Lit Bits: August 12, 2006

From the recent medical literature...

1. Treating Septic Shock: Does Every Minute Count?

Richard T. Ellison III, MD. Initiating antibiotic therapy within the first hour after the onset of hypotension appears to increase the likelihood of survival.

Summary
For patients with severe infections, earlier antibiotic therapy is generally believed to produce better outcomes. But how early is early? In a retrospective study partly supported by industry, investigators assessed the relation between time to initiation of effective antibiotic treatment and outcome in patients with septic shock. Subjects were 2731 adults who were treated for septic shock in 14 intensive care units in Canada and the U.S. between June 1989 and June 2004. Most patients had pneumonia (37%) or a gastrointestinal/intra-abdominal infection (29%); 56% of them died.

The survival rate was 83% in patients who received appropriate antibiotic treatment within the first 30 minutes after onset of documented hypotension, and 77% in patients who received appropriate treatment 30–60 minutes after onset. Over the next 5 hours, the survival rate decreased by approximately 8% per hour for each hour of delay in starting effective treatment. In multivariate analyses, time to initiation of effective antibiotic therapy was the factor most strongly associated with outcome, and the strong association held, regardless of the underlying pathogen or infection site.

Comment
These findings will likely have a major effect on clinical care, given the size of the patient population and the consistency of the results, even though the study suffers all the limitations of a retrospective analysis. The challenge for the future in treating septic shock is to develop effective strategies that allow clinicians to start effective antibiotics as quickly as possible yet still perform appropriate diagnostic evaluations and avoid indiscriminate use of antibiotics.
Source
Kumar A et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006 Jun; 34:1589-96.

2. One in Three Hospital Patients Is 65 or Older

Agency for Healthcare Research and Quality (AHRQ), Rockville, Maryland; http://hcup.ahrq.gov/HCUPnet.asp

The information in this article is from HCUPnet, an online query system that provides access to health statistics and information on hospital stays from the Healthcare Cost and Utilization Project (HCUP) sponsored by the Agency for Healthcare Research and Quality (AHRQ). This project includes the largest set of publicly available databases on all patients in the United States, regardless of type of insurance or whether the patients had insurance. To access HCUPnet, go to http://hcup.ahrq.gov/HCUPnet.asp.

Although only 12% of the US population was 65 years of age or older in 2003, the Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality says that this group accounted for one third of all patients admitted to the nation's community hospitals in that year -- over 13 million hospital stays.

The elderly also accounted for 44% of all hospital charges -- nearly $329 billion.

The most common procedure performed on elderly patients was blood transfusion. Sixty percent of all blood transfusions -- almost 1.2 million -- were administered to the elderly. Nearly 1 in every 11 elderly patients in the hospital received a transfusion. The second, third, fourth, and fifth most commonly performed procedures in the hospital for the elderly were, respectively, diagnostic cardiac catheterization and coronary arteriography (852,300), upper gastrointestinal endoscopy and biopsy (690,700), respiratory intubation and mechanical ventilation (500,900), and percutaneous coronary angioplasty (401,900).

The 5 leading reasons why elderly patients were hospitalized, as measured by number of admissions, were congestive heart failure (839,300), pneumonia (770,400), coronary atherosclerosis or hardening of the arteries (675,700), cardiac dysrhythmias (484,200), and acute myocardial infarction or heart attack (449,000).

The proportion of elderly patients who died while hospitalized was 5 times higher than that of younger patients.

These and other data are included in Hospitalizations in the Elderly Population, 2003, HCUP Statistical Brief # 6 at http://www.hcup-us.ahrq.gov/reports/statbriefs.jsp The report uses statistics from the Nationwide Inpatient Sample, a database of hospital inpatient stays that is nationally representative of all short-term, nonfederal hospitals. The data are drawn from hospitals that comprise 90% of all discharges in the United States and include all patients, regardless of insurance type, as well as the uninsured.

3. C-Reactive Protein: Not Ready for Population-Wide CVD Risk Assessment.

Traditional risk factors alone are still the best predictors of CVD risk.

In two new studies, researchers have evaluated the predictive value of novel cardiovascular disease (CVD) risk markers, including C-reactive protein (CRP).
In one study, coauthored by a coinventor of a CRP assay, 15,048 women (age, 45) were followed for a mean of 10 years; 390 developed CVD. When CRP values were added to prediction models that included traditional risk factors (age, blood pressure, smoking status, and HDL and total cholesterol levels), prediction of which women would develop CVD was not improved. The researchers also examined how often women classified by traditional risk factors as having <5%, 5%–<10%, 10%–<20%, or 20% risk were recategorized when CRP results were incorporated: 12%–14% of women in each group were reclassified into the next lower category, and 2%–10% were transferred to the next higher category. The authors concluded that use of CRP assays could help direct preventive interventions.

In another prospective U.S. cohort study, researchers assessed whether adding measurements of CRP or any of 18 other novel risk factors to traditional risk factors (age, race, sex, HDL and total cholesterol levels, systolic BP, use of antihypertensive agents, and smoking and diabetes status) improved prediction of incident coronary heart disease among nearly 16,000 adults (age, 45). Only lipoprotein-associated phospholipase A2 showed a statistically significant increase in predictive value compared with traditional risk factors only; however, this increase was not clinically important.

Comment: The debate about the incremental value of measuring CRP and other novel markers will not end with these studies. Authors of a review that accompanies the Annals of Internal Medicine study determined that measuring CRP might add modest predictive ability for people at intermediate risk. But editorialists note that CRP might not be related causally to CVD and lowering CRP levels might not improve outcomes. Given that only one in three people with elevated BP or cholesterol levels achieves adequate control, we agree with Archives of Internal Medicine editorialists who recommend focusing on treatment and control of traditional risk factors. For now, routine screening of CRP levels appears unwarranted.

­ Jamaluddin Moloo, MD, MPH, and Richard Saitz, MD, MPH, FACP, FASAM

Citation(s): Cook NR et al. The effect of including C-reactive protein in cardiovascular risk prediction models for women. Ann Intern Med 2006 Jul 4; 145:21-9; Folsom AR et al. An assessment of incremental coronary risk prediction using C-reactive protein and other novel risk markers: The atherosclerosis risk in communities study. Arch Intern Med 2006 Jul 10; 166:1368-73; Lloyd-Jones DM et al. Narrative review: Assessment of C-reactive protein in risk prediction for cardiovascular disease. Ann Intern Med 2006 Jul 4; 145:35-42; Davey Smith G et al. C-reactive protein and cardiovascular disease risk: Still an unknown quantity? Ann Intern Med 2006 Jul 4; 145:70-2; Lloyd-Jones DM and Tian L. Predicting cardiovascular risk: So what do we do now? Arch Intern Med 2006 Jul 10; 166:1342-4.

4. Selective radiography in 100 patients with suspected shoulder dislocation

Hendey GW, Chally MK, Stewart VB. J Emerg Med 2006;31:23-28.

Emergency Physicians frequently care for patients who have sustained a shoulder dislocation. Typically, pre-reduction radiographs are performed to confirm the dislocation and exclude fracture, and post-reduction films are ordered to confirm the reduction and exclude a fracture caused by the reduction. The notion that all such patients require both pre-reduction and post-reduction radiographs has been challenged by several authors. In two retrospective studies, no patient had a new fracture noted on post-reduction films, and both studies concluded that the routine practice of obtaining post-reduction films should be questioned. Three prospective studies reported that when physicians were clinically certain of joint position, their accuracy was 100%. A recent study found that 98% of fracture dislocations could be predicted using three clinical features, and could reduce pre-reduction films by 23%.

Based on the findings of many of the studies noted above, we previously derived a clinical decision rule for selective radiography in patients with a suspected shoulder dislocation (below). The algorithm suggests obtaining radiographs according to the mechanism of injury, previous dislocations, and the physician’s clinical certainty of joint position. The greatest potential savings in radiographs was noted in the subset of patients with recurrent dislocations by an atraumatic mechanism, where physicians were 100% accurate in their assessments of joint position, and there were no fractures or persistent dislocations. This suggests that this subgroup might be successfully managed without any radiographs in the Emergency Department (ED). The goal of the present study was to validate our previously derived clinical decision rule, and our specific objectives were: 1) to determine the actual reduction in X-ray utilization compared to the standard of pre- and post-reduction films for all dislocations, 2) to determine whether any fractures or dislocations were missed, 3) to compare the total ED time from triage to discharge, and 4) to assess patient satisfaction with an approach of selective radiography.

Decision Rule (paraphrased by DRV): You can safely skip radiographs in pts with recurrent shoulder dislocation, atraumatic mechanism, and physician certainty of diagnosis and relocation.

Abstract
We sought to prospectively validate an algorithm for selective radiography in the Emergency Department (ED) management of patients with suspected shoulder dislocation. Physicians ordered pre- and post-reduction radiographs based on an algorithm incorporating the mechanism of injury, previous dislocations, and the physician’s clinical certainty of joint position. Follow-up consisted of telephone calls and chart review. Of 100 patients, 94 had shoulder dislocation, and 59% were recurrent. Thirty percent had both pre- and post-reduction radiographs, 45% had pre- or post-reduction only, and 25% had no shoulder films, yielding an overall 46% reduction in X-ray utilization. Mean ED times were significantly shorter for patients managed without radiographs. On telephone follow-up (76%) and chart review (100%), we found no missed fractures or persistent dislocations. Use of a clinical decision rule for selective radiography reduced the number of radiographs and time spent in the ED, while missing no fractures or dislocations.

5. Vomiting of Liquid Corticosteroids in Children With Asthma.

Kim, Michael K. MD, et al. Pediatric Emergency Care. 22(6):397-401, June 2006.

Abstract
Background: Oral corticosteroids are an essential part of the management of children with acute asthma exacerbations. Vomiting is a frequently cited problem attributed to oral corticosteroids. A new formulation of prednisolone, Orapred, claims to have improved palatability that may decrease the incidence of vomiting.

Objective: To compare the incidence of vomiting and taste between patients who are given the generic preparation of prednisolone with those given Orapred.

Design/Methods: A randomized, double blind clinical trial was conducted at a tertiary care children s hospital emergency department. Children age 2 to 10 years presenting with acute asthma exacerbation were eligible. Patients with allergy to prednisolone, corticosteroid use within 2 weeks, history of vomiting in the last 24 hours, requirement for vascular access, and preference for other forms of corticosteroid were excluded. Enrolled patients were randomized and given either generic prednisolone (15 mg/5 ml) or Orapred (15 mg/5 ml). In children 6 years or older, a taste score was obtained using a 5 point hedonic face scale (1 = bad to 5 = great). After the administration, patients were observed for 30 minutes for vomiting. The Mann-Whitney U test was used to compare the median taste score between the two study groups. Relative risk (RR) of vomiting was calculated. Other confidence intervals were calculated when appropriate.

Results: During the study period, 211 eligible children were enrolled, of whom 23 were excluded. Of the remaining 188 subjects, 96 received generic prednisolone and 92 received Orapred. All baseline characteristics were similar in both groups. In the generic prednisolone group, 17 (17.7%) children vomited compared with 5 (5.4%) in the Orapred group (RR = 3.26, 95% CI, 1.25, 8.47). Taste scores were obtained from 18 children in the generic prednisolone group and from 19 children in the Orapred group. The median taste score was 2 for the generic prednisolone group and 4 for the Orapred group ([DELTA] = -2.0, 95% CI, -3.0, -1.0) (P = 0.0001).

Conclusions: In our study population, Orapred was associated with a significant less incidence of vomiting and better taste score compared to the generic prednisolone.

6. Risk factors for ectopic pregnancy in symptomatic first-trimester pregnancies

Barnhart KT, et al. Fertil Steril 2006;86:36-43.

Objective: To evaluate the association between ectopic pregnancy (EP) and clinical and historical factors among women presenting with pain and/or bleeding in early pregnancy.

Design: Nested case–control study. Setting: University medical center.

Patient(s): Women with symptomatic early pregnancies of unknown location presenting for care between January 1, 1990 and July 31, 1999.

Main Outcome Measure(s): Clinical and historical risk factors were compared between women with EP and women with ongoing intrauterine pregnancies or spontaneous abortions.

Result(s): The following factors were associated with increased risk of EP: prior EP (odds ratio, 2.98 [95% confidence interval, 1.88–4.73] for one prior EP and 16.04 [5.39–47.72] for 2 or more), pelvic inflammatory disease history (1.5 [1.11–2.05]), pain at presentation (1.42 [1.06–1.92]), vaginal bleeding at presentation (1.42 [1.04–1.93]), and hCG of 501–2,000 mIU/mL (1.73 [1.24–2.42]). Age younger than 25 years (0.59 [0.41–0.85]) and a history of abortion were protective from EP (0.58 [0.38–0.90]). Prior nontubal pelvic surgery, past intrauterine device use, prior cesarean section, and current cervical infection demonstrated no association with EP.

Conclusion(s): Evaluation of women with a symptomatic early pregnancy confirms and refutes some of the classical risk factors for EP. Prior EP is a strong risk factor, whereas pelvic inflammatory disease has an unexpected weak association. Previous abortion was found to have a negative association, whereas nontubal surgery, cesarean section, and a history of or concomitant cervical infection have no association. Knowledge of historical and clinical factors associated with EP may aid in early diagnosis.

7. Famciclovir: A Single-Dose Treatment for Herpes Labialis

Single-dose, patient-initiated famciclovir: A randomized, double-blind, placebo-controlled trial for episodic treatment of herpes labialis. Spruance SL, et al. J Amer Acad Dermatol 2006;55: 47-53.

Background
The brief period of viral replication in recurrent herpes labialis lesions suggests shorter therapeutic regimens are a logical episodic treatment strategy.

Objective
We sought to assess the efficacy and safety of single-dose and single-day famciclovir treatments.

Methods
In all, 701 randomly assigned patients self-initiated therapy with famciclovir (1500 mg once [single dose] or 750 mg twice a day for 1 day [single day]) or placebo within 1 hour of onset of the prodromal symptoms of an episode of herpes labialis. Lesion healing was monitored by diaries and frequent clinic visits.

Results
Median healing times of primary (first to appear) vesicular lesions in the famciclovir single-dose, famciclovir single-day, and placebo groups were 4.4, 4.0, and 6.2 days, respectively. There was no significant difference between the famciclovir regimens. Adverse events in the famciclovir groups were similar to placebo.

Limitations
The active arms of this trial were not directly compared to other antiviral regimens.

Conclusion
Single-dose famciclovir reduced time to healing of herpes labialis lesions by approximately 2 days compared with placebo.

8. Epinephrine May Edge Vasopressin in Cardiac Arrest

NEW YORK (Reuters Health) Jul 20 - Vasopressin offers no advantages over epinephrine for treatment of out-of-hospital cardiac arrest and may even be of less help neurologically, according to a review of the subject in the July issue of the Annals of Emergency Medicine.

"Vasopressin," lead author Dr. Peter C. Dwyer told Reuters Health "appears to be one of several powerful cardioactive drugs that may restart the heart after cardiac arrest in some patients without increasing survival to hospital discharge."

One study, he added, "suggested that it might increase likelihood of longer term survival in patients with cardiac ... asystole. Our analysis indicates that this observation was likely a result of chance."

In order to determine whether either agent increased survival to discharge, Dr. Wyer of Columbia University College of Physicians and Surgeons, Pelham Manor, New York and colleagues reviewed data from three "high-quality" randomized trials and one "rigorous" meta-analysis.

None of the findings, they note, confirmed a consistent benefit of vasopressin over epinephrine in increasing survival or improving neurological outcome in survivors.

Furthermore, continued Dr. Wyer, there is "a suggestion that the drug may worsen neurological outcome in those who do survive."

"We believe," he concluded, "that further research is necessary before this drug is recommended for widespread use in cardiac resuscitation patients."

Ann Emerg Med 2006;48:86-97.

9. NSAIDs Slightly Increase Risk of MI

NEW YORK (Reuters Health) Aug 01 - All nonsteroidal anti-inflammatory agents (NSAIDs), those that inhibit cyclo-oxygenase-2 (COX)-2 or the conventional, nonselective agents, raise the risk of myocardial infarction (MI), according to the results of a population-based, matched case-control study conducted in Finland.

"Our results do not support the view that COX-selectivity alone determines the cardiovascular adverse effects of NSAIDs, at least concerning MI," lead investigator Dr. Arja Helin-Salmivaara and colleagues note in their report, published in the July issue of the European Heart Journal.

Accumulating data on the cardiovascular risks associated with COX-2 inhibitors have called into question the safety of nonselective NSAIDs, they note. Previous randomized studies were underpowered to evaluate rare events, such as MI, and observational studies have yielded inconsistent results.

The investigators evaluated data for 33,309 patients with a first MI entered into the Finnish Hospital Discharge Register between 2000 and 2003. These subjects were compared with 138,949 control subjects matched by age, sex, and hospital catchment area.

The NSAIDs used included: conventional NSAIDs (diclofenac, ibuprofen, indomethacin, ketoprofen, naproxen, mefenamic acid, piroxicam, tenoxicam, tolfenamic acid, aceclofen, tiaprofenic acid); semiselective NSAIDs (etodolac, nabumetone, nimesulide and meloxicam); and COX-2 inhibitors (rofecoxib, celecoxib, valdecoxib and etoricoxib).

Dr. Helin-Salmivaara from the University of Turku, in Helsinki, and colleagues determined the adjusted odds ratio associated with current use of each drug, after adjusting for comorbidities, hormone therapy and other drugs that reduce MI risk.

They found that current use of any NSAID was associated with an adjusted odds ratio of 1.40. The risk of MI was significantly increased for all classes of NSAIDS, with adjusted odds ratios ranging from 1.3 to 1.5.

The mean adjusted odds ratios for MI tended to decline over time after discontinuation of NSAID, but this association reached statistical significance only for conventional NSAIDs.

Neither age nor gender appeared to modify the risk of MI in any NSAID category. However, significantly elevated risks for indomethacin, diclofenac, naproxen, nimesulide, or rofecoxib were observed only in subjects 76 years old or older.

Although "the risk was elevated regardless of the duration of therapy," Dr. Helin-Salmivaara's group concludes, it was "considerably less than the (2- to 5-fold greater) risk of serious upper gastrointestinal events."

Still, "even if the risk increase was modest, any risk of serious adverse event is important at the population level if a drug is not life-saving and is widely used, as is the case with NSAIDs," the authors conclude.

In a related editorial, Dr. Deepak L. Bhatt, from Cleveland Clinic Foundation in Ohio, points out that the report by Dr. Helin-Salmivaara's team is the largest population-based, matched case-control study of NSAIDs performed to date.

Because other studies have yielded different results, and some researchers have hypothesized that NSAIDs are cardioprotective, a large randomized trial is needed. To that end, Dr. Bhatt and his associates have launched a prospective trial to evaluate the safety of celecoxib, ibuprofen and naproxen among 20,000 patients with arthritis, either with cardiovascular disease or at high risk.

Eur Heart J 2006;27:1635-1636,1657-1663.

10. Termination of Out-of-Hospital Resuscitation Rule May Help EMTs

NEW YORK (Reuters Health) Aug 02 - A new three-item clinical prediction rule may help emergency medical personnel decide when to terminate basic life support resuscitative efforts in cases of out-of-hospital cardiac arrest.

The prediction rule recommends, in the absence of advanced cardiac life support, EMTs may consider the termination of basic life support resuscitative efforts: if there is no return of spontaneous circulation before transportation to the ED is initiated; if the patient received no shocks before transportation is initiated; and if the cardiac arrest was not witnessed by EMS personnel, clinicians report in August 3 issue of The New England Journal of Medicine.

Dr. Laurie J. Morrison of the University of Toronto and colleagues validated this rule by testing it in 24 emergency medical systems in Ontario, which included 1240 adults with presumed cardiac arrest who were treated by EMTs trained in the use of an automated external defibrillator.

Of the 776 patients for whom the prediction rule called for termination of basic life support, 4 survived (0.5%). "The rule had a specificity of 90.2 percent for recommending transport of survivors to the emergency department and had a positive predictive value for death of 99.5 percent when termination was recommended," the authors report.

"Implementation of this rule would result in a decrease in the rate of transportation from 100 percent of patients to 37.4 percent," they add.

Dr. Morrison and colleagues note that "substantial numbers" of out-of-hospital cardiac arrest patients with little or no potential for survival are regularly transported to emergency departments.

Guidelines to help EMTs identify which patients would truly benefit from resuscitation efforts would be "extremely useful" and economical.

N Engl J Med 2006;355:478-487.

11. Point-Of-Care USs May Be Better Than Landmark Identification to Place Central Lines

News Author: Laurie Barclay, MD. Aug. 24, 2005 ­ Point-of-care ultrasound (US) is superior to landmark identification for the placement of central venous cannulas, according to the results of a randomized trial published in the August 2005 issue of Critical Care Medicine. The investigators suggest that all central lines should be placed with US assistance.

"A 2001 Agency for Healthcare Research and Quality Evidence Report [AHRQ] on patient safety addressed point-of-care limited ultrasonography guidance for central venous cannulation and strongly recommended real-time, dynamic guidance for all central cannulas," write Truman J. Milling, Jr, MD, from the New York Methodist Hospital, and colleagues. "However, on the basis of one limited study, the report dismissed static assistance, a 'quick look' with ultrasound to confirm vein location before preparing the sterile field, as unhelpful."

The objective of the Third Sonography Outcomes Assessment Program (SOAP-3) Trial was to compare the overall success rate of central cannula placement with use of dynamic US, static US, and anatomical landmarks.

From September 2003 to February 2004 in a U.S. urban teaching hospital, 201 patients undergoing internal jugular vein central venous cannulation were randomized to placement with dynamic US (n = 60), static US (n = 72), or anatomical landmark (n = 69). All imaging was performed with iLook25 SonoSite (SonoSite, Bothell, Washington). Outcome measures were cannulation success, first attempt success, number of attempts, vein size, and clarity of anatomical landmarks. After adjustment for pretest difficulty assessment, results are expressed as odds improvement (95% confidence interval [CI]) over anatomical landmark for dynamic US and static US.

Dynamic US had an odds 53.5 (95% CI, 6.6 - 440) times higher for success than anatomical landmark, and static US had an odds 3 (95% CI, 1.3 - 7) times higher for success than anatomical landmark. Unadjusted success rates were 98% for dynamic US, 82% for dynamic ultrasound, and 64% for anatomical landmark. For dynamic US, odds for first success were 5.8 (95% CI, 2.7 - 13) times higher than for anatomical landmark, and for dynamic ultrasound, odds were 3.4 (95% CI, 1.6 - 7.2) times higher than for anatomical landmark. Unadjusted first-attempt success rates were 62% for dynamic US, 50% for static US, and 23% for anatomical landmark. The US groups had low complication rates.

Study limitations were that the study population did not include all central cannula recipients in the hospital during the study period; inclusion of study investigators in the group of US operators; lack of data on the urgency of cannula placement; and lack of blinding of investigators.

"Ultrasound assistance was superior to anatomical landmark techniques," the authors write. "D [dynamic US] outperformed S [static US] but may require more training and personnel. All central cannula placement should be conducted with ultrasound assistance. The 2001 Agency for Healthcare Research and Quality Evidence Report dismissing static assistance was incorrect."

The authors report no financial conflicts of interest.

Crit Care Med. 2005;33:1764-1769

12. Antibiotics for acute purulent rhinitis---wait and watch

Antibiotics should not be used as first line treatment for acute purulent rhinitis because of their gastrointestinal toxicity, even though they are probably effective. Arroll and Kenealy (BMJ 2006;333:279; 5 August) conducted a meta-analysis of seven randomised controlled trials in adults and children. The relative risks for benefits and harms with the antibiotics were 1.18 and 1.46 respectively. Antibiotics may be used when the symptoms continue long enough to concern patients, the authors add.

Abstract: http://bmj.bmjjournals.com/cgi/content/abstract/333/7562/279

13. Safety and effectiveness of intravenous regional anesthesia (Bier block) for outpatient management of forearm trauma

Bruce Mohr, MD. Whistler Health Care Centre, Whistler, BC. Can J Emerg Med 2006;8(4):247-50

ABSTRACT
Objective: To assess the safety and effectiveness of intravenous regional anesthesia (Bier block) in the management of forearm injuries (i.e., forearm, wrist or hand) by primary care physicians at a diagnostic and treatment facility.

Methods: A retrospective review was conducted of all patients at a single centre who underwent a Bier block for forearm injuries between September 2000 and March 2005.

Results: 1816 Bier blocks were performed on 1804 patients (64% male) during the study period. Patient age ranged from 4–70 (mean 25) years. Wrist fractures requiring reduction were the most common diagnosis. Adverse events were recorded in 9 cases (0.50%, 95% confidence interval 0.23%–0.94%): 1 case of medication error (0.06%); 3 of improper cuff inflation (0.17%); and 5 of inadequate analgesia (0.28%). None of the adverse events resulted in failure to complete the procedure or in serious morbidity or mortality.

Conclusion: Bier block anesthesia is a safe, effective and reliable technique in an outpatient primary care setting. This technique is a useful modality for physicians who manage acute upper-extremity injuries.

14. Radioisotopes Can Trigger Airport Radiation Detectors

[Though not immediately clinically relevant to many of our practices, this report was nevertheless fascinating.­DRV]

NEW YORK (Reuters Health) Aug 04 - The findings from a case report illustrate how treatment with radioisotopes can make patients radioactive for several weeks and capable of activating radiation detectors at airports.

"Patients receiving radioactive isotopes should be warned that they may trigger radiation alarms," lead author Dr. Kalyan Kumar Gangopadhyay and colleagues from City Hospital in Birmingham, UK, emphasize.

The case report, which appears in the August 5th issue of the British Medical Journal, involved a 46-year-old man with hyperthyroidism. Medical therapy was initially successful in treating his symptoms, but recurrences of thyrotoxicosis eventually led to treatment with radioactive iodine.

The nuclear medicine department gave the man a card describing the precautions to be taken following his treatment. However, the card made no mention of the possibility of setting off radiation detectors.

Six weeks later, the patient made a trip to the US, where he activated security alarms upon check-in at the airport in Orlando, Florida. The man was detained, strip-searched, and sniffer dogs were called to investigate. After a prolonged interrogation, the patient was eventually released after producing the card given to him by the nuclear medicine department.

Based on the type of radioisotope used, patients may be capable of triggering a radiation alarm for up to 95 days, the report indicates.

"Doctors show a worrying lack of awareness about such potential problems," the researchers note. "A literature search found only four case reports and this further highlights the problem."

The authors note that with more sensitive radiation detectors being installed at airports worldwide, there is a good chance that alarms caused by radioisotope-treated patients will increase.

BMJ 2006;333:293-294.

15. TPA Is Safe in Elderly Patients With Acute Ischemic Stroke

By Michelle Rizzo. NEW YORK (Reuters Health) Jul 28 - Results of a study published in the July issue of the Journal of Neurology, Neurosurgery, and Psychiatry suggest that thrombolysis can be safely applied in carefully selected elderly patients with acute ischemic stroke.

"Ischemic stroke patients over 80 can be successfully and safely treated with tPA," lead author Dr. Michael D. Hill, of the University of Calgary, Alberta, Canada, told Reuters Health. "Hopefully...practitioners will be less 'afraid' of the older age group and treat them just as aggressively with thrombolysis as they treat younger patients."

The researchers reviewed data prospectively collected from the Canadian Alteplase for Stroke Effectiveness Study (n = 1135). Two hundred seventy patients at least 80 years of age who were treated with tPA for acute ischemic stroke were compared with 865 patients younger than 80 years.

No significant differences were observed in the risk of symptomatic intracerebral hemorrhage between patients aged 80 years and older and those younger than 80 years (4.4% versus 4.6%).

Forty percent of patients younger than 80 years of age had a favorable outcome (defined as a modified Rankin Score of 0 to 1) at 90 days, compared to 25% of those 80 years and older (p < 0.001). At 3 months' follow-up, 35% of patients older than 80 were dead, compared with 18% of those younger than 80 years (p = 0.001).

Patients 80 years of age and older were more likely than those younger than 80 years to have atrial fibrillation (37% versus 18%, p < 0.001), congestive heart failure (11% versus 6%, p = 0 .004), hypertension (59% versus 48%, p = 0.002), and ischemic heart disease (30% versus 23%, p = 0.05).

The older patients were also more likely to have greater stroke severity than the younger patients. In patients 80 years and older, predictors of death included baseline serum glucose level and congestive heart failure.

"In carefully selected elderly patients, the use of intravenous tPA was not found to be associated with an increased risk of symptomatic intracerebral hemorrhage," the authors conclude.

J Neurol Neurosurg Psychiatry 2006;77:826-829.

16. Delay prescribing of antibiotics for acute conjunctivitis

Delayed prescribing of topical antibiotics is probably the best strategy for managing acute conjunctivitis in primary care, say Everitt and colleagues in the BMJ this week. They randomised more than 300 adults and children with acute infective conjunctivitis from 30 general practices to one of three prescribing strategies­immediate antibiotics (chloramphenicol eye drops), no antibiotics (controls), or delayed antibiotics (prescription to be collected at patients' discretion after three days). Prescribing strategies did not affect the severity of symptoms, but duration of moderate symptoms was less with antibiotics (immediate or delayed). However, delayed prescribing reduced antibiotic use and reattendance compared with immediate prescribing.

Abstract: http://bmj.bmjjournals.com/cgi/content/abstract/333/7563/321