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.