Thursday, June 15, 2006

Lit Bits: June 15, 2006

From the recent medical literature...

0. Emergency Rooms in Crisis, Reports Find

By Maggie Fox. WASHINGTON (Reuters) Jun 14 - U.S. emergency rooms are understaffed, overwhelmed and could not cope with a crisis, whether a pandemic, attack or natural disaster, according to three reports released on Wednesday.

Americans rely heavily on emergency departments and emergency medical services to save their lives when sudden illness or disaster strikes, yet these services are not properly funded and often do not live up to expectations, the reports from the Institute of Medicine found.

"We are definitely not prepared for the onslaught we would receive today in the event of an emergency (such as) a hurricane, bioterrorist attack...or a pandemic," Dr. Brent Eastman, Chief Medical Officer of Scripps Health in San Diego, told a news conference.

"We hope that this report will astonish the nation."

The Institute, an independent body that advises the federal government on health matters, issued three reports on the fragile status of emergency care in the United States. It noted that emergency services are the primary source of health care for many uninsured and on evenings and weekends when clinics are closed.

"Each year in the United States approximately 114 million visits to emergency department occur, and 16 million of these patients arrive by ambulance. In 2002, 43 percent of all hospital admissions in the United States entered through the emergency department," one of the reports stated.


Despite increasing attention placed on emergency and disaster preparedness in the United States after the September 11 attacks, emergency services received only 4 percent of $3.38 billion distributed by the Homeland Security Department for emergency preparedness in 2002 and 2003, the Institute said. The report did not give figures for 2004 or 2005.

"The result is that few hospital and EMS professionals have had even minimal disaster preparedness training," one report said.

"Even fewer have access to personal protective equipment; hospitals, many already stretched to the limit, lack the ability to absorb any significant surge in casualties; and supplies of critical hospital equipment, such as decontamination showers...ventilators, and intensive care unit beds, are wholly inadequate."

Experts say none of the complaints are new and yet little has been done to address the problem, perhaps because the U.S. healthcare system relies heavily on private enterprise.

"Hospitals must be reimbursed for the significant amounts of uncompensated emergency and trauma care they provide. To do otherwise threatens to destroy the critical emergency care infrastructure that all Americans depend on," said Dr. Rick Blum, president of the American College of Emergency Physicians.

The reports call for a pool of $50 million to pay for this.

State and federal governments must also work to ensure that hospitals and emergency medical services can communicate with police, fire departments and other emergency responders -- something many cannot do now.

Some of the nation's emergency medical services are municipally managed, others are privately owned. Some are organized under fire departments, while others are operated by hospitals or other medical organizations and they all need to coordinate better, the panel said.

It recommended that Congress allocate $88 million for projects to find ways to do this.

Hospitals also have to stop diverting patients to the emergency room, get patients out of the ER and into hospital rooms so they do not clog up the system, the committee said.

1. Study finds 4 in 10 medical liability claims are without merit

Source: American Hospital Association (
Date: May 11, 2006

About 40% of medical liability claims are without merit, according to a study
( in the New
England Journal of Medicine that reviewed a random sample of closed claims
from five liability insurers to determine whether a medical injury or error
had occurred. Claims that did not involve errors were more than twice as
likely to go to trial as claims that did. The average claim took five years
to resolve, and a third of claims took six years or longer.

The combination of defense costs and standard contingency fees charged by plaintiffs’ attorneys brought the total costs of litigating the claims studied to 54% of the compensation paid to plaintiffs. The authors conclude that reforms are needed to improve the liability system’s efficiency in handling reasonable
claims for compensation. The study was conducted by researchers at the
Harvard School of Public Health and Harvard Risk Management Foundation in

2. Otitis Media Treatment in the Age of Pediatric Pneumococcal Vaccines

Empiric First-line Antibiotic Treatment of Acute Otitis in the Era of the Heptavalent Pneumococcal Conjugate Vaccine

Jane Garbutt, MB, et al. PEDIATRICS Vol. 117 No. 6 June 2006, pp. e1087-e1094 (doi:10.1542/peds.2005-2651)

OBJECTIVES. Our goal was to estimate the local prevalence of Streptococcus pneumoniae nonsusceptible to penicillin and amoxicillin after widespread use of the heptavalent pneumococcal vaccine and to revise community-specific recommendations for first-line antibiotic treatment of acute otitis media.

METHODS. We conducted serial prevalence surveys between 2000 and 2004 in the offices of community pediatricians in St Louis, Missouri. Study participants were children <7>2 µg/mL were considered to be S pneumoniae nonsusceptible to amoxicillin.

RESULTS. There were 327 patients enrolled in the study. Between 2000 and 2004, vaccine coverage with 3 doses of heptavalent pneumococcal vaccine increased from 0% to 54%, but nasopharyngeal carriage of S pneumoniae was stable at 39%. The prevalence of S pneumoniae nonsusceptible to penicillin fell from 25% to 12% among patients, did not vary if <2 years of age, was reduced in children with 3 doses of heptavalent pneumococcal vaccine, and increased in child care attendees but reduced in attendees who had 3 doses of heptavalent pneumococcal vaccine. The prevalence of S pneumoniae nonsusceptible to amoxicillin in patients remained <5%.

CONCLUSIONS. In our community, widespread use of heptavalent pneumococcal vaccine has reduced the prevalence of S pneumoniae nonsusceptible to penicillin, and the prevalence of S pneumoniae nonsusceptible to amoxicillin remains low (<5%). If antibiotic treatment is elected for children with uncomplicated acute otitis media, we recommend treatment with standard-dose amoxicillin (40–45 mg/kg per day) for children with 3 doses of heptavalent pneumococcal vaccine, regardless of age and child care status. High-dose amoxicillin should be used for children with <3 doses of heptavalent pneumococcal vaccine and those treated recently with an antibiotic.

3. Dieting for six months pays off irrespective of the regimen

Following any one of four commercial dieting regimens (Atkins', Weight Watchers, Slim-Fast, and Rosemary Conley's) significantly reduces weight and body fat over six months compared with no dieting. Truby and colleagues randomised 300 otherwise healthy overweight or obese adults to one of the diets or a delayed treatment control group. The average weight loss in the intervention groups was 5.9 kg, and fat loss was 4.4 kg. Atkins' was the most successful diet during the first four weeks, but, overall, slimming did not depend on the regimen followed.

4. B-Type Natriuretic Peptide May Facilitate Evaluation of Acute Dyspnea

News Author: Laurie Barclay, MD. June 1, 2006 ­ Testing B-type natriuretic peptide (BNP) is cost-effective for patients with acute dyspnea, according to an analysis of the results of a prospective, randomized trial reported in the May 22 issue of the Archives of Internal Medicine. "BNP is a quantitative marker of heart failure that seems to be helpful in its diagnosis," write Christian Mueller, MD, from University Hospital, University of Basel in Switzerland, and colleagues.

"The randomized B-Type Natriuretic Peptide for Acute Shortness of Breath Evaluation (BASEL) study showed that more rapid and more accurate diagnosis results in a reduction in the rate of hospitalizations, time to discharge, and initial treatment cost. Therefore, BNP testing may confer improvements in both the costs and the effectiveness of treatment of patients with acute dyspnea."

To estimate the long-term cost-effectiveness of BNP guidance, the investigators randomized 452 patients who presented to the emergency department with acute dyspnea and who were enrolled in BASEL to a diagnostic strategy involving the measurement of BNP levels (n = 225) or to standard assessment (n = 227). Nonparametric bootstrapping helped to estimate the distribution of incremental costs and effects on the cost-effectiveness plane during 180 days of follow-up.

BNP testing resulted in several important changes in management of dyspnea, including a reduction in the initial hospital admission rate, the use of intensive care, and total days in the hospital at 180 days (median, 10 days [interquartile range, 2 - 24 days] in the BNP group vs 14 days [interquartile range, 6 - 27 days] in the control group; P = .005).

All-cause mortality at 180 days was 20% in the BNP group and 23% in the control group (P = .42). Total treatment cost was lower in the BNP group ($7930) than in the control group ($10,503; P = .004). Analysis of incremental 180-day cost-effectiveness revealed that BNP guidance was associated with lower mortality and lower cost in 80.6%, in higher mortality and lower cost in 19.3%, and in higher or lower mortality and higher cost in less than 0.1% each. These results were robust to changes in most variables but sensitive to changes in rehospitalization with BNP guidance.

Study limitations include possible limited generalizability to North American hospitals or to patients not presenting to the emergency department, and interpretation of BNP levels based on the data available when the study protocol was devised rather than on a more appropriate lower cutoff value in patients with renal disease.

"This study in patients presenting to the ED [emergency department] with acute dyspnea demonstrates that rapid BNP testing is cost-effective during the initial hospital encounter as well as at 180 days," the authors write. The Swiss National Science Foundation, Swiss Heart Foundation, Novartis Foundation, Krokus Foundation, and University of Basel supported this study. Biosite provided diagnostic devices and reagents (Triage).

The authors have disclosed no relevant financial relationships. Arch Intern Med. 2006;166:1081-1087

5. The Unexpected Death of a Patient in the Clinical Setting: Some Ethical Reflections

Posted 05/18/2006. Eike-Henner W. Kluge, PhD

Introduction: The death of a patient is always a significant event; however, the unexpected death of a patient is immeasurably more significant and can strike the physician with devastating force, stressing her or his ability to cope to the very limit. There are several reasons for this. They range from professional (Was the death a result of incompetence or negligence? Were other professional factors involved that could have been foreseen, dealt with, or avoided?) to psychological (Was the professional psychologically attached to her patients, in general, and to this patient, in particular?) to spiritual (Did her personal beliefs and values affect her outlook on death in a way that might cause personal turmoil?).

However, there is one factor that is almost invariably overlooked, yet it goes to the very heart of the situation. It concerns the ethical legitimacy of the feelings that are being experienced, and centers on 3 notions that are basic to medicine as a profession: the notion of a patient, the concept of healthcare, and the nature of medicine itself. What follows is a brief sketch of how these factors function, how they are interrelated, and how they may be resolved.

The Rest of the Article:

6. Haloperidol Useful in Acute Treatment of Migraine

News Author: Anthony J. Brown, MD. May 26, 2006 ­ Intravenous therapy with the neuroleptic agent haloperidol is highly effective in alleviating migraine pain and appears to be useful when standard treatments have failed, Finnish researchers report. However, side effects are common with this drug and may limit its use in some patients. Neuroleptics have been used to treat migraines, but they are generally given to control nausea and vomiting, not pain, lead author Dr. Jari Honkaniemi, from the University of Tampere, and colleagues note. Still, there is evidence that these drugs provide additional benefits and in a recent open-label trial, haloperidol helped relieve migraine pain.

In the present study, reported in the May issue of Headache, the researchers used a visual analog scale (VAS) to assess pain control in 40 patients with acute migraine who were randomized to receive intravenous haloperidol, 5 mg in 500 mL saline, or saline alone (placebo group). Subjects in the placebo group who reported no pain relief after the infusion were offered haloperidol in an open trial. VAS scores fell from 7.7 to 2.2 with haloperidol compared with 7.2 to 6.3 with placebo (p < 0.0001), the report indicates.

Eighty percent of haloperidol-treated patients reported significant pain relief compared with just 15% of control patients (p < 0.0001). In addition to 17 patients who had no response to placebo, seven patients who refused to participate in the double-blind study were included in the open trial. Similar to the previous results, VAS scores fell from 6.7 to 2.4 and 79% of patients reported significant pain relief. Sedation and akathisia were the most common side effects encountered with haloperidol.

Eighty percent of patients in the double-blind study and 88% in the open trial reported these adverse effects. For 16% of patients, these effects were particularly troublesome, leading them to request a different agent for future migraine attacks. The migraine relapse rate among haloperidol-treated patients was 3%, the investigators point out.

"Because the majority of the patients had taken other medication without response, haloperidol appears to be an effective rescue medication even when other types of treatment have failed," the authors conclude. They say this agent appears to be the most efficacious of the neuroleptics tested to date. Headache. 2006;46:781-787

7. New Blood Tests for Tuberculosis

Tuberculin skin testing produces many false negatives (e.g., in immunosuppressed patients) and false positives (e.g., in patients with atypical mycobacteria or prior BCG vaccination). Two new blood tests, T-SPOT.TB and QuantiFERON-TB Gold, detect interferon- that is produced in response to antigens specific to Mycobacterium tuberculosis. Both tests include positive controls; failure of a patient's blood to react to these controls yields an "indeterminate" result that suggests the patient is immunosuppressed and not necessarily pathogen-free.

To compare these new assays and the tuberculin skin test in routine practice, Italian investigators performed both assays on 393 consecutive patients with suspected latent or active tuberculosis; 318 patients also underwent tuberculin skin tests. Both blood tests agreed fairly well with the skin test results, but skin tests were positive more often than either blood test. Agreement between blood tests and skin tests was lower among subjects who had been vaccinated with BCG than among those not vaccinated with BCG. Indeterminate results were more common among patients who had cause to be immunosuppressed.

Comment: Because no gold standard exists for detection of latent TB infection, firmly establishing the sensitivity or specificity of any of these tests is difficult. Nevertheless, these two new blood tests might have a role in future TB control programs. In a recent CDC guideline for using the QuantiFERON-TB Gold test, several potential advantages of blood testing (compared with skin testing) are noted, including no need for a second visit at 48 to 72 hours, and avoidance of problems related to skin-test placement and interpretation. ­

Bruce Soloway, MD. Published in Journal Watch June 2, 2006. Source: Ferrara G et al. Use in routine clinical practice of two commercial blood tests for diagnosis of infection with Mycobacterium tuberculosis: A prospective study. Lancet 2006 Apr 22; 367:1328-34.

8. The Effects of Coffee and Napping on Nighttime Highway Driving: A Randomized Trial

Pierre Philip, et al. Ann Intern Med 2006;144: 785-791. The authors measured the nighttime highway driving performance of 12 young men immediately after coffee (containing 200 mg of caffeine), placebo (decaffeinated coffee containing 15 mg of caffeine), or a 30-minute nap. When daytime highway driving was used as a reference point for nighttime driving, 75% drove as well after coffee and 66% drove as well after a nap, but only 13% drove as well after placebo. Drinking coffee or napping significantly reduced nighttime highway driving impairment.


Accompanying editorial: Naps and Drugs To Combat Fatigue and Sleepiness by Christian Guilleminault and Kannan Ramar

The United States is progressing toward a 24-hour society, and sleep deprivation is a growing problem in the workplace. What can hospital staff do about sleepiness? What are possible countermeasures, and how effective are they?

9. An Evaluation of D-Dimer in the Diagnosis of PE: A Randomized Trial

Clive Kearon, et al for the Canadian Pulmonary Embolism Diagnosis Study (CANPEDS) Group Ann Intern Med 2006;144: 812-821.

In patients with a low clinical probability of pulmonary embolism who also have negative D-dimer test results, withholding additional diagnostic testing does not increase the frequency of venous thromboembolism during follow-up. Low clinical probability and negative D-dimer test results occur in 50% of outpatients and in 20% of inpatients who have suspected pulmonary embolism.

Ann Intern Med Editors' Notes
Context: Is it safe to withhold additional testing in patients with suspected pulmonary embolism (PE) and negative D-dimer test results?

Contribution: This randomized trial evaluated the effect of further testing after negative D-dimer test results in patients with low pretest probability (group A) or moderate or high pretest probability (group B) of PE. At 6 months, 0 of 182 (group A) and 1 of 41 (group B) patients with no further testing had had symptomatic venous thromboembolism, compared with 1 of 185 (group A) and 0 of 41 (group B) patients with further testing.

Cautions: Few moderate- or high-probability patients were studied. Implications: Additional diagnostic testing seems unnecessary in patients with low pretest probability of PE and negative D-dimer test results.


10. Laryngeal View During Laryngoscopy: A Randomized Trial Comparing Cricoid Pressure, Backward-Upward-Rightward Pressure, and Bimanual Laryngoscopy

Richard M. Levitan, MD et al. Ann Emerg Med 2006; 47: 548-555.

Study objective External cricoid and thyroid cartilage manipulations are commonly taught to facilitate laryngeal view during intubation. We compare the laryngeal views during laryngoscopy with 4 manipulations (no manipulation, cricoid pressure, backward-upward-rightward pressure [BURP], and bimanual laryngoscopy) to determine the method that optimizes laryngeal view.

Methods This was a randomized intervention study involving emergency physicians participating in airway training courses from December 2003 to November 2004. Direct laryngoscopies were performed with curved blades on fresh, non-fixed cadavers by using each of the 4 methods. The percentage of glottic opening (POGO), a validated scoring scale, was recorded for each laryngoscopy. Scores for bimanual laryngoscopy were recorded before the assistant applied external pressure.

Results A total of 1,530 sets of comparative laryngoscopies were performed by 104 participants. One thousand one hundred eighteen of 1,530 sets (73%) had POGO scores less than 100 with no manipulation. Compared to no manipulation, mean POGO scores with bimanual laryngoscopy improved by 25 (95% confidence interval [CI] 23 to 27); mean POGO score improvement with cricoid pressure and BURP were 5 (95% CI 3 to 8) and 4 (95% CI 1 to 7), respectively. POGO scores with bimanual laryngoscopy were higher compared to cricoid pressure (mean difference 20, 95% CI 17 to 22) and BURP (mean difference 21, 95% CI 19 to 24).

Among laryngoscopies with no manipulation in which the POGO score greater than 0 (n=1,434), laryngeal view worsened in 60 cases (4%, 95% CI 3% to 5%) with bimanual laryngoscopy, in 409 cases (29%, 95% CI 26% to 31%) with cricoid pressure, and in 504 cases (35%, 95% CI 33% to 38%) with BURP.

Conclusion Using a cadaver model, we found pressing on the neck during curved blade laryngoscopy greatly affects laryngeal view. Overall, bimanual laryngoscopy improved the view compared to cricoid pressure, BURP, and no manipulation. Cricoid pressure and BURP frequently worsen laryngoscopy. These data suggest bimanual laryngoscopy should be considered when teaching emergency airway management.

By the way, what exactly is ‘bimanual laryngoscopy”? From the article: “Bimanual laryngoscopy involves operator-directed manipulation of the thyroid cartilage (Figure 1). Unlike cricoid pressure and BURP, both done by an assistant, bimanual laryngoscopy coordinates manipulation by the operator’s right hand with simultaneous direct observation. After the view is optimized, laryngeal manipulation is then taken over by an assistant at that location, which frees the operator’s right hand to place the tracheal tube.”

11. Early Revascularization and Long-term Survival in Cardiogenic Shock Complicating AMI

Judith S. Hochman, MD; et al for the SHOCK Investigators. JAMA. 2006;295:2511-2515.

Context Cardiogenic shock remains the major cause of death for patients hospitalized with acute myocardial infarction (MI). Although survival in patients with cardiogenic shock complicating acute MI has been shown to be significantly higher at 1 year in those receiving early revascularization vs initial medical stabilization, data demonstrating long-term survival are lacking.

Objective To determine if early revascularization affects long-term survival of patients with cardiogenic shock complicating acute MI.

Design, Setting, and Patients The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial, an international randomized clinical trial enrolling 302 patients from April 1993 through November 1998 with acute myocardial infarction complicated by cardiogenic shock (mean [SD] age at randomization, 66 [11] years); long-term follow-up of vital status, conducted annually until 2005, ranged from 1 to 11 years (median for survivors, 6 years).

Main Outcome Measures All-cause mortality during long-term follow-up.

Results The group difference in survival of 13 absolute percentage points at 1 year favoring those assigned to early revascularization remained stable at 3 and 6 years (13.1% and 13.2%, respectively; hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.57-0.97; log-rank P = .03). At 6 years, overall survival rates were 32.8% and 19.6% in the early revascularization and initial medical stabilization groups, respectively. Among the 143 hospital survivors, a group difference in survival also was observed (HR, 0.59; 95% CI, 0.36-0.95; P = .03). The 6-year survival rates for the hospital survivors were 62.4% vs 44.4% for the early revascularization and initial medical stabilization groups, respectively, with annualized death rates of 8.3% vs 14.3% and, for the 1-year survivors, 8.0% vs 10.7%. There was no significant interaction between any subgroup and treatment effect.

Conclusions In this randomized trial, almost two thirds of hospital survivors with cardiogenic shock who were treated with early revascularization were alive 6 years later. A strategy of early revascularization resulted in a 13.2% absolute and a 67% relative improvement in 6-year survival compared with initial medical stabilization. Early revascularization should be used for patients with acute MI complicated by cardiogenic shock due to left ventricular failure.

12. Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study

BMJ 2006;332:1355 (10 June)

[Not that this should be our policy, but this paper opens the topic up for further investigation. DRV]

In recent guidelines for the treatment of community acquired pneumonia many recommendations could be supported by sound clinical evidence. The duration of antibiotic therapy is, however, an exception. The usual treatment recommendation of 7-10 days for uncomplicated pneumonia is not based on scientific evidence but has nevertheless gained acceptance over the years. Two older studies in adults have suggested that a significantly shorter duration than 7-10 days might be justified. These studies do not, however, meet the required standards of clinical trials. If a shorter duration of therapy is equally effective, this can be of major importance in decreasing antibiotic consumption.

On a population level there is a clear relation between total antibiotic consumption and resistance rates of the pathogens. Prolonged or repeated courses of antibiotics provide the selective pressure that favours the emergence of resistant isolates. Resistance rates among common respiratory pathogens for several antimicrobial agents are increasing. Decreasing the duration of antibiotic treatment in respiratory tract infection might therefore decrease resistance rates. A five day, high dose course of amoxicillin for respiratory tract infections in children resulted in a significantly lower rate of carriage of penicillin resistant Streptococcus pneumoniae than the standard duration of treatment.

Two recent studies in children with non-severe pneumonia showed that three days' treatment with oral amoxicillin was as clinically effective as five days' treatment. We carried out a randomised, double blind, placebo controlled, multicentre trial in adults admitted to hospital with mild to moderate-severe community acquired pneumonia to find out whether discontinuing treatment with amoxicillin after three days in patients showing substantial improvement is as effective as conventional treatment for eight days.

Objective To compare the effectiveness of discontinuing treatment with amoxicillin after three days or eight days in adults admitted to hospital with mild to moderate-severe community acquired pneumonia who substantially improved after an initial three days' treatment.

Design Randomised, double blind, placebo controlled non-inferiority trial.

Setting Nine secondary and tertiary care hospitals in the Netherlands.

Participants Adults with mild to moderate-severe community acquired pneumonia (pneumonia severity index score 110).

Interventions Patients who had substantially improved after three days' treatment with intravenous amoxicillin were randomly assigned to oral amoxicillin (n = 63) or placebo (n = 56) three times daily for five days.

Main outcome measures The primary outcome measure was the clinical success rate at day 10. Secondary outcome measures were the clinical success rate at day 28, symptom resolution, radiological success rates at days 10 and 28, and adverse events.

Results Baseline characteristics were comparable, with the exception of symptom severity, which was worse in the three day treatment group. In the three day and eight day treatment groups the clinical success rate at day 10 was 93% for both (difference 0.1%, 95% confidence interval - 9% to 10%) and at day 28 was 90% compared with 88% (difference 2.0%, - 9% to 15%). Both groups had similar resolution of symptoms. Radiological success rates were 86% compared with 83% at day 10 (difference 3%, - 10% to 16%) and 86% compared with 79% at day 28 (difference 6%, - 7% to 20%). Six patients (11%) in the placebo group and 13 patients (21%) in the active treatment group reported adverse events (P = 0.1).

Conclusions Discontinuing amoxicillin treatment after three days is not inferior to discontinuing it after eight days in adults admitted to hospital with mild to moderate-severe community acquired pneumonia who substantially improved after an initial three days' treatment.

13. Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study

BMJ 2006;332:1363 (10 June) [Hint: Bilious Vomitus is Green, not Yellow. DRV]

Introduction Classic teaching in paediatric surgery is that vomiting of bile in the newborn should be attributed to intestinal obstruction until proved otherwise. Reported series have confirmed the requirement for further investigation in this group, with a need for surgical intervention in 30-40%. To "avoid errors in judgment" these studies included only babies with green vomit and excluded babies with yellow vomit. Together with other neonatal surgeons we advocate prompt and thorough investigation of any infant with green vomit to specifically exclude mechanical obstruction.

In several infants referred to our unit with reported bile vomiting, however, a detailed history reveals only yellow vomiting, though we are aware that a proportion of such babies are found to have intestinal obstruction. We determined what colour was perceived by different observer groups to represent bile in a baby's vomit.

Objectives To identify the colour that different groups of observers thought represented bile in a newborn's vomit.

Design Questionnaires displaying eight colours (pale yellow to dark green).

Setting General practices in Glasgow, postnatal ward and level III special care baby unit in a university teaching hospital, and mother and toddler groups in Glasgow.

Participants 47 general practitioners, 29 nurses on the baby unit, 48 midwives, and 41 mothers of babies and infants.

Outcome measures Participants indicated which colour would represent bile in a baby's vomit. More than one colour could be chosen. Respondents were also asked to indicate one colour that was the best match for bile.

Results When any colour could be chosen, 12 (25%) general practitioners, 1 (3%) nurse on the baby unit, 5 (10%) postnatal midwives, and 23 (56%) parents did not consider green an appropriate colour for a baby's vomit containing bile. Twenty three (49%) general practitioners, 7 (24%) neonatal nurses, 15 (31%) postnatal midwives, and 29 (71%) parents thought yellow was the best colour match.

Conclusions There is little agreement about the colour of bile vomit in a newborn. It is more pertinent to ask parents about the colour of vomit rather than whether it contained bile. Many general practitioners and parents do not recognise green as an appropriate colour for bile in the vomit of newborns, which may delay surgical referral. Though yellow vomit does not exclude intestinal obstruction, the presence of green vomiting in a baby is a surgical emergency and requires expeditious referral.

14. Cool Advances in Medical Science

FDA Approves Cervical Cancer Vaccine.

The U.S. Food and Drug Administration (FDA) today (June 8) approved the first vaccine that can prevent cervical cancer. The vaccine targets human papillomavirus (HPV), which is widespread in the population. Roughly 500,000 women worldwide develop cervical cancer each year, and supporters hope the preventative will make a dent in the cancer's prevalence.

Capsule Endoscopy for Small Bowel Evaluation

Current approaches for evaluating bleeding and other adverse symptoms of the small bowel include enteroscopy (endoscopy beyond the ligament of Treitz), enteroclysis (double-contrast studies in conjunction with computed tomography or magnetic resonance imaging), radionuclide scanning, angiography, and capsule endoscopy (ingestion of a capsule containing a tiny video camera).

In an Italian study, researchers assessed the diagnostic efficiency of capsule endoscopy among 304 consecutive patients who required further evaluation after negative upper and lower gastrointestinal evaluations. The most common indications included unexplained or suspected GI bleeding, Crohn disease, polyposis, diarrhea, malignancy, and abdominal pain. Visualization of the small bowel was defined as adequate in 96% of cases; however, the cecum was not reached in 20% of cases.

Conclusive diagnoses (based on positive or negative findings sufficient to explain clinical symptoms) were made in 65% of cases. The proportions of cases with positive findings were 58% for obscure GI bleeds, 31% for suspected Crohn disease, 25% for diarrhea, and 17% for abdominal pain. Comment: Evidence from this large series supports that from earlier studies. Capsule endoscopy is becoming an important diagnostic tool in patients whose initial evaluations fail to provide clinical answers. ­

Jamaluddin Moloo, MD, MP. Published in Journal Watch June 9, 2006. Source: Sturniolo GC et al. Small bowel exploration by wireless capsule endoscopy: Results from 314 procedures. Am J Med 2006 Apr; 119:341-7.

Benznidazole may help treat chronic Chagas' disease

Ann Intern Med 2006;144: 724-34. [Whoops. How did this sneak into the lit bits? When was the last time we misdiagnosed Chagas?! DRV]

15. PCI delay increases risk in patients with ST-segment elevation MI

June 8, 2006. NEW YORK (Reuters Health) - For patients with ST-segment elevation myocardial infarction (STEMI), in-hospital mortality is independently associated with longer delay to percutaneous intervention ("door-to-balloon time"). Moreover, this association remains regardless of how long it takes for the patient to get to the ER or how many high-risk factors the patient has. Guidelines of the American College of Cardiology/American Heart Association recommend that PCI be performed within 90 minutes after the patient with STEMI presents at the hospital. However, this is the exception rather than the rule, according to senior investigator Dr. Harlan M. Krumholz and his associates.

To determine the effect of delay in STEMI patients who require PCI, Dr. Krumholz and his team evaluated data from the National Registry of Myocardial Infarction (NRMI-3 and -4) between 1999 and 2002. Included were roughly 29,000 STEMI patients who underwent primary PCI within 6 hours of presentation at 1 of 395 hospitals. According to their report in the Journal of the American College of Cardiology for June 6, the authors stratified patients based on the time from symptom onset to arrival at the hospital, and the presence of high-risk factors -- anterior/septal location, diabetes, heart rate > 100 beats/min, or systolic blood pressure < 100 mm Hg.

Dr. Krumholz, from Yale University School of Medicine in New Haven, Connecticut, and his team observed that 62% of patients presented within 2 hours of symptom onset, and that 58% had at least one high-risk feature. Most had door-to-balloon time of > 90 minutes. The risk of in-hospital mortality increased with door-to-balloon time for all risk groups. The authors calculate that the odds ratio was 1.08 for every increase in door-to-balloon time of 30 minutes, after adjusting for other risk factors (p < 0.0001). Dr. Krumholz and his associates suggest that "door-to-balloon time may be a proxy for general quality of care."

"These findings support the current guideline-based recommendations for rapid PCI," they write, "and provide evidence that this recommendation is valid for all patients with STEMI and presentation within 6 hours of the onset of symptoms."

In conclusion, they advise that efforts should be directed at decreasing the time that patients with STEMI wait for PCI, and that "degree of urgency should not depend on time of symptom onset or baseline risk factors."

J Am Coll Cardiol 2006;47:2180-2186.


Since 1994, California has experienced an epidemic of wound botulism among injecting drug users (IDUs). Over the past 5 years, 20–24 cases of laboratory-confirmed wound botulism among IDUs have been reported on a yearly basis in California. From January 1, 2006 to date, California has already logged 22 laboratory-confirmed cases, and has released antitoxin for another 14 IDU patients whose laboratory tests are pending or who were not laboratory-confirmed, either because specimens were found to be negative, were inadequate for testing, or did not reach MDL.

We do not know the reason for this year’s increase, but the primary cause of wound botulism among IDUs has been skin-popping contaminated black tar heroin. A clinician who suspects botulism in a patient must contact his/her local health department (LHD) in order to receive antitoxin and to trigger any local investigations that are necessary. This interaction requires that LHDs have functional and widely-advertised 24/7 emergency contact numbers. If the LHD respondent deems that antitoxin is warranted, he/she then contacts the DCDC Duty Officer of the Day (DOD).

Over the past several months, most botulism calls to the DCDC DOD came from LHDs, but other calls came from a variety of sources­: CDC, Poison Control Centers, ERs­indicating communication problems. When asked why they did not call their LHD, some physicians stated that they were not aware that they needed to contact the LHD, others could not find a number to contact, or could not get a response when calling the available LHD number, particularly if the call was made after working hours. We are aware that many LHDs have been furnishing their 24/7 numbers to local physicians, but suggest that more education may be helpful so that healthcare providers are not left to search for a responsive party when they urgently need antitoxin.

17. Emergency Department Wait Times Vary by State, Study Finds

Source: California Healthline (
Date: June 1, 2006

Visitors to U.S. hospital emergency departments wait an average of 222 minutes, or 3.7 hours, before being seen by a provider, according to a new
state-by-state study released by Press Ganey Associates, USA Today reports. The study, which examines wait times at EDs across the nation, is based on 1.5
million patient questionnaires filled out in 2005.

The study finds that EDs in Iowa and Nebraska had the shortest wait times, with averages of 138.3 minutes and 146.1 minutes, respectively. EDs in Arizona and Maryland had the worst wait times, at 297.3 minutes and 246.9 minutes,
respectively. Patients in California wait an average of 230.2 minutes.

Press Ganey President Melvin Hall said Midwestern states often have shorter ED wait times because of their lower occupancy rates. By contrast, metropolitan hospitals often have longer ED wait times because many patients go there for treatment of routine medical problems and are forced to wait longer while more critically injured patients are treated.

According to USA Today, the study's findings are important because ED patient satisfaction is based in large part on the amount of time spent waiting to be seen. As a result, many hospitals are seeking to improve patient satisfaction by promising to see patients quickly "as a marketing tool," USA Today reports.

"There is hardly a hospital in the country that is not in some way focused on
wait times in the emergency room," Hall said. Glenn Hamilton of Wright State
University added, "It's not just a satisfaction issue. It's a safety issue"
(Fuson, USA Today, 6/1).

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18. Manual Chest Compression vs Use of an Automated Chest Compression Device During Resuscitation Following Out-of-Hospital Cardiac Arrest: A Randomized Trial

Al Hallstrom; et al. JAMA. 2006;295:2620-2628.

Context High-quality cardiopulmonary resuscitation (CPR) may improve both cardiac and brain resuscitation following cardiac arrest. Compared with manual chest compression, an automated load-distributing band (LDB) chest compression device produces greater blood flow to vital organs and may improve resuscitation outcomes.

Objective To compare resuscitation outcomes following out-of-hospital cardiac arrest when an automated LDB-CPR device was added to standard emergency medical services (EMS) care with manual CPR.

Design, Setting, and Patients Multicenter, randomized trial of patients experiencing out-of-hospital cardiac arrest in the United States and Canada. The a priori primary population was patients with cardiac arrest that was presumed to be of cardiac origin and that had occurred prior to the arrival of EMS personnel. Initial study enrollment varied by site, ranging from late July to mid November 2004; all sites halted study enrollment on March 31, 2005.

Intervention Standard EMS care for cardiac arrest with an LDB-CPR device (n = 554) or manual CPR (n = 517).

Main Outcome Measures The primary end point was survival to 4 hours after the 911 call. Secondary end points were survival to hospital discharge and neurological status among survivors.

Results Following the first planned interim monitoring conducted by an independent data and safety monitoring board, study enrollment was terminated. No difference existed in the primary end point of survival to 4 hours between the manual CPR group and the LDB-CPR group overall (N = 1071; 29.5% vs 28.5%; P = .74) or among the primary study population (n = 767; 24.7% vs 26.4%, respectively; P = .62). However, among the primary population, survival to hospital discharge was 9.9% in the manual CPR group and 5.8% in the LDB-CPR group (P = .06, adjusted for covariates and clustering). A cerebral performance category of 1 or 2 at hospital discharge was recorded in 7.5% of patients in the manual CPR group and in 3.1% of the LDB-CPR group (P = .006).

Conclusions Use of an automated LDB-CPR device as implemented in this study was associated with worse neurological outcomes and a trend toward worse survival than manual CPR. Device design or implementation strategies require further evaluation.

Trial Registration Identifier: NCT00120965

19. Tenecteplase May Improve Survival After Cardiac Arrest Failing Standard ACLS

News Author: Laurie Barclay, MD. June 13, 2006 ­ Tenecteplase (TNK) increases the chance of survival from cardiac arrest failing standard protocol for Advanced Cardiac Life Support (ACLS), according to the results of a prospective, observational study reported in the June issue of Resuscitation.

"Prospective and retrospective studies have shown that empiric use of fibrinolytic agents in sudden cardiac arrest is safe and may improve outcomes in sudden cardiac arrest," write William P. Bozemana, MD, from Wake Forest University in Winston-Salem, NC, and colleagues. "Use of fibrinolytic agents for this indication is increasing in response to these data."

In 3 emergency departments, 50 patients received empiric fibrinolysis with TNK after failing to respond to ACLS. Mean duration of cardiac arrest was 30 minutes, and mean number of doses of ACLS medications was 8. The control group consisted of 113 concurrent patients who received standard ACLS measures.

The TNK group fared better than the control group in terms of return of spontaneous circulation (ROSC) and survival. Fifty ROSC occurred in 26% of TNK patients (95% confidence interval [CI], 16% - 40%) compared with 12.4% (95% CI, 6.9% - 20%) in ACLS controls (P = .04). In the TNK group, 12% (95% CI, 4.5% - 24%) survived to admission compared with none in the control group (P = .0007); 4% (95% CI, 0.5% - 14%) survived to 24 hours (P = not significant); and 4% (95% CI, 0.5% - 14%) survived to hospital discharge (P = not significant).

All survivors had a good neurologic outcome with Cerebral Performance Category 1 to 2. There was 1 intracranial hemorrhage, but no other significant bleeding complications.

"Empiric fibrinolysis with TNK in cardiac arrest is associated with increased ROSC and short term survival, and with survival to hospital discharge with good neurological function in patients who fail to respond to ACLS," the authors write. "Results may improve with earlier administration. Prospective controlled interventional trials are indicated to evaluate this promising new therapy."

Study limitations include observational design; use of unstructured clinical judgment by clinicians deciding whether to administer TNK to their patients; high risk of selection bias; emergency department resuscitation efforts continuing somewhat longer in the TNK group; small sample size; cardiac arrest interventions not standardized; variable timing of TNK; lack of heparin use until after ROSC; and incomplete patient medical histories and prearrest events at the time of treatment.

"Combined with animal and human evidence of improved neurological outcome after cardiac arrest, these data support the use of empiric fibrinolysis in selected cases of cardiac arrest refractory to standard ACLS measures and further reinforce the need for prospective randomized controlled trials of this therapy," the authors conclude. "Such trials will require adequate power to demonstrate differences in clinically relevant outcome and complications; will necessarily use an exemption from informed consent; and should institute fibrinolysis as soon as feasible in both the prehospital and emergency department settings."

The authors have disclosed no relevant financial relationships.

Resuscitation. 2006;69:399-406