30 to 90 Days with Positive Urinalyses Require LP

Despite the authors' conclusion that lumbar puncture is not needed, this study failed to show lower risk for meningitis in febrile infants with urinary tract infections.

Paquette K et al. Pediatr Emerg Care. 2011 Nov;27(11):1057-61.

Is a lumbar puncture necessary when evaluating febrile infants (30 to 90 days of age) with an abnormal urinalysis?

OBJECTIVES: Guidelines for the management of febrile infants aged 30 to 90 days presenting to the emergency department (ED) suggest that a lumbar puncture (LP) should be performed routinely if a positive urinalysis is found during initial investigations. The aim of our study was to assess the necessity of routine LPs in infants aged 30 to 90 days presenting to the ED for a fever without source but are found to have a positive urine analysis.

METHODS: We retrospectively reviewed the records of all infants aged 30 to 90 days, presenting to the Montreal Children's Hospital ED from October 2001 to August 2005 who underwent an LP for bacterial culture, in addition to urinalysis and blood and urine cultures. Descriptive statistics and their corresponding confidence intervals were used.

RESULTS: Overall, 392 infants were identified using the microbiology laboratory database. Fifty-seven patients had an abnormal urinalysis. Of these, 1 infant (71 days old) had an Escherichia coli urinary tract infection, bacteremia, and meningitis. This patient, however, was not well on history, and the peripheral white blood cell count was low at 2.9 × 10/L. Thus, the negative predictive value of an abnormal urinalysis for meningitis was 98.2%.

CONCLUSIONS: Routine LPs are not required in infants (30-90 days) presenting to the ED with a fever and a positive urinalysis if they are considered at low risk for serious bacterial infection based on clinical and laboratory criteria. However, we recommend that judicious clinical judgment be used; in doubt, an LP should be performed before empiric antibiotic therapy is begun..

12. Standard Therapy Is Sufficient for Most Patients with Saddle PE

In this small retrospective study, most patients responded to unfractionated heparin.

Saddle pulmonary embolism: Is it as bad as it looks? A community hospital experience.

Sardi A et al. Crit Care Med. 2011 Nov;39(11):2413-8.

BACKGROUND: Saddle pulmonary embolism represents a large clot and a risk for sudden hemodynamic collapse. However, the clinical presentation and outcomes vary widely. On the basis of the findings of right heart dysfunction on echocardiograms, computed tomography angiography, or cardiac enzyme elevation, some argue for the use of thrombolytics or catheter thrombectomy even for hemodynamically stable patients.

OBJECTIVE: To investigate the outcomes and management of patients with saddle pulmonary embolism, including radiographic appearance (estimate of clot burden) and echocardiographic features.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: This study is a retrospective evaluation of all patients with computed tomography angiography positive for pulmonary embolism from June 1, 2004, to February 28, 2009. Two radiologists selected those with saddle pulmonary embolism and evaluated the clot burden score. The clinical information, echocardiography, treatments, and outcomes of these patients were extracted via chart review. Saddle pulmonary embolism was found in 37 of 680 patients (5.4%, 95% confidence interval 4% to 7%) with documented pulmonary embolism on computed tomography angiography. For patients with saddle pulmonary embolism, the median age was 60 yrs and 41% were males. Major comorbidities were neurologic (24%), recent surgery (24%), and malignancy (22%). Transient hypotension occurred in 14% and persistent shock in 8%. One patient required mechanical ventilation. Echocardiography was performed in 27 patients (73%). Right ventricle enlargement and dysfunction were found in 78% and elevated pulmonary artery systolic pressure in 67%. Computed tomography angiography demonstrated a high median pulmonary artery clot burden score of 31 points. The median right ventricle to left ventricle diameter ratio was 1.39. Inferior vena cava filters were placed in 46%. Unfractionated heparin was administered in 33 (87%) and thrombolytics in four (11%). The median hospital length of stay was 9 days. Two of 37 saddle pulmonary embolism patients (5.4%) died in the hospital (95% confidence interval 0.7% to 18%).

CONCLUSIONS: Most patients with saddle pulmonary embolism found on computed tomography angiography responded to the standard management for pulmonary embolism with unfractionated heparin. Although ominous in appearance, most patients with saddle pulmonary embolism are hemodynamically stable and do not require thrombolytic therapy or other interventions.

13. Oxygen therapy for AMI: a systematic review and meta-analysis

Burls A, et al. Emerg Med J2011;28:917-923

Oxygen (O2) is widely recommended in international guidelines for treatment of acute myocardial infarction (AMI), but there is uncertainty about its safety and benefits. A systematic review and meta-analysis were performed to determine whether inhaled O2 in AMI improves pain or the risk of death.

Cochrane CENTRAL Register of Controlled Trials, MEDLINE, MEDLINE In-Process, EMBASE, CINAHL, LILACS and PASCAL were searched from start date to February 2010. Other sources included British Library ZETOC, Web of Science, ISI Proceedings, relevant conferences, expert contacts. Randomised controlled trials of inhaled O2 versus air in patients with suspected or proven AMI of less than 24 h onset were included. Two authors independently reviewed studies to confirm inclusion criteria met, and undertook data abstraction. Quality of studies and risk of bias was assessed according to Cochrane Collaboration guidance. Main outcomes were death, pain, and complications. Measure of effect used was the RR.

Three trials (n=387 patients) were included. Pooled RR of death on O2 compared to air was 2.88 (95%CI 0.88 to 9.39) on ITT analysis and 3.03 (95%CI 0.93 to 9.83) in confirmed AMI. While suggestive of harm, this could be a chance occurrence. Pain was measured by analgesic use. Pooled RR for the use of analgesics was 0.97 (95%CI 0.78 to 1.20).

Evidence for O2 in AMI is sparse, of poor quality and pre-dates advances in reperfusion and trial methods. Evidence is suggestive of harm but lacks power and excess deaths in the O2 group could be due to chance. More research is required.

Systematic review registration number Original protocol registered with the Cochrane Collaboration. RevMan ID 848507032313175590, doi:10.1002/14651858.CD007160.

14. Images in (Emergency) Medicine

Lingual Zoster
http://www.nejm.org/doi/full/10.1056/NEJMicm1107466

Man with Rash and Nausea
http://www.annemergmed.com/article/S0196-0644(11)00352-0/fulltext

Man with Shoulder Pain after a Fall
http://www.annemergmed.com/article/S0196-0644(11)00360-X/fulltext

Unilateral Facial Swelling With Fever
http://www.annemergmed.com/article/S0196-0644(11)00716-5/fulltext

15. Chest compressions linked to physical fitness

Russo SG, et al. BMC Emerg Med 2011;11:20

Assessment of BMI and physical fitness, particularly focusing on the upper body, can predict quality of external chest compressions, with rescuers with higher BMI and greater physical fitness performing better quality external chest compressions and experiencing less fatigue.

Full-text (free): http://www.biomedcentral.com/1471-227X/11/20/abstract

16. Do Alert, Neurologically Intact Trauma Patients with Persistent Midline Tenderness and Negative CT Results Require C-Spine MRI? Maybe

Ackland HM, et al. Ann Emerg Med. 2011;58:521-530.

Study objective: We aim to determine the prevalence and factors associated with cervical discoligamentous injuries detected on magnetic resonance imaging (MRI) in acute, alert, neurologically intact trauma patients with computed tomography (CT) imaging negative for acute injury and persistent midline cervical spine tenderness. We present the cross-sectional analysis of baseline information collected as a component of a prospective observational study.

Methods: Alert, neurologically intact trauma patients presenting to a Level I trauma center with CT negative for acute injury, who underwent MRI for investigation of persistent midline cervical tenderness, were prospectively recruited. Deidentified images were assessed, and injuries were identified and graded. Outcome measures included the presence and extent of MRI-detected injury of the cervical ligaments, intervertebral discs, spinal cord and associated soft tissues.

Results: There were 178 patients recruited during a 2-year period to January 2009. Of these, 78 patients (44%) had acute cervical injury detected on MRI. There were 48 single-column injuries, 15 two-column injuries, and 5 three-column injuries. Of the remaining 10 patients, 6 had isolated posterior muscle edema, 2 had alar ligamentous edema, 1 had epidural hematoma, and 1 had atlanto-occipital edema. The injuries to 38 patients (21%) were managed clinically; 33 patients were treated in cervical collars for 2 to 12 weeks, and 5 patients (2.8%) underwent operative management, 1 of whom had delayed instability. Ordinal logistic regression revealed that factors associated with a higher number of spinal columns injured included advanced CT-detected cervical spondylosis (odds ratio [OR] 11.6; 95% confidence interval [CI] 3.9 to 34.3), minor isolated thoracolumbar fractures (OR 5.4; 95% CI 1.5 to 19.7), and multidirectional cervical spine forces (OR 2.5; 95% CI 1.2 to 5.2).

Conclusion: In patients with cervical midline tenderness and negative acute CT findings, we found that a subset of patients had MRI-detected cervical discoligamentous injuries and that advanced cervical spine degeneration evident on CT, minor thoracolumbar fracture, and multidirectional cervical spine forces were associated with increased injury extent. However, a larger study is required to validate which variables may reliably predict clinically important injury in such patients, thereby indicating the need for further radiographic assessment.

17. Using appendicitis scores in the pediatric ED

Mandeville K, et al. Amer J Emerg Med 2011:29:972-977.

Study Objective: The aims of the study were to prospectively evaluate the Alvarado and Samuel (pediatric appendicitis score [PAS]) appendicitis scoring systems in children and determine performance based on sex.

Methods: Children with abdominal pain concerning for appendicitis were recruited. Nine parameters evaluated by the scores were documented before imaging/surgery consultation. Test characteristics were calculated on all patients and by sex.

Results: Two hundred eighty-seven patients enrolled; median age was 9.8 years; and 155 (54%) were diagnosed with pathologic examination-confirmed appendicitis. Patients with appendicitis had mean PAS of 7.6, and those without had mean of 5.6 (P less than .001). Patients with appendicitis had a mean Alvarado of 7.2, and those without had a mean of 5.2 (P < .001). In appendicitis patients, PAS cutoff of 6 or greater would give 137 correct diagnoses; sensitivity, 88%; specificity, 50%; and positive predictive value (PPV), 67%. An Alvarado cutoff of 7 or greater would give 118 correct diagnoses; sensitivity, 76%; specificity, 72%; and PPV, 76%. Both performed better in males than females.

Conclusion: Regardless of sex, neither PAS nor Alvarado has adequate predictive values for sole use to diagnose appendicitis.

18. Yoga Works for Chronic Low Back Pain: A Randomized Trial

Tilbrook HE, et al. Ann Intern Med. 2011; 155;569-578.

Background: Previous studies indicate that yoga may be an effective treatment for chronic or recurrent low back pain.

Objective: To compare the effectiveness of yoga and usual care for chronic or recurrent low back pain.

Design: Parallel-group, randomized, controlled trial using computer-generated randomization conducted from April 2007 to March 2010. Outcomes were assessed by postal questionnaire. (International Standard Randomised Controlled Trial Number Register: ISRCTN 81079604)

Setting: 13 non–National Health Service premises in the United Kingdom.

Patients: 313 adults with chronic or recurrent low back pain.

Intervention: Yoga (n = 156) or usual care (n = 157). All participants received a back pain education booklet. The intervention group was offered a 12-class, gradually progressing yoga program delivered by 12 teachers over 3 months.

Measurements: Scores on the Roland–Morris Disability Questionnaire (RMDQ) at 3 (primary outcome), 6, and 12 (secondary outcomes) months; pain, pain self-efficacy, and general health measures at 3, 6, and 12 months (secondary outcomes).

Results: 93 (60%) patients offered yoga attended at least 3 of the first 6 sessions and at least 3 other sessions. The yoga group had better back function at 3, 6, and 12 months than the usual care group. The adjusted mean RMDQ score was 2.17 points (95% CI, 1.03 to 3.31 points) lower in the yoga group at 3 months, 1.48 points (CI, 0.33 to 2.62 points) lower at 6 months, and 1.57 points (CI, 0.42 to 2.71 points) lower at 12 months. The yoga and usual care groups had similar back pain and general health scores at 3, 6, and 12 months, and the yoga group had higher pain self-efficacy scores at 3 and 6 months but not at 12 months. Two of the 157 usual care participants and 12 of the 156 yoga participants reported adverse events, mostly increased pain.

Limitation: There were missing data for the primary outcome (yoga group, n = 21; usual care group, n = 18) and differential missing data (more in the yoga group) for secondary outcomes.

Conclusion: Offering a 12-week yoga program to adults with chronic or recurrent low back pain led to greater improvements in back function than did usual care.

Full-text (free): http://www.annals.org/content/155/9/569.full.pdf+html

19. CNS Events in Children with Sickle Cell Disease Presenting Acutely with HA

Hines PC, et al. J Pediatr. 2011;159:472-478

Background. The incidence of headache as a chief complaint in children with sickle cell disease (SCD) is relatively common and not too different from the incidence in healthy children. However, the higher baseline risk for intracranial pathology in patients with SCD makes evaluation of headache in this population more concerning for clinicians. The goal of this study was to use existing data to determine whether an approach could be devised that would help guide clinicians on how aggressive to be in evaluating patients with SCD and headache.

Methods. The participants were children and young adults, ages 5-21 years, with homozygous SCD who were treated in the pediatric emergency department of a single children's hospital from 2001 to 2005. All patients had a chief complaint of headache. By reviewing various inpatient, emergency department, and outpatient records, the investigators obtained clinical data about the presentation of headache including vital signs, physical exam findings, and neurologic exam findings. They also collected data on medical history such as whether a child participated in transfusion protocols, participated in hydroxyurea protocols, and had a history of seizures or central nervous system (CNS) pathology such as stroke and obtained results of any previous CNS imaging.

Findings. The investigators identified 73 patients who presented with 102 episodes of headache during the study period, with 83% of those visits being conducted in the emergency department and the remainder in an acute access hematology clinic. Headache was the exclusive complaint in 60 of the 102 visits, whereas headache was an accompanying complaint in the other 42 visits. Across all visits, 6.9% of the headache episodes were associated with new or changes in known intracranial pathology. However, only 42% of the headache visits in children with SCD prompted imaging. Therefore, the frequency of new pathology in patients with SCD with headache who received imaging was 16.3%. Children with an acute CNS event were much more likely to have a history of a stroke, a transient ischemic attack, or a seizure (40%-60%) than children who did not have CNS events (4.6%-8.5%). With respect to neurologic complaints at presentation, 40%-50% of the children with an acute CNS event had vision changes, weakness, any focal weakness, or numbness compared with only 0%-8.2% of children with no CNS events. At least 1 focal neurologic complaint was found upon presentation in 85% of the children with an acute CNS event compared with 9.5% of the children with no CNS pathology. Similarly, 85% of the children with an acute CNS event had at least 1 neurologic exam abnormality compared with only 5.3% of the children without CNS events.

The investigators concluded that a history of stroke, transient ischemic attack, or the presence of neurologic symptoms or focal neurologic findings suggest a higher risk for CNS pathology in patients with SCD and acute headache. They emphasized that 6.9% of the visits for acute headache in children with SCD were associated with evidence of acute CNS pathology compared with frequencies of 0.5% in healthy children noted in other studies.

Comment: William T. Basco, Jr., MD. Medscape Emerg Med. Posted: 11/04/2011 Full-text: http://www.medscape.com/viewarticle/752295

20. Treating primary headaches in the ED: can droperidol regain its role?

Faine B, et al. Amer J Emerg Med. 2011; in press

Objective: The aim of this study was to describe the use and efficacy of low-dose (≤2 mg) droperidol for the treatment of primary headaches (ie, migraine, cluster, tension-type headache and trigeminal autonomic cephalalgias, and other primary headaches) in the emergency department (ED).

Methods: A report was generated from a pharmacy database to identify all adult patients who received low-dose droperidol in the ED over a 7-month period; a subsequent retrospective chart review was conducted. Low-dose droperidol was defined as a cumulative dose of ≤2 mg. Patients who received droperidol for any other reason than the treatment of a headache were excluded. Data were analyzed descriptively.

Results: Seventy-three cases in which droperidol was administered for the treatment of a headache were identified over the 7-month period. Most doses (92%) administered were 1.25 mg or less. Fifty-three patients (73%) had complete resolution or significant improvement of headache symptoms as subjectively or objectively (eg, numerical pain scale) documented by the treating physician. Eight patients (11%) had minimal improvement in their headaches symptoms; 12 patients (16%) received no relief after the administration of droperidol. The average time to discharge from the ED was 94.8 ± 67.2 minutes. No cardiac arrhythmias were noted. Other adverse events included 2 cases of extrapyramidal side effects; one patient reported restlessness/anxiousness and the other patient had dystonia.

Conclusion: The administration of low-dose (≤2 mg) droperidol may be safe and effective for the treatment of primary headaches in the ED.

21. Intraosseous Bests IV Access During Out-of-Hospital Cardiac Arrest: A Randomized Controlled Trial

Reades R, et al. Ann Emerg Med. 2011;58:509-516.

Study objective; Intraosseous needle insertion during out-of-hospital cardiac arrest is rapidly replacing peripheral intravenous routes in the out-of-hospital setting. However, there are few data directly comparing the effectiveness of intraosseous needle insertions with peripheral intravenous insertions during out-of-hospital cardiac arrest. The objective of this study is to determine whether there is a difference in the frequency of first-attempt success between humeral intraosseous, tibial intraosseous, and peripheral intravenous insertions during out-of-hospital cardiac arrest.

Methods: This was a randomized trial of adult patients experiencing a nontraumatic out-of-hospital cardiac arrest in which resuscitation efforts were initiated. Patients were randomized to one of 3 routes of vascular access: tibial intraosseous, humeral intraosseous, or peripheral intravenous. Paramedics received intensive training and exposure to all 3 methods before study initiation. The primary outcome was first-attempt success, defined as secure needle position in the marrow cavity or a peripheral vein, with normal fluid flow. Needle dislodgement during resuscitation was coded as a failure to maintain vascular access.

Results: There were 182 patients enrolled, with 64 (35%) assigned to tibial intraosseous, 51 (28%) humeral intraosseous, and 67 (37%) peripheral intravenous access. Demographic characteristics were similar among patients in the 3 study arms. There were 130 (71%) patients who experienced initial vascular access success, with 17 (9%) needles becoming dislodged, for an overall frequency of first-attempt success of 113 (62%). Individuals randomized to tibial intraosseous access were more likely to experience a successful first attempt at vascular access (91%; 95% confidence interval [CI] 83% to 98%) compared with either humeral intraosseous access (51%; 95% CI 37% to 65%) or peripheral intravenous access (43%; 95% CI 31% to 55%) groups. Time to initial success was significantly shorter for individuals assigned to the tibial intraosseous access group (4.6 minutes; interquartile range 3.6 to 6.2 minutes) compared with those assigned to the humeral intraosseous access group (7.0 minutes; interquartile range 3.9 to 10.0 minutes), and neither time was significantly different from that of the peripheral intravenous access group (5.8 minutes; interquartile range 4.1 to 8.0 minutes).

Conclusion: Tibial intraosseous access was found to have the highest first-attempt success for vascular access and the most rapid time to vascular access during out-of-hospital cardiac arrest compared with peripheral intravenous and humeral intraosseous access.

22. The Captain Morgan Technique for the Reduction of the Dislocated Hip

We highlighted this article in an earlier Lit Bits. It’s now in print and available for free. See below.

Article full-text: http://www.annemergmed.com/article/S0196-0644(11)01307-2/fulltext

Video: http://www.annemergmed.com/article/S0196-0644(11)01307-2/attachment?filename=mmc1.mpg

Lit Bits: Oct 31, 2011

2011-10-31T12:11:00.000-07:00

From the recent medical literature...

1. ROSC or Death: Some EMS Systems Stop Transporting Cardiac Arrest Patients, Perform CPR at Scene, Roadside, Ambulance Bay

Joanne Kenen, Ann Emerg Med. 2011;58:A17-A19.

The patient was alert and talking as the ambulance reached the Texas hospital. In the parking lot, he went into cardiac arrest. The paramedics started an aggressive attempt to restart his heart right there. He was then brought into the emergency department (ED), where efforts to resuscitate him continued, unsuccessfully. He died.

The initial effort to save him in the parking lot took place within view of the hospital ED itself, a foolproof recipe for miscommunication, misperception, misunderstanding. Yet ultimately the experience led to greater understanding of the boundaries and barriers—and bridges—between hospital and “out-of-hospital” care, of what the ever-evolving body of evidence now suggests may often be the best option for the patient, even if it runs counter to ingrained practices.

“If you looked out the window, you didn't understand the circumstances,” said Paul Hinchey, MD, MBA, who is the medical director of emergency services for Travis County, which includes Austin, and is also an attending emergency physician at South Austin Medical Center, where the parking lot incident occurred. “They didn't understand what was going on. All they saw was the [emergency medical services] EMS crew working a cardiac arrest in the parking lot. They didn't understand the patient had literally arrested right there.”

Eventually the tensions subsided after lots of discussions not just in that hospital but also in other hospitals in the larger community. And it led to an expanding appreciation that with out-of-hospital cardiac arrest seconds—not minutes, but seconds—count. It's not about on whose turf the patient's heart stopped but about how to improve the dismal odds of restarting it. If and when a similar situation arises in Austin, Dr. Hinchey said, the paramedics would again start aggressive care on the spot, even if the spot were a parking lot near the hospital. The difference is that next time emergency physicians may well come out and join them. Dr. Hinchey added that people inside the hospital often think it takes only seconds to move a patient from ambulance into the ED, but the EMS team knows the transition usually takes minutes.

The Bay Debate

“We discussed it extensively,” Dr. Hinchey said of his colleagues in the area hospitals. They came to understand and then re-examine the invisible but not unbreachable barrier between themselves and the patient outside their doors. “The whole point of EMS advanced care is to extend out to the field. But it's OK—not only OK but essential—for doctors to be part of the process,” added Dr. Hinchey, whose city is part of the “Take Heart America” demonstration project designed to show how cardiac arrest survival rates can be improved through state-of-the-art science partnered with interdisciplinary community approaches.

“It is the cooperative care that makes the difference. The focus should always be on the patient, and their outcome based on what we know in the science,” Dr. Hinchey later said in a follow-up e-mail. “EMS can never replace emergency department care, only supplement it. If done well, everyone benefits, most importantly our patients.”

Clifton W. Callaway, MD, PhD, Associate Professor, vice chair of the Department of Emergency Medicine, University of Pittsburgh, served on the advanced cardiac life support subcommittee when the American Heart Association updated its resuscitation guidelines. Dr. Callaway, who describes himself as “aggressive” when trying to resuscitate, appreciates why it might be better for ambulance crews that find themselves in a parking lot arrest situation to get to work right then and there.

But he likes the idea of having more ED staff, including physicians when practical and appropriate, to get out there and join them. If you can't get the patient to the ED, get the ED to the patient. Enough personnel on hand may also allow the patient to be transported inside while receiving good-quality compressions en route.

Two paramedics can't try resuscitation and move the patient. But 2 paramedics plus a couple of nurses, ED techs, and a physician may be able to. “That patient wants the maximum resources brought to bear if they are going to have a chance of survival,” Dr. Callaway said. “Leaving the paramedics to manage themselves when more experienced physicians or other resources are only a few meters away is not best for the patient.”

Improvement is sorely needed. According to the American Heart Association, EMS treat about 300,000 people with out-of-hospital cardiac arrest each year. Less than 8% survive.

In recent years, protocols have changed in communities across the country; not everyone is automatically rushed to the nearest hospital. For cardiac arrest, if the patient can't be resuscitated at the scene, there's usually no sense in rushing him or her to the hospital. (Several physicians interviewed observed that the exceptions would include cardiac arrest in a trauma victim, exsanguination, metabolic abnormalities, or a situation in which emergency vehicles were ill equipped and lacking defibrillators.)

Manually performed cardiopulmonary resuscitation (CPR) while a patient is in motion just doesn't work all that well, according to some studies. And CPR in the back of a speeding ambulance is dangerous to the patient, to the emergency medical technicians (EMTs) bouncing around unbelted while precariously perched over the patient's chest, and to the pedestrians and vehicles in the ambulance's path.

“The patient is at risk, and so is everyone else,” noted Brent Myers, MD, MPH, the medical director for the Wake County EMS System, whose community has also dealt with parking lot incidents near hospitals and who is also a strong advocate of treating the patient on site.

“I’ve done a lot of CPR in the back of moving vehicles for a long time. It's virtually impossible to do it well,” said Joseph P. Ornato, MD, chairman of emergency medicine at Virginia Commonwealth University Medical Center, as well as operational medical director of Richmond Ambulance Authority. With 37 years of experience working in hospitals, ambulances, helicopters, and fixed-wing aircraft, Dr. Ornato should know. He is also cardiac cochair for the National Institutes of Health–sponsored Resuscitation Outcomes Consortium, which performs large, randomized clinical trials on out-of-hospital cardiac arrest.

The rest of the article (free): http://www.annemergmed.com/article/S0196-0644(11)01551-4/fulltext

2. Scientific Support for Adrenaline’s (Temporary) Benefit in Cardiac Arrest

Adrenaline improves chance of return of spontaneous circulation but not survival to discharge.

Adrenaline has been used to treat patients with cardiac arrest for more than half a century but has not been evaluated in a placebo-controlled clinical trial in humans. Indeed, there is concern that it might have untoward effects on myocardial function and cerebral microcirculation in postcardiac arrest patients. In the first randomized, double-blind, placebo-controlled trial of adrenaline in cardiac-arrest patients, researchers in Australia randomized 534 adults (mean age, 65; 73% men) with out-of-hospital cardiac arrest from any cause to receive 1 mL of either adrenaline 1:1000 (i.e., 1 mg) or normal saline every 3 minutes to a maximum of 10 mL. No other resuscitation drugs were given. Paramedics were allowed to use other standard methods of cardiopulmonary resuscitation, including defibrillation.

Rates of survival to hospital discharge — the primary outcome — did not differ significantly between the adrenaline and control groups (4.0% and 1.9%; odds ratio, 2.2; 95% confidence interval 0.7-6.3). Patients receiving adrenaline had significantly higher likelihood of prehospital return of spontaneous circulation (ROSC) than placebo recipients (23.5% vs. 8.4%; OR, 3.4) and of admission to the hospital from the emergency department (25.4% vs. 13.0%; OR, 2.3).

Comment: This trial should diminish persistent speculation about the advantages of adrenaline in cardiac arrest. The finding that the more-than-doubled rate of survival to hospital discharge in adrenaline recipients failed to reach statistical significance might be explained by the fact that the trial was underpowered. The effect of the significantly higher rate of prehospital ROSC in the adrenaline group might be enhanced by use of post-ROSC hypothermic therapy, which has been shown to lower mortality and improve neurological outcomes at hospital discharge and thereafter.

— John A. Marx, MD, FAAEM. Published in Journal Watch Emergency Medicine October 14, 2011. Citation: Jacobs IG et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation 2011 Sep; 82:1138.

Medline abstract (free): http://www.ncbi.nlm.nih.gov/pubmed/21745533

3. Anterior Versus Lateral Needle Decompression of Tension Pneumothorax: Comparison by CT Chest Wall Measurement

Sanchez LD, et al. Acad Emerg Med. 2011;18:1022-1026.

Objectives: Recent research describes failed needle decompression in the anterior position. It has been hypothesized that a lateral approach may be more successful. The aim of this study was to identify the optimal site for needle decompression.

Methods: A retrospective study was conducted of emergency department (ED) patients who underwent computed tomography (CT) of the chest as part of their evaluation for blunt trauma. A convenience sample of 159 patients was formed by reviewing consecutive scans of eligible patients. Six measurements from the skin surface to the pleural surface were made for each patient: anterior second intercostal space, lateral fourth intercostal space, and lateral fifth intercostal space on the left and right sides.

Results: The distance from skin to pleura at the anterior second intercostal space averaged 46.3 mm on the right and 45.2 mm on the left. The distance at the midaxillary line in the fourth intercostal space was 63.7 mm on the right and 62.1 mm on the left. In the fifth intercostal space the distance was 53.8 mm on the right and 52.9 mm on the left. The distance of the anterior approach was statistically less when compared to both intercostal spaces (p less than 0.01).

Conclusions: With commonly available angiocatheters, the lateral approach is less likely to be successful than the anterior approach. The anterior approach may fail in many patients as well. Longer angiocatheters may increase the chances of decompression, but would also carry a higher risk of damage to surrounding vital structures.

4. Screened and Examined: Placebo on the Brain

Ballard, Dustin MD. Emerg Med News. 2011;33.

I had placebo on the brain the other day. This occurred shortly after I took my morning glucosamine supplement (to ward off arthritis, of course) and right before I ordered two mg of morphine for a drug-seeking patient with chronic pain.

The principle of placebo is at work all the time in our daily and professional lives, and its power is undeniable. The medical literature has demonstrated it in dozens of studies, and the media have followed that lead. Last year, for instance, a Newsweek cover story examined the remarkable performance of the placebo arms in clinical trials evaluating new anti-depressants. (http://bit.ly/p5vsP6) Their performance was so robust that it's making it difficult for drug makers to demonstrate the superiority of their new medications over placebo.

Similarly, a recent Harvard study of asthmatics found 45 percent improvement in symptoms with a fake inhaler and 46 percent improvement with impostor acupuncture compared with 50 percent with an actual treatment (albuterol). Beyond just tricking the brain to feel better, placebo treatments seem capable of causing actual neurological and physiological changes. But the trickery has been somewhat of a sticking point for placebo. Many physicians consider using an impure placebo (a treatment with dubious physiological effect) for its psychological benefits, but would not go as far as prescribing fake pills. In fact, a survey-based study found that approximately 50 percent of U.S. doctors report using such impure treatments. I count myself among them. It was with great interest, then, that I read a recent study of patients with irritable bowel syndrome (IBS) that utilized an “open-label” placebo, a placebo treatment without deception.

In this investigation, which was led by Ted J. Kaptchuk and colleagues and published in December 2010 in PLos ONE, 80 IBS patients were given either no additional therapy or open-label placebo. This placebo treatment was described to patients as “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes.”

Both arms of the study received a counseling session from a physician and nurse that emphasized the importance of maintaining a positive mindset toward the therapy (suspending disbelief). Self-reported symptom scores were assessed at 0, 11, and 21 days. The results demonstrated significant improvements in symptom severity and relief in the placebo group at 11 and 21 days. These included an improvement in the global improvement scores of the placebo group of 5 points (vs. 3.9 for the control group, p=.002).

This study was a small one, with possible confounders such as unreliability in patient symptom reporting, but it certainly is provocative and promising. For years, physicians have struggled with placebo treatments because we've assumed that trickery was necessary for them to work. Trickery puts us in an uncomfortable position, having to choose between two ethical principles: beneficence and autonomy. But if the results of the IBS study are borne out in subsequent studies, the ramifications are tremendous. The placebo effect may not require deception at all. Perhaps it's been mischaracterized for decades. To prescribe placebo freely without the troublesome concealment component opens up a pathway for placebo treatments for many conditions: depression, asthma, chronic pain, IBS, addiction, hypertension, and more. And in the ED? Well, I see some obvious possibilities:

The Patient: Bonked Brenda who bumped her head on a kitchen cabinet last week, and today was reminded of the Natasha Richardson tragedy by a friend.

The Treatment: Trick O'Tomography. This happy-thought scanner is radiation- and risk-free! Who cares that it doesn't generate any pictures? They weren't needed to begin with.

The Patient: Snotty Scott with a touch of congestion, convinced that he has the sinusitis.

The Treatment: Placebiotics. Sweet-tasting and side effect-free, these pills help provide exactly what's needed: some harmless reassurance.

The Patient: Worried Wilma who is not happy with the past 48 hours of her life, and wants to let someone know it.

The Treatment: DeceptoTherapy. This is where your registration clerk can come in super-therapeutic. Rather than call in the psychiatrist in the middle of the night, send in someone qualified to provide the necessary treatment: a set of ears.

The Patient: Anxious Alejandro. A high-stress meeting at work has him breathing like a bunny and complaining of tingling in the hands and feet. He tells you he just can't catch his breath.

The Treatment: A dose of Ativan plus two puffs from the Placebo Pump. With this benzo/placebo cocktail, Alejandro will be ready to bolt back to the office before you can even begin to consider an alternative diagnosis.

These are, of course, tongue-in-cheek examples but perhaps not that farfetched. Could we use placebo to help with the expectant management of conditions like rule-out strep, bronchitis, and, yes, sinusitis? And could we use a simple strategy to improve mood and alleviate discomfort in certain segments of our patient population? Of course. We already do this in myriad ways.

Clearly, the physiologic possibilities for placebo have limits. We can't expect mind-over-matter to work with a bleeding limb, widely metastatic cancer, or a hardcore tweaker. In fact, a 2010 Cochrane review suggests that placebo may be ineffective beyond conditions with subjective symptoms (like pain and nausea). But in the ED, the sickest patients are not always the trickiest ones. Instead they are often the ones with subjective complaints and requests for treatment they don't need. For them, open-label placebo holds tremendous promise.

For more on Dr. Ballard, http://journals.lww.com/em-news/Fulltext/2011/10201/Screened_and_Examined__Placebo_on_the_Brain.2.aspx

5. The Public Lacks Knowledge about Automated External Defibrillators and Willingness to Use Them

In a survey of international travelers in the Netherlands, less than half could identify an AED and less than half were willing to use one.

To investigate attitudes and understanding about automated external defibrillators (AEDs) among the public, investigators conducted a cross-sectional survey of adults traveling through the Central Railway Station in Amsterdam, the Netherlands. Participants were asked a series of structured open-ended questions (e.g., did they recognize an AED, were they aware of public access AED programs, would they be willing to use an AED).

A total of 1018 individuals from 38 countries participated. When asked what they would do when first encountering a person with cardiac arrest, only 6% of respondents mentioned defibrillation or AEDs, 64% knew what a defibrillator is used for, and 43% were aware that defibrillators are often available for public access. When the interviewer pointed to an AED, only 47% of participants correctly identified it, 53% knew what an AED is used for, and 47% said they would be willing to use one.

Comment: Widespread placement of public-access AEDs is incomplete without the requisite public education or a method of ensuring ready availability of trained personnel (e.g., employees) in all locations. Both requirements are tall orders.

— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine October 7, 2011. Citation: Schober P et al. Public access defibrillation: Time to access the public. Ann Emerg Med 2011 Sep; 58:240.

6. Docs admit malpractice fears lead to overly aggressive care

Doctors admit to being part of the healthcare problem, fessing up that they provide too much medical care in a nationwide survey published in the Archives of Internal Medicine. They said malpractice concerns, current reimbursement structure, and quality measurement systems drove them to practice more aggressive healthcare.

Almost half (42 percent) of the 627 surveyed physicians said their patients "were receiving too much medical care" and another 28 percent said they had ordered more tests and made more referrals to specialists than they would like, reports the Los Angeles Times.

The doctors said fear of malpractice lawsuits (76 percent) and clinical performance measures (52 percent) were the most common drivers of their more aggressive practices. Another 40 percent don't spend enough time with their patients to figure out what's wrong, so they ordered tests and consultations to provide answers.

Eighty-three percent of the physicians said they could be sued if they didn't order a test that was indicated, whereas only 21 percent said they could be sued for ordering a test that wasn't indicated, according to the Wall Street Journal. The incentives, therefore, point toward "when in doubt, do more," says Brenda Sirovich, an author of the study and a staff physician and research associate in the Outcomes Group at the VA Medical Center in White River Junction, Vt.

The study also found that 40 percent of doctors thought other primary care physicians were driven by extra income that results from ordering more tests, although only 3 percent said financial considerations influenced their own practice style, Reuters reports.

"I'm not saying that physicians do tests in order to make money--there is a potential to be a real cynic here--but I think that the reimbursement model for most healthcare encourages utilization in a variety of ways," Sirovich said. "It's a time for us to reflect about what incentives we have built into our healthcare system, and what directions they are taking us in," she added.

Abstract: http://archinte.ama-assn.org/cgi/content/short/171/17/1582

7. Diagnostic accuracy of venous blood gas electrolytes for identifying diabetic ketoacidosis in the ED

Menchine M, Acad Emerg Med. 2011 Oct;18(10):1105-8.

Objectives: Diagnosing diabetic ketoacidosis (DKA) has traditionally required a venous blood gas (VBG) to obtain serum pH and a serum chemistry panel to obtain electrolyte values. Because newer blood gas analyzers have the ability to report electrolyte values and glucose in addition to pH, this diagnostic process could theoretically be condensed. However, neither the diagnostic accuracy of the VBG for DKA nor the agreement between the VBG electrolytes and the serum chemistry electrolytes, including sodium, chloride, and bicarbonate, has been evaluated in the context of acute hyperglycemia. The purpose of this study was to assess the accuracy of VBG electrolytes for diagnosing DKA using serum chemistry electrolytes measures as the criterion standard and to describe the correlation between VBG and serum chemistry electrolytes in a sample of hyperglycemic patients seen in the emergency department (ED).

Methods: The authors prospectively identified a convenience sample of ED patients with serum blood glucose ≥ 250 mg/dL and examined their paired VBG and serum chemistry electrolytes. The diagnosis of DKA was made by using American Diabetes Association (ADA) criteria including serum glucose ≥ 250 mg/dL, serum anion gap above 10 mEq/L, bicarbonate ≤ 18 mEq/L, serum pH ≤ 7.30, and presence of ketosis. Serum chemistry electrolyte values were considered to be the criterion standard. Diagnostic test characteristics of VBG electrolytes including sensitivity and specificity were compared against this standard. In addition, correlation coefficients for individual electrolytes and anion gap between VBG and chemistry electrolytes were calculated.

Results: Paired VBG and serum chemistry panels were available for 342 patients, of whom 46 (13.5%) had DKA. The sensitivity and specificity of the VBG electrolytes for diagnosing DKA was 97.8% (95% confidence interval [CI] = 88.5% to 99.9%) and 100% (95% CI = 98.8% to 100%), respectively. One case of DKA was missed by the VBG. Correlation coefficients between VBG and serum chemistry were 0.90, 0.73, 0.94, and 0.81 for sodium, chloride, bicarbonate, and anion gap, respectively.

Conclusions: The VBG electrolytes were 97.8% sensitive and 100% specific for the diagnosis of DKA in hyperglycemic patients. These preliminary findings support the use of VBG electrolytes in lieu of VBG along with serum chemistry analysis to rule in or rule out DKA.

8. A Decision Rule for Chest Imaging in Blunt Trauma

A combination of seven clinical criteria was 99% sensitive for detection of significant thoracic injury.

Rodriguez RM et al. J Trauma 2011 Sep; 71:549
.
BACKGROUND: To derive a decision instrument (DI) that identifies patients who have virtually no risk of significant intrathoracic injury (SITI) visible on chest radiography and, therefore, no need for chest imaging.

METHODS: This is a prospective observational study. At three Level 1 trauma centers, physicians caring for blunt trauma patients above 14 years were asked to record the presence or absence of 12 clinical criteria before viewing chest imaging results. SITI was defined as pneumothorax, hemothorax, aortic/great vessel injury, two or more rib fractures, ruptured diaphragm, sternal fracture, and pulmonary contusion on official radiograph readings. The κ (interrater reliability) and screening performance of individual criteria were determined. By using recursive partitioning, the most highly sensitive combination of criteria for SITI was derived.

RESULTS: Of the 2,628 subjects enrolled, 271 (10.3%) were diagnosed with a total of 462 SITIs, with rib fractures (73%), pneumothorax (38%), and pulmonary contusion (29%) as the most common injuries. Chest pain and chest wall tenderness had the highest sensitivity for SITI (65%). The DI of chest pain, distracting injury, chest wall tenderness, intoxication, age over 60 years, rapid deceleration, and altered alertness/mental status had the following screening performance: sensitivity 99.3% (95% confidence interval [CI], 97.4-99.8), specificity 14.0% (95% CI, 12.6-15.4), negative predictive value 99.4% (95% CI, 97.8-99.8), and positive predictive value 11.7% (95% CI, 10.5-13.1). All seven criteria in the DI met the predetermined cut off for acceptable κ (range, 0.51-0.81).

CONCLUSIONS: We derived a DI consisting of seven clinical criteria that can identify SITI in blunt trauma patients with extremely high sensitivity. If validated, this instrument will allow for safe, selective chest imaging with potential resource savings.

9. Diagnostic Blood Loss from Phlebotomy and Hospital-Acquired Anemia during AMI

Salisbury AC, et al. Arch Intern Med. 2011;171(18):1646-1653.

Background: Hospital-acquired anemia (HAA) during acute myocardial infarction (AMI) is associated with higher mortality and worse health status and often develops in the absence of recognized bleeding. The extent to which diagnostic phlebotomy, a modifiable process of care, contributes to HAA is unknown.

Methods: We studied 17 676 patients with AMI from 57 US hospitals included in a contemporary AMI database from January 1, 2000, through December 31, 2008, who were not anemic at admission but developed moderate to severe HAA (in which the hemoglobin level declined from normal to below 11 g/dL), a degree of HAA that has been shown to be prognostically important. Patients' total diagnostic blood loss was calculated by multiplying the number and types of blood tubes drawn by the standard volume for each tube type. Hierarchical modified Poisson regression was used to test the association between phlebotomy and moderate to severe HAA, after adjusting for site and potential confounders.

Results: Moderate to severe HAA developed in 3551 patients (20%). The mean (SD) phlebotomy volume was higher in patients with HAA (173.8 [139.3] mL) vs those without HAA (83.5 [52.0 mL]; P less than .001). There was significant variation in the mean diagnostic blood loss across hospitals (moderate to severe HAA: range, 119.1-246.0 mL; mild HAA or no HAA: 53.0-110.1 mL). For every 50 mL of blood drawn, the risk of moderate to severe HAA increased by 18% (relative risk [RR], 1.18; 95% confidence interval [CI], 1.13-1.22), which was only modestly attenuated after multivariable adjustment (RR, 1.15; 95% CI, 1.12-1.18).

Conclusions: Blood loss from greater use of phlebotomy is independently associated with the development of HAA. These findings suggest that HAA may be preventable by implementing strategies to limit blood loss from laboratory testing.

10. Droperidol Analgesia for Opioid-Tolerant Patients

Richards JR, et al. J Emerg Med. 2011;41:389-396.

Background: Patients with acute and chronic pain syndromes such as migraine headache, fibromyalgia, and sickle cell disease represent a significant portion of emergency department (ED) visits. Certain patients may have tolerance to opioid analgesics and often require large doses and prolonged time in the ED to achieve satisfactory pain mitigation. Droperidol is a unique drug that has been successfully used not only as an analgesic adjuvant for the past 30 years, but also for treatment of nausea/vomiting, psychosis, agitation, sedation, and vertigo.

Objectives: In this review, we examine the evidence supporting the use of droperidol for analgesia, adverse side effects, and controversial United States (US) Food and Drug Administration (FDA) black box warning.

Discussion: Droperidol has myriad pharmacologic properties that may explain its efficacy as an analgesic, including: dopamine D2 antagonist, dose-dependent GABA agonist/antagonist, α2 adrenoreceptor agonist, serotonin antagonist, histamine antagonist, muscarinic and nicotinic cholinergic antagonist, anticholinesterase activity, sodium channel blockade similar to lidocaine, and μ opiate receptor potentiation.

Conclusion: Droperidol is an important adjuvant for patients who are tolerant to opioid analgesics. The FDA black box warning does not apply to doses below 2.5mg.

11. An Algorithm for Minimizing Pelvic X-Rays in Blunt Trauma

Implementation of the algorithm reduced pelvic x-ray charges at the study institution by $207,000 over 6 months.

The current Advanced Trauma Life Support protocol recommends anteroposterior plain pelvic radiographs for blunt trauma patients. However, if patients are undergoing abdominal pelvic computed tomography (AP-CT), pelvic radiographs are less accurate and redundant. These authors developed an algorithm for obtaining pelvic radiographs and conducted a prospective observational study of its effects during a 6-month period at a single level I trauma center in California. The algorithm dictated that blunt trauma patients undergoing AP-CT would forgo pelvic radiographs unless systolic blood pressure was below 90 mm Hg, hemoglobin was below 8 mg/dL, hemoglobin fell more than 3 mg/dL in the emergency department (ED), and significant pelvic examination findings were present. The algorithm could be overridden by the attending physician.

Of 978 consecutive blunt trauma patients scheduled for AP-CT, 57 (6%) underwent pelvic radiography. Reasons for ordering radiographs were severe pelvic pain (61%), proximal fractures (25%), unexplained hypotension (9%), and hip dislocation (5%). Patients who underwent pelvic radiography were older (mean, 46 vs. 37), had higher mean Injury Severity Scores (12 vs. 7), and required more transfusions (10.5% vs. 1.6%). Pelvic radiographs changed management in two patients: One received an immediate blood transfusion despite normotension, and one had a pelvic binder placed before undergoing AP-CT. There were no complications, including hypotension in the ED, delayed administration of blood products or pelvic binder, or delay in contacting interventional radiology.

Comment: Healthcare imaging costs have risen from US$7 billion to $14 billion in 6 years in the U.S. Compared with abdominal pelvic CT scans, pelvic radiographs have a sensitivity of 55% for identifying pelvic fractures. This simple algorithm eliminated 94% of pelvic radiographs, with a projected annual reduction in charges of nearly $400,000 at a single hospital. Implementing the algorithm makes sense and saves cents.

— John A. Marx, MD, FAAEM. Published in Journal Watch Emergency Medicine October 21, 2011. Citation: Barleben A et al. Implementation of a cost-saving algorithm for pelvic radiographs in blunt trauma patients. J Trauma 2011 Sep; 71:582.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21908996

12. Blood cultures in the ED evaluation of childhood pneumonia.

Shah SS, et al. Pediatr Infect Dis J. 2011 Jun;30(6):475-9.

BACKGROUND: Blood cultures are frequently obtained in the emergency department (ED) evaluation of children with community-acquired pneumonia (CAP).

OBJECTIVES: To determine the prevalence of bacteremia in children presenting to the ED with CAP, identify subgroups at increased risk for bacteremia, and quantify the effect of positive blood cultures on management.

METHODS: This case-control study was nested within a cohort of children followed up at 35 pediatric practices. Patients from this cohort who were ≤18 years of age, evaluated in the ED in 2006-2007, and diagnosed with CAP were eligible. Cases were those with bacteremia. Controls included those with negative blood cultures and those without blood cultures performed.

RESULTS: A total of 877 (9.6%) of 9099 children with CAP were evaluated in the ED. The mean age was 3.6 years; 53% were male. Blood cultures were obtained from 291 children (33.2%). Overall, the prevalence of bacteremia was 2.1% (95% confidence interval [CI]: 0.8%-4.4%). Bacteremia occurred in 2.6% (95% CI: 1.0%-5.6%) with an infiltrate on chest radiograph and in 13.0% (95% CI: 2.8%-33.6%) with complicated pneumonia. Streptococcus pneumoniae accounted for 4 of the 6 cases of bacteremia. Blood culture results altered management in 5 of the 6 bacteremic patients; 1 had an appropriate broadening and 4 had an appropriate narrowing of coverage. The contamination rate was 1.0% (95% CI: 0.2%-3.0%).

CONCLUSION: Children presenting to the ED for evaluation of CAP are at low-risk for bacteremia. Although positive blood cultures frequently altered clinical management, the overall impact was small because of the low prevalence of bacteremia.

13. Early stroke risk and ABCD2 score performance in tissue- vs time-defined TIA: A multicenter study.

Giles MF, et al. Neurology. 2011 Sep 27;77(13):1222-8.

OBJECTIVES: Stroke risk immediately after TIA defined by time-based criteria is high, and prognostic scores (ABCD2 and ABCD3-I) have been developed to assist management. The American Stroke Association has proposed changing the criteria for the distinction between TIA and stroke from time-based to tissue-based. Research using these definitions is lacking. In a multicenter observational cohort study, we have investigated prognosis and performance of the ABCD2 score in TIA, subcategorized as tissue-positive or tissue-negative on diffusion-weighted imaging (DWI) or CT imaging according to the newly proposed criteria.

METHODS: Twelve centers provided data on ABCD2 scores, DWI or CT brain imaging, and follow-up in cohorts of patients with TIA diagnosed by time-based criteria. Stroke rates at 7 and 90 days were studied in relation to tissue-positive or tissue-negative subcategorization, according to the presence or absence of brain infarction. The predictive power of the ABCD2 score was determined using area under receiver operator characteristic curve (AUC) analyses.

RESULTS: A total of 4,574 patients were included. Among DWI patients (n = 3,206), recurrent stroke rates at 7 days were 7.1%(95% confidence interval 5.5-9.1) after tissue-positive and 0.4% (0.2-0.7) after tissue-negative events (p diff less than 0.0001). Corresponding rates in CT-imaged patients were 12.8% (9.3-17.4) and 3.0% (2.0-4.2), respectively (p diff less than 0.0001). The ABCD2 score had predictive value in tissue-positive and tissue-negative events (AUC = 0.68 [95% confidence interval 0.63-0.73] and 0.73 [0.67-0.80], respectively; p sig less than 0.0001 for both results, p diff = 0.17). Tissue-positive events with low ABCD2 scores and tissue-negative events with high ABCD2 scores had similar stroke risks, especially after a 90-day follow-up.

CONCLUSIONS: Our findings support the concept of a tissue-based definition of TIA and stroke, at least on prognostic grounds.
__________

Context: The American Stroke Association has recently proposed revising the definitions from time-based to tissue-based criteria, advocating that stroke and TIA be distinguished by the presence or absence of brain infarction identified on diffusion-weighted MRI (DWI).

Cf: Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease Stroke 2009;40:2276–2293. Full-text (free): http://stroke.ahajournals.org/content/40/6/2276.long

Albers GW, Caplan LR, Easton JD, et al. Transient ischemic attack: proposal for a new definition. N Engl J Med 2002;347:1713–1716.

14. Morbidity related to emergency endotracheal intubation--a substudy of the KETAmine SEDation trial.

Jabre P, et al. Resuscitation. 2011;82(5):517-22.

OBJECTIVES: To evaluate the association between emergency tracheal intubation difficulty and the occurrence of immediate complications and mortality, when standardised airway management is performed by emergency physicians.

METHODS: The present study was a substudy of the KETAmine SEDation (KETASED) trial, which compared morbidity and mortality after randomisation to one of two techniques for rapid sequence intubation in an emergency setting. Intubation difficulty was measured using the intubation difficulty scale (IDS) score. Complications recognised within 5 min of endotracheal intubation were recorded. We used multivariate logistic regression analysis to determine the factors associated with the occurrence of complications. Finally, a Cox proportional hazards regression model was used to examine the association of difficult intubation with survival until 28 days.

RESULTS: A total of 650 patients were included, with mean age of 55 ± 19 years. Difficult intubation (IDS above 5) was recorded in 73 (11%) patients and a total of 248 complications occurred in 192 patients (30%). Patients with at least one complication had a significantly higher median IDS score than those without any complications. The occurrence of a complication was independently associated with intubation difficulty (odds ratio 5.9; 95% confidence interval (CI) [3.5;10.1], p less than 0.0001) after adjustment on other significant factors. There was a positive linear relationship between IDS score and complication rate (R(2) = 0.83; p less than 0.001). The Cox model for 28-day mortality indicated that difficult intubation (hazard ratio 1.59; 95%CI [1.04;2.42], p = 0.03) was a significant independent predictor of death.

CONCLUSION: Difficult intubation, measured by the IDS score, is associated with increased morbidity and mortality in patients managed under emergent conditions.

15. Emergency Airway Management: A Multi-Center Report of 8937 Emergency Department Intubations

Walls RM, et al. J Emerg Med. 2011;41:347-354.

Objective: Emergency department (ED) intubation personnel and practices have changed dramatically in recent decades, but have been described only in single-center studies. We sought to better describe ED intubations by using a multi-center registry.

Methods: We established a multi-center registry and initiated surveillance of a longitudinal, prospective convenience sample of intubations at 31 EDs. Clinicians filled out a data form after each intubation. Our main outcome measures were descriptive. We characterized indications, methods, medications, success rates, intubator characteristics, and associated event rates. We report proportions with 95% confidence intervals and chi-squared testing; p-values below 0.05 were considered significant.

Results: There were 8937 encounters recorded from September 1997 to June 2002. The intubation was performed for medical emergencies in 5951 encounters (67%) and for trauma in 2337 (26%); 649 (7%) did not have a recorded mechanism or indication. Rapid sequence intubation was the initial method chosen in 6138 of 8937 intubations (69%) and in 84% of encounters that involved any intubation medication. The first method chosen was successful in 95%, and intubation was ultimately successful in 99%. Emergency physicians performed 87% of intubations and anesthesiologists 3%. Several other specialties comprised the remaining 10%. One or more associated events were reported in 779 (9%) encounters, with an average of 12 per 100 encounters. No medication errors were reported in 6138 rapid sequence intubations. Surgical airways were performed in 0.84% of all cases and 1.7% of trauma cases.

Conclusion: Emergency physicians perform the vast majority of ED intubations. ED intubation is performed more commonly for medical than traumatic indications. Rapid sequence intubation is the most common method of ED intubation.

16. The “Million Hearts” Initiative — Preventing Heart Attacks and Strokes

Frieden TR, et al. N Engl J Med 2011; 365:e27

Each year, more than 2 million Americans have a heart attack or stroke, and more than 800,000 of them die; cardiovascular disease is the leading cause of death in the United States and the largest cause of lower life expectancy among blacks. Related medical costs and productivity losses approach $450 billion annually, and inflation-adjusted direct medical costs are projected to triple over the next two decades if present trends continue.1

To reduce this burden, the Department of Health and Human Services (DHHS), other federal, state, and local government agencies, and a broad range of private-sector partners are today launching a “Million Hearts” initiative to prevent 1 million heart attacks and strokes over the next 5 years by implementing proven, effective, inexpensive interventions (see tableThe Million Hearts Initiative: Principles and Examples of Interventions.).

Cardiovascular prevention works in two realms: the clinic and the community. Clinical and community interventions each contributed about equally to the 50% reduction in U.S. mortality due to heart attacks between 1980 and 2000.2 If used consistently, proven interventions could prevent more than half of heart attacks and strokes. It's time to take the next big step.

In the clinical realm, Million Hearts will improve management of the “ABCS” — aspirin for high-risk patients, blood-pressure control, cholesterol management, and smoking cessation. As for community-based prevention, the initiative will encourage efforts to reduce smoking, improve nutrition, and reduce blood pressure. It will implement the cardiovascular-disease–prevention priorities of the National Quality and National Prevention Strategies and help in meeting targets set by Healthy People 2020.

Improving management of the ABCS can prevent more deaths than other clinical preventive services.3 Patients reduce their risk of heart attack or stroke by taking aspirin as appropriate. Treating high blood pressure and high cholesterol substantially and quickly reduces mortality among high-risk patients. Even brief smoking-cessation advice from clinicians doubles the likelihood of a successful quit attempt, and the use of medications increases quit rates further.

Currently, less than half of people with ischemic heart disease take daily aspirin or another antiplatelet agent; less than half with hypertension have it adequately controlled; only a third with hyperlipidemia have adequate treatment; and less than a quarter of smokers who try to quit get counseling or medications. As a result, more than 100 million people — half of American adults — smoke or have uncontrolled high blood pressure or cholesterol; many have more than one of these cardiovascular risk factors. Increasing utilization of these simple interventions could save more than 100,000 lives a year.3 Measuring and monitoring can encourage providers to improve preventive care.4

The remainder of the essay (free): http://www.nejm.org/doi/full/10.1056/NEJMp1110421

17. Images in (Emergency) Medicine

A Woman with Unilateral Sudden Painless Vision Loss
http://www.annemergmed.com/article/S0196-0644(11)00351-9/fulltext

Man with Back Pain
http://www.annemergmed.com/article/S0196-0644(11)00350-7/fulltext

A Refractory Wart?
http://www.annemergmed.com/article/S0196-0644(11)00484-7/fulltext

Human Papillomavirus Lesions of the Oral Cavity
http://www.nejm.org/doi/full/10.1056/NEJMicm1104783

Multiple Intracranial Tuberculomas
http://www.nejm.org/doi/full/10.1056/NEJMicm1103165

18. Most Long-Term Survivors of Out-of-Hospital Cardiac Arrest Have Positive Neurological Outcomes

Although some suffer long-term memory deficits

Long-term survival after out-of-hospital cardiac arrest (OHCA) has improved dramatically during the last several decades, due in large part to the "chain of survival" concept, which emphasizes cardiopulmonary resuscitation (CPR) and early defibrillation. In this prospective study, researchers assessed cognitive function in long-term (beyond 6 months) survivors of OHCA due to ventricular fibrillation (VF).

Of 332 patients with OHCA due to VF in one Minnesota county from 1990 to 2008, 140 patients survived to hospital discharge and 79 were alive in 2009. Of these, 47 patients (mean age, 61) agreed to participate in the study. The median time between OHCA and neurological and neuropsychological testing was 7.8 years. The median call to shock time was 5.6 minutes. Mean test results for the study population were compared to age-standardized normal population values in the same county. Overall, the study population had generally positive neurological outcomes (ability to live independently; mean Mini-Mental State Examination scores similar to standard values) and preserved cognitive ability. Patients suffered minor long-term memory deficits, but these did not affect their ability to live independently. Delayed time to defibrillation and older age at time of arrest were not independent predictors of neurological impairment.

Comment: These results reaffirm the importance of public education and the chain of survival, and they provide emergency physicians with valuable information for counseling patients and their family members.

— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine October 28, 2011. Citation: Mateen FJ et al. Long-term cognitive outcomes following out-of-hospital cardiac arrest: A population-based study. Neurology 2011 Oct 11; 77:1438.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21917772

19. Selective Use of CT Compared With Routine Whole Body Imaging in Patients with Blunt Trauma

Gupta M, et al. Ann Emerg Med. 2011;58:407-416.e15.

Study objective: Routine pan–computed tomography (CT, including of the head, neck, chest, abdomen/pelvis) has been advocated for evaluation of patients with blunt trauma based on the belief that early detection of clinically occult injuries will improve outcomes. We sought to determine whether selective imaging could decrease scan use without missing clinically important injuries.

Methods: This was a prospective observational study of 701 patients with blunt trauma at an academic trauma center. Before scanning, the most senior emergency physician and trauma surgeon independently indicated which components of pan-CT were necessary. We calculated the proportion of scans deemed unnecessary that: (a) were abnormal and resulted in a pre-defined critical action or (b) were abnormal.

Results: Pan-CT was performed in 600 of the patients; the remaining 101 underwent limited scanning. One or both physicians indicated a willingness to omit 35% of the individual scans. An abnormality was present in 18% of scans, including 22% of desired scans and 10% of undesired scans. Among the 95 patients who had one of the 102 undesired scans with abnormal results, 3 underwent a predefined critical action. There is disagreement among the authors about the clinical significance of the abnormalities found on the 99 undesired scans that did not lead to a critical action.

Conclusion: Selective scanning could reduce the number of scans, missing some injuries but few critical ones. The clinical importance of injuries missed on undesired scans was subject to individual interpretation, which varied substantially among authors. This difference of opinion serves as a microcosm of the larger debate on appropriate use of expensive medical technologies.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(11)00611-1/fulltext

20. CMS Approves 10% Medi-Cal Provider Rate Cut

State Continues to Balance the Budget on the Backs of Patients & Physicians

Today, the Centers for Medicare & Medicaid Services (CMS) approved the State of California's 10% cut to provider reimbursement through the Medi-Cal program, which was approved as part of this year's budget deal to close another multi-billion dollar deficit.

The move will most certainly result in further access-to-care problems for Medi-Cal recipients, whose primary care providers may continue their exodus from the program. Provider rate cuts over the past five years have resulted in increased ED visits by Medi-Cal recipients - double digits in some counties - according to data compiled by California ACEP from the Office of Statewide Health Planning & Development.

California ACEP will explore all possible avenues to reverse this short-sighted move which is likely to further erode physician participation and faith in Medi-Cal, while exacerbating ED over-crowding in California.

21. CDC’s (!) Preparedness 101: Zombie Apocalypse

There are all kinds of emergencies out there that we can prepare for. Take a zombie apocalypse for example. That’s right, I said z-o-m-b-i-e a-p-o-c-a-l-y-p-s-e. You may laugh now, but when it happens you’ll be happy you read this, and hey, maybe you’ll even learn a thing or two about how to prepare for a real emergency.

A Brief History of Zombies
We’ve all seen at least one movie about flesh-eating zombies taking over (my personal favorite is Resident Evil), but where do zombies come from and why do they love eating brains so much? The word zombie comes from Haitian and New Orleans voodoo origins. Although its meaning has changed slightly over the years, it refers to a human corpse mysteriously reanimated to serve the undead. Through ancient voodoo and folk-lore traditions, shows like the Walking Dead were born.

In movies, shows, and literature, zombies are often depicted as being created by an infectious virus, which is passed on via bites and contact with bodily fluids. Harvard psychiatrist Steven Scholzman wrote a (fictional) medical paper on the zombies presented in Night of the Living Dead and refers to the condition as Ataxic Neurodegenerative Satiety Deficiency Syndrome caused by an infectious agent. The Zombie Survival Guide identifies the cause of zombies as a virus called solanum. Other zombie origins shown in films include radiation from a destroyed NASA Venus probe (as in Night of the Living Dead), as well as mutations of existing conditions such as prions, mad-cow disease, measles and rabies.

The rise of zombies in pop culture has given credence to the idea that a zombie apocalypse could happen. In such a scenario zombies would take over entire countries, roaming city streets eating anything living that got in their way. The proliferation of this idea has led many people to wonder “How do I prepare for a zombie apocalypse?”

Well, we’re here to answer that question for you, and hopefully share a few tips about preparing for real emergencies too!

Full-text (free) at the CDC: http://emergency.cdc.gov/socialmedia/zombies_blog.asp

Lit Bits: Oct 7, 2011

2011-10-07T06:14:00.000-07:00

From the recent medical literature...

1. Outcomes of patients undergoing early sepsis resuscitation for cryptic shock compared with overt shock.

Puskarich MA, et al. Resuscitation. 2011 Jun 23. [Epub ahead of print]

INTRODUCTION: We sought to compare the outcomes of patients with cryptic versus overt shock treated with an emergency department (ED) based early sepsis resuscitation protocol.

METHODS: Pre-planned secondary analysis of a large, multicenter ED-based randomized controlled trial of early sepsis resuscitation. All subjects were treated with a quantitative resuscitation protocol in the ED targeting 3 physiological variables: central venous pressure, mean arterial pressure and either central venous oxygen saturation or lactate clearance. The study protocol was continued until all endpoints were achieved or a maximum of 6h. Outcomes data of patients who were enrolled with a lactate ≥4mmol/L and normotension (cryptic shock) were compared to those enrolled with sustained hypotension after fluid challenge (overt shock). The primary outcome was in-hospital mortality.

RESULTS: A total of 300 subjects were enrolled, 53 in the cryptic shock group and 247 in the overt shock group. The demographics and baseline characteristics were similar between the groups. The primary endpoint of in-hospital mortality was observed in 11/53 (20%, 95% CI 11-34) in the cryptic shock group and 48/247 (19%, 95% CI 15-25) in the overt shock group, difference of 1% (95% CI -10 to 14; log rank test p=0.81).

CONCLUSION: Severe sepsis with cryptic shock carries a mortality rate not significantly different from that of overt septic shock. These data suggest the need for early aggressive screening for and treatment of patients with an elevated serum lactate in the absence of hypotension.

2. Mandatory Triage Delays Care for High-Acuity Patients

Triage was not completed within the recommended 10 minutes in more than half of high-acuity patients at a single emergency department.

Emergency physicians and nurses rely on triage to sort patients who can wait for care from those who cannot, yet mandatory triage consumes valuable nursing resources and might impede rapid access to care. In a retrospective chart review of all ambulatory patients who presented to a single U.S. academic emergency department (ED) during 2008, researchers assessed compliance with the 5-level Emergency Severity Index (ESI) triage system recommendation that all high-acuity patients (ESI 1 or 2) be treated by a physician within 10 minutes of presentation.

Among 3932 high-acuity ambulatory ED patients (63 ESI 1 and 3869 ESI 2), median time from arrival to completion of triage was 12.3 minutes (range, 0–128 minutes). Triage was completed within 10 minutes in 41% of patients, took more than 20 minutes in 25%, and took more than 30 minutes in 10%. For ESI 2 patients, triage times were significantly longer when presentation was during peak arrival time (10:00 AM to 10:00 PM).

Comment: Although practice should not change on the basis of this small, single-site study, elimination of triage should be strongly considered as part of efforts to decrease unnecessary wait times and to streamline emergency care.

— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine September 16, 2011. Citation: Weber EJ et al. Mandatory triage does not identify high-acuity patients within recommended time frames. Ann Emerg Med 2011 Aug; 58:137.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21514968

3. Validation of the Simplified Motor Score in the Out-of-Hospital Setting for the Prediction of Outcomes after Traumatic Brain Injury

Thompson DO, et al. Ann Emerg Med. 2011; in press.

Study objective: The Glasgow Coma Scale (GCS) score is widely used to assess patients with head injury but has been criticized for its complexity and poor interrater reliability. A 3-point Simplified Motor Score (SMS) (defined as obeys commands=2, localizes pain=1, and withdraws to pain or worse=0) was created to address these limitations. Our goal is to validate the SMS in the out-of-hospital setting, with the hypothesis that it is equivalent to the GCS score for discriminating brain injury outcomes.

Methods: This was a secondary analysis of an urban Level I trauma registry. Four outcomes and their composite were studied: emergency tracheal intubation, clinically meaningful brain injury, need for neurosurgical intervention, and mortality. The out-of-hospital GCS score and SMS were evaluated by comparing areas under the receiver operating characteristic curve with a paired nonparametric approach. Multiple imputation was used for missing data. A clinically significant difference in areas under the receiver operating characteristic curve was defined as greater than or equal to 0.05, according to previous literature.

Results: We included 19,408 patients, of whom 18% were tracheally intubated, 18% had brain injuries, 8% required neurosurgical intervention, and 6% died. The difference between the area under the receiver operating characteristic curve for the out-of-hospital GCS score and SMS was 0.05 (95% confidence interval [CI] −0.01 to 0.11) for emergency tracheal intubation, 0.05 (95% CI 0 to 0.09) for brain injury, 0.04 (95% CI −0.01 to 0.09) for neurosurgical intervention, 0.08 (95% CI 0.02 to 0.15) for mortality, and 0.05 (95% CI 0 to 0.10) for the composite outcome.

Conclusion: In this external validation, SMS was similar to the GCS score for predicting outcomes in traumatic brain injury in the out-of-hospital setting.

Accompanying Editorial

Steve Green. Cheerio, Laddie! Bidding Farewell to the Glasgow Coma Scale. Ann Emerg Med. 2011; in press

It is time to abandon the Glasgow Coma Scale (GCS). As discussed below, this ubiquitous neurologic scoring system is confusing, unreliable, and unnecessarily complex, and its manner of common clinical use is statistically unsound.

Teasdale and Jennett devised the GCS in 1974 not for acute care, but rather for the “repeated bedside assessment” in a neurosurgical unit to detect “changing states” of consciousness and to measure the “duration of coma.”1 They never intended for its elements to be assigned numeric scores or for its 3 subscales to be merged or totaled. Yet, despite their objections2 both such dubious modifications subsequently proved irresistible to the medical community.

The quantitative GCS subsequently has become the undisputed universal criterion standard for mental status assessment and is thus a fundamental part of the culture of emergency medicine, out-of-hospital care, trauma surgery, and neurosurgery.3-7 This scale is a core component of prominent trauma and life support courses,4-7 and in most of the developed world out-of-hospital care providers routinely assess the GCS for each patient with trauma or altered mental status.3-5 The original GCS article has been cited almost 6,000 times.

This editorial outlines the potent limitations of the GCS and why it should now be considered obsolete within acute care medicine. This scale might be useful, however, for detecting subtle neurologic changes over time in an ICU (as originally envisaged). Curiously, though, it has never been validated for this separate role.

PROBLEMS WITH THE GCS
The advantages of the GCS are that it has face validity, wide acceptance, and established statistical associations with adverse neurologic outcomes, including brain injury, neurosurgical intervention, and mortality.3,8,9 However, these are offset by several important limitations.

The GCS isn’t reliable. To be accurate and useful, a clinical scale must be reproducible. Unfortunately, the GCS contains multiple subjective elements (Figure) and has repeatedly demonstrated surprisingly low interrater reliability in a variety of settings.3,10-18

The remainder of the essay (subscription required): http://www.annemergmed.com/article/S0196-0644(11)00655-X/fulltext

4. Reperfusion Paradox in STEMI

Armstrong PW, et al. Ann Intern Med. 2011;155:389-391.

The current treatment paradigm for STEMI asserts superior reperfusion with primary percutaneous coronary intervention (PPCI) over fibrinolysis. However, most patients present to non-PPCI hospitals, and many end up not receiving the benefit of pharmacologic reperfusion. This article describes the treatment paradox in which efforts to promote PPCI for acute STEMI often lead to unnecessary avoidance and delay in the use of fibrinolysis. The authors believe that clinicians should embrace an integrated dual reperfusion strategy.

Abstract: http://www.annals.org/content/155/6/389.abstract

5. A Randomized Clinical Trial Comparing Oral, Aerosolized Intranasal, and Aerosolized Buccal Midazolam

Klein EJ, et al. Ann Emerg Med. 2011;58:323-329.

Study objective: We determine whether aerosolized intranasal or buccal midazolam reduces the distress of pediatric laceration repair compared with oral midazolam.

Methods: Children aged 0.5 to 7 years and needing nonparenteral sedation for laceration repair were randomized to receive oral, aerosolized intranasal, or aerosolized buccal midazolam. Patient distress was rated by blinded review of videotapes, using the Children's Hospital of Eastern Ontario Pain Score. Secondary outcomes included activity scores, sedation adequacy, sedation onset, satisfaction, and adverse events.

Results: For the 169 subjects (median age 3.1 years) evaluated for the primary outcome, we found significantly less distress in the buccal midazolam group compared with the oral route group (P=.04; difference −2; 95% confidence interval −4 to 0) and a corresponding nonsignificant trend for the intranasal route (P=.08; difference −1; 95% confidence interval −3 to 1). Secondary outcomes (177 subjects) favored the intranasal group, including a greater proportion of patients with an optimal activity score (74%), a greater proportion of parents wanting this sedation in the future, and faster sedation onset. Intranasal was the route least tolerated at administration. Adverse events were similar between groups.

Conclusion: When comparing the administration of midazolam by 3 routes to facilitate pediatric laceration repair, we observed slightly less distress in the aerosolized buccal group. The intranasal route demonstrated a greater proportion of patients with optimal activity scores, greater proportions of parents wanting similar sedation in the future, and faster onset but was also the most poorly tolerated at administration. Aerosolized buccal or intranasal midazolam represents an effective and useful alternative to oral midazolam for sedation for laceration repair.

6. Zofran Can Cause Dysrythmias? Darn!

From EP Monthly White Coat Blog September 2011. http://www.epmonthly.com/whitecoat/

FDA: Zofran May Be DEADLY. Get ready for a “black box” warning on Zofran.

The FDA has just issued a “safety alert” stating that Zofran may now be potentially deadly.

Link: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm272041.htm

The FDA is now recommending ECG monitoring in patients who receive Zofran who have potential “electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia), congestive heart failure, bradyarrhythmias, or in patients taking other medications that can lead to QT prolongation.”

After all, Zofran has now gone generic like previous anti-nausea medications that have also received black box warnings. The FDA approved Zofran for use in 1991, meaning that Zofran has been on the market for twenty years.

Now, through diligent research, the FDA has decided that that Zofran may cause QT prolongation — just like most of the other anti-nausea medications. Cf. http://www.epmonthly.com/whitecoat/2009/03/warning-labels-just-dont-puke/

As a result, GlaxoSmithKline has been ordered to perform studies to determine whether Zofran could prolong QT intervals, and, if so, to what extent.

Since the FDA states that it has been performing “ongoing safety studies” … for the past twenty years … why doesn’t the FDA actually publish the results of those safety studies that led to the posting of its alarming “safety notice”?

Now we have one less medication in our armamentarium to treat nausea and vomiting. I suppose we can always give ginger root until that gets a black box warning, too. It’s only been around for a few centuries.

Whoa. I think that my heart just skipped a beat. Reading FDA safety notices may have caused me to have QT prolongation. I think that we need to put black box warnings on FDA safety notices and no one should read them without proper EKG monitoring.

[Speaking of nausea, have you heard of the Barf Scale? Some call it the eighth vital sign…]

7. Development and validation of a pictorial nausea rating scale for children.

Baxter AL, et al. Pediatrics. 2011;127(6):e1542-9.

Laurie Barclay, MD. Medscape News. June 1, 2011 — A pictorial scale to measure the severity of pediatric nausea can detect change after treatment, according to the results of a study reported in the June issue of Pediatrics.

"A simple, reliable, validated pictorial scale for measuring nausea in children may help in its management," write Amy L. Baxter, MD, from Medical College of Georgia and Pediatric Emergency Medicine Associates in Atlanta, and colleagues. "Current pictorial scales for nausea have limited construct and convergent validity and may lack specificity in the presence of pain.... The goal of this study was to create and validate a pictorial scale with regular incremental levels between scores depicting increasing nausea intensity."

A total of 30 oncology patients and 15 nurses developed the Baxter Retching Faces (BARF) scale, a pictorial nausea scale with 6 faces scored from 0 to 10. The BARF scale was validated in 52 emergency department patients with vomiting and in 75 healthy patients undergoing day surgery procedures (age range, 7 - 18 years). Patients were presented with visual analog scales (VAS) for nausea and pain, the pictorial Faces Pain Scale–Revised (FPS-R), and the BARF scale. Patients receiving opioid analgesics or antiemetic medications were evaluated for pain and nausea before treatment and 30 minutes after treatment. Spearman ρ correlation coefficients were calculated, and a Wilcoxon matched-pair rank test was used to compare pain and nausea scores before and after antiemetic medications were received.

The Spearman ρ correlation coefficient was 0.93 for the first paired BARF and VAS for nausea scores. Patients requiring antiemetic medications had significantly higher VAS scores for nausea and BARF scores (P = .20), and these scores decreased significantly after treatment. In contrast, posttreatment pain scores (P = .47) did not decrease in patients receiving only antiemetic medications.

"We describe the development of a pictorial scale with beginning evidence of construct validity for a self-report assessment of the severity of pediatric nausea," the study authors write. "The scale had convergent and discriminant validity, along with an ability to detect change after treatment.... Its use in the clinical and research setting may assist in nausea management in children."

Limitations of this study include those involving use of the VAS as a comparator for pediatric nausea. In addition, the study was limited to a 2-center, single-country, English-speaking population.

"Future studies need to be performed to determine if there are age, gender, culture, ethnic, or language variations in the validation of the BARF scale," the study authors conclude. "Patient preferences of the BARF scale compared with the VAS or a global rating of change need to be determined, along with the minimum clinically important difference in BARF scores."

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21624874

8. Mandatory HPV Vaccination and Political Debate

Lawrence O. Gostin, JD. JAMA. Published online October 6, 2011.

Vaccinations are among the most cost-effective and widely used public health interventions but have provoked popular resistance, with compulsory vaccination framed as an unwarranted state interference. When the US Food and Drug Administration (FDA) approved a human papillomavirus (HPV) vaccine in 2006, conservative religious groups strongly opposed a mandate, arguing it would condone premarital sex and undermine parental rights. Yet Governor Rick Perry signed an executive order in 2007 making Texas the first state to enact a mandate—later revoked by the state legislature.

Mandatory HPV vaccination received additional attention during a recent debate among Republican presidential candidates. Michele Bachmann, US representative from Minnesota, Rick Santorum, former US senator from Pennsylvania, and Governor Perry had spirited exchanges about the executive order that Perry issued in 2007. Bachmann called the vaccine “a dangerous drug” and Santorum added, “There is no government purpose served for having little girls inoculated at the force and compulsion of the government.” Perry almost immediately disavowed his action, saying first that the vehicle of an executive order was wrong and then that vaccination should be “opt-in.”1

Comments such as these could cause parents to decide not to have their children vaccinated, thereby potentially leading to preventable illness and perhaps even death. The scientific evidence demonstrates that population-based HPV vaccination is safe and effective, justifying widespread adoption of the vaccine. The question is whether a state mandate would increase vaccination rates or result in a backlash not only against HPV vaccination but also wider childhood vaccinations. Given the political divisiveness, states should launch health education campaigns before resorting to compulsion.

HPV Vaccine Effectiveness and Safety

Human papillomavirus infection and HPV-associated cancers pose a major public health threat. Human papillomavirus is the most common sexually transmitted infection in the United States, with an estimated 20 million individuals currently infected and 6.2 million newly infected annually.2 The HPV prevalence among girls and women is 26.8% overall, with increasing prevalence each year from ages 14 to 24 years (44.8% for ages 20-24 years), followed by a gradual decline through age 59 years; high-risk HPV types are detected in only 3.4% of women tested.2

Nononcogenic HPV types 6 and 11 are associated with genital warts and recurrent respiratory papillomatosis. High-risk HPV types are detected in virtually all cervical, vaginal, and vulvar cancers in women, and HPV types 16 and 18 are associated with 70% of cervical cancers. Each year, more than 12 000 new cervical cancer cases are diagnosed in the United States, with more than 4000 deaths from cervical cancer occurring annually.3 Human papillomavirus also is associated with cancer of the penis, as well as cancers of the oropharynx and anus in both women and men. Persons with lower education and higher poverty experience disproportionate burdens of HPV-associated cancers.

In June 2006, the FDA licensed a prophylactic quadrivalent HPV vaccine against HPV types 6, 11, 16, and 18 for use among girls and women aged 9 to 26 years.4 In October 2009, the FDA approved a bivalent vaccine against HPV types 16 and 18.5 The Advisory Committee on Immunization Practices (ACIP) recommends routine quadrivalent or bivalent vaccination of girls aged 11 or 12 years with 3 doses that can start at age 9 years. The ACIP recommends “catch-up” vaccination for girls and women aged 13 to 26 years who have not been previously vaccinated. Quadrivalent HPV vaccine may be given to boys and men aged 9 to 26 years.6 Ideally, vaccination should begin before sexual activity.

Numerous public health organizations including the Centers for Disease Control and Prevention, the American Academy of Pediatrics, and the American Academy of Family Physicians endorse HPV vaccination for young women…

The remainder of the essay (full-text free): http://jama.ama-assn.org/content/early/2011/09/28/jama.2011.1525.full

9. Apixaban versus Warfarin in Patients with Atrial Fibrillation

Granger CB, et al. N Engl J Med 2011; 365:981-992

Background: Vitamin K antagonists are highly effective in preventing stroke in patients with atrial fibrillation but have several limitations. Apixaban is a novel oral direct factor Xa inhibitor that has been shown to reduce the risk of stroke in a similar population in comparison with aspirin.

Methods: In this randomized, double-blind trial, we compared apixaban (at a dose of 5 mg twice daily) with warfarin (target international normalized ratio, 2.0 to 3.0) in 18,201 patients with atrial fibrillation and at least one additional risk factor for stroke. The primary outcome was ischemic or hemorrhagic stroke or systemic embolism. The trial was designed to test for noninferiority, with key secondary objectives of testing for superiority with respect to the primary outcome and to the rates of major bleeding and death from any cause.

Results: The median duration of follow-up was 1.8 years. The rate of the primary outcome was 1.27% per year in the apixaban group, as compared with 1.60% per year in the warfarin group (hazard ratio with apixaban, 0.79; 95% confidence interval [CI], 0.66 to 0.95; P less than 0.001 for noninferiority; P=0.01 for superiority). The rate of major bleeding was 2.13% per year in the apixaban group, as compared with 3.09% per year in the warfarin group (hazard ratio, 0.69; 95% CI, 0.60 to 0.80; P less than 0.001), and the rates of death from any cause were 3.52% and 3.94%, respectively (hazard ratio, 0.89; 95% CI, 0.80 to 0.99; P=0.047). The rate of hemorrhagic stroke was 0.24% per year in the apixaban group, as compared with 0.47% per year in the warfarin group (hazard ratio, 0.51; 95% CI, 0.35 to 0.75; P less than 0.001), and the rate of ischemic or uncertain type of stroke was 0.97% per year in the apixaban group and 1.05% per year in the warfarin group (hazard ratio, 0.92; 95% CI, 0.74 to 1.13; P=0.42).

Conclusions: In patients with atrial fibrillation, apixaban was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding, and resulted in lower mortality

10. Rapid Rehydration in the ED Effective for Children

Tinker Ready and Jacqueline A. Hart, MD. September 26, 2011 — A 4-hour rehydration technique for children with gastroenteritis worked just as well as a 24-hour inpatient approach, according to a study published online September 26 in Pediatrics.

Researchers at the Royal Children's Hospital in Melbourne, Australia, led by Colin V.E. Powell, MD, FRACP, FRCPCH, screened more than 9000 children with acute gastroenteritis who arrived at 2 metropolitan teaching pediatric hospital emergency departments (EDs). Of the children screened, who ranged in age from 6 months to 6 years, 254 were randomly assigned to receive either standard nasogastric rehydration over the course of 24 hours in the hospital (n = 122) or treatment with rapid nasogastric rehydration (RNR) over the course of 4 hours in the ED (n = 132).

The researchers defined viral gastroenteritis as the sudden onset of nonbloody diarrhea with 2 loose stools in a 24-hour period, with or without vomiting, and lasting for a full week. Only children with moderate dehydration were included in the study.

Primary failure rates, defined as more than 2% weight loss during the rehydration period, were similar for RNR (11.8%; 95% confidence interval [CI], 6.0% - 17.6%) and standard nasogastric rehydration (9.2%; 95% CI, 3.7% - 14.7%; P = .52). Secondary treatment failure, defined as the inability to tolerate a nasogastric tube, frequent or persistent vomiting, need for intravenous rehydration, 3 clinical signs of continued moderate dehydration, a need for nasogastric fluids beyond 24 hours in the standard group, or impending circulatory collapse, was more common in the standard treatment group (44%; 95% CI, 34.6% - 53.4%) than in the RNR group (30.3%; 95% CI, 22.5% - 38.8%; P = .03).

Despite RNR, 22.7% of those treated in the ED were admitted to the hospital, and 7.6% were readmitted to the hospital within 24 hours.

"Primary treatment failure and clinical outcomes were similar for RNR and [standard nasogastric rehydration]," the authors concluded. "Although RNR generally reduced the need for hospitalization, discharge home from the ED failed for approximately one-fourth of the patients."

All of the children recovered without complications. The researchers note that although the sample size was too small for a noninferiority analysis, the findings did suggest that RNR in the ED offers "a useful alternative to 24-hour nasogastric rehydration in the inpatient setting."

The study has several additional limitations, including lack of blinding and that only the rehydration schedule was controlled; the remainder of the clinical decisions were left to the treating medical team.

Compared with intravenous rehydration, oral rehydration therapy is less likely to result in complications such as electrolyte imbalances, cerebral edema, or phlebitis, the researchers write. "Therefore, [oral rehydration therapy] is recommended as the treatment of choice for children with acute gastroenteritis and moderate dehydration."

They researchers point out that "[s]ince the introduction of a rotavirus vaccine, rates of hospitalization for treatment of acute gastroenteritis have decreased in many developed countries." However, in the developing world, "dehydration secondary to viral gastroenteritis remains a major cause of morbidity and death."

The study was supported by a clinical research grant from the Department of Human Services, Government of Victoria, Australia. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online September 26, 2011. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21949149

11. Mortality Does Not Increase with Time from Shock Diagnosis to Antibiotic Administration

But, patients who received antibiotics before shock criteria developed fared better than those who received them after.

Puskarich MA, et al. Crit Care Med. 2011 Sep;39(9):2066-2071.

OBJECTIVE: We sought to determine the association between time to initial antibiotics and mortality of patients with septic shock treated with an emergency department-based early resuscitation protocol.

DESIGN: Preplanned analysis of a multicenter randomized controlled trial of early sepsis resuscitation.

SETTING: Three urban U.S. emergency departments.

PATIENTS: Adult patients with septic shock.

INTERVENTIONS: A quantitative resuscitation protocol in the emergency department targeting three physiological variables: central venous pressure, mean arterial pressure, and either central venous oxygen saturation or lactate clearance. The study protocol was continued until all end points were achieved or a maximum of 6 hrs.

MEASUREMENTS AND MAIN RESULTS: Data on patients who received an initial dose of antibiotics after presentation to the emergency department were categorized based on both time from triage and time from shock recognition to initiation of antibiotics. The primary outcome was inhospital mortality. Of 291 included patients, mortality did not change with hourly delays in antibiotic administration up to 6 hrs after triage: 1 hr (odds ratio [OR], 1.2; 0.6-2.5), 2 hrs (OR, 0.71; 0.4-1.3), 3 hrs (OR, 0.59; 0.3-1.3). Mortality was significantly increased in patients who received initial antibiotics after shock recognition (n = 172 [59%]) compared with before shock recognition (OR, 2.4; 1.1-4.5); however, among patients who received antibiotics after shock recognition, mortality did not change with hourly delays in antibiotic administration.

CONCLUSION: In this large, prospective study of emergency department patients with septic shock, we found no increase in mortality with each hour delay to administration of antibiotics after triage. However, delay in antibiotics until after shock recognition was associated with increased mortality.

12. Do Mechanism-of-Injury Triage Criteria Predict Need for Trauma Center?

Some currently used criteria, including vehicle rollover and motor vehicle crash speed over 40 mph, are poor predictors.

Only anatomical and physiological criteria are validated indications for transport to a trauma center, but many systems also use mechanism of injury (MOI) criteria, which are largely based on expert consensus opinion. In a prospective observational 2-year study, investigators assessed the predictive value of MOI criteria in a convenience sample of 9483 adults who presented to three level I regional trauma centers directly from the scene of injury and who did not meet physiological or anatomical criteria. The trauma centers were primary receiving centers for patients with traumatic injuries, regardless of whether they met criteria for trauma-center transport.

Of 2363 patients who were transported to a trauma center on the basis of MOI criteria, 204 (9%) were considered in retrospect to need a trauma center (defined as nonorthopedic surgery within 24 hours, intensive care unit admission, or in-hospital death). Of the 7120 patients who did not meet MOI criteria, 310 (4%) were considered to need a trauma center. Death of another vehicle occupant, fall greater than 20 feet, and motor vehicle crash (MVC) extrication time above 20 minutes were good predictors of need for trauma center (positive likelihood ratio over 5); intrusion beyond 12 inches, ejection from a vehicle, and vehicle deformity more than 20 inches were moderate predictors (LRs 2–5); and MVC at greater than 40 mph, motorcycle crash at greater than 20 mph, vehicle rollover, rider separated from motorcycle, and pedestrian or bicyclist thrown, run over, or struck at speed above 5 mph were poor predictors of need for trauma center (LR 2).

Comment: Use of mechanism-of-injury criteria alone results in dramatic overtriage to trauma centers. Systems should rely on validated physiological and anatomical criteria to determine transport destination for trauma patients. For patients who do not meet physiological or anatomical criteria, death of another vehicle occupant, fall more than 20 feet, and extrication time greater than 20 minutes might predict need for trauma center.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine September 23, 2011. Citation: Lerner EB et al. Does mechanism of injury predict trauma center need? Prehosp Emerg Care 2011 Oct/Dec; 15:518.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21870946

13. Synopsis of the NIH and Clinical Excellence Guideline for Management of Transient Loss of Consciousness

Cooper PN, et al. Ann Intern Med. 2011; published online September 19, 2011

Description: Transient loss of consciousness (TLoC) is common and often leads to incorrect diagnosis, unnecessary investigation, or inappropriate choice of specialist referral. In August 2010, the National Institute for Health and Clinical Excellence published a guideline that addressed the initial assessment of and most appropriate specialist referral for persons who have experienced TLoC. The guideline focused on correct diagnosis and relevant specialist referral and did not make treatment recommendations. This synopsis describes the principal recommendations concerning assessment and referral of a patient with TLoC.

Methods: The National Clinical Guideline Centre developed the guidelines by using the standard methodology of the National Institute for Health and Clinical Excellence. A multidisciplinary guideline panel generated review questions, discussed evidence, and formulated recommendations. The panel included a technical team from the National Clinical Guideline Centre, who reviewed and graded all relevant evidence identified from literature searches published in English up to November 2009 and performed health-economic modeling. Both guideline development and final modifications were informed by comments from stakeholders and the public.

Recommendations: The panel made clear recommendations regarding the assessment of a person after TLoC, which emphasized the importance of clinical reasoning in diagnosis. Persons with uncomplicated faint, situational syncope, or orthostatic hypotension should receive electrocardiography but do not otherwise require immediate further investigation or specialist referral. Persons with features that suggest epilepsy should be referred for specialist neurologic assessment; brief seizure activity was recognized as a common occurrence during syncope that should not be regarded as indicating epilepsy. Persons with a suspected cardiac cause for TLoC or in whom TLoC is unexplained after initial assessment should receive specialist cardiovascular assessment. Guidance was provided on the appropriate choices of cardiovascular investigation, according to the presenting clinical circumstances.

Full-text (free): http://www.annals.org/content/early/2011/09/16/0003-4819-155-8-201110180-00368.full

The full version of the guideline is available on the NICE Web site at http://guidance.nice.org.uk/CG109/guidance/pdf

14. Clinical Decision Rules for Excluding PE: A Meta-analysis

Lucassen W, et al. Ann Intern Med. 2011;155:448-460.

Background: Clinical probability assessment is combined with d-dimer testing to exclude pulmonary embolism (PE).

Purpose: To compare the test characteristics of gestalt (a physician's unstructured estimate) and clinical decision rules for evaluating adults with suspected PE and assess the failure rate of gestalt and rules when used in combination with d-dimer testing.

Data Sources: Articles in MEDLINE and EMBASE in English, French, German, Italian, Spanish, or Dutch that were published between 1966 and June 2011.

Study Selection: 3 reviewers, working in pairs, selected prospective studies in consecutive patients suspected of having PE. Studies had to estimate the probability of PE by using gestalt or a decision rule and verify the diagnosis by using an appropriate reference standard.

Data Extraction: Data on study characteristics, test performance, and prevalence were extracted. Reviewers constructed 2 × 2 tables and assessed the methodological quality of the studies.

Data Synthesis: 52 studies, comprising 55 268 patients, were selected. Meta-analysis was performed on studies that used gestalt (15 studies; sensitivity, 0.85; specificity, 0.51), the Wells rule with a cutoff value less than 2 (19 studies; sensitivity, 0.84; specificity, 0.58) or 4 or less (11 studies; sensitivity, 0.60; specificity, 0.80), the Geneva rule (5 studies; sensitivity, 0.84; specificity, 0.50), and the revised Geneva rule (4 studies; sensitivity, 0.91; specificity, 0.37). An increased prevalence of PE was associated with higher sensitivity and lower specificity. Combining a decision rule or gestalt with d-dimer testing seemed safe for all strategies, except when the less-sensitive Wells rule (cutoff value ≤4) was combined with less-sensitive qualitative d-dimer testing.

Limitations: Studies had substantial heterogeneity due to prevalence of PE and differences in threshold. Many studies (63%) had potential bias due to differential disease verification.

Conclusion: Clinical decision rules and gestalt can safely exclude PE when combined with sensitive d-dimer testing. The authors recommend standardized rules because gestalt has lower specificity, but the choice of a particular rule and d-dimer test depend on both prevalence and setting.

15. The Sonographic Ottawa Foot and Ankle Rules Study (the SOFAR Study)

Canagasabey MD, et al. Emerg Med J 2011;28:838-840.

Introduction: Foot and ankle injuries are common in the Emergency Department (ED). Of those requiring radiographs in accordance with the Ottawa Foot and Ankle Rules, approximately 22% have a fracture. Ultrasound is developing as a tool for emergency musculoskeletal assessment—it is inexpensive and rapid, and visualises soft tissue and bony structures.

Methods: This diagnostic cohort study examined if ultrasound could detect acute bony foot and ankle injuries. Ottawa Rules-positive patients over 16 years were eligible. An ultrasound scan (USS) was performed blind to radiograph findings by an ED member. Patient management was according to radiograph. Significant fractures were defined as per the Ottawa Foot and Ankle Rules study group. All radiographic reporting was conducted blind to USS findings. All USS operators received specific 2-day training in musculoskeletal ultrasound.

Results: 110 subjects were recruited. 11 had significant radiological fractures, and 10 were seen on ultrasound. The single missed fracture arose due to the operator not scanning proximally enough on the fibula. On rescanning following radiograph review, the fracture was clearly seen. The sensitivity of USS is 90.9% (95% CI 65.7 to 98.3), and the specificity is 90.9% (95% CI 88.1 to 91.7). The positive predictive value is 0.526 (95% CI 0.380 to 0.569). The negative predictive value is 0.989 (95% CI 0.959 to 0.998). The positive likelihood ratio is 10.00 (95% CI 5.526 to 11.901), and the negative likelihood ratio is 0.100 (95% CI 0.018 to 0.389).

Conclusion: This pilot study demonstrates that ultrasound shows great promise for the sensitive detection of foot and ankle fractures, thus identifying patients who require radiographic evaluation more efficiently.

16. Images in Medicine

Abdominal Lump in an Old Woman
http://www.annemergmed.com/article/S0196-0644(11)00096-5/fulltext

Young Man With Skin Discoloration
http://www.annemergmed.com/article/S0196-0644(11)00131-4/fulltext

Elderly Male With Mesogastric Pain
http://www.annemergmed.com/article/S0196-0644(11)00462-8/fulltext

Ectopic Tooth in the Maxillary Sinus
http://www.nejm.org/doi/full/10.1056/NEJMicm1101021

Orbital and Cerebral Arteriovenous Malformations
http://www.nejm.org/doi/full/10.1056/NEJMicm1010443

Porphyria Cutanea Tarda
http://www.nejm.org/doi/full/10.1056/NEJMicm1100668

Patent Urachus
http://www.nejm.org/doi/full/10.1056/NEJMicm1101177

17. Lit Reviews in EM, Courtesy of Ann Emerg Med

A. Are Tissue Adhesives an Acceptable Alternative for Simple Lacerations?

Emergency physicians should incorporate the use of tissue adhesives for simple laceration repairs. Compared with standard wound closure, they result in equivalent cosmesis, less pain, and more rapid wound closure.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(11)00344-1/fulltext

B. Can a Negative D-dimer Result Rule Out Acute Aortic Dissection?

Nope.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(11)00390-8/fulltext

18. Contagion, the Movie: An Expert Medical Review

Paul A. Offit, MD. Medscape Infectious Disease. 09/13/2011

Medscape Editor's Note:
We thought that Medscape readers would be interested in hearing from one of our infectious disease experts about the medical aspects of the movie Contagion. So often, science is trumped by drama in popular movies -- but not this time, says Paul A. Offit, MD, a vaccine coinventor in real life. The movie was filmed in part at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, so we also provide links to stories about the work being done at CDC every day.

Hi. My name is Paul Offit, and I'm talking to you today from the Vaccine Education Center at the Children's Hospital of Philadelphia. I thought it might be fun to talk about a movie that I saw this weekend, Steven Soderbergh's Contagion. This movie deals with a pandemic-like influenza virus to which no one in the population has been previously exposed and which has the potential to do a tremendous amount of harm. It was an interesting movie. Typically when movies take on science, they tend to sacrifice the science in favor of drama. That wasn't true here.

The moviemakers did a very good job of illustrating how Southeast Asia can essentially serve as a "genetic reassortment laboratory" with influenza strains being created as a combination event among strains from pigs and chickens (and in this case, bats) to create a strain that the population has never seen before. They do a very good job of explaining that possibility and in showing how easy the virus can spread from one person to another. In fact, in bringing up the concept of contagiousness as "R0," they compare the R0 of influenza, polio, and smallpox. It's very interesting that they were willing to spend time explaining what contagiousness means.

They also do an excellent job of describing the phenomenon of fomites -- that one can, in fact, transmit microorganisms very easily by shaking a hand or touching a martini glass or a door handle. The camera lingered on these different items to the point that it essentially becomes a commercial for hand sanitizer (which they actually show at one point during the movie).

They discuss how difficult it is to try and stop this virus. The heroes of the story are vaccines. In discussing how they would go about making a vaccine, they make a distinction between a whole kill virus and a live attenuated vaccine. They show how the CDC, through active case hunting, can actually figure out exactly how this virus was generated and collaborate with academia -- in this case, a virologist in California named Sussman, played by Elliott Gould. You have to be able to imagine Elliott Gould as a virologist, but if you can, it really is a nice touch, showing how he is the first to be able to grow the virus in cell culture, allowing a vaccine to be made.

The movie then explores the difficulties in trying to decide who can get vaccine, given that the supply is limited. These are all the issues that we faced when we talked about the possibility of how devastating the most recent swine flu pandemic could be. The movie is quite accurate as it portrays how society breaks down in the face of potentially millions of deaths caused by limited vaccine and limited food supplies. It's really well done.

The movie also shows the antiscience forces. In this case, it's in the person of the appropriately named Alan Krumwiede, who is played by Jude Law. Krumwiede is a paranoid conspiracy theorist who believes that this is all just a government plot, and he is very antiscience. He has created a treatment (that he has taken himself), called Forsythia, a homeopathic remedy, which obviously is of no value because it is simply something diluted to the point that it's not there anymore. He claims that he has been treated by this product, even though he was actually never sickened by the virus. The movie demonstrates the impact of the Internet. In this case, Krumwiede has a blog called "Truth Serum Now" that creates -- or feeds into -- a lot of mistrust in the general population.

In Contagion, Dr. Sanjay Gupta interviews a CDC official played by Laurence Fishburne, and he gives Krumwiede equal time. It's interesting that what the conspiracy theorist talks about is people. Krumwiede confronts Fishburne with questions such as "What did you know?" and "When did you know it?" when, in fact, the issues are "How can we identify this virus?," "How can we make a vaccine against it?," and "How can we prevent its spread?" It's an issue of science, not an issue of people. But in this movie, Sanjay Gupta, playing himself, makes it an issue about people -- another example of art imitating life, because Gupta has been perfectly willing to allow antivaccine celebrities to be on his show. In another interesting example of art imitating life, Jude Law [reportedly] actually believes in homeopathy.

In summary, Contagion is an excellent movie in that it is willing to allow science to prevail over drama. It is quite well done, so I recommend it. Thank you.

See also: CDC: Contagion Movie: Fact and Fiction in Film
http://www.cdc.gov/Features/ContagionMovie/

19. Comparison of Aerobic Versus Resistance Exercise Training Effects on Metabolic Syndrome

Bateman LA, et al. Amer J Cardiol 2011;108:838-844.

Aerobic training (AT) improves the metabolic syndrome (MS) and its component risk factors; however, to our knowledge, no randomized clinical studies have addressed whether resistance training (RT) improves the MS when performed alone or combined with AT. Sedentary, overweight dyslipidemic men and women, aged 18 to 70 years completed a 4-month inactive run-in period and were randomized to 1 of 3 eight-month exercise programs (n = 196). The exercise programs were (1) RT (3 days/week, 3 sets/day of 8 to 12 repetitions of 8 different exercises targeting all major muscle groups); (2) AT (∼120 minutes/week at 75% of the maximum oxygen uptake), and (3) AT and RT combined (AT/RT) (exact combination of AT and RT).

Of the 196 randomized patients, 144 completed 1 of the 3 exercise programs. The 86 participants with complete data for all 5 MS criteria were used in the present analysis, and a continuous MS z score was calculated. Eight months of RT did not change the MS score. AT improved the MS score (p less than 0.07) and showed a trend toward significance compared to RT (p less than 0.10). AT/RT significantly decreased the MS score and was significantly different from RT alone. In conclusion, RT was not effective at improving the MS score; however, AT was effective. Combined AT and RT was similarly effective but not different from AT alone. When weighing the time commitment versus health benefit, the data suggest that AT alone was the most efficient mode of exercise for improving cardiometabolic health.

Full-text (free): http://www.ajconline.org/article/S0002-9149(11)01783-8/fulltext

20. New AAP Guidelines for Diagnosis and Management of Febrile UTI in Infants and Young Children

These recommendations outline a systematic approach to diagnosis and management that minimizes harm, maximizes benefit, and optimizes use of labs and procedures.

Diagnosis and management of urinary tract infection (UTI) in febrile infants are challenging for several reasons: Obtaining a sterile urine sample requires either inserting a urethral catheter or performing a suprapubic aspirate, both the route and duration of antibiotics are not standardized, and follow-up evaluation often includes voiding cystourethrography (VCUG) that involves irradiation of the pelvis. The American Academy of Pediatrics Subcommittee on UTI extensively reviewed studies published during the past 10 years on UTI in young children and developed sensible, updated evidence-based guidelines to direct practitioners in the diagnosis and management of febrile UTI in children aged 2 to 24 months. The seven key action statements are as follows:

Diagnosis

1. If a febrile patient with no known source of fever is deemed ill enough to require immediate antibiotic therapy, obtain urine culture by either catheterization or suprapubic aspiration before initiating treatment.

2. Assess the likelihood of UTI. Risk factors for UTI are female sex, not being circumcised, no other source of fever, and fever 39°C. Additional risk factors in girls are white race, age below 12 months, and fever for beyond 2 days. Additional risk factors in boys are nonblack race and fever for 24 hours.
• Low-risk patients can be followed clinically without urine evaluation.
• In patients who are not low risk, obtain a urine culture by either catheterization or suprapubic aspiration for urinalysis and culture, or obtain a urine specimen for urinalysis followed by culture if positive.

3. Establish UTI diagnosis. Diagnosis requires both abnormal urinalysis (pyuria, bacteriuria, or both) and urine culture with more than 50,000 CFU/mL of a urinary pathogen.

Management

4. Oral therapy and parenteral therapy are both efficacious, and decisions should be based on practical considerations (e.g., the patient's ability to take oral medication). Adjust antibiotics according to sensitivity patterns. Minimal duration of therapy is 7 days. No differences in efficacy have been documented among 7-, 10-, and 14-day regimens.

5. Evaluation after a first febrile UTI should include renal and bladder ultrasound. Increasing evidence indicates that antibiotic prophylaxis for low-grade reflux does not improve outcomes. Therefore, routine VCUG is not recommended after a first UTI.

6. VCUG should be performed in patients with a first UTI only if ultrasound suggests high-grade vesicoureteral reflux. VCUG is indicated for recurrent febrile UTI.

7. Following a confirmation of UTI, physicians should instruct parents to seek prompt care for future unexplained febrile illness.

Comment: In the era of conjugated vaccines for Haemophilus influenzae and Streptococcus pneumoniae, bacteria that cause UTI have become one of the most common causes of serious bacterial infection in infants aged 2 to 24 months. This extremely clear document outlines a systematic approach to diagnosis and management that minimizes harm, maximizes benefit, and optimizes the use of lab tests and procedures in patients who are most likely to receive benefit.

— Peggy Sue Weintrub, MD. Published in Journal Watch Pediatrics and Adolescent Medicine September 21, 2011

Citation: Subcommittee on Urinary Tract Infection. Urinary tract infection: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011 Sep; 128:595.

Full-text (free): http://pediatrics.aappublications.org/content/128/3/595.long

21. Too Many Tasks

Dustin Ballard, MD, MBE. Chair, KP CREST Network. Monday, September 19, 2011.

I’m sitting down to write on an important topic. “I should check my email. Right, where was I?” An important topic for students, parents, professionals, and, well, just about everyone. “Who’s texting me? Oh shoot; I need to finish that Amazon order. I forgot to call the plumber. And the dog needs to go out. Did I feed my daughter’s Brazilian water frog? I should check my email.” Wait, focus. Important topic. Interesting topic. And it’s critical that everyone understand the limitations and risks associated with it. “I really should check my email.” Multi... "must check email!” …Tasking.

Like many people in our digitalized and sensory-loaded world, I’m a fervent multi-tasker. Email, bills, scheduling, patient-care, child-care, pet-care, Twitter-care, fantasy sports; I can do it all. And I can do it all at the same time! At least so I thought. “Just checked my email for the fourth time this paragraph. My wife wants to know if we can go to a school fundraiser tonight. My boss is trying to schedule a tennis match. I wonder which QBs are available on the cbsportsline waiver wire? Expedia has a new fare alert for me. $299 bucks to fly to Omaha! Sweet.” Contrary to the ethos I’ve prided myself on, in a world of information overload, constant data processing can actually ‘smog,’ ‘asphyxiate,’ and starve away productive time. In fact, multi-tasking may threaten efficiency more than aid it.

Skeptical? Well, stay with me here (your stock portfolio and Facebook newsfeed can wait), and consider evidence from cognitive testing. Researchers looking at individuals performing two or more tasks at once have found that, quite consistently, people complete tasks faster if they do them serially (one, then the other) rather than in parallel (start one, start the other, back to the first, and so on). In fact, loss of efficiency has been estimated to be around half-a-second per task switch and up to twice the sum of the time needed to complete two tasks in order. So, for example, if it takes me two minutes to check and respond to my email and three minutes to order a new mattress online, it would take me up to ten minutes to do the two tasks ‘at the same time’ (switching back and forth between tasks with a delay with each switch). But if I did the tasks serially (i.e. focusing on one task and completing it before moving on to the next), the two tasks should take me only five minutes.

Now, as we all know, multi-tasking is more or less a fact of life. Most of us are forced to multi-task some or all of the time, both at work and at home. A busy shift in the Emergency Department (ED) is an excellent example of this, and one that I’m quite familiar with. I spend my days talking with patients, performing physical exams, entering orders, documenting, calling consultants, communicating with nursing and other personnel, performing procedures, making referrals, all while trying not to neglect an important task like prescribing the correct medication. Studies of ED physicians demonstrate that their tasks will be interrupted four to fourteen times per hour, or every four minutes or so. An observational study of nurses reported that ED nurses (at work) multitask 34% of the time. Each and every single one of the interruptions that ED providers experience could have disastrous consequences. (This is why we have developed safety mechanisms like timeouts and checklists.)

But of course, some multi-tasking is unavoidable. Our patients surely appreciate that we break away from a routine task, like charting, to tackle another more critical task, such as providing acute resuscitation. And, keep in mind that some ‘multitasking’ is not harmful. For some people, listening to music while driving or studying is not really multi-tasking at all but rather a multi-sensory approach to a task. This habit may or may not affect efficiency and performance. People are (according to cognitive studies) able to train themselves to block out distractions when performing an assignment. Note that I say ‘distractions’ and not tasks. Tasks, especially ones that require working memory - very short term memory designed to aid in completion of short term tasks - will be more efficiently completed in order and cannot be blocked out as part of a multisensory approach. Working memory is ephemeral and highly sensitive to interruptions. We all experience this as those ‘I lost my train of thought’ moments.

Can you minimize brain stalls and achieve a healthy level of multi-tasking? Maybe, but first you have to set aside dedicated time to think, focus, and plan. Creativity benefits from focus and people who have planned or rehearsed tasks beforehand are less likely to suffer delays. Here’s another tip: try to resist over-dosing on jolts of satisfaction (‘dopamine squirts’) associated with compulsive behavior – like checking email every 2.4 minutes. And when possible, finish what you started - NOW – rather than deferring it to the ‘later’ bucket. Working memory is temporary and what may seem unforgettable right now is actually quite forgettable in 15 minutes. Finally, experiment with focus adjuncts – meditation or paying attention to your breathing may help, as might noise-erasing headphones (which, my wife lovingly has dubbed ‘wife- and kid-erasers’). Of course, a lot of the modern world cannot be easily ‘noise-erased,’ but if you make an effort to slow down, especially with important endeavors, your reward, ultimately, will be higher efficiency and fewer mistakes.

Well, phew, I’ve made it through this task. Hope you did too. “How many unread emails do I have? That frog must be absolutely starving.” Now, if you’ll excuse me, I’ve got a few other things to do…

From his blog: http://incisionanddrainage.blogspot.com/

Lit Bits: Sept 12, 2011

2011-09-12T10:35:00.000-07:00

From the recent medical literature...

1. Prospective (in)validation of the ABCD2 score for patients in the ED with TIA

Perry JJ, Stiell IG, et al. CMAJ. 2011 Jul 12;183(10):1137-45.

BACKGROUND: The ABCD2 score (Age, Blood pressure, Clinical features, Duration of symptoms and Diabetes) is used to identify patients having a transient ischemic attack who are at high risk for imminent stroke. However, despite its widespread implementation, the ABCD2 score has not yet been prospectively validated. We assessed the accuracy of the ABCD2 score for predicting stroke at 7 (primary outcome) and 90 days.

METHODS: This prospective cohort study enrolled adults from eight Canadian emergency departments who had received a diagnosis of transient ischemic attack. Physicians completed data forms with the ABCD2 score before disposition. The outcome criterion, stroke, was established by a treating neurologist or by an Adjudication Committee. We calculated the sensitivity and specificity for predicting stroke 7 and 90 days after visiting the emergency department using the original "high-risk" cutpoint of an ABCD2 score of more than 5, and the American Heart Association recommendation of a score of more than 2.

RESULTS: We enrolled 2056 patients (mean age 68.0 yr, 1046 (50.9%) women) who had a rate of stroke of 1.8% at 7 days and 3.2% at 90 days. An ABCD2 score of more than 5 had a sensitivity of 31.6% (95% confidence interval [CI] 19.1-47.5) for stroke at 7 days and 29.2% (95% CI 19.6-41.2) for stroke at 90 days. An ABCD2 score of more than 2 resulted in sensitivity of 94.7% (95% CI 82.7-98.5) for stroke at 7 days with a specificity of 12.5% (95% CI 11.2-14.1). The accuracy of the ABCD2 score as calculated by either the enrolling physician (area under the curve 0.56; 95% CI 0.47-0.65) or the coordinating centre (area under the curve 0.65; 95% CI 0.57-0.73) was poor.

INTERPRETATION: This multicentre prospective study involving patients in emergency departments with transient ischemic attack found the ABCD2 score to be inaccurate, at any cut-point, as a predictor of imminent stroke. Furthermore, the ABCD2 score of more than 2 that is recommended by the American Heart Association is nonspecific.

2. Development of a Clinical Prediction Rule for 30-Day Cardiac Events in ED Patients with Chest Pain and Possible ACS

Hess EP, et al. Ann Emerg Med. 2011 Aug 31. [Epub ahead of print]

STUDY OBJECTIVE: Evaluation of emergency department (ED) patients with chest pain who are at low risk for acute coronary syndrome is resource intensive and may lead to false-positive test results and unnecessary downstream procedures. We seek to identify patients at low short-term risk for a cardiac event for whom additional ED investigations might be unnecessary.

METHODS: We prospectively enrolled patients older than 24 years and with a primary complaint of chest pain from 3 academic EDs. Physicians completed standardized data collection forms before diagnostic testing. The primary adjudicated outcome was acute myocardial infarction, revascularization, or death of cardiac or unknown cause within 30 days. We used recursive partitioning to derive the rule and validated the model with 5,000 bootstrap replications.

RESULTS: Of 2,718 patients enrolled, 336 (12%) experienced a cardiac event within 30 days (6% acute myocardial infarction, 10% revascularization, 0.2% death). We developed a rule consisting of the absence of 5 predictors: ischemic ECG changes not known to be old, history of coronary artery disease, pain typical for acute coronary syndrome, initial or 6-hour troponin level greater than the 99th percentile, and age greater than 50 years. Patients aged 40 years or younger required only a single troponin evaluation. The rule was 100% sensitive (95% confidence interval 97.2% to 100.0%) and 20.9% specific (95% confidence interval 16.9% to 24.9%) for a cardiac event within 30 days.

CONCLUSION: This clinical prediction rule identifies ED chest pain patients at very low risk for a cardiac event who may be suitable for discharge. A prospective multicenter study is needed to validate the rule and determine its effect on practice.

3. How Much CPR Before Defibrillation Shock?

Administering more cardiopulmonary resuscitation before defibrillation and rhythm analysis does not improve outcomes.

To examine the theory that a more perfused heart will respond better to defibrillation shock, researchers conducted a cluster-randomized study in 9933 patients with nontraumatic out-of-hospital cardiac arrest at 10 Resuscitation Outcomes Consortium sites in the U.S. and Canada. Patients were divided into two groups and received cardiopulmonary resuscitation (CPR) by emergency medical services (EMS) providers for either 30 to 60 seconds (until pads were applied) or 180 seconds before defibrillation and initial electrocardiograph rhythm analysis. EMS providers received study-specific training every 6 months that emphasized uninterrupted compressions and ventilations in a 30:2 ratio.

The primary outcome — survival to hospital discharge with satisfactory neurological function as measured by the modified Rankin score — was 5.9% in both groups. The authors concluded that delaying analysis of cardiac rhythm during EMS-administered CPR provided no advantage. Of note, despite aggressive training of already "high-functioning" EMS providers, the duration of CPR before the first rhythm analysis did not fall within the assigned target for 36% of patients.

Comment: Even the best CPR delivers only a small fraction of normal cardiac output, which, as this study shows, is insufficient to "prime" the heart for defibrillation shock. Achieving a normal effective rhythm as soon as possible remains the single most important goal of resuscitation. The 64% adherence to the assigned duration of CPR by EMS providers shows how messy things are in real-life delivery of care for out-of-hospital cardiac arrest. This study does not alter the mantra for bystander-delivered CPR: "Always push early and often."

— J. Stephen Bohan, MD, MS, FACP, FACEP

Published in Journal Watch Emergency Medicine September 9, 2011. Citation: Stiell IG et al. Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. N Engl J Med 2011 Sep 1; 365:787.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21879896

4. Sudden Death Etiologies Vary by Age Group

By Will Boggs MD. NEW YORK (Reuters Health) Sep 07 - The primary cause of sudden cardiac death in young adults differs before and after age 35, new data show.

"Screening programs focus disproportionate attention on the identification of hypertrophic cardiomyopathy," Dr. Robert E. Eckart from Brooke Army Medical Center, San Antonio, Texas told Reuters Health by email.

"While exclusion of this potentially deadly disease is critical, we should be focusing attention toward the leading cause of sudden death in the young, sudden arrhythmic death syndrome," he said.

As reported in the September 13th Journal of the American College of Cardiology, Dr. Eckart and colleagues used the Department of Defense Cardiovascular Death Registry to identify the cause of all nontraumatic sudden deaths over a 10-year period in military personnel 18 years of age and over.

Ultimately they reviewed 902 records with autopsy data for deaths of presumed cardiac etiology.

The mortality rate for sudden cardiac death per 100,000 person-years was 6.68 for males and 1.40 for females. Rates per 100,000 person-years rose from 3.25 for individuals under 20 years of age to 105.57 for those over 50.

Before age 35, the leading cause of sudden cardiac death -- accounting for 41% of cases -- was "sudden death without an identifiable cardiac structural abnormality, presumably arrhythmic," whereas for older individuals it was atherosclerotic coronary artery disease, which accounted for 73% of cases.

Only 57 deaths (6.3%) were attributed to hypertrophic cardiomyopathy and only 26 (2.9%) to hypertensive cardiomyopathy.

"Interestingly, cholesterol and BMI, conventional indicators, were not associated with risk of sudden death from atherosclerotic coronary disease, but the doubling of relative risk beyond age 35 years suggests we lower the standard ages at which we suspect disease, particularly in those with family history," Dr. Eckart said.

"As we look at newer modalities for detection of disease, not risk for disease, but actual disease states, like CT angiography, we need to consider adjusting risk models based on known incidence of fatal disease," he said.

"When a young adult dies, particularly in the public forum, whether that be a high school athletic field or on a military base, there is significant early media attention," Dr. Eckart continued. "When a cause is identified, the findings spread rapidly; but if a cause is not clearly identified, community interest wanes, as the outcome was felt to be a mystery, or simply inevitable."

"Of more importance is the significance of a family history of sudden death at a young age, particularly in someone who passes out," Dr. Eckart said. "If someone under age 35 loses consciousness or passes out without a clearly identifiable explanation, and they have a family history of sudden death, it is critical that they be evaluated by a cardiologist or a cardiac electrophysiologist without delay."

Eckart RE, et al. J Am Coll Cardiol. 2011 Sep 13;58(12):1254-61.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21903060

5. Medicare Prepares Rule to Penalize Hospitals with High Readmission Rates

By Jordan Rau. Kaiser Health News. August 29, 2011

When hospitals discharge patients, they typically see their job as done. But soon, they could be on the hook for what happens after Medicare patients leave the premises, and particularly if they are readmitted within a month.

In an effort to save money and improve care, Medicare, the federal program for the elderly and disabled, is about to release a final rule aimed at getting hospitals to pay more attention to patients after discharge.

A key component of the new approach is to cut back payments to hospitals where high numbers of patients are readmitted, prodding hospitals to make sure patients see their doctors and fill their prescriptions.

Medicare also wants to pay less to hospitals with higher-than-average costs for patient care. It has proposed calculating the costs by combining a patient's hospital expenses with fees incurred up to 90 days after discharge.

The efforts, called for in last year's health care law, are part of a push to make hospitals the hub for coordinating care. Hospital care is the largest chunk of Medicare spending; Medicare says readmissions alone cost $26 billion in a decade. Plus, many experts argue hospitals are the most organized actors in a splintered and often dysfunctional health system, and thus best able to take the lead in overseeing patient care.

But hospital groups complain that Medicare's plans could punish them for things they can't control, such as unavoidable readmissions and patients who can't afford the costs of prescriptions.

"A lot of this is very unfair," says Blair Childs, a vice president at Premier, an alliance of more than 200 hospitals. He says hospitals that don't have a lot of money to invest in improving their oversight of former patients could end up losing more money under Medicare's proposals, putting them in an even bigger financial hole. In particular, he says, the changes may hurt inner city hospitals.

"These are often very stressed hospitals, and they're the ones that are going to be penalized the most," Childs says.

Some academics who have studied hospitals also think Medicare may be being too harsh. "The truth is the 30-day readmission is a relatively lousy quality measure for a hospital, because a lot is happening outside a hospital's control," says Dr. Ashish Jha, a professor at Harvard's School of Public Health.

Medicare's penalties could be significant-and widespread. Almost 7 percent of acute-care hospitals -- 307 out of 4,498 -- had higher-than-expected readmissions rates for heart failure, heart attack or pneumonia, according to Medicare data. Under Medicare's draft proposal, which it put out in May, penalties would start in October 2012; hospitals with the worst readmissions rates eventually could lose up to 3 percent of their regular Medicare payments.

Hospitals with patients who cost Medicare lots of money during and after their hospital stays also could be hurt. Beginning in October 2013, these spending levels would count for a fifth of Medicare's "value-based purchasing program," which alters hospital payments based on long list of quality measures.

"The incentives we're putting into place have created a whole new way to think about hospital care," says Jonathan Blum, deputy administrator of the federal Centers for Medicare & Medicaid Services, or CMS.

These initiatives come on top of other Medicare experiments that will make not just hospitals but also surgeons responsible for costs run up from complications that occur beyond the operating room. One approach is "bundled payments," where Medicare pays a set fee for the entire cost of a patient's treatment, including expenses after discharge. And Medicare's high-profile venture to create "accountable care organizations," where teams of doctors and hospitals share the financial risks and rewards for caring for patients, would also hold hospitals partially to account for the costs of treatments that patients get elsewhere.

Hospitals "can no longer see our job as just being within the four walls we've built," says Leah Binder, chief executive of the Leapfrog Group, a nonprofit that evaluates hospital quality.

CMS has limited leeway to tinker with the readmissions rule, because much of it was spelled out in the health care law. CMS has more freedom to change its plan to measure per-patient spending, as the law didn't detail how it should work.

Regardless of what CMS ultimately decides, many hospitals are already scrambling to change how they supervise former patients, says Chas Roades, chief research officer at The Advisory Board Company, a health care consultancy. "One of the big themes I'm hearing now across the hospital industry is, 'We can no longer think of ourselves as just hospital companies, we have to be full-service health care managers,'" he says.

Consider Trinity Health, which owns 50 hospitals around the country, including Holy Cross in Silver Spring, Md. Before patients leave the hospital, Trinity's nurses now set up appointments for them with their regular doctors. They also make sure patients can get to the appointment, either by helping them figure out whether Medicare or Medicaid pays for transportation, or by paying for the trips directly.

"We're trying to do a better job of sending them home better-prepared, rather than just saying good luck," says Dr. Terry O'Rourke, Trinity's chief clinical officer. But he says there are limits to what they can do: "The majority of physicians are not employed by the hospital, and we don't have control over their practices."

Dr. Kavita Patel, a Brookings Institution fellow and former Obama administration official, says changes occurring in both the private sector and Medicare will speed up the trend of hospitals' overseeing the care of former patients.

For example, she says, many hospitals are buying the practices of primary care doctors, making it easier for them to arrange and oversee the care of patients after discharge. "The more hospitals realize they're going to be held accountable, that's where they are going to get creative," Patel says.

6. Chocolate consumption and cardiometabolic disorders

Buitrago-Lopez A, et al. Chocolate consumption and cardiometabolic disorders: systematic review and meta-analysis. BMJ 2011; 343:d4488

High levels of chocolate consumption might be associated with a one third reduction in the risk of developing heart disease, according to this systematic review and meta-analysis. The findings confirm results of existing studies that generally agree on a potential beneficial link between chocolate consumption and heart health. However, the authors stress that further studies are needed to test whether chocolate actually causes this reduction or if it can be explained by some other unmeasured (confounding) factor.

Full-text (free): http://www.bmj.com/content/343/bmj.d4488.full

7. Immediate Complications of IV Contrast for CT Imaging in the Outpatient Setting Are Rare

Mitchell AM, et al. Acad Emerg Med. 2011;18:1005-1009.

Objectives: Despite increasing attention to the long-term risks of radiation exposure and contrast-induced nephropathy (CIN), institutional guidelines and patient consent procedures for contrast-enhanced computed tomography (CECT) imaging in the emergency department (ED) setting have focused primarily on more immediate complications, directly attributable to the administration of intravenous (IV) iodinated contrast administration. Thus, this study sought to define the risk of these immediate complications with the overall aim of improving institutional guidelines and patient consent procedures.

Methods: This was a prospective, consecutive cohort study of patients undergoing CECT of any body region in the ED, for complications occurring within 1 week of contrast administration, using predefined implicit definitions. Severe complications were defined as any of the following requiring medical or surgical intervention: bronchospasm with acute respiratory failure, airway obstruction, anaphylactoid shock, or acute pulmonary edema. The development of compartment syndrome, lactic acidosis, or pulmonary edema within 1 week of contrast administration was also considered a severe complication.

Results: Of 633 patients, only five (0.8%, 95% confidence interval [CI] = 0.3% to 1.8%) reported any immediate complications, all of which were classified as minor. No patient developed a reaction meeting the study definition of a severe complication.

Conclusions: The frequency of severe, immediate complications from CECT imaging that includes IV contrast is less than 1%, and the frequency of mild complications is less than 2%. The authors conclude that CECT is associated with a very low rate of severe immediate complications.

8. Decision Rule Falls Short in Identifying Children at Low Risk for Pneumonia

Even the lowest-risk group had a 7.6% pneumonia rate.

In a prospective cohort study of 2574 patients (age, below 21 years; median age, 2.3 years) who presented to a tertiary pediatric emergency department and who underwent chest radiography for suspected pneumonia, investigators sought to develop a clinical decision rule for chest radiography.

Overall, 422 patients (16%) had radiographic pneumonia (radiograph suggestive of pneumonia); a subset of 199 patients (8% of the total) had definite pneumonia (radiograph diagnostic for pneumonia). In multivariate analysis, significant predictors of both radiographic pneumonia and definite pneumonia (with odds ratios ranging from 1.37–3.69) were oxygen saturation (O2 sat) 92% at triage, chest pain, focal rales, and O2 sat between 93% and 96% at triage. Wheezing on exam was a significant negative predictor in the entire cohort but not in patients younger than 5 years.

Recursive partitioning stratified patients into risk groups as follows: 20 patients with O2 sat 92%, no wheeze, and focal rales had the highest risk for radiographic pneumonia (pneumonia rate, 70.0%); 38 patients with O2 sat above 92%, no history of fever, no focal decreased breath sounds, and no focal rales were at lowest risk (pneumonia rate, 7.6%). Among patients younger than 5 years, O2 sat 92% at triage was the best predictor of radiographic pneumonia (pneumonia rate 39% vs. 15% for those with O2 sat above 92%); investigators were unable to characterize low-risk characteristics in patients younger than 5.

Comment: Radiation exposure from a single chest x-ray is negligible (0.05–0.10 millisieverts), and missing 7.6% of pediatric pneumonia cases is unacceptable. Unfortunately, this rule misses too many positive cases, and further refinement will be needed before it is a useful clinical tool.

— Katherine Bakes, MD. Published in Journal Watch Emergency Medicine August 26, 2011.
Citation: Neuman MI et al. Prediction of pneumonia in a pediatric emergency department. Pediatrics 2011 Aug; 128:246.

OBJECTIVE: To study the association between historical and physical examination findings and radiographic pneumonia in children who present with suspicion for pneumonia in the emergency department, and to develop a clinical decision rule for the use of chest radiography.

METHODS: We conducted a prospective cohort study in an urban pediatric emergency department of patients younger than 21 who had a chest radiograph performed for suspicion of pneumonia (n = 2574). Pneumonia was categorized into 2 groups on the basis of an attending radiologist interpretation of the chest radiograph: radiographic pneumonia (includes definite and equivocal cases of pneumonia) and definite pneumonia. We estimated a multivariate logistic regression model with pneumonia status as the dependent variable and the historical and physical examination findings as the independent variables. We also performed a recursive partitioning analysis.

RESULTS: Sixteen percent of patients had radiographic pneumonia. History of chest pain, focal rales, duration of fever, and oximetry levels at triage were significant predictors of pneumonia. The presence of tachypnea, retractions, and grunting were not associated with pneumonia. Hypoxia (oxygen saturation ≤92%) was the strongest predictor of pneumonia (odds ratio: 3.6 [95% confidence interval (CI): 2.0-6.8]). Recursive partitioning analysis revealed that among subjects with O(2) saturation above 92%, no history of fever, no focal decreased breath sounds, and no focal rales, the rate of radiographic pneumonia was 7.6% (95% CI: 5.3-10.0) and definite pneumonia was 2.9% (95% CI: 1.4-4.4).

CONCLUSION: Historical and physical examination findings can be used to risk stratify children for risk of radiographic pneumonia.

9. Comparison of Serial Qualitative and Quantitative Assessments of Caval Index and Left Ventricular Systolic Function During Early Fluid Resuscitation of Hypotensive ED Patients

Weekes AJ, et al. Acad Emerg Med. 2011;18:912-921.

Objectives: The objective was to determine whether serial bedside visual estimates of left ventricular systolic function (LVF) and respiratory variation of the inferior vena cava (IVC) diameter would agree with quantitative measurements of LVF and caval index in hypotensive emergency department (ED) patients during fluid challenges. The authors hypothesized that there would be moderate inter-rater agreement on the visual estimates.

Methods: This prospective observational study was performed at an urban, regional ED. Patients were eligible for enrollment if they were hypotensive in the ED as defined by a systolic blood pressure (sBP) below 100 mm Hg or mean arterial pressure of ≤65 mm Hg, exhibited signs or symptoms of shock, and the treating physician intended to administer intravenous (IV) fluid boluses for resuscitation. Sonologists performed a sequence of echocardiographic assessments at the beginning, during, and toward the end of fluid challenge. Both caval index and LVF were determined by the sonologist in qualitative then quantitative manners. Deidentified digital video clips of two-dimensional IVC and LVF assessments were later presented, in random order, to an ultrasound (US) fellowship–trained emergency physician using a standardized rating system for review. Statistical analysis included both descriptive statistics and correlation analysis.

Results: Twenty-four patients were enrolled and yielded 72 caval index and LVF videos that were scored at the bedside prior to any measurements and then reviewed later. Visual estimates of caval index compared to measured caval index yielded a correlation of 0.81 (p below 0.0001). Visual estimates of LVF compared to fractional shortening yielded a correlation of 0.84 (p below 0.0001). Inter-rater agreement of respiratory variation of IVC diameter and LVF scores had simple kappa values of 0.70 (95% confidence interval [CI] = 0.56 to 0.85) and 0.46 (95% CI = 0.29 to 0.63), respectively. Significant differences in mean values between time 0 and time 2 were found for caval index measurements, the visual scores of IVC diameter variation, and both maximum and minimum IVC diameters.

Conclusions: This study showed that serial visual estimations of the respiratory variation of IVC diameter and LVF agreed with bedside measurements of caval index and LVF during early fluid challenges to symptomatic hypotensive ED patients. There was moderate inter-rater agreement in both visual estimates. In addition, acute volume loading was associated with detectable acute changes in IVC measurements.

10. Another Trial of “Open-Label Placebo”

Placebo Effects and the Common Cold: A Randomized Controlled Trial

Barrett B, et al. Ann Fam Med 2011;9:312-322.

PURPOSE We wanted to determine whether the severity and duration of illness caused by the common cold are influenced by randomized assignment to open-label pills, compared with conventional double-blind allocation to active and placebo pills, compared with no pills at all.

METHODS We undertook a randomized controlled trial among a population with new-onset common cold. Study participants were allocated to 4 parallel groups: (1) those receiving no pills, (2) those blinded to placebo, (3) those blinded to echinacea, and (4) those given open-label echinacea. Primary outcomes were illness duration and area-under-the-curve global severity. Secondary outcomes included neutrophil count and interleukin 8 levels from nasal wash at intake and 2 days later.

RESULTS Of 719 randomized study participants, 2 were lost and 4 exited early. Participants were 64% female, 88% white, and aged 12 to 80 years. Mean illness duration for each group was 7.03 days for those in the no-pill group, 6.87 days for those blinded to placebo, 6.34 days for those blinded to echinacea, and 6.76 days for those in the open-label echinacea group. Mean global severity scores for the 4 groups were no pills, 286; blinded to placebo, 264; blinded to echinacea, 236; and open-label echinacea, 258. Between-group differences were not statistically significant. Comparing the no-pill with blinded to placebo groups, differences (95% confidence interval [CI]) were –0.16 days (95% CI, –0.90 to 0.58 days) for illness duration and –22 severity points (95% CI, –70 to 26 points) for global severity. Comparing the group blinded to echinacea with the open-label echinacea group, differences were 0.42 days (95% CI, –0.28 to 1.12 days) and 22 severity points (95% CI, –19 to 63 points). Median change in interleukin 8 concentration and neutrophil cell count, respectively by group, were 30 pg/mL and 1 cell for the no-pill group, 39 pg/mL and 1 cell for the group binded to placebo, 58 pg/mL and 2 cells for the group blinded to echinacea, and 70 pg/mL and 1 cell for the group with open-label echinacea, also not statistically significant. Among the 120 participants who at intake rated echinacea’s effectiveness as greater than 50 on a 100-point scale for which 100 is extremely effective, illness duration was 2.58 days shorter (95% CI, –4.47 to –0.68 days) in those blinded to placebo rather than no pill, and mean global severity score was 26% lower but not significantly different (–97.0, 95% CI, –249.8 to 55.8 points). In this subgroup, neither duration nor severity differed significantly between the group blinded to echinacea and the open-label echinacea group.

CONCLUSIONS Participants randomized to the no-pill group tended to have longer and more severe illnesses than those who received pills. For the subgroup who believed in echinacea and received pills, illnesses were substantively shorter and less severe, regardless of whether the pills contained echinacea. These findings support the general idea that beliefs and feelings about treatments may be important and perhaps should be taken into consideration when making medical decisions.

11. Unexplained chest pain in the ED: could it be panic?

Foldes-Busque G, et al. Amer J Emerg Med. 2011;29:743-751.

Purpose: This study aimed at (1) establishing the prevalence of paniclike anxiety in emergency department (ED) patients with unexplained chest pain (UCP); (2) describing and comparing the sociodemographic, medical, and psychiatric characteristics of UCP patients with and without paniclike anxiety; and (3) measuring the rate of identification of panic in this population.

Basic Procedure: A structured interview, the Anxiety Disorders Interview Schedule for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, was administered to identify paniclike anxiety and evaluate patients' psychiatric status. Anxious and depressive symptoms were evaluated with self-report questionnaires. Medical information was extracted from patients' medical records.

Main Findings: The prevalence of paniclike anxiety was 44% (95% CI, 40%-48%) in the sample (n = 771). Psychiatric disorders were more common in panic patients (63.4% vs 20.1%), as were suicidal thoughts (21.3% vs 11.3%). Emergency physician diagnosed only 7.4% of panic cases.

Principal Conclusions: Paniclike anxiety is common in ED patients with UCP, and this condition is rarely diagnosed in this population.

12. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: results from the international registry of acute aortic dissection

Rogers AM, et al. Circulation. 2011;123(20):2213-8.

BACKGROUND: In 2010, the American Heart Association and American College of Cardiology released guidelines for the diagnosis and management of patients with thoracic aortic disease, which identified high-risk clinical features to assist in the early detection of acute aortic dissection. The sensitivity of these risk markers has not been validated.

METHODS AND RESULTS: We examined patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2009. The number of patients with confirmed acute aortic dissection who presented with 1 or more of 12 proposed clinical risk markers was determined. An aortic dissection detection (ADD) risk score of 0 to 3 was calculated on the basis of the number of risk categories (high-risk predisposing conditions, high-risk pain features, high-risk examination features) in which patients met criteria. The ADD risk score was tested for sensitivity. Of 2538 patients with acute aortic dissection, 2430 (95.7%) were identified by 1 or more of 12 proposed clinical risk markers. With the use of the ADD risk score, 108 patients (4.3%) were identified as low risk (ADD score 0), 927 patients (36.5%) were intermediate risk (ADD score 1), and 1503 patients (59.2%) were high risk (ADD score 2 or 3). Among 108 patients with no clinical risk markers present (ADD score 0), 72 had chest x-rays recorded, of which 35 (48.6%) demonstrated a widened mediastinum.

CONCLUSIONS: The clinical risk markers proposed in the 2010 thoracic aortic disease guidelines and their application as part of the ADD risk score comprise a highly sensitive clinical tool for the detection of acute aortic dissection.

13. When Doctors Become Patients

By ERIC D. MANHEIMER. New York Times. September 2, 2011

FRANK SINATRA’S greatest hits album, filtered through the jet engine noise of the Varian linear accelerator, was not what I felt like hearing at 9 a.m. I made a mental note to bring a Steely Dan CD for my next appointment.

I was strapped to a hard metal sheet, and the technician had just bolted my head down using a black mask that had been heat-molded to the contours of my face. The sheet and I would slide first up and then back in an overhead arc that would send high-energy electrons into my head and neck from computerized data sets outlining my throat cancer and its spread into adjacent lymph nodes.

I wasn’t a doctor anymore. I was a patient.

That was almost three years ago. This spring, the Archives of Internal Medicine published a much-discussed study that showed that doctors might recommend different treatments for their patients than they would for themselves. They were far more likely to prescribe for patients a potentially life-saving treatment with severe side effects than they were to pick that treatment for themselves.

Understandably, people are worried that this means doctors know something they’re not telling their patients. But my own experience with illness taught me a simpler truth: when it comes to their own health, doctors are as irrational as everyone else.

The remainder of the essay: http://www.nytimes.com/2011/09/03/opinion/when-doctors-become-patients.html

14. A Prospective Comparison of Procedural Sedation and Ultrasound-guided Interscalene Nerve Block for Shoulder Reduction in the ED

Blaivas M, et al. Acad Emerg Med. 2011;18:922-927.

Objectives: Emergency physicians (EPs) are beginning to use ultrasound (US) guidance to perform regional nerve blocks. The primary objective of this study was to compare length of stay (LOS) in patients randomized to US-guided interscalene block or procedural sedation to facilitate reduction of shoulder dislocation in the emergency department (ED). The secondary objectives were to compare one-on-one health care provider time, pain experienced by the patient during reduction, and patient satisfaction between the two groups.

Methods: This was a prospective, randomized study of patients presenting to the ED with shoulder dislocation. The study was conducted at an academic Level I trauma center ED with an annual census of approximately 80,000. Patients were eligible for the study if they were at least 18 years of age and required reduction of a shoulder dislocation. A convenience sample of patients was randomized to either traditional procedural sedation or US-guided interscalene nerve block. Procedural sedation was performed with etomidate as the sole agent. Interscalene blocks were performed by hospital-credentialed EPs using sterile technique and a SonoSite MicroMaxx US machine with a high-frequency linear array transducer. Categorical variables were evaluated using Fisher’s exact test, and continuous variables were analyzed using the Wilcoxon rank sum test.

Results: Forty-two patients were enrolled, with 21 patients randomized to each group. The groups were not significantly different with respect to sex or age. The mean (±SD) LOS in the ED was significantly higher in the procedural sedation group (177.3 ± 37.9 min) than in the US-guided interscalene block group (100.3 ± 28.2 minutes; p below 0.0001). The mean (±SD) one-on-one health care provider time was 47.1 (±9.8) minutes for the sedation group and 5 (±0.7) minutes for the US-guided interscalene block group (p below 0.0001). There was no statistically significant difference between the two groups in patient satisfaction or pain experienced during the procedure. There were no significant differences between groups with respect to complications such as hypoxia or hypotension (p = 0.49).

Conclusions: In this study, patients undergoing shoulder dislocation reduction using US-guided interscalene block spent less time in the ED and required less one-on-one health care provider time compared to those receiving procedural sedation. There was no difference in pain level or satisfaction when compared to procedural sedation patients.

15. Hypothermia Aids Survival After Cardiac Arrest With Non-Shockable Initial Rhythms

By Will Boggs MD. NEW YORK (Reuters Health) Sep 05 - Therapeutic hypothermia (TH) was tied to lower in-hospital mortality in a new meta-analysis of cardiac arrest patients with non-shockable initial rhythms, researchers have found.

"The available evidence indicates that TH is probably beneficial, and certainly not harmful, for promoting survival and neurological recovery of patients with non-ventricular fibrillation (non-VF) rhythms," said senior author Dr. Clifton W. Callaway.

"Given the absence of any other therapies, physicians should use TH in this population," Dr. Callaway, of the University of Pittsburgh, told Reuters Health by email.

The new meta-analysis and systematic review, published online August 9 in Resuscitation, included two randomized trials with 44 patients and 12 nonrandomized trials with 1,292 patients. All patients had return of spontaneous circulation after cardiac arrest with non-shockable initial rhythm.

The two randomized trials showed a 15% improvement in six-month mortality with TH, although the effect was not statistically significant. The one randomized trial that reported neurological outcome showed a nonsignificant improvement of 12% in the TH group.

In 10 nonrandomized trials reporting survival at hospital discharge, TH was associated with a significant 16% reduction in mortality, but the difference in neurological outcome between TH and normothermia did not reach significance.

In subgroup analyses, TH was linked to improved survival after out-of-hospital cardiac arrest, in single center studies, and in prospective studies. The procedure also significantly cut the risk of poor neurological outcome in prospective studies, but not in any of the other subgroups.

Overall, however, the quality of the evidence was very low in both the randomized and nonrandomized trials, Dr. Callaway and his colleagues report.

"TH is a component of a comprehensive package of care for patients after cardiac arrest," he said. "Particularly in observational studies, it is impossible to separate whether any observed benefit resulted from the temperature control or from the associated aspects of care that go along with TH (sedation, monitoring, altered timing for neurological prognostication, blood pressure goals, etc.). While many of us are enthusiastic about TH, researchers in this field recognize the low quality of available data, and are actively trying to create higher levels of evidence."

The authors note that mild TH for 12 to 24 hours after cardiac arrest is now strongly recommended for comatose adult patients with return of spontaneous circulation after out-of-hospital cardiac arrest with ventricular fibrillation.

Nevertheless, there is conflicting evidence even for these patients, with one recent study showing a doubling of survival with TH and another failing to find such an effect (see Reuters Health reports of September 29, 2010, and June 24, 2011.)

"The ideal trial would include a normothermia control group (36-37C) and a hypothermia intervention group (32-34C), and would enroll patients resuscitated from non-VF as well as VF cardiac arrest," Dr. Callaway said. "However, clinicians in North America have reservations about potentially withholding the only promising therapy from patients who would be randomized to a normothermia control group."

Dr. Callaway added, "I am aware that researchers in Sweden do have an ongoing randomized clinical trial that will compare normothermia (36C) to hypothermia (33C) for 24 hours in a cohort of patients. There may be data from that trial in a couple of years."

Kim YM, et al. Resuscitation. 2011 Aug 9. [Epub ahead of print]

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21835145

16. ED Utilization: Impact of Foreclosure Rates and Health Care Reform

A. Foreclosure Rates Correlated With ED Visits, Hospitalizations

Janet Currie, Erdal Tekin. NBER Working Paper No. 17310. Issued in August 2011

We investigate the relationship between foreclosure activity and the health of residents using zip code level longitudinal data. We focus on Arizona, California, Florida, and New Jersey, four states that have been among the hardest hit by the foreclosure crisis. We combine foreclosure data for 2005 to 2009 from RealtyTrac with data on emergency room visits and hospital discharges. Our zip code level quarterly data allow us to control for many potential confounding factors through the inclusion of fixed effects for each zip code as well as for each combination of county, quarter, and year.

We find that an increase in the number of foreclosures is associated with increases in medical visits for mental health (anxiety and suicide attempts), for preventable conditions (such as hypertension), and for a broad array of physical complaints that are plausibly stress-related. They are not related to visits for cancer morbidity, which arguably should not respond as rapidly to stress. Foreclosures also have a zero or negative effect on elective procedures, as one might expect. Age specific results suggest that the foreclosure crisis is having its most harmful effects on individuals 20 to 49. We also find that larger effects for African-Americans and Hispanics than for whites, consistent with the perception that minorities have been particularly hard hit.

B. Massachusetts' Health Care Reform and ED Utilization

Chen C, et al. N Engl J Med. September 7, 2011

Does an expansion of health insurance increase or decrease use of the emergency department (ED)? Both predictions can be justified logically. On the one hand, research on patient cost sharing predicts that by reducing the out-of-pocket costs of an ED visit, expanded insurance coverage, especially in the face of physician shortages, could result in increased ED utilization.1 This view has been echoed by elected leaders: Senator Jon Kyl (R-AZ), citing the Massachusetts experience with health care reform, claimed that if anything, universal coverage brought even higher rates of emergency room visits due to increased difficulty in getting appointments for outpatient physician visits.2 Others have predicted that expanded coverage would actually reduce ED use, since previously uninsured patients would now have access to preventive care. The relative importance of these countervailing forces is a question that clearly weighs on physicians: in a survey of emergency physicians conducted in April 2010, about 71% said they expected emergency visits to increase after the passage of the Affordable Care Act (ACA).3

To explore the importance of these effects, we examined the Massachusetts experience. The state's 2006 health care reform was a model for the ACA and reduced the proportion of Massachusetts adults under the age of 65 who were uninsured by 7.7 percentage points between the fall of 2006 and the fall of 2009.4 To determine whether any changes in ED utilization in Massachusetts reflected the effect of Massachusetts' reform or were merely representative of broader regional trends in ED utilization, we used New Hampshire and Vermont as control states.

The remainder of the article: http://www.nejm.org/doi/full/10.1056/NEJMp1109273

17. Comparison of bedside ultrasound and panorex radiography in the diagnosis of a dental abscess in the ED

Adhikari S, et al. Amer J Emerg Med. 2011;29:790-795.

Objective: The purpose of the study was to compare bedside ultrasound (US) and panorex radiography in the diagnosis of a dental abscess in emergency department (ED).

Methods: A retrospective review of ED records of adult patients with atraumatic facial pain, swelling, and toothache who received a panorex x-ray and bedside US was performed. Medical records were reviewed for ED evaluation and disposition. Sensitivity and specificity of US and panorex x-ray were calculated to determine the clinical utility of the 2 tests.

Results: A total of 19 patients were identified. No periapical abscess was reported on panorex x-rays in 7 (37%) of 19 patients. Ultrasound agreed with panorex x-rays in 6 (86%) of 7 cases. One case where US disagreed with x-rays was evaluated by dentistry consultants; and incision and drainage were performed, confirming the presence of an abscess. An x-ray diagnosis of periapical abscess was made in 12 (63%) of 19 patients. Ultrasound agreed with panorex x-ray in 10 (83%) of 12 cases. In 1 of the 2 cases where US disagreed with panorex x-rays, x-ray abnormalities were reported on the nonsymptomatic side. The other patient was given antibiotics and recommended outpatient follow-up. Follow-up information was not available to further confirm the presence of an abscess. Assuming that the patient who was lost to follow-up had dental abscess, the sensitivity and specificity of US in diagnosing a dental abscess were 92% and 100%, respectively.

Conclusions: Bedside US is nonionizing, is readily available, and can provide an alternative to panorex x-rays in the evaluation of a dental abscess in ED.

18. Aging Gracefully? Patient Safety Advocates Call for Ongoing Skills Assessments for Older Physicians

McKenna M. Ann Emerg Med. 2011;58:A15-A17.

In an era focused on quality measures, it has become common to compare medicine with aviation. The air industry's practices, from checklists during procedures to training exercises for entire teams, seem to offer lessons for medical institutions still struggling with errors and health care–associated infections.

Some patient advocates are asking whether medicine—and especially emergency medicine, a specialty that, like flying, runs on adrenaline and relies on quick decisionmaking—should adopt another aviation practice: a mandatory retirement age.

Advocates are pressing at least for medicine to adopt some standardized means of assessing any age-related decay in physicians' practice skills. The crucial lack, say advocates, is that periodic recertification—which older physicians in some specialties can escape through grandfathering—addresses only didactic knowledge and does not measure clinical expertise.

“The overarching problem in our system is that we don't regularly test the competency of doctors throughout their careers,” said Lisa McGiffert, BA, director of the Safe Patient Project at Consumers' Union. “There has to be some real experience testing—not just pencil and paper knowledge tests, but ability to examine a patient and diagnose a patient.”

“Some people are as good at 80 as they were at 60, no question,” said Diane Pinakiewicz, MBA, executive director of the National Patient Safety Foundation. “But the fact that there is no process to evaluate that, and that it is left to the discretion of the individual to perceive—you don't find that in other industries. We have come a long way in patient-safety work by looking at other industries and learning from them, and we should do that with respect to this issue as well.”

Pilot Performance

In aviation, she offered, pilots undergo ongoing simulator training, as well as periodic observation by another pilot while they are flying an aircraft. Even with those benchmarks, commercial airline pilots must retire from active service by age 65 years.
“I personally feel that [a mandatory retirement age] is something we should be looking at,” Pinakiewicz said. At least, she added, there should be some assessment of a physician's skill by someone other than the physician himself.

“You hear stories of physicians who are well thought of for their clinical skill, who begin a decline due to inevitable aging, and there is no structured way for anyone to deal with that, so that it falls to a brave colleague to try to convince them,” she said. “It is inconceivable to me that in an industry like ours, where the stakes are everything, we do not have any check and balance on this issue.”

A small but consistent body of literature confirms the intuitive assumption that physicians' skills decay as they age.

As far back as 1972, researchers from Johns Hopkins School of Medicine found that primary care physicians with decades in private practice were less likely to prescribe drugs appropriately than physicians who had left training recently.1 In 2000, health care quality analysts at Cornell University found that the risk of death after carotid endarterectomy increased with the surgeon's age.2 In 2002, faculty from McMaster University in Ontario reported that older general-practice physicians scored lower than younger ones on performance assessments that included mock encounters with standardized patients.3 In 2005, Harvard surgeon and author Atul Gawande, MD, MPH, and his collaborators analyzed the results of a multicenter Veterans Administration trial of open versus laparoscopic herniorrhaphies and found that the risk of recurrence was 1.72 times higher for surgeons older than 45 years.4

And a 2005 meta-analysis of 62 studies of physician performance and age or time since licensure found that more than half confirmed the inverse relationship. The longer a physician had been in practice, the worse his or her outcomes were likely to be, and participation in continuing medical education and recertification made no difference to the result.5

An accompanying editorial, written by staff from the American Board of Internal Medicine, called for dramatic changes in professional development requirements. “The profession cannot ignore this striking finding and its implications: Practice does not make perfect, but it must be accompanied by ongoing active effort to maintain competence and quality of care,” they said. “The message is clear for certifying boards (which have the responsibility to ensure the public of the ongoing competence of physicians in their specialty) and medical specialty societies (which have the responsibility to provide relevant and effective continuing education and tools that enable physicians to maintain competence).”6

To be fair, none of the studies that examined the relationship between physician competence and aging looked specifically at emergency physicians. But there seems little reason to believe emergency physicians would be exempt from the effects of aging that have been observed in practitioners from other specialties.

Survey Said

In fact, one survey of emergency physicians, conducted in 2006 to 2007 on behalf of the American College of Emergency Physicians (ACEP) (publisher of Annals of Emergency Medicine) suggests how universal the effects of aging may be. The college sent surveys to a random sample of 1,000 ACEP members who were older than 55 years and received 802 usable replies. Although the respondents saw themselves as competent clinicians experiencing little decline in their procedural skills, the survey also showed that

1. 74% had difficulty recovering from nightshifts;

2. 44% experienced emotional exhaustion at the end of a shift;

3. 40% felt less ability to manage heavy patient volume;

4. 36% reported they were less able to manage the overall stress of emergency medicine;

5. 28% believed their memory was somewhat or considerably worse;

6. 25% believed they were less able to incorporate new diagnosis and treatment modalities into their practice.7

Those percentages were robust enough to provoke action, and the college began drafting guidelines to help older members think about the demands of their practice, as well as to offer resources for questions about finances in relation to approaching retirement.

In a policy statement, posted online in June 2009, the college observed that 30% of its membership was aged 50 years or older and urged “workload modifications” as appropriate. Changes included minimizing rotating shifts, moving older physicians off nightshifts, scheduling additional recovery time after nightshifts, shortening shifts to 8 to 10 hours or less, and encouraging physicians to transition from clinical to administrative work.8

The remainder of the essay (with reference) full-text free: http://www.annemergmed.com/article/S0196-0644(11)01299-6/fulltext

19. Ultrasound Does Not Detect Early Blood Loss in Healthy Volunteers Donating Blood

Resnick J, et al. J Emerg Med. 2011;41:270-275.

Background: Ultrasound has been suggested as a useful non-invasive tool for the detection of early blood loss. Two possible sonographic markers for hypovolemia are the diameter of the inferior vena cava (IVC) and the thickness of the left ventricle (LV).

Study Objectives: The goal of the study was to evaluate the utility of ultrasound to detect signs of early hemorrhagic shock in healthy volunteers, compared with changes in vital signs.

Methods: In the current study, healthy volunteers from blood donation drives were used as models for early hemorrhage. Changes in vital signs, IVC diameter, and LV wall thickness were recorded after approximately 500 cc of blood loss.

Results: Thirty-eight subjects were enrolled and completed the study. After blood donation, there was a 7-mm Hg (8%) decrease in mean arterial pressure without a significant change in heart rate. There was a decrease in maximum IVC diameter (IVCmax) (12% decrease [95% confidence interval (CI) −6 to −19] in short axis and 20% decrease [95% CI −12 to −27] in long axis), but no change was seen in the respiratory caval index ((IVCmax − IVCmin)/IVCmax) × 100). There was no change in LV wall thickness.

Conclusion: In this study, serial changes in vital signs, IVC diameter, and LV wall thickness were clinically insignificant after approximately 500 cc of blood loss in healthy volunteers.

20. Guess the Uncommon Cause of This Rhythm

Kyuhyun Wang, MD. MedScape Emergency Medicine. 09/08/2011

http://www.medscape.com/viewarticle/748907

21. For Physicians: The Perils and Pitfalls of Social Networks

Désirée Lie, MD, MSEd. MD Consult. Posted: 08/26/2011

A Primer for Responsible Social Networking

Consider the following situations:

A. You maintain a personal Facebook account that identifies you by photograph, name, age, and practice status. You use the highest privacy setting. A patient who lives in your neighborhood and whose children go to the same school as yours makes an online request to "friend" you. You Google the patient and find her social contacts and information about her employment and political opinions. How would you respond to her request?

B. You are in private practice and maintain contact with colleagues through online social networks. You notice a recent tweet from a colleague employed by a prominent local hospital asking for advice from psychiatrists about management of an acutely suicidal patient without explicit patient permission. What, if anything, should you do?

These situations raise some key questions. Can physicians, nurses, pharmacists, and other healthcare professionals separate their personal and professional identities online? What are the duties of healthcare providers to maintain the integrity and status of their respective professions when it comes to other clinicians' use of social media?

The remainder of the essay (one-time registration required): http://www.medscape.com/viewarticle/748400

Lit Bits: August 27, 2011

2011-08-27T09:24:00.000-07:00

From the recent medical literature...

1. Malpractice Risk According to Physician Specialty

Jena AB, et al. N Engl J Med 2011;365:629-636.

Background: Data are lacking on the proportion of physicians who face malpractice claims in a year, the size of those claims, and the cumulative career malpractice risk according to specialty.

Methods: We analyzed malpractice data from 1991 through 2005 for all physicians who were covered by a large professional liability insurer with a nationwide client base (40,916 physicians and 233,738 physician-years of coverage). For 25 specialties, we reported the proportion of physicians who had malpractice claims in a year, the proportion of claims leading to an indemnity payment (compensation paid to a plaintiff), and the size of indemnity payments. We estimated the cumulative risk of ever being sued among physicians in high- and low-risk specialties.

Results: Each year during the study period, 7.4% of all physicians had a malpractice claim, with 1.6% having a claim leading to a payment (i.e., 78% of all claims did not result in payments to claimants). The proportion of physicians facing a claim each year ranged from 19.1% in neurosurgery, 18.9% in thoracic–cardiovascular surgery, and 15.3% in general surgery to 5.2% in family medicine, 3.1% in pediatrics, and 2.6% in psychiatry. The mean indemnity payment was $274,887, and the median was $111,749. Mean payments ranged from $117,832 for dermatology to $520,923 for pediatrics. It was estimated that by the age of 65 years, 75% of physicians in low-risk specialties had faced a malpractice claim, as compared with 99% of physicians in high-risk specialties.

Conclusions: There is substantial variation in the likelihood of malpractice suits and the size of indemnity payments across specialties. The cumulative risk of facing a malpractice claim is high in all specialties, although most claims do not lead to payments to plaintiffs. (Funded by the RAND Institute for Civil Justice and the National Institute on Aging.)

Full-text (free): http://www.nejm.org/doi/full/10.1056/NEJMsa1012370#t=articleTop

2. The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism.

Hugli O, et al. J Thromb Haemost. 2011;9:300-4.

BACKGROUND: The Pulmonary Embolism Rule-out Criteria (PERC) rule is a clinical diagnostic rule designed to exclude pulmonary embolism (PE) without further testing. We sought to externally validate the diagnostic performance of the PERC rule alone and combined with clinical probability assessment based on the revised Geneva score.

METHODS: The PERC rule was applied retrospectively to consecutive patients who presented with a clinical suspicion of PE to six emergency departments, and who were enrolled in a randomized trial of PE diagnosis. Patients who met all eight PERC criteria [PERC((-))] were considered to be at a very low risk for PE. We calculated the prevalence of PE among PERC((-)) patients according to their clinical pretest probability of PE. We estimated the negative likelihood ratio of the PERC rule to predict PE.

RESULTS: Among 1675 patients, the prevalence of PE was 21.3%. Overall, 13.2% of patients were PERC((-)). The prevalence of PE was 5.4% [95% confidence interval (CI): 3.1-9.3%] among PERC((-)) patients overall and 6.4% (95% CI: 3.7-10.8%) among those PERC((-)) patients with a low clinical pretest probability of PE. The PERC rule had a negative likelihood ratio of 0.70 (95% CI: 0.67-0.73) for predicting PE overall, and 0.63 (95% CI: 0.38-1.06) in low-risk patients.

CONCLUSIONS: Our results suggest that the PERC rule alone or even when combined with the revised Geneva score cannot safely identify very low risk patients in whom PE can be ruled out without additional testing, at least in populations with a relatively high prevalence of PE.

3. New Options in Anticoagulation for Atrial Fibrillation

del Zoppo GJ, et al. N Engl J Med 2011; Aug 10. [Epub ahead of print]

The presence of atrial fibrillation significantly increases the risk and burden of thromboembolic stroke.1 Warfarin is the reference standard treatment for the primary prevention of embolic stroke during atrial fibrillation.2 However, the long-term use of warfarin has its limitations. Although guidelines suggest a target international normalized ratio (INR) of 2.5 (range, 2.0 to 3.0) for this indication,2 only about 60% of patients have an INR within the recommended range at a given time in usual clinical practice. This is the reason that is most often given for the search for other oral antithrombotic agents that could be simpler to manage and that might replace warfarin in such patients.

Two recent studies have compared new antithrombotic agents with warfarin for the primary prevention of thromboembolic events in patients with nonvalvular atrial fibrillation. In this issue of the Journal, Patel et al.3 report the results of the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF), in which the investigators compared rivaroxaban, a direct factor Xa inhibitor, with warfarin. This study follows on the heels of the report of the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial (ClinicalTrials.gov number, NCT00262600),4 showing that dabigatran, a direct thrombin inhibitor, was not inferior to warfarin. Both studies provide some points to ponder for a condition in which placebo-controlled trials are no longer possible.

One interesting point is how the interpretation of ROCKET AF depends on the results from the three different protocol-specified analyses of the primary outcome of stroke or systemic embolism. The primary analysis included only patients who were treated according to protocol and were followed for outcome events only for the period during which they were actually receiving the assigned treatment (or within 2 days after the last dose). This analysis, designated the “per-protocol, as-treated” analysis, resulted in a conservative test for noninferiority5 and showed that rivaroxaban was significantly noninferior to warfarin. The authors also tested for superiority using an intention-to-treat analysis, which did not show superiority for rivaroxaban over warfarin.

Between these two analyses, the authors conducted another analysis in the “as-treated safety population.” Here, they included all patients who received at least one dose of a study drug and were followed for events while receiving the drug (or within 2 days after the last dose), regardless of adherence to protocol. It is not surprising that the annual event rates in the two study groups in this analysis were much closer to those of the per-protocol analysis than to those in the intention-to-treat analysis. As a consequence, in the safety analysis, the between-group P value was significant, even though the results do not show superiority for rivaroxaban over warfarin, since the intention-to-treat analysis was negative. Thus, the multiple analyses have muddied the waters regarding rivaroxaban's efficacy and effectiveness over warfarin.

Trials comparing new oral antithrombotic agents with warfarin are dependent on the quality of the management of the warfarin cohort. Overall compliance varies. Trials like ROCKET AF and RE-LY use algorithms for imputing the dummy INR of the warfarin placebo in patients who are not receiving warfarin in order to maintain blinding. They also use the concept of “time in therapeutic range” to assess the quality of warfarin management. Such trials typically use a method described by Rosendaal et al.,6 in which the measured INR values and the interval between INR tests are both taken into account. On the basis of this approach, INR values were within the therapeutic range a mean of 55% of the time in ROCKET AF and 64% in the RE-LY trial. So the interpretation of noninferiority in a given trial may also depend both on the homogeneity and treatment accuracy of the warfarin cohort and on the dummy INR algorithm that is used.

Overall, the frequency of major hemorrhagic events in ROCKET AF did not differ significantly between the rivaroxaban group and the warfarin group. A similar finding was seen in the RE-LY study. However, interestingly, both studies showed a reduction in the rate of intracranial hemorrhage with the new oral antithrombotic agent, as compared with warfarin. The reasons for the potential reduction in intracranial hemorrhage that was associated with these agents are not clear, but one possibility is the effect on a single target in the hemostatic system by the new antithrombotic agents versus the multiple targets by warfarin.7 More intriguing is the possibility that cerebral vascular beds have protective features that are more apparent at the doses of either of the new agents tested. The presence of large amounts of tissue factor in the cerebral vascular neighborhood could modulate vascular hemostatic activity within brain vessels. It is possible that neither rivaroxaban nor dabigatran affects the complex made up of tissue factor and factor VIIa, whereas warfarin decreases factor VII activity. Does this difference influence the risk of hemorrhage? Fundamental studies of cerebral vascular responses to these agents and of the differential risk of intracranial hemorrhage in the two trials would be instructive.

For the management of atrial fibrillation, oral alternatives to warfarin have arrived. Their simplicity of use is attractive, and they appear to have an efficacy similar to that of warfarin, with the proviso that comparisons seem to depend on how easily the patient can be treated with warfarin. An important concern that these clinical trials do not address is the absence of antidotes to rapidly reverse the anticoagulant effects of either rivaroxaban or dabigatran in the case of life-threatening hemorrhage or surgery. All these issues need to be taken into account in clinical decision making. Further studies will be necessary to refine the treatment of a growing population of patients with atrial fibrillation in order to reduce the risk of stroke.

References: http://www.nejm.org/doi/full/10.1056/NEJMe1107516

4. ECG Findings in ED Patients with Syncope

Quinn J, et al. Acad Emerg Med. 2011; 18:714–718

Objectives: To determine the sensitivity and specificity of the San Francisco Syncope Rule (SFSR) electrocardiogram (ECG) criteria for determining cardiac outcomes and to define the specific ECG findings that are the most important in patients with syncope.

Methods: A consecutive cohort of emergency department (ED) patients with syncope or near syncope was considered. The treating emergency physicians assessed 50 predictor variables, including an ECG and rhythm assessment. For the ECG assessment, the physicians were asked to categorize the ECG as normal or abnormal based on any changes that were old or new. They also did a separate rhythm assessment and could use any of the ECGs or available monitoring strips, including prehospital strips, when making this assessment. All patients were followed up to determine a broad composite study outcome. The final ECG criterion for the SFSR was any nonsinus rhythm or new ECG changes. In this specific study, the initial assessments in the database were used to determine only cardiac-related outcomes (arrhythmia, myocardial infarction, structural, sudden death) based on set criteria, and the authors determined the sensitivity and specificity of the ECG criteria for cardiac outcomes only. All ECGs classified as “abnormal” by the study criteria were compared to the official cardiology reading to determine specific findings on the ECG. Univariate and multivariate analysis were used to determine important specific ECG and rhythm findings.

Results: A total of 684 consecutive patients were considered, with 218 having positive ECG criteria and 42 (6%) having important cardiac outcomes. ECG criteria predicted 36 of 42 patients with cardiac outcomes, with a sensitivity of 86% (95% confidence interval [CI] = 71% to 94%), a specificity of 70% (95% CI = 66% to 74%), and a negative predictive value of 99% (95% CI = 97% to 99%). Regarding specific ECG findings, any nonsinus rhythm from any source and any left bundle conduction problem (i.e., any left bundle branch block, left anterior fascicular block, left posterior fascicular block, or QRS widening) were 2.5 and 3.5 times more likely associated with significant cardiac outcomes.

Conclusions: The ECG criteria from the SFSR are relatively simple, and if used correctly can help predict which patients are at risk of cardiac outcomes. Furthermore, any left bundle branch block conduction problems or any nonsinus rhythms found during the ED stay should be especially concerning for physicians caring for patients presenting with syncope.

The SF Syncope Rule: http://www.mdcalc.com/san-francisco-syncope-rule-to-predict-serious-outcomes

Related syncope abstract on the ROSE Decision Instrument in Ann Emerg Med Sept 2011: http://www.annemergmed.com/article/S0196-0644(10)01931-1/abstract

5. Cycling is good for you—even in the big city

The health risks and benefits of cycling in urban environments compared with car use: health impact assessment study

Rojas-Rueda D, et al. BMJ 2011;343:d4521

Objective: To estimate the risks and benefits to health of travel by bicycle, using a bicycle sharing scheme, compared with travel by car in an urban environment.

Design: Health impact assessment study.

Setting: Public bicycle sharing initiative, Bicing, in Barcelona, Spain.

Participants: 181 982 Bicing subscribers.

Main outcomes measures: The primary outcome measure was all cause mortality for the three domains of physical activity, air pollution (exposure to particulate matter smaller than 2.5 µm), and road traffic incidents. The secondary outcome was change in levels of carbon dioxide emissions.

Results: Compared with car users the estimated annual change in mortality of the Barcelona residents using Bicing (n=181 982) was 0.03 deaths from road traffic incidents and 0.13 deaths from air pollution. As a result of physical activity, 12.46 deaths were avoided (benefit:risk ratio 77). The annual number of deaths avoided was 12.28. As a result of journeys by Bicing, annual carbon dioxide emissions were reduced by an estimated 9 062 344 kg.

Conclusions: Public bicycle sharing initiatives such as Bicing in Barcelona have greater benefits than risks to health and reduce carbon dioxide emissions.

6. Low Prevalence of Bacteremia in Children with Community Acquired Pneumonia

Shah SS et al. Pediatr Infect Dis J 2011;30:475

Blood culture results rarely changed management, and did so mainly in children with complicated CAP.

Background: Blood cultures are frequently obtained in the emergency department (ED) evaluation of children with community-acquired pneumonia (CAP).

Objectives: To determine the prevalence of bacteremia in children presenting to the ED with CAP, identify subgroups at increased risk for bacteremia, and quantify the effect of positive blood cultures on management.

Methods: This case–control study was nested within a cohort of children followed up at 35 pediatric practices. Patients from this cohort who were ≤18 years of age, evaluated in the ED in 2006–2007, and diagnosed with CAP were eligible. Cases were those with bacteremia. Controls included those with negative blood cultures and those without blood cultures performed.

Results: A total of 877 (9.6%) of 9099 children with CAP were evaluated in the ED. The mean age was 3.6 years; 53% were male. Blood cultures were obtained from 291 children (33.2%). Overall, the prevalence of bacteremia was 2.1% (95% confidence interval [CI]: 0.8%–4.4%). Bacteremia occurred in 2.6% (95% CI: 1.0%–5.6%) with an infiltrate on chest radiograph and in 13.0% (95% CI: 2.8%–33.6%) with complicated pneumonia. Streptococcus pneumoniae accounted for 4 of the 6 cases of bacteremia. Blood culture results altered management in 5 of the 6 bacteremic patients; 1 had an appropriate broadening and 4 had an appropriate narrowing of coverage. The contamination rate was 1.0% (95% CI: 0.2%–3.0%).

Conclusion: Children presenting to the ED for evaluation of CAP are at low-risk for bacteremia. Although positive blood cultures frequently altered clinical management, the overall impact was small because of the low prevalence of bacteremia..

7. Diagnosis of Spinal Cord Compression in Nontrauma Patients in the ED

Dugas AF, et al. Acad Emerg Med. 2011;18:719–725

Objectives: The objectives were to evaluate the presenting signs and symptoms of spinal cord and cauda equina compression (SCC) and to determine the incidence of emergency department (ED) misdiagnosis.

Methods: This was a retrospective chart review at an urban, tertiary care hospital of patients discharged from an inpatient stay (April 2008 through July 2009) with an International Classification of Diseases, Ninth Revision (ICD-9) code indicating spinal disease, who had visited the ED for a related complaint within the previous 30 days, and who had a final diagnosis of new SCC. Trauma and transferred patients were excluded. The authors defined a misdiagnosis as no ED-documented diagnosis of SCC and failure to perform an appropriate diagnostic study either prior to arrival, in the ED, or immediately upon admission.

Results: Of 1,231 charts reviewed, 63 met inclusion criteria. The most common presenting symptoms in patients with SCC were pain (44, 70%), difficulty ambulating (38, 60%), and weakness (35, 56%). On physical examination, motor deficits (45, 71%) were more common than sensory deficits (27, 43%); however, 15 (24%) patients had no motor or sensory deficit, and 13 (23%) patients only had unilateral findings. Impaired gait was present in 14 patients of only 20 tested, three of whom had no associated motor or sensory deficit. SCC was misdiagnosed in 18 (29%, 95% confidence interval [CI] = 19% to 41%) cases, which resulted in a significant delay to diagnosis (median = 54 hours, interquartile range [IQR] = 38 to 77 vs. 5.3 hours, IQR = 3.0 to 15) in these patients.

Conclusions: SCC can have a subtle presentation with absent or unilateral motor and sensory deficits, but gait ataxia may be an additional finding. ED misdiagnosis of SCC in nontrauma patients is common.

8. Intraosseous Versus Intravenous Vascular Access during Out-of-Hospital Cardiac Arrest: A Randomized Controlled Trial

Reades R, et al. Ann Emerg Med. 2011; in press

Study objective: Intraosseous needle insertion during out-of-hospital cardiac arrest is rapidly replacing peripheral intravenous routes in the out-of-hospital setting. However, there are few data directly comparing the effectiveness of intraosseous needle insertions with peripheral intravenous insertions during out-of-hospital cardiac arrest. The objective of this study is to determine whether there is a difference in the frequency of first-attempt success between humeral intraosseous, tibial intraosseous, and peripheral intravenous insertions during out-of-hospital cardiac arrest.

Methods: This was a randomized trial of adult patients experiencing a nontraumatic out-of-hospital cardiac arrest in which resuscitation efforts were initiated. Patients were randomized to one of 3 routes of vascular access: tibial intraosseous, humeral intraosseous, or peripheral intravenous. Paramedics received intensive training and exposure to all 3 methods before study initiation. The primary outcome was first-attempt success, defined as secure needle position in the marrow cavity or a peripheral vein, with normal fluid flow. Needle dislodgement during resuscitation was coded as a failure to maintain vascular access.

Results: There were 182 patients enrolled, with 64 (35%) assigned to tibial intraosseous, 51 (28%) humeral intraosseous, and 67 (37%) peripheral intravenous access. Demographic characteristics were similar among patients in the 3 study arms. There were 130 (71%) patients who experienced initial vascular access success, with 17 (9%) needles becoming dislodged, for an overall frequency of first-attempt success of 113 (62%). Individuals randomized to tibial intraosseous access were more likely to experience a successful first attempt at vascular access (91%; 95% confidence interval [CI] 83% to 98%) compared with either humeral intraosseous access (51%; 95% CI 37% to 65%) or peripheral intravenous access (43%; 95% CI 31% to 55%) groups. Time to initial success was significantly shorter for individuals assigned to the tibial intraosseous access group (4.6 minutes; interquartile range 3.6 to 6.2 minutes) compared with those assigned to the humeral intraosseous access group (7.0 minutes; interquartile range 3.9 to 10.0 minutes), and neither time was significantly different from that of the peripheral intravenous access group (5.8 minutes; interquartile range 4.1 to 8.0 minutes).

Conclusion: Tibial intraosseous access was found to have the highest first-attempt success for vascular access and the most rapid time to vascular access during out-of-hospital cardiac arrest compared with peripheral intravenous and humeral intraosseous access

9. Placebo by Proxy: Effects on the Patient’s Friends and Family

Grelotti DJ, et al. BMJ 2011;343:d4345

Clinicians’ and family members’ feelings and perceptions about a treatment may influence their judgments about its effectiveness

The effect of placebo on the patient and the patient’s environment is often debated, but people other than the patient may also feel better when a patient receives placebo treatment. The anthropologist Claude Lévi-Strauss alluded to this when he described how medical treatments, including those where ritual alone provides the cure, occur in a social context and convey a “sense of security” to the social group.1

Clinicians and family members may have an emotional response to a patient’s treatment and think that the treatment is helping the patient even in the absence of any direct physiological benefit to the patient or indication from the patient that the treatment is working. These feelings and perceptions may arise when placebos, including “impure” placebos, such as active drugs or operations that have no effect on the disease process, are used in clinical practice and research settings. Because these feelings and perceptions are not accounted for in descriptions of the placebo effect and can exist independently of any placebo effect on the patient, they can be described as placebo effects by proxy, or placebo by proxy for short. Although placebo by proxy has important implications, the phenomenon is underappreciated and rarely discussed.

Placebo by proxy could be as ubiquitous as the placebo effect, and in some situations placebo by proxy can dominate clinical decision making. For example, the parents of a child with a viral upper respiratory illness may believe that the child needs antibiotics, and parental expectations or the doctor’s perception of parental expectations (or both) may influence prescribing patterns.2 3 Antibiotics are overprescribed in these situations and function as impure placebos4; the psychological benefit to the parent, such as a relief from worry, represents placebo by proxy.

In the absence of evidence to support long term use of antipsychotics in patients with dementia and a history of agitation, aggression, or psychosis,5 6placebo by proxy may help to explain why clinicians often maintain their patients on these drugs. In a controlled double blind study of discontinuation of psychotropics in a sample of patients with dementia who were taking these drugs because of a history of agitation (67.3% were taking antipsychotics), the authors found a lack of an effect of psychotropics when they compared mean scores on behaviour rating scales during the treatment and placebo phases of the trial.6 However, clinical workers were resistant to stopping treatment because they had “a great deal of faith in the utility of these drugs to control agitation in this population.”6 Psychotropics functioned as impure placebos for many of these patients, and the concern of clinicians that patients would decompensate without these drugs provides another example of placebo by proxy.

In addition to influencing clinical decision making, placebo by proxy could influence estimations of treatment outcome in trials, especially when the perceptions of clinicians or family members are favoured over objective markers of patient response.7 In placebo controlled clinical trials of secretin to reduce symptoms of autism, the patient’s response to secretin was primarily based on the opinions of parents, teachers, or clinicians (or a combination thereof).8 Ten randomised controlled trials and a meta-analysis showed robust and consistent reductions in core symptoms of autism as measured by standardised rating scales in both the treatment and placebo groups, but no significant differences were seen between the groups on these measures.8 9 The robust response to placebo may have been influenced by anecdotal reports, which generated positive press about secretin and gave rise to the need for clinical trials.8 9 Perception or misperception by parents may also partially explain a larger placebo response in children than in adults participating in clinical trials of treatment resistant epilepsy.10

Placebo by proxy may also explain findings from meta-analyses where improvement measured by observers is much higher than improvement reported by patients. For example, for depression, the mean effect size of observer rated improvement is 1.85 (95% confidence interval 1.69 to 2.01), compared with 0.67 (0.49 to 0.85) for patient reported improvement.11 For irritable bowel syndrome, the pooled placebo response rate for physician rated improvement is 53.0%, compared with 37.4% for patient rated improvement (P=0.005).12

The different mechanisms that underlie the placebo effect are likely to shape placebo by proxy also.12 These processes may include seeing other patients respond to the same drug, associative learning such as conditioning, a supportive physician-patient relationship, and reduced anxiety.

Placebo by proxy and the placebo effect may interact to create positive change. For example, if clinicians and family members feel empowered and optimistic about a disease, the patient’s environment can become less stressful and more supportive. Clinicians and family members may react to placebo by smiling more, paying more attention to the patient, promoting treatment adherence, encouraging the patient to engage in new activities, or creating other targets for behavioural change.8 9 In this way, placebo by proxy may elicit changes in the patient’s psychosocial context that mediate the placebo effect.

Although placebo by proxy may enhance clinical outcomes, it might also cause harm. If treatment related decisions are unduly weighted towards providing a psychological benefit to people other than the patient, the patient may not benefit from the treatment yet may still bear the risks. The treatments mentioned above cost money and are not benign: antibiotics cause diarrhoea and are associated with antibiotic resistance, antipsychotics are associated with an increased risk of death in elderly patients with dementia related psychosis, and secretin infusion may result in a life threatening allergic reaction. Placebo by proxy may create a false sense that a patient is getting better and thereby prevent more appropriate treatment,7 8 or it may produce changes in attitude and behaviour towards the patient that lead to neglect. Placebo by proxy is probably more likely to cause harm when decisions are made in the absence of clinical evidence and when patients cannot make decisions for themselves.

Treatment benefits could be maximised and harms mitigated if placebo by proxy were taken into account when making clinical decisions. For many of the above clinical situations, an appreciation of placebo by proxy may prompt clinicians to question attachments to treatment practices that are not supported by evidence. Placebo by proxy could be used as a potential clinical tool. For example, it may be possible to boost the psychological benefit of a patient’s treatment by generating appropriate enthusiasm for treatment among those involved in the patient’s care. Because almost every treatment related decision is shared and patients sometimes agree to treatment to make their clinicians and family members happy, clinicians should be aware of placebo by proxy when guiding clinical decisions and evaluating treatment response.

10. Evidence-based Diagnostics: Adult Septic Arthritis

Carpenter CR, et al. Acad Emerg Med. 2011;18:782-796.

Background: Acutely swollen or painful joints are common complaints in the emergency department (ED). Septic arthritis in adults is a challenging diagnosis, but prompt differentiation of a bacterial etiology is crucial to minimize morbidity and mortality.

Objectives: The objective was to perform a systematic review describing the diagnostic characteristics of history, physical examination, and bedside laboratory tests for nongonococcal septic arthritis. A secondary objective was to quantify test and treatment thresholds using derived estimates of sensitivity and specificity, as well as best-evidence diagnostic and treatment risks and anticipated benefits from appropriate therapy.

Methods: Two electronic search engines (PUBMED and EMBASE) were used in conjunction with a selected bibliography and scientific abstract hand search. Inclusion criteria included adult trials of patients presenting with monoarticular complaints if they reported sufficient detail to reconstruct partial or complete 2 × 2 contingency tables for experimental diagnostic test characteristics using an acceptable criterion standard. Evidence was rated by two investigators using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS). When more than one similarly designed trial existed for a diagnostic test, meta-analysis was conducted using a random effects model. Interval likelihood ratios (LRs) were computed when possible. To illustrate one method to quantify theoretical points in the probability of disease whereby clinicians might cease testing altogether and either withhold treatment (test threshold) or initiate definitive therapy in lieu of further diagnostics (treatment threshold), an interactive spreadsheet was designed and sample calculations were provided based on research estimates of diagnostic accuracy, diagnostic risk, and therapeutic risk/benefits.

Results: The prevalence of nongonococcal septic arthritis in ED patients with a single acutely painful joint is approximately 27% (95% confidence interval [CI] = 17% to 38%). With the exception of joint surgery (positive likelihood ratio [+LR] = 6.9) or skin infection overlying a prosthetic joint (+LR = 15.0), history, physical examination, and serum tests do not significantly alter posttest probability. Serum inflammatory markers such as white blood cell (WBC) counts, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are not useful acutely. The interval LR for synovial white blood cell (sWBC) counts of 0 × 109–25 × 109/L was 0.33; for 25 × 109–50 × 109/L, 1.06; for 50 × 109–100 × 109/L, 3.59; and exceeding 100 × 109/L, infinity. Synovial lactate may be useful to rule in or rule out the diagnosis of septic arthritis with a +LR ranging from 2.4 to infinity, and negative likelihood ratio (–LR) ranging from 0 to 0.46. Rapid polymerase chain reaction (PCR) of synovial fluid may identify the causative organism within 3 hours. Based on 56% sensitivity and 90% specificity for sWBC counts above 50 × 109/L in conjunction with best-evidence estimates for diagnosis-related risk and treatment-related risk/benefit, the arthrocentesis test threshold is 5%, with a treatment threshold of 39%.

Conclusions: Recent joint surgery or cellulitis overlying a prosthetic hip or knee were the only findings on history or physical examination that significantly alter the probability of nongonococcal septic arthritis. Extreme values of sWBC (above 50 × 109/L) can increase, but not decrease, the probability of septic arthritis. Future ED-based diagnostic trials are needed to evaluate the role of clinical gestalt and the efficacy of nontraditional synovial markers such as lactate.

11. Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study

Douma RA, et al. Ann Intern Med. 2011;154(11):709-18.

BACKGROUND: Several clinical decision rules (CDRs) are available to exclude acute pulmonary embolism (PE), but they have not been directly compared.

OBJECTIVE: To directly compare the performance of 4 CDRs (Wells rule, revised Geneva score, simplified Wells rule, and simplified revised Geneva score) in combination with d-dimer testing to exclude PE.

DESIGN: Prospective cohort study.

SETTING: 7 hospitals in the Netherlands.

PATIENTS: 807 consecutive patients with suspected acute PE.

INTERVENTION: The clinical probability of PE was assessed by using a computer program that calculated all CDRs and indicated the next diagnostic step. Results of the CDRs and d-dimer tests guided clinical care.

MEASUREMENTS: Results of the CDRs were compared with the prevalence of PE identified by computed tomography or venous thromboembolism at 3-month follow-up.

RESULTS: Prevalence of PE was 23%. The proportion of patients categorized as PE-unlikely ranged from 62% (simplified Wells rule) to 72% (Wells rule). Combined with a normal d-dimer result, the CDRs excluded PE in 22% to 24% of patients. The total failure rates of the CDR and d-dimer combinations were similar (1 failure, 0.5% to 0.6% [upper-limit 95% CI, 2.9% to 3.1%]). Even though 30% of patients had discordant CDR outcomes, PE was not detected in any patient with discordant CDRs and a normal d-dimer result.

LIMITATION: Management was based on a combination of decision rules and d-dimer testing rather than only 1 CDR combined with d-dimer testing.

CONCLUSION: All 4 CDRs show similar performance for exclusion of acute PE in combination with a normal d-dimer result. This prospective validation indicates that the simplified scores may be used in clinical practice.

12. Three Evidence Based Summaries

A. Does Therapeutic Hypothermia Benefit Survivors of Cardiac Arrest?

Seupaul RA, et al. Ann Emerg Med 2011;58:282-283

Take Home Message: Therapeutic hypothermia with conventional cooling methods improves survival and neurologic outcomes at hospital discharge for patients who have experienced a cardiac arrest.

Full text (free): http://www.annemergmed.com/article/S0196-0644(11)00115-6/fulltext

B. Do Triptans Effectively Treat Acute Cluster Headache in the Emergency Department?

Seupaul RA, et al. Ann Emerg Med 2011;58:284-285

Take Home Message: Triptans, particularly if administered subcutaneously, provide rapid relief for acute cluster headache.

Full text (free): http://www.annemergmed.com/article/S0196-0644(11)00126-0/fulltext

C. Is the Canalith Repositioning Maneuver Effective in the Acute Management of Benign Positional Vertigo?

Brown MD. Ann Emerg Med 2011;58:286-287

Take Home Message: The Epley maneuver is a very effective treatment for benign paroxysmal positional vertigo.

Full text (free): http://www.annemergmed.com/article/S0196-0644(11)00139-9/fulltext

13. Diagnostic Accuracy of High-Sensitivity Troponin Assays at 2 Hours

The high negative predictive value provides one more stone in the road to a 2-hour rule-out protocol for AMI.

New high-sensitivity troponin (hs-Tn) assays can detect minute amounts of troponin, potentially allowing earlier definitive diagnosis of acute myocardial infarction (AMI) than is currently possible (JW Emerg Med Apr 16 2010). In a prospective observational international study, researchers compared the diagnostic accuracy of absolute and relative changes in troponin I and T levels measured with hs-Tn assays in 1197 consecutive patients who presented to emergency departments with symptoms suggesting AMI and without ST-segment elevation on the initial electrocardiogram. Usual care was provided. The final diagnosis of AMI was determined by independent cardiologists who were blinded to the hs-Tn assay results.

Blood samples drawn at presentation and at 1, 2, 3, and 6 hours were available for 590 patients. AMI was the final diagnosis in 108 patients (13%). Absolute changes in troponin levels performed significantly better than relative changes on all performance measures. The absolute change in troponin T within 2 hours had a sensitivity of 89%, specificity of 93%, positive predictive value of 64%, and negative predictive value of 98% for AMI; results were similar for troponin I. Absolute changes at 6 hours (available for 305 patients) did not improve on the accuracy of those at 2 hours.

Comment: This was a study of chemical measurements, not of clinical care, which proceeded in the usual fashion; thus, the findings should not change practice. The study does, however, offer the prospect of changes to guidelines, which could speed throughput and allow more rapid determination of the need for interventional cardiology measures.

— J. Stephen Bohan, MD, MS, FACP, FACEP. Published in Journal Watch Emergency Medicine August 12, 2011. Citation: Reichlin T et al. Utility of absolute and relative changes in cardiac troponin concentrations in the early diagnosis of acute myocardial infarction. Circulation 2011 Jul 12; 124:136.

14. Neuron overload and the juggling physician

Danielle Ofri. The Lancet. 2010; 376:1820 – 1821.

Patients often complain that their doctors don't listen. Although there are probably a few doctors who truly are tone deaf, most are reasonably empathic human beings, and I wonder why even these doctors seem prey to this criticism. I often wonder whether it is sheer neuron overload on the doctor side that leads to this problem. Sometimes it feels as though my brain is juggling so many competing details, that one stray request from a patient—even one that is quite relevant—might send the delicately balanced three-ring circus tumbling down.

…Studies have debunked the myth of multitasking in human beings. The concept of multitasking was developed in the computer field to explain the idea of a microprocessor doing two jobs at one time. It turns out that microprocessors are in fact linear, and actually perform only one task at a time. Our computers give the illusion of simultaneous action based on the microprocessor “scheduling” competing activities in a complicated integrated algorithm. Like microprocessors, we humans can't actually concentrate on two thoughts at the same exact time. We merely zip back and forth between them, generally losing accuracy in the process. At best, we can juggle only a handful of thoughts in this manner.

The more thoughts we juggle, the less we are able to attune fully to any given thought. To me, this is a recipe for disaster. Today I only forgot an insurance company form. But what if I'd forgotten to order her mammogram, or what if I'd refilled only five of her six medicines? What if I'd forgotten to fully explain the side-effects of one of her medications? The list goes on, as does the anxiety.

The remainder of the essay (full-text free): http://danielleofri.com/wp-content/uploads/2010/11/Neuron-Overload-Ofri.pdf

15. Vasopressin During Resuscitation May Help Asystolic Patients

NEW YORK (Reuters Health) Aug 09 - Vasopressin has no overall benefit in cardiac arrest, but it may be useful in asystole - especially when administered promptly, according to a meta-analysis reported July 25 in Resuscitation.

"The novel finding... was that in the large asystole subgroup (n=3,210), vasopressin use was associated with an increased probability of long-term survival," the authors report.

They said the absolute increase was about 1.0%, corresponding to 10 additional survivors for every 1,000 treated patients.

Furthermore, the vasopressin-related survival benefit was quadrupled in the 642 asystole patients whose average time-to-drug was under 20 minutes. That subgroup had an absolute increase of 4.0%, corresponding to 40 additional survivors for every 1,000 treated patients.

Dr. Spyros D. Mentzelopoulos, with Evaggelismos General Hospital in Athens, Greece, and colleagues say they undertook the study because there had been new trial data reported since the last review in 2004, and also because there was a possibility of increased vasoconstricting efficacy of current vasopressin regimens during CPR.

The team identified six high-quality randomized controlled trials comparing vasopressin-containing regimens with adrenaline/epinephrine alone in 4,475 adults with cardiac arrest.

Overall, vasopressin didn't increase the chance of sustained return of spontaneous circulation (odds ratio 1.25; p=0.18), long-term survival (OR 1.13; p=0.61) or favorable neurologic outcome (OR 0.87; p=0.62), the report indicates.

However, when the initial cardiac rhythm was identified as asystole (as opposed to pulseless electrical activity or ventricular fibrillation or tachycardia), vasopressin use was associated with a higher likelihood of long-term survival (OR 1.80; p=0.04). Moreover, in asystolic patients treated within 20 minutes of collapse, the odds ratio increased to 2.84 (p=0.02), Dr. Mentzelopoulos and colleagues found.

They conclude, "New randomized controlled trials specifically assessing vasopressin effects on subgroup neurological outcome are warranted."

Resuscitation 2011. In press. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21787738

16. Images in Medicine

Fixed Drug Eruption
http://www.nejm.org/doi/full/10.1056/NEJMicm1013871

An Unusual Cause of Trigger Finger
http://www.nejm.org/doi/full/10.1056/NEJMicm1012468

“Thumb Sign” of Epiglottitis
http://www.nejm.org/doi/full/10.1056/NEJMicm1009990

Hemorrhagic Herpes Zoster
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60238-9/fulltext

Bed Bugs
http://www.scielo.br/img/revistas/abd/v86n1/en_a28fig01m.jpg

*More on Bed Bugs*
Case presentation: http://www.ncbi.nlm.nih.gov/pubmed/21437544 (with link to full-text)

Criado PR, et al. Bedbugs (Cimicidae infestation): the worldwide renaissance of an old partner of human kind. Braz J Infect Dis. 2011 Feb;15(1):74-80. http://www.ncbi.nlm.nih.gov/pubmed/21412594 (with link to full-text)

National Geographic Video (2 minutes): http://www.youtube.com/watch?v=WfKCcSPCOQo

17. Flu Update: Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza

CDC. Ann Emerg Med. 2011;58:299-303.

Influenza viruses can cause disease among persons in any age group, but rates of illness are highest among children.1, 2 During most influenza seasons, rates of serious illness and death are highest among persons aged 65 years or older, children younger than 2 years, and persons of any age who have medical conditions that place them at increased risk for complications from influenza.3, 4 In addition, data from epidemiologic studies conducted during the 2009 influenza A (H1N1) pandemic indicated that the risk for influenza complications was also increased among persons who are morbidly obese (body mass index ≥40 kg/m2) and American Indians/Alaska Natives.5, 6, 7, 8 In the postpandemic period, 2009 H1N1 virus strains now are considered to be the predominant seasonal influenza A (H1N1) virus strains. On the basis of epidemiologic studies of seasonal influenza or 2009 H1N1, persons at higher risk for influenza complications include:

• children younger than 5 years (especially those younger than 2 years);

• adults aged 65 years or older;

• persons with chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic, hematologic (including sickle cell disease), or metabolic disorders (including diabetes mellitus) or neurologic and neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability [mental retardation], moderate to severe developmental delay, muscular dystrophy, or spinal cord injury)9;

• persons with immunosuppression, including that caused by medications or by HIV infection;

• women who are pregnant or postpartum (within 2 weeks after delivery);

• persons aged 18 years or younger who are receiving long-term aspirin therapy;

• American Indians/Alaska Natives;

• persons who are morbidly obese (ie, body mass index ≥40 kg/m2); and

• residents of nursing homes and other chronic-care facilities.

For children, the risk for severe complications from seasonal influenza is highest among those younger than 2 years, who have much higher rates of hospitalization for influenza-related complications compared with older children.3 Medical care and emergency department (ED) visits attributable to influenza are increased among children younger than 5 years compared with older children.10

Annual influenza vaccination is the most effective method for preventing seasonal influenza virus infection and its complications. All persons aged 6 months or older should receive annual influenza vaccination.11 Antiviral medications are effective for the prevention of influenza and, when used for treatment, can reduce the duration and severity of illness.6, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 Early antiviral treatment can reduce the risk for severe illness or death related to influenza.6, 12, 23, 24, 25, 26, 27 However, the emergence of resistance to one or more of the 4 licensed antiviral agents (oseltamivir, zanamivir, amantadine, and rimantadine) among some circulating influenza virus strains during the past 5 years has complicated antiviral treatment and chemoprophylaxis recommendations. The selection of antiviral medications should be considered in the context of any available information about surveillance data on influenza antiviral resistance patterns among circulating influenza viruses; local, state, and national influenza surveillance information on influenza virus type or influenza A virus subtype; the characteristics of the person who is ill; and results of influenza testing if testing is conducted. Empiric antiviral treatment often is required to avoid treatment delays.28

Primary Changes and Updates in the Recommendations

These recommendations include 6 principal changes or updates from previous recommendations for use of antivirals for the prevention and control of influenza:

• Antiviral treatment is recommended as soon as possible for patients with confirmed or suspected influenza who have severe, complicated, or progressive illness or who require hospitalization.

• Antiviral treatment is recommended as soon as possible for outpatients with confirmed or suspected influenza who are at higher risk for influenza complications because of their age or underlying medical conditions; clinical judgment should be an important component of outpatient treatment decisions.

• Recommended antiviral medications include oseltamivir and zanamivir, according to recent viral surveillance and resistance data indicating that greater than 99% of currently circulating influenza virus strains are sensitive to these medications. Amantadine and rimantadine should not be used because of the high levels of resistance to these drugs among circulating influenza A viruses, but information about these drugs is provided for use if current recommendations change because of the reemergence of adamantane-susceptible strains.

• Oseltamivir may be used for treatment or chemoprophylaxis of influenza among infants younger than 1 year when indicated.

• Antiviral treatment also may be considered according to clinical judgment for any outpatient with confirmed or suspected influenza who does not have known risk factors for severe illness if treatment can be initiated within 48 hours of illness onset.

• Because antiviral resistance patterns can change over time, clinicians should monitor local antiviral resistance surveillance data.

The remainder of the text (free): http://www.annemergmed.com/article/S0196-0644(11)01304-7/fulltext

Abridged from MMWR Morb Mortal Wkly Rep. 2011;60:1-24. Full-text (free): http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6001a1.htm?s_cid=rr6001a1_w

18. Captain Morgan, The Rum Pirate, Lends A Knee To Hip Dislocation

Linda Thrasybule, NPR blog, August 12, 2011

If you were to dislocate your hip, you'd need the able hands of a physician to push your thighbone back into the socket where it belongs. But that effort of "reducing" a hip dislocation can be a tricky and even risky task.

That's why some doctors now look to Captain Morgan — yes, the pirate on the bottle of rum — for inspiration. If you've ever looked closely at the label, you might notice Morgan standing confidently, one foot on top of a barrel. That pose turns out to be a good way for doctors to apply force to the hip without having to crawl up on the patient's gurney.

A case series out this week in the Annals of Emergency Medicine found the technique to be a success for 12 out of 13 patients. But study authors caution that they haven't yet proved the technique is any faster, easier, or has fewer complications than other way of fixing hip dislocations.

"We actually started the technique in our hospital a couple of years ago," Gregory Hendey, a professor of clinical emergency medicine at the University of California, San Francisco, Fresno and one of the study authors, tells Shots. "One day, while watching a Captain Morgan's commercial, it just struck me that that's the position we do."

Hip dislocation happens when the head of the thighbone — the femur — slips out of its socket in the hipbone. Car accidents are the most common cause, according to the American Academy of Orthopedic Surgeons. People with hip replacements are also prone to them, as are athletes who play high contact sports like football.

"It's extremely painful," says Hendey. "You can't walk. You're incapacitated. It has to be taken care of immediately."

Other techniques for fixing hip dislocations can be precarious. Consider the Allis Maneuver, which requires the doctor to straddle the patient on a gurney, then bend the affected leg 90 degrees, while keeping the other leg down. The doctor then lifts the leg and applies force to the hip, popping the leg bone back into the hip socket. Doctors can injure their backs or fall off the gurney, the study said.

Although Hendey admits the study doesn't prove whether the Captain Morgan technique is better than other techniques, he does believe it's safer and easier for doctors to perform. "Once they start using the Captain, they never go back," he says.

Full-text (with an image of the Captain): http://www.npr.org/blogs/health/2011/08/12/139573713/captain-morgan-the-rum-pirate-lends-a-knee-to-hip-dislocation?ps=sh_sthdl

Hendley GW, et al. Ann Emerg Med 2011; in press. Full-text (currently free):
http://www.annemergmed.com/webfiles/images/journals/ymem/gwhendey.pdf

19. Value of post-resuscitation ECG in the diagnosis of AMI in out-of-hospital cardiac arrest patients

Sideris G, et al. Resuscitation. 2011;82:1148-1153.

Background: Diagnosis of acute myocardial infarction (AMI) in out-of-hospital cardiac arrest (OHCA) patients is important because immediate coronary angiography with coronary angioplasty could improve outcome in this setting. However, the value of acute post-resuscitation electrocardiographic (ECG) data for the detection of AMI is debatable.

Methods: We assessed the diagnostic characteristics of post-resuscitation ECG changes in a retrospective single centre study evaluating several ECG criteria of selection of patients undergoing AMI, in order to improve sensitivity, even at the expense of specificity. Immediate post resuscitation coronary angiogram was performed in all patients. AMI was defined angiographically using coronary flow and plaque morphology criteria.

Results: We included 165 consecutive patients aged 56 (IQR 48–67) with sustained return of spontaneous circulation after OHCA between 2002 and 2008. 84 patients had shockable, 73 non-shockable and 8 unknown initial rhythm; 36% of the patients had an AMI. ST-segment elevation predicted AMI with 88% sensitivity and 84% specificity. The criterion including ST-segment elevation and/or depression had 95% sensitivity and 62% specificity. The combined criterion including ST-segment elevation and/or depression, and/or non-specific wide QRS complex and/or left bundle branch block provided a sensitivity and negative predictive value of 100%, a specificity of 46% and a positive predictive value of 52%.

Conclusion: In patients with OHCA without obvious non-cardiac causes, selection for coronary angiogram based on the combined criterion would detect all AMI and avoid the performance of the procedure in 30% of the patients, in whom coronary angiogram did not have a therapeutic role.

20. Correction Factor for CSF Protein Levels in Traumatic Lumbar Puncture

Nigrovic LE et al. J Pediatr 2011 Jul; 159:158

Subtract 1.1 mg/dL protein for every 1000-cell increase in CSF red blood cell count.

Abstract: We sought to determine the relationship between cerebrospinal fluid (CSF) protein and CSF red blood cells in children with traumatic lumbar punctures. For every 1000 cell increase in CSF red blood cells per mm(3), CSF protein increases by 1.1 mg/dL (95% CI, 0.9-1.1 mg/dL).

21. More U.S. Children Being Diagnosed with Youthful Tendency Disorder

Redlands, CA--Nicholas and Beverly Serna's daughter Caitlin was just 4 years old, but they already knew there was a problem.

Day after day, upon arriving home from preschool, Caitlin would retreat into a bizarre fantasy world. Sometimes she would pretend to be people and things she was not. Other times, without warning, she would burst into nonsensical song. Some days she would run directionless through the backyard of the Sernas' comfortable Redlands home, laughing and shrieking as she chased imaginary objects. When months of sessions with a local psychologist failed to yield an answer, Nicholas and Beverly took Caitlin to a prominent Los Angeles pediatric neurologist for more exhaustive testing. Finally, on September 20, the Sernas received the heartbreaking news: Caitlin was among a growing legion of U.S. children suffering from Youthful Tendency Disorder.

"As horrible as the diagnosis was, it was a relief to finally know,' Beverly said. At least we knew we weren't bad parents.'

Youthful Tendency Disorder (YTD), a poorly understood neurological condition that afflicts an estimated 20 million U. S. children, is characterized by a variety of senseless, unproductive physical and mental exercises, often lasting hours at a time. In the thrall of YTD, sufferers run, jump, climb, twirl, shout, dance, do cartwheels, and enter unreal, unexplainable states of 'make-believe.'

Slowly, methodically through an elaborate system of rewards and punishments, Caitlin has shown improvement. But the road ahead is long.

"We get a lot of platitudes from the so-called experts,' Mr. Serna said. 'We hear a lot of, 'Oh, she'll grow out of it, just give it time.' That's easy for them to say--their kid's not running around the neighborhood claiming to be Superwoman."

Common YTD WARNING SIGNS
--Near constant running, jumping, skipping
--Sudden episodes of shouting and singing
--Preferring playtime and flights of fancy to schoolwork
--Confusing self with animals and object, including tiger, dinosaurs, and airplanes
--Conversations with "imaginary friends"
--Poor impulse control with regard to sugared snacks

Help for families struggling with YTD may soon be on the way. Last month, Pfizer unveiled Juvenol, a promising YTD drug which, pending FDA approval, could reach the U.S. market as early as next spring.

But until such help arrives, the parents of YTD sufferers can do little more than try to get through each day.

'I love my child with all my heart,' said Caitlin's mother. 'But when she's in the throes of one of her skipping fits, it's hard not to feel a little envious of parents with normal, healthy children.'"

The Onion. 2000;36:34.

22. Selected Readings that Promote Thriving, Personally and Globally

Kristoff and WuDunn, Half the Sky: Turning Oppression into Opportunity for Women Worldwide (New York: Knopf, 2011). http://www.halftheskymovement.org/

David Brooks, The Social Animal: The Hidden Sources of Love, Character, and Achievement (New York: Random House, 2011). http://www.thedailybeast.com/newsweek/2011/02/27/david-brooks-wants-to-be-friends.html

Lit Bits: Aug 3, 2011

2011-08-03T09:09:00.000-07:00

From the recent medical literature...

1. Sensitivity of CT performed within six hours of onset of headache for diagnosis of SAH: prospective cohort study

Perry JJ, Stiell IG, et al. BMJ 2011; 343:d4277

Objective: To measure the sensitivity of modern third generation computed tomography in emergency patients being evaluated for possible subarachnoid haemorrhage, especially when carried out within six hours of headache onset.

Design: Prospective cohort study.

Setting: 11 tertiary care emergency departments across Canada, 2000-9.

Participants: Neurologically intact adults with a new acute headache peaking in intensity within one hour of onset in whom a computed tomography was ordered by the treating physician to rule out subarachnoid haemorrhage.

Main outcome measures: Subarachnoid haemorrhage was defined by any of subarachnoid blood on computed tomography, xanthochromia in cerebrospinal fluid, or any red blood cells in final tube of cerebrospinal fluid collected with positive results on cerebral angiography.

Results: Of the 3132 patients enrolled (mean age 45.1, 2571 (82.1%) with worst headache ever), 240 had subarachnoid haemorrhage (7.7%). The sensitivity of computed tomography overall for subarachnoid haemorrhage was 92.9% (95% confidence interval 89.0% to 95.5%), the specificity was 100% (99.9% to 100%), the negative predictive value was 99.4% (99.1% to 99.6%), and the positive predictive value was 100% (98.3% to 100%). For the 953 patients scanned within six hours of headache onset, all 121 patients with subarachnoid haemorrhage were identified by computed tomography, yielding a sensitivity of 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%).

Conclusion: Modern third generation computed tomography is extremely sensitive in identifying subarachnoid haemorrhage when it is carried out within six hours of headache onset and interpreted by a qualified radiologist.

2. WHO Says Hospital Admission Far Riskier than Flying

By Stephanie Nebehay, Reuters Health Information. GENEVA, Jul 21 - Millions of people die each year from medical errors and infections linked to health care and going into hospital is far riskier than flying, the World Health Organization said on Thursday.

"If you were admitted to hospital tomorrow in any country... your chances of being subjected to an error in your care would be something like 1 in 10. Your chances of dying due to an error in health care would be 1 in 300," Dr. Liam Donaldson, the WHO's newly appointed envoy for patient safety, told a news briefing.

This compared with a risk of dying in an air crash of about 1 in 10 million passengers, according to Dr. Donaldson, formerly England's chief medical officer.

"It shows that health care generally worldwide still has a long way to go," he said.

Hundreds of millions of people suffer infections linked to health care each year. Patients should ask questions and be part of decision-making in hospitals, which must use basic hygiene standards and WHO's checklist to ensure safe surgical procedures were followed.

More than 50 percent of acquired infections can be prevented if health care workers clean their hands with soap and water or an alcohol-based handrub before treating patients.

Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection, according to the United Nations agency.

"The longer patients stay in an ICU (intensive care unit), the more at risk they become of acquiring an infection," it said. Medical devices such as urinary catheters and ventilators are associated with high infection rates.

'HIGH-RISK BUSINESS'

Each year in the United States, 1.7 million infections are acquired in hospital, leading to 100,000 deaths, a far higher rate than in Europe where 4.5 million infections cause 37,000 deaths, according to WHO.

"Health care is a high-risk business, inevitably, because people are sick and modern health care is delivered in a fast-moving, high-pressured environment involving a lot of complex technology and a lot of people," Dr. Donaldson said.

A heart operation can involve a team of up to 60 people, about the same number needed to run a jumbo jet, he said.

"Infection is a big problem, injuries after falls in hospitals is a big problem and then there are problems that are on a smaller scale but result in preventable deaths. Medication errors are common," he said.

Risk is even higher in developing countries, with about 15% of patients acquiring infections, said Dr. Benedetta Allegranzi of the WHO's "Clean Care is Safer Care" program.

"The risk is really higher in high-risk areas of the hospitals, in particular ICUs or neonatal units in developing countries."

About 100,000 hospitals worldwide now use the WHO's surgical safety checklist, which the agency said has been shown to reduce surgery complications by 33% and deaths by 50%.

If the checklist is effectively used worldwide, an estimated 500,000 deaths could be prevented each year, it says.

"Frankly, if I was having an operation tomorrow I wouldn't go into a hospital that wasn't using the checklist because I wouldn't regard it as safe," said Dr. Donaldson.

3. CLUE: a randomized Comparative effectiveness trial of IV nicardipine versus Labetalol Use in the ED

Peacock WF, et al. Crit Care. 2011 Jun 27;15(3):R157.

INTRODUCTION: Our purpose was to compare the safety and efficacy of food and drug administration (FDA) recommended dosing of IV nicardipine versus IV labetalol for the management of acute hypertension.

METHODS: Multicenter randomized clinical trial. Eligible patients had 2 systolic blood pressure (SBP) measures [greater than or equal to]180 mmHg and no contraindications to nicardipine or labetalol. Before randomization, the physician specified a target SBP +/- 20 mmHg (the target range: TR). The primary endpoint was the percent of subjects meeting TR during the initial 30 minutes of treatment.

RESULTS: Of 226 randomized patients, 110 received nicardipine and 116 labetalol. End organ damage preceded treatment in 143 (63.3%); 71 nicardipine and 72 labetalol patients. Median initial SBP was 212.5 (IQR 197, 230) and 212 mmHg (IQR 200,225) for nicardipine and labetalol patients (P=0.68), respectively. Within 30 minutes, nicardipine patients more often reached TR than labetalol (91.7 vs. 82.5%, P=0.039). Of 6 BP measures (taken every 5 minutes) during the study period, nicardipine patients had higher rates of five and six instances within TR than labetalol (47.3% vs. 32.8%, P=0.026). Rescue medication need did not differ between nicardipine and labetalol (15.5 vs. 22.4%, P=0.183). Labetalol patients had slower heart rates at all time points (P less than 0.01). Multivariable modeling showed nicardipine patients were more likely in TR than labetalol patients at 30 minutes (OR 2.73, P=0.028; C stat for model = 0.72)

CONCLUSION: Patients treated with nicardipine are more likely to reach the physician-specified SBP target range within 30 minutes than those treated with labetalol.

Full-text (free): http://ccforum.com/content/pdf/cc10289.pdf

4. EM Myths Exploded: ED Care Less Than 2% of Health Care Spending

Berger E. Ann Emerg Med. 2011;58:A18-A20.

Coffee sobers you up.

Going out in cold weather makes you sick.

Too much sugar makes your kids hyperactive.

Chewing gum, once swallowed, takes 7 years to digest.

To be safe, wait 30 minutes after eating before swimming.

Taking vitamin C, echinacea, or zinc prevents colds.

These are half a dozen medical myths that much of the American population, and even more than a handful of physicians, believes. Here's one more: Emergency medical care is expensive and inefficient.

Readers of this article probably won't be taken in by that myth, but in this respect, readers of this journal are out of step with the general public and, perhaps still more important, policymakers. Consider a Senate bill (SB 1781) introduced in October 2009, called the Reducing Emergency Department Utilization Through Coordination and Empowerment (REDUCE) Act. According to its language, the bill sought to address emergency department (ED) overuse, improve quality of care, and save taxpayers' money by establishing pilot programs to better coordinate care for frequent ED users.

“Far too many people rely on emergency room services for routine or primary care,” said US Senator Sherrod Brown (D-OH), one of the bill's authors. ”By strategically expanding outreach services to frequent ER visitors and better coordinating their care, we can cut the associated costs to taxpayers. This initiative takes an important step toward fixing our broken health care system and improving the quality of care for communities in Ohio and across the country.”

Brown is not alone in holding such beliefs. In March 2011, Health and Human Services Secretary Kathleen Sebelius joined the public radio talk program The Diane Rehm Show and responded to a small business owner in Nantucket, MA, who was concerned about paying $1,600 per month for health insurance coverage for her family of 3 under the state's universal health insurance plan, with a $5,000 deductible because of her son's preexisting condition.

“Right now, as a taxpayer, the family from Nantucket is also paying for everyone who doesn't have insurance who is coming through emergency room doors accessing the health care system, often in a very expensive way,” Sebelius said.

In recognition of this pervasive myth about emergency care, as well as others, the American College of Emergency Physicians (ACEP) launched the “Just 2% Campaign” in April 2011. The national public education campaign seeks to promote the value of emergency medicine and to educate the public and policymakers that emergency care is less than 2% of the nation's health care dollar.

During a talk at ACEP's Health Writer's Conference in New York City on April 19, President Sandra Schneider, MD, a professor and chair emeritus in the Department of Emergency Medicine, University of Rochester, Rochester, NY, laid out the campaign for members of the media.

“Health care spending is a huge issue in the United States, representing more than 16% of our gross domestic product. Yet, as became clear during the health care reform debate last year, there are misconceptions about the costs and efficiencies of emergency rooms,” she said. “The bottom line is this: Policymakers seeking to trim fat from the nation's rising health care bills are looking in the wrong place if they take aim at emergency departments.”

ACEP launched the campaign amid a widespread rhetoric from policymakers, public policy wonks, and some sectors of the health care industry on the need to reduce visits to the ED as a way to control increasing health care costs. This article, then, seeks to amplify this educational effort by dispelling the “too costly” myth, as well as others being bandied about by politicians and the press.

Myth No. 1: Emergency Care is Too Expensive…

Myth No. 2: EDs are Crowded by Patients with Nonurgent Medical Issues…

Myth No. 3: Undocumented Immigrants Cause ED crowding…

Myth No. 4: Health Care Reform Will Lead to a Substantial Reduction in Costly ED Visits…

The remainder of the essay can be found here (full-text free): http://www.annemergmed.com/article/S0196-0644(11)00617-2/fulltext

5. Stable Patients with Pulmonary Embolism Can Be Treated as Outpatients

In a randomized trial of outpatient versus inpatient care, outcomes did not differ between groups.

Typically, diagnosis of pulmonary embolism (PE) means certain admission. Researchers performed an open-label, randomized, noninferiority study to compare outcomes of outpatient and inpatient treatment in consecutive adult patients who presented to 19 emergency departments in Europe and the U.S. with symptomatic PE and risk for death less than 4% (based on the PE Severity Index; see table). Patients were excluded if they had oxygen saturation below 90% on room air, systolic blood pressure below 100 mm Hg, chest pain requiring opioids, active bleeding, or were at high risk for hemorrhage (recent stroke or gastrointestinal bleeding or platelet count above 75,000/mm3). All patients initially received subcutaneous enoxaparin (1 mg/kg twice daily) followed by anticoagulation with vitamin K antagonists for at least 90 days.

Overall, the study included 171 outpatients (mean age, 47) and 168 inpatients (mean age, 49). Cancer prevalence was 1% and 2%, respectively. Within 90 days, one patient in each group died, neither from PE. Recurrent venous thromboembolism occurred in only one patient (outpatient group). Major bleeding occurred within 90 days in three outpatients (intramuscular hematoma on day 3 and day 13 and menometrorrhagia on day 50) and no inpatients. At 14 days, more than 90% of patients in both groups were satisfied or very satisfied with treatment.

Comment: These data suggest that stable low-risk patients with PE can be safely and effectively treated as outpatients with low-molecular-weight heparin. The results might not be applicable to older patients than those in this study or to patients with cancer.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine July 22, 2011. Citation: Aujesky D et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: An international, open-label, randomised, non-inferiority trial. Lancet 2011 Jul 2; 378:41.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21703676

6. MRSA Superbug: Can Coffee And Tea Protect You?

Meghan Neal, The Huffington Post. Posted: 7/15/11.

More good news for coffee drinkers? Possibly.

A government study looked at 5,500 Americans and found those that drank tea or coffee had half the chance of carrying the MRSA superbug in their nasal carriage. Scientists have long been aware of tea and coffee's antimicrobial properties.

"Our findings raise the possibility of a promising new method to decrease MRSA nasal carriage that is safe, inexpensive, and easily accessible," wrote the study authors in the Annals Of Family Medicine.

Still, more research is needed. Lead researcher Eric Matheson, of the University of South Carolina, told Reuters: “The study shows an association between the two, but you never can conclude causation from an association. I can't tell you that this finding isn't just a coincidence.”

Since its discovery in the early 1960s, the antibiotic-resistant "superbug" MRSA, short for Methicillin-resistant Staphylococcus Aureus, has been quickly spreading across the U.S. and oversees -- suggesting epidemic levels.

In June a new strain of MRSA was discovered in cow's milk. While alarming, researchers said it was unlikely the bacteria would seep into the food chain.

Matheson EM, et al. Ann Family Med 2011;9:299-304. Abstract: http://www.annfammed.org/cgi/content/abstract/9/4/299

7. Do Children With Blunt Head Trauma and Normal Cranial CT Scan Results Require Hospitalization for Neurologic Observation?

Holmes JF, et al with PECARN Network. Ann Emerg Med. Article in press.

Study objective: Children evaluated in the emergency department (ED) with minor blunt head trauma, defined by initial Glasgow Coma Scale (GCS) scores of 14 or 15, are frequently hospitalized despite normal cranial computed tomography (CT) scan results. We seek to identify the frequency of neurologic complications in children with minor blunt head trauma and normal ED CT scan results.

Methods: We conducted a prospective, multicenter observational cohort study of children younger than 18 years with blunt head trauma (including isolated head or multisystem trauma) at 25 centers between 2004 and 2006. In this substudy, we analyzed individuals with initial GCS scores of 14 or 15 who had normal cranial CT scan results during ED evaluation. An abnormal imaging study result was defined by any intracranial hemorrhage, cerebral edema, pneumocephalus, or any skull fracture. Patients with normal CT scan results who were hospitalized were followed to determine neurologic outcomes; those discharged to home from the ED received telephone/mail follow-up to assess for subsequent neuroimaging, neurologic complications, or neurosurgical intervention.

Results: Children (13,543) with GCS scores of 14 or 15 and normal ED CT scan results were enrolled, including 12,584 (93%) with GCS scores of 15 and 959 (7%) with GCS scores of 14. Of 13,543 patients, 2,485 (18%) were hospitalized, including 2,107 of 12,584 (17%) with GCS scores of 15 and 378 of 959 (39%) with GCS scores of 14. Of the 11,058 patients discharged home from the ED, successful telephone/mail follow-up was completed for 8,756 (79%), and medical record, continuous quality improvement, and morgue review was performed for the remaining patients. One hundred ninety-seven (2%) children received subsequent CT or magnetic resonance imaging (MRI); 5 (0.05%) had abnormal CT/MRI scan results and none (0%; 95% confidence interval [CI] 0% to 0.03%) received a neurosurgical intervention. Of the 2,485 hospitalized patients, 137 (6%) received subsequent CT or MRI; 16 (0.6%) had abnormal CT/MRI scan results and none (0%; 95% CI 0% to 0.2%) received a neurosurgical intervention. The negative predictive value for neurosurgical intervention for a child with an initial GCS score of 14 or 15 and a normal CT scan result was 100% (95% CI 99.97% to 100%).

Conclusion: Children with blunt head trauma and initial ED GCS scores of 14 or 15 and normal cranial CT scan results are at very low risk for subsequent traumatic findings on neuroimaging and extremely low risk of needing neurosurgical intervention. Hospitalization of children with minor head trauma after normal CT scan results for neurologic observation is generally unnecessary.

8. Discontinuation of low dose aspirin and risk of MI

Individuals with a history of cardiovascular events who stop taking low dose aspirin are at increased risk of non-fatal myocardial infarction compared with those who continue treatment, say the authors of this case-control study in UK primary care. Editorialists Giuseppe Biondi-Zoccai and Giovanni Landoni say that these findings are important and support previous studies showing an increase in adverse events after aspirin withdrawal. They suggest that patients should be advised never to stop aspirin unless explicitly told to do so, and doctors should maintain their patients on low dose aspirin for as long as they can.

García Rodríguez LA, et al. BMJ 2011; 343:d4094

Objective:s To evaluate the risk of myocardial infarction and death from coronary heart disease after discontinuation of low dose aspirin in primary care patients with a history of cardiovascular events.

Design: Nested case-control study.

Setting: The Health Improvement Network (THIN) database in the United Kingdom.

Participants: Individuals aged 50-84 with a first prescription for aspirin (75-300 mg/day) for secondary prevention of cardiovascular outcomes in 2000-7 (n=39 513).

Main outcome measures: Individuals were followed up for a mean of 3.2 years to identify cases of non-fatal myocardial infarction or death from coronary heart disease. A nested case-control analysis assessed the risk of these events in those who had stopped taking low dose aspirin compared with those who had continued treatment.

Results: There were 876 non-fatal myocardial infarctions and 346 deaths from coronary heart disease. Compared with current users, people who had recently stopped taking aspirin had a significantly increased risk of non-fatal myocardial infarction or death from coronary heart disease combined (rate ratio 1.43, 95% confidence interval 1.12 to 1.84) and non-fatal myocardial infarction alone (1.63, 1.23 to 2.14). There was no significant association between recently stopping low dose aspirin and the risk of death from coronary heart disease (1.07, 0.67 to 1.69). For every 1000 patients, over a period of one year there were about four more cases of non-fatal myocardial infarction among patients who discontinued treatment with low dose aspirin (recent discontinuers) compared with patients who continued treatment.

Conclusions: Individuals with a history of cardiovascular events who stop taking low dose aspirin are at increased risk of non-fatal myocardial infarction compared with those who continue treatment.

Full-text (free): http://www.bmj.com/content/343/bmj.d4094

9. Current methods of diagnosis and treatment of scaphoid fractures

Rhemrev SJ, et al. International J Emerg Med. 2011;4:4

Fractures of the scaphoid bone mainly occur in young adults and constitute 2-7% of all fractures. The specific blood supply in combination with the demanding functional requirements can easily lead to disturbed fracture healing. Displaced scaphoid fractures are seen on radiographs. The diagnostic strategy of suspected scaphoid fractures, however, is surrounded by controversy. Bone scintigraphy, magnetic resonance imaging and computed tomography have their shortcomings. Early treatment leads to a better outcome. Scaphoid fractures can be treated conservatively and operatively. Proximal scaphoid fractures and displaced scaphoid fractures have a worse outcome and might be better off with an open or closed reduction and internal fixation. The incidence of scaphoid non-unions has been reported to be between 5 and 15%. Non-unions are mostly treated operatively by restoring the anatomy to avoid degenerative wrist arthritis.

Full-text (free): http://www.springerlink.com/content/x1k754879q244222/fulltext.pdf

10. Rocuronium Versus Succinylcholine: Cochrane Synopsis Reconsidered

Strayer RJ, et al. Ann Emerg Med. 2011;58:217-218.

To the Editor:

I read with interest the summary by Seupaul and Jones1 of the 2008 Cochrane systematic review comparing intubating conditions produced by rocuronium and succinylcholine during rapid sequence intubation. The summary reports the study's conclusion, which is that succinylcholine produces excellent intubating conditions more frequently than rocuronium, with a relative risk of 0.86. This result is taken from 37 studies, of which 24 used rocuronium at a dose of 0.6 mg/kg, 5 used a dose of 0.9 mg/kg or greater, and 8 used a combination of doses.

The speed with which rocuronium causes paralysis is dose dependent. At the classically recommended dose of 0.6 mg/kg, excellent intubating conditions are significantly delayed. At 1.0 mg/kg, excellent intubating conditions are produced at 60 seconds, about 15 seconds later than with succinylcholine. At 1.2 mg/kg, the currently recommended dose, rocuronium produces excellent intubating conditions at 40 seconds and cannot be distinguished from succinylcholine.2 In fact, the authors of the Cochrane review state, “We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2 mg/kg rocuronium.” A recent emergency department (ED)–based head-to-head comparison supports this conclusion.3

The Cochrane authors follow this evidence-based result with the following assertion: “…[H]owever, succinylcholine was clinically superior as it has a shorter duration of action.” Mallon et al4 used a similar argument in their cited critical appraisal.

The longer duration of action of rocuronium is an advantage, not a disadvantage. Emergency clinicians who believe they are protected against a can't-intubate, can't-ventilate scenario by the short duration of succinylcholine are usually wrong5 and make dangerous decisions as a result. When early attempts at laryngoscopy fail, further attempts are hindered by the return of the patient's airway reflexes; this already precarious situation is worsened if the patient puts his now-functioning muscles to use by vomiting.

These problems are eliminated by the longer duration of rocuronium. Furthermore, rocuronium is not burdened by a list of rare but lethal contraindications, most of which are not routinely screened for by emergency physicians. Succinylcholine also occasionally causes masseter spasm, rendering laryngoscopy impossible until a nondepolarizing paralytic is located and administered.

In conclusion, succinylcholine is more likely to produce excellent intubating conditions than rocuronium only if the incorrect dose of rocuronium is used. At 1.2 mg/kg, rocuronium is as effective as succinylcholine at facilitating laryngoscopy and offers a host of other advantages. Although both drugs are safe and effective for rapid sequence intubation in the ED, rocuronium should be the preferred agent in most circumstances.

References: http://www.annemergmed.com/article/S0196-0644(11)00281-2/fulltext

11. Ultrasound-Guided Central Line Placement: No X-Ray Needed?

No pneumothoraces were detected on chest x-ray in 1202 asymptomatic patients after ultrasound-guided central venous line placement.

With ultrasound-guided central line placement, is a postinsertion chest x-ray still necessary to assess for pneumothorax? Researchers reviewed records for 1258 real-time, ultrasound-guided, internal jugular vein central line placements and 4 external jugular vein placements performed in 1066 patients during 4 years in the vascular and interventional radiology suite at a single U.S. hospital.

Postprocedure upright chest x-rays were obtained in 1202 patients (after an average of 65 minutes); supine chest x-rays were performed as part of routine care in 66 hospitalized and bedridden patients. No patient had symptoms or radiographic evidence of pneumothorax. The authors conclude that eliminating routine postprocedure x-rays would save time and costs and reduce radiation exposure.

Comment: This study was performed in a more controlled environment than an emergency department. Chest x-ray is not necessary after ultrasound-guided internal jugular vein cannulation when assessment of catheter positioning is not needed. When pneumothorax is suspected, bedside ultrasound for lung sliding likely is a better test than a chest x-ray (JW Emerg Med Nov 6 2009).

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine July 29, 2011. Citation: Oner B et al. Pneumothorax following ultrasound-guided jugular vein puncture for central venous access in interventional radiology: 4 years of experience. J Intensive Care Med 2011 Jul 14; [e-pub ahead of print].

12. Children Presenting With Acute Pericarditis to the ED

Ratnapalan S, et al, Pediatr Emerg Care. 2011;27(7):581-585.

Objective: The objective of the study was to evaluate the clinical features and the outcome of children who presented to the emergency department and were ultimately diagnosed with pericarditis.

Methods: A retrospective chart review of all children diagnosed with acute pericarditis from January 2000 through March 2007 was conducted.

Results: There were 94 children with pericarditis as the sole or one of the discharge diagnoses: 34 with postsurgical pericarditis and 38 with pericarditis as a component of a generalized illness were not examined further. Of the 22 children included in the study, the mean age was 12.3 (SD, 2.7) years, and 80% were males. Chest pain was present in 96%, and fever was present in 56%. All children had electrocardiographic changes comprising ST and T-wave abnormalities. Initial chest radiographs were reported as normal in 40%; although 82% (n = 18) had a pericardial effusion on echocardiography, 7 (32%) required pericardiocentesis. The etiology was considered idiopathic in 68% (n = 15). All children improved on treatment with nonsteroidal anti-inflammatory drugs. Eight children (36%) had recurrent pericarditis, of whom 2 had multiple recurrences.

Conclusions: Children presenting with chest pain require further investigation if electrocardiographs show any abnormalities. Children presenting with pericarditis require follow-up and caution about recurrence.

13. Association of Hospitalist Care with Medical Utilization After Discharge: Evidence of Cost Shift From a Cohort Study

Kuo YF, et al. Ann Intern Med 2011;155:152-159.

Most studies of hospitalist care have focused on the inpatient stay. This study compared hospitalized patients who were cared for by primary care physicians with those cared for by hospitalists. Hospitalists' patients had shorter and less expensive hospitalizations. During the 30 days after discharge, however, hospitalists' patients had more visits to the emergency department, more readmissions to the hospital, and higher total expenses. Savings during hospitalization that are associated with hospitalist care may be offset by higher expenses after discharge.

Abstract: http://www.annals.org/content/155/3/152.abstract

14. Accuracy of Stated Energy Contents of Restaurant Foods

Urban LE, et al. JAMA. 2011 Jul 20;306(3):287-93.

Context: National recommendations for the prevention and treatment of obesity emphasize reducing energy intake. Foods purchased in restaurants provide approximately 35% of the daily energy intake in US individuals but the accuracy of the energy contents listed for these foods is unknown.

Objective: To examine the accuracy of stated energy contents of foods purchased in restaurants.

Design and Setting: A validated bomb calorimetry technique was used to measure dietary energy in food from 42 restaurants, comprising 269 total food items and 242 unique foods. The restaurants and foods were randomly selected from quick-serve and sit-down restaurants in Massachusetts, Arkansas, and Indiana between January and June 2010.

Main Outcome Measure: The difference between restaurant-stated and laboratory-measured energy contents, which were corrected for standard metabolizable energy conversion factors.

Results: The absolute stated energy contents were not significantly different from the absolute measured energy contents overall (difference of 10 kcal/portion; 95% confidence interval [CI], −15 to 34 kcal/portion; P = .52); however, the stated energy contents of individual foods were variable relative to the measured energy contents. Of the 269 food items, 50 (19%) contained measured energy contents of at least 100 kcal/portion more than the stated energy contents. Of the 10% of foods with the highest excess energy in the initial sampling, 13 of 17 were available for a second sampling. In the first analysis, these foods contained average measured energy contents of 289 kcal/portion (95% CI, 186 to 392 kcal/portion) more than the stated energy contents; in the second analysis, these foods contained average measured energy contents of 258 kcal/portion (95% CI, 154 to 361 kcal/portion) more than the stated energy contents (P less than.001 for each vs 0 kcal/portion difference). In addition, foods with lower stated energy contents contained higher measured energy contents than stated, while foods with higher stated energy contents contained lower measured energy contents (P less than.001).

Conclusions: Stated energy contents of restaurant foods were accurate overall. However, there was substantial inaccuracy for some individual foods, with understated energy contents for those with lower energy contents.

15. Images in Emergency Medicine

Elderly Female with Syncope
http://www.annemergmed.com/article/S0196-0644(10)01705-1/fulltext

Man with Generalized Weakness
http://www.annemergmed.com/article/S0196-0644(10)01649-5/fulltext

Infant With Facial Lesions
http://www.annemergmed.com/article/S0196-0644(11)00024-2/fulltext

Woman With Hypertension and Seizure
http://www.annemergmed.com/article/S0196-0644(11)00022-9/fulltext

Small-Intestinal Volvulus
http://www.nejm.org/doi/full/10.1056/NEJMicm0806895

Evolution of a Jellyfish Sting
http://www.nejm.org/doi/full/10.1056/NEJMicm1009713

Angioedema
http://www.nejm.org/doi/full/10.1056/NEJMicm1014034

Thrombosis of the Inferior Vena Cava and Dilated Veins of the Trunk
http://www.nejm.org/doi/full/10.1056/NEJMicm1010652

Dependent Rubor
http://www.nejm.org/doi/full/10.1056/NEJMicm1010160

16. IV Volume Expansion Helpful in Hemolytic Uremic Syndrome

Laurie Barclay, MD. Medscape News. July 25, 2011 — In children who have diarrhea and are at risk for hemolytic uremic syndrome (HUS), intravenous volume expansion may help protect against oligoanuric renal failure, according to the results of a prospective, observational cohort study reported online July 22 in the Archives of Pediatrics and Adolescent Medicine. Since an Escherichia coli outbreak was first reported in Germany in May 2011, there have been more than 900 cases of HUS reported in 16 countries in Europe and North America.

"[T]he pathophysiologic cascade leading to renal failure might provide an opportunity to mitigate renal damage," write Christina A. Hickey, MD, from Washington University School of Medicine and St. Louis Children's Hospital, Missouri, and colleagues. "If patients at risk for HUS are recognized early in illness, then the brief interval between first presentation with diarrhea and HUS onset could be exploited to maintain or improve renal perfusion, possibly averting renal shutdown."

The study goal was to assess the effect of interventions during the pre-HUS diarrhea phase on maintenance of urine output during HUS. At 11 pediatric hospitals in the United States and Scotland, children younger than 18 years with diarrhea-associated HUS received intravenous fluid within the first 4 days of diarrhea onset. Inclusion criteria were hematocrit level lower than 30% with smear evidence of intravascular erythrocyte destruction, thrombocytopenia with platelet count lower than 150 × 103/mm3, and impaired renal function, defined as serum creatinine concentration higher than the upper limit of reference range for age. The main study endpoint was presence or absence of oligoanuria, defined as a urine output of 0.5 mL/kg/hour or less for more than 1 day.

Among the 50 participants, the overall oligoanuric rate was 68%, but those who received no intravenous fluids in the first 4 days of illness had an oligoanuric rate of 84%. When fluids were not given during this time, the relative risk for oligoanuria was 1.6 (95% confidence interval, 1.1 - 2.4; P = .02).

Compared with children without oligoanuria, those with oligoanuric HUS received less total intravenous fluid (r = −0.32; P = .02) and sodium (r = −0.27; P = .05) during the first 4 days of illness. The most significant covariate in multivariable analysis was volume infused, but volume and sodium strongly covaried.

"Intravenous volume expansion is an underused intervention that could decrease the frequency of oligoanuric renal failure in patients at risk of HUS," the study authors write.

Limitations of this study include the lack of randomization and the inability to address the optimal sodium content of the fluid given or the value or safety of isotonic intravenous volume expansion in children whose serum creatinine concentrations are rising, but who are still urinating.

"Because presence and/or duration of oligoanuria are so repeatedly associated with long-term sequelae in children with HUS, it seems appropriate to prioritize maintenance of urine output during HUS, even though our data do not permit us to state that pre-HUS intravenous volume expansion prevents long-term renal sequelae," the study authors conclude. "Intravenous volume expansion appears to be a logical strategy that can be used now to achieve this goal, because we cannot hasten renal recovery once oligoanuria is established. We reiterate that volume expansion in these situations must be accompanied by assiduous monitoring for cardiopulmonary overload and hypertension."

The Doris Duke Clinical Research Fellowship supported this study. The study authors have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2011 Jul 22. PubMed Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21784993

17. A Task Analysis of Emergency Physician Activities in Academic and Community Settings

Chisholm CD, et al. Ann Emerg Med. 2011;58:117-122.

Study objective: We characterize and compare the work activities, including peak patient loads, associated with the workplace in the academic and community emergency department (ED) settings. This allows assessment of the effect of future ED system operational changes and identifies potential sources contributing to medical error.

Methods: This was an observational, time-motion study. Trained observers shadowed physicians, recording activities. Data included total interactions, distances walked, time sitting, patients concurrently treated, interruptions, break in tasks, physical contact with patients, hand washing, diagnostic tests ordered, and therapies rendered. Activities were classified as direct patient care, indirect patient care, or personal time with a priori definitions.

Results: There were 203 2-hour observation periods of 85 physicians at 2 academic EDs with 100,000 visits per year at each (N=160) and 2 community EDs with annual visits of 19,000 and 21,000 (N=43). Reported data present the median and minimum-maximum values per 2-hour period. Emergency physicians spent the majority of time on indirect care activities (academic 64 minutes, 29 to 91 minutes; community 55 min, 25 to 95 minutes), followed by direct care activities (academic 36 minutes, 6 to 79 minutes; community 41 minutes, 5 to 60 minutes). Personal time differed by location type (academic 6 minutes, 0 to 66 minutes; community 13 minutes, 0 to 69 minutes). All physicians simultaneously cared for multiple patients, with a median number of patients greater than 5 (academic 7 patients, 2 to 16 patients; community 6 patients, 2 to 12 patients).

Conclusion: Emergency physicians spend the majority of their time involved in indirect patient care activities. They are frequently interrupted and interact with a large number of individuals. They care for a wide range of patients simultaneously, with surges in multiple patient care responsibilities. Physicians working in academic settings are interrupted at twice the rate of their community counterparts.

18. Examination of staphylococcal stethoscope contamination in the ED

Tang PHP, et al. CJEM 2011;13(4):239-244

Introduction: The objective of this study was to determine the prevalence of Staphylococcus-contaminated stethoscopes belonging to emergency department (ED) staff and to identify the proportion of these that were Staphylococcus aureus or methicillin-resistant Staphylococcus aureus (MRSA).

Methods: We conducted a prospective observational cohort study of bacterial cultures from 100 ED staff members' stethoscopes at three EDs. Study participants were asked to complete a questionnaire.

Results: Fifty-four specimens grew coagulase-negative staphylococci and one grew methicillin-susceptible S. aureus. No MRSA was cultured. Only 8% of participants, all of whom were nurses, reported cleaning their stethoscope before or after each patient assessment. Alcohol-based wipes were most commonly used to clean stethoscopes. A lack of time, being too busy, and forgetfulness were the most frequently reported reasons for not cleaning the stethoscope in the ED.

Conclusions: This study indicates that although stethoscope contamination rates in these EDs are high, the prevalence of S. aureus or MRSA on stethoscopes is low.

19. Interexaminer Agreement in Physical Examination for Children with Suspected Soft Tissue Abscesses

Giovanni JE. Pediatr Emerg Care. 2011;27(6):475-478.

Objective: This study aimed to measure interexaminer agreement for physical examination (PE) findings in children with a suspected soft tissue abscess.

Methods: A prospective study was conducted from March 1 to July 31, 2007, at an urban, tertiary care children's hospital emergency department. Children presenting to the emergency department with a suspected local skin abscess were independently examined by 2 physicians. Interrater agreement of 7 PE findings for children with a suspected soft tissue abscess was assessed. Interrater agreement was calculated for the diagnosis of the lesion and decision to incise and drain.

Results: A total of 105 paired observations were completed by a total of 27 physicians. The patients examined were aged 2 weeks to 18 years, with a mean age of 80 months. Lesions were most frequently encountered on the buttocks (38%). Incision and drainage was attempted in 75% of cases, with purulent material obtained in 92% of all attempts. Interrater agreement was substantial for erythema (κ = 0.66) and size of the lesion (intraclass correlation coefficient = 0.78), moderate for drainage (κ = 0.57) and tenderness (κ = 0.40), fair for fluctuance (κ = 0.35), and poor for warmth (κ = 0.15) and showed no agreement for induration (κ = −0.08). There was moderate agreement on diagnosing the lesion as an abscess (κ = 0.48) and determination if the lesion required incision and drainage (κ = 0.44).

Conclusions: Interexaminer agreement of examination findings and diagnosis of an abscess was fair to moderate, implying a lack of precision of PE as the primary means for diagnosis. Future studies of diagnostic adjuncts, such as bedside ultrasonography, may lead to improved management of soft tissue infections in children.

20. ED Management of Patients on Warfarin Therapy

Meeker E, et al. Ann Emerg Med. 2011;58:192-199.

Study objective: To characterize warfarin management in the emergency department (ED).

Methods: This was a retrospective, cross-sectional, observational study of patients who were receiving warfarin and were discharged from a tertiary care, academic urban ED between June and August 2007. We abstracted patient demographics, presenting complaint, international normalized ratio (INR) if tested, indication for warfarin if documented, new medications administered or prescribed in the ED, and discharge instructions. Presenting complaints were categorized according to whether they were warfarin-related and concerning for thrombosis or bleeding. The primary outcome measure was the prevalence of warfarin therapy. The secondary outcome measures were frequency with which ED providers obtained an INR result, response to nontherapeutic results, administration or prescription of interacting medications, and percentage of patients receiving recommendations for anticoagulation follow-up.

Results: Two percent (111/7,195) of all patients presenting to and discharged from the ED during the study period were found to be receiving warfarin. Seventy-one percent (79/111) had an INR checked. Nontherapeutic INRs were recorded for 49% (39/79) of patients; ED providers intervened to address these results in 21% (8/39) of cases. Seventy-one percent (5/7) of patients with a supratherapeutic INR received an intervention compared with 9% (3/32) of patients with a subtherapeutic INR. Seventeen percent (19/111) and 13% (14/111) of patients received or were prescribed potentially interacting medications, respectively. Recommendations for specific anticoagulation follow-up were documented for 19% (21/111) of all patients.

Conclusion: Patients receiving warfarin frequently present to the ED and often have nontherapeutic INRs. Potential areas for improvement in ED management include greater attention to subtherapeutic INRs, interacting medications, and discharge planning.

21. Performance of stroke risk scores in older people with atrial fibrillation not taking warfarin: comparative cohort study from BAFTA trial

Hobbs FDR, et al. BMJ 2011; 342:d3653

Objective: To compare the predictive power of the main existing and recently proposed schemes for stratification of risk of stroke in older patients with atrial fibrillation.

Design: Comparative cohort study of eight risk stratification scores.

Setting: Trial of thromboprophylaxis in stroke, the Birmingham Atrial Fibrillation in the Aged (BAFTA) trial.

Participants: 665 patients aged 75 or over with atrial fibrillation based in the community who were randomised to the BAFTA trial and were not taking warfarin throughout or for part of the study period.

Main outcome measures: Events rates of stroke and thromboembolism.

Results: 54 (8%) patients had an ischaemic stroke, four (0.6%) had a systemic embolism, and 13 (2%) had a transient ischaemic attack. The distribution of patients classified into the three risk categories (low, moderate, high) was similar across three of the risk stratification scores (revised CHADS2, NICE, ACC/AHA/ESC), with most patients categorised as high risk (65-69%, n=460-457) and the remaining classified as moderate risk. The original CHADS2 (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes, previous Stroke) score identified the lowest number as high risk (27%, n=180). The incremental risk scores of CHADS2, Rietbrock modified CHADS2, and CHA2DS2-VASc (CHA2DS2-Vascular disease, Age 65-74 years, Sex) failed to show an increase in risk at the upper range of scores. The predictive accuracy was similar across the tested schemes with C statistic ranging from 0.55 (original CHADS2) to 0.62 (Rietbrock modified CHADS2), with all except the original CHADS2 predicting better than chance. Bootstrapped paired comparisons provided no evidence of significant differences between the discriminatory ability of the schemes.

Conclusions: Based on this single trial population, current risk stratification schemes in older people with atrial fibrillation have only limited ability to predict the risk of stroke. Given the systematic undertreatment of older people with anticoagulation, and the relative safety of warfarin versus aspirin in those aged over 70, there could be a pragmatic rationale for classifying all patients over 75 as “high risk” until better tools are available.

Full-text (free): http://www.bmj.com/content/342/bmj.d3653.full