Lit Bits: December 14, 2006

From the recent medical literature...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ABSTRACT

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

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

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

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

3. Heavy Smokers Who Cut Back Fail to Reduce Mortality

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

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

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

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

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

4. Early Administration of Adenosine Improves MI Outcomes

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

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

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

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

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

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

Eur Heart J 2006;27:2400-2405.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Arch Intern Med 2006;166:2375-2380.

8. Lower Cervical Bupivacaine Injection Treats Headache in the ED

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

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

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

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

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

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

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

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

Headache 2006;46:1441-1449.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MMWR. 2006;55:1269-1292.

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

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

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

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

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

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

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

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

12. Low Literacy Leads to Prescription-Label Misunderstandings

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

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

Findings included:

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

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

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

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

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

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

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

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

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

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

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

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

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

14. New Oral Anticoagulants Raise Hopes for Warfarin Replacement

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

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

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

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

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

15. Oral Steroids May Trigger Some Cases of Diabetes

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

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

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

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

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

Diabetes Care 2006;29:2728-2729.

16. Risk for Thrombosis Persists After Discontinuation of Heparin Therapy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

19. Algorithm Could Aid in Management of Abnormal Uterine Bleeding

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

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

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

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