Lit Bits: December 14, 2006

From the recent medical literature...

1. Strategies for Reducing the Door-to-Balloon Time in AMI

Bradley ED, Magid DJ, et al. New Engl J Med 2006; 355:2308-2320

INTRO
Prompt treatment increases the likelihood of survival for patients who have myocardial infarction with ST-segment elevation. Hospitals can therefore influence the outcomes for such patients by developing and implementing systems and processes that minimize the interval between arrival at the hospital and the administration of reperfusion therapy. Since percutaneous coronary intervention (PCI) has become the preferred approach for treating myocardial infarction with ST-segment elevation, hospitals are seeking ways to reduce the door-to-balloon time, defined as the time between arrival at the hospital and the first balloon inflation during PCI.

The importance of the door-to-balloon time is highlighted by its inclusion as one of the core quality measures collected and reported by the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations. Concomitant with national efforts to improve the care of patients with acute myocardial infarction have been substantial improvements in performance on many core measures (such as the use of aspirin and beta-blockers). However, performance with respect to the door-to-balloon time continues to lag behind national standards, which recommend an interval of 90 minutes or less. A minority of hospitals treat patients who present with myocardial infarction with ST-segment elevation within 90 minutes after their arrival, and hospital performance has not improved substantially in recent years.

Previous qualitative work has identified some common approaches among hospitals that have achieved a rapid door-to-balloon time. However, it is not clear which strategies are most effective or how great their effect might be. We sought to identify operational and clinical processes for treating patients who have myocardial infarction with ST-segment elevation and to quantify the association of these measures with hospital door-to-balloon times.

ABSTRACT
Background: Prompt reperfusion treatment is essential for patients who have AMI with ST-segment elevation. Guidelines recommend that the interval between arrival at the hospital and intracoronary balloon inflation (door-to-balloon time) during primary percutaneous coronary intervention should be 90 minutes or less. However, few hospitals meet this objective. We sought to identify hospital strategies that were significantly associated with a faster door-to-balloon time.

Methods: We surveyed 365 hospitals to determine whether each of 28 specific strategies was in use. We used hierarchical generalized linear models and data on patients from the Centers for Medicare and Medicaid Services to determine the association between hospital strategies and the door-to-balloon time.

Results: In multivariate analysis, six strategies were significantly associated with a faster door-to-balloon time. These strategies included having EM physicians activate the catheterization laboratory (mean reduction in door-to-balloon time, 8.2 minutes), having a single call to a central page operator activate the laboratory (13.8 minutes), having the ED activate the catheterization laboratory while the patient is en route to the hospital (15.4 minutes), expecting staff to arrive in the catheterization laboratory within 20 minutes after being paged (vs. >30 minutes) (19.3 minutes), having an attending cardiologist always on site (14.6 minutes), and having staff in the ED and the catheterization laboratory use real-time data feedback (8.6 minutes). Despite the effectiveness of these strategies, only a minority of hospitals surveyed were using them.

Conclusions: Several specific hospital strategies are associated with a significant reduction in the door-to-balloon time in the management of AMI with ST-segment elevation.

DISCUSSION
In a cross-sectional study of 365 acute care hospitals in the United States, we identified several hospital strategies that were strongly associated with the door-to-balloon time in the performance of PCI for patients with acute myocardial infarction with ST-segment elevation. In some cases, specific practices were associated with time savings of 10 to 15 minutes, a clinically important advantage in a group of institutions with a mean value of 100 minutes for median door-to-balloon times. Many of the strategies are not commonly used in hospitals in the United States, which may account in part for the relatively poor performance of such hospitals in meeting guidelines for the door-to-balloon time.

Although implementation of some of the advantageous strategies would require investment in new resources, other strategies that are currently used by only a minority of hospitals could be implemented with existing resources. For instance, having emergency medicine physicians determine whether a myocardial infarction with ST-segment elevation is present and activate the catheterization team without involvement of a cardiologist was strongly associated with a reduced door-to-balloon time but was used in only about 23% of hospitals during weekdays and in 27% of hospitals at night or on weekends. Furthermore, having the catheterization laboratory activated by a single call from the emergency department to a central page operator, who then paged both the interventional cardiologist and the catheterization laboratory staff, was strongly associated with a faster door-to-balloon time, but the single-call process was used in only about 14% of hospitals in this study. Research on the time to fibrinolytic therapy20 and small, single-hospital studies of the door-to-balloon time have also indicated that treatment is more rapid if emergency medicine physicians make the treatment decision without the involvement of a cardiologist. Nonetheless, most hospitals still involve a cardiologist in the decision to activate the catheterization laboratory.

In addition to the strategies that focus on processes within the hospital, the hospital's coordination with emergency medical services was strongly associated with the door-to-balloon time. Previous studies have shown that performing electrocardiography en route to the hospital can reduce the door-to-balloon time, and the National Heart Attack Alert Program Coordinating Committee has recommended increased use of such electrocardiographic services. In our study, the percentage of patients with acute coronary syndrome who underwent electrocardiography en route was not associated with the door-to-balloon time. Instead, it was the way that such electrocardiograms were used by hospitals that was important. Hospitals that activated the catheterization laboratory on the basis of electrocardiography performed while the patient was en route and those that had varied strategies to respond to electrocardiographic data transmitted from emergency medical services had an advantage. Determining the optimal approach for incorporating such electrocardiographic data into hospital processes to expedite the door-to-balloon time is an important area for future research.

False alarms were reported to be infrequent in our study, even at hospitals where emergency medicine physicians were responsible for activation of the catheterization laboratory on the basis of electrocardiography performed en route to the hospital. We were not able to obtain independent confirmation of the accuracy of the hospitals' estimates of false alarms. However, we have no evidence to suggest that these data are inaccurate, and we believe that perceptions about the number of false alarms are probably as important as is the true number of false alarms in determining whether noncardiologists are permitted to activate the catheterization laboratory. This issue may be clarified by further study….
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The research, which was led by Elizabeth Bradley and a team of researchers that included David Magid, MD, MPH, Kaiser Permanente emergency medicine physician and researcher. Dr. Magid practices at Exempla Saint Joseph Hospital and as part of this study partnered with the hospital to adopt the life-saving strategies. Saint Joseph Hospital is one of the first hospitals in the country to make these important improvements. "The great point about these strategies is that most involve little or no cost to implement," said Magid. "The study offers a terrific guide for hospitals to follow as they push to improve door-to-balloon times and the quality of care for patients."

Full-text (requires subscription): http://content.nejm.org/cgi/content/full/355/22/2308

2. Arrival in the ED by Ambulance for Headache: A Marker of High Risk for SAH

Perry JJ, Ian G. Stiell, et al. Acad Emerg Med 2006;13(5, suppl 1):138-9.

ABSTRACT

Objective: There is currently little emphasis on the mode of arrival of emergency department (ED) headache patients with regard to risk of nontraumatic subarachnoid hemorrhage (SAH). This study assessed the use of ambulance for acute headache patients for the outcome of SAH.

Methods: This prospective cohort study was a substudy of a large multicenter study to derive a clinical decision rule for SAH. Six university tertiary care EDs in 5 medium to large cities participated in this study. Consecutive adult patients with an acute headache, without neurologic deficit, were enrolled. Analysis included descriptive statistics with appropriate univariate analysis and odds ratios (ORs) with 95% confidence intervals (95% CIs) for arrival by ambulance and referral from rural ED for the outcome of SAH.

Results: There were 3,051 enrolled patients with mean age 43.5 years (standard deviation [SD] 17.4), 60.2% female, and 157 (5.2%) SAH cases. Overall, 629 (20.6%) of the patients arrived by ambulance and 8.8% were referrals. Of patients who arrived by ambulance, 91 (14.5%) had SAH. Univariate chi-squared analysis found that arriving by ambulance was highly significant for SAH (p less than 0.001), OR 6.0 (95% CI: 4.3-8.4). This compares with the OR of 2.5 (95% CI: 1.7-3.9) for patients referred from other EDs. Excluding patients referred from other EDs did not alter the OR for arrival by ambulance (OR = 6.3, 95% CI: 4.4-9.1).

Conclusions: To the best of the authors' knowledge, this was the first prospective study to determine the relationship between arrival by ambulance and subarachnoid hemorrhage in neurologically intact headache patients. This study demonstrates that patients or their relatives are more likely to request an ambulance based on the seriousness of the condition. Physicians should consider mode of arrival as part of the diagnostic assessment of acute headache patients.

3. Heavy Smokers Who Cut Back Fail to Reduce Mortality

Heavy smokers who cut down but fail to quit do not appear to significantly reduce their risk for death, according to a study published in the December issue of Tobacco Control.

The prospective cohort study, conducted in Norway, involved 51,000 adults who were first screened for cardiovascular risk factors in the mid-1970s, screened again after 3 to 13 years, and then followed through 2003. It compared those who smoked at least 15 cigarettes a day at the start but then cut consumption by at least half with those who continued to smoke heavily.

It found that those who reduced smoking did not significantly lower their risk for dying from all causes, cardiovascular disease, ischemic heart disease, smoking-related cancer, or lung cancer.

The authors conclude that we need to reassess the practice of advising patients to cut down on smoking if they can't quit as a permanent solution -- a practice that may offer false expectations, as "a reduction in consumption does not seem to bring about harm reduction."

Full article: http://tc.bmj.com/cgi/content/full/15/6/472

4. Early Administration of Adenosine Improves MI Outcomes

By Will Boggs, MD. NEW YORK (Reuters Health) Nov 28 - Adjunctive administration of adenosine along with early reperfusion therapy improves outcomes after acute myocardial infarction (MI), according to a report in the October issue of the European Heart Journal.

"There is hope for the concept of cardio-protection," Dr. Robert A. Kloner from Good Samaritan Hospital, Los Angeles, California told Reuters Health. "That is, pharmacologic agents can be given at the time of acute heart attack and further reduce the size of the heart attack and improve outcome above and beyond opening the infarct artery by thrombolysis or percutaneous coronary intervention." Dr. Kloner and colleagues investigated the efficacy of high-dose intravenous adenosine in relation to reperfusion time and modality in patients presenting with ST-segment elevation anterior acute MI.

Compared with those who received placebo, patients who started reperfusion therapy within 3.17 hours of symptom onset and who received adenosine had significantly lower mortality at both 1 month (9.2% vs 5.2%) and 6 months (11.2% vs 7.3%), the investigators report. In contrast, the results indicate, adenosine did not improve clinical outcomes in patients reperfused later than 3.17 hours after onset.

Patients benefited from adenosine therapy regardless of whether they were treated with primary percutaneous coronary intervention (PCI) or with thrombolytic therapy, the researchers note, although those treated with PCI had lower rates of death at 1 and 6 months and less in-hospital congestive heart failure.

"There have been many attempts to try to improve outcome of myocardial infarction by giving adjunctive therapy acutely along with reperfusion for myocardial infarction," Dr. Kloner said. "Unfortunately most of these efforts have failed in large clinical trials. Adenosine appears to be one exception." He added: "My opinion is that a larger outcomes study that targets only patients who are reperfused early and have anterior infarcts is needed before adenosine can become a standard therapy."

However, Dr. Kloner noted that "some interventional cardiologists use adenosine in the setting of 'no reflow' when it appears that there is sluggish distal flow in a coronary artery that has received an intervention such as angioplasty or stenting. Thus, it is already being used in the catheterization laboratory in some settings."

Eur Heart J 2006;27:2400-2405.

5. Multislice CT Should Be Initiated Before Resuscitation in Blunt Major Trauma Patients

November 28, 2006 (Chicago) — Despite having a broad armamentarium of diagnostic protocols, emergency medicine physicians are often unable to provide an accurate diagnosis of patients who have suffered blunt major trauma, especially if they are unconscious. A study reported here at the 92nd scientific assembly and annual meeting of the Radiological Society of North America suggests that diagnoses should begin with multislice computed tomography (MSCT) protocols, even before resuscitation.

Common methods of assessing injury include conventional radiography, focused assessment with sonography for trauma (FAST), computed tomography (CT), and the invasive diagnostic peritoneal lavage (DPL). All have limitations, according to the study authors.

This was a retrospective cohort study of 370 patients (77.6% men, 22.4% women) with a mean age of 42.1 ± 17.7 years. "Demographic data were comparable in both cohorts," according to the authors.

Inclusion criteria were survival to admission to the intensive care unit (ICU), and 1 or more life-threatening injuries to the head, thorax, or abdomen. The injury must have received an injury severity score (ISS) of at least 17, with an abbreviated injury score (AIS) of at least 4. According to the abstract, the mean ISS of the study population (n = 370) was 27.1 ± 10.9 points.

Patients were divided into 2 cohorts (n = 185 each), the "resuscitation first" cohort and the "CT scan first" (MSCT) cohort. The former received resuscitation followed by a diagnostic procedure of either conventional radiography, FAST, or CT. The "CT-scan first" cohort underwent MSCT prior to resuscitation.

TRISS analysis was performed and SAPS II score was calculated. In addition, time in the emergency department, surgery length, ICU stay, total in-hospital stay, and survival were statistically analyzed, according to the study abstract.

In the "CT-scan first" cohort, a definitive diagnosis of injuries was achieved after 12 ± 9 minutes in 92.4% of patients compared with 41 ± 27 minutes in 76.2% of patients in the "resuscitation first" cohort. Several subsequent parameters were also shorter in the "CT-scan first" population vs the "resuscitation-first" population, including total time in the emergency department (70 vs 104 min), surgical procedure length (159 vs 186 min), ICU stay (13.6 vs 16.8 days), and total length of hospital stay (29.0 vs 32.5 days).

The authors conclude that performing MSCT in patients with blunt major trauma was safe and effective, and it led to faster and more accurate diagnoses as well as shorter stays in the emergency department, on the operating table, and in the ICU. They point out that if the MSCT is followed by adequate fluid resuscitation, the administration of contrast medium to patients in traumatic shock would have no negative effects on renal function.

"What this protocol says is doing major trauma by algorithm rather than individual patient assessment," Donald Bachman, MD, told Medscape. He is a radiologist in private practice at Metro West Medical Center in Wayland, Massachusetts. Dr. Bachman was not affiliated with this study.

"It's a technique that major trauma centers use," Dr. Bachman said. "In somebody with major life-threatening injury it may have overall benefits, but as far as I'm concerned, there are significant downsides to that approach as well."

He continued, "In young people, you are exposing people to a very large amount of radiation, which may or may not be necessary. It [also] tends to encourage doing things by a cookbook. For people who are mediocre or less than mediocre, that's probably good, but not for highly trained medical personnel who are accustomed to making assessments.

"[Emergency department] doctors tend to order studies first, and think about what to do with them afterwards. I think that runs up the cost of healthcare and results in many instances in sloppy thinking. However, it may be warranted in situations of overwhelming threatening trauma," Dr. Bachman concluded.

RSNA 92nd Annual Scientific Assembly and Annual Meeting: Abstract SSE14-06. Scheduled for presentation November 27, 2006.

6. A clinical tool for assessing risk after self-harm.

Cooper J, et al. Ann Emerg Med. 2006; 48(4):459-66

Editor’s Capsule Summary
What is already known on this topic: Decisions about the disposition of patients who harm themselves can be difficult, especially in emergency departments (EDs) with limited access to providers with expertise in the assessment of such patients.

What question this study addressed: The authors of this study of 9,086 patients who harmed themselves attempted to develop a rule for identifying those at low risk for attempting suicide during the subsequent 6 months.

What this study adds to our knowledge: The Manchester Self-Harm rule suggests that patients who (1) have no history of self-harm, (2) have never had psychiatric treatment [in the past or currently], and (3) did not use benzodiazepines in the current attempt are at low risk for repeated attempt of suicide. The rule successfully identified all 22 suicides within the 6-month period after ED presentation and had high sensitivity (94%) for subsequent self-harm. Twenty-five percent of patients met the low-risk criteria.

How this might change clinical practice: This English study suggests that patients who met the low-risk criteria could be safely sent home with outpatient referral. Unfortunately, most patients will not meet these criteria, leaving EDs with limited psychiatric evaluation resources in a dilemma about how to evaluate and treat these patients.

STUDY OBJECTIVE: Our aim is to develop a risk-stratification model for use by emergency department (ED) clinical staff in the assessment of patients attending with self-harm.

METHODS: Participants were patients who attended 5 EDs in Manchester and Salford, England, after self-harm between September 1, 1997, and February 28, 2001. Social, demographic, and clinical information was collected for each patient at each attendance. With data from the Manchester and Salford Self-Harm Project, a clinical decision rule was derived by using recursive partitioning to discriminate between patients at higher and lower risk of repetition or subsequent suicide occurring within 6 months. Data from 3 EDs were used for the derivation set. The model was validated with data from the remaining 2 EDs.

RESULTS: Data for 9,086 patients who presented with self-harm were collected during this study period, including 17% that reattended within 6 months and 22 patients who died by suicide within 6 months. A 4-question rule, with a sensitivity of 94% (92.1-95.0% [95% confidence interval]) and specificity of 25% (24.2-26.5% [95% confidence interval]), was derived to identify patients at higher risk of repetition or suicide.

CONCLUSION: Application of this simple, highly sensitive rule may facilitate assessment in the ED and help to focus psychiatric resources on patients at higher risk.

7. Even Under Optimal Conditions, CPR Quality May Fail to Meet Guidelines

NEW YORK (Reuters Health) Nov 30 - Highly trained physicians in a modern emergency department frequently meet international guidelines for cardiopulmonary resuscitation (CPR), according to a prospective observational study conducted at the Medical University of Vienna in Austria. However, "there is room for improvement," the authors say, especially with regard to hyperventilation and failure to identify ventricular fibrillation.

Recent reports exposed shortcomings often encountered when in-hospital CPR is administered, Dr. Fritz Sterz and associates note in the Archives of Internal Medicine for November 27.

In general, chest compression rates tend to be too low and ventilation rates too high, the authors note. International standards require a compression rate of 100 per minute, compression depth of 40-50 mm, and ventilation rate of 12 per minute.

Dr. Sterz's group conducted their study between 2002 and 2006, under conditions that they consider optimal. The emergency department was "fully equipped with monitors, ventilators, and complete nursing facilities." At least four physicians and six nurses were on duty around the clock.

They note that the 30 physicians were well versed in CPR and had more than 10 years of acute care clinical experience. The duration of cardiac arrest among the 80 patients in the study averaged 11.2 minutes.

The primary outcome was the hands-off ratio, defined as the hands-off time divided by the cardiac arrest time. The investigators observed that hands-off ratio (mean 12.7%) was linearly associated with duration of CPR (p <> 6 months, and six survived with a good neurological outcome.

The authors express concern that correct ventilation rates were achieved only 18% of the time during CPR. "An excessive ventilation rate during CPR will result in increased positive intrathoracic pressures, decreased coronary perfusions, and decreased survival rate." Also at issue was the delay in detecting ventricular fibrillation for up to 7 minutes.

Dr. Sterz and his team recommend greater attention to ventilation rates, and that no-flow time be reduced by keeping pulse checks and other examinations to a minimum.

Arch Intern Med 2006;166:2375-2380.

8. Lower Cervical Bupivacaine Injection Treats Headache in the ED

NEW YORK (Reuters Health) Nov 24 - For the treatment of headache pain in the emergency department, intramuscular injections of small amounts of 0.5% bupivacaine bilateral to the sixth or seventh cervical vertebrae provides safe and effective headache relief.

These are the findings of a retrospective study that included all 417 headache patients, 18 years of age or older, who received this treatment over a 1-year period at a single emergency department.

Complete headache relief occurred in 271 patients (65.1%) and partial headache occurred in 85 patients (20.4%). Fifty-seven patients (13.7%) reported no significant headache relief and 4 (1%) reported a worsening of headache pain.

Overall, bupivacaine injections yielded a therapeutic response in 356 of 417 patients (85.4%), report Dr. Larry B. Mellick of the Medical College of Georgia in Augusta and colleagues in the October issue of the journal Headache.

"Headache relief was typically rapid with many patients reporting complete headache relief in 5 to 10 minutes," the authors note. Headache relief was often accompanied by resolution of associated signs and symptoms such as allodynia, nausea, vomiting, and sensitivity to sound and light.

The mechanism of headache relief following lower cervical intramuscular bupivacaine injections is unknown, the authors note, but may involve calming of sensitized trigeminocervical complex.

Dr. Mellick and colleagues note that headache is a "common chief complaint" of patients who present to the emergency department. Many come to the ED as a last resort after other interventions have failed to provide headache relief.

Based on their experience, the authors say lower cervical injections of 0.5% bupivacaine "appears to be a safe and effective therapeutic intervention for the treatment of headache pain caused by a spectrum of etiologies presenting to the ED setting."

Headache 2006;46:1441-1449.

9. Highlights From MMWR: CDC Advises Routine Screening for HIV; and info on RSV

December 1, 2006 — The US Centers for Disease Control and Prevention (CDC) has reported in the December 1 issue of the Morbidity and Mortality Weekly Report on (1) the high rate of individuals who test positive for HIV late in the course of disease, underscoring the importance of routine screening for all adolescents and adults; and (2) recommendations to include respiratory syncytial virus in the differential diagnosis of respiratory tract infections and administer immune prophylaxis to eligible children.

(1) High Proportion of "Late Testers" for HIV: Routine Screening Advised

A CDC study has revealed that 41.3% of individuals testing HIV-positive in South Carolina over the last 5 years were diagnosed with AIDS less than 1 year later ("late testers"), including 16.5% who were diagnosed within 30 days of testing. Late testers were more likely to black (81.2% vs white, 16.4%), male (68.2%), and aged 20 to 49 years (80.1%).

Despite awareness campaigns aimed at testing high-risk individuals for HIV during healthcare visits, the majority of late testers (73%) had at least 1 documented visit to a healthcare facility during 1997 to 2005 at a mean of 2.5 years prior to HIV diagnosis and a substantial proportion of these (33.9%) were identified as injection drug users or men who have sex with men.

Whereas these practices should have prompted HIV screening if risk histories had been elicited by healthcare professionals, most of the diagnoses reported during these visits (78.6%) were not likely to prompt an HIV test and many (78.9%) occurred in an emergency department setting.

The CDC notes that South Carolina ranked 10th in the number of reported AIDS cases in the United States during 2004 (18.1 cases per 100,000 population). Moreover, approximately 50% of patients newly diagnosed with HIV during 2004-2005 had CD4+ T-cell counts less than 350 cells/mm3 (and nearly 33% had less than 200 cells/mm3), suggesting a high prevalence and long duration of undiagnosed HIV infections in this state.

The findings underscore the importance of routine HIV screening for all patients aged 13 to 64 years in all healthcare settings (unless they decline testing), as advocated by the CDC in September 2006

(2) RSV Should Be Included in Differential Diagnosis of Lower RTIs, Immune Prophylaxis Advised for At-Risk Children

From July 8 to November 18, 2006, respiratory syncytial virus (RSV) was detected in 62 laboratories from 37 states that participate in the National Respiratory and Enteric Virus Surveillance System (NREVSS). In the last season (July 2005 - June 2006), widespread RSV activity began during the third week of November and continued for 21 weeks until early April. Regionally, the highest levels of RSV activity occurred first in the South (December), later in the Northeast and Midwest (January), and latest in the West (February).

Whereas 91% of RSV detections occurred prior to mid-April, sporadic cases occurred until September 2006 and occurred at a high rate in Florida (48%). Preliminary data suggest that the annual peak for the current season began in Florida during the last week of June, followed by the rest of the south in mid-October, and the Northeast in the second week of November.

The CDC notes that RSV is a major cause of lower respiratory tract infections (LRTIs) among young children and can also cause severe disease and death among the elderly and individuals with compromised respiratory, cardiac, or immune systems.

Healthcare providers are advised to consider RSV in the differential diagnosis for patients of all ages with LRTIs during the annual seasonal peak. Although several tests can be used to diagnose RSV in young children, only reverse transcription–polymerase chain reaction (RT-PCR) assays are a reliable diagnostic tool for older children and adults.

Because no vaccine is currently available, infants and children at risk for serious RSV infection should receive immune prophylaxis with monthly doses of humanized murine anti-RSV monoclonal antibody product during the season.

Those considered at risk include infants aged less than 2 years with chronic lung disease who have required medical therapy within 6 months of RSV season onset; infants and children with hemodynamically significant heart disease; and preterm infants born at less than 32 weeks' gestation or born at 32 to 35 weeks' gestation and having at least 2 additional risk factors during their first RSV season. Risk factors include day care attendance, exposure to environmental pollutants, school-aged siblings, congenital airway abnormalities, and neuromuscular disease.

The CDC notes that RSV activity can vary among regions and communities. Local clinical laboratories should be consulted for information on the latest trends. Alternatively, additional information may be obtained online at http://www.cdc.gov/ncidod/dvrd/revb/nrevss/index.htm

MMWR. 2006;55:1269-1292.

10. Scoring System Reduces Unnecessary Antibiotic Use in Children with Pharyngitis

Use of a simple clinical decision rule in assessing children with pharyngitis reduced unnecessary antibiotic prescriptions, according to a study from Brazil published in the current issue of Pediatrics.

The study included 220 children with pharyngitis, about three quarters of whom tested culture-negative for group A streptococcus. The researchers developed a scoring system based on three criteria: age, viral signs, and bacterial signs. The specificity of the scoring system was 84%. Use of the system would reduce unnecessary antibiotic use by about 55% in clinics where bacteriologic diagnosis is of limited availability and by about 40% in clinics where it is completely unavailable, the researchers estimated.

Smeesters PR, et al. PEDIATRICS Vol. 118 No. 6 December 2006, pp. e1607-e1611

Article in Pediatrics: http://pediatrics.aappublications.org/cgi/content/full/118/6/e1607
Scoring System: http://pediatrics.aappublications.org/cgi/content-nw/full/118/6/e1607/T1
Treatment decision Rule: http://pediatrics.aappublications.org/cgi/content-nw/full/118/6/e1607/T2

11. Revisiting Swallowed Troubles: Intestinal Complications Caused by Two Magnets

A Case Report, Review and Proposed Revision to the Algorithm for the Management of Foreign Body Ingestion. Vijaysadan J. Am Board Fam Med 2006;19:511-516.

Here’s a nice review: Free full-text: http://www.jabfm.org/cgi/content/full/19/5/511

12. Low Literacy Leads to Prescription-Label Misunderstandings

Patients, particularly those with low literacy, frequently misunderstand the instructions on labels for common prescription drugs, finds a study released early online by the Annals of Internal Medicine.

Researchers asked nearly 400 English-speaking patients (recruited in clinics serving indigent populations) to read instructions from the bottles of five common prescription drugs. Participants were then asked to repeat the instruction information for each medication, and, for one of the medications, to demonstrate how many pills they would take in a day.

Findings included:

-- Almost half of patients misstated at least one label instruction; the majority of errors concerned dosage.

-- About 70% of low-literacy patients could restate the directions "take 2 tablets…twice daily," but only 35% could demonstrate the daily dose.

-- Most participants ignored auxiliary labels, such as "do not chew."

-- Taking a greater number of prescriptions was independently associated with increased risk for misunderstanding directions.

The authors caution that asking patients to repeat label instructions -- a method currently recommended for confirming patient understanding -- may not be adequate.

Editorial: http://www.annals.org/cgi/content/full/0000605-200612190-00145v1

13. Are Sore Throat Patients Who Hope for Antibiotics Actually Asking for Pain Relief?

Annals of Family Medicine 2006;4:494-499.

PURPOSE Antibiotics are still overprescribed for self-limiting upper respiratory tract infections such as acute sore throat, and physicians mention patient’s desire for antibiotics as a driving force. We studied patients’ concerns when visiting their family physician for acute sore throat, more specifically the importance they attach to antibiotic treatment and pain relief.

METHODS Family physicians in 6 peer groups in Belgium participated in an observational postvisit questionnaire survey. Patients aged 12 years and older making an office visit for acute sore throat were invited to indicate the importance of different reasons for the visit.

RESULTS Sixty-eight family physicians provided data from 298 patients. The 3 most frequently endorsed reasons for visiting the physician were examination to establish the cause of the symptoms, pain relief, and information on the course of the disease. Hopes for an antibiotic ranked 11th of 13 items. Patients who considered antibiotics very/rather important valued pain relief significantly more than patients who considered them little/not important (P less than .001). Patients who hoped for antibiotics felt more unwell (P less than .001), had more faith in antibiotics to speed recovery (P less than .001), and were less convinced that sore throat was a self-limiting disease (P less than .012). A multivariate model, adjusted for age, sex, and educational status, showed that the desire for pain relief is a strong predictor of the hope to receive a prescription for antibiotics.

CONCLUSION Our study suggests that patients with acute sore throat and who hope for antibiotics may in fact want treatment for pain. Trials are needed to test whether exploring patients’ expectations about pain management and offering adequate analgesia can assist physicians in managing sore throats without prescribing antibiotics.

Free full-text: http://www.annfammed.org/cgi/content/full/4/6/494

14. New Oral Anticoagulants Raise Hopes for Warfarin Replacement

from Heartwire — a professional news service of WebMD. December 8, 2006 (Gothenburg, Sweden) - A host of potential new oral anticoagulant agents, which could become much-needed replacements for warfarin and could also be used as an alternative to heparins or other antithrombin agents, are making good progress in development, with at least two agents now in phase 3 trials.

But experts are cautious following the fall from glory of the first such agent to be developed--ximelagatran--which actually reached the market in Europe but was swiftly withdrawn because of liver toxicity. Nevertheless, as there are so many new compounds in development, researchers are optimistic that this time at least one or two will succeed and provide the millions of patients who are--or should be--taking warfarin with a much more user-friendly treatment.

The two agents furthest on in development are the factor IIa inhibitor dabigatran (Boehringer Ingelheim) and the factor Xa inhibitor rivaroxaban (Bayer and Ortho-McNeil). Several other companies also have orally available factor Xa inhibitors in earlier clinical development, including Bristol-Myers Squibb, Lilly, Yamanouchi, and DuPont, and there are also other agents with different mechanisms in the pipeline, including a factor IXa inhibitor, TTP889 (TransTech Pharma), and an orally active glycosaminoglycan enhancer, odiparcil (SmithKline Beecham).

These agents are initially being developed for the prevention of thrombosis in orthopedic-surgery patients, but both dabigatran and rivaroxaban are also now starting late-stage trials for the prevention of stroke in atrial-fibrillation patients (as a replacement for warfarin) and in the treatment of acute coronary syndromes. Researchers in the field are optimistic that these agents will become easier-to-use alternatives to warfarin.

One of the leaders in this field, orthopedic surgeon Dr Bengt Eriksson (Sahlgrenska University Hospital, Gothenburg, Sweden), told heartwire: “I am hopeful that at least one of these new agents will reach the market within the next two to three years for the prevention of venous thromboembolism after major orthopedic surgery, and then these agents will gradually replace current anticoagulants.”

15. Oral Steroids May Trigger Some Cases of Diabetes

By David Douglas. NEW YORK (Reuters Health) Dec 08 - Use of oral glucocorticoids could be a precipitating factor in some cases of new-onset diabetes, UK researchers report in the December issue of Diabetes Care.

Lead investigator Dr. Martin C. Gulliford told Reuters Health the study results "suggest that use of orally administered glucocorticoids may be associated with up to 2% of all new cases of diabetes in primary care." Dr. Gulliford and colleagues at King's College London School of Medicine note that frequency of atopic disease is increasing, as is the burden of diabetes.

To examine whether there might be a relationship between steroid therapy for atopic conditions and new-onset diabetes, the researchers used a family practice database to conduct a case-control study. In all, 2647 patients with newly diagnosed diabetes were identified and compared with 5294 matched controls.

The researchers found that the adjusted odds ratio for diabetes associated with 3 or more prescriptions for oral glucorticoids was 1.36. Such patients appeared to account for about 2% of incident cases of diabetes.

However, "there appears to be either minimal or no association of new diabetes with prescribing of glucocorticoid-containing inhalers, topical preparations, eye drops, or infrequent glucocorticoid injections for joint problems," Dr. Gulliford concluded.

Diabetes Care 2006;29:2728-2729.

16. Risk for Thrombosis Persists After Discontinuation of Heparin Therapy

December 11, 2006 — The US Food and Drug Administration (FDA) and Baxter Healthcare Corp have warned healthcare professionals regarding the risk for delayed-onset heparin-induced thrombocytopenia (HIT) in patients receiving heparin sodium injection. HIT is a serious antibody-mediated reaction that results from irreversible platelet aggregation and can lead to the development of heparin-induced thrombocytopenia and thrombosis (HITT).

Patients presenting with thrombocytopenia or thrombosis within several weeks of discontinuing heparin therapy should be evaluated for HIT and HITT, according to an alert sent Friday from MedWatch, the FDA's safety information and adverse event reporting program.

HITT can present as thromboembolic events, including deep vein thrombosis (DVT), pulmonary embolism (PE), cerebral vein thrombosis, limb ischemia, stroke, myocardial infarction, mesenteric thrombosis, renal arterial thrombosis, skin necrosis, gangrene of the extremities that can lead to amputation, and possibly death.

Heparin sodium injection is indicated for the prophylaxis and treatment of venous thrombosis, PE, and peripheral arterial embolism; treatment of atrial fibrillation with embolization; diagnosis and treatment of acute and chronic consumptive coagulopathies; and for the prevention of clotting in arterial and cardiac surgery.

Heparin is also indicated for use as an anticoagulant in blood transfusions, extracorporeal circulation, dialysis procedures, and blood samples for laboratory purposes. A low-dose regimen may be used to prevent postoperative DVT and PE in patients undergoing major abdominothoracic surgery and those at risk for developing thromboembolic disease due to other reasons.

During treatment, thrombocytopenia of any degree should be closely monitored; if platelet counts decrease to less than 100,000/mm3, heparin should be promptly discontinued and alternative anticoagulant therapy considered if needed.

17. Patterns of Errors Contributing to Trauma Mortality: Lessons Learned From 2594 Deaths

Gruen RL, et al. Annals of Surgery 2006;244:371-80.

Objective: To identify patterns of errors contributing to inpatient trauma deaths.

Methods: All inpatient trauma deaths at a high-volume level I trauma center from 1996 to 2004 inclusive were audited. Data were collected with daily trauma registry chart abstraction, weekly morbidity and mortality reports, hospital quality assurance reports, and annual trauma registry analyses of risk of death using TRISS and HARM methodology. Deaths that met criteria for low to medium probability of mortality or those with quality of care concerns were analyzed for errors and then subjected to 3-stage peer review at weekly departmental, monthly hospital, and annual regional forums. Patterns of errors were constructed from the compiled longitudinal data.

Results: In 9 years, there were 44,401 trauma patient admissions and 2594 deaths (5.8%), of which 601 met low to medium mortality risks. Sixty-four patients (0.14% admissions, 2.47% deaths) had recognized errors in care that contributed to their death. Important error patterns included: failure to successfully intubate, secure or protect an airway (16%), delayed operative or angiographic control of acute abdominal/pelvic hemorrhage (16%), delayed intervention for ongoing intrathoracic hemorrhage (9%), inadequate DVT or gastrointestinal prophylaxis (9%), lengthy initial operative procedures rather than damage control surgery in unstable patients (8%), over-resuscitation with fluids (5%), and complications of feeding tubes (5%). Resulting data-directed institutional and regional trauma system policy changes have demonstrably reduced the incidence of associated error-related deaths.

Conclusions: Preventable deaths will occur even in mature trauma systems. This review has identified error patterns that are likely common in all trauma systems, and for which policy interventions can be effectively targeted.

18. A model for troponin I as a quantitative predictor of in-hospital mortality

Waxman DA, et al. J Am Coll Cardiol. 2006; 48(9):1755-62

OBJECTIVES: We evaluated log-transformed troponin I as a predictor of mortality in 2 independent populations.

BACKGROUND: The troponin I result is typically dichotomized by a single diagnostic cutoff. Its performance as a continuous prognostic variable has not previously been well-characterized.

METHODS: We studied the first troponin I sent from the emergency department (ED) as a predictor of all-cause inpatient mortality, with retrospectively gathered data. We performed our study in 2 stages, deriving our model with data from a single medical center and validating it with data from another. Subjects included every patient who had a troponin I sent from the ED during the period from November 2002 to January 2005. We assessed prognostic independence by including other potential confounders in nested logistic regression models. The troponin assay was identical at both sites (Ortho-Clinical Diagnostics, Rochester, New York).

RESULTS: There were a total of 34,227 patients (12,135 derivation and 22,092 validation). Odds ratio for mortality as a function of log10-troponin was 2.08 (95% confidence interval [CI] 1.85 to 2.32) in the derivation set and 2.07 (95% CI 1.92 to 2.24) for the validation set. Troponin I remained a strong predictor after inclusion of age, electrocardiogram normality, renal insufficiency, arrival mode, chief complaint, admission diagnosis, and abnormal vital signs into bivariate and nested multivariate models.

CONCLUSIONS: The presence of any detectible troponin I at ED presentation is associated with increased inpatient mortality. In 2 distinct clinical populations, the odds of death approximately doubled with any 10-fold increase in troponin result. This held true at levels below current diagnostic cutoffs. The placement and utility of dichotomous cutoffs might merit reconsideration.

19. Algorithm Could Aid in Management of Abnormal Uterine Bleeding

Researchers have designed a comprehensive, evidence-based algorithm to help primary care physicians manage abnormal uterine bleeding in women between menarche and menopause.

The algorithm, described in the November/December issue of the Journal of the American Board of Family Medicine, was drafted based on a review of the published literature, then revised and validated based on the actual care given to 300 patients at a gynecology clinic.

The algorithm advises clinicians first to rule out pregnancy, then to identify one of four bleeding patterns; for each of the patterns it offers extensive guidance about tests and treatments. Though the authors concede that the algorithm is lengthy, they write that they "wanted a practical tool that could stand alone at the point of care." The article includes a handheld-computer version of the algorithm.

Full-text (free): http://www.jabfm.org/cgi/content/full/19/6/590

Lit Bits: November 29, 2006

From the latest medical literature...

1. Systolic BP Predicts Mortality in Acute Heart Failure

News Author: Steve Stiles. from Heartwire — a professional news service of WebMD

November 8, 2006 — Systolic hypertension is not only common in patients hospitalized with acute heart failure, but it may also help protect against death while in the hospital and for several months after discharge, regardless of left ventricular (LV) systolic function at admission, suggest data from a huge multicenter registry published in the November 8 issue of JAMA. The adjusted in-hospital mortality for more than 48,000 patients hospitalized with heart failure varied inversely with their admission systolic blood pressure (SBP) and was about 4 times higher when the SBP was lower than 120 mm Hg as compared with higher than 161 mm Hg.

"Hypertension is very frequent in patients hospitalized with heart failure, including those with reduced systolic function as well as those with preserved systolic function," Gregg C. Fonarow, MD, of the University of California, Los Angeles, Medical Center, a coauthor of the analysis, told heartwire. Half of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry cohort — more than a third of patients with LV systolic dysfunction and more than half of those with preserved LV function — had an admission SBP of more than 140 mm Hg.

The inverse relationship between admission SBP and in-hospital mortality, Dr. Fonarow observed, applied to both groups of patients. Postdischarge mortality also rose significantly with declining admission SBP, regardless of any treatment with vasodilators or inotropic agents, in a subgroup of the cohort that was followed up for 2 to 3 months.

The OPTIMIZE-HF analysis by Mihai Gheorghiade, MD, of Northwestern University in Chicago, Illinois, and colleagues, not only suggests that admission SBP is independently prognostic in patients hospitalized with heart failure, they have implications for therapy, observed Dr. Fonarow. They suggest, he said, that "with the characteristics and outcomes so different among the patients by varied SBP levels, management will need to vary. Rather than grouping all of these patients together, we'll potentially need to stratify them."

The report states that "Elevated SBP appears to signal specific pathophysiological processes that differ from the underlying processes in patients with low SBP. Because the characteristics and outcomes are different among patients with heart failure with varying SBP levels, management may need to vary according to SBP at admission."

For the rest of the article: http://www.medscape.com/viewarticle/547410?sssdmh=dm1.224007&src=nldne

2. Survey examines drivers of rising ED use in California

Source: AHA News Now. Date: October 26, 2006

Nearly half of emergency department users in California say their ED visits during the past year could have been handled by a primary care physician had one been available, according to a survey by Harris Interactive. Insured patients whose health conditions are not true emergencies are increasingly using the state’s EDs due to a lack of access to other forms of medical care and advice on how to handle sudden medical problems, the survey found.

ED users were considerably less likely to have a primary care doctor and more likely to state that their ED is their main source of care. Medicaid recipients were more than twice as likely as privately insured individuals to have visited the ED in the past year. Patients with chronic conditions also visited the ED more, indicating that their primary care physician may need to improve their care management. Harris surveyed insured consumers as well as primary care and emergency physicians.

3. Length of Stay by Route of Contrast Administration for Diagnosis of Appy by CT Scan

Evan R. Berg, MD, et al. Acad Emerg Med. 2006;13: 1040-1045.

INTRO: Appendicitis remains one of the leading surgical causes of acute abdominal pain in adults, with nearly 7% to 9% of the population experiencing this condition at some point in their lifetime. Timely diagnosis is important for improving clinical outcomes. Delays can result in higher rates of perforation, increased levels of patient discomfort, and decreased patient satisfaction with their emergency department (ED) visit. Computed tomography (CT) scanning of the abdomen has been reported to have high sensitivity, specificity, positive predictive value, and negative predictive value for the assessment of patients with suspected appendicitis and has emerged as the diagnostic test of choice in many EDs.

Various methods to enhance visibility of CT have been studied, including CT with any combination of oral, intravenous (IV), or rectal-contrast material. The most commonly used technique for evaluating the appendix is a scan of the entire abdomen and pelvis after administration of both oral and IV contrast. However, the administration of oral contrast is a time-consuming step, and the two-hour prep time for terminal ileal and cecal visualization can delay diagnosis and prolong the patient's ED length of stay.

Several studies have shown CT with rectal-contrast material to be as accurate (98%) and safe as CT with oral-contrast material. Rectal-contrast administration is performed quickly and requires only minutes to ensure visualization of the appendix. Therefore, CT scanning using rectal contrast instead of oral contrast may decrease time to diagnosis and disposition and may shorten patients' overall length of stay in the ED by reducing the time to obtain a CT. The goal of this study was to compare ED length of stay for patients receiving rectal contrast to length of stay for patients receiving the standard of care (oral contrast). In addition, we compared patient satisfaction, level of discomfort, and symptoms between patients receiving oral or rectal contrast.

ABSTRACT: OBJECTIVES: Studies show equivalent accuracy of abdominal computed tomography (CT) using rectal contrast compared with oral contrast for diagnosing appendicitis. The authors evaluated whether emergency department (ED) length of stay and satisfaction differed by route of contrast administration for abdominal CT.

METHODS: This before-and-after intervention evaluated adult patients in an urban academic ED who were undergoing abdominal CT to screen for suspected appendicitis. Phase 1 subjects had a CT after oral contrast. Phase 2 patients had a CT after rectal contrast infused by gravity drip. Patients were interviewed after CT scan to assess satisfaction and discomfort. The primary outcome was ED length of stay. Medians, 95% binomial confidence intervals (CI), and Wilcoxon rank sum test of differences were calculated.

RESULTS: One hundred twelve patients were enrolled; half received rectal contrast. There was a significant decrease in length of stay for patients who were administered rectal contrast (261 min, 95% CI = 236 to 305 min) vs. oral contrast (332 min, 95% CI = 299 to 362 min), p = 0.009. Although subjects in the rectal-contrast group waited 65 minutes longer than did oral-contrast patients before receiving contrast after the CT order, the time from contrast administration to CT was 13 minutes, vs. 150 minutes for patients receiving oral contrast (p less than 0.001). Patient satisfaction and discomfort did not differ by route of contrast administration.

CONCLUSIONS: Rectal contrast for patients undergoing abdominal CT to rule out appendicitis reduced ED length of stay by more than an hour and did not affect patient satisfaction or discomfort. Rectal-contrast administration for abdominal CT may significantly shorten patient throughput time for individuals undergoing evaluation for appendicitis.

4. "Checklist" Identifies Opioid Abuse in Chronic Pain Patients

NEW YORK (Reuters Health) Nov 10 - The Addiction Behaviors Checklist (ABC) is a useful assessment tool to measure inappropriate opioid use in patients with chronic pain, according to findings published in the October issue of the Journal of Pain and Symptom Management.

"Diagnosing addictive disease in patients with chronic nonmalignant pain has proven to be a clinical challenge," Dr. Bruce D. Naliboff, of the University of California, Los Angeles, and colleagues write. "Standardized diagnostic criteria for opioid addiction in pain-free populations have proven to be less than valid or difficult to apply in the context of chronic pain and therapeutic opioid prescription."

The ABC is a 20-item clinician-based assessment tool designed to track behaviors that are characteristic of addiction to prescription opioids in chronic pain populations. Items on the measure included observable behaviors recorded during and between clinic visits. The team reports on interrater reliability and sensitivity and specificity for cut-off scores for the ABC.

Included in the study were 136 consecutive veterans, with chronic pain and a mean age of 53 years, who were receiving long-term opioid medication treatment. The score as obtained based on subject responses, interviewer observations of behavior during the session, and information gathered from medical chart reviews.

Results of the study demonstrate strong interrater reliability for the ABC. This supported the reliability and objective nature of the individual items and total score. The team notes that the ABC total score showed good concurrent validity in terms of its relationship with global clinical judgments of appropriate opioid use.

Results of the sensitivity and specificity analysis showed that a cut-off score of 3 or more on the ABC is a good estimate of whether a patient is displaying inappropriate opioid use.

A total of 38 patients had their prescriptions discontinued because of objective misuse criteria established within the clinic setting. "The ABC mean score gradually increased, approaching a total mean score of 3, as the participants neared the final visit in which they were dropped due to problematic opioid medication use," Dr. Naliboff and colleagues explain.

"ABC mean scores for participants who either completed the study or were dropped due to non-problematic reasons tended to remain fairly stable around a mean score of about 1.2 to 1.3.

J Pain Symptom Manage 2006;32:342-351.

The 20 Items
Addiction behaviors since last visit
1. Patient used illicit drugs or evidences problem drinking. 2. Patient has hoarded meds.
3. Patient used more narcotic than prescribed. 4. Patient ran out of meds early.
5. Patient has increased use of narcotics. 6. Patient used analgesics PRN when prescription is for time contingent use.
7. Patient received narcotics from more than one provider. 8. Patient bought meds on the streets.

Addiction behaviors within current visit
1. Patient appears sedated or confused (e.g., slurred speech, unresponsive). 2. Patient expresses worries about addiction.
3. Patient expressed a strong preference for a specific type of analgesic or a specific route of administration. 4. Patient expresses concern about future availability of narcotic.
5. Patient reports worsened relationships with family. 6. Patient misrepresented analgesic prescription or use.
7. Patient indicated she or he ‘‘needs’’ or ‘‘must have’’ analgesic meds. 8. Discussion of analgesic meds was the predominant issue of visit.
9. Patient exhibited lack of interest in rehab or self-management. 10. Patient reports minimal/inadequate relief from narcotic analgesic.
11. Patient indicated difficulty with using medication agreement.

Other: 1. Significant others express concern over patient’s use of analgesics

5. Adenosine vs. IV Ca--channel antagonists for the treatment of PSVT

Holdgate A; Foo A. Cochrane Database Syst Rev. 2006; (4):CD005154 (ISSN: 1469-493X)

BACKGROUND: Patients with paroxysmal supraventricular tachycardia frequently present to the Emergency Department. Where vagal manoeuvres fail, the two most commonly used drugs are adenosine and calcium channel antagonists. Both are known to be effective but both have a significant side-effect profile.

OBJECTIVES: To examine the relative effects of adenosine and calcium channel antagonists and, if possible, to determine which is most appropriate for the management of supraventricular tachycardia.

MAIN RESULTS: Eight trials were identified. In the pooled analysis there was no significant difference in reversion rate or relapse rate between the two drugs. Time to reversion was slower for verapamil than adenosine in all studies that reported this outcome, but the data were not suitable for combining. Minor adverse events such as nausea, chest tightness, shortness of breath and headache were reported much more frequently in patients treated with adenosine with 10.8 % of patients reporting at least one of these events, compared with 0.6% of those treated with verapamil (OR 0.15, 95% CI 0.09 to 0.26, P less than 0.001). There was no significant difference in the rate of major adverse events between the two groups, although hypotension was reported exclusively in the verapamil treatment group (3/166 patients treated with verapamil, 0/171 treated with adenosine).

AUTHORS' CONCLUSIONS: Adenosine and verapamil are both effective treatments for supraventricular tachycardia in the majority of patients. However, given the high incidence of minor but unpleasant side effects in patients treated with adenosine and the potential for hypotension with verapamil, patients should be fully informed of these risks prior to treatment.

6. Tamiflu May Be Linked to Risk for Self-Injury and Delirium

November 14, 2006 — The US Food and Drug Administration (FDA) and Roche Laboratories Inc have notified healthcare professionals regarding safety labeling revisions for oseltamivir phosphate (Tamiflu capsules and suspension) that warn of the potential risk for neuropsychiatric events associated with its use.

The warning was based on postmarketing reports (primarily from Japan) suggesting that patients with influenza receiving oseltamivir, particularly children, may be at increased risk for self-injury and delirium.

Although the role of the drug remains unclear, patients receiving oseltamivir should be closely monitored for signs of abnormal behavior, according to an alert sent yesterday from MedWatch, the FDA's safety information and adverse event reporting program.

Oseltamivir is indicated for the prophylaxis of influenza and treatment of uncomplicated acute illness in those who have been symptomatic for no longer than 2 days. It is approved for use in patients aged 1 year and older.

Adverse events potentially related to use of oseltamivir should be reported to the FDA's MedWatch reporting program by phone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch or by mail to 5600 Fishers Lane, Rockville, MD 20852-9787.

7. Presence of Calcium of EBCT Leads to Improved Use of Statins, Aspirin in Asymptomatic Men

from Heartwire — a professional news service of WebMD. November 13, 2006 (Chicago, IL) - Finding coronary artery calcium (CAC) on an EBCT (EB= electron beam) scan appears to improve use of preventive medicine in asymptomatic men above and beyond presence of traditional risk factors, new results from the Prospective Army Coronary Calcium Project suggest. Whether better use of preventive drugs leads to improved outcomes remains unknown, but according to Dr Allen J Taylor (Walter Reed Army Medical Center, Washington, DC), appreciating the impact of scans on patient management is an important piece of the puzzle.

"We've learned that calcium scans are an independent predictor of risk, but the knock against calcium scanning has been that it hasn't previously been shown that the scan leads to improved management decisions or outcomes," Taylor told heartwire during a poster session at the AHA 2006 Scientific Sessions. "This is the first time we've seen that management is shifted by a calcium scan."

Taylor and colleagues looked at use of aspirin, statins, and both medications among 1640 men between the ages of 40 and 50 participating in the PACC project, a community-based screening initiative among asymptomatic, otherwise healthy men. All study participants underwent risk factor assessment and an EBCT scan at study outset.

Baseline use of statins and of aspirin was greater in patients found to have coronary calcium than in patients with no calcium (approximately 10% vs 5% for statins and 18% vs 10% for aspirin)--reflecting more complex risk factor profiles. Over six years of follow-up, both statin and aspirin use increased to a greater degree in patients found to have coronary calcium on baseline EBCT, with the curves for both drugs diverging clearly after the baseline scan.

"There's something that's being recognized as risk, over and above standard risk factors, and that's leading to more use of preventive medication," Taylor told heartwire. What the study can't answer is what's driving the increase in medication use, whether it's patient-driven or physician decision-making, he added. Still, he says, "the bottom line is that this is the first community-based screening study to show that management of patients after calcium screening is improved . . . so it's an important advance in our understanding of this test as a tool in preventive cardiology."

As for whether management decisions lead to improved outcomes, "that's only really addressable by a randomized trial, but I don't think that trial is ever going to be done," Taylor said. "You can reasonably infer that if patients are using statins and aspirin, their outcomes should be better, but that's a leap of faith. This is an important step in the right direction."

8. Tdap from the CDC: to be used only once and limited to those aged 11- 65 years.

Tdap was licensed in 2005. It is the first vaccine for adolescents and adults that protects against all three diseases.

Who should get Tdap vaccine and when?

Adolescents 11 through 18 years of age should get one booster dose of Tdap.
• A dose of Tdap is recommended for adolescents who got DTaP or DTP as children but have not yet gotten a dose of Td. The preferred age is 11-12.
• Adolescents who have already gotten a booster dose of Td are encouraged to get a dose of Tdap as well, for protection against pertussis. Waiting at least 5 years between Td and Tdap is encouraged, but not required.
• Adolescents who did not get all their scheduled doses of DTaP or DTP as children should complete the series using a combination of Td and Tdap.

Adults 19 through 64 years of age should substitute Tdap for one booster dose of Td. Td should be used for later booster doses.
• Adults who expect to have close contact with an infant younger than 12 months of age should get a dose of Tdap. Waiting at least 2 years since the last dose of Td is suggested, but not required.
• Healthcare workers who have direct patient contact in hospitals or clinics should get a dose of Tdap. A 2-year interval since the last Td is suggested, but not required.

An adolescent or adult who gets a severe cut or burn might need protection against tetanus infection. Tdap may be used if the person has not had a previous dose.

If vaccination is needed during pregnancy, Td usually is preferred over Tdap. Ask your doctor. New mothers who have never received a dose of Tdap should get a dose as soon as possible after delivery.

Tdap may be given at the same time as other vaccines.

Td should be used rather than Tdap if Tdap is not available, and for:
- Anybody who has already gotten Tdap,
- Adults 65 years of age and older,
- Children 7 through 9 years of age.

http://www.cdc.gov/nip/publications/VIS/vis-tdap.pdf

9. Do we really need plain and soft-tissue radiographies to detect radiolucent foreign bodies in the ED?

Turkcuer I, et al. Amer J Emerg Med 2006;24:763-768.

Abstract
Objective: The objective of this study was to compare 3 imaging techniques—plain radiography, soft-tissue radiography, and ultrasonography—in detecting nonradiopaque foreign bodies in soft tissue.

Methods: In this randomized, blinded, and descriptive in vitro study, 40 chicken thighs with 2 types of nonradiopaque foreign bodies (wood and rubber) and 40 chicken thighs as part of a control group were evaluated to detect soft-tissue foreign bodies with plain radiography, soft-tissue radiography, and high-frequency ultrasonography.

Results: The overall sensitivity, specificity, as well as positive predictive and negative predictive values of plain radiography for both nonradiopaque foreign bodies were 5%, 90%, 33%, and 48%, respectively; those of soft-tissue radiography for both nonradiopaque foreign bodies were 5%, 90%, 33%, and 48%, respectively; and those of ultrasonography for both nonradiopaque foreign bodies were 90%, 80%, 81%, and 89%, respectively.

Conclusions: In this experimental model, the results show that high-frequency ultrasonography is superior to plain and soft-tissue radiographies and that the latter 2 techniques are similarly poor at detecting nonradiopaque foreign bodies.

10. Study Raises Questions on Safety of Naproxen

Aleve (naproxen) may increase the risk for cardiovascular and cerebrovascular events, according to research published in Public Library of Science Clinical Trials.

The data are from the NIH's Alzheimer's Disease Anti-Inflammatory Prevention Trial (ADAPT), which was halted early because of concerns about the heart risks of NSAIDS in the wake of the Vioxx withdrawal. At that time, the NIH issued a warning about the risks associated with naproxen, but the results were not previously available.

For the composite outcome of MI, heart failure, stroke, TIA, or cardiovascular death, the researchers found a hazard ratio of 1.63 for naproxen versus placebo, just reaching statistical significance.

The authors conclude that -- although not definitive -- the data suggest an increased risk for cardiovascular and cerebrovascular events with naproxen. However, an editorialist notes that the trial was stopped by the NIH, not the study's data safety monitoring board; this "resulted in data that cannot be reliably interpreted."

PLoS clinical trial: http://clinicaltrials.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pctr.0010033

11. Oral medroxyprogesterone acetate and combination OCs for acute uterine bleeding: a RCT.

Munro MG, et al. Obstet Gynecol. 2006; 108(4):924-9 (ISSN: 0029-7844)

OBJECTIVE: To compare the efficacy of multidose medroxyprogesterone acetate and a multidose monophasic combined oral contraceptive (OC) for hemodynamically stable women with nongestational, acute uterine bleeding.

METHODS: Hemodynamically stable patients with acute uterine bleeding sufficient to justify immediate medical or surgical intervention were enrolled in an open-label, randomized trial comparing oral medroxyprogesterone acetate 20 mg and a monophasic combination OC containing 1 mg norethindrone and 35 mug of ethinyl estradiol, each administered TID for one week. Doses were reduced after 1 week to 20 mg per day and one tablet per day for the next 3 weeks for the medroxyprogesterone acetate and OC groups, respectively. Following baseline assessment, patients completed daily treatment and symptom logs collected at 14 and 28 days after initiation of therapy.

RESULTS: Forty patients were randomly assigned, 20 in each group; 33 were evaluated at the 14-day visit. Emergency surgical procedures were avoided in 100% of those women taking medroxyprogesterone acetate and 95% of the OC group. Cessation of bleeding had occurred in 88% of the OC group and 76% of those receiving medroxyprogesterone acetate, with a median time to bleeding cessation of 3 days for both groups. Compliance with therapy was higher in the medroxyprogesterone acetate group than the OC group, but there was no overall difference in the incidence of treatment-related nausea and bloating.

CONCLUSION: This randomized trial is limited by sample size but suggests that both regimens may be effective and reasonably well tolerated.

12. Herniated Disk Improves With Either Surgical or Nonsurgical Treatment

News Author: Laurie Barclay, MD. November 21, 2006 — Patients with herniated disks had improved outcomes during 2 years whether treated surgically or nonsurgically, according to the results of a randomized trial with an accompanying observational cohort reported in the November 22/29 issue of JAMA.

"Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial," write James N. Weinstein, DO, MSc, of the Dartmouth Medical School in Hanover, New Hampshire, and colleagues from the Spine Patient Outcomes Research Trial (SPORT).

Based on intent-to-treat analyses, both treatment groups had substantial improvements for all primary and secondary outcomes. Between-group differences in improvements were consistently in favor of surgery, but these were small and not statistically significant for the main endpoints.

"Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period," the authors write. "Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis."

The second report describes outcomes in the observational cohort of patients who met the SPORT eligibility criteria but declined randomization between March 2000 and March 2003. Of the 743 patients enrolled, 528 patients received surgery, and 191 received usual nonoperative treatment.

At 3 months, patients who opted for surgery had greater improvement in the primary outcome measures of bodily pain (mean change: surgery, 40.9 vs nonoperative care, 26.0; treatment effect, 14.8; 95% confidence interval [CI], 10.8 - 18.9), physical function (mean change: surgery, 40.7 vs nonoperative care, 25.3; treatment effect, 15.4; 95% CI, 11.6 - 19.2), and Oswestry Disability Index (mean change: surgery, -36.1 vs nonoperative care, -20.9; treatment effect, -15.2; 95% CI, -18.5. to -11.8). These differences were less pronounced at 2 years.

"Patients with persistent sciatica from lumbar disk herniation improved in both operated and usual care groups," the authors write. "Those who chose operative intervention reported greater improvements than patients who elected nonoperative care. However, nonrandomized comparisons of self-reported outcomes are subject to potential confounding and must be interpreted cautiously."

In an accompanying editorial, Eugene Carragee, MD, of the Stanford University Medical Center in California, notes that "these findings suggest that in most cases there is no clear reason to advocate strongly for surgery apart from patient preference. For the patient with emotional, family, and economic resources to handle mild or moderate sciatica, surgery may have little to offer."
A second editorial, by David R. Flum, MD, MPH, of the University of Washington in Seattle, describes the difficulty in interpreting surgical trials with subjective outcomes. "Because of limitations in design and study operation, the proper role and benefits of these competing interventions are still unclear," Dr. Flum concludes. "Given the large number of patients potentially exposed to the risks of these strategies, a sham surgical trial may be the only effective and ethical next step."

JAMA. 2006;296:2441-2450, 2451-2459, 2483-2485, 2485-2487

JAMA editorials: http://jama.ama-assn.org/cgi/content/full/296/20/2483
http://jama.ama-assn.org/cgi/content/full/296/20/2485

13. Target Expands $4 Generic Program to All Pharmacies

Target announced on Monday that all of its nearly 1300 pharmacies will now offer $4 generic prescriptions. Wal-Mart recently expanded its own $4 generic program to cover about 3000 of its pharmacies in 38 states.

Which drugs are offered? http://sites.target.com/images/pharmacy/4dollar_program_list_111706.pdf

14. Late PCI Found to Be of No Clinical Benefit After MI

Reopening persistently occluded arteries after myocardial infarction does not produce an additional clinical benefit over optimal medical therapy, concludes an article released online in the New England Journal of Medicine.

In the study, 2166 stable patients were randomized either to undergo PCI and receive medical therapy, or to receive medical therapy alone. The patients had all suffered infarction and had confirmed total occlusion of the infarct-related artery 3 to 28 days later.

The estimated 4-year cumulative event rate (a composite of death from any cause, nonfatal reinfarction, or NYHA class IV heart failure) did not differ between the groups.

An editorial, offering advice on incorporating these results into care of patients after MI, says that repeated angiography is not warranted in most such patients and that all survivors of infarction should receive a beta-blocker indefinitely.

NEJM editorial: http://content.nejm.org/cgi/reprint/NEJMe068251v1.pdf

15. Benefit of early invasive therapy in ACS: a meta-analysis of contemporary randomized clinical trials.

Bavry AA, et al. J Am Coll Cardiol. 2006; 48(7):1319-25 (ISSN: 1558-3597)

OBJECTIVES: This study sought to systematically determine whether early invasive therapy improves survival and reduces adverse cardiovascular events in the management of non-ST-segment elevation acute coronary syndromes.

BACKGROUND: Although early invasive therapy reduces recurrent unstable angina, the magnitude of benefit on other important adverse outcomes is unknown.

METHODS: Clinical trials that randomized non-ST-segment elevation acute coronary syndrome patients to early invasive therapy versus a more conservative approach were included for analysis.

RESULTS: In all there were 7 trials with 8,375 patients available for analysis. At a mean follow-up of 2 years, the incidence of all-cause mortality was 4.9% in the early invasive group, compared with 6.5% in the conservative group (risk ratio [RR] = 0.75, 95% confidence interval [CI] 0.63 to 0.90, p = 0.001), and at 1 month (RR = 0.82, 95% CI 0.50 to 1.34, p = 0.43). At 2 years of follow-up, the incidence of nonfatal myocardial infarction was 7.6% in the invasive group, versus 9.1% in the conservative group (RR = 0.83, 95% CI 0.72 to 0.96, p = 0.012), and at 1 month (RR = 0.93, 95% CI 0.73 to 1.19, p = 0.57). At a mean of 13 months of follow-up, there was a reduction in rehospitalization for unstable angina (RR = 0.69, 95% CI 0.65 to 0.74, p less than 0.0001).

CONCLUSIONS: Managing non-ST-segment elevation acute coronary syndromes by early invasive therapy improves long-term survival and reduces late myocardial infarction and rehospitalization for unstable angina.

16. Canadian Study Indicates BNP Test for Suspected Heart Failure is Cost-Effective

from Heartwire — a professional news service of WebMD

November 16, 2006 (Chicago, IL) – The use of N-terminal pro-brain-type natriuretic peptide (NT-proBNP) testing in conjunction with clinical assessment improves the overall management of patients presenting to the emergency room with suspected acute heart failure, and saves around $1000 per patient, according to the results of the IMPROVE-CHF study presented in a late-breaking clinical trials session here by Dr Gordon W Moe (St Michael's Hospital, Toronto, Canada).

"In the Canadian system, this test is not reimbursed by the government and its use is still limited in spite of the data," Moe told heartwire. "Canadian doctors are already very good at making a diagnosis [of heart failure] so we did the test to see if it provided incremental benefit. The test saved money because a low level is very specific at ruling out heart failure, so doctors were able to discharge patients faster. On the other hand, if you have a high level, you know the patient is going to be very sick and you can administer therapy faster."

Discussant of the trial, Dr Margaret M Redford (Rochester, MN) said the results of IMPROVE-CHF, taken together with previous studies in this area, "provide consistent and compelling proof-of-concept evidence that the use of BNP testing in the evaluation of patients with dyspnea does improve cost savings without any adverse effects on outcomes."

Reduction in duration of ER stay. Moe and colleagues randomized 501 patients presenting with shortness of breath to seven emergency departments across Canada to usual care or BNP testing. All patients actually received a BNP test, but the results were not disclosed to doctors treating the usual care group.

Physicians immediately committed to a diagnosis for each patient based on their professional opinion, and these diagnoses were later judged and confirmed by cardiologists blinded to the BNP results, which were measured in the emergency room and again at 72 hours in those who were hospitalized.

There was a significant reduction in duration of emergency room visit in the BNP group compared with the usual care patients (5.6 hours vs 6.3 hours; p=0.038), but no differences between the groups in terms of ICU admission, duration of ICU stay or initial hospitalization from the emergency department.

There were cost savings, however, of $961 per patient ($4631 per patient in the BNP group overall compared with $5592 in the usual-care group). There was also significantly reduced rehospitalization within 60 days in the BNP group (33 patients vs 51).

For a test that costs Can $21, these findings are pretty good, Moe said. In a healthcare system like that of Canada that mandates judicious use of resources, " the use of the BNP test will improve the overall management of these patients and . . . should be part of the routine management," he commented.

Findings consistent with other studies. Redford said the study had some strengths--including the fact that it excluded patients with obvious causes of dyspnea and looked at whether BNP testing adds incremental value (which few other studies have done). But it also had some limitations, she noted, such as relatively small numbers of patients, which limited the power for mortality assessment and subgroup analyses.

Also, the researchers were not really able to say whether the savings in cost were related to better and more rapid treatment of patients or due to less use of diagnostic testing, nor were they able to determine whether the assay was most helpful in ruling out, or ruling in, heart failure, she noted.

Several studies have now compared the ability of BNP to make a diagnosis of heart failure, she said, including PRIDE, BASEL, the BNP trial, and the New Zealand one. When comparing the area under the receiver operating curve (AUC) for the BNP assay with the AUC for clinical diagnosis of heart failure, the current study's findings are quite consistent with those of the other trials for both indices, she said.

In terms of cost savings, the 15% savings in cost at 60 days in IMPROVE-CHF is consistent with the other studies in which economic data were reported, such as the BASEL study, which described a 25% saving in hospital costs with the BNP test vs no test, which was maintained out to six months, she concluded.

17. Statins Lower Risks in Patients Without CVD

Statins can take a role in the primary prevention of major coronary and cerebrovascular events in patients at moderate to moderately high risk, a meta-analysis in Archives of Internal Medicine finds. Statins did not, however, significantly reduce all-cause mortality or coronary heart disease mortality in these patients.

Researchers analyzed seven randomized, controlled trials comprising 42,848 subjects who either took statins for primary prevention or received a placebo. Ninety percent of the patients had no evidence of cardiovascular disease at enrollment.

Subjects taking statins for a mean of 4.3 years had a lower incidence of heart attack, stroke, revascularization, and other events than controls. The authors estimate the following numbers needed to treat for 4.3 years: 60, to prevent one major coronary event; 268 for stroke; 61 for nonfatal myocardial infarction and 93 for revascularization.

Thavendiranathan P, et al. Arch Intern Med. 2006;166:2307-2313.

18. Discordant Cardiac Biomarkers: Frequency and Outcomes in ED Patients With CP

Storrow AB, et al. Ann Emerg Med 2006;48:660-665.

Editor’s Capsule Summary
What is already known on this topic: Cardiac biomarkers are important in diagnosis and risk stratification of patients with suspected acute coronary syndrome. How to interpret discordant biomarkers is unclear.

What question this study addressed: Among patients with suspected non–ST-segment elevation acute coronary syndrome, how should emergency department (ED) clinicians interpret the following pairs of discordant cardiac biomarkers: increased CKMB+normal creatine kinase levels, increased troponin+normal CKMB levels, and normal troponin+increased CKMB levels?

What this study adds to our knowledge: In an ED population with suspected non–ST-segment elevation acute coronary syndrome, increase of either cardiac troponin or CKMB levels appears to increase the odds of acute coronary syndrome compared with that of patients with normal concordant cardiac biomarkers. Because of the constraints of incorporation and evaluation bias, these conclusions should be viewed as tentative at this time.

How this might change clinical practice: Until more information becomes available, it appears wise to regard increase of either cardiac troponin or CKMB as a true positive result and proceed accordingly.

Abstract: Study objective
We evaluate associations between pairs of discordant cardiac biomarkers (positive MB band of creatine kinase [CKMB] with negative creatine kinase, positive CKMB with negative cardiac troponin, and positive troponin with negative CKMB) and the presence of acute coronary syndromes in emergency department (ED) chest pain patients.

Methods
This was a secondary analysis of a prospective registry. Data were obtained from the multicenter Internet Tracking Registry of Acute Coronary Syndromes, which included 17,713 ED visits for possible acute coronary syndrome between June 1999 and August 2001. First visits and first ED cardiac biomarker results from the 9 sites, 8 in the United States and 1 in Singapore, were included. Subjects were excluded for incomplete information or an initial ECG consistent with ST-segment elevation myocardial infarction. Acute coronary syndrome was defined by diagnosis-related group code indicating myocardial infarction, positive invasive or noninvasive diagnostic testing, revascularization, or death during hospitalization or within 30 days.

Results
Of 8,769 eligible patients, 1,614 (18.4%) had acute coronary syndrome. The CKMB and cardiac troponin results were discordant in 7% of patients (CKMB+/cardiac troponin–, 4.9%, CKMB–/cardiac troponin+ 2.1%), whereas increased CKMB with normal creatine kinase levels occurred in 239 (3.1%) patients. The unadjusted odds ratios with 95% confidence intervals for acute coronary syndrome in patients with and without discordant markers were: CKMB+/CK− 5.7 (4.4-7.4), CKMB+/CK+ 4.4 (3.6-5.2), CKMB−/cTn+ 4.8 (3.4-6.8), CKMB+/cTn− 2.2 (1.7-2.8), CKMB+/cTn+ 26.6 (18.0-39.3). For the group with cardiac troponin, the reference category was negative troponin and negative CKMB; for the group with creatine kinase, the reference category was negative CKMB but either a positive or negative creatine kinase.

Conclusion
Among the spectrum of ED patients with chest pain, an increased CKMB level with a normal creatine kinase level identifies patients at increased risk for acute coronary syndrome. Similarly, an increased troponin level regardless of CKMB level and an increased CKMB level regardless of troponin level identify patients at higher risk for acute coronary syndrome than those with uniformly normal cardiac biomarker levels. Our data suggest that discordant cardiac biomarkers may identify patients at increased risk for acute coronary syndrome.

19. The Internet Tracking Registry of Acute Coronary Syndromes (i*trACS): A Multicenter Registry of Patients With Suspicion of ACS Reported Using the Standardized Reporting Guidelines for ED Chest Pain Studies

Lindsell CJ, et al. Ann Emerg Med 2006;48:666-677.

Editor’s Capsule Summary
What is already known on this topic: Randomized controlled trials can demonstrate the effectiveness of therapies but do not focus on the complex clinical presentations of acute coronary syndrome. Observational data sets that contain systematically recorded information on every patient who could have an acute coronary syndrome can help examine interactions between patient characteristics, presentations, practice patterns, and outcomes.

What question this study addressed: The investigators established a 9-emergency department network that collected standardized information on a convenience sample of patients in whom acute coronary syndrome was considered. They present information on more than 17,000 patient encounters.
What this study adds to our knowledge: This study provides information about these patients’ demographics, cardiac enzyme patterns, and 30-day outcomes.

How this might change clinical practice: This study alone will not change clinical practice but provides a model for clinical networks whose data might eventually lead to better strategies for the risk stratification of patients to different diagnostic and therapeutic regimens.

Abstract:
Study objective
Observational studies of well-described patient populations presenting to emergency departments (EDs) with suspicion of acute coronary syndrome are necessary to understand the relationships between patients’ signs and symptoms, cardiac risk profile, test results, practice patterns, and outcomes. We describe the methods for data collection and the ED population enrolled in a multicenter registry of patients with chest pain.

Methods
Patients older than 18 years, presenting to one of 8 EDs in the United States or 1 ED in Singapore, and with possible acute coronary syndrome were enrolled in the Internet Tracking Registry of Acute Coronary Syndromes between June 1999 and August 2001. Prospective data, including presenting signs and symptoms, ECG findings, and the ED physician’s initial impression of risk, were systematically collected. Medical record review or daily follow-up was used to obtain cardiac biomarker results, invasive and noninvasive testing, treatments, procedures, and inhospital outcomes. Thirty-day outcomes were determined by telephone follow-up and medical record review.

Results
The registry includes 15,608 patients, with 17,713 visits. Chest pain was the chief complaint in 71% of visits. The ECG was diagnostic of ischemia or infarction in 10.1% and positive cardiac biomarkers were observed in 10% of visits. Forty-three percent of patients were sent home directly from the ED. Of admitted patients, 5% died by 30 days, and 3% had documented coronary artery disease or had undergone percutaneous coronary intervention or coronary artery bypass grafting within 30 days. For patients discharged directly from the ED, 0.4% died or had a documented myocardial infarction within 30 days. Coronary artery bypass graft surgery, percutaneous coronary intervention, or a diagnosis of coronary artery disease was found in 0.5% of discharged patients.

Conclusion
A unique description of undifferentiated ED chest pain patients with suspected acute coronary syndrome is provided. The data set can be used to generate and explore hypotheses to improve understanding of the complex relationships between presentation, treatment, testing, intervention and outcomes.

20. A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures.

J Bone Joint Surg Br. 2006 Oct;88(10):1351-60.

Wait a minute—I don’t even know what a Gustilo fracture is…so I think we’ll skip this one.

Lit Bits: November 9, 2006

From the recent medical literature...

1. CT Scan Improves Chest-Pain Triage in ED

from Heartwire — a professional news service of WebMD. October 31, 2006 (Boston, MA) — Noninvasive assessment of coronary artery disease by coronary 64-slice multidetector computed tomography (MDCT) can be used for ruling out ACS in subjects presenting with chest pain to the emergency department and may be useful for improving early triage, a new study suggests.

The study, published online in Circulation on October 30, 2006, was conducted by a team led by Dr Udo Hoffman (Massachusetts General Hospital, Boston, MA). They explain that accurate triage of patients presenting with acute chest pain to the emergency department remains difficult because chest-pain history, a single set of biochemical markers for myocardial necrosis, and the initial 12-lead ECG, alone or in combination, cannot identify a group of patients who can be safely discharged without further diagnostic testing. As a consequence, more than 60% of patients with chest pain who are admitted to the hospital turn out not to have ACS. In addition, the rate of missed diagnosis of ACS remains unacceptably high (2% to 8%).

They point out that as coronary artery disease is the major underlying cause of ACS, a noninvasive method that quickly and accurately excludes the presence of CAD could substantially improve the ability to triage patients with chest pain and that MDCT could be the answer. This scan requires patients to be injected intravenously with a contrast agent and to hold their breath during the 15-second exam.

CT results matched eventual clinical diagnosis

In the current study, patients presenting with chest pain to the emergency department underwent MDCT for the assessment of coronary atherosclerotic plaque and significant coronary artery stenosis. An expert panel, blinded to the CT data, determined the presence or absence of ACS on the basis of all data accrued during the index hospitalization and five-month follow-up. Among 103 patients, only 14 patients were found to have ACS. The MDCT results correlated well with other methods of diagnosis. Both the absence of significant coronary artery stenosis and nonsignificant coronary atherosclerotic plaque on the CT scan accurately predicted the absence of ACS, with a negative predictive value of 100%. Multivariate logistic regression analyses demonstrated that adding the extent of plaque from a MDCT scan significantly improved the initial models containing only traditional risk factors or clinical estimates of the probability of ACS.

Hoffman commented to heartwire that this is the first study that has "very rigorously" looked at the role of MDCT in a cardiology clinical application. "MDCT is an emerging technology and is not used routinely yet, but it is probably used most in patients with stable angina to help decide whether to send them to angiography. We may do about 10 a day, and many private practices will offer this, but there is a reimbursement issue at the moment as it is not an established diagnostic modality yet," he explained.

But Hoffman believes that MDCT has great potential as a diagnostic aid in chest-pain patients presenting in the emergency room. "At present, just acting on the traditional risk factors and tests conducted in the emergency department, it can still be difficult to differentiate those patients with an ACS from those whose chest pain is not cardiac related. Many patients are admitted to the hospital for stress tests and angiography, but fewer than 40% of patients admitted after initially normal blood tests and ECG turn out to have symptoms related to heart disease. But if we add the CT information to those tests conducted in the emergency department, things become a lot clearer," he said.

Hoffman believes MDCT will be used to exclude ACS rather than to confirm it. "I am not suggesting that MDCT be used at present to decide whether patients need a stent or not— it's not ready for that yet—but it probably does have a role in helping to decide who needs to be sent to angiography and who can be sent home. MDCT does not give the level of knowledge necessary to know whether a stent is required—you need angiography for that—but it can tell you whether there is significant stenosis or not. The beauty of MDCT is that it is much easier to perform than angiography. It takes less time, requires less physician time, it is less invasive, has fewer complications, and is much less expensive. It's not going to replace angiography but it may enable fewer patients to be sent to angiography by ruling out ACS beforehand," he told heartwire.

For the remainder of the Heartwire article, click here. For the abstract, click here.

Hoffmann U, Nagurney JT, Moselewski F, et al. Coronary multidetector computed tomography in the assessment of patients with acute chest pain. Circulation 2006; DOI: 10.1161/CIRCULATIONAHA.106.634808.

2. Do opiates affect the clinical evaluation of patients with acute abdominal pain?

Ranji SR; Goldman LE; Simel DL; Shojania KG. JAMA. 2006; 296(14):1764-74 (ISSN: 1538-3598)

CONTEXT: Clinicians have traditionally withheld opiate analgesia from patients with acute abdominal pain until after evaluation by a surgeon, out of concern that analgesia may alter the physical findings and interfere with diagnosis.

OBJECTIVE: To determine the impact of opiate analgesics on the rational clinical examination and operative decision for patients with acute abdominal pain.

DATA SOURCES AND STUDY SELECTION: MEDLINE (through May 2006), EMBASE, and hand searches of article bibliographies to identify placebo-controlled randomized trials of opiate analgesia reporting changes in the history, physical examination findings, or diagnostic errors (those resulting in "management errors," defined as the performance of unnecessary surgery or failure to perform necessary surgery in a timely fashion).

DATA EXTRACTION: Two authors independently reviewed each study, abstracted data, and classified study quality. A third reviewer independently resolved discrepancies.

DATA SYNTHESIS: Studies both in adults (9 trials) and in children (3 trials) showed trends toward increased risks of altered findings on the abdominal examination due to opiate administration, with risk ratios for changes in the examination of 1.51 (95% confidence interval [CI], 0.85 to 2.69) and 2.11 (95% CI, 0.60 to 7.35), respectively. When the analysis was restricted to the 8 adult and pediatric trials that reported significantly greater analgesia for patients who received opiates compared with those who received placebo, the risk of physical examination changes became significant (risk ratio, 2.13; 95% CI, 1.14 to 3.98). These trials exhibited significant heterogeneity (I2 = 68.6%; P = .002), and only 2 trials distinguished clinically significant changes such as loss of peritoneal signs from all other changes; consequently, we analyzed risk of management errors as a marker for important changes in the physical examination.

Opiate administration had no significant association with management errors (+0.3% absolute increase; 95% CI, -4.1% to +4.7%). The 3 pediatric trials showed a nonsignificant absolute decrease in management errors (-0.8%; 95% CI, -8.6% to +6.9%). Across adult and pediatric trials with adequate analgesia, opiate administration was associated with a nonsignificant absolute decrease in the risk of management errors (-0.2%; 95% CI, -4.0% to +3.6%).

CONCLUSIONS: Opiate administration may alter the physical examination findings, but these changes result in no significant increase in management errors. The existing literature does not rule out a small increase in errors, but this error rate reflects a conservative definition in which surgeries labeled as either delayed or unnecessary may have met appropriate standards of care. In published research reports, no patient experienced major morbidity or mortality attributable to opiate administration.

3. Real-Time US-Guided IJ Vein Catheterization in the ED Increases Success Rates and Reduces Complications: A Randomized, Prospective Study

Leung J, Duffy M, Finckh A. Ann Emerg Med 2006 (Nov);48:540-547.

Study objective
We compare real-time ultrasonographic guidance and the traditional landmark technique for the insertion of internal jugular vein catheters in an emergency department (ED) setting.

Methods
This was a prospective, randomized, clinical study performed in a tertiary ED between August 2003 and May 2005 on patients requiring central venous access. Ultrasonographically guided catheters were inserted under real time using the Sonosite ultrasonographic system with a 10 to 5 MHz 38-mm linear array transducer. Standardized data were collected on operator experience, method of insertion, reason for central venous access, and comorbidities. Outcome measures included successful insertion of an internal jugular vein catheter, number of attempts, access times, and complications.

Results
One hundred thirty patients were enrolled. Cannulation of the internal jugular vein was successful in 61 of 65 patients (93.9%) using ultrasonography and in 51 of 65 patients (78.5%) using the landmark technique, a significant difference of 15.4% (P=.009, 95% confidence interval [CI] 3.8% to 27.0%). Fifty of 61 (82.0%) of the successful ultrasonographically guided catheters were inserted on the first attempt compared with 36 of 51 (70.6%) of the successful landmark catheters. Mean access times to venipuncture and successful insertion were 138 and 281 seconds by ultrasonographic guidance and 132 and 271 seconds by the landmark technique. There was a 10.8% complication rate, with 11 complications (16.9%) in the landmark group and 3 (4.6%) in the ultrasonographic group, a difference of 12.3% (95% CI 1.9% to 22.8%).

Conclusion
Ultrasonographically guided internal jugular vein catheterization in the ED setting was associated with a higher successful insertion rate and a lower complications rate.

4. Should Proton Pump Inhibitors Be Used for Acute Peptic Ulcer Bleeding?

Barnet Eskin, et al. Ann Emerg Med. 2006;48:624-626

Systematic review source
This is a systematic review abstract, a regular feature of the Annals’ Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area.

Conclusions
Proton pump inhibitor treatment in peptic ulcer bleeding reduces rebleeding and surgical and further endoscopic intervention rates in studies comparing treatment with placebo or H2RA; however, there is no evidence of an overall effect on mortality.

5. Emergency department visits continue to rise, AHA annual survey finds

Source: AHA News Now. Date: October 20, 2006

Hospitals treated more than 114 million patients in the emergency department in 2005, while inpatient visits remained constant at 35.2 million, according to the AHA's Annual Survey of Hospitals. ED visits have increased by about one-third since 1990 while the number of EDs has declined, increasing pressure on EDs that remain open. Worker shortages, challenges securing on-call coverage by specialty physicians, reduced behavioral health resources and ambulance diversions also posed challenges to hospital EDs. According to the survey, the financial state of hospitals remains fragile, with one-third of hospitals operating with negative margins. Medicare reimbursed 92 cents for every dollar hospitals spent caring for Medicare patients, while Medicaid reimbursement again dropped in 2005 to 87 cents on the dollar.

AHA President Dick Davidson said: "These are the numbers behind the reality that the women and men in America's hospitals face every day. Despite these many challenges, they manage to deliver the crucial services their communities need. The AHA and its member hospitals are committed to working with legislators and others to solve emergency room overcrowding, workforce shortages, Medicare and Medicaid reimbursement shortfalls and the many other issues that stand in the way of a better health care system." The survey data can be found in AHA Hospital Statistics - 2007.

6. CDC Committee Recommends Shingles Vaccine for Older Adults

The CDC's Advisory Committee on Immunization Practices voted unanimously Wednesday to recommend Zostavax, Merck's live attenuated zoster vaccine to prevent shingles in adults age 60 and older.

Zostavax was approved by the FDA in May. A clinical trial involving more than 38,000 volunteers found that the vaccine reduced the risk of developing shingles by about half during roughly 3 years of follow up. Among volunteers who developed shingles, those who were vaccinated were about 40% less likely to develop postherpetic neuralgia than those who did not receive vaccine. Side effects included headache and injection-site reactions. The vaccine is about 15 times more potent than regular chickenpox vaccine.

The single-dose vaccine costs about $150. A Merck official said some health plans already cover it, but the committee's recommendation is likely to increase coverage.

The advisory committee's specific recommendations are under review by the CDC and are expected to be published later in MMWR.

CDC Press Release.

7. SIDS Linked to Abnormalities in Brainstem Serotoninergic System

November 1, 2006 — Sudden infant death syndrome (SIDS) is linked to abnormalities in the brainstem serotoninergic system, according to the results of an autopsy study reported in the November 1 issue of JAMA. The findings suggest that medullary 5-hydroxytryptamine (5-HT) pathology in SIDS is more extensive than previously thought, pointing the way to future screening tests or interventions.

"This study confirms that there is a biological basis for SIDS, that it's not a mystery event that happens for no known reason," lead author David Paterson, PhD, an instructor in pathology at Children's Hospital in Boston, Massachusetts, told Medscape. "We don't know exactly what causes these abnormalities," Dr. Paterson said. "We believe that it's a developmental process that begins in utero, involving probably environmental as well as genetic factors. Finding out exactly what the pathogenesis is a big step toward trying to intervene and stop this."

The triple risk model suggests that sudden death results from a combination of an underlying vulnerability, an exogenous stressor such as prone sleep position or bed sharing, and the critical developmental period during the first 6 months of postnatal life, when the infant is at greatest risk for SIDS.

Until screening tests and potential interventions become available, Dr. Paterson recommends following the mandates of the national "Back to Sleep" campaign, which urges caregivers to put babies to bed on their backs. In fact, 65% of the SIDS cases in this study were sleeping prone or on their side at the time of death, indicating the need for continued public health messages on safe sleeping practices. Other recommended sleeping practices for infants are use of firm sleeping surfaces and avoidance of soft bedding, overheating, and exposure to prenatal and postnatal cigarette smoke.

"This study reinforces the risk reduction strategies that have been recommended, so parents and potential parents should follow those closely," Dr. Paterson said.

JAMA. 2006;296(17):2124-2132, 2143-2144.

8. It is Helpful to Add Atrovent to a Continuous Albuterol Neb?

A randomized, clinical trial comparing the efficacy of continuous nebulized albuterol (15 mg) versus continuous nebulized albuterol (15 mg) plus ipratropium bromide (2 mg) for the treatment of acute asthma

David Salo, MD, et al. J Emerg Med 2006 (Nov);31: 371-376

Multiple studies have examined adding nebulized ipratropium bromide to intermittent albuterol for the treatment of acute asthma. Although continuous nebulized treatments in themselves offer benefits; few data exist regarding the efficacy of adding ipratropium bromide to a continuous nebulized system. To compare continuous nebulized albuterol alone (A) vs. albuterol and ipratropium bromide (AI) in adult Emergency Department (ED) patients with acute asthma, a prospective, randomized, double-blind, controlled clinical trial was conducted on a convenience sample of patients (IRB approved). The setting was an urban ED.

Consenting patients greater than 18 years of age with peak expiratory flow rates (PEFR) less than 70% predicted, between October 15 and December 28, 1999, were randomized to albuterol (7.5 mg/h) + ipratropium bromide (1.0 mg/h), or albuterol alone via continuous nebulization using the Hope Nebulizer (B&B Technologies Inc., Orangevale, CA) for 2 h.

Main outcome measures were changed in mean improvement at 60 and 120 min PEFR compared to baseline (time 0). Secondary measures were admission rates. Data were analyzed using appropriate parametric and non-parametric tests. Sixty-two patients (30 women) completed enrollment: 32 in (AI) and (30) in (A). Four (A) and 2 (AI) patients are without 120 min data: 3 (A) and 1 (AI) were discharged after 60 min, whereas one each (A) and (AI) worsened and were admitted before 120 min. There were no statistically significant differences between treatment groups in age, sex, predicted or initial PEFR. Thirteen (19.4%) patients were admitted.

There was no statistically significant difference in improvement of mean PEFR at 60 min or 120 min compared to baseline, between groups, using repeated measures analysis of variance. There was no statistically significant difference in admission rates between groups: 5/30 (A) and 8/32 (AI) (p = 0.62). There were no significant differences in mean improvement of PEFR at either 60 or 120 min between ED patients with acute asthma receiving continuous albuterol alone vs. those receiving albuterol in combination with ipratropium bromide.

9. Shiga Toxin in Feces Now Reportable in California

The California Department of Health Services (CDHS) has made the detection of Shiga toxin (Stx) in feces reportable by healthcare providers and laboratories. This addition to California’s reportable disease list responds to a trend by clinical laboratories toward testing for Shiga toxin-producing E. coli (STEC) infections using enzyme immunosorbant assay (EIA) or other non-culture based methods, and the resulting need for timely and reliable notification of STEC infections that may not be culture-confirmed.

At CDHS, the Infectious Diseases Branch will be working with Laboratory Field Services and the Microbial Diseases Laboratory to alert clinical laboratories to the reporting change. We will also continue to work with clinical and public health laboratories to ensure that follow-up culture is performed on Shiga toxin positive specimens.

For now, please use the Case Report form used for cases of E.coli O157, HUS, and other STEC to follow up on patients with feces positive for Shiga toxin, marking on top of the form “Shiga toxin positive in feces.” We will update this form in the near future. For further questions on Stx testing or on the new regulation for reporting of Shiga toxin in stool, please contact Dr. Charlotte Wheeler by email at cwheeler@dhs.ca.gov or by phone at (510) 620-3434.

10. Popularity of Energy Drinks Sparks Worry

Nutritionists are warning parents about the dangers of caffeine-and-sugar-filled energy drinks, such as Red Bull, the Associated Press reports. About 7.6 million U.S. teens, or 31%, consume energy drinks, according to survey data cited by the AP.

Nutritionists warn that the drinks are just as likely as soda to contribute to obesity. In addition, energy drinks contain large doses of vitamins and other additives that may pose risks. Many teens consume several cans in rapid succession to get a high, which may lead to caffeine poisoning. A recent study at a Chicago poison control center found an increase in reports of caffeine overdose, about 12% of which required a trip to the hospital.

When consumed with alcohol the drinks may increase the risk of alcohol poisoning because they mask the symptoms of drunkenness, one study found.

What is the caffeine content of various sport drinks? Consult Wikipedia.

11. Feasibility of Forearm US-Guided Nerve Blocks of the Radial, Ulnar, and Median Nerves for Hand Procedures in the ED

Otto Liebmann, MDa, et al. Ann Emerg Med 2006;48: 558-562.

Study objective
We determine the feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves, performed by emergency physicians, to provide procedural anesthesia of the hand in the emergency department (ED).

Methods
This was a prospective study involving a convenience sample of 11 patients presenting to an adult ED with hand pathology requiring a procedural intervention. Adults 18 years and older who presented to the ED during the 3-month study period were eligible. Physicians performing the nerve blocks were attending physicians, ultrasonography fellows, or residents who had participated in a 1-hour training session. The participants underwent ultrasonography-guided nerve blocks in the forearm to provide anesthesia. Any additional anesthesia or analgesia required to perform the procedure in the anesthetized region was recorded.

Subjects rated their pain on a 100mm visual analog scale before the nerve block and 15 minutes after the nerve block. The primary outcomes for feasibility were the percentage of cases completed without rescue anesthesia or analgesia and the median reduction in pain on the visual analog scale after the nerve block. Secondary outcomes for feasibility included the median time to completion of the entire nerve block procedure for each subject (from initiation of ultrasonography to completion of the last injection) and the percentage of participants wishing to have the same procedure for similar injuries in the future. Other secondary outcomes included the percentage of participants with complications during the procedure and at 3 months.

Results
All procedures (100%) were completed without additional anesthesia or analgesia. The median reduction in visual analog scale score was 5.0 cm (interquartile range 3.0, 8.0; P=.003). The median time to completion of nerve blocks was 9 minutes per patient (interquartile range 6 minutes 30 seconds, 10 minutes 0 seconds), with a median of 2 blocks per patient. Ten of 11 patients (92%) stated they would wish to have the ultrasonography-guided nerve block in the future for similar injuries. There were no immediate complications and no complications reported at 3 months.

Conclusion
Attending physicians, fellows, and residents can perform forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves quickly, without additional anesthesia and with high patient satisfaction, after minimal training. Although pilot data are suggestive, randomized controlled trials are needed to determine efficacy and safety. Ultrasonography-guided nerve blocks to provide anesthesia for hand procedures appear to be feasible in the ED.

12. A Randomized, Controlled Trial of IV Versus IM Ketamine for Sedation of Pediatric Patients Receiving ED Orthopedic Procedures

Mark G. Roback, MD, et al. Ann Emerg Med 2006 (Nov); 48: 605-612.

Study objective
We compare adverse events, efficacy, and length of sedation of intravenous (IV) versus intramuscular (IM) ketamine procedural sedation and analgesia for orthopedic procedures in the emergency department (ED).

Methods
Pediatric patients receiving ketamine for orthopedic procedures were enrolled in a prospective, randomized, controlled trial in a children’s hospital ED. All patients were initially randomized to receive ketamine either 1 mg/kg IV or 4 mg/kg IM. Demographics, adverse events, sedation efficacy, and length of sedation were recorded.

Results
Two hundred twenty-five patients were randomized (116 IV, 109 IM). Two hundred eight patients, aged 14 months to 15 years, completed the study, 109 IV and 99 IM. Respiratory adverse events were similar between groups (IV 8.3% versus IM 4.0%; odds ratio [OR] 0.47; 95% confidence interval [CI] 0.14 to 1.6). Vomiting in the ED was more common in the IM group (26.3% versus 11.9%; OR 2.60; 95% CI 1.2 to 5.9).

Using the Faces Pain Scale, patients in the IM group reported significantly less pain from the procedure. Video observers reported significantly lower distress in the IM group during the painful procedure (Observation Score of Behavioral Distress scores 0.35 IM versus 0.74 IV; mean difference 0.38; 95% CI 0.04 to 0.72). Length of sedation was significantly longer in the IM group (median 129 versus 80 minutes). Satisfaction of sedation was high in parents and physicians, with no difference in reported satisfaction between groups. This study was terminated early because of nursing resistance based on the longer recovery times observed in patients receiving ketamine IM.

Conclusion
In this study of pediatric sedation for orthopedic procedures, we found that ketamine 4 mg/kg IM was more effective than 1 mg/kg IV but demonstrated significantly longer recovery times and more vomiting.

13. Improving Alertness and Performance in ED Physicians and Nurses: The Use of Planned Naps

Rebecca Smith-Coggins, MD, et al. Ann Emerg Med 2006;48: 596-604.e3.

Study objective
We examine whether a 40-minute nap opportunity at 3 am can improve cognitive and psychomotor performance in physicians and nurses working 12-hour night shifts.

Methods
This is a randomized controlled trial of 49 physicians and nurses working 3 consecutive night shifts in an academic emergency department. Subjects were randomized to a control group (no-nap condition=NONE) or nap intervention group (40-minute nap opportunity at 3 am=NAP). The main outcome measures were Psychomotor Vigilance Task, Probe Recall Memory Task, CathSim intravenous insertion virtual reality simulation, and Profile of Mood States, which were administered before (6:30 pm), during (4 am), and after (7:30 am) night shifts. A 40-minute driving simulation was administered at 8 am and videotaped for behavioral signs of sleepiness and driving accuracy. During the nap period, standard polysomnographic data were recorded.

Results
Polysomnographic data revealed that 90% of nap subjects were able to sleep for an average of 24.8 minutes (SD 11.1). At 7:30 am, the nap group had fewer performance lapses, reported more vigor, less fatigue, and less sleepiness. They tended to more quickly complete the intravenous insertion, exhibit less dangerous driving and display fewer behavioral signs of sleepiness during the driving simulation. Immediately after the nap (4 am), the subjects scored more poorly on Probed Recall Memory.

Conclusion
A nap at 3 am improved performance and subjective report in physicians and nurses at 7:30 am compared to a no-nap condition. Immediately after the nap, memory temporarily worsened. The nap group did not perform any better than the no-nap group during a simulated drive home after the night shift.

14. Patient perceptions of emergency physicians: The gender gap still exists

Louise A. Prince, MD, at al. J Emerg Med 2006 (Nov); 31: 361-364

This study examines whether female emergency physicians are less likely than male emergency physicians to be recognized by patients as physicians. A convenience sample of adult patients seen while a trained observer was on duty in an academic ED constituted the study population. After the first physician contact, the observer asked the patient if a physician had seen the patient yet. The observer recorded the physician’s sex, the patient’s response, sex, age, and race. The frequencies that male and female physicians were recognized as physicians were compared.

For the 184 physician-patient contacts evaluated, 98/105 (93.3%) of males were recognized as physicians and 62/79 (78.5%) of females were recognized as physicians. Females were significantly less likely than males to be recognized as physicians (chi-square, p = 0.003). Female emergency physicians are less likely than male emergency physicians to be recognized by patients as physicians.

15. Burst fracture of the first lumbar vertebra and conus-cauda syndrome complicating a single convulsive seizure: A challenge of diagnosis in the ED

Fereydoon Roohi, MD, Andrew Fox, MD. J Emerg Med 2006 (Nov); 31:381-385.

Fractures of the thoracic and lumbar vertebrae as a direct consequence of generalized epileptic convulsions are the most common non-traumatic type of fracture complicating epileptic seizures. The majority of these fractures are compression fractures that occur with minimal symptoms and virtually no permanent neurological sequela. Nevertheless, muscle contractions generated during generalized motor seizures can result in severe axial skeletal trauma and grave neurological complications.

We describe the case of a 35-year-old man who suffered a burst fracture of the first lumbar vertebral body and acute conus medullaris-cauda equina syndrome as a direct consequence of a single grand mal seizure. The aim of this report is to draw attention to this serious complication of generalized convulsive seizures and alert readers to epilepsy-related vertebral fractures. Diagnosis and management of acute cauda equina-conus medullaris syndrome caused by lumbar fracture are reviewed.

16. Thoracic and lumbar spine radiographs for walking trauma patients—is it necessary?

Eran Tamir, MD, et al. J Emerg Med; 2006 (Nov); 31:403-405

Numerous patients ambulating independently arrive in the Emergency Department complaining of back pain after being involved in a motor vehicle crash (MVC). We examined the yield of routine screening radiographs of the lumbar and thoracic spine in these patients. A retrospective review was carried out of the records of 3173 patients who were involved in a MVC during a 1-year period and presented to a single medical center. Radiographs of the lumbar spine, thoracic spine, or both were obtained in all patients complaining of back pain.

Of 3173 ambulating MVC trauma patients, 35% (1110 patients) complained of thoracic or lumbar back pain. None of the lumbar and thoracic spine radiographs that were obtained in these patients was positive for a fracture or dislocation. The current study suggests that the yield of the routine use of spinal radiographs is very low in patients ambulating independently and complaining of back pain after a MVC.

17. NSAID Use May Raise Risk of Hospitalization for Heart Failure

NEW YORK (Reuters Health) Nov 03 - Current NSAID use is associated with a slightly increased risk of a first hospitalization for heart failure, according to a report in the November issue of Heart. Similarly, NSAID use may worsen preexisting heart failure.

The new findings, which stem from a case-control analysis, agree with those of epidemiologic studies linking NSAID use with increased risks of incident heart failure, hospitalization for heart failure, and heart failure relapse. Researchers believe that by blocking prostaglandin synthesis, NSAIDs increase systemic resistance and decrease renal perfusion, both of which would be expected to increase the risk of heart failure.

After adjusting for various confounders, current NSAID use was associated with a 30% increased risk of first hospitalization for heart failure, the authors note. No dose or duration effects were noted.

Current NSAID users with preexisting heart failure were 8.6-times more likely to have a first hospitalization for heart failure than nonusers without this medical history.

"Heart failure is a common cause of morbidity and mortality in the elderly and even a small increase in the risk can translate into a significant disease burden in the general population," the investigators write. "Therefore, NSAIDs should be used with caution by patients with a high risk of hospital admission due to heart failure such as those with prior clinical heart failure, diabetes, renal failure or treatment with hypertension drugs."

Heart 2006;92:1610-1615.

18. STEMI Treatment Faster With Emergency Physician Initiation of PCI

October 18, 2006 (New Orleans) — Involvement of emergency medicine physicians in initiating treatment of or facilitating transfer for ST-segment elevation acute myocardial infarction (STEMI) patients were deemed cutting-edge topics in recent emergency research presented here at the American College of Emergency Medicine Scientific Assembly.

One Illinois study found that median "door-to-balloon" time (MDBT) in STEMI patients improved significantly when emergency physicians initiated 1% primary percutaneous coronary intervention (PCI) emergent angioplasty in patients rather than waiting for a cardiology consultation. In the study of 60 patients conducted by University of Chicago Hospitals researchers, MDBT decreased to 88 minutes from 114 minutes.

"We have long since realized that time is muscle and that emergency physicians can make that decision [about starting PCI] as quickly and effectively as cardiologists," said Arthur Kellermann, MD, professor and chair of the department of emergency medicine at Emory University in Atlanta, Georgia, a comoderator of the session at which the Illinois study was presented. Researchers found that no inappropriate activations of cardiac catheterization occurred.

Whether PCI is initiated by emergency physicians should depend not just on timing or cardiologist availability but primarily on the physician's ability to safely and competently start the treatment. That's no longer the issue it once was, according to Jerome Hoffman, MD, professor of medicine and emergency medicine at the University of California David Geffen School of Medicine in Los Angeles, who comoderated the research highlights session. "Of course competent emergency physicians are the best people to do these things...that other people have traditionally considered theirs. If it's good for patients we should do it," he said, adding that "the important issue is that we do it well and safely."

Dr. Hoffman, who is also a clinical epidemiologist and health services researcher, cautioned, however, that the issue of PCI in STEMI should also be viewed in the larger picture of when interventions warrant protocol status. "We have to look at what is appropriate and rational, and we have to remember that only a tiny percentage of patients seen by paramedics have STEMI — it's a reasonable guess that 1 in 100 chest pains in the field is a STEMI."

Despite that low incidence, Dr. Hoffman said that evidence supports that PCI is both efficacious and generally safe for patients with STEMI. "It is good if you can get it," he said, but he urged healthcare systems to look at the cost-benefit ratio, risks of both over- and undertriage, and the potential for other "lost opportunities" before making protocol changes.

A second study by Minnesota researchers found that most STEMI patients can be safely transferred from rural facilities and community hospitals without PCI capability to angioplasty centers without increasing transfer-associated morbidity and mortality. That study of 746 consecutive patients transferred from 28 rural and community hospitals to a Minneapolis cardiac tertiary care center showed that even unstable patients weathered the transfer well; no deaths occurred during transfer, despite the fact that 11.7% of the patients were in cardiogenic shock and 6.7% had experienced pretransfer arrest.

Those findings should offer some peace of mind to emergency physicians trying to decide which MI patients to transport and when, said Dr. Kellermann. "This study showed a very low mortality rate and high success and safety rates with transfer times of about 30 minutes — and that's an important issue out there," he said, for emergency physicians working in rural facilities and suburban centers.

Two thirds of patients were transported by air and one third by ground ambulance, with median transport times of 28 and 32 minutes, respectively. Endotracheal intubation was performed in 4.5% of patients pretransfer and in 0.7% during transport, and all 12 patients who experienced cardiopulmonary arrest during transport were returned to spontaneous circulation. Three patients died in hospital (2 during angioplasty and 1 due to anoxic brain injury). The remaining patients were neurologically intact at discharge. The use of the standardized protocol — which called for transfer of all STEMI patients to Abbott Northwestern Hospital —was initiated in 2003.

ACEP 37th Annual Scientific Assembly. Presented October 16, 2006.

19. Stroke Uncommon Among Patients With Dizziness Symptoms

NEW YORK (Reuters Health) Oct 27 - Less than 1% of patients who present to the ER with isolated dizziness symptoms, including vertigo and imbalance, have a stroke or TIA, according to a report in the October issue of Stroke.

However, because so many people present with these symptoms, the absolute number of stroke cases presenting in this fashion may be high, the authors note.

Findings from case reports and small series have shown that dizziness may be the principal or only complaint in stroke patients, but until now no large population-based study has investigated the frequency of stroke among patients seen in the ER for dizziness symptoms.

The current study involved all patients, older than 44 years of age, with dizziness symptoms who presented to an ER or were directly admitted to a hospital in Neuces County, Texas between January 1, 2000 and June 30, 2003.

Of the 1666 patients who had dizziness symptoms, 53 (3.2%) had a final diagnosis of stroke or TIA, senior author Dr. Lewis B. Morgenstern, from the University of Michigan Medical School in Ann Arbor, and colleagues report. Moreover, just 0.7% of patients with dizziness symptoms as the only presenting complaint had a stroke or TIA.

The average age of stroke/TIA patients was 69.3 years, significantly older than the 65.3 years noted in non-stroke/TIA patients, the report indicates. Male gender was linked to stroke/TIA, whereas isolated dizziness symptoms tended to support a non-stroke diagnosis.

Among the various dizziness symptoms, imbalance was a predictor of stroke/TIA, the report indicates.

"This study suggests that of the patients presenting with dizziness symptoms, those with other neurologic symptoms, who are older and male, are at the highest risk for a cerebrovascular etiology," the authors conclude. "More detailed population-based studies and prospective clinical studies on the relationship of stroke and dizziness symptoms are critically needed so that stroke can be rapidly identified."

Stroke 2006;37:2484-2487.

20. Heart Failure with Preserved EF Also Has High Mortality

Heart failure with or without preserved left ventricular function is equally common and deadly, report two studies in the November 8 issue of JAMA.

Bursi and colleagues, studying 556 heart failure patients from a Minnesota community, found that 55% had preserved ejection fraction. Mortality at six months was high (16%) in both reduced and preserved EF groups. Ejection fraction aside, isolated diastolic dysfunction was present in 44% of patients.

Gheorghiade and colleagues also found preserved systolic function in about half of 41,267 patients hospitalized with heart failure. Regardless of EF, patients with higher systolic blood pressure at admission had lower mortality in-hospital and post-discharge.

For the full-text of the Bursi study, click here.