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.