Lit Bits: July 25, 2006

From the recent medical literature...

1. Hospital Quality for AMI: Correlation Among Process Measures and Relationship With Short-term Mortality

Elizabeth H. Bradley, PhD; David J. Magid, MD, MPH [Kaiser, Denver]; et al.

JAMA. 2006;296:72-78.

Context The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) measure and report quality process measures for acute myocardial infarction (AMI), but little is known about how these measures are correlated with each other and the degree to which inferences about a hospital's outcomes can be made from its performance on publicly reported processes.

Objective To determine correlations among AMI core process measures and the degree to which they explain the variation in hospital-specific, risk-standardized, 30-day mortality rates.

Design, Setting, and Participants We assessed hospital performance in the CMS/JCAHO AMI core process measures using 2002-2003 data from 962 hospitals participating in the National Registry of Myocardial Infarction (NRMI) and correlated these measures with each other and with hospital-level, risk-standardized, 30-day mortality rates derived from Medicare claims data.

Main Outcome Measures Hospital performance on AMI core measures; hospital-specific, risk-standardized, 30-day mortality rates for AMI patients aged 66 years or older.

Results We found moderately strong correlations (correlation coefficients 0.40; P values <.001) for all pairwise comparisons between -blocker use at admission and discharge, aspirin use at admission and discharge, and angiotensin-converting enzyme inhibitor use, and weaker, but statistically significant, correlations between these medication measures and smoking cessation counseling and time to reperfusion therapy measures (correlation coefficients <0.40; P values <.001). Some process measures were significantly correlated with risk-standardized, 30-day mortality rates (P values <.001) but together explained only 6.0% of hospital-level variation in risk-standardized, 30-day mortality rates for patients with AMI.

Conclusions The publicly reported AMI process measures capture a small proportion of the variation in hospitals' risk-standardized short-term mortality rates. Multiple measures that reflect a variety of processes and also outcomes, such as risk-standardized mortality rates, are needed to more fully characterize hospital performance.

2. Outpatient DVT Management: Safely Keeping Patients Out of the ED

Vinson DR, Berman DA, Patel PB, Hickey DO. Outpatient management of deep venous thrombosis: Two models of integrated care. Amer J Manag Care. 2006;12:405-410.

Objective: To describe and evaluate the impact, effectiveness, and safety of 2 models of outpatient deep venous thrombosis (DVT) management.
Study Design: Observational health-records survey conducted in 2 community hospitals using a comparative design.

Methods: The model centered around the emergency department (ED) was studied from April 15, 1997, through December 31, 1999; the decentralized model was studied from July 15, 2002, through March 15, 2004. The effect of the decentralized model on processes of care was determined by comparing the percentages of patients who were managed by office-based primary care providers under the 2 models. Two-week clinical outcomes also were compared, including symptomatic pulmonary embolism, symptomatic progression of index DVT, new DVT, major bleeding, minor bleeding, and death.

Results: During the study periods, 187 and 254 outpatients were enrolled in the ED-centered model and the decentralized model, respectively. Under the ED-centered model, 17 (22.1%) of 77 patients who presented to the primary care providers’ offices on weekdays before 1:30 PM (on-hours) were managed exclusively within the clinic setting. Under the decentralized model, 78 (91.8%) of 85 patients who presented on-hours were managed within the clinics­a difference of 69.7 absolute percentage points (95% confidence intervals, 58.7%, 80.7%; P < .001). The models had comparable 2-week clinical outcomes.

Conclusions: The decentralized model for outpatient DVT management allowed more primary care clinic patients to receive their initial care exclusively in the clinic setting. There was no significant difference between the models in short-term effectiveness of therapy and patient safety.

Full-text (free): http://www.ajmc.com/files/articlefiles/AJMC_06julVinson405to410.pdf

3. Aminotransferase Elevations in Healthy Adults Receiving 4 Grams of Acetaminophen Daily: A Randomized Controlled Trial

Paul B. Watkins, MD; et al. JAMA. 2006;296:87-93.

Context During a clinical trial of a novel hydrocodone/acetaminophen combination, a high incidence of serum alanine aminotransferase (ALT) elevations was observed.

Objective To characterize the incidence and magnitude of ALT elevations in healthy participants receiving 4 g of acetaminophen daily, either alone or in combination with selected opioids, as compared with participants treated with placebo.

Design, Setting, and Participants A randomized, single-blind, placebo-controlled, 5-treatment, parallel-group, inpatient, diet-controlled (meals provided), longitudinal study of 145 healthy adults in 2 US inpatient clinical pharmacology units.

Intervention Each participant received either placebo (n = 39), 1 of 3 acetaminophen/opioid combinations (n = 80), or acetaminophen alone (n = 26). Each active treatment included 4 g of acetaminophen daily, the maximum recommended daily dosage. The intended treatment duration was 14 days.

Main Outcomes Serum liver chemistries and trough acetaminophen concentrations measured daily through 8 days, and at 1- or 2-day intervals thereafter.

Results None of the 39 participants assigned to placebo had a maximum ALT of more than 3 times the upper limit of normal. In contrast, the incidence of maximum ALT of more than 3 times the upper limits of normal was 31% to 44% in the 4 treatment groups receiving acetaminophen, including those participants treated with acetaminophen alone. Compared with placebo, treatment with acetaminophen was associated with a markedly higher median maximum ALT (ratio of medians, 2.78; 95% confidence interval, 1.47-4.09; P<.001). Trough acetaminophen concentrations did not exceed therapeutic limits in any participant and, after active treatment was discontinued, often decreased to undetectable levels before ALT elevations resolved.

Conclusions Initiation of recurrent daily intake of 4 g of acetaminophen in healthy adults is associated with ALT elevations and concomitant treatment with opioids does not seem to increase this effect. History of acetaminophen ingestion should be considered in the differential diagnosis of serum aminotransferase elevations, even in the absence of measurable serum acetaminophen concentrations.

4. EM in the US

The CDC released their annual report on emergency department (ED) care in the US. This report is based on 2004 visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the following ED statistics were notable.

Visit frequency
- Over 110 million visits were made in 2004, an increase of 18% over 10 years
- There were 38.2 visits per 100 persons, including one-fifth of all US adults in the past 12 months
- The total number of EDs in the US decreased by 12.4% over 10 years

Acuity measures
- Abdominal pain, chest pain and fever, all high-risk, were the most frequent chief complaints
- Medications were prescribed in three-quarters and procedures were performed in half of patients
- 15% arrived by ambulance
- 13% were admitted
- Of those classified, 15% of visits were emergent, 44% were urgent, 26% were semi-urgent and 15% were non-urgent

Overcrowding indices
- The mean time to see a physician was 47 minutes
- The mean time from arrival to admission or discharge was 3.3 hours
- About 2% left before being seen by a healthcare provider

To see a full copy of the report, go to http://www.cdc.gov/nchs/data/ad/ad372.pdf For more information about the ED utilization from the National Center for Health Statistics (NCHS) Ambulatory Health Care, go to http://www.cdc.gov/nchs/nhamcs.htm

5. Diagnostic Accuracy of TEE, Helical CT, and MRI for Suspected Thoracic Aortic Dissection: Systematic Review and Meta-analysis

Toshiya Shiga, MD, PhD; et al. Arch Intern Med. 2006;166:1350-1356.

Background Patients with suspected thoracic aortic dissection require early and accurate diagnosis. Aortography has been replaced by less invasive imaging techniques including transesophageal echocardiography (TEE), helical computed tomography (CT), and magnetic resonance imaging (MRI); however, accuracies have varied from trial to trial, and which imaging technique should be applied to which risk population remains unclear. We systematically reviewed the diagnostic accuracy of these imaging techniques in patients with suspected thoracic aortic dissection.

Methods Published English-language reports on the diagnosis of thoracic aortic dissection by TEE, helical CT, or MRI were identified from electronic databases. Sensitivity, specificity, and positive and negative likelihood ratios were pooled in a random-effects model.

Results Sixteen studies involving a total of 1139 patients were selected. Pooled sensitivity (98%-100%) and specificity (95%-98%) were comparable between imaging techniques. The pooled positive likelihood ratio appeared to be higher for MRI (positive likelihood ratio, 25.3; 95% confidence interval, 11.1-57.1) than for TEE (14.1; 6.0-33.2) or helical CT (13.9; 4.2-46.0). If a patient had shown a 50% pretest probability of thoracic aortic dissection (high risk), he or she had a 93% to 96% posttest probability of thoracic aortic dissection following a positive result of each imaging test. If a patient had a 5% pretest probability of thoracic aortic dissection (low risk), he or she had a 0.1% to 0.3% posttest probability of thoracic aortic dissection following a negative result of each imaging test.

Conclusion All 3 imaging techniques, ie, TEE, helical CT, and MRI, yield clinically equally reliable diagnostic values for confirming or ruling out thoracic aortic dissection.

6. Emergent Hyperpyrexia in Children Should Be Treated With Antibiotics

News Author: Laurie Barclay, MD. July 17, 2006 ­ Children presenting to an emergency department (ED) with hyperpyrexia are equally at risk for viral and bacterial infection and should be treated with antibiotics, according to the results of a prospective study reported in the July issue of Pediatrics.

"Previous studies of children with temperatures [of] 106°F (hyperpyrexia) disagree as to whether hyperpyrexia confers a high risk of serious bacterial infection (SBI)," write Barbara W. Trautner, MD, from Baylor College of Medicine in Houston, Tex, and colleagues. "The purpose of our study was to evaluate the incidence of SBI in children presenting to the ED with hyperpyrexia and to determine whether any aspects of their presentation were predictive of the risk of SBI."

During a 2-year period, the investigators prospectively collected data on all children younger than 18 years who presented to a pediatric ED and who had rectal temperatures of 106°F. All patients were evaluated with history, physical examination, complete blood cell counts, blood cultures, and nasopharyngeal viral cultures.

Of 130,828 visits, 103 children had hyperpyrexia, or 1 per 1270 patient visits. Of these 103 subjects, 20 had serious bacterial infection, and 22 had laboratory-proven viral illness. One subject had bacterial/viral coinfection. Chronic underlying illness or diarrhea was associated with increased risk for SBI, and rhinorrhea or any other viral symptom (excluding diarrhea) was associated with decreased risk for SBI. Age, maximum temperature, and total white blood cell count were not helpful in distinguishing bacterial from viral illness.

"Children with hyperpyrexia are at equally high risk for serious bacterial infection and for viral illness," the authors write. "No aspect of the clinical presentation reliably distinguishes between bacterial and viral illness. We recommend consideration of antibiotic treatment for all children presenting to the emergency department with hyperpyrexia without confirmed viral illness."

Study limitations include limited sample size, time of the study before the widespread use of the conjugate pneumococcal vaccine in children, and lack of identified etiology for fever in the majority of febrile children in this study.

"We conclude that hyperpyrexia is a medical emergency that carries a high risk of SBI," the authors conclude. "These findings should hold true despite the subsequent introduction of the conjugate pneumococcal vaccine. We advise treatment with antibiotics for all children with hyperpyrexia who do not have a confirmed viral illness and for all children with hyperpyrexia and a confirmed viral illness who are ill enough to require hospitalization."

The US Public Health Service supported this study. The authors have disclosed no relevant financial relationships.

Pediatrics. 2006;118:34-40

7. A Woman Presenting With Rapidly Progressive Flaccid Paralysis

Hmmm, Sherlock. What’s the diagnosis? http://www.medscape.com/viewarticle/537345_2

8. Degree of Obesity Correlates With Mortality Risk

By Martha Kerr. NEW YORK (Reuters Health) Jul 06 - In women, the risk of all-cause and coronary heart disease mortality continues to increase as body mass index (BMI) rises above 30, according to the latest findings from the Women's Health Initiative (WHI) Observational Study.

"It's not good enough to consider obesity alone," principal investigator Dr. Kathleen McTigue of the University of Pittsburgh, Pennsylvania, told Reuters Health. "You need to look at degree of obesity."

In a study published in the July 5th Journal of the American Medical Association, Dr. McTigue and colleagues studied patterns of morbidity and mortality risk according to BMI in 90,185 women in the WHI study who were not in the diet or hormone treatment arms of the study. Average follow-up was 7 years.

Body mass index (BMI) was classified using NIH definitions of normal, overweight and obesity. Normal weight BMI ranged from 18.5 to 24.9 and overweight was defined as a BMI of 25-29.9. The investigators defined three categories of obesity: obesity 1 (BMI of 30-34.9), obesity 2 (BMI 35-39.9) and extreme obesity (BMI 40 and higher).

"The risks of extreme obesity have not been well-defined," Dr. McTigue noted. "This was a large enough sample to assess risk."

The prevalence of extreme obesity varied by ethnicity, occurring in 10% of black women and 1% of Asian and Pacific Islanders. However, all-cause mortality, coronary heart disease mortality and coronary heart disease incidence did not vary by ethnicity.

"There is an increasing risk of all-cause mortality with increasing weight, but it doesn't reach statistical significance until obesity exists," Dr. McTigue told Reuters Health. Compared with normal-weight women, she continued, "the risk of dying was increased 12% in all women in obesity category 1, while risk was increased 86% over seven years in women in obesity category 3."

Summing up, she said, "The coronary heart disease and all-cause mortality risk increases along a continuum."

In a University of Pittsburgh release, the researcher pointed out that "earlier studies, which tended to reflect lower degrees of obesity, may underestimate the risks of extremely obese individuals and overestimate the risk for mildly obese individuals in diverse groups."

She concluded, "More accurately assessing weight-related health risk may both improve policy decisions about obesity and assist women in making informed decisions about their health."

JAMA 2006;296:79-86.

9. Migraine With Aura Linked to Increased Risk for MI and Stroke

News Author: Laurie Barclay, MD. July 18, 2006 ­ Migraine with aura is associated with increased risk for myocardial infarction and stroke, whereas migraine without aura is not, according to the results of a large, prospective study in women reported in the July 19 issue of JAMA.

"Migraine with aura has been associated with an adverse cardiovascular risk profile and prothrombotic factors that, along with migraine-specific physiology, may increase the risk of vascular events," write Tobias Kurth, MD, ScD, from Brigham and Women's Hospital and Harvard Medical School in Boston, Mass, and colleagues. "Although migraine with aura has been associated with increased risk of ischemic stroke, an association with cardiovascular disease (CVD) and, specifically, coronary events remains unclear."

This prospective cohort study evaluated 27,840 US women aged 45 years or older who were enrolled in the Women's Health Study, were free of CVD and angina at study entry (1992-1995), and who had data on self-reported migraine and aura status, and lipid measurements. Follow-up data for this analysis were available through March 31, 2004.

The main endpoint was the combined end point of major CVD (first instance of nonfatal ischemic stroke, nonfatal myocardial infarction, or death due to ischemic CVD). Secondary outcomes were first ischemic stroke, myocardial infarction, coronary revascularization, angina, and death due to ischemic CVD.
At study entry, 5125 women (18.4%) reported any history of migraine. Of the 3610 women with active migraine, defined as migraine in the prior year, 1434 (39.7%) reported aura symptoms. During a mean of 10 years of follow-up, there were 580 major CVD events.

Compared with women with no migraine history, those who reported active migraine with aura had multivariable-adjusted hazard ratios of 2.15 (95% confidence interval [CI], 1.58 - 2.92; P < .001) for major CVD, 1.91 (95% CI, 1.17 - 3.10; P = .01) for ischemic stroke, 2.08 (95% CI, 1.30 - 3.31; P = .002) for myocardial infarction, 1.74 (95% CI, 1.23 - 2.46; P = .002) for coronary revascularization, 1.71 (95% CI, 1.16 - 2.53; P = .007) for angina, and 2.33 (95% CI, 1.21 - 4.51; P = .01) for ischemic CVD death.
Adjustment for age resulted in 18 additional major CVD events attributable to migraine with aura per 10,000 women per year. Women who reported active migraine without aura were not at increased risk for any vascular events or angina.

"In this large, prospective cohort of women, active migraine with aura was associated with increased risk of major CVD, myocardial infarction, ischemic stroke, and death due to ischemic CVD, as well as with coronary revascularization and angina," the authors write. "Active migraine without aura was not associated with increased risk of any CVD event."

Study limitations include self-reported migraine and aura status not classified according to strict International Headache Society criteria; and use of a broad definition of aura, difficulty in distinguishing some aura features from symptoms of transient ischemic attack, lack of detailed information regarding the use of migraine-specific drugs, possible residual confounding because of observational study design, and lack of data regarding the duration of migraine prior to study entry or migraine frequency during follow-up.

"Since migraine without aura is far more common than migraine with aura, our data demonstrate no increased risk of CVD for the majority of migraine patients," the authors conclude. "Future research should focus on a better understanding of the relationship between migraine, aura status, and cardiovascular events."

The Donald W. Reynolds Foundation, Las Vegas, Nev, and the National Institutes of Health supported this study. The authors have disclosed no relevant financial relationships.

In an accompanying editorial, Richard B. Lipton, MD, and Marcelo E. Bigal, MD, PhD, from the Albert Einstein College of Medicine and the Montefiore Headache Center in Bronx, NY, discuss potential explanations for the association between migraine with aura and CVD. "For patients with migraine with aura, clinicians should have heightened vigilance for modifiable cardiovascular risk factors, such as hypertension, hyperlipidemia, and smoking," Drs. Lipton and Bigal write. "Ultimately, it will be important to determine whether migraine with aura is itself a modifiable risk factor for CVD. Future studies should investigate the possibility that preventive medications for migraine or antiplatelet therapy might reduce the risk of CVD in patients with migraine with aura."

Drs. Lipton and Bigal have disclosed no relevant financial relationships.

JAMA. 2006;296:283-291, 332-333

10. Heart Failure With Preserved Ejection Fraction Becoming More Common

NEW YORK (Reuters Health) Jul 19 - Findings from a new study indicate that the prevalence of heart failure with preserved ejection fraction (EF) has increased in recent years, according to a report in the July 20th issue of The New England Journal of Medicine.

The results of a related study suggest that a preserved EF does not significantly affect the survival of heart failure patients.

In the first study, Dr. Margaret M. Redfield and colleagues, from the Mayo Clinic in Rochester, Minnesota, assessed trends in heart failure prevalence and outcome by analyzing data from all consecutive patients who were hospitalized at their center for decompensated heart failure between 1987 and 2001.

A total of 6076 patients were identified during the study period and EF data was available for 4596 of them. Overall, 47% of patients had a preserved EF (50% or greater) and 53% had a reduced EF.

The proportion of heart failure patients with a preserved EF climbed from 38% at the beginning of the study period to 54% at the end. The authors also found that rates were higher among community patients than among referrals: 55% vs. 45%.

Prevalence rates of diabetes, hypertension, and atrial fibrillation among heart failure patients increased during the study period, the report indicates. Heart failure patients with a reduced EF experienced an improvement in survival over time, whereas those with preserved EF did not.

In the second study, Dr. Peter P. Liu, from Toronto General Hospital, and colleagues focused on the outcomes of 2802 patients who were admitted to 103 hospitals in Ontario, Canada between April 1999 and March 2001.

Dr. Liu's team found no significant survival benefit for an EF of 50% or greater. The 1-year mortality rates with preserved and reduced EFs were 22% and 26%, respectively (p = 0.07). The authors also found that having a preserved EF did not reduce heart failure readmission rates or in-hospital complications.

In a related editorial, Dr. Gerard P. Aurigemma, from the University of Massachusetts Medical School in Worcester, comments that "the two current studies remind us that ejection fraction is not a good predictor of clinical disability and suggest that congestive symptoms are more closely related to the filling properties of the ventricles than to the ejection properties."

He adds that the findings are provocative in that they challenge "the widely held perception that the survival rate among patients with most forms of heart disease is inversely related to the ejection fraction."

N Engl J Med 2006;355:251-269.

11. FDA Warns Against Use of Triptans With Certain Antidepressants

Yael Waknine. July 20, 2006 ­ The US Food and Drug Administration (FDA) has warned healthcare professionals regarding the risk for life-threatening serotonin syndrome associated with use of 5-hydroxytryptamine receptor antagonists (triptans) in conjunction with selective serotonin reuptake inhibitors (SSRIs) or selective serotonin/norepinephrine reuptake inhibitors (SNRIs).

Coadministration of these drugs has an additive effect on serotonin levels that can lead to serotonin syndrome, according to an alert sent yesterday from MedWatch, the FDA's safety information and adverse event reporting program. Symptoms may include restlessness, hallucinations, loss of coordination, tachycardia, rapid blood pressure changes, increased body temperature, overactive reflexes, nausea, vomiting, and diarrhea.

Healthcare professionals prescribing a triptan, SSRI, or SNRI are advised to consider that triptans are often used intermittently, and that drugs from all 3 classes may be prescribed by different clinicians; the potential risk for serotonin syndrome should be weighed against the potential benefit of using a triptan with an SSRI or SNRI.

SSRI- or SNRI-treated patients receiving triptans should be followed closely, particularly during initiation of therapy, dose increases, or the addition of another serotonergic drug.

Patients receiving combination therapy should be made aware of the risk for serotonin syndrome and advised to seek immediate medical attention for associated symptoms.
The FDA has requested that safety labeling for triptans, SSRIs, and SNRIs be changed to reflect the potential for this additive reaction.

Triptans are used to treat migraines, and the class includes drugs such as naratriptan HCl (Amerge, made by GlaxoSmithKline); almotriptan malate (Axert, made by Ortho-McNeil Pharmaceutical, Inc); frovatriptan succinate (Frova, made by Endo Pharmaceuticals); sumatriptan/sumatriptan succinate (Imitrex, made by GlaxoSmithKline); rizatriptan benzoate (Maxalt and Maxalt-MLT, made by Merck and Company, Inc); eletriptan HBr (Relpax, made by Pfizer, Inc); and zolmitriptan (Zomig and Zomig ZMT, made by AstraZeneca Pharmaceuticals LP).

SSRIs and SNRIs are used to treat depression and other mood disorders.

SSRIs include citalopram HBr (Celexa, made by Forest Laboratories, Inc); fluvoxamine (previously marketed as Luvox by Solvay Pharmaceuticals, Inc, and now available in generic formulations); escitalopram oxalate (Lexapro, made by Forest Laboratories, Inc); paroxetine HCl (Paxil, made by GlaxoSmithKline); fluoxetine HCl (Prozac, made by Eli Lilly and Company); olanzapine/fluoxetine (Symbyax, made by Eli Lilly); and sertraline HCl (Zoloft, made by Pfizer, Inc). SNRIs include duloxetine HCl (Cymbalta, made by Eli Lilly) and venlafaxine HCl (Effexor, made by Wyeth Pharmaceuticals Inc).

Healthcare professionals are encouraged to report adverse events related to use of triptans in conjunction with SSRIs or SNRIs 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.

Reviewed by Gary D. Vogin, MD.

12. The comparison and efficacy of 3 different alpha1-adrenergic blockers for distal ureteral stones.

Yilmaz E, et al. J Urol. 2005 Jun;173(6):2010-2.

INTRO: Several factors are thought to influence the spontaneous passage of ureteral stones, such as stone size, configuration and location, smooth muscle spasm, submucosal edema, and anatomy. To ease the spontaneous passage of the distal ureteral stones in recent years, some adjunctive pharmacological medications have been started on trial. To achieve the spontaneous passage, [alpha]-adrenergic blockers, calcium channel blockers, prostaglandin synthesis inhibitors, glyceryl trinitrate and steroid treatment to relieve edema are being used.

Currently [alpha]1-adrenergic receptor antagonists represent the treatment of choice for lower urinary tract symptoms, as shown in many randomized controlled trials as well as in several studies. [alpha]1-adrenergic receptors were demonstrated in human, pig, dog and horse ureters. [alpha]1-adrenergic receptors are found more densely in the ureter smooth muscle than the other adrenergic receptors. They inhibit the basal tonus, peristaltic wave frequency and the ureteral contraction in the intramural parts. While the [alpha]1A receptors are found widespread in the proximal urethra, prostate and bladder outflow, [alpha]1B receptors are found more densely in the vascular smooth muscles, and [alpha]1D receptors are predominantly found in the detrusor. [alpha]1D receptors are effective in the relaxation of the detrusor and the spasm of the 1/3 distal part of the ureter (especially the intramural part). In our study the efficacies of 3 different [alpha]1-adrenergic blockers are evaluated, and their comparison with respect to each other is made.

METHODS SPECIFICS: A total of 114 patients between 18 and 65 years old, and who had radiopaque stones 10 mm or smaller located in the distal tract of the ureter (juxtavesical tract and ureterovesical junction) were included in the study.

The exclusion criteria were the presence of urinary system infection, radiolucency stones, severe hydronephrosis, diabetes, ulcer disease, hypotension and having calcium antagonist medication. Also, patients who had had distal ureter surgery were excluded from the study.

The 29 patients in group 2 received tamsulosin (0.4 mg daily), the 28 patients in group 3 received terazosin [Hytrin] (5 mg daily) and the 29 patients in group 4 received doxazosin (4 mg daily). Tamsulosin was recommended to be taken after breakfast in the morning, whereas terazosin and doxazosin were to be taken before going to bed in the evening. These agents were given for up to 1 month. All patients were allowed to use symptomatic therapy with injections of 75 mg diclofenac (on demand) and were required to consume a minimum of 2 liters of water daily.

ABSTRACT:
PURPOSE: alpha1-Adrenergic blockers have recently been shown to increase the rate of spontaneous passage of distal ureteral stones. We compared efficacy of 3 different alpha1-adrenergic blockers for this purpose.

MATERIALS AND METHODS: A total of 114 patients between 18 and 65 years old who had lower ureteral stones were included in the study. Patients were randomly divided into 4 groups. Group 1 consisted of 28 patients and acted as the control group. Group 2 comprised 29 patients who received tamsulosin, group 3 was 28 patients receiving terazosin and group 4 was 29 patients receiving doxazosin. These agents were given for up to a month and hydration was also recommended simultaneously. Every week patients were controlled with x-rays of the kidneys, ureters, bladder and urinary ultrasonography. Meanwhile the number of pain episodes, analgesic dosage and the number of days for spontaneous passage of the calculi through the ureter were also recorded.

RESULTS: There were no differences between the groups with respect to age, weight, height, sex and stone size. The calculi passed through the ureter spontaneously in 15 patients in group 1 (53.57%), in 23 patients in group 2 (79.31%), in 22 patients in group 3 (78.57%), and in 22 patients in group 4 (75.86%). In groups 2 to 4 the number of pain episodes, expulsion time and analgesic dosage were found to be lower compared with those in group 1. CONCLUSIONS: alpha1-Adrenergic blockers increase the frequency of spontaneous passage of the distal ureteral calculi. All 3 agents tested were equally efficacious.

13. Women prefer speculum examinations without stirrups

Women feel less vulnerable and experience less discomfort when speculum examinations (as part of routine gynaecological examination) are carried out without stirrups. Seehusen and colleagues (BMJ 2006;333:171; 22 July) randomised 197 adult women from a US family medicine outpatient clinic who were undergoing routine gynaecological examination and cervical smear to examination with or without stirrups. When the women's perceived levels of physical discomfort were measured on 100 mm visual analogue scales, the level for those examined without stirrups was 17.2 compared with 30.4 in the stirrups group. Sense of vulnerability in the group of women examined without stirrups was reduced from 23.6 to 13.1, whereas sense of loss of control was the same in both groups.

Abstract: http://bmj.bmjjournals.com/cgi/content/abstract/333/7560/171

14. Consider whooping cough even if a child has been immunised

A substantial proportion of immunised children of school age who present to primary care with a persistent cough may have had a recent infection with Bordetella pertussis. Harnden and colleagues (BMJ 2006;333:174; 22 July) recruited 179 children aged 5 to 16 years (from 18 UK general practices) who had been coughing for two weeks or more. Serological evidence of a recent Bordetella pertussis infection was found in 37% of the children, and 86% of these children had been fully immunised. Making a secure diagnosis of whooping cough may reassure the parents and prevent inappropriate investigations and treatment, conclude the authors.

Abstract: http://bmj.bmjjournals.com/cgi/content/abstract/333/7560/174

15. A Simple Way to Diagnose the Restlessness of Akathisia

Vinson DR. J Emerg Med. 2006;31:139-145.

What is akathisia? Akathisia is an extrapyramidal syndrome most often caused by medications that modulate central neurotransmitters. This dysphoric movement disorder is characterized by a compulsive urge to move and an inability to maintain a posture for several minutes. Restless behavior observed in akathisic patients includes rocking back and forth, shifting side to side, purposeless leg and foot movements while seated, foot tapping, walking in place, and pacing.

What causes it? Akathisia occurs commonly in EM as a side-effect of parenteral metoclopramide, droperidol, prochlorperazine, and chlorpromazine (dopamine receptor D2 antagonists) used in the treatment of nausea, headache, and agitation. Despite the frequency with which emergency physicians encounter akathisia, this adverse drug reaction is commonly overlooked. Failure to diagnose akathisia may be attributable, in part, to the lack of diagnostic criteria applicable to the emergency setting. To be readily applied at the bedside, diagnostic criteria must be simple, straightforward, logical, and easy to remember. It is here the assessment of akathisia could be improved. Simpler diagnostic criteria would likely achieve wider utilization.

How does this new diagnostic tool work? Simple. Ask the patient “Do you feel a restless urge to move, especially in your legs?” before and after administration of a dopamine antagonist. If they answer “Yes”, have them grade the restlessness as mild, moderate, or severe. If the grade increases after having received the drug and you observe any corroborating restless motor activity, you have the diagnosis. Proceed to treatment with diphenhydramine (J Emerg Med. 2004; 26:265-70). This simplified instrument is an accurate as the fancier, more cumbersome ones, but is far easier to use. It should facilitate the detection and treatment of akathisia in EM.

16. Management of burns blisters: What’s the evidence?

Jonathan Shaw. Emergency Medicine Journal 2006;23:648-649;
Best evidence topic reports (BETs)

A short cut review was carried out to establish whether leaving intact, deroofing, or aspirating the blisters of partial thickness burns best minimised infection and promoted healing. In total, 153 papers were found using the reported searches, of which one presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this best paper are tabulated. It is concluded that the evidence remains poor, but that leaving the blister intact seems to reduce infection rates and should therefore be the default option.

Clinical scenario
A 30 year old chef attends the emergency department, having sustained burns to his forearm from hot fat. Clinical examination reveals blistering to the area and some erythema. You are not sure whether to leave, aspirate, or completely deroof the blisters, and wonder if there is any research to point you in the right direction.

Three-part question
In adults with partial thickness burns is de-roofing or aspirating the blisters better than conservative management in minimising infection and promoting healing?

Comments
There seems to be a paucity of good clinical evidence related to this subject, despite several review articles. The sole paper found involved a small sample, but showed infection rates to be higher if blisters are aspirated or deroofed, and that pain scores were higher in the group that underwent deroofing.

CLINICAL BOTTOM LINE
Based on the current available evidence, blisters should, wherever possible, be left intact to reduce the risk of infection, but if anatomical position necessitates intervention for functional purposes, aspiration appears to result in less pain than deroofing.

17. Cope’s early diagnosis of the acute abdomen, 21st ed

Z Cope, revised by W Silen. Oxford Oxford University Press, 2005, £35.99, ISBN 0-19-517546-8

Reviewed by G Hughes in Emergency Medicine Journal 2006;23:662.

This classic textbook was first published in 1921. It comes around as regularly as the Olympic Games and as reliably as the full moon.

Why is it so good? Its emphasis is on clinical and not laboratory or radiological diagnosis and it does not rely on algorithms, protocols, pathways, or a plethora of long lists to memorise. Its style initially seems old fashioned, and to many eyes it may seem turgid; however, if you stick with it, it grows on you. It becomes very readable.

In our specialty, which tends towards a "rule out" approach to diagnosis and assessment, many will think this book has no place. Nothing can be further from the truth. It should be required reading for all trainees. Consultants who have not read it before will also learn from it.

Including the index, it is 298 pages long. Although the line drawings (which are plentiful) are fine, the radiological illustrations are nothing to write home about. It doesn’t matter. It’s all in the history and examination, not the investigations. Read it.

18. Multidetector CT for Coronary Stenosis

Multidetector computed tomography (MDCT) has been proposed as a noninvasive method of detecting coronary artery stenosis. In a multicenter trial of patients referred for nonemergent coronary angiography, Garcia and colleagues assessed the accuracy of 16-row MDCT to detect a more than 50% luminal narrowing in coronary artery segments. The authors found an unacceptably high number of false-positive and nonevaluable segments using MDCT, limiting the utility of 16-row MDCT for primary diagnosis of coronary artery stenosis.

Accuracy of 16-Row Multidetector Computed Tomography for the Assessment of Coronary Artery Stenosis. Mario J. Garcia, MD; Jonathan Lessick, MD, DSc; Martin H. K. Hoffmann, MD; for the CATSCAN Study Investigators

JAMA. 2006;296:403-411.

Abstract: http://jama.ama-assn.org/cgi/content/abstract/296/4/403