Lit Bits: May 5, 2007

From the recent medical literature...

1. Antibiotics Not Required for Healing of Simple Cutaneous Abscesses

By Martha Kerr. NEW YORK (Reuters Health) Apr 20 - A course of antibiotics is not required following incision and drainage of simple cutaneous abscesses, a team at the University of Pennsylvania in Philadelphia report in an April 11th online release of an article in press for the Annals of Emergency Medicine.

Guidelines on the best management of abscesses are not clear, Dr. Abigail Hankin and Dr. Worth W. Everett note. Current guidelines from the Infectious Diseases Society of America and the Centers for Disease Control and Prevention state that incision and drainage alone is adequate. However, recurrent abscesses should be presumed to be infected with methicillin-resistant Staphylococcus aureus (MRSA), and should be treated with antibiotics.

The two investigators reviewed the literature and identified five studies and one abstract that directly addressed the issue of use of antibiotics in treating abscesses.

In presenting their findings in the Best Available Evidence section of the Annals, Drs. Hankin and Everett write that "each of the studies concluded that patients treated with incision and drainage alone exhibit resolution of their infection at the same rate as patients who are treated with incision and drainage plus antibiotic therapy." Both groups showed a greater than 90% resolution of symptoms without complications.

None of the studies addressed cases in which there is significant cellulitis accompanying the abbess. Reuters Health asked Dr. Everett about this: "Only one pediatric study suggested that overlying cellulitis greater than 5cm was predictive of later hospitalization," Dr. Everett explained. "But for the practicing clinician, in general, if the extent of the redness is limited to the skin overlying the abscess or only slightly beyond, simple incision and drainage would be recommended. Presence of systemic symptoms (fever, vomiting, etc.) felt to be related to the infection would warrant consideration of antibiotic therapy, but not an absolute," he advised.

Overall, Dr. Everett said, it's a matter of balancing probable benefits and risks. "No practicing physician has a crystal ball and can absolutely predict who will go on to clinical resolution or failure, so almost as important as deciding which course to take is to make sure the patient understands that the wound needs to be rechecked in 2 days and possibly again later to ensure proper healing."

Not using antibiotics means less cost and inconvenience to the patient, Dr. Everett pointed out. "At the same time we are not introducing the elements of adverse medication reactions and side effects, the possibility of drug-drug interactions for those taking other medications, and the potential for breeding antibiotic resistant organisms."

However, questions remain and a multicenter, randomized, placebo-controlled trial is "sorely needed," the U Penn team says.

Hankin A, Everett WW. Ann Emerg Med 2007; print publication pending.

2. New Guidelines for Treatment of Acute Ischemic Stroke

News Author: Susan Jeffrey. April 19, 2007 — The American Heart Association/American Stroke Association has released new guidelines for the early management of acute ischemic stroke. The guidelines continue to endorse the use of intravenous tissue-type plasminogen activator (tPA) but note that other modalities such as intra-arterial tPA show promise. For the first time, the authors have included recommendations for palliative care.

"Our goal was to focus on the first few hours after stroke onset where we think time is so critical," Harold P. Adams Jr., MD, from the University of Iowa Stroke Center in Iowa City, chair of the guidelines writing committee, told Medscape. "The audience is primarily physicians, but we've also included information for general emergency medical services, and some things for the public as well, focusing on the idea that from the first symptom, time is brain, and everything we can do to expedite the process to hopefully treat the patients and reduce the likelihood of an unfavorable outcome is crucial," he said.

The guidelines were published in the April 12 Stroke ASAP issue and will appear in the May print issue of Stroke.

"Time Is Brain"

The new guidelines were extensively revised since 2003. Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise, including imaging and interventional experts.

"Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials," the authors write. Recommendations have been made using an evidence-grading algorithm.

The panel considered aspects of care beginning in the prehospital setting, Dr. Adams said, including recommendations for more public education about the symptoms of stroke, and recommendations about how emergency medical services should interface with hospitals. For example, they recommend that patients should be taken to hospitals with facilities for emergency stroke care, even if this means bypassing closer hospitals. To this end, the authors recommend that more medical centers should consider seeking certification as primary or comprehensive stroke centers from the Joint Commission on Accreditation of Healthcare Organizations.

The "Engine for Emergency Stroke Care"

Intravenous tPA is still recommended as the key treatment of stroke, Dr. Adams noted, "and remains the engine for emergency stroke care." However, the guidelines discuss the use of intra-arterial tPA, he said, "which is becoming an important alternative for patients who cannot receive IV [intravenous] tPA."

The guidelines also discuss the use of mechanical devices such as the Mechanical Embolus Removal in Cerebral Embolism (MERCI) retriever that has been approved for clot removal in the setting of stroke. "We emphasize that this is approved by the FDA [Food and Drug Administration] but we also suggest that there needs to be more evidence to show these sorts of interventions help to improve outcomes," Dr. Adams commented. There has been some controversy that devices are held to a lower standard in this regard compared with drugs, where it must be shown that they not only recanalize a vessel but also result in an improved clinical outcome.

In terms of imaging, there is expanded discussion of magnetic resonance imaging (MRI) for the assessment of acute stroke. "While CT [computed tomography] remains the preferred diagnostic study because it can be done quickly and is more readily available, we also recognize there are advantages from MRI as well, and those are mentioned," Dr. Adams noted.

There also is discussion of general emergent treatment, including a recommendation for aggressive management of hyperglycemia, although this is, "I must admit, based on no definitive data," Dr. Adams added. Other areas of acute treatment such as blood pressure management are still "fertile areas for research," although some recommendations are made.

Finally, for the first time, the authors include discussion of palliative care for patients who have had acute stroke. "For those patients who have such horrendous brain injuries from stroke, who we may not be able to successfully treat, there are options that physicians and families may need to consider in that very difficult situation," Dr. Adams said.

Stroke. 2007;38:1655-1711.

3. Guideline Use Improves Pain Control in Emergency Department

NEW YORK (Reuters Health) Apr 18 - Implementation of pain control guidelines can improve the management of acute pain in the emergency department setting, new research indicates.

Despite being the most common presenting complaining in the emergency department, acute pain is often not managed adequately, Dr. Isabelle Decosterd, from the University of Lausanne in Switzerland, and colleagues note. The goal of the present study was to determine if the implementation of new pain control guidelines could improve analgesia in this setting.

The study, which is reported in the April 16th online issue of the Annals of Emergency Medicine, involved 249 patients who were evaluated for acute pain in the emergency department of the University Hospital Center prior to guideline implementation (Phase I) and 192 who were seen after implementation (Phase II). The guidelines were generated by a multidisciplinary team and presented in algorithm form for use by emergency room personnel.

Prior to the intervention, 40% of patients received analgesia with a 13% satisfaction rate. After the intervention, 63% of patients received analgesia and the satisfaction rate climbed to 69%.

Implementation of the guidelines was associated with greater use of morphine and at higher doses. In addition, use of NSAIDs and acetaminophen increased.

However, the intervention was not associated with more expeditious delivery of analgesia.

The door-to-analgesia "interval did not improve from Phase I to Phase II," Dr. Decosterd said in a statement. "In both phases, three-quarters of patients did not receive analgesia in the first 30 minutes after admission. This suggests that there is further opportunity to better train hospital staff to make rapid pain relief a priority and to meet patient expectations of rapid pain relief after admission to the emergency department."

Ann Emerg Med 2007; in press. Abstract: http://www.annemergmed.com/article/PIIS0196064407000790/abstract

4. Omeprazole Found Beneficial Before Endoscopy for Gastrointestinal Bleeding

The proton-pump inhibitor omeprazole hastened resolution of gastrointestinal bleeding in patients undergoing endoscopy.

In a double-blind, randomized, placebo-controlled trial, some 640 patients in Hong Kong admitted for upper gastrointestinal bleeding received either continuous intravenous infusions of high-dose omeprazole or placebo overnight before endoscopy. The omeprazole group were less likely to require endoscopic treatment (relative risk, 0.67) and were less likely to require therapy for bleeding ulcers (RR, 0.61) than the placebo group.

While acknowledging its limitations (patients on long-term aspirin were excluded), the authors say their study reaffirms that "acid suppression facilitates clot formation over arteries in bleeding peptic ulcers."

Commenting on the study, Journal Watch General Medicine Editor-in-Chief Dr. Allan Brett writes that the trial "corroborates the wisdom of what has already become the standard of care for patients with upper GI bleeding in the U.S. — initiation of a high-dose PPI while the patient awaits upper endoscopy."

NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/short/356/16/1631

5. Guidelines Discourage Routine Antibiotic Prophylaxis for Dental Procedures

New guidelines from the American Heart Association greatly reduce the number of patients for whom antibiotic prophylaxis is recommended to prevent infective endocarditis.

The guidelines, released online in Circulation, recommend prophylaxis only in patients at highest risk for an adverse outcome from endocarditis. These include patients with prosthetic cardiac valves, heart transplant recipients who develop cardiac valvulopathy, those who have previously had infective endocarditis, and some patients with congenital heart disease (unrepaired cyanotic CHD, up to 6 months after a repair with prosthetic material or device, or repaired CHD with residual defects).

In these patients, the guidelines recommend prophylaxis before dental procedures involving the gingival tissue or the periapical region of the teeth or that perforate the oral mucosa. These patients should also receive prophylaxis for procedures on the respiratory tract, infected skin, skin structures, or musculoskeletal tissue.

Antibiotic prophylaxis is not recommended for genitourinary or gastrointestinal tract procedures.

AHA Guidelines: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095v1

6. Niacin (Foolishly) Used in Attempt to Defeat Drug Tests

In a report in today’s MMWR, the CDC describes multiple calls to a poison control center by people who experienced adverse reactions after taking large doses of niacin (nicotinic acid or vitamin B3) to try to prevent positive results on urine drug screenings. The most common reactions were tachycardia, flushed skin, rash, nausea, and vomiting.

The claim that niacin can mask the presence of marijuana in urine tests appears on a large number of websites. An editorial note in MMWR states that "no scientific evidence indicates that taking niacin can alter a urine drug test result." The note goes on to warn clinicians that, "with the Internet now a common source of medical information, clinicians can expect to encounter patients with unusual ADRs resulting from nonscientific drug use."

MMWR article: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5615a2.htm

7. Migraine Increases Risk of Cardiovascular Disease in Men, Just as in Women

Kurth T, et al. Arch Intern Med. 2007;167:795-801.

Background: The vascular component of the migraine-specific physiologic profile and the observed adverse cardiovascular risk profile in migraineurs suggest an association between migraine and cardiovascular disease (CVD). In women, migraine has been associated with increased risk of CVD, including coronary events. Compatible data in men are lacking.

Methods: Prospective cohort study of 20 084 men aged 40 to 84 years participating in the Physicians' Health Study. In yearly questionnaires, men were asked for information on migraine, risk factors, and the occurrence of study end points. We classified men as having migraine if they indicated migraine during the first 5 years, after which time follow-up began. Information on aura was not available. All the men were free of CVD at the start of follow-up. During a mean of 15.7 years, we followed up participants for the occurrence of a first major CVD event (nonfatal ischemic stroke, nonfatal myocardial infarction, or death from ischemic CVD). We also evaluated the individual end points, coronary revascularization, and angina.

Results: A total of 1449 men (7.2%) reported migraine, and during follow-up, 2236 major CVD events occurred. Compared with nonmigraineurs, men who reported migraine had multivariable-adjusted hazard ratios (95% confidence intervals) of 1.24 (1.06-1.46; P = .008) for major CVD, 1.12 (0.84-1.50; P = .43) for ischemic stroke, 1.42 (1.15-1.77; P less than .001) for myocardial infarction, 1.05 (0.89-1.24; P = .54) for coronary revascularization, 1.15 (0.99-1.33; P = .068) for angina, and 1.07 (0.80-1.43; P = .65) for ischemic cardiovascular death.

Conclusion: In this large prospective cohort of apparently healthy men, migraine was associated with increased risk of major CVD, which was driven by increased risk of myocardial infarction.

8. Using Video Images of Dementia in Advance Care Planning

Volandes AE, et al. Arch Intern Med. 2007;167:828-833.

Background: Advance care planning is a process by which patients plan for future medical care under circumstances of impaired decision-making. Central to this process is the patient's understanding and ability to imagine future health states.

Methods: A before and after oral survey was used to compare the effect of a video depiction with that of a verbal description of a patient with advanced dementia for individuals selecting level of medical care at 7 primary care clinics at 2 US medical centers. The study enrolled 120 adults, half of whom were nonwhite.

Results: A total of 120 subjects completed the interview. Before watching the video, 60 (50.0%) subjects preferred comfort care, 25 (20.8%) desired life-prolonging care, 22 (18.3%) chose limited care, and 13 (10.8%) were unsure of their preferences. Subject preferences changed significantly after the video: 107 (89.2%) of the subjects chose comfort care, none desired life-prolonging care, 10 (8.3%) chose limited care, and 3 (2.5%) were unsure of their preferences (P less than .001). Unadjusted analysis revealed a statistically significant difference regarding preferences, based on race/ethnicity, before watching the video: 40% of African Americans and 43% of Latinos chose comfort care, compared with 58% of whites (P = .04). Differences were also noted for educational level (P = .03). After the video, differences in preferences based on race/ethnicity and educational level disappeared.

Conclusions: Watching the video significantly changed preferences for care, transcending apparent differences in preferences associated with race/ethnicity and educational level. This study suggests that using video in addition to improved verbal communication may lead to more informed advance care planning by enhancing the ability of patients to imagine a hypothetical health state.

9. Flu Vaccine Could Prevent Heart Disease Deaths, Study Suggests

Coronary deaths increase during influenza epidemics, a study concludes.

The study, published in the European Heart Journal, was based on about 35,000 autopsy-confirmed deaths from acute myocardial infarction and chronic ischemic heart disease in St. Petersburg, Russia over an 8-year period. During flu epidemics, the odds for MI deaths increased by 1.30 and ischemic heart disease deaths by 1.10, compared with off-season periods.

The investigators conclude that more effort should be made to vaccinate people at risk for coronary heart disease against influenza.

European Heart Journal article (Free abstract; full text requires subscription): http://eurheartj.oxfordjournals.org/cgi/content/abstract/ehm035v1

10. Very Elderly Patients With ACS Benefit From Guideline-Based Care

from Heartwire — a professional news service of WebMD. April 25, 2007 — Increasing adherence to guideline-recommended therapies is associated with reduced mortality in patients with acute coronary syndromes (ACSs) who are aged 90 years or older, according to an analysis of data from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) registry.

The study, published online in the April 13 In Press issue and in the May 1 print issue of the Journal of the American College of Cardiology, was conducted by a group led by Adam H. Skolnick, MD, from Beth Israel Deaconess Medical Center in Boston, Massachusetts.

Senior author David J. Cohen, MD, MSc, from Saint Luke's Mid America Heart Institute in Kansas City, Missouri, commented to heartwire, "There is very little data on patients over 90 years of age, but the CRUSADE database includes more than 5000 ACS patients of this age group, which is one of the largest cohorts of nonagenarians and centenarians ever studied. We showed that although these patients had a higher risk of bleeding complications from aggressive treatment, the benefit still outweighed this risk. In fact, those very elderly patients treated most aggressively had outcomes that were nearly as good as a somewhat younger group of patients. So age in itself should not be a contraindication to aggressive treatment."

In the current study, the authors conclude, "These findings reinforce the importance of optimizing care patterns for even the oldest patients with NSTE [non–ST-segment elevation]-ACS while examining novel approaches to reduce the risk of bleeding for this rapidly expanding patient population."

They note that although just 2% of the US population is older than 85 years, this group accounts for 30% of all myocardial infarction–related deaths. However, these patients often are excluded from clinical trials and are underrepresented in clinical registries, therefore it has not been known whether treatment guidelines, which have been developed on the basis of observations from predominantly younger populations, are applicable to this age group. The authors therefore analyzed data from the CRUSADE registry and compared contemporary treatment and outcomes of 5557 patients with NSTE-ACS 90 years or older with those of 46,270 patients aged 75 to 89 years.

Results showed that in-hospital outcomes for the older elderly were poor, with 1 in 4 patients suffering a major adverse outcome and 1 in 8 not surviving to discharge. Although both groups had much in common, compared with the younger elderly, the older elderly were less likely to be diabetic, smokers, or obese. Among patients without contraindications, the older elderly were less likely to receive glycoprotein IIb/IIIa inhibitors and statins during the first 24 hours and were less likely to undergo cardiac catheterization within 48 hours. The older elderly were more likely to die (12.0% vs 7.8%) and experienced more frequent adverse events (26.8% vs 21.3%) during hospitalization — differences that persisted after adjustment for baseline patient and hospital characteristics.

However, although the older elderly were less likely than their younger elderly counterparts to receive guideline-recommended acute hospital care, there was a strong, graded relationship between receipt of such therapies and lower in-hospital mortality. This relationship was observed despite a graded increase in major bleeding among the older elderly associated with receiving a greater number of antithrombotic and invasive interventions.

J Am Coll Cardiol. Published online April 13, 2007. 2007;49:1790-1797.

11. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade?

Roy CL, et al. JAMA. 2007;297:1810-1818.

Context: Cardiac tamponade is a state of hemodynamic compromise resulting from cardiac compression by fluid trapped in the pericardial space. The clinical examination may assist in the decision to perform pericardiocentesis in patients with cardiac tamponade diagnosed by echocardiography.

Objective: To systematically review the accuracy of the history, physical examination, and basic diagnostic tests for the diagnosis of cardiac tamponade.

Data Sources: MEDLINE search of English-language articles published between 1966 and 2006, reference lists of these articles, and reference lists of relevant textbooks.

Study Selection: We included articles that compared aspects of the clinical examination to a reference standard for the diagnosis of cardiac tamponade. We excluded studies with fewer than 15 patients. Of 787 studies identified by our search strategy, 8 were included in our final analysis.

Data Extraction: Two authors independently reviewed articles for study results and quality. A third reviewer resolved disagreements.

Data Synthesis: All studies evaluated patients with known tamponade or those referred for pericardiocentesis with known effusion. Five features occur in the majority of patients with tamponade: dyspnea (sensitivity range, 87%-89%), tachycardia (pooled sensitivity, 77%; 95% confidence interval [CI], 69%-85%), pulsus paradoxus (pooled sensitivity, 82%; 95% CI, 72%-92%), elevated jugular venous pressure (pooled sensitivity, 76%; 95% CI, 62%-90%), and cardiomegaly on chest radiograph (pooled sensitivity, 89%; 95% CI, 73%-100%). Based on 1 study, the presence of pulsus paradoxus greater than 10 mm Hg in a patient with a pericardial effusion increases the likelihood of tamponade (likelihood ratio, 3.3; 95% CI, 1.8-6.3), while a pulsus paradoxus of 10 mm Hg or less greatly lowers the likelihood (likelihood ratio, 0.03; 95% CI, 0.01-0.24).

Conclusions: Among patients with cardiac tamponade, a minority will not have dyspnea, tachycardia, elevated jugular venous pressure, or cardiomegaly on chest radiograph. A pulsus paradoxus greater than 10 mm Hg among patients with a pericardial effusion helps distinguish those with cardiac tamponade from those without. Diagnostic certainty of the presence of tamponade requires additional testing.

12. JCAHO Tweaks Emergency Departments’ Pneumonia Treatment Standards

Mike Mitka. JAMA. 2007;297:1758-1759.

A performance measure for emergency departments’ treatment of pneumonia is being modified in hopes of better reflecting the true quality of care administered. But will it do so?

At issue is a measure established by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) involving the timing of administration of antibiotics to patients diagnosed with community-acquired pneumonia. When originally issued in 2004, meeting the standard (known as PN-5b) required giving patients who present to an emergency department and are discharged with a diagnosis of pneumonia an antibiotic within 4 hours of presentation. The standard was developed after publication of 2 large retrospective studies showing an association between antibiotic timing and outcomes in patients with pneumonia.

Beginning this month, JCAHO is expanding the antibiotic administration window to the first 6 hours following patient presentation. The agency also will allow a new data element, “diagnostic uncertainty,” if an emergency physician documents that the diagnosis of pneumonia was not clear at the time of the patient’s arrival in the emergency department.

Cases designated as having “diagnostic uncertainty” will not be included in calculations of an emergency department’s success or failure rate regarding the timing of antibiotic administration for pneumonia. This is important not only for emergency departments fulfilling certain quality certifications but also could play a big role in the future as the Centers for Medicare and Medicaid Services introduces “pay-for-performance,” a program for disbursing Medicare funds to hospitals depending, in part, on how well they meet various quality measures, such as timely antibiotic administration for pneumonia.

The antibiotic timing element has frustrated many emergency departments since its inception. Emergency physicians and researchers have argued that this requirement does not reflect real-word experiences of facilities, even those offering high-quality care. They suggest the time limit can have unintended consequences that result in poorer emergency department care of patients without pneumonia, said Jesse M. Pines, MD, an emergency physician at the Hospital of the University of Pennsylvania in Philadelphia. “This is a huge issue in emergency departments,” Pines said. “Because of overcrowding, they are creating protocols where they prioritize pneumonia patients over others.”

INCREASING RESISTANCE?

Another concern is that the time pressure could lead to unnecessary treatment for patients with suspected pneumonia who ultimately receive a different diagnosis, potentially contributing to antibiotic resistance. A retrospective case series study of the UCSF (University of California, San Francisco) Medical Center released in March found the facility was unable to achieve a self-imposed goal of achieving a 90% success rate in giving antibiotics to patients with pneumonia within 4 hours of emergency department presentation (Fee C and Weber EJ. Ann Emerg Med, published online ahead of issue January 8, 2007). In the study of patients admitted to the emergency department during 2005 with an initial diagnosis of community-acquired pneumonia documented at or before admission, only 99 of 152 (65.1%) received antibiotics within the 4-hour time frame. The other 53 patients received antibiotics after 4 hours; and of these patients, 31 (58.5%) received a final diagnosis that was not pneumonia.

“It became clear to me that we’d never hit our 90% core measure without giving inappropriate doses of antibiotics,” said lead author Christopher Fee, MD, assistant clinical professor of medicine in the Division of Emergency Medicine at the University of California, San Francisco. The 90% core measure is the level signifying quality of care recommended by the University
Health Consortium, an alliance of 97 academic medical centers and 153 of their affiliated hospitals, Fee explained.

13. Single Fascia Iliaca Compartment Block for Post-Hip Fracture Pain Relief

Monzon DG, et al. J Emerg Med 2007;32:257-62.

Introduction
More than 500,000 hip fractures occur annually in the United States. About 80% of the fall-related fractures occur in elderly women with osteoporosis. The mechanisms underlying hip fracture in the elderly are complex and multifactorial, involving an interaction between risks for falling and an age-associated decline in bone and muscle mass (possibly related to increased intake of animal proteins), and impairment of neuromuscular function.

Hip fractures usually cause considerable pain. Untreated or under-treated pain and potent systemic analgesics can increase the risk of delirium, especially in elderly patients. The relationship of pain relief to decreased morbidity and mortality remains controversial. The benefits of the acute analgesia play an important role in patient comfort. It permits clinicians to take a more accurate history and do a better physical examination, improves systemic vital signs, and avoids the intense use of non-steroidal analgesics (with the accompanying risk of epigastric pain and coagulation abnormalities), or opioids (altering the sensorium). Therefore, the physician’s goal to relieve pain whenever possible in the most rapid and least damaging manner suggests that a safe and easily performed regional block, rather than mind-altering systemic analgesics, may be a very effective tool.

Pain control is often not a high priority and systemic analgesics can cause or complicate problems, especially in the elderly population most susceptible to hip fractures. Elderly patients (50 years or older) with hip fractures report a 50% to 70% incidence of “severe to very severe” pain in the first 24 h post-injury. Although narcotics continue to be the mainstay for pre- and post-operative pain relief, in this patient group, avoiding or using very low doses of opioids to treat pain significantly decreases the risk to them of developing delirium.

Abstract
Hip fractures can cause considerable pain when untreated or under-treated. To enhance pain relief and diminish the risk of delirium from typically administered parenteral analgesics and continued pain, we tested the efficacy of using fascia-iliaca blocks (FICB), administered by one of four attending physicians working in the emergency department (ED), with commonly available ED equipment. After informed consent, a physician administered one FICB to 63 sequential adult ED patients (43 women, 20 men; ages 37–96 years, mean 73.5 years) with radiographically diagnosed hip fractures.

Under aseptic conditions, a 21 g, 2-inch IM injection needle was inserted perpendicularly to the skin 1 cm below the juncture of the lateral and medial two-thirds of a line that joins the pubic tubercle to the anterior superior iliac spine. The needle was inserted until a loss of resistance was felt twice (fascia lata and fascia iliaca), at which point 0.3 mL/kg of 0.25 bupivacaine was infused. The physician tested the block’s efficacy by assessing sensory loss. Pain assessments were done using a 10-point Likert Visual Analog Scale (VAS) before, and at 15 min, 2 h, and 8 h post-block. Block failure was having the same level of pain as before the block. Oral analgesics were administered as needed. The IRB approved this study.

Post-procedure pain was reduced in all patients, but not completely abolished in any. Before the FICB, the pain ranged from 2 to 10 points (average 8.5) using the VAS; at 15 min post-injection, it ranged from 1 to 7 points (average 2.9); at 2 h post-injection, it ranged from 2 to 6 points (average 2.3); at 8 h post-injection, it ranged from 4 to 7 points (average 4.4). Analgesic requests in the first 24 h after admission averaged 1.2 doses (range 1 to 4 doses) of diclofenac 75 mg. There were no systemic complications and only two local hematomas. Resident physicians learned the procedure and could perform it successfully with less than 5 min instruction. Physicians rarely use the FICB in EDs, although the technique is simple to learn and use. This rapid, effective, and safe method of achieving excellent pain control in ED patients with hip fractures can be performed using standard ED equipment.

14. Role of Early Supported Discharge in Acute Stroke Patients

Stead LG, et al. Ann Emerg Med 2007;49:693-5.

Conclusions
Selected stroke patients in a hospital setting who received input from an early supported discharge service returned home earlier than those receiving conventional care. They were also less likely to be in institutional care; they had decreased risk of death or dependency, at approximately 5 to 6 per 100 in whom intervention was undertaken. Not surprisingly, the greatest benefit was noted in patients with mild to moderate disability who had the most tightly coordinated early supported discharge. The multidisciplinary and structured nature of early supported discharge also appears to increase the patient, but interestingly not caregiver, satisfaction, perhaps because the burden of care would start earlier for the caregiver. The benefits of these results are masked by the fact that patients with less initial disability were recruited and conclusions were based on a relatively small number of trials.

Commentary: Clinical Implication
Stroke is the third leading cause of death in the United States and a major cause of serious, long-term disability. Successful acute stroke intervention depends on early recognition of symptoms, prompt emergency transport, and rapid in-hospital treatment. Considering this increase in incidence, extensive research has been performed to improve patient care and functional outcome. RCTs have shown that care of stroke patients in dedicated stroke units improves outcome compared with alternative forms of care and that beneficial effects are still detectable 5 years after stroke.

This Cochrane review of early discharge after the initial stroke unit care demonstrates that home-based rehabilitation and care is beneficial for patients, especially for those with mild symptoms. Physical and psychosocial elements of the environment influence patients’ ability to perform desired activities and attain targeted levels of participation during rehabilitation. It has also been suggested that increased patient involvement in control of rehabilitation has a better outcome and that diminished control can have an adverse effect on emotional and physical health. Home-based rehabilitation is shown to increase motor and functional gain, with community reintegration and a better perception of physical health.

This systematic review is important to emergency physicians because it highlights the need for stroke care to begin as early as possible, with the emergency physicians identifying and initiating goal-directed management in the emergency department (ED) itself. According to the initial presentation and disability, potential candidates for early supported discharge can be identified. Physical support and rehabilitation units should also be contacted early to enable early supported discharge. Communication can be sent to the stroke unit and rehabilitation department on presentation to the ED. Results of this review lend themselves to the creation of a streamlined protocol whereby the appropriate services such as neurology, physical medicine and rehabilitation, social services, speech and occupational therapy, and psychology could be automatically deployed as early as ED presentation.

The most important limitations in the application of these results stem from the fact that they are based on a limited number of studies and their estimates are influenced by the admission disability. For example, an overall decrease in hospital length of stay is noted. Some of this is influenced by the local practices of individual countries; in countries in which the hospital length of stay is already shorter than “average,” the same benefit may not be possible. Furthermore, the decrease in shorter hospitalization lengths is primarily driven by the more severe strokes, and one questions whether shorter stays for the sickest patients are truly possible or beneficial. Another limitation is that patients with missing data for death outcomes were assumed to be alive and independent, which would bias the benefit of early supported discharge measures. These concerns notwithstanding, the concept of early supported discharge, which requires the formal cooperation of all those involved in the care of a stroke victim, is a proactive approach that deserves further study.

Take-Home Message
With an increase in the incidence of strokes, emergency physicians can expect to encounter more cases in the ED. According to this review, early initiation of supported discharge measures in the ED, in addition to conventional care, may reduce the total duration of hospital stay and thus reduce the overall cost of hospitalization, depending on the initial presentation and disability. Some might argue that large RCTs in this patient population are urgently needed to answer this question definitively; however, in the meantime, this is yet another example of the need for emergency physicians to link with their specialist colleagues to improve the care provided to patients from the time they present to the ED.

15. Comparison of Oral Prednisolone/Paracetamol [APAP] and Oral Indomethacin/Paracetamol Combination Therapy in the Treatment of Acute Goutlike Arthritis: A Double-Blind, RCT

Man CY, et al. Ann Emerg Med 2007;49:670-677.

Background
Acute gouty arthritis is a crystal-induced inflammation of the joint that primarily affects middle-aged and elderly adults. It is the commonest cause of inflammatory joint disease in men older than 40 years. It has been estimated that the overall prevalence in the United Kingdom is 10 per 1,000, with men affected more commonly than women. The diagnosis of acute gout is typically made clinically by the presence of rapid onset of severe pain, swelling, and erythema of an affected joint and definitively by demonstrating the presence of negatively birefringent uric acid crystals in aspirated joint fluid. The diagnosis is often made in the absence of joint aspiration because this procedure is painful, poorly tolerated by some patients, and declined by others and is sometimes difficult or inconvenient to perform in a busy emergency department (ED). The treatment of such patients is inconsistent, and evidence-based guidelines to support clinical management are lacking. Gout is an increasingly prevalent condition worldwide and creates a heavy economic burden.

Importance
Oral nonsteroidal antiinflammatory drugs (NSAIDs) administered in high doses are recommended as first-line agents in the management of gout but may be contraindicated because of gastrointestinal hemorrhage or renal failure. Oral colchicine may be as effective as NSAIDs but is limited by toxicity at higher doses. Intraarticular corticosteroids may also be administered for monoarticular disease and intramuscular corticosteroids for podagra. A few small controlled studies have compared oral NSAIDs with intraarticular or intramuscular steroids and suggest that NSAIDs are as effective as steroids in the treatment of acute gout. However, NSAIDs have a significant rate of adverse effects, including gastric irritation, gastrointestinal hemorrhage, and renal failure. Although steroids cause severe adverse events if taken at high doses for long periods, there appear to be few adverse effects if they are taken in low to moderate doses for short periods. The gastrointestinal adverse effects also appear to be less severe than those of NSAIDs. Long-term effects, such as osteoporosis and muscle wasting, are not relevant to acute gout treatment. Oral NSAIDs have not been compared to oral steroids in the management of acute gout.

Editor’s Capsule Summary
What is already known on this topic: Acute gouty arthritis is typically treated with nonsteroidal antiinflammatory agents, though prednisone has also been recommended. Their relative efficacy is unknown.

What question this study addressed: The efficacy and adverse effects of oral prednisolone and oral indomethacin in the treatment of acute goutlike arthritis in emergency department patients.

What this study adds to our knowledge: In this 90-patient randomized controlled trial, the treatments exhibited similar efficacy. Adverse effects were more common in patients given indomethacin, including gastrointestinal bleeding in 11%.

How this might change clinical practice: A short course of prednisolone is at least as effective as indomethacin and may be safer.

Study objective
We compare the analgesic efficacy and adverse effects of oral prednisolone/acetaminophen and oral indomethacin/acetaminophen combination therapy in the treatment of acute goutlike arthritis in patients presenting to an emergency department (ED).

Methods
This is a double-blind, randomized, controlled study in a university hospital emergency department (ED) in the New Territories of Hong Kong. Patients older than 17 years and presenting between February 1, 2003, and June 30, 2004, with a clinical diagnosis of goutlike arthritis were randomized to receive either oral prednisolone/acetaminophen or oral indomethacin/acetaminophen combination therapy. Primary outcome measures were pain scores, time to resolution of symptoms and signs, and adverse effects. Secondary outcome measures were the need for additional acetaminophen and relapse rate.

Results
There were 90 patients randomized: 46 patients to the indomethacin group and 44 patients to the prednisolone group. Baseline characteristics, including pain scores, were similar in the 2 groups. Both treatment groups had a similar decrease in pain score in the ED. The mean rate of decrease in pain score with activity for indomethacin was −1.7±1.6 (SD) mm per day and for prednisolone was −2.9±2.0 (SD) mm per day (mean difference 1.2 mm/day; 95% confidence interval 0.4 to 2.0 mm/day; P=.0026). Although these differences were statistically significant, at no time was the difference in mean pain score greater than 13 mm. Therefore, it is unclear whether these differences are clinically significant. The mean total dose of acetaminophen consumed by the prednisolone group was significantly more than in the indomethacin group (mean 10.3 g, range 1 to 21 g versus mean 6.4 g, range 1 to 21 g). Twenty-nine patients in the indomethacin group and 12 patients in the prednisolone group experienced adverse effects (P less than .05). The commonest adverse effects in the indomethacin group were nausea, indigestion, epigastric pain, dizziness, and gastrointestinal bleeding (N=5; 11%). None of the patients in the prednisolone group developed gastrointestinal bleeding. The relapse rate for both groups was similar.

Conclusion
In the treatment of acute goutlike arthritis, oral prednisolone/acetaminophen combination is as effective as oral indomethacin/acetaminophen combination in relieving pain but is associated with fewer adverse effects.

16. Decline in Rates of Death and Heart Failure in Acute Coronary Syndromes, 1999-2006

Fox KA, et al, for the GRACE Investigators. JAMA. 2007;297:1892-1900.

Context: Randomized trials provide robust evidence for the impact of pharmacological and interventional treatments in patients with ST-segment elevation and non–ST-segment elevation acute coronary syndromes (NSTE ACS), but whether this translates to changes in clinical practice is unknown.

Objective: To determine whether changes in hospital management of patients with ST-segment elevation myocardial infarction (STEMI) and NSTE ACS are associated with improvements in clinical outcome.

Design, Setting, and Patients: In the Global Registry of Acute Coronary Events (GRACE), a multinational cohort study, 44 372 patients with an ACS were enrolled and followed up in 113 hospitals in 14 countries between July 1, 1999, and December 31, 2006.

Main Outcome Measures: Temporal trends in the use of evidence-based pharmacological and interventional therapies; patient outcomes (death, congestive heart failure, pulmonary edema, cardiogenic shock, stroke, myocardial infarction).

Results: Use of pharmacological medications increased over the study period (beta-blockers, statins, angiotensin-converting enzyme inhibitors, thienopyridines with or without percutaneous coronary intervention [PCI], glycoprotein IIb/IIIa inhibitors, low-molecular-weight heparin; all P less than .001). Pharmacological reperfusion declined in patients with STEMI by –22 percentage points (95% confidence interval [CI], –27 to –17), whereas primary PCI increased by 37 percentage points (95% CI, 33-41). In patients with non-STEMI, rates of PCI increased markedly by 18 percentage points (95% CI, 15-20). Rates of congestive heart failure and pulmonary edema declined in both populations: STEMI, –9 percentage points (95% CI, –12 to –6) and NSTE ACS, –6.9 percentage points (95% CI, –8.4 to –4.7). In patients with STEMI, hospital deaths decreased by 18 percentage points (95% CI, –5.3 to –1.9) and cardiogenic shock by –24 percentage points (95% CI, –4.3 to –0.5). Risk-adjusted hospital deaths declined –0.7 percentage points (95% CI, –1.7 to 0.3) in NSTE ACS patients. Six-month follow-up rates declined among STEMI patients: stroke by –0.8 percentage points (95% CI, –1.7 to 0.1) and myocardial infarction by –2.8 percentage points (95% CI, –6.4 to 0.9). In NSTE ACS, 6-month death declined –1.6 percentage points (95% CI, –3.0 to –0.1) and stroke by 0.7 percentage points (95% CI, –1.4 to 0.1).

Conclusions: In this multinational observational study, improvements in the management of patients with ACS were associated with significant reductions in the rates of new heart failure and mortality and in rates of stroke and myocardial infarction at 6 months.

17. Optic Nerve Sheath Test Identifies Increased Intracranial Pressure

NEW YORK (Reuters Health) May 02 - Sonographic measurement of optic nerve sheath diameter accurately detects increased intracranial pressure in adult patients after head injury, according to a new report.

Although still investigational, measurement of optic nerve sheath diameter is an example of how ultrasound can be applied to common clinical problems, Dr. Vivek S. Tayal from Carolinas Medical Center, Charlotte, North Carolina told Reuters Health.

Dr. Tayal and colleagues investigated whether dilation of the optic nerve sheath, detected in the emergency department with a bedside ultrasonographic measurement, could accurately predict elevated intracranial pressure imaged with cranial CT in 59 adult patients after acute head trauma.

Bedside ultrasonography accurately identified all 8 patients that had CT findings of elevated intracranial pressure, the authors report, for a sensitivity of 100%, they report in the April Annals of Emergency Medicine. In contrast, clinical assessment by treating physicians identified only 2 of the patients with elevated intracranial pressure (sensitivity, 25%), the results indicate.

Both optic nerve sheath diameter and clinical assessment had similar numbers of false-positive results (their specificities for identifying elevated intracranial pressure were 63% and 75%, respectively), the researchers note. The sensitivity of mean binocular optic nerve sheath diameter of 5.00 mm or more for any traumatic intracranial injury found by CT was 84% and the specificity was 73%, the report indicates.

"The answer, so far (I would emphasize this is preliminary work), is that if the optic nerve sheath diameter is high, you need further imaging," Dr. Tayal said. "If the optic nerve sheath diameter is below 5 mm, at least by this work, there is no elevated intracranial pressure."

Ann Emerg Med 2007;49:508-514.

18. Risk Score Useful in Assessing Chest Pain With Normal Troponin Levels

NEW YORK (Reuters Health) Apr 27 - A new risk scoring system is useful in predicting the outcomes of patients with non-ST-segment elevation chest pain and normal troponin levels, according to a recent report.

Dr. Juan Sanchis of the Universitat de Valencia and colleagues in Barcelona, Spain categorized a group of 1,449 patients with chest pain related to non-ST-segment elevation into four groups. A risk score was calculated based on five variables related to death or myocardial infarction at one year:

-- Group 1 had no ST depression, normal troponin and a risk score below 3 (633 patients);

-- Group 2 had no ST depression, a normal troponin level but a risk score of 3 or higher (158 patients);

-- Group 3 had no troponin increase and no ST depression (106 patients); and

-- Group 4 had a troponin increase (552 patients).

Mean follow-up was 26 months. Adverse events at 30 days had occurred in 1.7% of the first group, 10.8% of the second group, 6.6% of the third group and 9.5% of the fourth group. Adverse events at long-term follow-up occurred in 9.4%, 26%, 30% and 25% of groups 1, 2, 3 and 4, respectively. There were no differences in long-term outcome between groups 2, 3 and 4.

Dr. Sanchis' team concludes, in the March 15th issue of the American Journal of Cardiology, that "application of a risk score to patients without troponin increase or ST deviation identified a high-risk group with prognosis similar to that of patients with troponin increase or ST depression and affords a practical classification for the full spectrum of non-ST-elevation chest pain."

Am J Cardiol 2007;99:797-801.

How do they calculate their risk score? Here’s the abstract from an earlier publication:

OBJECTIVES: The purpose of this research was to develop a risk score for patients with chest pain, non-ST-segment deviation electrocardiogram (ECG), and normal troponin levels.

BACKGROUND: Prognosis assessment in this population remains a challenge.

METHODS: A total of 646 consecutive patients were evaluated by clinical history (risk factors and chest pain score according to pain characteristics), ECG, and early exercise testing. ST-segment deviation and troponin elevation were exclusion criteria. The primary end point was mortality or myocardial infarction at one year. The secondary end point was mortality, myocardial infarction, or urgent revascularization at 14 days (similar to the Thrombolysis In Myocardial Infarction [TIMI] risk score).

RESULTS: Primary and secondary end point rates were 6.7% and 5.4%. A risk score was constructed using the variables related to the primary end point: chest pain score 10 points or greater (hazard ratio [HR] = 2.5; 1 point), 2 or more pain episodes in last 24 h (HR = 2.2; 1 point), age 67 years or greater (HR = 2.3; 1 point), insulin-dependent DM (HR = 4.2; 2 points), and prior PTCA (HR = 2.2; 1 point). Patients were classified into five categories of risk (p = 0.0001): 0 points, 0% event rate; 1 point, 3.1%; 2 points, 5.4%; 3 points, 17.6%; 4 or more points, 29.6%. The accuracy of the score was greater than that of the TIMI risk score for the primary (C index of 0.78 vs. 0.66, p = 0.0002) and secondary (C index of 0.70 vs. 0.66, p = 0.1) end points.

CONCLUSIONS: Patients presenting with chest pain despite no ST-segment deviation or troponin elevation show a non-negligible rate of events at one year. A risk score derived from this specific population allows more accurate stratification than when using the TIMI risk score.

Sanchis J, et al. New risk score for patients with acute chest pain, non-ST-segment deviation, and normal troponin concentrations: a comparison with the TIMI risk score. J Am Coll Cardiol. 2005;46:443-9. Full-text: http://content.onlinejacc.org/cgi/reprint/46/3/443

19. Guidelines Updated for Treatment of Spontaneous Intracerebral Hemorrhage in Adults

Laurie Barclay, MD. May 3, 2007 — The American Heart Association (AHA) and American Stroke Association have issued updated evidence-based guidelines for treatment of spontaneous intracerebral hemorrhage (ICH) in adults. The new recommendations, which update the first AHA guidelines for the management of spontaneous ICH published in 1999, are published in the May 3 Stroke ASAP issue and will appear in the June print issue of Stroke.

Recommendations for initial medical therapy for ICH are as follows:

-- Manage blood pressure based on the presently available incomplete evidence, pending results from ongoing clinical trials of blood pressure intervention for ICH.

-- In 1 moderate-sized phase 2 trial, treatment with recombinant activated factor VII within the first 3 to 4 hours after onset appeared to slow progression of bleeding. However, the efficacy and safety of this treatment must be confirmed in phase 3 trials before its use in ICH can be recommended outside of a clinical trial (IIb, B).

-- Use protamine sulfate to reverse heparin-associated ICH, with the dose depending on the time from cessation of heparin (I, B).

-- To reverse the effects of warfarin, treat patients who have warfarin-associated ICH with intravenous vitamin K and with treatment to replace clotting factors (I, B).

-- Prothrombin complex concentrate, factor IX complex concentrate, and recombinant activated factor VII normalize the laboratory elevation of the international normalized ratio very rapidly and with lower volumes of fluid than fresh frozen plasma. However, potential of thromboembolism is greater. Fresh frozen plasma is an option but is associated with greater volumes and much longer infusion times (II, B).

"The first scientifically proven treatments for acute ICH are likely to become a reality during the next 5 years, and possibly sooner for some, such as rFVIIa," the authors conclude. "New trials of antihypertensive therapy, surgical removal of ICH, and other adjunctive therapies are ongoing, but sustained efforts are needed to decrease the high morbidity and mortality rates associated with this deadly type of stroke."

Stroke. Published online May 3, 2007. Full-text: http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.107.183689

20. Busy Admission Days May Jeopardize Patient Safety at Overloaded Hospitals

Weissman JS, et al. Med Care. 2007;45:448-455.

NEW YORK (Reuters Health) May 04 - At hospitals already running at full or over capacity, high admission rates and low staffing levels are associated with an increased risk of adverse patient events, according to report in the May issue of Medical Care.

"While financial and political pressures to make healthcare more efficient are leading to increased hospital occupancy and greater patient turnover, patients and policymakers are quite rightly demanding that health delivery systems be made safer," lead author Dr. Joel Weissman, from Massachusetts General Hospital in Boston, said in a statement. He added, "Our study suggests that pushing efficiency efforts to their limits could be a double-edged sword that may jeopardize patient safety."

The findings stem from an analysis of outcomes for 6841 patients who were discharged between October 2000 and September 2001 from two urban and two suburban teaching hospitals in the US. The daily workload of each hospital was assessed on four parameters: volume (enhanced occupancy rate), throughput (a measure of admissions and discharges), intensity (aggregate diagnosis related group weight), and the patient-to-nurse ratio.

Adverse events were catalogued from chart reviews and included 18 types of injury secondary to medical care (not a result of a patient's underlying condition), and included items such as wound infection, operative injury, postoperative shock, pulmonary embolism, and falls. In total, 1530 adverse events were identified.

The authors found that one of the urban centers had particularly high occupancy rates. Throughout much of the 1-year study period, this hospital was operating at or beyond its designated capacity. At this high-occupancy center, admissions and the patient-to-nurse ratio were directly linked to the adverse event rate (p less than 0.05). For example, for each 10% rise in the patient-to-nurse ratio, the adverse event rate rose 28%. By contrast, these workload variables had little effect on risk at the other three hospitals with lower occupancy rates.

"These data suggest that high workload may be risky at organizations with little slack, and suggest that administrators should adopt an array of measures to try to minimize risk under these circumstances," Dr. Weissman and colleagues conclude.

21. Forced versus minimal intravenous hydration in the management of acute renal colic: a randomized trial.

Springhart WP, et al. J Endourol. 2006;20:713-6.

BACKGROUND AND PURPOSE: The management of acute renal colic is a problem commonly encountered by both urologists and emergency medicine physicians. The classic approach to managing uncomplicated acute renal colic involves hydration, along with imaging and pain control. Previous studies have suggested that hydration has a significant impact on patient comfort, as well as spontaneous stone passage. This study evaluated the effects of maintenance v forced hydration and its effect on the pain experienced from renal colic.

PATIENTS AND METHODS: Forty male and 18 female patients with a mean age of 41 years suspected to have acute renal colic were identified in the emergency department. After screening and informed consent, the patients were enrolled in the study, and 43 patients were eventually available for analysis. Patients received intravenous (IV) analgesia, imaging with a noncontrast CT scan of abdomen and pelvis, and assignment to either forced IV hydration with 2 L of normal saline over 2 hours (N = 20) or minimal IV hydration at 20 mL of normal saline per hour (N = 23). A visual analog pain scale was completed hourly for a total of 4 hours. Demographic information, laboratory and imaging results, narcotic use in morphine equivalents (ME), and pain scores were recorded and compared. Spontaneous stone passage rates were also calculated by careful patient follow-up. Results were considered statistically significant at p less than 0.05.

RESULTS: Stone size was equivalent in the two treatment groups (p greater than 0.05). There was no difference in the narcotic requirement in ME (p = 0.644) between the two groups. Similarly, there was no difference in hourly pain score or stone-passage rates between the groups (p greater than 0.05).

CONCLUSIONS: Treatment of uncomplicated renal colic has traditionally included vigorous intravenous hydration, as well as medications for the control of pain and nausea. Our data suggest that maintenance intravenous fluids are as efficacious as forced hydration with regard to patient pain perception and narcotic use. Moreover, it appears the state of hydration has little impact on stone passage.