Lit Bits: July 28, 2007

From the recent medical literature...

1. Following JCAHO Guidelines for Pneumonia Leads to Wrong Diagnoses, Wrong Treatments

NEW YORK (Reuters Health) Jul 04 - Physicians in Detroit have found that tight adherence to guidelines for managing community-acquired pneumonia (CAP) - such as initiating antibiotics within 4 hours of registration in the emergency department (ED) - raises the risk of misdiagnosis and inappropriate use of antibiotics.

Dr. Mohamad G. Fakih and associates at St. John Hospital and Medical Center looked at outcomes of patients admitted to the ED with a diagnosis of CAP during 6-month periods prior to and after publication of the guidelines. There were 199 patients treated between January and June, 2003, and 319 patients treated between January and June, 2005.

"We have seen almost a 60% increase in the hospital admitting diagnosis of CAP compared to a less than 25% increase in the hospital discharge diagnosis of CAP," the research team reports in the June issue of Chest.

Results showed that the goal of starting antibiotic treatment within 4 hours increased from 54% to 66% in the latter period (p = 0.007).

However, more patients in 2005 had a diagnosis of CAP without radiographic abnormalities (28.5% versus 20.6%, p = 0.04). Of those misdiagnosed, only a minority were diagnosed with any type of infection, implying inappropriate antibiotic utilization.

Dr. Fakih's group observed no significant improvement over time in average hospital length of stay or in-hospital mortality. They therefore advocate a 6-hour window between arrival at the ED and administration of antibiotics as a more feasible target.

"This target may provide more time for physicians to provide a better evaluation of the patient," Dr. Fakih and his colleagues write.

Chest 2007;131:1865-1869.

2. "America's Best Hospitals" in the Treatment of Acute Myocardial Infarction

Wang OJ, et al. Arch Intern Med. 2007;167:1345-1351.

Background: The ranking of "America's Best Hospitals" by U.S. News & World Report for "Heart and Heart Surgery" is a popular hospital profiling system, but it is not known if hospitals ranked by the magazine vs nonranked hospitals have lower risk-standardized, 30-day mortality rates (RSMRs) for patients with acute myocardial infarction (AMI).

Methods: Using a hierarchical regression model based on 2003 Medicare administrative data, we calculated RSMRs for ranked and nonranked hospitals in the treatment of AMI. We identified ranked and nonranked hospitals with standardized mortality ratios (SMRs) significantly less than the mean expected for all hospitals in the study.

Results: We compared 13 662 patients in 50 ranked hospitals with 254 907 patients in 3813 nonranked hospitals. The RSMRs were lower in ranked vs nonranked hospitals (16.0% vs 17.9%, P less than 0.001). The RSMR range for ranked vs nonranked hospitals overlapped (11.4%-20.0% vs 13.1%-23.3%, respectively). In an RSMR quartile distribution of all hospitals, 35 ranked hospitals (70%) were in the lowest RSMR or best performing quartile, 11 (22%) were in the middle 2 quartiles, and 4 (8%) were in the highest RSMR or worst performing quartile. There were 11 ranked hospitals (22%) and 28 nonranked hospitals (0.73%) that each had an SMR significantly less than 1 (defined by a 95% confidence interval with an upper limit of less than 1.0).

Conclusions: On average, admission to a ranked hospital for AMI was associated with a lower risk of 30-day mortality, although about one-third of the ranked hospitals fell outside the best performing quartile based on RSMR. Although ranked hospitals were much more likely to have an SMR significantly less than 1, many more nonranked hospitals had this distinction.

3. Rocephin Plus Calcium Linked to Fatal Reactions in Neonates

BETHESDA, MD -- July 6, 2007 -- Roche and FDA informed healthcare professionals of revisions to the Contraindications, Warnings, Precautions, Adverse Reactions and Dosage and Administration sections of the prescribing information for Rocephin for Injection.

The revisions are based on new information that describes the potential risk associated with concomitant use of Rocephin with calcium or calcium containing solutions or products. Cases of fatal reactions with calcium-ceftriaxone precipitates in the lungs and kidneys in both term and premature neonates were reported. Hyperbilirubinemic neonates, especially prematures, should not be treated with Rocephin.

The drug must not be mixed or administered simultaneously with calcium-containing solutions or products, even via different infusion lines. Additionally, calcium-containing solutions or products must not be administered within 48-hours of the last administration of ceftriaxone.

In vitro studies have shown that ceftriaxone can displace bilirubin from binding to serum albumin, potentially leading to bilirubin encephalopathy, the FDA said. Use of ceftriaxone is therefore contraindicated in hyperbilirubinemic neonates, especially those who are premature.

4. Diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: a 2-year experience

Adhikari S, et al. Amer J Emerg Med. 2007;25:591-596.

Objectives: The objective of this study was to describe diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasound (US) in an established emergency US program.

Methods: This was a retrospective study on patients presenting over a 2-year period performed at a level I urban academic emergency department (ED). The ED sees 78000 patients annually and has a residency and active US program. Patients were eligible for inclusion if they were pregnant, seen in the ED for a first-trimester complication, and underwent a bedside emergency US suggesting an ectopic pregnancy. Emergency department US logs were reviewed for findings suggestive of ectopic pregnancy. Medical records were reviewed for history, physical examination findings, laboratory results, additional diagnostic testing, management, hospital course, and a discharge diagnosis by the admitting obstetric service (OB). Patients with incomplete data were excluded from analysis. Statistical analysis consisted of descriptive statistics.

Results: Seventy-four patients ranging in age from 16 to 39 years (mean, 25 years) were included in the study. Eight patients with incomplete data were excluded from analysis. Emergency-physician US diagnoses included definite ectopic pregnancy (6/74), probable ectopic pregnancy (28/74), and possible ectopic pregnancy (40/74). Forty-seven (64%) of these patients were eventually diagnosed with definite ectopic pregnancy by the OB. During initial consultation, the OB disagreed with the diagnosis of ectopic pregnancy in 15 (32%) of the 47 eventual patients with ectopic pregnancy, calling them miscarriages. Other eventual diagnoses included 9 (12%) patients with possible ectopic pregnancy, 11 (14%) patients with miscarriage, and 7 (9%) with intrauterine pregnancy. Emergency sonologists found tubal rings in 9 (19%) patients with eventual ectopic pregnancy, complex adnexal mass in 29 (61%) patients, and a large amount of echogenic fluid in the cul-de-sac in 10 (21%) patients. Six (13%) patients had live ectopic pregnancy. The OB ordered a radiology US in 10 cases but did not change the diagnosis or management. Beta-human chorionic gonadotropin (beta-hCG) levels ranged from 41 to 59846 mIU/mL (mean, 4602 mIU/mL), but for live ectopic pregnancy, the range was 2118 to 59846 mIU/mL (mean, 36341 mIU/mL). Seventeen (36%) patients had beta-hCG levels of lower than 1000 mIU/mL. Of 47 eventual ectopic pregnancies, 29 (62%) patients underwent operative intervention, 17 (36%) patients received methotrexate, and 1 patient left against medical advice. Five (11%) of these patients with definite ectopic pregnancy were initially managed by emergency physicians with follow-up ED visits and serial US examinations without OB consultation.

Conclusion: Our study demonstrates that with increased experience, emergency sonologists can accurately diagnose ectopic pregnancy. Furthermore, patients at risk for ectopic pregnancy should not be denied US examinations if their beta-hCG levels fall below an arbitrary discriminatory zone.

5. Dark Chocolate Associated with Lowered Blood Pressure

Small amounts of dark chocolate can modestly lower blood pressure in people with untreated hypertension, a small randomized trial in JAMA concludes.

Researchers studied 44 older adults who were assigned to eat either 6.3 grams of dark or white chocolate daily. The patients had untreated blood pressures in the upper prehypertension range or were in stage 1 hypertension. After 18 weeks, systolic blood pressure fell about 3 mm and diastolic 2 mm in those eating dark chocolate but did not change in the control group. The authors point to dark chocolate's role in increasing the production of nitric oxide in the vascular endothelium as a possible mechanism.

The authors note that the improvements were similar to those seen with comprehensive dietary modifications. Eating a little chocolate is easier and "may be a promising behavioral approach to lower blood pressure in individuals with above-optimal blood pressure," the authors write.

JAMA article (Free abstract; full text requires subscription): http://jama.ama-assn.org/cgi/content/short/298/1/49

6. The Clinical Features and Outcomes of ED Patients with Delayed Diagnosis of PE

Kline JA, et al. Acad Emerg Med. 2007;14:592-598.

Objectives: The authors hypothesized that emergency department (ED) patients with a delayed diagnosis of pulmonary embolism (PE) will have a higher frequency of altered mental status, older age, comorbidity, and worsened outcomes compared with patients who have PE diagnosed by tests ordered in the ED.

Methods: For 144 weeks, all patients with PE diagnosed by computed tomographic angiography were prospectively screened to identify ED diagnosis (testing ordered from the ED) versus delayed diagnosis (less than 48 hours postadmission). Serum troponin I level, right ventricular hypokinesis on echocardiography, and percentage pulmonary vascular occlusion were measured at diagnosis; patients were prospectively followed up for adverse events (death, intubation, or circulatory shock).

Results: Among 161 patients with PE, 141 (88%) were ED diagnosed and 20 (12%) had a delayed diagnosis. Patients with a delayed diagnosis were older than ED-diagnosed patients (61 [±15] vs. 51 [±17] years; p less than 0.001), had a longer median time to heparin administration (33 vs. 8 hours; p less than 0.001), and had a higher frequency of altered mental status (30% vs. 8%; p = 0.01) but did not have a higher frequency of prior cardiopulmonary disease (25% vs. 23%). Patients with a delayed diagnosis had equal or worse measures of PE severity (right ventricular hypokinesis on echocardiography, 60% vs. 58%; abnormal troponin I level, 55% vs. 24%); on computed tomographic angiography, ten of 20 patients with a delayed diagnosis had PE in lobar or larger arteries and more than 50% vascular obstruction. Patients with a delayed diagnosis had a higher rate of in-hospital adverse events (9% vs. 30%; p = 0.01).

Conclusions: In this single-center study, the diagnosis of PE was frequently delayed and outcomes of patients with delayed diagnosis were worse than those of patients with PE diagnosed in the ED.

7. An Elusive Balance — Residents' Work Hours and the Continuity of Care

Okie S. N Engl J Med. 2007; 356:2665-2667.

Four years after national limits on duty hours for medical residents took effect — and nearly two decades after similar limits were enacted by New York State — conversations with residency directors, attending physicians, health care researchers, and sleep-medicine experts suggest that neither patient care nor medical education is optimal under the current system and that further reforms are needed. But there is little agreement on what should be done or even on whether the work-hour limits should be tightened or relaxed.

U.S. teaching hospitals are handling more admissions, treating older and sicker patients, and discharging patients more quickly than in past decades — factors that have intensified residents' workload, despite the limitations in hours. "We're looking at whether the current limits need refining," said Ingrid Philibert, senior vice president for field activities at the Accreditation Council for Graduate Medical Education (ACGME), which accredits U.S. residency programs. The ACGME is "being pushed from both sides," she says, "by folks who think we've gone too far and by those who think we've not gone far enough."

One reason is that there are no reliable national data measuring the effects of the work-hour limitations on training or patient care. The rules were intended to improve patient safety by reducing medical errors and to enhance residents' educational experience and protect them from accidents, injuries, and other consequences of sleep deprivation. Sleep-medicine experts contend that U.S. residents still work too many hours — and that the currently permitted 30-hour shifts and 80-hour workweeks are unsafe for both doctors and patients. Residents in Europe work about 56 hours per week, and after August 2008, they will be allowed to work only 48 hours. Studies have documented that clinical performance suffers and errors increase when physicians are fatigued. "Twenty-four hours is too long" to be continuously on duty, said Steven Lockley of the Division of Sleep Medicine at Brigham and Women's Hospital in Boston. "You can only work appropriately for 16 to 18 hours."

There has been considerably less research, however, on whether preventable errors also increase when responsibility for patients is transferred repeatedly from one resident to another. Such "handoffs" have become much more frequent in teaching hospitals as a result of the scheduling changes made to comply with the work-hour rules (for example, the use of "night float" residents who admit patients during the night and pass them on to another team in the morning). At the University of California at San Francisco, for example, such changes in scheduling resulted in an average of 15 handoffs per patient during a 5-day hospitalization. Each intern was involved in more than 300 handoffs during an average month-long rotation, a 40% increase in the number reported before the duty-hour limits were in place.1 With 6 million patients receiving care in U.S. teaching hospitals annually, the impact on medical care is potentially large — but difficult to measure…

For the rest of the article (full-text free): http://content.nejm.org/cgi/content/full/356/26/2665

8. The value of loupe magnification: an underused tool in emergency medicine

Hart RG, et al. Amer J Emerg Med. 2007;25:705-707.

Study Objectives: Loupe magnification is widely used in medicine. Hand surgeons, in particular, use magnification for virtually all cases. The physical examination is more effective with magnification including improved tissue and foreign body identification. It is valuable for meticulous debridement of foreign material. Skin closure is much improved with more clearly identified wound edges. The detail and precision is vastly better allowing more ideal surgical repairs.

These principles could improve wound care quality for emergency physicians as well. This article will compare wound visualization with the naked eye and 2.5 magnification loupes to determine the relative value for an emergency physician.

Materials and Methods: Using a cadaver model, this article will compare relative visualization using no magnification and 2.5 loupe magnification. Comparative photographs will be used for identification of wound edges and anatomical structures.

Results: The photographs presented demonstrate relative visualization with the naked eye and the 2.5 loupes. These photographs demonstrate the advantage of magnification in wound care and closure. The only significant costs are the loupes which should not be a deterrent for emergency physicians.

Discussion: Loupe magnification is the standard for quality wound care and closure in hand surgery. They are also used in many other fields of medicine, including facial and plastic surgery. Magnification is now common and has proven effective. Emergency physicians, in general, have not readily embraced the use of magnification. Hand wounds and facial laceration repairs in the emergency department (ED) are 2 areas magnification could be particularly helpful. This study clearly demonstrates the relative advantage of magnification for tissue identification, debridement, and skin closure. Magnification is a potentially valuable tool in laceration repair in the ED. It greatly enhances results at minimal costs.

9. FDA Warns about Strange Propofol Reactions

FDA ALERT [6/15/2007] - FDA is issuing this alert to inform healthcare professionals about several clusters of patients who have experienced chills, fever, and body aches shortly after receiving propofol for sedation or general anesthesia.

FDA full-text: http://www.fda.gov/cder/drug/infopage/propofol/default.htm

10. Older Diabetes Drugs at Least as Effective as Newer Ones

Older oral drugs for type 2 diabetes are at least as effective as newer agents, according to a systematic review released early online in Annals of Internal Medicine.

The review included data from more than 200 studies of older diabetes agents (metformin and second-generation sulfonylureas) and newer drugs (e.g., thiazolidinediones). Among the findings:

--Most agents lowered hemoglobin A1c to a similar extent.
--Metformin was the only drug that decreased LDL cholesterol and one of the only ones that didn't increase body weight.
--Thiazolidinediones raised HDL cholesterol but also increased LDL cholesterol.
--Second-generation sulfonylureas were associated with greater risk for hypoglycemia; metformin with gastrointestinal symptoms; and thiazolidinediones with edema.

The authors conclude that metformin "seemed to have the best profile of benefit to risk." They note that metformin and sulfonylureas offer three advantages over newer agents: "lower cost, longer use in practice, and more intensive scrutiny in long-term trials."

Ann Intern Med article (Free): http://www.annals.org/cgi/content/full/0000605-200709180-00178v1

11. Low-risk Community-acquired Pneumonia in North American EDs: Macrolides are Fine…and Don’t Bother with Sputum Cultures

Rowe BH, et al. Acad Emerg Med. 2007;14:607-614.

Background: Limited information on antibiotic resistance of Streptococcus pneumoniae (SP) exists for patients discharged from emergency departments with community-acquired pneumonia.

Objectives: Using a standardized collection process, this study examined sputum microbiology in outpatient community-acquired pneumonia.

Methods: This was a multicenter, prospective cohort study conducted in North American emergency departments between December 2001 and May 2003. Thirty-one emergency departments enrolled patients older than 18 years with a Pneumonia Severity Index of I to III. All patients received oral clarithromycin and were followed up for four weeks. SP resistance to macrolides and penicillin was determined by a central laboratory.

Results: Among the 317 cultured sputum samples, 116 (37%; 95% confidence interval [CI] = 32% to 42%) grew an identifiable organism; 74 (23% of cultured cases; 95% CI = 19% to 28%) grew non-SP organisms and 42 grew SP organisms (SP positive; 13% of cultured cases; 95% CI = 10% to 17%). A total of 13 resistant organisms (4% of cultured cases; 95% CI = 2% to 6%) were identified. Resistance to macrolides occurred in nine patients (3% of cultured cases [95% CI = 1% to 5%]; 24% of SP-positive cases [95% CI = 11% to 37%]); and resistance to penicillin occurred in nine patients (3% of all sputum-positive cases [95% CI = 1% to 5%]; 21% of SP-positive cases [95% CI = 9% to 34%]). The four-week cure rates were similar in both groups.

Conclusions: Among outpatients with community-acquired pneumonia, half produced adequate sputum samples and most were culture negative. SP resistance was similar to rates from large national databases, and results were of little (if any) consequence. In low-risk Pneumonia Severity Index cases, sputum cultures should not be collected routinely.

12. Needlestick Injuries: Do We Respond Like Surgical Residents?

Makary MA, et al. N Engl J Med. 2007; 356:2693-2699.

Background: Surgeons in training are at high risk for needlestick injuries. The reporting of such injuries is a critical step in initiating early prophylaxis or treatment.

Methods: We surveyed surgeons in training at 17 medical centers about previous needlestick injuries. Survey items inquired about whether the most recent injury was reported to an employee health service or involved a "high-risk" patient (i.e., one with a history of infection with human immunodeficiency virus, hepatitis B or hepatitis C, or injection-drug use); we also asked about the perceived cause of the injury and the surrounding circumstances.

Results: The overall response rate was 95%. Of 699 respondents, 582 (83%) had had a needlestick injury during training; the mean number of needlestick injuries during residency increased according to the postgraduate year (PGY): PGY-1, 1.5 injuries; PGY-2, 3.7; PGY-3, 4.1; PGY-4, 5.3; and PGY-5, 7.7. By their final year of training, 99% of residents had had a needlestick injury; for 53%, the injury had involved a high-risk patient. Of the most recent injuries, 297 of 578 (51%) were not reported to an employee health service, and 15 of 91 of those involving high-risk patients (16%) were not reported. Lack of time was the most common reason given for not reporting such injuries among 126 of 297 respondents (42%). If someone other than the respondent knew about an unreported injury, that person was most frequently the attending physician (51%) and least frequently a "significant other" (13%).

Conclusions: Needlestick injuries are common among surgeons in training and are often not reported. Improved prevention and reporting strategies are needed to increase occupational safety for surgical providers.

13. FAFfing about: Avian flu versus AIDS.

One has caught the imagination of the public and the media, the other is a full blown epidemic and 60 million people are infected. The BMJ's deputy editor compares and contrasts.

Delamothe T. BMJ 2007;334 (30 June), doi:10.1136/bmj.39259.443646.47

Somewhere, I imagine, there's a small group of people proud to be counted among the Friends of Avian Flu, or FAF for short. I suspect they have a catchy mission statement, such as "Keeping the nightmare alive," and lapel badges of vaguely bird-like shape.

Their challenge is to keep bird flu forever in the public eye. This should be getting harder, as influenza H5N1 is proving particularly resistant to undergoing the killer mutation that would allow efficient human to human transmission of the virus. Ten years after the strain first appeared in humans, it has killed just 191 people. This is despite the most propitious of circumstances: millions of people and poultry living in very close proximity in South East Asia. Although these deaths are a tragedy for the victims and their families, it's as well to remember that a similar number of people die on the roads world wide every 84 minutes.

Traditionally, we've blamed the drug companies for talking up the risks of diseases, or even inventing diseases, but this is not the case with bird flu. The track record of oseltamivir (Tamiflu) as a treatment for H5N1 is decidedly mixed, and its use in seasonal flu has been linked to suicides and neuropsychiatric symptoms in Japanese teenagers. FAF has incorporated this pharmaceutical failure into its story for bird flu: The Drugs Don't Work. Be afraid. Be very afraid.

FAF knows that the best way to generate column inches is high profile scientific conferences with well oiled media machines, and in this week's BMJ Richard Smith, our previous editor, reports on a session he chaired at a conference of Health Technology Assessment International (doi: 10.1136/bmj.39255.606713.DB). Some of the observations were familiar: the inevitability of the pandemic and the possibility of drug resistance. But others were relatively new: the terminological mutation from "avian flu" to "pandemic flu," in recognition of H5N1's failure to mutate genetically.

H5N1 had been groomed for stardom, but now it can be any influenza strain that becomes pandemic, further details unknown. As influenza pandemics occurred in 1918, 1957, and 1968, another one is likely. But why should we be any more worried in 2007 than in 1997 or 2017? Couldn't those responsible for planning for the next pandemic do their planning less publicly and put the frighteners on the rest of us at the appropriate time?

For AIDS, however, it really is apocalypse now. Sceptics used to point out that there were more papers on AIDS than people with the condition, but that was a very long time ago. Sixty million people have now been infected with HIV and another 14,000 are acquiring the infection every day. A vaccine against HIV would seem the best way to halt the AIDS epidemic, but as Alison Tonks points out in her review, an effective vaccine is as far away as ever (doi: 10.1136/bmj.39240.416968.AD). The AIDS Vaccine Advocacy Coalition regards it as more challenging than landing a man on the moon. "When it came down to the space race, we knew where we were; we knew where the moon was; and we knew, roughly, how to get there. It was, essentially, an engineering problem. When it comes to an AIDS vaccine, we don't know where the moon is—yet."

14. One-Third of Primary Care Patients Report Insomnia

One-third of adults visiting primary care practices suffer from insomnia, according to a study in the current issue of the Journal of the American Board of Family Medicine.

More than 1900 adults at five primary care practices in North Carolina completed surveys on sleep problems. Participants were, on average, 50 years old; about two-thirds were female. Overall:

--34% had sleep maintenance insomnia, defined as typically waking up at least three times a night;

--28% experienced symptoms of restless legs syndrome once weekly or more;

--14% had sleep apnea symptoms at least monthly;

--37% dozed off during daily activities once a week or more.

The authors write that "effective management of sleep complaints involves screening, diagnosis, the search for and treatment of risk factors, and the identification and treatment of specific syndromes," such as restless legs syndrome or obstructive sleep apnea syndrome.

Journal of the American Board of Family Medicine article (Free): http://www.jabfm.org/cgi/content/full/20/4/365

15. Catheter Ablation for Afib: An Ongoing Debate

Pressure is mounting for physicians to use catheter ablation to treat atrial fibrillation — although for this indication, the procedure hasn't been approved, is controversial, and often isn't reimbursed completely, the New York Times reports.

The Heart Rhythm Society, in partnership with the American College of Cardiology, the American Heart Association, and three other medical groups, recently issued a consensus statement recommending catheter ablation for afib patients who do not respond to drug therapy and, in rare cases, as a first-line therapy.

Advocates say that, compared with drugs, atrial ablation does a better job of preventing recurrent fibrillation and is ultimately more cost-effective. Critics argue that early trials are promising but flawed and that outcomes may not be as positive as they appear.
The FDA will soon hold a public meeting on the off-label use of various devices and drugs to treat atrial fibrillation.

Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation (Free PDF): http://www.hrsonline.org/News/Media/press-releases/upload/HR-and-Euro-Copy-for-Print.pdf

16. BNP Useful in Emergency Dept Diagnosis of Heart Failure

NEW YORK (Reuters Health) Jul 17 - B-type natriuretic peptide (BNP) level can be useful in differentiating heart failure from other causes of dyspnea in patients presenting to the emergency department, according to a report in the June 26th issue of BMC Emergency Medicine.

Although several organizations have recommended the inclusion of BNP in the work-up of heart failure, the authors explain, some have questioned whether published results support its use.

Dr. Deborah Korenstein from Mount Sinai School of Medicine, New York and colleagues conducted a systematic review of the literature to summarize the available evidence about the sensitivity and specificity of BNP in diagnosing heart failure in the emergency department.

Ten studies involving 3344 patients met inclusion criteria.

Sensitivity of a BNP at a cutoff of 100 pg/mL for diagnosing heart failure (often cited as the best cutoff for this purpose) ranged from 86% to 96%, the authors report. This cutoff level was associated with a specificity ranging from 31% to 94%.

Lower cutoffs did not improve sensitivity, but specificity increased with higher cutoff levels. For example, the researchers note, cutoffs between 300 pg/mL and 400 pg/mL yielded specificities between 84% and 92%.

"Our determinations of the performance characteristics of BNP support the use of two diagnostic cutoffs," the authors conclude. "A lower cutoff to rule out heart failure and a higher cutoff to rule in heart failure is supported by the evidence and has, in fact, been adopted in practice guidelines."

BMC Emerg Med 2007;7. Full-text: http://www.biomedcentral.com/1471-227X/7/6

17. One Soft Drink a Day Raises Risk for Metabolic Syndrome

Middle-aged people who drink just one soft drink a day have a substantially increased risk for metabolic syndrome, a Circulation study finds.

The results, from the offspring cohort of the Framingham Heart Study, were released early online. The study found that adults drinking one or more soft drinks a day had a 48% higher prevalence of metabolic syndrome than those who drank them infrequently. The incidence of the metabolic syndrome was similarly increased among the cohort over 4 years of follow-up.

The study found that both regular and diet soda appear to carry similar metabolic hazards. The authors suggested several possible explanations for the association, including the idea that consuming sweet drinks increases preferences for other sweetened items. They say that lowering the consumption of soft drinks "may be associated with a lowering of the burden of metabolic risk factors in adults."

Abstract: http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.689935v1

18. First Episodes of Bronchiolitis in Infants: Steroids Don't Improve Outcomes

Infants presenting with first episodes of bronchiolitis do not benefit from dexamethasone, reports a study in the New England Journal of Medicine.

In the multicenter study, 600 infants aged 2 to 12 months who presented to the emergency department with first episodes of bronchiolitis were randomized to receive either a single oral dose of dexamethasone or placebo. All episodes of bronchiolitis were moderate or severe.

There were no differences between the groups with respect to respiratory improvement after 4 hours of observation, hospitalization (including the need for subsequent medical visits), or length of hospital stay.

Journal Watch editors find the study definitive: "First episode of wheezing means no steroids, period," writes J. Stephen Bohan in Emergency Medicine; and in Pediatrics and Adolescent Medicine, Howard Bauchner comments, "I do not believe that steroids have a role in the treatment of bronchiolitis."

Abstract: http://content.nejm.org/cgi/content/short/357/4/331

19. An ED Diagnostic Protocol for Patients With TIA: A Randomized Controlled Trial

Ross MA, et al. Ann Emerg Med. 2007;50:109-119.

Study objective: To determine whether transient ischemic attack patients treated with an accelerated diagnostic protocol in an emergency department (ED) observation unit will experience shorter lengths of stay, lower costs, and comparable clinical outcomes relative to patients with traditional inpatient admission.

Methods: A prospective randomized study of ED transient ischemic attack patients with a normal head computed tomography scan, ECG, and laboratory test results and no known embolic source. Patients were randomized to an inpatient bed or to accelerated diagnostic protocol care. Both groups had orders for serial clinical examinations, a neurology consultation, carotid Doppler tests, echocardiography, and cardiac monitoring. Accelerated diagnostic protocol patients with positive testing results were admitted. Study outcomes were length of stay, 90-day total direct cost, recidivism, and clinical outcome.

Results: One hundred forty-nine transient ischemic attack patients were randomized to the accelerated diagnostic protocol (75) or admission (74), with both groups similar in age, percentage of male patients, and stroke risk factors. Accelerated diagnostic protocol patient median length of stay was lower (25.6 hours [interquartile range 21.9 to 28.7 hours] versus 61.2 hours [interquartile range 41.6 to 92.2 hours]), and their 90-day costs were less ($890 [interquartile range $768 to 1,510] versus $1,547 [interquartile range $1,091 to 2,473]). Fifteen percent of accelerated diagnostic protocol patients were admitted, with all positive clinical outcomes occurring while patients were in the observation unit. More accelerated diagnostic protocol patients received carotid imaging (97% versus 91%) and in less time (median 13.0 hours versus 25.2 hours), and more received echocardiography (97% versus 73%) in less time (median 19.1 versus 43.0 hours). Both groups had comparable rates of related return visits (12% each), subsequent strokes (3 versus 2), and major clinical event (4 each).

Conclusion: A diagnostic protocol for transient ischemic attack using an accelerated diagnostic protocol is more efficient and less costly than traditional inpatient admission and demonstrated clinical outcomes comparable to those of traditional inpatient admission.

20. Does This Child Have Appendicitis?

Bundy DG, et al. JAMA. 2007;298:438-451.

Context: Evaluation of abdominal pain in children can be difficult. Rapid, accurate diagnosis of appendicitis in children reduces the morbidity of this common cause of pediatric abdominal pain. Clinical evaluation may help identify (1) which children with abdominal pain and a likely diagnosis of appendicitis should undergo immediate surgical consultation for potential appendectomy and (2) which children with equivocal presentations of appendicitis should undergo further diagnostic evaluation.

Objective: To systematically assess the precision and accuracy of symptoms, signs, and basic laboratory test results for evaluating children with possible appendicitis.

Data Sources: We searched English-language articles in MEDLINE (January 1966–March 2007) and the Cochrane Database, as well as physical examination textbooks and bibliographies of retrieved articles, yielding 2521 potentially relevant articles.

Study Selection: Studies were included if they (1) provided primary data on children aged 18 years or younger in whom the diagnosis of appendicitis was considered; (2) presented medical history data, physical examination findings, or basic laboratory data; and (3) confirmed or excluded appendicitis by surgical pathologic findings, clinical observation, or follow-up. Of 256 full-text articles examined, 42 met inclusion criteria.

Data Extraction: Twenty-five of 42 studies were assigned a quality level of 3 or better. Data from these studies were independently extracted by 2 reviewers.

Results: In children with abdominal pain, fever was the single most useful sign associated with appendicitis; a fever increases the likelihood of appendicitis (likelihood ratio [LR], 3.4; 95% confidence interval [CI], 2.4-4.8) and conversely, its absence decreases the chance of appendicitis (LR, 0.32; 95% CI, 0.16-0.64). In select groups of children, in whom the diagnosis of appendicitis is suspected and evaluation undertaken, rebound tenderness triples the odds of appendicitis (summary LR, 3.0; 95% CI, 2.3-3.9), while its absence reduces the likelihood (summary LR, 0.28; 95% CI, 0.14-0.55). Midabdominal pain migrating to the right lower quadrant (LR range, 1.9-3.1) increases the risk of appendicitis more than right lower quadrant pain itself (summary LR, 1.2; 95% CI, 1.0-1.5). A white blood cell count of less than 10 000/µL decreases the likelihood of appendicitis (summary LR, 0.22; 95% CI, 0.17-0.30), as does an absolute neutrophil count of 6750/µL or lower (LR, 0.06; 95% CI, 0.03-0.16). Symptoms and signs are most useful in combination, particularly for identifying children who do not require further evaluation or intervention.

Conclusions: Although the clinical examination does not establish a diagnosis of appendicitis with certainty, it is useful in determining which children with abdominal pain warrant immediate surgical evaluation for consideration of appendectomy and which children may warrant further diagnostic evaluation. More child-specific, age-stratified data are needed to improve the utility of the clinical examination for diagnosing appendicitis in children.

21. A Randomized Controlled Trial Comparing a Fascia Iliaca Compartment Nerve Block to a Traditional Systemic Analgesic for Femur Fractures in a Pediatric ED

Wathen JA, et al. Ann Emerg Med. 2007;50:162-171.e1

Study objective: We determine whether a fascia iliaca compartment nerve block can provide superior pain management compared with intravenous morphine sulfate for the initial pain management of femur fracture patients presenting to a pediatric emergency department. The primary outcome measured is pain scores; a difference of 15% in scores assessed at 30 minutes from the study’s baseline pain management is considered clinically meaningful. Secondary outcomes include the duration of analgesia, the need for additional medications, adverse events, nerve block complications, and satisfaction scores.

Methods: This was a prospective, randomized, unblinded, controlled trial conducted on children aged 15 months to 18 years with acute femur fractures, presenting to a free-standing, tertiary care children’s hospital. Patients were randomized to receive intravenous morphine sulfate or a fascia iliaca compartment nerve block using ropivacaine (Naropin). Pain scores (Children’s Hospital of Eastern Ontario Pain Scale [CHEOPS]; Face, Legs, Activity, Cry and Consolability Pain Scale; Faces Pain Scale) were recorded at initial analgesic administration (baseline), at 5, 10, 15, 30, and 60 minutes, and then hourly up to 6 hours from baseline by trained nursing observers and research assistants.

Results: Fifty-five patients, 26 in the fascia iliaca compartment nerve block group and 29 in the morphine sulfate group, ranged in age from 16 months to 15 years (median 5.7 years). Baseline mean CHEOPS scores were similar: 9.4 fascia iliaca compartment nerve block and 9.5 morphine sulfate. Mean CHEOPS scores at 30 minutes after initial treatment were 5.87 for fascia iliaca compartment nerve block and 7.54 for morphine sulfate, with a difference of 1.67, which corresponds to an 18% (95% confidence interval [CI] 8% to 27%) difference in pain reduction between the 2 groups, according to the average baseline score of 9.45. Similar lower pain scores were observed in the fascia iliaca compartment nerve block group as early as 10 minutes from baseline and throughout the 6-hour duration of the study. In comparing the entire 6-hour CHEOPS pain scores, patients who received a fascia iliaca compartment nerve block showed lower scores by approximately 15% (95% CI 6% to 24%) compared to patients who received morphine sulfate. Median duration of analgesia was longer in the fascia iliaca compartment nerve block group compared with that in the morphine sulfate group (313 minutes [95% CI 154 to 360 minutes] versus 60 minutes [95% CI 10 to 255 minutes]). Fewer additional medications were given to patients who received the fascia iliaca compartment nerve block. No complications from the nerve block occurred. Satisfaction scores were higher with the fascia iliaca compartment nerve block among the medical staff.

Conclusion: Fascia iliaca compartment nerve block provided clinically superior pain management compared with intravenous morphine sulfate at 30 minutes from baseline and throughout the initial 6 hours of medical treatment of children 16 months to 15 years who had isolated acute femur fractures. The results of this study, however, may be inflated by the nonblinding of the pain observers. Despite this potential bias, the fascia iliaca compartment nerve block should be considered as a valuable procedure in managing the pain commonly observed in these injured children.

Lit Bits: July 5, 2007

From the recent medical literature...

1. Evidence-Based Guidelines Issued to Detect and Treat Sepsis

June 12, 2007 — A review in the June issue of the Southern Medicine Journal provides evidence-based guidelines to help detect and treat sepsis. These treatment guidelines are endorsed by 11 professional societies representing multispecialty groups.

"If you could reduce the mortality rate by one quarter in a patient population afflicted with a condition with mortality rates of 30 to 50%, and which affects 750,000 people annually in the US, would you?" write Douglas Schlichting, RN, MS, MPA, and Jill Shwed McCollam, PharmD, BS, BCPS, from Eli Lilly and Co in Indianapolis, Indiana. "The condition is severe sepsis. Evidence-based guidelines and tools are available now that can help you achieve reductions in mortality and reduce length of stay."

The authors performed a literature review concerning the epidemiology and pathophysiology of severe sepsis, including alterations in inflammation, coagulation, and impaired fibrinolysis occurring during the course. Severe sepsis is common, with about 750,000 cases each year in the United States. Although the mortality rate for severe sepsis is 30% to 50%, this climbs to 80% to 90% for septic shock with multiple organ dysfunction.

In terms of the pathophysiology of severe sepsis, a cascade of inflammation and activation of the coagulation system associated with impaired fibrinolysis causes changes in microvascular circulation associated with organ dysfunction, severe sepsis, multiple organ dysfunction syndrome, and death.

The Institute for Healthcare Improvement (IHI) has highlighted sepsis as an area of focus and has identified several deficiencies that may cause suboptimal care of patients with severe sepsis.

These deficiencies include inconsistency in the early diagnosis of severe sepsis and septic shock, frequent inadequate volume resuscitation without defined endpoints, late or inadequate use of antibiotics, frequent failure to support the cardiac output when depressed, frequent failure to control hyperglycemia adequately, frequent failure to use low tidal volumes and pressures in acute lung injury, and frequent failure to treat adrenal inadequacy in refractory shock.

To address these deficiencies, the Surviving Sepsis Campaign and IHI have revised and added to the Surviving Sepsis Guidelines and created 2 sepsis treatment bundles (resuscitation and management) to guide therapy for patients with severe sepsis.

"Implicit in the use of the bundles is the need to adopt all the elements contained in the bundle," the authors write. "One cannot choose to apply only selected items from the bundle and expect to achieve comparable benefit. The IHI sepsis website also provides tools to screen patients for severe sepsis, as well as to measure success with adherence to implementing the bundles (http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis).”

The sepsis resuscitation bundle, which should be accomplished as soon as possible and scored during the first 6 hours, includes the following: Measure serum lactate level; Obtain blood cultures before antibiotic administration; From the time of presentation, administer broad-spectrum antibiotics within 3 hours for emergency department admissions and within 1 hour for non–emergency department intensive care unit (ICU) admissions.

In the event of hypotension and/or lactate level greater than 4 mmol/L (36 mg/dL), deliver an initial minimum dose of 20 mL/kg of crystalloid (or colloid equivalent); use vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure of 65 mm Hg or greater.

In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate level greater than 4 mmol/L (36 mg/dL), achieve central venous pressure of 8 mm Hg or greater and achieve central venous oxygen saturation of 70% or greater or a mixed venous oxygen saturation of 65% or greater.

"Timely recognition and diagnosis of severe sepsis is the first step," the authors write. "Applying the evidence-based guidelines created under the auspices of the Surviving Sepsis Campaign is the second step. Following up by measuring adherence to the guidelines is equally important to successfully implement change."

The sepsis management bundle, which should be accomplished as soon as possible and scored during the first 24 hours, includes the following: Low-dose steroids should be administered for septic shock, following a standardized ICU protocol; Activated drotrecogin alfa should be administered following a standardized ICU protocol; Glucose control should maintain glucose level at or above the lower limit of normal, but less than 150 mg/dL (8.3 mmol/L); For mechanically ventilated patients, inspiratory plateau pressures should be maintained at less than 30 cm H2O.

"Tools are available for use today that will guide the clinician in providing comprehensive and evidence-based care to the patient suffering from severe sepsis," the authors conclude. "Hopefully, once the patient is identified, multidisciplinary teams will rapidly and appropriately apply a series of evidence-based interventions. If the interventions are applied in a systematic fashion and adherence to standardized guidelines is followed and measured, then we will know if the Surviving Sepsis Campaign's goal of a 25% reduction in mortality from sepsis by the year 2009 had been obtained."

The authors are employees of Eli Lilly and Co, the maker of drotrecogin alfa (activated).

South Med J. 2007;100:594-600.

2. CDC Updates Concussion-Management Tool Kit

The CDC has revised its multimedia tool kit that helps physicians recognize, manage, and make appropriate referrals for concussions earlier.

The CDC's announcement highlights one component of the new kit, the Acute Concussion Evaluation (ACE) form, designed to aid in the initial evaluation and diagnosis of patients with a known or suspected concussion. In addition, the ACE Care Plan offers guidance for helping patients to recover and avoid reinjury.

Other components include a "Facts for Physicians" booklet; fact sheets on concussion prevention, available in both English and Spanish; a palm card for on-field management of sports-related concussion; and a CD-ROM with additional resources.

The "Heads Up: Brain Injury in Your Practice" kit is available free of charge on the CDC's website.

"Heads Up: Brain Injury in Your Practice" tool kit (Free): http://www.cdc.gov/ncipc/tbi/physicians_tool_kit.htm

CDC press release (Free): http://www.cdc.gov/od/oc/media/pressrel/2007/r070607.htm?s_cid=mediarel_r070607_x

3. Validation of the Simplified Motor Score for the Prediction of Brain Injury Outcomes After Trauma—As Good as the Glasgow, But Much Simpler

Haukoos JS, et al. Ann Emerg Med. 2007;50:18-24.

Traumatic brain injury is a leading cause of death and disability among children and young adults in the United States, and each year approximately 1.4 million people sustain traumatic brain injury in the United States, at an approximate cost of $40 billion. The Glasgow Coma Scale (GCS) was originally developed in 1974 in an effort to help formalize the assessment of patients with altered levels of consciousness. It was slightly modified and quickly adopted for the assessment of traumatic brain injury after being transformed into a 15-point numeric GCS score. Although originally devised as a formal construct to overcome the ambiguities that arose when information about comatose patients was compared, the GCS score has since been used extensively in the assessment of patients with and without traumatic brain injury.

The GCS score has also been met with controversy. Multiple investigators have criticized the GCS score for its complexity, its lack of discriminatory ability, especially with scores in the middle of its range, its poor interrater agreement, and its difficulty in being applied to intubated or nonverbal patients.

This study addressed whether a 3-point Simplified Motor Score (SMS) using only 3 points can perform as well as the GCS for predicting outcome. The SMS gives 2 points to patients who can obey commands, 1 point to patients who localize pain, and 0 points to patients whose best level of function is withdrawal from pain.

Methods: This was a secondary analysis of a prospectively maintained trauma registry with consecutive trauma patients who presented to a Level I trauma center from 1995 through 2004. Test performance of the GCS and the Simplified Motor Score relative to 4 clinically relevant traumatic brain injury outcomes (emergency intubation, clinically significant brain injury, neurosurgical intervention, and mortality) was evaluated with areas under the receiver operating characteristic curves (AUCs).

Results: Of 21,170 patients included in the analysis, 18% underwent emergency intubation, 14% had clinically significant brain injuries, 7% underwent neurosurgical intervention, and 5% died. The AUCs for the GCS and its components ranged from 0.76 to 0.92 across the 4 outcome measures. The AUCs for the Simplified Motor Score ranged from 0.71 to 0.89, and the relative differences from the GCS AUCs ranged from 3% to 7%, with a median difference of 5%.

Conclusion: In this external validation study, the 3-point Simplified Motor Score demonstrated similar test performance when compared with the 15-point GCS score and its components for the prediction of 4 clinically important traumatic brain injury outcomes.

4. CMS Site Rates Hospitals on Quality of Cardiac Care

The Centers for Medicare & Medicaid Services has released 30-day mortality measures from all U.S. acute care hospitals for Medicare patients discharged with myocardial infarction or heart failure.

Hospitals are rated as better, worse, or no different than the national rate. For heart failure, 38 hospitals performed better than the national rate, and 35 worse. For MI, 17 are better and 7 worse. The data were adjusted for hospitals' patient mix and based on claims data from July 2005 to June 2006.

The Associated Press quoted HHS Secretary Mike Leavitt as saying, "People need to know not only what their health care costs, but how good it is."

The ratings are available at http://www.hospitalcompare.hhs.gov

5. Acute Sciatica: What the Latest?

Most patients with acute sciatica have a favourable prognosis but about 20%-30% have persisting problems after one or two years

The diagnosis is based on history taking and physical examination

Imaging is indicated only in patients with "red flag" conditions or in whom disc surgery is considered

Passive (bed rest) treatments have been replaced with more active treatments

Consensus is that initial treatment is conservative for about 6-8 weeks

Disc surgery may provide quicker relief of leg pain than conservative care but no clear differences have been found after one or two years

Diagnosis and treatment of sciatica. Koes BW, et al. BMJ 2007;334:1313-1317.

6. Should We Culture Abscess Fluid? It’s Debatable

In support of the practice: Heilpern KL. Ann Emerg Med. 2007;50:64-66.

Community-associated MRSA has emerged as a major pathogen in skin and soft tissue infections. To date, surveillance data are inadequate and dynamic. These strains demonstrate extraordinary fitness, transmissibility, and potential for limb- and life-threatening complications. Routine culture of soft tissue abscesses will allow practitioners to stay 1 step ahead of this nimble pathogen. This is the edge needed to provide appropriate, state-of-the-art, empiric, antimicrobial therapy and enhance predictability and management of invasive disease.

The counterpoint: Abrahamiam FM, et al. Ann Emerg Med. 2007;50:66-67.

In conclusion, the majority of stable patients with first time, uncomplicated abscess(es) will be cured by simple incision and drainage alone. Isolation of MRSA does not change the management of these cases. Similarly, for those stable patients with abscesses requiring antibiotic therapy, in areas with known high MRSA prevalence and susceptibility patterns, empiric therapy can be chosen based on local susceptibilities, and cultures reserved only for treatment failures.

7. Can You Precipitate a PE by Disturbing a DVT During the US Test? Who Knows…

Nunn KP. Et al. Emerg Med J. 2007;24:494-495;

A short cut review was carried out to establish whether patients with deep vein thrombosis (DVT) are at risk of embolism during ultrasound compression testing. No papers were found that directly answered the clinical question. The clinical bottom line is that currently there is no evidence to suggest that compressing vessels in order to identify a DVT could cause an embolic event. Therefore we can consider ultrasound assessment a safe reliable investigation for the diagnosis of DVT with no evidence of causing harm.

8. Patients Want to Shake Their Physicians' Hands

Makoul G, et al. Arch Intern Med. 2007;167:1172-1176.

When greeting their physician, most patients desire a handshake, a study in Archives of Internal Medicine finds. Researchers conducted a nationwide telephone survey on patient expectations on first meeting a physician. Of 415 adults who responded:

--78% said they wanted the physician to shake their hand during the greeting;

--50% wanted their first name used by the physician, and 24% wanted the physician to use both their first and last names;

--56% wanted physicians to introduce themselves using their own first and last names.

The authors note that appropriate greetings "can set a positive tone for the encounter and increase the chance of developing a therapeutic clinical relationship."

ABSTRACT: Background: Widely used models for teaching and assessing communication skills highlight the importance of greeting patients appropriately, but there is little evidence regarding what constitutes an appropriate greeting.

Methods: To obtain data on patient expectations for greetings, we asked closed-ended questions about preferences for shaking hands, use of patient names, and use of physician names in a computer-assisted telephone survey of adults in the 48 contiguous United States. We also analyzed an existing sample of 123 videotaped new patient visits to characterize patterns of greeting behavior in everyday clinical practice.

Results: Most (78.1%) of the 415 survey respondents reported that they want the physician to shake their hand, 50.4% want their first name to be used when physicians greet them, and 56.4% want physicians to introduce themselves using their first and last names; these expectations vary somewhat with patient sex, age, and race. Videotapes revealed that physicians and patients shook hands in 82.9% of visits. In 50.4% of the initial encounters, physicians did not mention the patient's name at all. Physicians tended to use their first and last names when introducing themselves.

Conclusions: Physicians should be encouraged to shake hands with patients but remain sensitive to nonverbal cues that might indicate whether patients are open to this behavior. Given the diversity of opinion regarding the use of names, coupled with national patient safety recommendations concerning patient identification, we suggest that physicians initially use patients' first and last names and introduce themselves using their own first and last names.

9. New AAP Guidelines Issued for Evaluating Physical Abuse in Children

News Author: Laurie Barclay, MD. June 7, 2007 — The American Academy of Pediatrics has issued guidelines providing a clinical approach to accurately evaluate and diagnose children who appear to have been physically abused in the past or present. The new recommendations are published in the June issue of Pediatrics.

"Physical abuse remains an underreported (and often undetected) problem for several reasons including individual and community variations in what is considered 'abuse,' inadequate knowledge and training among professionals in the recognition of abusive injuries, unwillingness to report suspected abuse, and professional bias," write Nancy D. Kellogg, MD, and colleagues from the Committee on Child Abuse and Neglect. "Misdiagnosed victims [are] more likely to be younger, white, have less severe symptoms, and live with both parents when compared with abused children who [are] not initially misdiagnosed. Such studies suggest a need for practitioners to be vigilant to the possibility of abuse when evaluating children who have atypical accidental injuries or obscure symptoms that are suggestive of traumatic etiologies but who do not have a history of trauma."

In the United States, 152,250 children and adolescents were confirmed victims of physical abuse in 2004, but the estimated number of victims is much higher. One retrospective cohort study of 8613 adults showed that 26.4% reported having had some form of physical abuse during childhood, and approximately 1.3% to 15% of childhood injuries leading to emergency department visits are thought to be abuse related.

The serious sequelae of child abuse may include death, severe incapacitation, and behavioral and functional problems including conduct disorders, physically aggressive behaviors, poor school performance, cognitive impairment, anxiety, depression, and problems with social adjustment and relationships.

Accurate and timely diagnosis of children who are suspected victims of abuse is essential to facilitate appropriate evaluation, investigation, and optimal outcomes for these children and their families. The current guidelines describe the evaluation of suspected physical abuse in children, including the medical evaluation encompassing the history, physical examination, and additional testing as appropriate. The clinician should evaluate the characteristics of the injury or injuries, the consistency of the explanation, and the child's developmental capabilities; report suspected abuse; and act as a liaison to other professionals to offer immediate and long-term treatment and follow-up for victims.

"Tests should be ordered judiciously and in consultation with the appropriate genetics, hematology, radiology, and child abuse specialists," the authors write. "Careful consideration of the patient's history, age, and clinical findings should guide selection of the appropriate tests."

Specific diagnostic tests that may be useful in the medical evaluation of suspected physical abuse and differential diagnoses are as follows:

A skeletal survey for fractures is recommended for all children with fractures and children younger than 2 years with any suspicious injuries. This should include radiographs of the humeri, forearms, femurs, lower legs, hands, feet, skull, cervical spine, thorax (including oblique views), lumbar spine, and pelvis. For high-risk cases, the skeletal survey should be repeated in 2 weeks. Single whole-body x-ray films are not an acceptable substitute for the skeletal survey.

For evaluation of bruises, tests for hematologic disorders are recommended when bleeding disorder is a concern because of the clinical presentation or family history. Testing should include complete blood count, platelets, prothrombin time, partial thromboplastin time, international normalized ratio, and bleeding time. After the initial screening tests, additional testing, such as factor levels, may be indicated. Platelet function activity, measured with the Platelet Function Analyzer-100, is better than bleeding time for establishing platelet function but is not widely available.

For patients with intracranial injury, a disseminated intravascular coagulation screening should be performed, because intraparenchymal damage can affect coagulation.

For more, see full-text: http://pediatrics.aappublications.org/cgi/content/full/119/6/1232

Pediatrics. 2007;119:1232-1241.

10. Poor Test Characteristics for the Digital Rectal Examination in Trauma Patients

Shlamovitz GZ, et al. Ann Emerg Med. 2007;50:25-33.

Editor’s Capsule Summary: The digital rectal examination is recommended as part of the secondary survey for trauma patients. There is little evidence about its utility. The sensitivity and specificity of the digital rectal examination for the detection of spinal cord, bowel, rectal, bony pelvis, and urethral injuries.

In this 1,401-patient retrospective medical record review, digital rectal examination had low sensitivity for the detection of these injuries, rendering it of little use as a screening test, especially if used alone. This article is insufficient to change clinical practice but suggests that recommendations about the use of digital rectal examination be carefully reexamined.

11. Does This Patient Have Erythema Migrans? It’s an Educated Guess

Tibbles CT, et al. JAMA. 2007;297:2617-2627.

Context: Erythema migrans, while not pathognomonic, is the most common manifestation of early Lyme disease. Accurate diagnosis of this rash is essential to initiating appropriate antibiotic therapy. Objective: To determine the sensitivity of history and physical examination characteristics for the diagnosis of erythema migrans…

Results: We separately analyzed the studies from Europe and analyzed both Lyme-endemic and nonendemic areas of the United States to search for potential differences in the clinical presentation. Thirty-two studies from Europe, 20 studies from the United States, and 1 from Europe and the United States met inclusion criteria for a total of 8493 patients. Sensitivity was calculated for each of the variables. No studies included patients without erythema migrans, so specificity data and likelihood ratios could not be determined. Many patients do not recall a tick bite. Associated systemic symptoms, such as fever and headache, are frequently reported. Nausea and vomiting are rare. A solitary lesion is the most frequent presentation in both US (81%; 95% confidence interval [CI], 72%-87%) and European patients (88%; 95% CI, 81%-93%). Central clearing is less common in the endemic United States (19%; 95% CI, 11%-32%) vs Europe (79%; 95% CI, 69%-86%) and the nonendemic United States (80%; 95% CI, 63%-90%).

Conclusions: Our analysis of the current available literature suggests that there is no single element in the history or physical examination that is highly sensitive by itself for the diagnosis of erythema migrans. Clinicians should be aware of the wide variability in the clinical presentation of erythema migrans and the need to factor in multiple components of the clinical examination and epidemiological context.

12. Unrecognized Misplacement of Endotracheal Tubes by Ground Prehospital Providers

Wirtz DD, et al. Prehosp Emerg Care. 2007;11:213-218.

Objective. Endotracheal intubation by emergency medical services (EMS) is well established. Esophageal misplacement is a catastrophic complication that has until recently been studied by using methods that have called into question the accuracy of the reported data. The purpose of our study was to determine the incidence of unrecognized endotracheal tube misplacement, reasons for deferred intubations in the field, and to report outcomes in those patients with unrecognized misplacement.

Methods. This was a prospective observational study with a consecutive sample. All arriving with an endotracheal tube or in whom endotracheal intubation was performed within 10 minutes of arrival were included, and a physician immediately determined placement. Hospital records were reviewed to determine outcome of those patients in whom the tube was misplaced. Unrecognized esophageal misplacement triggered communication to the medical director of the transporting agency.

Results. During the enrollment period, 192 patients were evaluated. Overall, 132 of 192 (69%) were intubated in the prehospital environment, and 60 were intubated within 10 minutes of arrival in the emergency department. Among prehospital intubation attempts, 12 of 132 (9%; 95 CI 5.3-15.2), 11 esophageal, and 1 hypopharyngeal were misplaced. Right mainstem intubation occurred in an additional 20 of 132 (15%; 95 CI 10.0-22.3). Among patients arriving with unrecognized esophageal misplacement of the endotracheal tube, one patient survived to hospital discharge.

Conclusion. The rate of esophageal misplacement of endotracheal tubes in the prehospital environment in our urban setting and the poor clinical course of patients with unrecognized misplacement is consistent with previous reports, suggesting that the benefit of prehospital airway management does not clearly supercede the potential risks.

13. Thrombolytic Therapy for Submassive Pulmonary Embolism? Not Well Supported

Worster A., et al. Ann Emerg Med. 2007;50:78-84.

Study objective
The purpose of this review was to determine the effectiveness of adding thrombolytics to standard heparin therapy for treatment of submassive pulmonary embolism. Patients with submassive pulmonary embolism were considered to be those with evidence of right ventricular dysfunction but without hemodynamic instability.

Methods
We searched for trials comparing thrombolytics to heparin in the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE. We included only studies assessing the effectiveness of thrombolytic therapy for submassive pulmonary embolism and reported the patient-important outcomes of mortality, recurrent pulmonary embolism, and major hemorrhage.

Results
Two randomized trials met the inclusion criteria; one with a total of 256 patients presenting with submassive pulmonary embolism and the other trial including a subgroup of 46 patients with submassive pulmonary embolism. In the larger study, the relative risk (RR) for mortality, recurrent pulmonary embolism, and major hemorrhage was 1.56 (95% confidence interval [CI] 0.36 to 6.83), 1.17 (95% CI 0.30 to 4.57), and 0.23 (95% CI 0.03 to 1.97), respectively. Our post hoc subgroup analysis of the smaller trial identified 2 deaths and 5 patients with recurrent pulmonary embolism among 23 controls, whereas none of the 23 patients randomized to thrombolytics died or had recurrent pulmonary embolism. None of these findings were statistically significant.

Conclusion
Results of randomized trials comparing the addition of thrombolytic therapy to standard heparin therapy for treatment of submassive pulmonary embolism fail to show any significant differences in clinically important outcomes.

14. Lower-Extremity Fractures or Recent Surgery Greatly Increases Risk for VTE

The risk associated with fractures and surgery was manyfold higher than the risk associated with factors such as obesity, comorbid illness, and oral contraceptive use.

In a prospective cohort study, researchers assessed the incidence of and risk factors for venous thromboembolism (VTE) in the general U.K. population. Among 1.8 million people enrolled in the General Practice Research Database and followed for 8.8 million person-years, 6550 had a new diagnosis of deep venous thrombosis, pulmonary embolism, or both.

The overall incidence of VTE was 74.5 cases per 100,000 person-years. The incidence increased strikingly with age. Fracture of a lower extremity was strongly associated with development of VTE during the next month (odds ratios, 69.4 for hip fractures and 33.2 for other lower-extremity fractures). Surgery was also a strong predictor for developing VTE, particularly within the first month after the procedure (OR, 34.4). Use of oral contraceptives and of estrogen–progesterone hormone replacement therapy was each associated with small risk increases (OR, 1.9). Other conditions that were associated with small-to-modest increases (ORs, 1.8–7.4) included recent healthcare contact, overweight, and comorbid disorders (cancer, varicose veins, heart failure, and inflammatory bowel disease).

Comment: New imaging technology and risk scores make the diagnosis of VTE much easier than in the past, but, before these can be used for diagnosis, clinicians must first consider VTE as the cause of a patient’s symptoms. Although risk factors, per se, are not particularly useful in informing us whether a particular patient has disease, recent lower- extremity fracture or surgery clearly increases risk dramatically.

— J. Stephen Bohan, MD. Published in Journal Watch Emergency Medicine, June 15, 2007. From Huerta C et al. Arch Intern Med. 2007;167:935-43.

15. Study Questions Self-Monitoring of Glucose in Some Type 2 Diabetics

Self-monitoring of blood glucose does not improve glycemic control among patients with "reasonably well controlled" type 2 diabetes, according to a study published online in the British Medical Journal.

Some 450 adults whose type 2 diabetes was controlled with diet or oral hypoglycemic agents (mean hemoglobin A1c, 7.5%) were randomized to one of three interventions: (1) usual care including goal setting and review of physical activity and diet, (2) self-monitoring of blood glucose with instruction to report consistently high or low levels, or (3) self-monitoring and training in interpretation of glucose levels to increase adherence to a healthy lifestyle and drug regimens.

The primary endpoint — hemoglobin A1c at 12 months — did not differ significantly among the groups. The authors conclude that for patients with "reasonably well controlled non-insulin treated type 2 diabetes," the "cost, effort, and time involved in [routine self-monitoring of blood glucose] may be better directed to supporting other health related behaviours."

BMJ article: http://www.bmj.com/cgi/content/full/bmj.39247.447431.BEv1

16. Meta-Analysis Finds Echinacea Has Benefits in Cold Prevention and Treatment

A meta-analysis concludes that echinacea supplements decrease the incidence and duration of the common cold.

The analysis, published early online in Lancet Infectious Diseases, suggests that echinacea decreases the odds of developing a cold by 58% and shortens the duration of a cold by 1.4 days. The analysis included 14 studies, which together enrolled about 1400 subjects to study echinacea's effect on incidence and 1600 to study the effect on cold duration.

The authors note that more than 800 U.S. products contain echinacea. They caution that before the plant becomes standard cold treatment, safety studies and large-scale randomized studies are needed, controlling for the dose, the species of echinacea used, the quality of its preparation, the method of cold induction, and the objectivity of the studies' endpoints. Also of note, according to the authors, is that echinacea is an inhibitor of cytochrome P450, and thus may interact with other drugs.

[Physician’s First Watch editorial note: Although Lancet Infectious Diseases has released this article from embargo, it has not posted the article on its website. Rather than delay coverage further while awaiting that posting, we have provided a link to the Lancet's early-release page, where the article will eventually appear: http://www.thelancet.com/journals/eop]

17. Probiotic Drink Helps Reduce Antibiotic-Associated Diarrhea

Consuming a probiotic drink containing Lactobacillus may help older hospitalized patients avoid antibiotic-associated diarrhea, according to a study published online in the British Medical Journal.

In the manufacturer-supported study, 135 hospitalized patients older than 50 who were prescribed antibiotics were randomized to consume a probiotic yogurt drink or a placebo milkshake. The drinks were consumed twice a day concurrent with antibiotic treatment and for a week afterward.

Significantly fewer intervention patients than controls developed antibiotic-associated diarrhea (12% vs. 34%). The number needed to treat (NNT) to prevent one case of antibiotic-associated diarrhea was 5. The NNT to prevent one case of C. difficile-associated diarrhea was 6.

The authors estimate that it would cost $120 to prevent one case of C. difficile-associated diarrhea, whereas it costs an average of $3700 to treat a case in the U.S. They conclude that the drink "has the potential to decrease morbidity, healthcare costs, and mortality if used routinely in patients aged over 50."

BMJ article: http://www.bmj.com/cgi/content/full/bmj.39231.599815.55v1

18. Middle Age Not Too Late to Lower Cardiac Risk

Adopting a healthy lifestyle after age 45 may confer cardiovascular and mortality benefits even just 4 years later, according to a study in the July edition of the American Journal of Medicine.

To study the origin and progression of atherosclerosis, researchers prospectively followed roughly 16,000 adults aged 45 to 64 at baseline. After 6 years, about 1000 had newly adopted an overall healthy lifestyle, defined as four behaviors: eating at least five fruits and vegetables daily, exercising at least 2.5 hours weekly, maintaining a BMI between 18.5 and 30, and not smoking. Some 11,000 were following three or fewer of these behaviors.

During the next 4 years, those who had newly adopted all four behaviors had a 40% reduction in all-cause mortality and a 35% reduction in cardiovascular events, compared with those who were following three or fewer healthy behaviors.

The authors conclude that adhering to a healthy lifestyle is "extremely worthwhile, and that middle-age is not too late to act."

King DA, et al. Amer J Med. 2007; 120: 598-603.

19. Which Patients Need Immediate Transfer to a Trauma Center?

Five readily available clinical criteria help identify patients who need advanced trauma care.

Most trauma triage research has focused on patients transported to level I and II trauma centers. Little is known about the need for triage to higher levels of care in injured patients transported to nontertiary centers. Researchers retrospectively studied 12,183 adult patients in Oregon during a 6-year period who met criteria for entry into the state trauma system, were transported to 1 of 42 nontertiary hospitals (level III or IV trauma centers), and survived the emergency department visit.

The primary outcome measure was a composite of death within 3 days of presentation (3% of patients), need for major nonorthopedic surgery within 3 days (22%), and intensive care unit stay of 2 days or more (10%). In regression analysis, the following 5 of 13 clinical variables that are available at the bedside early in a patient’s evaluation had high specificity for predicting early mortality or need for specialized trauma resources: emergent airway intervention, initial Glasgow Coma Scale score less than 11, blood transfusion, initial systolic blood pressure less than 100 or greater than 220 mm Hg, and initial respiratory rate less than 10 or more than 32 breaths per minute. The authors suggest that the presence of one or more of these factors should trigger prompt mobilization of surgical and intensive care resources, search for occult injuries, and immediate transfer to a higher-level trauma center.

Comment: Early identification of injured patients who would benefit from advanced trauma care would prevent delays in definitive treatment that occur while patients undergo further diagnostic testing. If validated prospectively, the five clinical factors identified in this study will help physicians at nontertiary trauma centers determine which patients have immediate need for higher-level services.

— Kristi L. Koenig, MD. Published in Journal Watch Emergency Medicine, June 15, 2007.
Citation(s): Newgard CD et al. Prehosp Emerg Care. 2007; 11:154-63.

20. Rural Strategy Shortens Time to PCI, Improves STEMI Outcomes

By Megan Rauscher. NEW YORK (Reuters Health) Jun 18 - A strategy to shorten time to infarct artery patency in patients with ST-segment elevation myocardial infarction (STEMI) is proving successful in three rural counties in Oregon and northern California, clinicians report.
The strategy has paramedics, trained in electrocardiographic criteria for STEMI, identify the condition and directly triage patients to a pre-alerted percutaneous coronary intervention (PCI)-capable hospital.

"We're finding that paramedics can be trained to effectively identify STEMI in the field," Dr. Brian W. Gross of the Heart Clinic of Southern Oregon and Northern California in Medford, Oregon, told Reuters Health.

"And with a pre-alert to the PCI hospital (and bypass of smaller hospitals) and with expedited triage to the catheterization lab, we can have a profound effect on getting the infarct artery open in less than 90 minutes of arrival," Dr. Gross said. "This goal of heart attack angioplasty therapy is only rarely achieved in most regions," he noted.

In the American Journal of Cardiology dated May 15, the investigators report time to PCI reperfusion and in-hospital mortality for 233 consecutive patients with STEMI encountered after the protocol was initiated between June 2003 and December 2004.

Ninety-minute initial hospital door-to-patent infarct artery was achieved in 58.3% of paramedic-diagnosed and directly triaged patients compared with 5.2% who initially presented to a referring hospital ED and with 37.5% of PCI hospital "walk-in" patients.

Moreover, Dr. Gross said: "Since the study was initiated, we have seen a continued improvement in our less than 90-minute door-to-balloon times for paramedic-identified and triaged patients from 58% to our present 92% of the time."

Additionally, he said overall in-hospital mortality for the study cohort was "extremely low -- 2.1% in the study compared to historical controls of 8% to 11%."

It's clear, Dr. Gross concludes, that "synchronous activation and cooperative regional efforts by paramedics, referring hospitals and cardiac interventional teams can have a profound impact on facilitating the early diagnosis, treatment and favorable outcomes of STEMI."

Am J Cardiol 2007;99:1360-1363.

21. Trauma Management Outcomes Associated With Nonsurgeon Versus Surgeon Trauma Team Leaders—No Difference

Ahmed JM, et al. Ann Emerg Med 2007;50:7-12.

Study objective
We compare the effectiveness of surgeon and nonsurgeon trauma team leaders.

Methods
This retrospective study was conducted using data from a Canadian trauma registry database. Data from April 1, 1998, to March 31, 2005, from blunt and penetrating trauma patients aged 16 years or older and with trauma team activation (and without major burns) were included. Patient age, sex, trauma team leader (surgeon or nonsurgeon), mechanism of injury, Injury Severity Score, survival to 3 hours and to discharge, length of stay in the hospital, and Trauma and Injury Severity Score (TRISS) z scores were tabulated.

Results
Data from 807 patients were included. Because of the limited number of penetrating trauma cases, analyses focused on blunt trauma. Surgeon and nonsurgeon trauma team leader groups did not differ on injury severity, age, or sex. No difference was noted in survival to discharge (nonsurgeon 84.8%−surgeon 81.8%=3%; 95% confidence interval [CI] −3.5% to 9.5%), survival to 3 hours (nonsurgeon 96.8%−surgeon 96%=0.8%; 95% CI −2.2% to 3.8%), length of stay (median 13 days for nonsurgeon and 12 days for surgeon groups), or difference between actual and predicted survival (TRISS z scores nonsurgeon 0.64; surgeon 0.99). No trend toward group differences on any outcome variable was observed in penetrating trauma cases.

Conclusion
No differences were found in the outcome of trauma patients treated by nonsurgeon versus surgeon trauma team leaders. These findings support a more collaborative approach to resuscitative trauma management with involvement of nonsurgeons as trauma team leaders.