Saturday, September 22, 2007

Lit Bits: September 22, 2007

From the recent medical literature...

1. Patients with Possible ACS Can Be Safely Admitted to Non-Cardiology Units

By Martha Kerr. NEW YORK (Reuters Health) Sept 05 - Patients presenting to the emergency department (ED) with possible acute coronary syndrome (ACS) need not be held there until there is an available bed in the cardiology unit.

Patients with suspected ACS who are admitted to a family practice unit have similar outcomes as those admitted to a cardiology unit, according to a report published in the Annals of Emergency Medicine and available online.

The original study on the impact of implementation of the Agency for Healthcare Policy and Research's Unstable Angina Guidelines, conducted between 2000 and 2001, showed that the guidelines had no significant impact on emergency physicians' triage decisions.

In the current analysis, Dr. David A. Katz, of the University of Iowa, Iowa City, and colleagues determined whether systematic use of the Agency for Healthcare Policy and Research recommendations for risk stratification would improve physician decision making in 544 ED patients admitted with symptoms of possible ACS after a "nondiagnostic initial evaluation."

After 30 days, Dr. Katz's team reviewed the medical records and conducted telephone surveys of the patients to assess the incidence of adverse events and in-hospital and follow-up care.

One third (34%) of admitted patients had confirmed ACS.

"The incidence of ED revisits and rehospitalizations, functional status, and adverse cardiovascular events were similar" in patients admitted to the cardiology service and those who were admitted to another service, the investigators found.

Patients admitted to a cardiology service were 2.7 times more likely to undergo evaluation for ischemic heart disease than those admitted to a noncardiology service.

"Although patients admitted to a cardiology bed received more aggressive diagnostic testing than those admitted to a non-cardiology service bed in our study, the overall 30-day outcomes were very similar," Dr. Katz told Reuters Health. In addition, the patients on a cardiology unit "were not more likely to receive recommended therapies."

"According to a recent Institute of Medicine report, 'Hospital-based Emergency Care: At the Breaking Point,' the most common contributor to ED crowding is the inability to move admitted patients from the ED to inpatient hospital beds," Dr. Katz said.

"These results should be confirmed in larger studies with longer follow-up of patient outcomes," he noted. In the meantime," given the volume of patients with possible ACS treated in emergency departments - approximately 5 million every year - and the paucity of cardiology beds at certain times, emergency physicians can safely admit many of these patients to non-cardiology units and possibly reduce overcrowding in their emergency departments."

Full-text (free for now) from Ann Emerg Med, on-line articles in press:

2. Beta-Blockers Are Associated With Reduced Risk of AMI after Cocaine Use

Dattilo PB, et al. Ann Emerg Med. 2007; in press.

Study objective: Beta-Blocker use is associated with coronary artery spasm after cocaine administration but also decreases mortality in patients with myocardial infarction or systolic dysfunction. We conduct a retrospective cohort study to analyze the safety of beta-blockers in patients with positive urine toxicology results for cocaine.

Methods: The cohort consisted of 363 consecutive telemetry and ICU patients who were admitted to a municipal hospital and had positive urine toxicology results for cocaine during a 5-year period (307 patients). Fifteen patients with uncertain history of beta-blocker use before admission were excluded. The primary outcome measure was myocardial infarction; secondary outcome measure was inhospital mortality. Logistic regression analysis using generalized estimating equations models and propensity scores compared outcomes.

Results: Beta-Blockers were given in 60 of 348 admissions. The incidence of myocardial infarction after administration of beta-blocker was significantly lower than without treatment (6.1% versus 26.0%; difference in proportion 19.9%; 95% confidence interval [CI] 10.3% to 30.0%). One of 14 deaths occurred in patients who received beta-blockade (incidence 1.7% versus 4.5% without beta-blockade; difference in proportion 2.8%; 95% CI –1.2% to 6.7%). Multivariate analysis showed that use of beta-blockers significantly reduced the risk of myocardial infarction (odds ratio 0.06; 95% CI 0.01 to 0.61).

Conclusion: In our cohort, administration of beta-blockers was associated with reduction in incidence of myocardial infarction after cocaine use. The benefit of beta-blockers on myocardial function may offset the risk of coronary artery spasm. [Ann Emerg Med. 2007;xx:xxx.]

Full-text (free for now) from Ann Emerg Med, on-line articles in press:

3. TZDs: Good for the Glucose, but Bad for the Heart—Pioglitazone and Rosiglitazone: Different Effects on Heart Disease

Two new meta-analyses in JAMA confirm the increased risk for heart failure associated with pioglitazone and rosiglitazone, but they show disparate results for other cardiovascular outcomes.

In an analysis of data from 19 randomized controlled trials involving some 16,000 patients with type 2 diabetes, those randomized to pioglitazone showed an 18% reduced risk for the composite of death, MI, and stroke. There was also a nonsignificant reduction in risk for MI alone. The drug manufacturer contributed all data.

Another research group analyzed four long-term, randomized controlled trials of rosiglitazone in which cardiovascular safety was a prespecified endpoint; some 14,000 patients were included. Overall, rosiglitazone increased the risk for MI by 42%.

Editorialists note that the increased risk for MI observed with rosiglitazone is similar to the risk reported in a recent, much publicized meta-analysis. They add that "with many other available oral agents for diabetes, the potential benefit of [thiazolidinediones] requires reevaluation."

For these two JAMA abstracts, see TOC for Sept 12, 2007:

4. FDA Issues Warning on Cardiovascular Effects of Haloperidol

The FDA is warning clinicians about the risks for cardiovascular side effects and sudden death from haloperidol.

The agency says there are "at least 28 case reports" of QT prolongation and Torsades de Pointes in the literature associated with the antipsychotic drug, "especially when given intravenously"; some cases have been fatal. A 2005 postmarketing study conducted for the Italian drug authority, but only recently submitted to the FDA by Johnson & Johnson, found 13 additional cases. The FDA notes that the drug is often used intravenously off-label, especially in intensive care units, to treat severe agitation.

Label warnings will be strengthened, the FDA says, and it recommends ECG monitoring if the drug is used intravenously. The FDA urges particular caution in patients with other QT-prolonging conditions, such as electrolyte imbalance (especially hypokalemia and hypomagnesemia).

FDA alert (Free):

5. Randomized Trial of Single-Dose IM Dex Compared With 5 days of Prednisolone for Children With Acute Asthma

Gordon S, et al. Pediatric Emergency Care. 2007;23:521-527.

Objectives: To compare the clinical efficacy of single-dose intramuscular (IM) dexamethasone phosphate (dex) to a 5-day course of oral prednisolone for the treatment of moderate asthma exacerbations in young children discharged from the emergency department (ED).

Methods: We performed a prospective, randomized trial in children aged 18 months to less than 7 years with asthma who presented to the ED with a clinical asthma score of 3 to 7 on a 9-point scale. Children were randomized to 1 dose of IM dex (0.6 mg/kg, maximum 15 mg) or oral prednisolone (2 mg/kg, maximum 50 mg) once daily for 5 days. The primary outcome, measured only for patients discharged from the ED, was change in asthma score from ED presentation to 4-day follow-up examination, as assessed by a physician masked to group assignment. We assessed secondary clinical course outcomes by a structured interview at 4 and 14 days.

Results: Eighty-eight patients were appropriately randomized to dex and 93 to prednisolone. Group characteristics were similar at baseline. Among those discharged from the ED, 62 (90%) of 69 and 64 (90%) of 74 patients in the dex and prednisolone groups, respectively, were reassessed at 4 days for the primary outcome. The mean change in total asthma score at 4-day follow-up was 3.6 in the dex group and 3.4 in the prednisolone group (difference, 0.2; 95% confidence interval, -0.4 to 0.7). Of patients initially discharged, 5.9% of dex patients and 4.1% of prednisolone patients were admitted before the 2-week follow-up (difference, 1.8%; 95% confidence interval, -5.4% to 9.0%).

Conclusions: A single dose of IM dex showed no clinically meaningful difference in outcomes compared with a 5-day course of oral prednisolone for the treatment of moderate acute asthma exacerbations in young children who are discharged from the ED.

6. Association of Overweight With Increased Risk of Coronary Heart Disease Partly Independent of Blood Pressure and Cholesterol Levels: A Meta-analysis of 21 Cohort Studies Including More Than 300,000 Persons

Bogers RP, et al. Arch Intern Med. 2007;167:1720-1728.

Background: The extent to which moderate overweight (body mass index [BMI], 25.0-29.9 [calculated as weight in kilograms divided by height in meters squared]) and obesity (BMI, 30.0) are associated with increased risk of coronary heart disease (CHD) through adverse effects on blood pressure and cholesterol levels is unclear, as is the risk of CHD that remains after these mediating effects are considered.

Methods: Relative risks (RRs) of CHD associated with moderate overweight and obesity with and without adjustment for blood pressure and cholesterol concentrations were calculated by the members of a collaboration of prospective cohort studies of healthy, mainly white persons and pooled by means of random-effects models (RRs for categories of BMI in 14 cohorts and for continuous BMI in 21 cohorts; total N = 302 296).

Results: A total of 18 000 CHD events occurred during follow-up. The age-, sex-, physical activity–, and smoking-adjusted RRs (95% confidence intervals) for moderate overweight and obesity compared with normal weight were 1.32 (1.24-1.40) and 1.81 (1.56-2.10), respectively. Additional adjustment for blood pressure and cholesterol levels reduced the RR to 1.17 (1.11-1.23) for moderate overweight and to 1.49 (1.32-1.67) for obesity. The RR associated with a 5-unit BMI increment was 1.29 (1.22-1.35) before and 1.16 (1.11-1.21) after adjustment for blood pressure and cholesterol levels.

Conclusions: Adverse effects of overweight on blood pressure and cholesterol levels could account for about 45% of the increased risk of CHD. Even for moderate overweight, there is a significant increased risk of CHD independent of these traditional risk factors, although confounding (eg, by dietary factors) cannot be completely ruled out.

7. Do All Children with Pyelonephritis Require Hospital Admission?

Treatment with oral antibiotics alone is as effective as standard treatment with parenteral antibiotics followed by oral antibiotics.

Risk for sepsis and long-term renal scarring has led some authorities to recommend inpatient treatment with parenteral antibiotics for young children in whom pyelonephritis is suspected. In a multicenter open-label study, investigators in Italy randomized 502 children (age range, 1 month to 7 years) with pyelonephritis to receive either oral amoxicillin plus clavulanic acid (50 mg/kg amoxicillin in 3 divided doses daily) for 10 days or standard treatment with parenteral ceftriaxone (50 mg/kg in a single daily dose) for 3 days followed by oral amoxicillin plus clavulanic acid (50 mg/kg in 3 divided doses daily) for 7 days. All participants were admitted to the hospital until defervescence or for at least 3 days. Children with severe sepsis, dehydration, vomiting, or history of pyelonephritis or abnormal ultrasound were excluded.

About 20% of patients were lost to follow-up by 12 months. Among the remaining participants, the incidence of scarring as detected by scintigraphy did not differ significantly between the group that received standard treatment and the group that received oral treatment only (17.7% and 13.7%). Secondary outcomes — time to fever reduction, amount of reduction in inflammatory indices, and percentage of patients with sterile urine after 72 hours — also were similar in the two groups. Escherichia coli was identified as the pathogen in 94.4% of positive urine cultures.

This study suggests that children with first-time urinary tract infections with fever who are otherwise healthy, clinically stable, and not vomiting can be treated as outpatients, provided that local antibiotic sensitivities are considered, caretakers are reliable, and close follow-up can be arranged.

As a cannula is often in place for initial sampling of blood cultures and electrolytes, most sick children will probably receive initial parenteral treatment. Of note, 10% of the children in Montini's study who started oral treatment were switched to intravenous treatment due to diarrhoea or vomiting caused by antibiotics or intercurrent rotavirus gastroenteritis.

Montini G, et al. BMJ. 2007;335:386. Abstract:

8. Septic Shock — What’s the Best Vasopressor?

Epinephrine alone and norepinephrine plus dobutamine had similar efficacy and safety in this multicenter, randomized, controlled trial.

International guidelines for management of septic shock recommend that dopamine or norepinephrine are preferable to epinephrine. However, no large comparative trial has yet been done. We aimed to compare the efficacy and safety of norepinephrine plus dobutamine (whenever needed) with those of epinephrine alone in septic shock.

This prospective, multicentre, randomised, double-blind study was done in 330 patients with septic shock admitted to one of 19 participating intensive care units in France. Participants were assigned to receive epinephrine (n=161) or norepinephrine plus dobutamine (n=169), which were titrated to maintain mean blood pressure at 70 mmHg or more. The primary outcome was 28-day all-cause mortality. Analyses were by intention to treat.

There were no patients lost to follow-up; one patient withdrew consent after 3 days. At day 28, there were 64 (40%) deaths in the epinephrine group and 58 (34%) deaths in the norepinephrine plus dobutamine group (p=0·31; relative risk 0·86, 95% CI 0·65–1·14). There was no significant difference between the two groups in mortality rates at discharge from intensive care (75 [47%] deaths vs 75 [44%] deaths, p=0·69), at hospital discharge (84 [52%] vs 82 [49%], p=0·51), and by day 90 (84 [52%] vs 85 [50%], p=0·73), time to haemodynamic success (log-rank p=0·67), time to vasopressor withdrawal (log-rank p=0·09), and time course of SOFA score. Rates of serious adverse events were also similar.

There is no evidence for a difference in efficacy and safety between epinephrine alone and norepinephrine plus dobutamine for the management of septic shock.

Annane D, et al. The Lancet 2007; 370:676-684.

9. Symptom Benefits, but no Life Savings with Noninvasive Ventilation for Acute Cardiogenic Pulmonary Edema

September 4, 2007 (Vienna, Austria) - Noninvasive ventilation, in the form of continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NIPPV) may speed up the recovery of patients with acute cardiogenic pulmonary edema, but it doesn't help them live any longer, results from the 3CPO trial show. Both CPAP and NIPPV force air at different pressures into the patients' airways, thereby alleviating some of the effort of inhalation.

Presenting the results here at the European Society of Cardiology Congress 2007, Dr David Newby (Royal Infirmary, Edinburgh, Scotland) said that this is the first evidence from a sizable trial that a practice widely in use may not actually have an impact on hard clinical outcomes.

"Noninvasive ventilation does make the patient feel better in the acute setting, so in the first few hours, it is a very useful treatment, irrespective of which type you're using," Newby commented. "However, it is not a life-saving treatment."

No major benefits, no major harm

The 3CPO study was conducted at 26 sites in the UK, with patients presenting with acute cardiogenic pulmonary edema randomized to standard oxygen therapy, CPAP, or NIPPV, with physicians encouraged to use nitrates and diuretics. In all, 1156 patients were recruited and randomized to one of the three treatments.

While both noninvasive ventilation strategies were better than standard therapy for reducing several physiologic end points, including respiratory rate, heart rate, and acidosis, with no differences between the two types of ventilation approaches, neither therapy alone or in combination was better than standard oxygen therapy at reducing seven- or 30-day mortality.

There were no differences in subsequent MI or hospitalization rates across all three treatment strategies, Newby noted, and all forms of therapy were well tolerated.

Newby emphasized that previous randomized trials have all been very small, with a "plethora of meta-analyses"--many of which have suggested a mortality reduction with noninvasive ventilation--"dangerously close to outnumbering the randomized studies." The dearth of large randomized trials is conspicuous for a strategy whose use dates back 70 years, when investigators used a standard household vacuum cleaner and warned physicians of the need to make sure dust was adequately expelled from the vacuum before it was used to force air into a patient's lungs.

Seven decades later, the 3CPO trial should help put some of the misconceptions about administering higher-pressure oxygen to rest, he said.

"When patients come into the hospital with fluid on the lung, they're often in great distress, they're breathless, they're clammy: it's a very uncomfortable, unpleasant condition to be in. So the more rapid resolution of their symptoms is a beneficial thing. It's a simple treatment, just applying a mask, so it's a useful method for relieving suffering," Newby explained. "But in terms of the longer-term outcomes, it doesn't cause any harm, but it doesn't cause much benefit. My message is, use it to relieve suffering in the early hours of this severe illness, but don't overinterpret its overall benefit."

That message, however, goes against some solidly entrenched faith in the benefits of noninvasive ventilation in this patient group. Dr G Filippatos (Athens University Hospital, Attikon, Greece), the discussant for the study, said that when he first saw the results of the trial, he had trouble believing it was negative. He still believes there may be some patients who, in the right hands, might still experience hard clinical benefits from noninvasive ventilation.

But he also pointed out that the improvements in physiologic end points reported by Newby et al, while statistically significant, may not be clinically meaningful, because the absolute differences heart rate and ventilation between standard oxygen therapy and ventilation with pressure were very small.

"In clinical practice, it's hard to find clinical significance in a difference of one respiration per minute," Filippatos said.

10. Diagnosis and Guided Reduction of Forearm Fractures in Children Using Bedside Ultrasound

Chen L, et al. Pediatric Emergency Care. 2007;23:528-531.

Background: Forearm fractures are common injuries in children. Displaced and angulated fractures usually require reduction. Ultrasound diagnosis and guided reduction offer several potential advantages: (1) the procedure does not involve ionizing radiation; (2) compared with fluoroscopy units, the newer ultrasound units are more portable; and (3) repeated studies can be obtained easily and quickly.

Objective: The primary objective was to investigate the accuracy of emergency department (ED) physician-performed ultrasound in the diagnosis and guided reduction of forearm fractures in children.

Methods: Children suspected of having forearm fractures were enrolled prospectively in an urban pediatric ED from June 2004 to November 2004. A bedside ultrasound of the forearm bones was performed by a pediatric emergency medicine physician. Ultrasound findings were compared with radiograph findings. Reductions were performed under ultrasound guidance. Postreduction radiographs were performed. Any need for further reduction was recorded.

Results: During the study period, 68 patients were enrolled. Radiographs revealed forearm fractures in 48 patients. Twenty-nine subjects had fractures of the radius alone; 17 had fractures of both the radius and the ulna, and 2 had fractures of the ulna alone. Ultrasound revealed the correct type and location of the fracture in 46 patients. The sensitivity for the detection of forearm fractures was 97% (95% confidence interval [CI], 89%-100%) using ultrasound. The specificity was 100% (95% CI, 83%-100%). Twenty-six subjects underwent reduction of their fractures in the ED. Two subjects required re-reduction after the initial reduction. The initial success rate of ultrasound-guided reduction was 92% (95% CI, 75%-99%).

Conclusions: Bedside ultrasound performed by pediatric emergency medicine physicians is a reliable and convenient method of diagnosing forearm fractures in children. It is also useful in guiding the reduction of these fractures.

11. Rocephin Should Not Be Administered with Calcium in Patients of Any Age

Rocephin (ceftriaxone) and intravenous calcium-containing solutions should not be given within 48 hours of each other — "even via different infusion lines at different sites" — Roche has advised healthcare professionals in a letter to the FDA.

The warning applies to treatment in patients of any age. Previously, the manufacturer had warned about mixing ceftriaxone with calcium in newborns, given reports of at least eight fatal reactions with calcium-ceftriaxone precipitates in the lungs and kidneys. To date, there have been no reports of such reactions in older patients.

FDA Safety Alert:

12. New CPR Promises Better Results by Compressing Abdomen, Not Chest

By Anthony J. Brown, MD. NEW YORK (Reuters Health) Sept 21 - Performing "only rhythmic abdominal compression" (OAC) rather than standard chest compressions may improve the coronary perfusion achieved during cardiopulmonary resuscitation (CPR), according to an animal study reported in the September issue of the American Journal of Emergency Medicine.

"The biggest finding is that OAC-CPR provides blood flow AND artificial respiration," lead author Dr. Leslie Geddes, from Purdue University in West Lafayette, Indiana, told Reuters Health. As such, "OAC-CPR does not require chest compression, nor does it require mouth-to-mouth breathing," which "eliminates the risk of rib fractures and transfer of infection."

Previous research has shown that conventional CPR has success rates of just 5% to 10%. Moreover, for every 1 minute that transpires before CPR is started, the chance of success falls 10%.

"In other words, at 10 minutes, the resuscitation is absolutely ineffective," Dr. Geddes said in a statement. "Any medical procedure that had that low a success rate would be abandoned right away. But the alternative is not very good, either: don't do CPR and the person is going to die."

With OAC CPR, the compressions work by forcing blood out of the vascular bed supplying the abdominal organs, which is known to contain about 25% of the total blood volume. This blood is then redirected to other sites, including the coronary circulation.

In their study, Dr. Geddes' team tested OAC CPR on pigs with experimentally induced ventricular fibrillation. The coronary perfusion index, which is calculated using aortic and right-atrial pressure curves, was used to assess perfusion effectiveness.

The researchers found that 60% more coronary perfusion was achieved with OAC CPR than with standard chest-compression CPR, using the same amount of effort. Moreover, there was no evidence that OAC damaged the visceral organs, and it naturally avoided the risk of rib fracture.

Geddes A, et al. Amer J Emerg Med 2007;25:786-790.

13. Do all fractures need full immobilisation? Evidence Based Case Report

Glasziou P. BMJ 2007;335:612-613 (22 September). Centre for Evidence-based Medicine, Department of Primary Health Care, University of Oxford, Oxford OX3 7LF

As I was about to start my morning general practice clinic, the receptionist told me of a patient who was coming in with an injury and handed me a faxed report from radiology, which stated: "possible fracture of the radial head." The "possible" suggested it was undisplaced or minimally displaced, so I wondered if it needed treating at all. While waiting for the first patient to arrive and sipping my tea, I checked the orthopaedics texts in my room and did a PubMed search.

I went to the Clinical Queries section of PubMed Central (which is bookmarked on my Firefox toolbar) and used the narrow version of the "therapy" filter (which filters for randomised trials). I entered search terms to describe the condition "fracture and radial and head," which brought up seven studies. Two of these studies were not trials and three were not relevant (two looked at different types of internal fixation, and one looked at different methods of reduction), which left two that were relevant. I used the most recent study (2002) [1] because it was more relevant to this patient's problem and I had access to the full text. I had access only to the abstract of the second trial, [2] but this seemed to be consistent with the findings of the first trial. My search took only a few minutes.

The trial [1] randomised 60 patients into two groups. One group was treated with rest in a broad sling for five days followed by mobilisation, and the other was treated with immediate mobilisation and an exercise programme that started 24 hours after injury. The randomisation process was haphazard rather than randomised, but baseline characteristics were not significantly different between the two groups (although the immediate mobilisation group seemed to have had more minor fractures). Follow-up assessments were done by an independent observer who was blinded to treatment, but the authors did not mention loss to follow-up. As is usual, the trial was not perfect, but none of the flaws seemed sufficient to invalidate the results.

All fractures in both groups united without problems. At the end of the first week, the early mobilisation group had slightly more pain (10 v 6 on a 25 point scale) but better range of motion (flexion of 112 degrees v 98 degrees). However, most measures showed no difference at that time or at further follow-up (four and 12 weeks).

When I saw the patient, it was clear that she had tenderness over the radial head but still had a full—though somewhat painful—range of elbow movement. I explained the choices to her—that immobilisation would help a little with the pain but make no long term difference, and it would mean that temporarily her arm would be a little stiffer. She opted for no immobilisation with a simple bandage for comfort. Of course, I could have called the local orthopaedic registrar, and that is often the wise thing to do. But once I had seen the patient I was sure that this was just a "minor" fracture that could be dealt with in primary care.

Clinical training and practice is replete with heuristics—rules of thumb—in both diagnosis and treatment. For example, "beware the unilateral red eye," "if a child fails to speak by 16 months then assume that the child is deaf until proved otherwise," and "where there is pus, let it out." One treatment rule we use for soft tissue injury is RICE (rest, ice, compression, and elevation). However, is this rule based on good research? Recently some colleagues and I questioned this advice, and did a systematic review of whether immobilisation is best for the treatment of limb injuries. We identified 49 trials, and we found that less rest and more mobility seemed to be better, even in the 14 studies of fractured limbs. [3] Subsequently, a trial showed that short arm plasters were preferable to long arm plasters for forearm fractures in children. Some people have suggested we change the rule from RICE to MICE (mobilisation, ice, compression, elevation). However, applying this general principle to individual patients and injuries is not always straightforward.

I was puzzled about exactly when I can apply the MICE heuristic to injuries, but a helpful reviewer suggested that, "The majority of hand fractures and radial head fractures are now treated by mobilisation. Many minor lower limb fractures are similarly treated. In many distal radial fractures and most proximal humeral and clavicle fractures, immobilisation is simply for pain relief." With that clarified, I am now left wondering how many other mnemonics provide misleading advice? Indeed, a colleague—Carl Heneghan—pointed out that the C of RICE is also questionable, with a trial in ankle sprains showing that compression bandages provide no advantage and lead to a greater use of analgesia. [4]

1. Liow RY, Cregan A, Nanda R, Montgomery RJ. Early mobilisation for minimally
displaced radial head fractures is desirable. A prospective randomised study of
two protocols. Injury 2002;33:801-6.
2. Unsworth-White J, Koka R, Churchill M, D'Arcy JC, James SE. The non-operative management of radial head fractures: a randomized trial of three treatments. Injury 1994;25:165-7.
3. Nash CE, Mickan SM, Del Mar CB, Glasziou PP. Resting injured limbs delays recovery: a systematic review. J Fam Pract 2004;53:706-12.
4. Watts BL, Armstrong B. A randomised controlled trial to determine the effectiveness of double Tubigrip in grade 1 and 2 (mild to moderate) ankle sprains. Emerg Med J 2001;18:46-50.
14. Self-reported Medication Adherence and Cardiovascular Events in Patients with Stable Coronary Heart Disease: The Heart and Soul Study

Gehi AK, et al. Arch Intern Med. 2007;167:1798-1803.

Background: Nonadherence to physician treatment recommendations is an increasingly recognized cause of adverse outcomes and increased health care costs, particularly among patients with cardiovascular disease. Whether patient self-report can provide an accurate assessment of medication adherence in outpatients with stable coronary heart disease is unknown.

Methods: We prospectively evaluated the risk of cardiovascular events associated with self-reported medication nonadherence in 1015 outpatients with established coronary heart disease from the Heart and Soul Study. We asked participants a single question: "In the past month, how often did you take your medications as the doctor prescribed?" Nonadherence was defined as taking medications as prescribed 75% of the time or less. Cardiovascular events (coronary heart disease death, myocardial infarction, or stroke) were identified by review of medical records during 3.9 years of follow-up. We used Cox proportional hazards analysis to determine the risk of adverse cardiovascular events associated with self-reported medication nonadherence.

Results: Of the 1015 participants, 83 (8.2%) reported nonadherence to their medications, and 146 (14.4%) developed cardiovascular events. Nonadherent participants were more likely than adherent participants to develop cardiovascular events during 3.9 years of follow-up (22.9% vs 13.8%, P = .03). Self-reported nonadherence remained independently predictive of adverse cardiovascular events after adjusting for baseline cardiac disease severity, traditional risk factors, and depressive symptoms (hazards ratio, 2.3; 95% confidence interval, 1.3-4.3; P = .006).

Conclusions: In outpatients with stable coronary heart disease, self-reported medication nonadherence is associated with a greater than 2-fold increased rate of subsequent cardiovascular events. A single question about medication adherence may be a simple and effective method to identify patients at higher risk for adverse cardiovascular events.

15. Febrile seizures in young children: What role is played by excess fluids?

Cann SAH. Med Sci Monit 2007; 13(9): RA159-167.

Febrile seizures are a common occurrence in young children with incidence rates varying from 3–14%, depending on the geographic region. Studies have suggested that an elevated temperature is a factor in their development, though other factors may synergistically lower the seizure threshold. While it is recognized that excessive or rapid dilute fluid intake can cause seizures in young children, and in adults during strenuous physical activity, less focus has been paid to its involvement during febrile illnesses.

Young children are more vulnerable to the development of febrile seizures due to their small skull size relative to brain volume. In animals, reduced serum sodium levels have been shown to lower the threshold to convulsive stimuli, while hypertonic saline has been shown to rapidly reverse these effects. Similarly vasopressin, frequently elevated during acute infections, enhances fluid retention and may also be a precipitating factor for febrile seizures. Although an elevated temperature may augment seizure risk, antipyretics have not been shown to prevent them. In fact, some may increase seizure risk through a reduction in urine output. It has long been observed that fluid retention occurs during febrile infections, followed by diuresis during convalescence. This characteristic observation led to recommendations for restricted fluid intake during acute infections dating back more than 2,000 years.

Only recently has there been a return to restricted fluid intake for patients with potentially reduced free water excretion. Further studies are required to determine the role of the overall fluid balance in the etiology of childhood febrile seizures.

Full-text (free) through this link:

16. Efficacy and Impact of IV Morphine before Surgical Consultation in Children with RLQ Pain Suggestive of Appendicitis: A Randomized Controlled Trial

Bailey B, et al. Ann Emerg Med 2007; 50:371-378.

Although many studies have demonstrated that opioids do not interfere with the diagnosis of acute abdomen, early analgesia is not yet routine practice, particularly for children. In 8- to 18-year-old children with moderate to severe right lower quadrant abdominal pain, does morphine (0.1 mg/kg intravenously) delay the surgical disposition decision? In this 90-person randomized trial, intravenous morphine did not delay surgical decision-making, a particularly compelling finding, given the high prevalence of appendicitis in the sample (66%). Placebo effect was unusually strong in this study, resulting in pain relief similar to that of morphine.

This study provides persuasive evidence that physicians should routinely provide analgesia to children with possible appendicitis. Research we’d like to see: Now that it seems well established that lower doses of opioids are safe in acute abdominal pain, it appears justified to study analgesic titration to a greater degree of pain relief.

17. Is Epinephrine Harmful When Used With Anesthetics for Digital Nerve Blocks?

Waterbrook AL, et al. Ann Emerg Med 2007; 50:472-475

Patients with injuries to the fingers and toes commonly present to the emergency department. These injuries tend to be painful, and anesthesia is often achieved by digital nerve blocks. There is an established dogma that the use of epinephrine with local anesthetics for digital blocks is dangerous because it may lead to vascular insufficiency and necrosis. Most emergency medicine textbooks recommend against using epinephrine in digital blocks, despite several prospective trials and comprehensive reviews of the literature that show evidence to the contrary. One study using color Doppler ultrasonography demonstrated that blood flow to the digit was fully restored in 60 to 90 minutes, without any local or systemic complications after digital anesthesia with epinephrine. We reviewed the available evidence to evaluate the safety of using epinephrine in conjunction with local anesthetics for digital blocks.

The Bottom Line
There are 2 published prospective, randomized, clinical trials evaluating the use of epinephrine in conjunction with local anesthetics for digital blocks. Although these studies report no complications, improved hemostasis, decreased pain, increased duration of anesthesia, and decreased anesthetic requirement in subjects receiving epinephrine, the investigations were small. There is also a small prospective study evaluating digital blood flow after local anesthesia with epinephrine was administered. This study reveals full return of blood flow to the digits at 60 or 90 minutes and resulted in no local or systemic complications.

In addition, there are 3 comprehensive literature reviews that fail to report any cases of digital necrosis caused by the use of commercial lidocaine-epinephrine anesthetic. Cases in which digital necrosis did occur were attributable to other causes, such as nonstandardized epinephrine concentrations, use of expired and possibly acidic procaine, inappropriate usage of tourniquets, overdistention of the tissues, and poor surgical technique. According to current evidence, we conclude that the use of epinephrine with lidocaine in standard commercial concentrations for digital blocks is not harmful and is likely advantageous.

18. Emergency Treatment of Hemorrhagic Complications of Thrombolysis

Rasler F. Ann Emerg Med.2007;50:485.

Symptomatic intracerebral hemorrhage following intravenous thrombolysis for stroke occurred in 6% of patients, with a 3% risk of death during the original NINDS study. Higher rates of bleeding have been found with deviations from the study protocol. This understandably causes hesitation when recommending thrombolysis for acute stroke. Despite the known risk, many emergency departments (EDs) and intensive care/coronary care units are not prepared to treat hemorrhagic complications with the urgency they require. Although specific reversal agents are available, when a critical hemorrhage happens you don’t have time to begin thinking about treatment options or call a hematologist for advice.

Whether thrombolysis is used for stroke, heart attack or pulmonary embolism, every hospital would benefit from having written guidelines immediately available in the ED and intensive care/coronary care units for the complications. A specific table of treatment guidelines was created at our institution (see URL below), which may be copied. We keep the table in a visible location with our “thrombolytic box,” rather than just being attached to a manual with other hospital protocols.

Nurses and physicians must be diligent in watching for early signs of intracranial and other bleeding complications, and ready to initiate the guidelines. Based on clinical signs alone, it may be necessary to stop the thrombolytic infusion and begin thawing cryoprecipitate even before an immediate computed tomographic scan is done. Time is the critical issue when beginning thrombolysis, and this same urgency is essential to help limit damage if hemorrhage occurs.

Elevated blood pressure following intracranial hemorrhage must also be addressed to potentially limit hematoma expansion. Avoid rapid blood pressure reduction and use 30° head elevation. Acute treatment goals have not yet been established and each patient should be individualized. Recommendations for treating spontaneous intracerebral hemorrhagic (bleeding not caused by thrombolysis), suggest a systolic blood pressure less than 180 and mean arterial pressure less than 130 mm. Bleeding associated with thrombolysis, however, may benefit from lower pressure.

Seizure prophylaxis should be considered because there is a 10% risk of early seizure, usually with an early onset, and especially with lobar hemorrhage. If intubation is performed, the usual measures to minimize its acute effect on intracranial pressure should be used. Activated Factor VII theoretically offers an option to treating bleeding associated with thrombolysis, but will require study before any recommendations can be made.

For the Table, see:

19. Use of a triage pain protocol in the ED

Fosnocht DE, et al. Amer J Emerg Med. 2007;25:791-793.

This study was designed to evaluate the ability of a triage pain protocol to improve frequency and time to delivery of analgesia for musculoskeletal injuries in the emergency department (ED).

Basic Procedures
Frequency and time to analgesic administration were measured before and after use of a triage pain protocol. The protocol allowed analgesic medications to be given at the time of triage.

Main Findings
Time to medication administration was 76 minutes (95% confidence interval [CI], 68-84 minutes) before and 40 minutes (95% CI, 32-47 minutes) after the protocol. Five hundred fifty-nine (70%) of 800 patients received analgesics using the protocol compared with 212 of 471 (45%) patients prior.

Principal Conclusions
Use of a triage pain protocol increased the number of patients with musculoskeletal injury who received pain medication in the ED. Use of the protocol also resulted in a decrease in the time to analgesic medication administration.

20. Ophthalmic diagnoses in the ED: optic neuritis

Germann CA, et al. Amer J Emerg Med. 2007;25:834-837.

Optic neuritis is the most common cause of decreased vision due to optic nerve dysfunction in patients who are 20 to 40 years of age. Optic neuritis, or inflammation of the optic nerve, is primarily due to idiopathic demyelination. Demyelinative lesions seen in optic neuritis are not unlike those seen in plaque associated with multiple sclerosis. In fact, acute inflammatory demyelination of the optic nerve commonly occurs as an initial manifestation of multiple sclerosis.

Key features of optic neuritis include a vision loss occurring over 1 to 10 days, color vision impairment, eye pain with motility, and an afferent pupillary defect. This significant diagnosis can be challenging to an emergency physician as it is relatively infrequently observed.

21. In Treating Migraine in the ED, What Influences our Drug Choices?

Hurtado T, et al. Headache. 2007;47:1134-1143.

Study Objective.—To evaluate the factors that influence clinicians' choices of parenteral medications in the emergency department (ED) management of migraine headache.

Background.—Migraine headache is a common problem in the United States. Many migraineurs require periodic ED management. Though a large variety of parenteral medications are used by ED clinicians in the treatment of migraine, little research has been directed to the reasons why providers use the medications they do.

Methods.—This study used a self-administered questionnaire for providers from 3 geographically distinct EDs to evaluate their pharmacotherapeutic preferences in the treatment of uncomplicated migraine based on a fictitious scenario. Factors influencing medication choices were rated on a 5-point Likert scale and analyzed descriptively. Hypothetical practice patterns from the questionnaires were compared with actual practice patterns from a prior study from the same institutions.

Results.—Eighty-three percent of surveys were returned, the majority from attending physicians (71%), as their initial drugs-of-choice providers preferred dopaminergic antiemetics (93%) and parenteral NSAIDs (22%). If initial therapy failed, opioids (40%) with nonspecific antiemetics (24%) were preferred as second-line agents. Choice of therapy was influenced (in descending order) by medication availability and its antimigraine properties, the providers' training, current departmental practice patterns, and national practice guideline recommendations. Opioid use was influenced by patients' failure to respond to ED and outpatient alternatives and the presence of contraindications/intolerances to non-opioids. When these results were compared to a prior study of actual practice patterns, a range of discordance was observed, which varied significantly by institution.

Conclusion.—Emergency clinicians report that a variety of factors influence their parenteral pharmacotherapy in the management of patients with migraine headache. The comparison of hypothetical practice patterns with actual practice patterns reveals a range of institution-specific discordance. There is discordance between providers' responses to a fictitious scenario and their previously recorded practice patterns with regional variation.

22. Spinal Cord Injury Improves Mental Health?

Perceived quality of life was better than normal among men with spinal cord injuries.

Spinal cord injury (SCI) can have devastating consequences for physical functioning, related to the level of injury. Most of us assume that the emotional and social consequences are similarly severe. Researchers recruited subjects at two Veterans Administration hospitals to examine whether men’s self-perceived quality of life was linked to injury severity.

The study population consisted of 20 men with "high SCI" with lesions at or above T6 (some were quadriplegics), 10 with "low SCI" with lesions below T7, and 11 nondisabled men (controls). Injuries occurred many years previously (mean: high-SCI group, 27.9 years; low-SCI group, 16.5 years). Some controls had mononeuropathies or mild polyneuropathies. Subjects rated their life satisfaction, quality of life, and depression.

As expected, the high-SCI group had the lowest mean rating for physical functioning. The three groups rated their overall satisfaction with life similarly, including physical role, general health, and social functioning. The high-SCI group had the highest perceived emotional role in society and vitality. In further analysis, the worse the physical disability, the better was the overall mental health, especially in the high-SCI group. Depression levels did not differ among the groups. Analyses in patients without histories of traumatic brain injury had similar results.

Comment: More "severe" SCI was associated with better perceived quality of life, even compared with control group ratings. Although the controls were not completely healthy (some had neuropathies, which are often treated with psychiatric medications), this finding appears paradoxical. The authors hold that the finding may have a neurophysiologic basis, related to changes in sympathetic pathways and somatic sensory input. This study challenges our notions about the consequences of physical disability and highlights the need for empirical data rather than reliance on "logical" assumptions.

— Jonathan Silver, MD. Published in Journal Watch Psychiatry. September 17, 2007. Citation:
Abrantes-Pais F de N et al. Psychological or physiological: Why are tetraplegic patients content? Neurology 2007 Jul 17; 69:261.