Lit Bits: January 26, 2007

From the recent medical literature...

1. Combination Therapy Reduces Exacerbations in Severe COPD

NEW YORK, NY -- January 15, 2007 -- For patients with severe chronic obstructive pulmonary disease (COPD), combining a long-acting bronchodilator with an inhaled corticosteroid reduced the number of exacerbations by 35%.

The research appears in the second issue for January 2007 of the American Journal of Respiratory and Critical Care Medicine, published by the American Thoracic Society. Peter Kardos, MD, of the Respiratory Medicine Section of Maingau Hospital in Frankfurt am Main, Germany, and three associates treated patients with moderate to severe COPD from 92 respiratory centers across Germany. All had less than a 50% predicted lung function capability for their age group.

The researchers treated 487 patients with salmeterol, a long-acting bronchodilator, and gave 507 a combination therapy of salmeterol and fluticasone propionate, an inhaled corticosteroid. Of the total cohort, 792 patients completed all phases of the 44-week study. In the combined therapy group, 324 patients experienced moderate to severe exacerbations, as compared to 464 in the control group. The authors believe that this reduction in exacerbations is likely of clinical importance for patients with severe COPD.

"Exacerbations are a major cause of disease-related problems," said Dr. Kardos. "In particular, they greatly contribute to the decline of the health-related quality of life, increase symptoms and breathlessness, speed progression of the disease and increase the risk of mortality. In addition, exacerbations induce enormous economic costs. They can occur at any stage of the disease, but become more frequent as lung function impairment worsens."

In the United States, COPD is the fourth leading cause of death, killing 122,283 Americans in 2003. In 2004, more than 11 million U.S. adults were estimated to suffer from the disease, which results from chronic bronchitis and emphysema, two lung diseases that frequently co-exist and interferes with normal breathing. Smoking is the primary cause of COPD.

To date, no medication has been effective in halting long-term decline in lung function, which is the hallmark of the disease. Medications can only be used to provide relief from symptoms and prevention complications.

In an editorial on the research in the same issue of the journal, Dennis E. Niewoehner, MD, and Timothy J. Wilt, MD, of the Veterans Affairs Medical Center and the University of Minnesota, wrote: "As in all previous large inhaled corticosteroid (ICS) trials, Dr. Kardos administered relatively high doses of fluticasone. High dose ICS causes localized adverse effects in the upper airway and on the skin, but only infrequently do these complications cause discontinuation of therapy."

"Of greater concern is the systemic absorption of small amounts of ICS and the potential for long-term sequelae, particularly involving the bones and eyes," the editorialists continued. "The largely elderly population of patients with COPD may be at greater risk, and, as discussed in a recent review, the extent of the relationship between long-term ICS and bone and eye complications has yet to be fully clarified."

"Dr. Kardos and associates identify an additional safety concern with ICS not mentioned in previous publications. Based on adverse event reporting, 23 cases of pneumonia occurred in the combined-treatment group compared with only seven in the salmeterol arm. This difference is statistically significant and represents an excess pneumonia rate of about 3 per 100 patient years in patients given fluticasone."

The authors noted that similar results were obtained in patients who received fluticasone in TOwards a Revolution in COPD Health (TORCH), a survival study that aimed to determine the impact of salmeterol/fluticasone propionate combination and the individual components on the survival of COPD patients. "In light of the known immunosuppressive properties of corticosteroids, an excess pneumonia rate from a high local concentration of ICS is not particularly surprising," the editorialists wrote.

The authors also pointed out that only a small minority of patients treated with ICS would achieve "clinically noticeable improvement in health status." They concluded: "Therefore, decisions to initiate ICS combined with a long-acting beta agonist should focus on severely symptomatic and exacerbation-prone patients and balance the recently demonstrated benefits against increased drug costs and adverse effects."

SOURCE: American Thoracic Society

2. Clinical Prediction Rule for Identifying Children With CSF Pleocytosis at Very Low Risk of Bacterial Meningitis

Nigrovic LE, at al. JAMA. 2007;297:52-60.

Context: Children with cerebrospinal fluid (CSF) pleocytosis are routinely admitted to the hospital and treated with parenteral antibiotics, although few have bacterial meningitis. We previously developed a clinical prediction rule, the Bacterial Meningitis Score, that classifies patients at very low risk of bacterial meningitis if they lack all of the following criteria: positive CSF Gram stain, CSF absolute neutrophil count (ANC) of at least 1000 cells/µL, CSF protein of at least 80 mg/dL, peripheral blood ANC of at least 10 000 cells/µL, and a history of seizure before or at the time of presentation.

Objective: To validate the Bacterial Meningitis Score in the era of widespread pneumococcal conjugate vaccination.

Design, Setting, and Patients: A multicenter, retrospective cohort study conducted in emergency departments of 20 US academic medical centers through the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. All children aged 29 days to 19 years who presented at participating emergency departments between January 1, 2001, and June 30, 2004, with CSF pleocytosis (CSF white blood cells 10 cells/µL) and who had not received antibiotic treatment before LP.

Main Outcome Measure: The sensitivity and negative predictive value of the Bacterial Meningitis Score.

Results: Among 3295 patients with CSF pleocytosis, 121 (3.7%; 95% confidence interval [CI], 3.1%-4.4%) had bacterial meningitis and 3174 (96.3%; 95% CI, 95.5%-96.9%) had aseptic meningitis. Of the 1714 patients categorized as very low risk for bacterial meningitis by the Bacterial Meningitis Score, only 2 had bacterial meningitis (sensitivity, 98.3%; 95% CI, 94.2%-99.8%; negative predictive value, 99.9%; 95% CI, 99.6%-100%), and both were younger than 2 months old. A total of 2518 patients (80%) with aseptic meningitis were hospitalized.

Conclusions: This large multicenter study validates the Bacterial Meningitis Score prediction rule in the era of conjugate pneumococcal vaccine as an accurate decision support tool. The risk of bacterial meningitis is very low (0.1%) in patients with none of the criteria. The Bacterial Meningitis Score may be helpful to guide clinical decision making for the management of children presenting to EDs with CSF pleocytosis.

3. Getting our terminology up-to-date

A. 2005: “Near-drowning” is out.

For over a year now, “drowning” has been the proper term to describe all liquid submersion events, whether the victim dies or walks away from it. To describe an event as a “near-drowning” is as out of vogue as describing a car crash as a “MVA” (see below).

A new definition of drowning: towards documentation and prevention of a global public health problem

van Beeck EF, at al. Bull World Health Organ vol.83 no.11 Genebra Nov. 2005

Drowning is a major global public health problem. Effective prevention of drowning requires programmes and policies that address known risk factors throughout the world. Surveillance, however, has been hampered by the lack of a uniform and internationally accepted definition that permits all relevant cases to be counted. To develop a new definition, an international consensus procedure was conducted. Experts in clinical medicine, injury epidemiology, prevention and rescue from all over the world participated in a series of "electronic" discussions and face-to-face workshops. The suitability of previous definitions and the major requirements of a new definition were intensely debated. The consensus was that the new definition should include both cases of fatal and nonfatal drowning.

After considerable dialogue and debate, the following definition was adopted: "Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid." Drowning outcomes should be classified as: death, morbidity, and no morbidity. There was also consensus that the terms wet, dry, active, passive, silent, and secondary drowning should no longer be used. Thus a simple, comprehensive, and internationally accepted definition of drowning has been developed. Its use should support future activities in drowning surveillance worldwide, and lead to more reliable and comprehensive epidemiological information on this global, and frequently preventable, public health problem.

B. Remember when MVAs gave way to MVCs?

About 10 years ago, the term MVC (Motor Vehicle Crash) was to replace MVA. The more recent literature reflects this. “Accident” suggests that these crashes are unavoidable, outside of human influence or control. But many times, MVCs are predictable and preventable events. The change was made official by Ricardo Martinez, Administrator, National Highway Traffic Safety Administration, June 8, 1997.

4. Free Online Fitness Tools from the AHA

With an eye on Americans who spend too much time sitting behind computer screens and not enough time getting exercise, the American Heart Association is pitching fitness with an online nutrition tracker. Just in time to rescue waning New Year's resolutions, the AHA has launched several online tools to help users eat right and exercise. The tools, all part of the AHA's new "Start!" program, include:

-- A fitness tracker that tells users how many calories they net based on daily food intake and exercise. Users can also sign up for recorded celebrity wake-up calls.

-- An eating guide that offers low-fat recipes, tips for buying healthier food, and recommendations for the number of calories to eat to maintain a healthy weight.

-- A request form for the AHA to set up a walking program in a user's workplace.

All the tools are free, but some require online registration. Go to http://www.heart.org/presenter.jhtml?identifier=3040839

5. Pneumonia Severity Index Guides Care Decisions in the ED

NEW YORK (Reuters Health) Jan 09 - When patients present to the emergency department with pneumonia, the Pneumonia Severity Index (PSI) is a useful aid in making initial site-of-treatment decisions, a multicenter, prospective study conducted in 16 French hospitals confirms.

"Our results confirm previous interventional studies, and bring additional evidence for incorporating the PSI in the ED policies and its more widespread clinical use in the ED setting," Dr. Bertrand Renaud from Centre Hospitalier Universitaire Henri Mondor, Paris, France told Reuters Health.

Over the 3- to 5-month study period, eight participating EDs used the PSI to guide site-of-treatment decisions and eight study EDs did not. The outcomes examined included the proportion of "low risk" patients treated as outpatients, all-cause 28-day mortality, admission of inpatients to the ICU, and subsequent hospitalization of outpatients.

According to the team's report in Clinical Infectious Diseases for January 1, the proportion of patients at low risk who were treated as outpatients was nearly twice as high with routine use of the PSI as that for nonuse of the PSI (42.8% vs 23.9%), "without compromising their safety."

"The actual rate of outpatient care was 18.9% higher for patients who were treated in EDs that routinely used the PSI," they note.

In analyses adjusted for pneumonia severity, short-term mortality was lower in patients from EDs using the PSI, whereas subsequent hospitalization for outpatients and ICU admissions for inpatients did not differ between patients from PSI-user and PSI-nonuser EDs.

According to Dr. Renaud, this study marks the first "real life" assessment of the value of the PSI in guiding hospitalization decisions in patients presenting with community-acquired pneumonia.

Clin Infect Dis 2007;44:41-49.

For the PSI calculator: http://pda.ahrq.gov/clinic/psi/psicalc.asp

6. Cough and Cold Medications May Be Lethal to Infants

NEW YORK (Reuters Health) Jan 11 - After investigating the deaths of three infants between 1 and 6 months of age linked to cough and cold medication use, officials with the US Centers for Disease Control and Prevention are emphasizing that these drugs should be used only after talking with a physician.

Dr. A. Srinivasan and colleagues at the CDC note in the January 12th issue of the Morbidity and Mortality Weekly Report that during 2004 and 2005, approximately 1500 children less than 2 years old were treated in US emergency departments for adverse events associated with cough and cold medications.

For each of the three dead infants, a medical examiner or coroner determined that the cough and cold medications were the underlying causes of death.

Blood levels of the decongestant pseudoephedrine at autopsy ranged from 4700 to 7100 ng/mL; that compares to plasma concentrations of 180-500 ng/mL expected after therapeutic dosing in children ages 2 to 12 years old.

"Because of the risks for toxicity, absence of dosing recommendations, and limited published evidence of effectiveness of these medications in children aged less than 2 years, parents and other caregivers should not administer cough and cold medications to children in this age group without first consulting a health-care provider and should follow the provider's instructions precisely," the authors advise.

In an editorial note, the CDC says controlled trials indicate that cough and cold medications are no more effective than placebo in children younger than 2 years of age.

Furthermore, the American College of Chest Physicians in 2006 released clinical practice guidelines for management of cough, advising clinicians to refrain from recommending cough suppressants.

Safer and probably more effective treatments for young patients' symptoms include softening nasal secretions with saline nose drops or a cool-mist humidifier, then clearing nasal congestion with a rubber suction bulb.

Mor Mortal Wkly Rep CDC Surveill Summ 2007;56:1-4.
Full free-text article: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5601a1.htm

7. (Poor) Association Between Performance Measures and Clinical Outcomes for Patients Hospitalized With Heart Failure

Fonarow GC, et al. JAMA. 2007;297:61-70.

Context: Assessment of quality of care in heart failure has focused on the development and use of process-based performance measures, with the presumption that these processes are associated with improved clinical outcomes. However, this link remains largely untested.

Objective: To examine the relationship between current American College of Cardiology/American Heart Association (ACC/AHA) performance measures for patients hospitalized with heart failure and relevant clinical outcomes.

Design, Setting, and Patients: The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure, a registry and performance improvement program for patients hospitalized with heart failure. Sixty- to ninety-day postdischarge follow-up data were prospectively collected from 5791 patients at 91 US hospitals in a prespecified 10% sample between March 2003 and December 2004. Mean patient age was 72.0 years, 51% were male, 78% were white, and 42% had ischemic etiology. Multivariable and propensity-adjusted analyses were performed to assess the process-outcome relationship for each performance measure in eligible patients. Additionally, we evaluated the process-outcome link of a potential performance measure for -blockade at discharge among eligible patients hospitalized with heart failure.

Main Outcome Measures: Sixty- to ninety-day mortality and combined mortality/rehospitalization rates.

Results: Mortality during follow-up was 8.6% and mortality/rehospitalization was 36.2%. None of the 5 ACC/AHA heart failure performance measures was significantly associated with reduced early mortality risk, and only angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use at discharge was associated with 60- to 90-day postdischarge mortality or rehospitalization. -Blockade at the time of hospital discharge, currently not a heart failure performance measure, was strongly associated with reduced risk of mortality (hazard ratio, 0.48; 95% confidence interval, 0.30-0.79; P = .004) and mortality/rehospitalization during follow-up.

Conclusions: Current heart failure performance measures, aside from prescription of an ACE inhibitor or an ARB at discharge, have little relationship to patient mortality and combined mortality/rehospitalization in the first 60 to 90 days after discharge. Additional measures and better methods for identifying and validating heart failure performance measures may be needed to accurately assess and improve care of patients with heart failure.

8. The Future: Emerging Therapies for the Management of Decompensated Heart Failure: From Bench to Bedside

deGoma EM, at al. J Am Coll Cardiol. 2006;48:2397-409

While pharmaceutical innovation has been highly successful in reducing mortality in chronic heart failure, this has not been matched by similar success in decompensated heart failure syndromes. Despite outstanding issues over definitions and end points, we argue in this paper that an unprecedented wealth of pharmacologic innovation may soon transform the management of these challenging patients. Agents that target contractility, such as cardiac myosin activators and novel adenosine triphosphate-dependent transmembrane sodium-potassium pump inhibitors, provide inotropic support without arrhythmogenic increases in cytosolic calcium or side effects of more traditional agents.

Adenosine receptor blockade may improve glomerular filtration and diuresis by exerting a direct beneficial effect on glomerular blood flow while vasopressin antagonists promote free water excretion without compromising renal function and may simultaneously inhibit myocardial remodeling. Urodilatin, the renally synthesized isoform of atrial natriuretic peptide, may improve pulmonary congestion via vasodilation and enhanced diuresis. Finally, metabolic modulators such as perhexiline may optimize myocardial energy utilization by shifting adenosine triphosphate production from free fatty acids to glucose, a unique and conceptually appealing approach to the management of heart failure. These advances allow optimism not only for the advancement of our understanding and management of decompensated heart failure syndromes but for the translational research effort in heart failure biology in general.

9. Randomized Clinical Trial of Etomidate Versus Propofol for Procedural Sedation in the ED

Miner JR, et al. Ann Emerg Med 2007;49:

Intro
Patients undergoing painful procedures in the emergency department (ED), such as orthopedic manipulations or abscess drainage, often require moderate or deep procedural sedation for successful performance of the procedure. This sedation is achieved with the use of a sedative agent administered at a dose that allows patients to maintain airway reflexes and have some response to verbal stimuli (moderate sedation) or to pain (deep sedation). The ideal sedative agent for this purpose would provide adequate sedation to perform the procedure successfully, with a minimum of cardiorespiratory adverse effects, and have a short duration of action. Etomidate and propofol are 2 ultrashort-acting sedative agents thought to provide these characteristics. Despite their common use in procedural sedation, the performance and safety of these 2 agents have not been compared in a randomized controlled fashion.

Propofol has an onset of action of approximately 45 seconds and begins to redistribute from the blood to fat and muscle in 3 to 5 minutes, with a rapidly resolving clinical effect. Propofol provides reliable amnesia and rapid recovery when used for procedural sedation. Etomidate has an onset of action of approximately 1 minute and duration of action of 5 to 15 minutes. It is considered to have the least homodynamic effect of any of the agents available for procedural sedation. A number of studies have found that etomidate provides effective, reliable sedation with minimal adverse effects.

Importance
Both of these agents are frequently used for procedural sedation in the ED, but it is not yet known whether one of these agents is more effective or safe than the other. Determining differences in the effectiveness and safety of these agents will allow the development of more specific guidelines about their use.

Study objective
We compare the efficacy, adverse events, and recovery duration of etomidate and propofol for use in procedural sedation in the emergency department (ED).

Methods
This was a randomized nonblinded prospective trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients received either propofol or etomidate. Doses, vital signs, nasal end-tidal CO2 (etco2), pulse oximetry, and bispectral electroencephalogram analysis scores were recorded. Subclinical respiratory depression was defined as a change in etco2 greater than 10 mm Hg, an oxygen saturation of less than 92% at any time, or an absent etco2 waveform at any time. Clinical events related to respiratory depression, including an increase in supplemental oxygen, the use of a bag-valve-mask apparatus, airway repositioning, or stimulation to induce breathing, were noted during the procedure. After the procedure, patients completed visual analog scales about perceived pain during the procedure and recall of the procedure.

Results
Two hundred twenty patients were enrolled; 214 underwent sedation and were analyzed. One hundred five patients received etomidate and 109 received propofol. No clinically significant complications were noted. Subclinical respiratory depression was observed in 36 of 105 (34.3%) patients in the etomidate group and 46 of 109 (42.2%) in the propofol group (difference –7.9%; 95% confidence interval [CI] –20.9% to 5.1%). Myoclonus was noted in 21 of 105 (20.0%) patients in the etomidate group and 2 of 109 (1.8%) in the propofol group (difference 18.2%; 95% CI 10.1% to 26.2%). The mean difference between baseline systolic blood pressure and the nadir was 3.8% (95% CI 2.3% to 5.3%) for etomidate and 7.9% (95% CI 6.1% to 9.7%) for propofol. Clinical events related to respiratory depression included an increase in supplemental oxygen in 6.7% of etomidate patients and 5.5% of propofol patients (difference 1.2%; 95% CI –5.2% to 7.6%), the use of bag-valve-mask apparatus in 3.8% of patients in the etomidate groups and 4.6% in the propofol group (difference –0.8%; 95% CI –6.1% to 4.6%), airway repositioning in 13.3% of etomidate patients and 11.0% of propofol patients (effect size 2.3%; 95% CI –6.4% to 11.1%), and stimulation to induce breathing in 11.4% of etomidate patients and 11.9% of propofol patients (difference –0.5%; 95% CI –9.1% to 8.1%). The procedures were successful in 93 of 105 (88.6%) for etomidate and 106 of 109 (97.2%) for propofol (difference –7.4%; 95% CI –14.3% to –1.1%).

Conclusion
Etomidate and propofol appear equally safe for ED procedural sedation; however, etomidate had a lower rate of procedural success and induced myoclonus in 20% of patients.

10. A Prospective Evaluation of “Ketofol” (Ketamine/Propofol Combination) for Procedural Sedation and Analgesia in the ED

Willman EV, et al. Ann Emerg Med 2007;49:28-30.

Study objective
We evaluate the effectiveness and consider the safety of intravenous ketamine/propofol combination (“ketofol”) in the same syringe for procedural sedation and analgesia in the emergency department (ED).

Methods
A prospective case series of consecutive ketofol procedural sedation and analgesia events in the ED of a trauma-receiving community teaching hospital from July 2005 to February 2006 was studied. Patients of all ages, with any comorbid conditions, were included. Ketofol (1:1 mixture of ketamine 10 mg/mL and propofol 10 mg/mL) was administered intravenously at the discretion of the treating physician by using titrated aliquots. The presence or absence of adverse events was documented, as were procedural success, recovery time, and physician, nurse, and patient satisfaction. Physiologic data were recorded with established hospital procedural sedation and analgesia guidelines.

Results
One hundred fourteen procedural sedation and analgesia events using ketofol were performed for primarily orthopedic procedures. The median dose of medication administered was ketamine at 0.75 mg/kg and propofol at 0.75 mg/kg (range 0.2 to 2.05 mg/kg each of propofol and ketamine; interquartile range [IQR] 0.6 to 1.0 mg/kg). Procedures were successfully performed without adjunctive sedatives in 110 (96.5%) patients. Three patients (2.6%; 95% confidence interval [CI] 0.6% to 7.5%) had transient hypoxia; of these, 1 (0.9%; 95% CI 0.02% to 4.8%) required bag-valve-mask ventilation. Four patients (3.5%; 95% CI 1.0% to 8.7%) required repositioning for airway malalignment, 4 patients (3.5%; 95% CI 1.0% to 8.7%) required adjunctive medication for sedation, and 3 patients (2.6%; 95% CI 0.6% to 7.5%) had mild unpleasant emergence, of whom 1 (0.9%; 95% CI 0.02% to 4.8%) received midazolam. No patient had hypotension or vomiting or received endotracheal intubation. Median recovery time was 15 minutes (range 5 to 45 minutes; IQR 12 to 19 minutes). Median physician, nurse, and patient satisfaction scores were 10 on a 1-to-10 scale.

Conclusion
Ketofol procedural sedation and analgesia is effective and appears to be safe for painful procedures in the ED. Few adverse events occurred and were either self-limited or responded to minimal interventions. Recoveries were rapid, and staff and patients were highly satisfied.

11. Physician Organizations Offer Principles for Reform of US Healthcare System

By Martha Kerr. NEW YORK (Reuters Health) Jan 11 - In what they call an historic move, ten large American professional medical associations have banded together to issue principles for the reform of the country's healthcare system.

The eleven Principles for the Reform of the U. S. Health Care System were issued today, and are "intended to help provide the impetus for bipartisan Congressional action to cover the uninsured," according to a statement from the alliance.

The associations involved in crafting the principles are the American Medical Association; the American Academy of Family Physicians; the American Association of Orthopedic Surgeons; the American College of Cardiology; the American College of Emergency Physicians; the American College of Obstetricians and Gynecologists; the American College of Physicians; the American College of Surgeons; the American College of Osteopathic Family Physicians; and the American Osteopathic Association.

"Healthcare coverage for all is needed to ensure quality of care and to improve the health status of Americans," the first principle states. Healthcare should be provided "without unreasonable financial barriers to care." The associations also call for catastrophic health coverage for all to protect Americans from financial ruin. Access to and financing for appropriate health services "must be a shared public/private cooperative effort," the reformers say. Cost management "by all stakeholders ... is critical to attaining a workable, affordable and sustainable healthcare system."

The coalition also stipulates a reduction of administrative systems, which is essential to reduce costs, improve efficiency and maximize funding for healthcare services. Quality and safety must also be improved. Sufficient funding must also be earmarked for research and education, for preventive and trauma care and for mental health services. The final principle is for "comprehensive medical liability reform," which is "essential to ensure access to quality healthcare."

President of the American Academy of Family Physicians, Dr. Rick Kellerman told Reuters Health that the coalition is "historic" and encompasses the majority of physicians practicing in the US. "Physicians see how dysfunctional our healthcare system is," said Dr. Kellerman, who is on the faculty of the University of Kansas School of Medicine and a family physician in Wichita.

The states are serving as incubators of a variety of approaches to healthcare reform, such as seen with Gov. Arnold Schwarzenegger's proposal for California and laws covering healthcare coverage in Massachusetts and Virginia. "We are seeing a convergence of thought processes," Dr. Kellerman commented. "Forty-seven million Americans are without healthcare insurance...and the vast majority of those individuals work. Many have two jobs," Dr. Kellerman pointed out.

He said other associations, including health insurance companies, are also working to propose solutions to healthcare system and a statement from them may be issued as early as next week.

12. Algorithm Identifies Patients Likely to Respond to Later Thrombolysis After Stroke

By Will Boggs, MD. NEW YORK (Reuters Health) Jan 01 - The Stroke-Thrombolytic Predictive Instrument (Stroke-TPI) can be used to select patients likely to respond to thrombolysis 3 to 6 hours after stroke onset, according to a report in the December issue of Stroke.

"Our work shows that, even if the Stroke-TPI works imperfectly in this later time window, it can still identify patients who get substantial clinical benefit, though they are currently ineligible for therapy," Dr. David M. Kent told Reuters Health.

Dr. Kent from Tufts University School of Medicine, Boston, Massachusetts and colleagues investigated whether their multivariable predictive instrument for thrombolysis in stroke might be useful for identifying patients with a favorable risk-benefit profile for treatment beyond 3 hours after stroke onset.

Among all patients treated 3 to 6 hours after symptom onset, the authors report, there was no significant difference in good outcomes between patients treated with recombinant tissue plasminogen activator (rt-PA) and those not treated.

However, patients selected by Stroke-TPI as treatment-favorable showed an absolute margin of benefit from rt-PA of 9.8%, the results indicate. Those selected as treatment-unfavorable were more likely to suffer harm from rt-PA.

"Whether the Stroke-TPI can select such treatment-favorable patients in the period after the 3 hour window needs to be validated on an independent population," Dr. Kent said. "Ongoing trials in this later time window, such as ECASS-3 or IST-3, may provide a substrate to test this."

Stroke 2006;37:2963-2969.

13. Effect of Intoxication Among Blunt Trauma Patients Selected for Head CT Scanning

Bracken ME, Hoffman JR, et al. Ann Emerg Med 2007;49:45-51.

Study objective
We examine the prevalence and types of intracranial injuries sustained by intoxicated blunt trauma patients.

Methods
The study was conducted as a secondary analysis of National Emergency X-Radiography Utilization Study II head injury database. Treating physicians prospectively assessed presenting signs and symptoms on all blunt trauma patients who underwent head computed tomography (CT). Intoxication status was determined by the examining physician and was based on a history of intoxication, positive toxicologic screen result, or physical evidence suggesting intoxication. Intracranial injury diagnoses were based on final CT interpretations provided by attending radiologists.

Results
Intracranial injury was detected in 1,193 of the 13,728 enrolled patients (8.7%), and intoxication was evident in 3,356 (24.4%) patients. Physicians were unable to assess intoxication status in 620 individuals. Intracranial injury was present in 231 intoxicated patients (231/3,356; 6.9%; 95% confidence interval [CI] 6.0 to 7.8), 789 of 9,752 nonintoxicated patients (8.1%; 95% CI 7.6% to 8.6%), and 173 of the 620 patients who could not be assessed for intoxication (prevalence 27.9%; 95% CI 24.4% to 31.6%). Intracranial injury was identified in only 5 of 299 intoxicated patients (1.7%) who had normal neurological examination results and no evidence of trauma to the calvarium.

Conclusion
The prevalence of intracranial injury among intoxicated blunt trauma patients who are selected for head CT is lower than among nonintoxicated patients selected for imaging, which likely represents heightened concern in the presence of intoxication, even without other findings suggestive of intracranial injury. This conclusion is supported by the fact that few intoxicated patients with normal neurologic findings and no evidence of trauma to the calvarium had positive findings on CT imaging.

14. White Blood Cell Ratio Differentiates Tonsillitis from Mononucleosis

The ratio between lymphocytes and the total number of white blood cells can help quickly distinguish between bacterial tonsillitis and mononucleosis, according to a study in Archives of Otolaryngology -- Head and Neck Surgery.

Researchers retrospectively analyzed white counts in 100 patients with tonsillitis and 120 with mononucleosis (diagnosed with the mononucleosis spot test). Patients with tonsillitis had a lower mean ratio of lymphocytes to total white blood cells (0.1) than did patients with mononucleosis (0.5). All tonsillitis cases fell below a 0.35 cutoff, while most mononucleosis cases measured above. The authors say that their data suggest that a ratio higher than 0.35 has a 90% sensitivity and a 100% specificity for detecting mononucleosis.

Physicians should use the cell ratio, the authors conclude, "as an indicator to decide whether mononucleosis spot tests are required."

Abstract: http://archotol.ama-assn.org/cgi/content/abstract/133/1/61

15. Antiplatelet Therapy Necessary at Least a Year with Drug-Eluting Stents

An advisory from the American Heart Association and four other organizations recommends that patients receive dual antiplatelet therapy for at least a year after receiving drug-eluting stents.

The recommended treatment is aspirin plus either clopidogrel (Plavix) or ticlopidine (Ticlid). The statement, published online in Circulation, said such therapy is sometimes stopped prematurely by patients or healthcare providers who do not realize the "potentially severe consequences" -- a greatly increased risk for stent thrombosis, which leads to myocardial infarction or death in about two-thirds of cases. In particular, it urged against interrupting therapy for dental procedures.

The statement also recommends:

-- Telling patients before discharge to contact their cardiologist before ceasing therapy, even if instructed to stop by another healthcare provider;

-- Deferring elective procedures with a significant risk for bleeding until patients finish their year of therapy;

-- Foregoing use of drug-eluting stents in patients who are unlikely to comply with therapy or who will need surgery in the next year.

AHA Press Release: http://www.americanheart.org/presenter.jhtml?identifier=3044640

16. Patient Satisfaction: It’s All a Matter of Meeting Expectations

The disconfirmation paradigm: Throughput times and emergency department patient satisfaction

Cassidy-Smith TN, et al. J Emerg Med 2007;32:7-13.

This study examined the relationship between throughput times, expectations, and patient satisfaction using the Disconfirmation Paradigm (DP), which proposes that dissatisfaction arises when service expectations are not met.

Before discharge or admission, adult emergency department (ED) patients estimated how long they waited for three intervals (Perceived Times): triage to patient care area, patient care area placement to physician evaluation, and physician evaluation to disposition. Acceptable waiting times and satisfaction for the same intervals were then provided by the subject (Acceptable Times and Throughput Time Satisfaction, respectively). Perceived Times were subtracted from Acceptable Times to yield an index of Expectancy Disconfirmation.

There were 1118 (72%) of 1550 eligible patients interviewed. Throughput Time Satisfaction predicted overall satisfaction (r = 0.56 to 0.62, p less than 0.001). In turn, Expectancy Disconfirmation predicted Wait Time Satisfaction (r = 0.42 to 0.64, p less than 0.001).

Consistent with the DP, when throughput times exceeded expectations, dissatisfaction with those throughput times arose, leading to general dissatisfaction with the ED visit.

17. Do Children Require ECG Evaluation and Inpatient Telemetry After Household Electrical Exposures?

Chen EH, et al. Ann Emerg Med. 2007;49:64-67

Emergency physicians must often make decisions about patient management without clear-cut data of sufficient quality to support clinical guidelines or evidence-based reviews. Topics in the Best Available Evidence section must be relevant to emergency physicians, are formally peer reviewed, and must have a sufficient literature base to draw a reasonable conclusion but not such a large literature base that a traditional “evidence-based” review, meta-analysis, or systematic review can be performed.

Electrical injuries in children often occur in the home and are associated with electrical cords (60% to 70%) and wall outlets (10% to 15%); by contrast, adults are typically injured in the workplace. Electrical power sources are characterized as high-voltage exposures or low-voltage exposures. The National Electric Code defines high-voltage exposure as greater than 600 V, although in the medical literature, high-voltage exposures are considered to be greater than 1,000 V. Utility power lines are typically greater than 13,800 V, whereas common household circuits (in the United States and Canada) provide 240 V for high-power appliances and 120 V for general use (220 to 260 V in Australia, Europe, and Asia).

The pathway of the current through the body determines which organs are damaged; a transthoracic current increases the risk of a cardiac injury. Moreover, the extent of tissue injury depends on source voltage, current type (alternating versus direct), current intensity (amperage), pathway of current flow, duration of contact, and local tissue resistance. The most serious cardiac complication of electrical injury is ventricular fibrillation causing cardiac arrest, although electricity can also cause direct myocardial necrosis, which can affect the myocardium, conduction pathways, and coronary arteries. Other nonfatal arrhythmias have been reported (eg, sinus tachycardia, QT prolongation, variable heart block, and nonspecific ST-segment abnormality) but are often transient.

As early as the 1960s, the international medical community published case series describing the life-threatening cardiac manifestations of electrical injury, so it became the standard of care to admit all patients for routine cardiac monitoring for 24 hours. The first studies that questioned this practice were performed primarily in adults and suggested that asymptomatic patients with a low-voltage exposure and a normal initial ECG do not benefit from inpatient cardiac monitoring. We therefore searched the literature to determine whether we can identify a group of pediatric patients at very low risk for a cardiac injury who might not require an ECG evaluation or inpatient telemetry and be safely discharged from the emergency department (ED).

The bottom line
Healthy children exposed to common household currents (120 to 240 V, no water contact), if asymptomatic at ED presentation and without a ventricular arrhythmia or cardiac arrest in the field, are at very low risk for developing cardiac arrhythmias. Patients with a normal initial ECG result do not develop late dysrhythmias, and those with nonfatal arrhythmias or nonspecific ECG abnormalities typically resolve spontaneously within 24 hours. Therefore, this review of available literature supports the practice of safely discharging these children without an initial ECG evaluation or inpatient cardiac monitoring after a common household current exposure. Our recommendations do not pertain to patients who might require admission for other injuries.

18. Utility of LP in the Afebrile vs. Febrile Elderly Patient with AMS: a Pilot Study

Shah K, et al. J Emerg Med 2007;32:15-18.

We conducted a pilot study to compare the diagnostic utility of a lumbar puncture (LP) in febrile vs. afebrile elderly patients with altered mental status (AMS). Our null hypothesis was that there is no utility of performing an LP on the afebrile elderly patient with AMS.

A retrospective study was conducted at an urban, university tertiary care referral center. The study population included all elderly patients (age 65 years and older) who had cerebrospinal fluid (CSF) samples sent to the laboratory over 1 year. A structured chart review was performed. Exclusion criteria were normal mental status, recent neurosurgical procedure or presence of a ventricular shunt, and missing medical records. An LP was considered diagnostically useful if it yielded a diagnosis.

Of the 125 patients who met the study criteria, 84 patients were afebrile and 41 patients were febrile. Of the 84 afebrile patients with AMS, 15 patients (18%; 95% confidence interval [CI] 10–26%) had an abnormal LP. Ten (12%) had some form of meningitis and five (6%) had unclear diagnoses. Of the 41 febrile patients with AMS, 10 patients (24%; 95% CI 11–38%) had an abnormal LP. Three (7%) had some form of meningitis or encephalitis. Comparing the elderly patient group without fever with the elderly patient group with fever, there was no statistical difference in the incidence of abnormal LPs or diagnostically useful LPs.

Based on the results of this pilot study, we were unable to reject the null hypothesis that there is no utility of performing LP on afebrile elderly patients with altered mental status. We would advocate not relying solely on the presence or absence of fever to determine management in the elderly.

19. Dietary Supplements Linked to Serious Adverse Incidents

The American Association of Poison Control Centers keeps data that indicate dietary supplements are more dangerous than many believe -- particularly for children, according to an essay in the New York Times (by Dan Hurley, Jan 16, 2007).

The database collected about 1.6 million reports of adverse reactions to vitamins, minerals, essential oils, herbs, and other supplements over a 23-year period, the essayist writes. More than 250,000 of those incidents required hospitalization and there were 257 deaths. Nearly 75% of the reported incidents occurred in children younger than 6 years.

In 2005, ordinary vitamins were linked to the most poisonings in the category, followed by minerals. Of the herbs and other products, melatonin and homeopathic remedies caused the most problems. But common and popular products, such as St. John’s wort and echinacea, were also linked to hundreds of incidents, many of them serious enough to require hospitalization.

20. Does the Presence of Crystal Arthritis rule out Septic Arthritis?

Shah K, et al. J Emerg Med 2007;32:23-26.

The objective of this study was to determine the incidence of septic arthritis in the presence of joint crystals.

A retrospective study was conducted at a university tertiary care referral center. The study population included all patients with synovial fluid crystals in the joint aspirate sent to the laboratory during the 7-year study period. Septic arthritis was defined as a positive synovial culture.

Of the 265 joint aspirates containing crystals, 183 (69.0%) contained gout crystals, 81 (30.6%) contained pseudogout crystals, and 1 (0.4%) contained both. Four (1.5%) of the aspirates had positive cultures. The mean synovial WBC of the 4 samples with concomitant crystals and septic arthritis was 113,000 (95% confidence interval [CI] 72,700–153,200), which was significantly higher than the entire population at 23,200 (95% CI 19,400–27,000; p less than 0.01). Of note, all 4 patients with concomitant disease had significant co-morbidities and synovial WBC counts greater than 50,000.

Septic arthritis and acute crystal-induced arthritis can occur simultaneously; there were 4 cases (1.5%) of concomitant disease in our study population. The presence of crystals cannot exclude septic arthritis with certainty.

21. Minimally-angulated Pediatric Wrist Fractures: Is Immobilization without Manipulation Enough?

Al-Ansari K, et al. Can J Emerg Med 2007;9:9-15

Background: Emergency department (ED) manipulation of complete minimally angulated distal radius fractures in children may not be necessary, due to the excellent remodeling potential of these fractures.

Objectives: The primary objective of this study was to determine the proportion of minimally angulated distal radius fractures managed in the ED with plaster immobilization that subsequently required manipulation. Our secondary objective was to document, at follow-up, changes in angulation for each wrist fracture.

Methods: This retrospective cohort study reviewed consecutive records of all children with bi-cortical minimally angulated (≤ 15º of angulation in the sagittal plane and ≤ 0.5 cm of displacement) distal metaphyseal radius fractures, alone or in combination with distal ulnar fracture. Details of treatment, radiographic findings, and clinical outcomes during the subsequent orthopedic follow up were recorded.

Results: Of 124 patients included in the analysis, none required manipulation after their ED visit. All but 14 (11.3%) fractures were angulated ≤ 20° within the follow-up period. Two (1.6%) fractures that were initially angulated ≤ 15° progressed to 30°-35°, but remodeled within 2 years to nearly perfect anatomic alignment. By 6 weeks post-injury, no patients had clinically apparent deformity and all had normal function.

Conclusions: Minimally angulated fractures of the distal metaphyseal radius managed in plaster immobilization without reduction in the ED are unlikely to require future surgical intervention.

Lit Bits: January 1, 2007

From the latest medical literature...

1. Guidelines Issued for Adult Tetanus-Diphtheria-Pertussis (Tdap) Vaccination

The CDC's Advisory Committee on Immunization Practices has issued recommendations for adult use of Adacel -- Sanofi Pasteur's tetanus, diphtheria, and acellular pertussis (Tdap) vaccine, licensed last year.

The guidelines, published in MMWR, suggest the Tdap vaccine be given:

-- to adults aged 19 to 64 to replace the tetanus and diphtheria toxoids vaccine (Td) for booster immunization if they got their last dose of the older vaccine at least 10 years earlier

-- at intervals of less than 10 years for those at increased risk for pertussis

-- to child-care providers and other adults having close contact with infants (ideally before pregnancy for mothers)

-- to health care workers with direct patient contact

For the last three groups, the CDC recommends an interval as short as 2 years from the last dose of Td, and says shorter intervals may be used.

MMWR report: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm

Also, the CDC issued its latest immunization guidelines Dec first: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5515a1.htm

2. PCI in Octogenarians Becoming Safer but Risk Still Substantial

By Martha Kerr. NEW YORK (Reuters Health) Dec 18 - Elective percutaneous coronary intervention (PCI) in patients who are in their eighties has an "acceptable outcome" in the stent era, with "acceptable short-term mortality." However, emergency PCI in this age group still carries substantial risk, New York investigators report in the current issue of the American Journal of Cardiology.

At New York Presbyterian Hospital-Weill Cornell Medical Center in New York City, Dr. Dmitriy N. Feldman and colleagues used the New York State Angioplasty Registry of 2000-2001 to compare in-hospital mortality and major adverse events (death, stroke or coronary artery bypass grafting) in three age groups: patients younger than 60 years of age, patients between 60 and 80 and patients older than 80 years of age.

There were 10,964 patients undergoing emergency PCI and 71,176 patients undergoing elective PCI.

Elderly patients were, in general, more unstable upon presentation and had more co-morbidities, including extensive coronary artery disease and other cardiovascular diseases.

For patients undergoing emergency PCI, the in-hospital mortality rates were 1.0%, 4.1% and 11.5% for patients in the youngest, middle and oldest age groups, respectively. Among patients undergoing elective PCI, mortality rates were 0.1%, 0.4% and 1.1%, respectively.

"Therefore, in the very elderly patients, a thorough discussion about risks and benefits of percutaneous revascularization is needed, particularly if emergency PCI is being considered, Dr. Feldman commented in correspondence with Reuters Health. However, a surgical revascularization option in this age group may carry an even higher rate of postprocedural complications compared with PCI."

"Our overall mortality in the 60-80 group was 0.8% and in the older than 80 group it was 2.2%, which is lower than previously reported in patients undergoing PCI in late 1990's. This suggests that PCI outcomes have improved in the era of widespread use of stenting and greater use of glycoprotein IIb/IIIa inhibitors," he pointed out.

Dr. Feldman concluded that "elective PCI procedures in the elderly are safe and have an acceptable short-term mortality when performed at experienced institutions." However, elderly patients undergoing emergency PCI continue to have a substantially higher risk of adverse events.

Am J Cardiol 2006;98:1334-11339.

3. Expedited Code Stroke Protocol Safely Fosters Earlier Thrombolysis

By Will Boggs, MD. NEW YORK (Reuters Health) Dec 22 - An expedited code stroke protocol can safely allow earlier administration of thrombolytic agents, according to a report in the December issue of Stroke.

"It is safe to do thrombolysis on acute stroke patients without waiting for routine tests such as platelet count or chest x-ray," Dr. Patrick D. Lyden from University of California, San Diego School of Medicine, told Reuters Health.

Dr. Lyden and colleagues implemented an expedited code stroke protocol to meet their benchmark onset-to-treatment time of 2 hours and investigated the safety and feasibility of the protocol.

Key features of the protocol included in-person triage of all code stroke calls, unmixed rt-PA at the bedside, proceeding without coagulation test results or chest x-ray unless specifically indicated, no delay for formal CT interpretation, and no delay for written consent.

The overall risk of symptomatic intracerebral hemorrhage was only 3.9%, the authors report, and this risk did not differ significantly between patients treated before 2 hours and patients treated 2 to 3 hours after symptom onset.

Patients treated 2 to 3 hours after symptom onset had arrived at the hospital a median 15 minutes later than those treated within 2 hours of symptom onset, the results indicate, but most steps in the process of care occurred at about the same time in the 2 groups (except the treatment decision, which took an additional 21 minutes in the 2- to 3-hour group).

"More experience will be necessary to confirm whether occasional mistakes, made in haste, lead to measurable increases in adverse events," the researchers conclude. "Our ongoing registry will continue to amass patient experience to address [outcomes] while maintaining considerable attention to safety."

"Too many patients miss out on an opportunity for thrombolysis due to physician ignorance of the protocol," Dr. Lyden added.

Stroke 2006;37:2935-2939.

4. U.S. Clears Cyanokit (hydroxocobalamin) to Treat Cyanide Poisoning

WASHINGTON (Reuters) Dec 18 - A drug made by Germany's Merck KGaA to treat cyanide poisoning was approved this month by U.S. regulators, who said it could be a useful weapon in the event of a terror attack.

Cyanokit has been used in France for 10 years in pre-hospital and hospital settings to treat cyanide poisoning resulting from smoke inhalation, ingestion and other causes. Although recognized in Europe for many years, only recently has the risk of cyanide exposure in fire smoke gained recognition in the U.S. The U.S. maintains one of the highest fire-related death rates of industrialized countries even though the number of fires has steadily decreased over the past two decades. Smoke inhalation is responsible for up to 80 percent of U.S. fire-related injuries and deaths. According to the United States Fire Administration (USFA), in 2004, the most recent year for which statistics are available:

3,900 civilians and 117 firefighters lost their lives in fires, with an additional 17,785 civilians injured as the result of fire. Of all civilian fire-related deaths, 83 percent of them occurred in residences.

An estimated 20,800 residential structure fires are attributed to mattresses, pillows, and bedding materials, all of which are highly likely to contain synthetic materials that release hydrogen cyanide when they smolder.

The active ingredient in Cyanokit, hydroxocobalamin, is a precursor of vitamin B12. Hydroxocobalamin works by binding directly to the cyanide, creating cyanocobalamin, a natural form of vitamin B12, which is excreted in the urine. The advantage of this approach is that methemoglobin is not produced and the oxygen-carrying capacity of the victim's blood is not lowered. Therefore, it is suitable for use in smoke inhalation victims. The most common side effect seen in clinical trials of hydroxocobalamin is injection site redness and temporary pink discoloration of the skin, urine and mucous membranes.

5. First and Only Chewable Birth Control Pill Now Available in U.S.

New Spearmint-Flavored Femcon(TM) Fe Offers Convenient New Option for More Than 11 Million Women Using Oral Contraceptives

ROCKAWAY, NJ -- December 7, 2006 -- Warner Chilcott announced today the availability of the first birth control pill that offers women the option of chewing their daily tablet, called Femcon(TM) Fe.

As the first and only FDA-approved chewable birth control pill, Femcon Fe* is indicated for the prevention of pregnancy. The chewable version is also designed to provide a convenient, new option for women "on-the-go" taking oral contraceptives. Additionally, the active ingredients and doses in Femcon Fe provide effective cycle control and may be a good choice for women who are experiencing breakthrough bleeding with their current oral contraceptive.

"Research has shown that compliance still impacts oral contraceptive failure rates, and anything we can do to make it easier for our patients to maintain a daily regimen is a notable advancement," said Laurent Delli-Bovi, MD, Medical Director, Women's Health Services at Chestnut Hill Family Planning Facility in Boston, Massachusetts. "We're excited to be able to offer a chewable formulation to patients looking for convenience or to those who may be experiencing problems on other pills, such as breakthrough bleeding."

When taken correctly, oral contraceptives have a failure rate of less than one% per year. However, studies show that 47% of women miss one or more pills per month and missing pills can increase the risk of pregnancy.

"Women who rely on the birth control pill tend to lead busy lives and have less time," said Roger Boissonneault, Chief Executive Officer of Warner Chilcott, the company that markets Femcon Fe in the United States. "We wanted to offer women a convenient, easy-to-use option for those "on-the-go" with the same reliability as the traditional swallowed pill."

Femcon Fe contains the same active ingredients as found in other combination oral contraceptives -- a progestin, norethindrone 0.4 mg, and an estrogen, ethinyl estradiol 35 mcg. Available in a 28-day regimen, each blister-package of Femcon Fe contains 21 round white tablets with norethindrone and ethinyl estradiol, followed by seven "reminder" brown (inactive) tablets to complete a four-week-cycle. The reminder tablets also contain 75 mg of ferrous fumarate (iron). The pill may be chewed, followed by a full glass of liquid, or swallowed whole.

6. Impact of a negative prior stress test on emergency physician disposition decision in ED patients with CP syndromes

Nerenberg RH, Hollander JE, et al. Amer J Emerg Med 2007;25:39-44.

Objective
Many emergency department (ED) patients with potential acute coronary syndromes (ACS) have prior visits and prior cardiac testing; however, the effect of knowledge of prior testing on the emergency physician disposition decision making is not known. We studied the impact of prior noninvasive testing (ie, stress testing) for myocardial ischemia on disposition decision making in ED patients with potential ACS.

Methods
We performed a prospective cohort study of ED patients with chest pain who received an electrocardiogram for potential ACS. Data included demographics, medical history, stress test history, and TIMI risk score. Patients were followed in-house; 30-day telephone interviews were performed for follow-up. Main outcomes were ED disposition (admit/discharge) and a composite of 30-day death, acute myocardial infarction, and revascularization stratified on the basis of prior stress testing known at the time of presentation. Standard statistical techniques were used with 95% confidence intervals (CI).

Results
There were 1853 patients enrolled and 97% had follow-up. Patients had a mean age of 53 ± 14 years; 60% were women, 67% were black. There were 1491 (79%) patients without a prior stress test, 291 (16%) had a normal prior stress test result, and 89 (5%) had an abnormal prior stress test result. Admission rates were 92% (95% CI, 87%-98%) for patients with a prior abnormal stress test, 73% (95% CI, 67%-78%) for patients with a normal prior stress test, and 70% (95% CI, 67%-72%) for patients without a prior stress test. Adverse outcomes were the highest among patients with prior abnormal stress test but did not differ significantly between patients with no prior stress test and patients with prior normal stress test (10.1% [95% CI, 3.6-16.7%] vs 5.2% [95% CI, 4.1-6.4%] vs 4.8% [95% CI, 2.4-7.3%]).

Conclusion
Patients without prior stress tests and patients with prior normal stress tests were admitted for potential ACS at the same rate and had the same 30-day cardiovascular event rates. This suggests that prior stress testing does not affect subsequent disposition decisions. Perhaps cardiac catheterization or computed tomography coronary angiograms would have more of an impact on subsequent visits, making them potentially more cost-effective in the low-risk patient.

7. Sumatriptan for the treatment of undifferentiated primary headaches in the ED?

Miner JR, Biros M, et al. Amer J Emerg Med 2007;25:60-64.

Objective
In this study, we determine the effectiveness and adverse effects of sumatriptan when used in the emergency department (ED) as a first-line treatment for benign undifferentiated headaches, and determine if the International Headache Society (IHS) classification of migraine, probable migraine, or tension-type headache has any effect on the effectiveness of the treatment. We hypothesize that there is no difference in the effectiveness of pain relief or frequency and severity of adverse effects between patients with migraine, probable migraine, or tension-type headaches when treated with sumatriptan.

Methods
This was a prospective observational study of adult ED patients undergoing treatment for primary headaches (ie, patients in whom head trauma, vascular disorders, infection, or disorders of facial or cranial structures have been clinically excluded). Other exclusions were renal impairment, hepatic impairment, and risk factors for coronary artery disease. Consenting patients then were asked to complete a 100-mm visual analog scale (VAS) representing their perceived pain, after which they were interviewed by a research assistant who completed a headache diagnosis worksheet, which differentiates the headache by IHS criteria. The patient repeated the VAS score at 30 and 60 minutes. Data were analyzed using descriptive statistics and ?2 tests.

Results
One hundred forty-seven patients were enrolled: 84 (57.1%) patients with migraine headache, 45 (30.7%) with a probable migraine headache, and 18 (12.2%) with a tension headache. A 50% reduction in VAS scores 60 minutes postdose was seen in 87 (59%) of 147 patients; 50 (60%) of 84 of migraine patients, 25 (56%) of 45 of probable migraine patients, and 12 (67%) of 18 tension patients (P = .72). There were no serious adverse events reported. Forty-seven patients (32%) received rescue medications after the 60-minute VAS score: 29 (34.5%) patients in the migraine group, 15 (33.3%) patients in the probable migraine group, and 3 (15.8%) patients in the tension-type headache group (P = .26).

Conclusions
Most of the patients presenting with primary headaches had migraine or probable migraine headaches. There was no difference in sumatriptan's effectiveness based on the classification of the headache using IHS criteria.

8. ED Physicians Can Help Implement Asthma Guidelines

NEW YORK (Reuters Health) Dec 19 – ED physicians can foster implementation of national asthma guidelines by initiating maintenance anti-inflammatory medication in children treated for acute asthma attacks, according to a report in the December issue of Pediatrics.

"Children with uncontrolled asthma are a difficult population to study, and there continues to be a need to study new and innovative interventions to increase their use of appropriate maintenance medications," Dr. Heather K. Lehman from the University at Buffalo School of Medicine and Biomedical Sciences, New York told Reuters Health.

Dr. Lehman and colleagues evaluated a pediatric emergency department-based intervention designed to create a new role for the ED physician in asthma management. With the primary care physician's approval, 40 children with persistent asthma were provided sample anti-inflammatory medications, and a letter outlining the treatment plan was faxed to the patient's primary care physician the next day. It was up to the primary care physician to prescribe ongoing anti-inflammatory medication.

Twenty-eight of the patients followed up with their primary care physicians, the authors report, and the anti-inflammatory medication was continued in 21 of those who followed up. One patient was lost to follow-up and 20 of the remaining patients had a prescription written and dispensed, the results indicate. However, seven of these patients had the prescription filled.

Overall, one third continued on a long-term anti-inflammatory controller after their initial intervention in the pediatric emergency department. Children with severe persistent asthma were more likely to follow up with their primary physician and to continue the intervention, the researchers note.

"We were pleased with our results, since all these patients prior to the study were not on anti-inflammatory therapy," Dr. Lehman said. "So even a small change in controller medication use could translate into large gains in patient care, outcomes, and economics."

"Primary care physicians need to see their asthmatic patients (especially those with moderate to severe asthma)...on a more frequent basis, rather than episodic care, to more closely monitor their use of, and response to, maintenance medications, and to stress to the family the seriousness of their child's asthma," Dr. Lehman said.

"While the emergency department can successfully function as a checkpoint to make sure children are receiving appropriate maintenance anti-inflammatory medications, primary physicians should be encouraged to always assess the severity of their patients' asthma using current guideline measures, and place them on controller medications, where appropriate," Dr. Lehman advised.

Pediatrics 2006;118:2394-2401.

9. Cognitive Training May Aid Functioning of Older Adults

Cognitive training not only can delay cognitive decline in older adults, it may also help them function independently longer. So suggests a 5-year study in a December issue of JAMA.

Researchers randomized 2832 people age 65 or older without dementia to receive either 10 weekly sessions of training in one of three domains (memory, reasoning, or processing speed) or no training.

All trained groups had less subsequent decline in the domain trained than did the other groups. Those with reasoning training also retained more of their abilities in instrumental activities of daily living.

Editorialists write that "cognitive training programs, once standardized and developed for mass market application, might be made available to seniors through [both] nonhealth care facilities ... and health care facilities." Such programs "may give individuals a greater sense of control over the disturbing prospect of cognitive decline and have a beneficial effect on their quality of life," they add.

JAMA article (free): http://jama.ama-assn.org/cgi/content/full/296/23/2805

10. Biomarkers Add Little to Standard Cardiovascular Risk Factors

Certain biomarkers predict risks of death and first major cardiovascular events, but add little to conventional risk factors, a study finds in the Dec 21st issue of the New England Journal of Medicine.

Using data from some 3200 participants in the Framingham Offspring Study, researchers assessed the predictive value of 10 biomarkers: C-reactive protein (CRP), B-type natriuretic peptide (BNP), N-terminal pro-atrial natriuretic peptide, aldosterone, renin, fibrinogen, plasminogen-activator inhibitor type 1, D-dimer, homocysteine, and urinary albumin/creatinine ratio. Participants were followed up for a median of 7.4 years.

After adjustment for traditional cardiovascular risk factors, five biomarkers -- BNP, CRP, albumin/creatinine ratio, homocysteine, and renin -- were associated with higher risk of death from any cause, and two -- BNP and albumin/creatinine ratio -- with risk of first major cardiovascular events. However, statistically, these biomarkers added only moderately to the predictive ability of conventional risk factors.

NEJM abstract: http://content.nejm.org/cgi/content/short/355/25/2631

11. Methamphetamine use increases risk of carotid artery dissection and stroke

December 27, 2006 (Irvine, CA) - Methamphetamine use may be linked to increased risk of carotid artery dissection and stroke, according to an article published in the December 26, 2006 issue of Neurology.

"It appears methamphetamine use is toxic to large blood vessels,” said Dr Wengui Yu (University of California, Irvine). "While methamphetamine use has been associated with aortic dissection . . . this is the first time there's been a possible link between methamphetamine use and carotid artery dissection."

The article reported the cases of two women, ages 36 and 29, who suffered sudden onset of speech difficulty and weakness following recent use of methamphetamine. The 29 year-old had a ten-year history of methamphetamine use. Yu acknowledged that cocaine has similar effects. "It’s therefore likely that the tears in the arteries may be due to a drug class effect rather than a specific drug, like methamphetamine."

MRI confirmed both women had severe strokes due to carotid artery dissection. The 36 year-old woman had a National Institute of Health Stroke Scale (NIHSS) of 21 (a stroke scale over 16 predicts a high probability of death or severe disability). She was treated quickly with IV tissue plasminogen activator (tPA) and improved significantly, returning to work within four months with only mild expressive aphasia. The 29 year-old woman had an NIHSS score of 17. She was treated with stent-assisted angioplasty and had moderate expressive aphasia at four months. Follow-up angiography at seven months showed no restenosis.

Yu credited timely evaluation and treatment by a multidisciplinary stroke team with the almost complete recovery of the subjects, and not the youth of the subjects themselves. "Without effective acute treatment, patients would be less likely to have good recovery."

A prospective multi-center study of young adults with stroke is warranted to further investigate the association between methamphetamine/cocaine use and neck artery dissection, the authors write. "The results of such study will not only address the drug class effect but also help physicians to better diagnose, treat, and prevent stroke in young adults," said Yu.

Yu W, McIntosh A, Hungs M, et al. Carotid artery dissection and middle cerebral artery stroke following methamphetamine use. Neurology 2006; 67:2259-2260.

12. Ondansetron Available in Generic Form

The FDA this month announced the availability of ondansetron, an antiemetic, in generic form.

According to the announcement, ondansetron, marketed by GlaxoSmithKline as Zofran, was the 20th highest-selling brand-name drug in the U.S. in 2005, with sales totaling nearly $840 million that year.

FDA announcement: http://www.fda.gov/bbs/topics/NEWS/2006/NEW01539.html

13. Hospital Ratings May Not Be True Quality Measure

Source: Washington Post. Date: December 13, 2006

Conventional wisdom holds that one sure way to improve health-care quality is to measure it. A study being published today in the Journal of the American Medical Association comes to the unconventional conclusion that it's not necessarily so.

The study by researchers at the University of Pennsylvania's School of Medicine found that going to a hospital that scored well on Medicare-mandated quality measures did not significantly reduce a patient's risk of dying.

The study examined 2004 data from 3,657 hospitals, comparing their performance on quality-of-care measures for treating heart attacks, heart failure and pneumonia with the death rates for the same patients. The quality measures charted such matters as whether patients who had a heart attack received aspirin within 24 hours of being admitted and how soon patients with bacterial pneumonia were given antibiotics.

Patients at hospitals that scored near the top on the quality-of-care measures did do better than those at hospitals near the bottom -- but not dramatically so. For every 1,000 heart attack patients, there were about five fewer deaths at the better-performing hospitals than at the lower-performing ones, the study found. The figures were similar for patients with heart failure and pneumonia.

Rachel M. Werner, an assistant professor of medicine and the study's lead author, said the results point up the need for more meaningful quality measures. "Measuring quality is clearly a good idea," Werner said. "It's a great first step. But at the same time . . . there are other things that are making outcomes different at different hospitals, and we are not capturing those differences using these measures. There is a fallacy in assuming that just taking these measures and applying them to hospitals is going to reveal important things about the differences in quality across hospitals."

14. IV Dex to prevent the recurrence of benign headache after discharge from the ED: a randomized, double-blind, placebo-controlled clinical trial

Baden EY, Hunter CJ. Can J Emerg Med 2006;8:393-400.

From the Brooke Army Medical Center and Wilford Hall Medical Center, San Antonio, Texas

Intro: Headaches are a common cause of emergency department (ED) visits. Up to 85% of the US adult population complains of headaches occasionally, and it is the chief complaint in 2%-5% of all ED visits. The vast majority of headaches in patients presenting to the ED are benign, with tension headaches representing 50%, migraine headaches 10% and mixed-type 30%.

In clinical practice, the distinction between migraine and tension-type headaches is often blurred. The International Headache Society classification for benign idiopathic headache acknowledges that some patients may simultaneously satisfy diagnostic criteria for migraine and tension-type headaches. Both are characterized by similar abnormal vascular flow and inflammatory responses, suggesting that they may represent variations of the same disease process. For purposes of ED headache treatment, there is usually little need to differentiate between these benign headache etiologies.

Although the acute symptoms can generally be relieved, 8%-66% of patients will suffer a recurrence within 48 hours, and inflammation appears to play a critical role in these recurrences. Therefore, prolonged suppression of this inflammatory process may be an important component of acute headache management. Dexamethasone, a corticosteroid with 25 times the anti-inflammatory potency of hydrocortisone, has been tested as a treatment for migraines, with generally positive results. By suppressing the sterile inflammatory response, dexamethasone may also prevent the recurrence of benign headaches after successful ED treatment.

The purpose of this study was to determine whether patients discharged from the ED after treatment for a benign headache have a lower incidence of recurrence when treated with intravenous (IV) dexamethasone before discharge. Our secondary aim was to determine whether such administration of dexamethasone could improve patients' quality of life by reducing the number of return ED or primary care clinic visits for "rescue" therapy, thus allowing them to return to normal daily activities.

Objective: To evaluate whether the addition of intravenous (IV) dexamethasone to standard emergency department (ED) benign headache therapy would reduce the incidence of headache recurrence at 48-72 hours.

Methods: This randomized, double-blind, placebo-controlled clinical trial of adult patients presenting with the chief complaint of headache was conducted in the ED of 2 academic, urban Level 1 hospitals. Headache evaluation and therapy were determined by the treating physician, and, before discharge, patients were administered either 10 mg of IV dexamethasone or placebo. The treatment groups had similar baseline characteristics, abortive therapy, IV fluids and degree of pain relief achieved before discharge. Patients were contacted 48-72 hours following discharge and asked whether their headache was "better," "worse" or "remained unchanged" when compared with their symptoms at discharge. Those whose headaches were "worse" or "unchanged," and those who reported a return of headache after being pain free at discharge were considered to be treatment failures and classified as having had a recurrence. The patient's headache at follow-up was further categorized as severe (i.e., provoking another physician visit or interfering with daily activity) or mild (i.e., requiring self-medication or no treatment).

Results: Fifty-seven patients met the inclusion criteria and 2 were lost to follow-up, leaving 55 for analysis. At follow-up, 9.7% (3/31) of those receiving dexamethasone had headache recurrence, versus 58.3% (14/24) of those receiving placebo (p less than 0.001). Four dexamethasone recipients (12.9%) had severe headaches at follow-up compared with 8 (33.3%) in the placebo group (p = 0.14).

Conclusions: In this study, IV dexamethasone reduced headache recurrence at 48-72-hour follow-up. Given its excellent safety profile and likely benefit, IV dexamethasone should be considered for ED headache patients after standard evaluation and therapy.

15. Rapid Influenza Testing in the ED Spares Febrile Infants Needless Tests

By Will Boggs, MD. NEW YORK (Reuters Health) Dec 20 - Rapid viral testing for influenza A and B in febrile infants spares them additional testing in the emergency room, according to a report in the December issue of The Pediatric Infectious Disease Journal.

"The use of rapid testing for influenza in children younger than 36 months during influenza seasons in the emergency department setting reduces the number of ancillary tests ordered and decreases antibiotic use and unnecessary hospitalization," lead investigator Dr. Javier Benito-Fernandez told Reuters Health. "Rapid viral tests are easy to perform and you can get the result in only 10 to15 minutes."

Dr. Benito-Fernandez and colleagues at the Hospital de Cruces, Bizkaia, Spain, and colleagues assessed the impact of introducing rapid viral testing for influenza into the routine protocol for the management of febrile infants with no signs of focal infection during influenza season.

Influenza tests were positive in 40.7% of 206 febrile infants, the authors report.

Infants who tested positive were less likely to undergo blood tests, urinalysis, chest X-rays, and lumbar puncture, the results indicate, and they had shorter stays in the pediatric emergency department, compared with febrile infants whose rapid influenza tests were negative.

None of the infants who tested positive for influenza received empiric antibiotic treatment, the researchers note, compared with 38.5% of infants who tested negative. Only two influenza-positive infants (2.3%) required hospital admission for observation, the report indicates, whereas 20 influenza-negative infants (16.4%) were admitted to the hospital. All influenza-positive infants had a favorable clinical course, the investigators report.

There are advantages to using rapid viral testing for influenza as part of the standard guidelines for managing fever of unknown origin in infants in good general condition during flu season, the authors conclude.

"We have introduced rapid test for influenza in our current practice when we attend a febrile infant during epidemic season," Dr. Benito-Fernandez said. "We are now studying rapid testing for respiratory syncytial virus (RSV) in very young (less than 3 months old) febrile infants."

Pediatr Infect Dis J 2006;25:1153-1157.

16. Catheterization Facilities May Not Improve AMI Outcomes

By Will Boggs, MD. NEW YORK (Reuters Health) Dec 21 - Myocardial infarction (MI) outcomes are no better at hospitals with catheterization facilities than at hospitals without such facilities, according to a report in the November European Heart Journal.

Recent trial results favor primary percutaneous coronary intervention (PCI) over thrombolysis for the emergency treatment of acute MI, the authors explain, but trial results may not be so easily obtained in the day-to-day practice of busy hospitals.

Dr. Hans Van Brabandt and colleagues from Belgian Health Care Knowledge Centre, Brussels, Belgium evaluated the costs and effects of treatment at three levels of hospitals to which acute MI patients were initially referred-hospitals with PCI capabilities, hospitals with coronary angiography but not PCI capabilities, and hospitals having only thrombolysis as a means of reperfusion. The percentage of patients reperfused was similar across the three levels of care of initial admission, the authors report.

The probability of having had a PCI or coronary artery bypass grafting at the end of the episode of care was significantly higher in patients initially admitted to the highest level of care hospitals, the results indicate, and this difference persisted after 3 years. "This suggests that supply induces demand independent of patient needs," the investigators write.

The cardiac care level of the initial admission had no significant influence on the 5-year survival of patients, the researchers note, and rates of readmissions and reinterventions were similar between the care levels.

The cost of treating a patient during the initial admission was 4072 at hospitals with thrombolysis only, the report indicates, compared with 5083 at hospitals with coronary angiography and 7741 at hospitals with PCI capabilities.

"For an infarction patient in Belgium, the nearest hospital is the best," Dr. Van Brabandt concluded. "We have shown that cardiac emergency teams working in secondary hospitals are keen enough to decide which patients should be referred to a higher level center."

"Moreover, being admitted to a lower level hospital means for a patient having an absolute 20% lower risk of being revascularized without any difference in outcome (i.e., short and long term mortality, re-infarction, re-admission, re-angiography within the next five years)," he continued.

"Additional studies are needed to better define those subgroups of acute MI patients who present at the secondary level, for whom immediate transfer to the tertiary level is beneficial," the investigators write.

"Improving compliance to guidelines and shortening the time interval between onset of symptoms and starting thrombolytic treatment when appropriate will likely result in a more efficient use of resources than the multiplication of expensive tertiary services for primary invasive treatment of acute MI patients."

Eur Heart J 2006;27:2649-2654.

17. Delays in the treatment of cauda equina syndrome due to its variable clinical features in ED patients

Ibrahim Jalloh and Pawan Minhas. Emerg Med J 2007;24:33-34.

Patients with cauda equina syndrome (CES) characteristically present with a history of lower back pain, bilateral sciatica, motor and sensory disturbance including sacral and perianal anaesthesia, and sphincter disturbance. It may progress to permanent sensory loss, motor loss and incontinence. Emergent decompression of CES is important in improving the outcome. A meta-analysis involving 322 patients from 104 studies showed that considerable improvements in sensory, motor and sphincter deficits were possible if surgery was performed within 48 h.

Many patients presenting with CES do not receive an urgent referral to a specialist. Difficulties in diagnosis may arise because of the variability of the clinical features that are present on attendance to the emergency department, and also because of the association of urinary retention and constipation with pain and opioid analgesia.

The purpose of this study was to identify reasons for delay in management and to see which features of this syndrome patients present with.

Delays in the treatment of CES were most often due to delay in making the diagnosis. Predictably, this was more likely when fewer features of CES were established at the time of presentation.

Only 19% of patients presented with the characteristic combination of bilateral sciatica, lower limb weakness, saddle anaesthesia and sphincter disturbance. The strongest presenting features of CES are lower back pain, sacral sensory loss and urinary symptoms.

Patients may not clearly manifest all the characteristic features of CES. Diagnosis is also complicated by sphincter disturbance due to pain and opioid-based analgesia. By highlighting the importance of examining for sacral sensory loss as a sensitive and relatively specific sign that is quick and easy to examine for, clinicians will be quicker in recognising it and thus improve outcomes in patients with CES.

18. Is CT effective in cases of upper oesophageal fish bone ingestion?

Das D, et al. Emerg Med J 2007;24:48-49.

Clinical scenario: A 60-year-old man attends the ED complaining that a fish bone has got stuck in his throat. Clinical examination rules out impaction within the pharynx so you are concerned that the bone has become impacted within the oesophagus. Prior experience tells you that oesophageal abrasions secondary to ingested bones can often mimic impaction, that rigid oesophgoscopy (the definitive investigation) carries a significant mortality and morbidity rate, and that the most readily available non-invasive investigations, lateral neck and chest x rays, are often unreliable. You wonder whether a computed tomography (CT) scan of the neck would be a more accurate non-invasive tool?

Question: In [patients who are suspected to have fish or chicken bones impacted in the oesophagus] is [computerised tomography better than plain radiography] at [identifying and localising a foreign body]?

Comments: The studies reviewed clearly show that CT of the neck is an extremely accurate, non-invasive diagnostic tool with a high positive predictive value. However, of the 58 patients in the four series with positive x-ray findings, there were only 3 false-positives. Positive results on plain films, which include soft tissue changes, warrant oesophagoscopy, while negative results should lead to a CT scan of the neck. Bearing in mind that there was 100% sensitivity amongst the 144 patients undergoing CT, and that there was just one false positive amongst the 80 patients with positive results, only visualisation of an actual fish or chicken bone should result in an oesophagoscopy at this point. Similarly, a negative CT scan should confidently exclude fish and chicken bones.

CLINICAL BOTTOM LINE: CT is more effective than plain radiography at identifying and excluding impacted oesophageal fish and chicken bones. However, plain radiography is also specific enough for positive results to warrant oesophagoscopy without any further imaging, and should thus continue being utilised as the first line radiological investigation.

19. Sword swallowing and its side effects

Witcombe B. BMJ 2006; 333:1285-1287.

Intro: Sword swallowers know their occupation is dangerous. The Sword Swallowers' Association International (SSAI, http://www.swordswallow.org/) recognises those who can swallow a non-retractable, solid steel blade at least two centimetres wide and 38 centimetres long. As we found only two English language case reports of injury resulting from sword swallowing, we explored the technique and side effects of this unusual practice.

Objective: To evaluate information on the practice and associated ill effects of sword swallowing.

Design: Letters sent to sword swallowers requesting information on technique and complications.

Setting: Membership lists of the Sword Swallowers' Association International.

Participants: 110 sword swallowers from 16 countries.

Results: We had information from 46 sword swallowers. Major complications are more likely when the swallower is distracted or swallows multiple or unusual swords or when previous injury is present. Perforations mainly involve the oesophagus and usually have a good prognosis. Sore throats are common, particularly while the skill is being learnt or when performances are too frequent. Major gastrointestinal bleeding sometimes occurs, and occasional chest pains tend to be treated without medical advice. Sword swallowers without healthcare coverage expose themselves to financial as well as physical risk.

Conclusions: Sword swallowers run a higher risk of injury when they are distracted or adding embellishments to their performance, but injured performers have a better prognosis than patients who suffer iatrogenic perforation.

20. Phenotypic differences between male physicians, surgeons, and film stars: comparative study

Trilla A, et al. BMJ 2006; 333:1291-1293.

Intro: We finished our medical training at the University of Barcelona more than 25 years ago, and have enjoyed our work ever since. At medical school we noted certain differences between male trainees who selected either surgery or medicine as their specialty. The tallest and most handsome male students were more likely to go for surgery, and the shortest (and perhaps not so good looking) ones were more likely to become physicians (including doctors of internal medicine and its subspecialties). Now, after all these years we hypothesise that, on average, surgeons are taller and better looking than physicians. We conducted a comparative study to test this hypothesis.

Objectives: To test the hypothesis that, on average, male surgeons are taller and better looking than male physicians, and to compare both sets of doctors with film stars who play doctors on screen.

Design: Comparative study.

Setting: Typical university hospital in Spain, located in Barcelona and not in a sleepy backwater.

Methods: We selected a random sample of senior staff surgeons and physicians working at the University of Barcelona Hospital Clinic (a 700 bed public hospital), matched by age (52 ±7 years) and sex (all men), from the staff payroll of the surgical and medical departments. We contacted all eligible participants by email. If they agreed to participate, their height (in cm) was recorded and they were asked to submit a digital picture. Age (in years) was registered and checked against that recorded in the payroll database. The external controls were four well known film stars, mostly in their 50s—Harrison Ford as Dr Richard Kimble (a neurosurgeon in the film The Fugitive), George Clooney as Dr Doug Ross (a paediatrician in the television series ER), Patrick Dempsey as Dr Derek Shepherd (a surgeon in the television series Grey's Anatomy), and Hugh Laurie as Dr Gregory House (a nephrologist and infectious disease specialist in the television series House).

We randomly organised the pictures of all surgeons, physicians, and external controls and showed them to an independent group of eight female observers—three doctors and five nurses from our hospital. All observers were in the same age group as the participants (no further checking of this information was attempted). We decided to avoid (for the time being) male observers, because of potential bias. Observers used the "good looking score" to classify each participant. This score measures the degree of handsomeness on a seven point Likert scale (1, ugly; 7, very good looking).

We discarded the highest and lowest score (outliers) for each participant and used the six remaining scores for our study. Mean scores, differences in means with 95% confidence intervals, and standard deviations were used to compare the three groups. We used the standard t test to compare age and the non-parametric (Mann-Whitney U) test to compare height and mean good looking scores.

Results: Surgeons were significantly taller than physicians (mean height 179.4 v 172.6 cm; P=0.01). Controls had significantly higher good looking scores than surgeons (mean score 5.96 v 4.39; difference between means 1.57, 95% confidence interval 0.69 to 2.45; P=0.013) and physicians (5.96 v 3.65; 2.31, 1.58 to 3.04; P=0.003). Surgeons had significantly higher good looking scores than physicians (4.39 v 3.65; 0.74; 0.25 to 1.23; P=0.010).

We did not make individual results public. However, widespread rumours, discussions, polls, and illegal bets arose throughout the institution as a by-product of our study. If they requested, participants were privately told about their personal score compared with the average score of the relevant group.

Discussion: Our study shows that, on average, senior male surgeons are significantly taller and better looking than senior male physicians. It also shows that film stars who play doctors are significantly better looking than real surgeons and physicians.

Differences between surgeons and physicians: Perhaps because of their training, surgeons have a different attitude and approach to the practice of medicine compared with physicians. The surgeon's image is that of competence, trust, expertise, and compassion. Surgeons are the only doctors who practise what has been called "confidence based medicine," which is based on boldness. They are often practical and fast acting, and they exert tight control on their natural turf—the operating theatre. Being taller and better looking has several evolutionary advantages for surgeons. Their extra height makes them more likely to be masters and commanders, and gives them a better view of the operating room, including the patient lying on the table. Also, as the senior male surgeon is normally surrounded by junior surgical staff, training fellows, nurses, anaesthetists, and the like, his height and appearance make him easily identifiable as their leader.

How do surgeons become taller and better looking than physicians? There are several potential explanations for the phenotypic changes between surgeons and physicians. Firstly, surgeons spend a lot of time in operating rooms, which are cleaner, cooler, and have a higher oxygen content than the average medical ward, where physicians spend most of their time. Furthermore, surgeons protect (but not always properly) their faces with surgical masks, a barrier to facial microtrauma, and perhaps an effective anti-ageing device (which deserves further testing). They often wear clog-type shoes, a confounding factor that adds 2-3 cm to their perceived height. The incidental finding that fewer surgeons are bald might be related to these environmental conditions and to the use of surgical caps.

In contrast, senior physicians are surrounded by fewer people in their habitat (the patient's bedside and the office), and they therefore have less need to be easily identified or spotted by families and nurses in the middle of a swarm. Physicians tend to hang heavy stethoscopes around their necks, which bows their heads forward and reduces their perceived height. They also complain of a (clearly abnormal) need to endlessly update their knowledge in accordance with the current evidence based approach to medicine by reading and studying heaps of medical journals; this overload of information further grinds them down. Although a prospective study found that doctor's white coats decrease in weight with increasing seniority, no significant difference was found between the mean weight of physicians' coats and surgeons' coats (1.4 v 1.5 kg).