Monday, January 01, 2007

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:

Also, the CDC issued its latest immunization guidelines Dec first:

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.

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.

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).

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%]).

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.

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.

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.

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).

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):

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:

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:

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, 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).