Lit Bits: April 17, 2007

From the recent medical literature...

1. Doctors Aggressively Treat Early Heart Attacks, Research Shows

WINSTON-SALEM, NC -- April 9, 2007 -- An international study involving 467 hospitals in 12 countries found that doctors do a good job of aggressively treating the early stages of heart attacks – even before laboratory tests confirm the diagnosis.

"There has always been a concern that patients may be treated less aggressively when they present with heart attack symptoms before laboratory tests are able to confirm the diagnosis," said Chadwick Miller, MD, lead author and an emergency medicine physician at Wake Forest University School of Medicine. "But these findings suggest doctors are doing an appropriate job of aggressively treating these patients."

Results from the research, which included more than 8,000 patients, are reported on-line in the European Heart Journal and will appear in a future print issue.

Laboratory testing is one tool used by doctors to confirm whether a patient is experiencing a heart attack. The tests measure levels of the protein troponin, which increase when there is damage to the heart muscle. However, it can take six to eight hours after symptoms begin for these markers to increase.

"These tests are also used by doctors to determine which therapies would benefit the patient the most," said Miller. "Those with elevated markers are at higher risk, and more aggressive treatments are warranted. But, in patients who come to the emergency department immediately after their symptoms begin, it can be difficult to determine if they are having a heart attack. This uncertainty could lead to delay in treatment."

The study compared results among three groups of patients: those with initially normal levels of troponin that became elevated within the next 12 hours – and were considered to be having an "evolving" heart attack; those whose markers were elevated at the time of the evaluation and were diagnosed with a heart attack; and those whose markers did not become elevated within 12 hours.

"We wanted to determine if these patients with early symptoms were being treated the same as patients who were known to be having a heart attack, or if the doctors were waiting for elevated heart markers before beginning treatment," said Miller. "Our findings suggest that doctors were treating both of these high-risk patient groups the same and were not waiting for the heart markers to elevate."

The results showed that in both groups that had heart attacks, doctors treated patients with aspirin and other blood-thinning medications. The groups also had similar rates of angioplasty and surgery to bypass blocked arteries.

Miller said the results suggest that doctors are using other immediately available data, such as information from the patient's history and electrocardiogram, to make treatment decisions.

The researchers also found that those patients who were having an "evolving" heart attack were 19% less likely to die or have a second heart attack within 30 days than patients who were immediately diagnosed with a heart attack. Although the exact reason for this finding cannot be determined from this research, this finding could be due to earlier treatment, said Miller. The patients with "evolving" heart attacks came to the emergency department a median of 1.7 hours after their symptoms developed, compared to 4 hours for those whose heart attack markers had already increased.

Of the 8,312 patients in the study, 66% were diagnosed with a heart attack at enrollment, 20% had an "evolving" heart attack that showed up on lab tests within 12 hours and 13 percent of participants didn't have elevated markers within 12 hours.

The research was an analysis of a larger trial, the Superior Yield of the New strategy of Enoxaparin, Revascularization, and GlYcoprotein IIb/IIIa inhibitors (SYNERGY) trial. The study included patients who met two of the following criteria: at least 60 years old, elevated heart markers and an electrocardiogram test that indicated a possible heart attack. The SYNERGY trial was funded by sanofi-aventis.

SOURCE: Wake Forest University Baptist Medical Center

2. Anaphylaxis Articles

A. Comorbidities Common in Cases of Fatal Anaphylaxis

NEW YORK (Reuters Health) Apr 03 - The time between exposure and onset of severe symptoms is usually less than 30 minutes in cases of fatal anaphylaxis, and comorbidities are frequent in such cases, suggests a study published in the March issue of the Annals of Allergy, Asthma, and Immunology.

In a retrospective case review, Dr. Paul A. Greenberger, of Northwestern University Feinberg School of Medicine, Chicago, and colleagues examined the causes of death, anatomical findings, and comorbid diseases in 25 episodes of fatal anaphylaxis. Each case report included details on the fatal reaction, a medical record review, and findings from laboratory and autopsy reports. Serum tryptase levels were measured in seven cases.

Of the 25 cases of anaphylactic deaths, seven were reactions to medications, six were from radiocontrast media, six from Hymenoptera stings, and four from food. The remaining two cases possibly resulted from reactions to insect repellent and hair coloring products. The subjects had mean age of 59 years. The team reports that uticaria was found in only one case.

The anaphylactic reaction began within 30 minutes of allergen exposure in 21 cases. Thirteen of the cases died within 60 minutes. Four patients died between 1 and 6 hours after exposure, and four died between 24 and 96 hours after exposure. The time was unknown in four patients.

Autopsies were performed in 23 cases. Of these, specific anatomical findings consistent with anaphylaxis were present in 18 cases. Of the seven patients in whom serum total tryptase was analyzed, four had markedly elevated levels. Overall, 22 patients (88%) had at least one comorbid condition identified pathologically at the time of death.

"Patients who have experienced and survived an episode [of anaphylaxis] should try to identify the cause so that preventive measures...can be carried out," Dr. Greenberger told Reuters Health. "Patients should be taught how and when to self-administer epinephrine if another episode of anaphylaxis begins," he added.

Dr. Greenberger also noted that subjects who have experienced anaphylaxis "should be referred to an allergist-immunologist who is best trained to provide the necessary discovery/verification of the diagnosis and recommend the best treatments."

Ann Allergy Asthma Immunol 2007;98:252-257.

B. New Pediatric Guidelines for Self-Injecting Epinephrine for Anaphylaxis Treatment

Laurie Barclay, MD. March 27, 2007 — A clinical report by the American Academy of Pediatrics recommends best practices for administering self-injectable epinephrine for first-aid treatment of anaphylaxis in children in the community. The new guidelines are published in the March issue of Pediatrics. Controversies in management addressed by these guidelines include the selection of dose, indications for prescribing an autoinjector, and decisions regarding when to inject epinephrine.

Based primarily on anecdotal evidence, the recommended epinephrine dose for anaphylaxis in children is 0.01 mg/kg, not to exceed 0.30 mg. The preferred route of administration for first-aid treatment is intramuscular injection of epinephrine into the vastus lateralis of the lateral thigh, which allows early peak epinephrine concentration needed for effective management. Intravenous administration of epinephrine carries increased risks for dilution errors and dosing errors, which may lead to overdose and adverse effects such as cardiac dysrhythmias.

Epinephrine autoinjectors are currently available in only 2 fixed doses: 0.15 and 0.30 mg. On the basis of most recent, but somewhat limited data, the guidelines recommend using autoinjectors with 0.15 mg of epinephrine for otherwise healthy young children weighing 10 to 25 kg (22 - 55 lb) and autoinjectors with 0.30 mg of epinephrine for those weighing 25 kg (55 lb) or more. However, specific clinical circumstances also must be considered in these decisions.

"The lack of additional autoinjector doses is a serious concern," the authors write. "Nevertheless, pediatricians are advised to prescribe the optimal dose from an autoinjector for each child, even when that dose cannot possibly be precisely 0.01 mg/kg.... For children who weigh less than 10 kg (22 lb), the physician and family should weigh the risks of delay in dosing and dosing errors when an ampule/syringe/needle is used against accepting nonideal autoinjector doses, taking into consideration the specific health needs of the individual child and abilities of the caregivers."

The primary indication for prescription of self-injectable epinephrine is a history of anaphylaxis in an individual who may re-encounter the triggering agent outside of a medical setting or who has idiopathic anaphylaxis, which is uncommon in childhood. Identification of individuals who have experienced anaphylaxis is not necessarily easy. It is clear that persons with a previous episode of anaphylaxis that was characterized by respiratory or cardiovascular compromise to a trigger that may be encountered outside the hospital should carry self-injectable epinephrine, but only approximately 70% of individuals with anaphylaxis have respiratory symptoms, and even fewer (only approximately 10%) experience cardiovascular symptoms. Skin manifestations such as urticaria, angioedema, flushing, or itching occur in more than 80% of children with anaphylaxis. When present, these symptoms are helpful in the recognition of anaphylaxis; when absent, they make the recognition of anaphylaxis more difficult.

Moreover, acute generalized urticaria and angioedema alone may not necessarily warrant a diagnosis of "anaphylaxis" (a point of controversy). However, on the basis of available evidence, self-injectable epinephrine should be prescribed for a child who has experienced generalized acute urticaria after an insect sting, because the risk of a more severe reaction from a future sting is approximately 10%. Finally, physicians cannot assume that patients and caregivers necessarily recognize and report all symptoms, because even trained health care professionals underrecognize anaphylaxis. For all of these reasons, a high index of suspicion is needed to identify those who have had anaphylaxis and require an epinephrine prescription.

An additional point of judgment regarding prescription of self-injectable epinephrine is that a physician may identify a child who has not yet experienced anaphylaxis but may nevertheless be at increased risk of anaphylaxis and may warrant prescription of self-injectable epinephrine. Vander Leek et al showed that among 24 young children with peanut allergy whose first reaction was isolated to the skin after ingestion or skin contact, 18 (75%) experienced symptoms beyond the skin in a subsequent reaction. Indeed, severity of a previous reaction is a poor guide to symptoms during a future reaction. In young children with peanut- or tree nut–related anaphylaxis, episodes may worsen progressively with time, perhaps related to the fact that increased numbers of such children develop asthma as they get older. Asthma, which is associated with severe and fatal anaphylaxis, is an important comorbidity that should influence the decision to prescribe self-injectable epinephrine. Some "high-risk" circumstances that may justify prescription of self-injectable epinephrine in the absence of previous anaphylaxis are summarized in Table 3 (see link to article below). Definitive evaluations of such children by an allergy/immunology specialist with American Board of Allergy and Immunology certification or international equivalent should be encouraged.

Pediatrics. 2007;119:638-646. Full-text (free): http://pediatrics.aappublications.org/cgi/content/full/119/3/638

3. Stimulant Abuse May Increase Stroke Among Young Adults

April 16, 2007 — A study shows that among young adults 18 to 44 years old who were hospitalized in Texas between 2000 and 2003, amphetamine abuse was associated with a 5-fold increase in the risk for hemorrhagic stroke. The findings are published in the April issue of the Archives of General Psychiatry.

Amphetamine abuse was observed to increase 77.5% during that time, and strokes associated with amphetamine abuse also significantly increased, the researchers noted. Cocaine abuse was associated with increased risk for both hemorrhagic and ischemic stroke.

"I think this is part of the process of really trying to flesh out what the exact risks of these substances are, and helps inform people in the community, patients and doctors as to what sort of risk they may be dealing with," Arthur N. Westover, MD, from the University of Texas Southwestern at Dallas, told Medscape. "It also helps people who are involved in public policy to know what the trends are."

The prevalence of methamphetamine use has been on the rise for the last decade. This trend has been particularly noted in the western, southwestern, and midwestern United States and in rural communities. In addition to wider use, there is evidence that the amount of methamphetamine being abused per individual is rising. Among patients who use methamphetamine, the percentage of individuals meeting criteria for drug abuse or dependence nearly doubled between 2002 and 2004. In addition, the rate of methamphetamine-related deaths rose by a factor of nearly 100% between 2002 and 2003, whereas mortality rates related to heroin decreased.

There is conflicting data as to whether amphetamine or cocaine may significantly increase the risk for stroke. The authors of the current study perform a cross-sectional analysis to examine these associations.

Study Highlights

The study cohort was drawn from a database of International Classification of Disease, Ninth Revision, Clinical Modification codes from Texas. Texas requires reporting these codes to a state agency for the generation of quality indicators, and this system captures 95.1% of hospital admissions in the state. The current study examines admissions among patients between the ages of 18 and 44 years between 2000 and 2003.

The main study outcome was the relationship between the diagnoses of stroke and either active cocaine or amphetamine abuse. Strokes were differentiated as hemorrhagic, ischemic, or "other" in 2003 only. The authors adjusted the main study result for possible confounding risks for stroke, and they followed rates of hospital mortality as well.

There were a total of 3,148,165 patients with discharge data available for analysis. Alcohol was the drug most frequently abused, followed by cocaine, cannabis, opioids, amphetamines, and hallucinogens. However, amphetamine use increased to a greater degree than all these drugs during the 4-year study period. Amphetamine abuse was more commonly reported in rural vs urban hospitals.

1935 strokes were reported in 2003. On multivariate logistic regression analysis of data from 2003, amphetamine use was significantly associated with an increase in the risk for hemorrhagic stroke (odds ratio [OR], 4.95) but not ischemic stroke (OR, 1.04). However, cocaine use increased the relative risk for both hemorrhagic and ischemic strokes (OR, 2.33 and 2.03, respectively).

Using cannabis increased the risk for ischemic but not hemorrhagic stroke while alcohol use failed to have a significant effect on the risk for stroke.

Combinations of abused drugs did not significantly contribute to the risk model, and the main study findings did not vary by patients' race.

In-hospital mortality was increased to a greater degree following hemorrhagic stroke (OR, 58.3) vs patients who did not report a stroke, and this relative increase in mortality was greater than that found for ischemic stroke (OR, 11.7). Among patients with hemorrhagic strokes, amphetamine use, coagulation defects, and hypertension were the only factors associated with a significantly increased risk for in-hospital death, and amphetamine use carried the highest risk for death among these factors.

Overall, the authors concluded that drug abuse could account for 28.8% of all strokes in Texas during 2003.

Arch Gen Psychiatry. 2007;64:495-502.

4. The usefulness of CT for patients with carpal bone fractures in the ED

You JS, et al. Emerg Med J 2007;24:248-250

Objective: The wrist is the most commonly injured joint in the body. However, wrist injuries are often missed in the emergency department (ED). If the fracture is not diagnosed and remains untreated, the patient runs a considerable risk of chronic disability. The utility of CT as an aid in the diagnosis of carpal bone fracture was investigated.

Materials and methods: A retrospective analysis was performed of patients who underwent CT and plain radiography for wrist injury in the ED between March 2003 and February 2006. Plain radiograph interpretations were classified into three groups: (1) the definite fracture group, (2) the no fracture group, and (3) the ambiguous fracture group. The CT results were analysed in relation to the classification of the plain radiograph interpretation. The final diagnoses reviewed from the medical records were used as the reference standard.

Results: 36 carpal fractures in 33 patients were identified from 45 patients who underwent plain radiography and CT. The interpretations of plain radiographs were classified into definite fractures (n = 10), ambiguous fractures (n = 15) and no fractures (n = 20). When both the definite fracture and ambiguous fracture groups were considered positive, the sensitivity and specificity were 69.7% and 83.3%, respectively. The sensitivity and specificity of CT scans were both 100%.

Conclusion: Emergency physicians should consider CT of the wrist after plain radiography when patients with suspected carpal fracture show normal radiographic findings.

5. Combination Sumatriptan-Naproxen Provides Improved Migraine Relief

A combination of sumatriptan and naproxen provides better short-term and sustained migraine relief than does monotherapy with either agent, concludes an industry-sponsored trial in JAMA.

In each of two replicate double-blind trials, researchers randomized some 1700 migraine sufferers to treatment at the onset of a moderate or severe migraine with either a single tablet containing 85 mg of sumatriptan and 500 mg of naproxen, sumatriptan alone, naproxen alone, or placebo. At 2 hours after dosing, more patients were pain-free in the sumatriptan-naproxen group (34% in trial 1, 30% in trial 2) than in any of the other groups (for sumatriptan alone, the results were 25% pain-free in trial 1, 23% in trial 2). The pattern was similar at 24 hours, with about 25% of those in the combination group remaining pain-free.

Abstract: http://jama.ama-assn.org/cgi/content/abstract/297/13/1443

6. New Indications for Steroids, Beyond the ED

A. Pretreatment with Corticosteroids Helps Prevent Postextubation Laryngeal Edema

Pretreatment with corticosteroids significantly decreases the occurrence of postextubation laryngeal edema -- and the need for reintubation -- according to a placebo-controlled, double-blind study published today in Lancet.

Researchers randomized 761 adults -- all of whom were in ICUs and had been intubated for more than 36 hours -- to receive either intravenous saline or 20 mg of methylprednisolone every 4 hours, starting 12 hours before planned extubation. The incidence of postextubation laryngeal edema was 3% in the methylprednisolone group, compared with 22% in the placebo group. Additionally, methylprednisolone treatment cut the reintubation rate in half and nearly eliminated reintubation due to laryngeal edema.

The authors of an accompanying commentary conclude: "On the basis of these findings, we would recommend the routine use of this treatment in all eligible patients without a specific contraindication."

Bruno F, et al. The Lancet 2007; 369:1083-1089.

B. Corticosteroids for the Prevention of A Fib After Cardiac Surgery: A Randomized Controlled Trial

It worked!

Halonen J, et al. JAMA. 2007;297:1562-1567.

7. CDC Recommends Cephalosporins, Not Fluoroquinolones, for Gonorrhea

With surveillance showing dramatically increased rates of fluoroquinolone-resistant Neisseria gonorrhoeae in the U.S. over the past 5 years, the CDC is no longer recommending the use of this antibiotic class for the treatment of gonorrhea, according to an article in the current MMWR.

The CDC assessed antimicrobial susceptibility of gonorrhea isolates collected from men receiving care at some 30 STD clinics. Researchers with the agency observed increases in fluoroquinolone-resistant gonorrhea among both men who have sex with men (from 1.6% in 2001 to 29% in 2005) and among heterosexual men (from 0.9% to 3.8%). Preliminary data indicate that in the first half of 2006, the prevalence of fluoroquinolone resistance had increased to 38.3% among MSM and 6.7% among heterosexual men.

The article includes a summary of recommended treatment options, while observing that "the options for treating gonococcal infections in the United States are limited."

MMWR article: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm

8. Contemporary Clinical Profile and Outcome of Prosthetic Valve Endocarditis

Wang A, et al. JAMA. 2007;297:1354-1361.

Context: Prosthetic valve endocarditis (PVE) is associated with significant mortality and morbidity. The contemporary clinical profile and outcome of PVE are not well defined.

Objectives: To describe the prevalence, clinical characteristics, and outcome of PVE, with attention to health care–associated infection, and to determine prognostic factors associated with in-hospital mortality.

Design, Setting, and Participants: Prospective, observational cohort study conducted at 61 medical centers in 28 countries, including 556 patients with definite PVE as defined by Duke University diagnostic criteria who were enrolled in the International Collaboration on Endocarditis-Prospective Cohort Study from June 2000 to August 2005.

Main Outcome Measure: In-hospital mortality.

Results: Definite PVE was present in 556 (20.1%) of 2670 patients with infective endocarditis. Staphylococcus aureus was the most common causative organism (128 patients [23.0%]), followed by coagulase-negative staphylococci (94 patients [16.9%]). Health care–associated PVE was present in 203 (36.5%) of the overall cohort. Seventy-one percent of health care–associated PVE occurred within the first year of valve implantation, and the majority of cases were diagnosed after the early (60-day) period. Surgery was performed in 272 (48.9%) patients during the index hospitalization. In-hospital death occurred in 127 (22.8%) patients and was predicted by older age, health care–associated infection (62/203 [30.5%]; adjusted odds ratio [OR], 1.62; 95% confidence interval [CI], 1.08-2.44; P = .02), S aureus infection (44/128 [34.4%]; adjusted OR, 1.73; 95% CI, 1.01-2.95; P = .05), and complications of PVE, including heart failure (60/183 [32.8%]; adjusted OR, 2.33; 95% CI, 1.62-3.34; P less than .001), stroke (34/101 [33.7%]; adjusted OR, 2.25; 95% CI, 1.25-4.03; P = .007), intracardiac abscess (47/144 [32.6%]; adjusted OR, 1.86; 95% CI, 1.10-3.15; P = .02), and persistent bacteremia (27/49 [55.1%]; adjusted OR, 4.29; 95% CI, 1.99-9.22; P less than .001).

Conclusions: Prosthetic valve endocarditis accounts for a high percentage of all cases of infective endocarditis in many regions of the world. Staphylococcus aureus is now the leading cause of PVE. Health care–associated infection significantly influences the clinical characteristics and outcome of PVE. Complications of PVE strongly predict in-hospital mortality, which remains high despite prompt diagnosis and the frequent use of surgical intervention.

9. Thoracic Intervertebral Disk Herniation: A Commonly Missed Diagnosis

Linscott MS, et al. J Emerg Med. 2007;32:235-8.

Abstract
In the emergency department and the physician’s office, it is often difficult to distinguish benign causes of back pain from more serious ones. The diagnosis of thoracic intervertebral disk herniation is often missed because of its complex and variable presentation. In order to further investigate this condition, 78 patient charts were reviewed in the largest single study of thoracic disk herniation in the world’s literature. Injury was associated with disk herniation in approximately half of patients, much higher than reported in previous studies. Back pain was the most common presenting symptom (73% of cases) and weakness was the most common physical finding (42% of cases). Eighty-five percent of patients had either historical or physical findings consistent with neuropathy; 26% of patients had multiple thoracic disk herniations. These findings will aid physicians in the diagnosis of this potentially serious condition.

10. Active Interventions, Act-As-Usual Have Similar Outcomes After Whiplash Injury

News Author: Laurie Barclay, MD. April 2, 2007 — Immobilization, act-as-usual, and mobilization had similar effects regarding prevention of pain, disability, and work capability 1 year after whiplash injury, according to the results of a randomized, parallel-group, controlled trial reported in the March 15 issue of Spine.

"Long-lasting pain and disability, known as chronic whiplash-associated disorder (WAD), may develop after a forced flexion-extension trauma to the cervical spine," write Alice Kongsted, DC, PhD, from the University of Southern Denmark in Ringe, and colleagues. "It is unclear whether this, in some cases disabling, condition can be prevented by early intervention. Active interventions have been recommended but have not been compared with information only."

In this study, 458 participants were recruited from emergency units and general practitioners within 10 days after a whiplash injury. They were randomized to receive 1 of the following: immobilization of the cervical spine in a rigid collar followed by active mobilization, advice to act as usual, or an active mobilization program (Mechanical Diagnosis and Therapy). At 3-, 6-, and 12-month follow-ups, treatment effect was measured in terms of headache and neck pain intensity (scale, 0 - 10), disability, and work capability.

At the 1-year follow-up, 48% of participants reported considerable neck pain, 53% reported disability, and 14% were still listed as sick. There were no significant differences noted between the 3 intervention groups. Per-protocol analyses showed results very close to the primary analyses (intent-to-treat), but the neck collar group tended to have a poorer outcome.

"Immobilization, act-as-usual, and mobilization had similar effects regarding prevention of pain, disability, and work capability 1 year after a whiplash injury," the authors write. "We find our results adequately sound to conclude that earlier recommendations of active treatment regimens cannot be supported. Moreover, taking the per protocol analyses into account, use of a stiff neck collar should be discouraged as a standard approach."

Study limitations include poor compliance with treatment, frequent use of treatment other than prescribed, and more participants lost to follow-up in the act-as-usual group.

"The present trial shows clearly that active intervention in the first weeks after an injury does not result in a better outcome than an 'act as usual' program when prescribed to a high-risk patient group," the authors conclude. "There might be subgroups that respond to treatment, but in a large group of patients the prognosis was not improved by active treatment. Until such subgroups have been identified, our general recommendation is that advice to act as usual, the less expensive intervention, should be the preferred treatment."

Spine. 2007;32:618-626.

11. What Benefit Do Statins Provide? The List Gets Ever Longer and Longer…

A. Hospitalization for Sepsis Lower in Dialysis Patients Taking Statins

Statin use is strongly associated with a reduced risk of hospitalization for sepsis in patients with chronic kidney disease receiving dialysis, according to a prospective observational study.

The study, published in JAMA, was based on about 1000 people receiving outpatient dialysis, 14% of whom were on statins. During mean follow-up of 3.4 years, the risk of hospitalization for sepsis was 62% lower among statin users, after adjustment for comorbidities and other factors.

The authors said statins may minimize the risk for sepsis in patients with infections by regulating the immune response to infection.

Abstract: http://jama.ama-assn.org/cgi/content/abstract/297/13/1455

B. Preadmission Use of Statins Improves Outcomes After Pneumonia Hospitalisation

Presented at European Congress of Clinical Microbiology and Infectious Diseases conference. By Chris Berrie. MUNICH, GERMANY -- April 9, 2007 -- Preadmission use of statins is associated with significantly reduced mortality rates within 90 days of admission in patients hospitalised with pneumonia, independent of comorbidity levels, according to a population-based cohort study.

Pneumonia is becoming an ever more frequent cause of morbidity and mortality with the aging of Western populations, Dr. Thomsen said. Therefore, his team conducted their study in an attempt to help to resolve the conflict as to whether statin use prior to hospitalisation could improve outcomes in patients hospitalised with pneumonia.

"There has been considerable interest in the role of statins in infection in general," Dr. Thomsen said. Studies to date have had conflicting results on whether statins may increase or decrease the risk of severe infections in pneumonia patients, he said in his presentation on April 2nd. His study therefore assessed whether the preadmission use of statins was associated with mortality, pulmonary complications or bacteraemia among adults hospitalised with pneumonia.

The overall mortality rates for statin users and nonusers were 10.8% and 15.7% 30 days after discharge (adjusted MRR, 0.69; 95% confidence interval [CI], 0.58-0.82), and 17.0% vs 22.4% after 90 days (adjusted MRR, 0.75; 95% CI, 0.65-0.86).Following stratification of the mortality curves according to patients with low, medium and high Charlson comorbidity index, the researchers found that the lower mortality rates for statin users were independent of their morbidity levels.Dr. Thomsen noted that these adjusted 30-day mortality rate ratios were robust and consistently indicated benefits of preadmission statin use across various subanalyses.

Presentation title: Preadmission Use of Statins and Outcomes After Hospitalisation With Pneumonia: Population-Based Cohort Study of 29,900 Adult Patients. Abstract P1190

12. Pneumococcal Conjugate Vaccine Associated with Reduction in U.S. Pneumonia Admissions

Routine infant immunization with the seven-valent pneumococcal conjugate vaccine (PCV7, or Prevnar) has reduced hospitalization rates for all-cause pneumonia by 39% and for pneumococcal pneumonia by 65% in children younger than 2 years, a Lancet study estimates.

The study, based on an analysis of U.S. hospital discharge data, compares pneumonia admission rates before and after vaccination began in 2000. The findings suggest that in 2004, about 41,000 fewer children were admitted for all-cause pneumonia than would have been expected.

"Our study suggests a substantial effect on one of the most common reasons for U.S. hospital admissions," the authors write. The author of an accompanying comment argues that a concurrent decline of some 25,000 pneumonia admissions among adults aged 18 to 39 "provides further evidence of the herd immunity effect from routine vaccination of children and infants."

Grijalva CG, et al. The Lancet 2007; 369:1179-1186

13. Tigan Dumped by FDA as Useless

FDA Orders Trimethobenzamide Suppositories Off the Market

The Food and Drug Administration has ordered companies to stop producing and distributing antinausea suppositories that contain trimethobenzamide.

The FDA said that, in suppository form, the drug has no demonstrated efficacy in treating nausea and vomiting in children or adults, and so the suppositories -- marketed under names including Tigan, T-Gen, Tebamide, Trimazide, and Trimethobenz -- are not approved. A number of injections and oral capsules containing trimethobenzamide have been approved by the FDA and remain on the market.

FDA Press release: http://www.fda.gov/bbs/topics/NEWS/2007/NEW01601.html

14. Boarding Patients in the ED is Financially Imprudent

Falvo T, et al. The Opportunity Loss of Boarding Admitted Patients in the Emergency Department. Acad Emerg Med 2007;14:332-337.

Objectives: Boarding admitted patients in emergency department (ED) treatment beds has been recognized as a major cause of ED crowding and ambulance diversions. When process delays impede the transfer of admitted patients from the ED to inpatient units, the department's capacity to accept new arrivals and to generate revenue from additional patient services is restricted. The objective of this study was to determine the amount of functional ED treatment capacity that was used to board inpatients during 12 months of operations at a community hospital and to estimate the value of that lost treatment capacity.

Methods: Historical data from 62,588 patient visits to the ED of a 450-bed nonprofit community teaching hospital in south central Pennsylvania between July 2004 and June 2005 were used to determine the amount of treatment bed occupancy lost to inpatient holding and the revenue potential of utilizing that blocked production capacity for additional patient visits.

Results: Transferring admitted patients from the ED to an inpatient unit within 120 minutes would have increased the functional treatment capacity of the ED by 10,397 hours during the 12 months of this study. By reducing admission process delays, the hospital could potentially have accommodated another 3,175 patient encounters in its existing treatment spaces. Providing emergency services to new patients in ED beds formerly used to board inpatients could have generated $3,960,264 in additional net revenue for the hospital.

Conclusions: Significantly higher operational revenues could be generated by reducing output delays that restrict optimal utilization of existing ED treatment capacity.

15. Prescribing Opioids: Are We Trafficker or Healer? And Who’s the Victim?

By JOHN TIERNEY. New York Times. ALEXANDRIA, Va., March 26 — The case of the United States v. William Eliot Hurwitz, which began in federal court here on Monday, is about much more than one physician. It’s a battle over who sets the rules for treating patients who are in pain: narcotics agents and prosecutors, or doctors and scientists.

When Dr. Hurwitz, who is now 62, was sent to prison in 2004 for 25 years on drug trafficking and other charges, the United States attorney for Eastern Virginia, Paul J. McNulty, called the conviction “a major achievement in the government’s efforts to rid the pain management community of the tiny percentage of doctors who fail to follow the law and prescribe to known drug dealers and abusers.”

Siobhan Reynolds, the president of an advocacy group called the Pain Relief Network, hailed Dr. Hurwitz’s singular dedication and compared his plight to Galileo’s. Some of the country’s foremost researchers in pain treatment and addiction supported his appeal for a retrial, which was ordered because the jury in the first case was improperly instructed to ignore whether Dr. Hurwitz had acted in “good faith.” These scientists say they are upset by how their research has been distorted by prosecutors in this case, and suppressed by the Drug Enforcement Administration in its campaign against the misuse of OxyContin and other opioid painkillers.

In the first trial, the prosecution accused Dr. Hurwitz of crossing the line from doctor to trafficker by prescribing irresponsibly high doses of painkillers to his patients in the Virginia suburbs of Washington. He was accused of ignoring blatant “red flags” or signs that some patients were misusing or selling the drugs. That is an emotionally powerful argument for a jury: warning signs can seem perfectly clear with the benefit of hindsight.

But to researchers who study deceptive patients, there is no such thing as a blatant red flag. Deception is notoriously difficult to spot, as Dr. Beth F. Jung and Dr. Marcus M. Reidenberg of Cornell University document in a new survey of the literature. They note, for starters, an experiment showing that even police officers and judges — ostensibly experts at detecting fraud — do no better than chance at detecting lying.

Doctors are especially gullible because they have a truth bias: they are trained to treat patients by trusting what they say. Doctors are not good at detecting liars even when they have been warned, during experiments, that they will be visited at some point by an actor faking some condition (like back pain, arthritis or vascular headaches). In six studies reviewed by the Cornell researchers, doctors typically detected the bogus patient no more than 10 percent of the time, and the doctors were liable to mistakenly identify the real patients as fakes.

When treating people with chronic pain, doctors have to rely on what patients tell them because there is no proven way to diagnose or measure it. Also, there is no standard dosage of medicine: A prescription for opioids that would incapacitate or kill one patient might be barely enough to alleviate the pain of another.

Full-text: http://www.nytimes.com/2007/03/27/science/27tier.html?_r=1&ref=science&oref=slogin

16. The use of intrapleural anaesthetic to reduce the pain of chest drain insertion

May G, et al. Emerg Med J. 2007; 24:300-301.

Clinical scenario
A 25-year-old male with a history of spontaneous pneumothorax presents to the emergency department with a further large pneumothorax. Unfortunately, attempted aspiration fails due to a permanent leak, and he requires an intercostal drain. He has had a chest drain inserted in the past and admits that it was very painful whilst the drain was in situ. You wonder whether administration of local anaesthetic down the tube would provide good analgesia, and decrease the need for oral/or intravenous medications.

A short cut review was carried out to establish whether there is any evidence that intrapleural anaesthetic is effective in relieving pain in patients with chest drains. 190 papers were found using the reported search, of which two answered the clinical question. The authors, patient groups, outcomes results and key weaknesses of this evidence are presented. The clinical bottom line is that intrapleural bupivicaine should be considered in patients who have chest drains inserted, in addition to their regular oral/parenteral analgesia.

Comment(s)
Patients with indwelling chest drains may have severe pain and require oral or intravenous analgesia including opiates. There has been much research on the use of intrapleural analgesia after chest trauma and thoracostomy, but only one study which looks at the use of intrapleural analgesia solely for the relief of pain from the indwelling drain.

Although the number of patients is small, it seems to suggest that there may be a role for intrapleural analgesia in this subset of patients. No side effects of treament were noted.

The biggest benefit of intrapleural bupivicaine seems to be gained with its early introduction, and also if it is given regularly, at least every 4 h, due to its short half life. Oral analgesia should still be given to these patients.

Better pain relief in this group of patients would also be beneficial, as it would improve the patients’s ablility to cough and deep breathe, and thus reduce the number of secondary chest infections.

CLINICAL BOTTOM LINE: Intrapleural bupivicaine should be considered in patients who have chest drains inserted, in addition to regular oral/parenteral analgesia.

17. ED Evaluation of Ventricular Shunt Malfunction: Is the Shunt Series Really Necessary?

Pitetti R. Pediatric Emerg Care. 2007;23:137-141.

Objective: The malfunction of a ventricular shunt is one of the most common clinical problems encountered in pediatric neurosurgery. Standard emergency department (ED) evaluation of suspected shunt malfunction consists of plain radiographs of the skull, neck, chest, and abdomen (shunt series) to look for mechanical breaks, kinks, and disconnections in the shunt, and a cranial computed tomography (CT) scan to evaluate for signs of increased ventricular size. We hypothesized, however, that in the context of a cranial CT scan that did not demonstrate a shunt malfunction, obtaining the shunt series would not prove to be clinically useful.

Methods: A retrospective chart review was conducted of all patients younger than 18 years with a history of a ventricular shunt who presented to an urban, tertiary pediatric ED between January 1, 2000, and September 30, 2004, for suspected shunt malfunction. Demographic and clinical characteristics of patients were recorded, as well as the results of shunt series and cranial CT scans. Shunt malfunction was defined as the performance of a shunt revision within 1 week of radiographic evaluation.

Results: During the study period, 291 children with a ventricular shunt were evaluated in the ED 461 times for suspected shunt malfunction. The mean age of patients was 90.6 months (SD, 71.5 months); 163 (58.5%) were men, and 209 (71.8%) were white. Three hundred sixty patients (78.1%) had a shunt series performed during their ED evaluation, and 410 (88.9%) had a CT scan of the head. Seventy-one patients (15.4%) were diagnosed with shunt malfunction. Twenty-two had a normal cranial CT scan. Of these patients, 6 had an abnormal shunt series, and 14 had a normal shunt series.

Conclusions: The routine use of the shunt series seems warranted in the evaluation of the child with suspected shunt malfunction as children with shunt malfunction may present with a normal cranial CT scan but an abnormal shunt series.

18. Subarachnoid Hemorrhage Frequently Missed in ED Setting

Caroline Cassels. April 13, 2007 — A new study shows about 1 in 20 patients with nontraumatic subarachnoid hemorrhage (SAH) has a missed diagnosis during their initial visit to the emergency department (ED).

In the largest study of misdiagnosis to date, investigators at the Institute for Clinical Evaluative Sciences, in Toronto, Ontario, found 5.4% of SAH patients are not identified when they first present to the ED.

"This is a kind of a good-news/bad-news story. In terms of overall missed diagnosis [of SAH] — which has been reported as being anywhere from 12% to 50% — our study reports a much lower rate. On the other hand, it still means we are missing 5% of these patients, which, in my opinion, is unacceptable," the study's principal investigator, Michael Schull, MD, told Medscape. In addition, although a missed diagnosis was less likely if patients attended a teaching institution, this finding was not explained by the hospitals' annual volume of SAHs or access to CT technology. The study is published in the April issue of Stroke.

Needle in a Haystack

According to Dr. Schull, SAH presents a diagnostic challenge for physicians in large part because of its common symptoms and frequently subtle signs.

"The most common manifestation of subarachnoid hemorrhage is headache. Headache is also a remarkably common presenting complaint in hospital EDs. The challenge is to distinguish between these 2 groups of patients, and this is not an easy thing to do. It really can be like finding the needle in the haystack," he said.

According to Dr. Schull, little is known about population rates of misdiagnosis of SAH or hospital factors that may contribute to it. To determine this, the investigators conducted a population-based study that included all patients in the province of Ontario, which has a population of 12.5 million, admitted to the hospital with nontraumatic SAH between April 1, 2002 and March 31, 2005. The hospital admission records of SAH patients were linked to all visits to any of the province's 176 EDs in the 14 days prior to hospital admission, excluding the admitting visit. SAH was defined as missed if a patient attended an ED for a complaint related to SAH in the 14 days before hospital admission.

In addition, investigators examined the association between the institutions' teaching status and missed SAH and also looked at whether access to CT scanning and the annual ED volume of SAH were determining factors in missed diagnosis.

Over the 3-year study period, 1603 patients were hospitalized with a diagnosis of nontraumatic SAH. Of these, 1507 (94%) were admitted through the ED. Of Ontario's 176 EDs, 147 (83.5%) admitted at least 1 patient with SAH, ranging from 1 to 49 per ED. A total of 150 patients visited a hospital ED in the 14 days preceding their SAH admission. Of these, a SAH diagnosis was missed in 81 (5.4%) cases.

Lower-Acuity Patients at Greater Risk

Most of the missed SAH cases — more than 40% — were initially diagnosed as migraine or headache and classified as low-acuity presentation. The rate of misdiagnosis among patients seen in nonteaching hospitals was twice as high — 6.1% vs 3.0% — as the rate in teaching institutions. However, researchers found that neither an institution's annual SAH volume nor CT availability was an independent predictor of missed SAH.

While the reasons for this are unclear, Dr. Schull said the relative rarity of SAH means the number of cases may not be large enough to create a volume effect. It also means even physicians who work in "high-volume" SAH centers are seldom exposed to the condition.

"The highest-volume center sees fewer than 2 cases per month. If you have 20 emergency physicians spread out over that month, that means an individual physician could go several years without ever seeing a single [SAH] case," he said.

To complicate matters, the study found 37% of missed cases went to a different hospital than the one they visited for their initial complaint. This means, said Dr. Schull, that the first institution may never become aware of the missed diagnosis.

As for access to CT technology, Dr. Schull said that when a physician is faced with a low-acuity patient, it may not be the access to imaging technology that poses a challenge but the decision of whether or not to move from assessment to investigation or appropriately following up a negative CT with a lumbar puncture.

Centralized, Educational Approach

Improving the rate of missed SAH diagnosis, said Dr. Schull added, may lie in a centralized, educational approach.

"Because of the rarity of this condition and because of the even rarer number of missed diagnoses, I think we need to take a network approach to learning and share our experiences between institutions and across specialty lines, which would provide us with a great opportunity for enhanced understanding between physicians."

In an accompanying editorial, Jonathan Edlow, MD, from Beth Israel Deaconess Medical Center, in Boston, Massachusetts, agreed with Dr. Schull's educational approach toward improving diagnosis.

"Given the whole spectrum of presentation of SAH, we will probably never completely eliminate misdiagnosis. However, future resources ought to be spent less on study and on more education. We must educate our patients about which symptoms constitute sufficient reason to consult a physician, and we must educate physicians about the many pitfalls inherent in the diagnosis of SAH," he writes.

Stroke. 2007;38:1216-1221, 1129-31.

19. Malpractice Juries Usually Side With Physicians

NEW YORK (Reuters Health) Apr 11 - Contrary to what many believe, the juries in medical malpractice cases usually sympathize more with the physician than with the patient, according to a report slated to appear in the May edition of the Michigan Law Review.

When there is any doubt after hearing all the evidence and expert opinions, juries usually return a verdict in favor of the physician, study author Philip G. Peters, from the University of Missouri-Columbia's School of Law, said in a statement.

Peters reached this conclusion after conducting an extensive review of studies of malpractice cases from 1989 to 2006. The studies included cases involving all medical specialties and assessed expert medical opinions as well as the merits of the claims.

Key points reached by the review include:

* Plaintiffs seldom win weak cases. They are more likely to succeed in toss-up cases and if there is strong evidence of negligence.

* Juries are usually able to recognize week cases, agreeing with legal experts 80% to 90% of the time.

* Physicians win 50% of the cases that independent legal experts believed the plaintiff would win.

* A number of factors exist that favor victory by the medical defendant, such as their superior resources, social standing, and the social norm against "profiting" by injury.

"The data show that defendants and their hired experts are more successful than plaintiffs and their hired experts at persuading juries to reach verdicts that are contrary to the evidence," Peters said.

20. Chondroitin Doesn't Reduce Pain in Osteoarthritis

Chondroitin does not appear to reduce joint pain in people with osteoarthritis and its use should be discouraged, concludes a study in the Annals of Internal Medicine.

In their meta-analysis of 20 trials comparing chondroitin with either placebo or no treatment, the authors found evidence of benefit only in small, methodologically weak studies. "Large-scale, methodologically sound trials indicate that the symptomatic benefit is minimal to nonexistent," they conclude, and "its use [in advanced disease] should be discouraged." However, because researchers found no adverse effects associated with chondroitin use, an editorialist did not completely agree: "If patients say that they benefit from chondroitin, I see no harm in encouraging them to continue taking it as long as they perceive a benefit."

The editorial says the U.S. expends $1 billion annually for chondroitin, which is usually taken with glucosamine -- itself found ineffective in a trial published last year.

Editorial: http://www.annals.org/cgi/content/full/146/8/611