Friday, December 28, 2007

Lit Bits: December 28, 2007

From the recent medical literature...

1. ACC and AHA Update STEMI Guidelines

The American College of Cardiology and the American Heart Association have updated their 2004 guidelines for managing ST-segment-elevation myocardial infarction.

The update, released online in the Journal of the American College of Cardiology, offers charts listing how recommendations have changed.

The latest guidelines emphasize adding clopidogrel to aspirin and the need for speedy thrombolysis when patients cannot get timely percutaneous coronary intervention. STEMI patients arriving at a hospital without PCI capability should receive fibrinolytic therapy within 30 minutes unless they can be transferred to a PCI center and receive treatment within 90 minutes of their first medical contact.

Journal of the American College of Cardiology article (Free):

Related interests: New PCI guidelines:

2. Hospitalist Care Associated With Shorter Length of Stay for Common Diagnoses

Patients seen by hospitalists have slightly shorter lengths of stay — but similar mortality and readmission rates — compared with those treated by internists or family physicians, according to an article in the New England Journal of Medicine.

"The hospitalist model is rapidly altering the landscape for inpatient care in the United States, yet evidence about the clinical and economic outcomes of care by hospitalists is derived from a small number of single-hospital studies examining the practices of a few physicians," write Peter K. Lindenauer, MD, from the Baystate Medical Center in Springfield, Massachusetts, and colleagues. "As compared with traditional inpatient care, the hospitalist model offers many potential advantages.... At the same time, the hospitalist model introduces handoffs at the time of admission and at discharge, transitions during which the risk of errors and adverse events is high."

Researchers retrospectively reviewed data on nearly 77,000 adults admitted to 45 hospitals nationwide; diagnoses included pneumonia, heart failure, chest pain, ischemic stroke, UTI, COPD exacerbation, and MI. Among the findings from multivariable-adjusted analyses:

  • Length of stay was nearly half a day shorter among patients seen by hospitalists than among those treated by internists or family physicians.
  • Rates of death and 14-day readmission did not differ among the three physician groups.
  • Cost per patient was nearly $270 less with hospitalist care than with internist care; costs did not differ significantly between hospitalists and family physicians.

The authors conclude: "There remains a need to understand how hospitalist systems should be structured in order to improve the quality and outcomes of care."

N Engl J Med. 2007;357:2589-2600 (Free):

NEJM editorial (Free):

3. Origins of magic: review of genetic and epigenetic effects

Ramagopalan SV, et al. BMJ 2007;335:1299-1301

Objective: To assess the evidence for a genetic basis to magic.
Design: Literature review.
Setting: Harry Potter novels of J K Rowling.
Participants: Muggles, witches, wizards, and squibs.
Interventions: Limited.

Main outcome measures: Family and twin studies, magical ability, and specific magical skills.

Results: Magic shows strong evidence of heritability, with familial aggregation and concordance in twins. Evidence suggests magical ability to be a quantitative trait. Specific magical skills, notably being able to speak to snakes, predict the future, and change hair colour, all seem heritable.

Conclusions: A multilocus model with a dominant gene for magic might exist, controlled epistatically by one or more loci, possibly recessive in nature. Magical enhancers regulating gene expressionmay be involved, combined with mutations at specific genes implicated in speech and hair colour such as FOXP2 and MCR1.

4. New Statement on Safety of MRI with CV Devices

Lisa Nainggolan. from Heartwire — a professional news service of WebMD. December 4, 2007 — The American Heart Association has published a scientific statement on the safety of magnetic resonance imaging (MRI) in patients with cardiovascular devices, which has also been endorsed by the American College of Cardiology, the North American Society for Cardiac Imaging, and the Society for Cardiovascular Magnetic Resonance [1]. The document states that for most devices, if there is a good clinical indication for an MRI scan, then the benefits probably outweigh the risks.

Lead author Dr Glenn N Levine (Baylor College of Medicine, Houston, TX) told heartwire: "This is the first document that specifically addresses these issues." He explained that, over the years, decisions have been made about when it is safe to do an MRI scan with a particular device, but these have not been based for the most part on any good evidence. "When coronary stents first came out, for example, it was decided that you had to wait a minimum of six weeks before doing an MRI scan, but that was not based on any firm data. And there are still people out there who won't do an MRI ever in a patient with a stent, and that is absurd. We wanted to make recommendations that are in line with actual data and expert opinion."

The exceptions to this are pacemakers and implantable cardioverter-defibrillators (ICDs). "Whether one can safely MRI-scan a patient with a pacemaker and/or ICD has been controversial," Levine explained. "However, we didn't want to make a blanket statement that you shouldn't scan, because in certain cases MRI is the best imaging modality to resolve a clinical question. But we also wanted to be careful to stress that MRI should be done in these patients only at very experienced centers, with expertise in MRI physics, MRI safety, and electrophysiology," he noted.

For most devices, MRI is generally safe. Levine said that when his group was trying to put together this guidance, "one of the things I encouraged in our conference calls was that I did not just want to regurgitate what was on the approved labeling but rather state what the experts in the country felt and what they should be telling people."

With regard to the majority of devices, which Levine says are either nonferromagnetic or weakly ferromagnetic, "we decided our overriding principle would be that if there is a good clinical indication to scan anytime after implantation of the device—even if only one day afterward—then one should generally go ahead and perform the scan."

If, however, the MRI is completely elective, "while it may be safe to perform the scan at that time, it is prudent in some cases to wait six weeks after implantation before scanning," he says. Such cases include the following devices: all commonly implanted coronary stents, many peripheral stents, many embolization coils, many inferior vena cava (IVC) filters, many aortic stent grafts, all prosthetic heart valves and annuloplasty rings, certain cardiac closure and occluder devices, and loop recorders.

"Here's the general thing," he says. "For most of these devices, it's probably safe to scan the patient anytime, but let's say someone has had knee pain for five years and needs an MRI but has just had a device implanted two days ago. They've waited five years so they might as well wait another few weeks. But if they are admitted to the hospital after being hit by a car, and now they are having acute knee pain and the surgeons want to do an MRI, then there's a good clinical indication to do the procedure at that time."

Levine GN, et al. Circulation 2007;116:2878-2891. Full text:

5. Volumetric Bladder US performed by trained Nurses increases Cath success in Kids

Baumann BM, et al. Amer J Emerg Med. 2008;26:18-23.

The objective of the study was to determine whether the use of volumetric ultrasound by trained pediatric emergency department (ED) nurses improves first-attempt urine collection success rates.

This randomized controlled trial was conducted in children aged ≤36 months requiring diagnostic urine samples. Children were randomized to either the conventional (nonimaged) or the ultrasound arm. Demographics, number of catheterizations required for success, postponements, and collection times were recorded.

Forty-five children were assigned to the conventional and 48 to the ultrasound arm (n = 93). First-attempt success rates were higher in the ultrasound arm: 67% (conventional) vs 92% (ultrasound) (P = .003). Both urinalysis and culture were less likely to be completed on conventional group specimens (91% vs 100%; P = .04). However, mean conventional group urine collection time was less than the ultrasound group's collection time (12 vs 28 minutes; P less than .001).

Although there is a time delay, urine collection in the ultrasound arm generated a significant improvement over conventional catheterization in obtaining an adequate urine sample.

6. ED Procedural Sedation with Propofol: It Really Is Safe!

J Emerg Med. 2007;33:355-361.

Propofol is a sedative agent gaining popularity for Emergency Department Procedural Sedation (EDPS). However, some institutions across the country continue to restrict the use of propofol secondary to safety concerns. The purpose of our study was to evaluate the complication rate of EDPS with propofol.

We conducted a prospective, observational, multi-center study of EDPS patients aged ≥ 18 years, consenting to procedural sedation with propofol. Eighty-two patients from two Level I trauma centers were enrolled between August 1, 2002 and January 31, 2003.

Transient hypoxemia was the only noted sedation complication. Nine patients (11%) had brief hypoxemia. The combined average hypoxemia time was 1.2 min (SD 0.4), and in all instances responded to simple airway maneuvers or increased oxygen concentration. No patient required advanced airway maneuvers such as intubation or even positive pressure ventilation. EDPS with propofol seems to be safe in our population.

7. U.S. ED Visits by Seniors Rising

By Lisa Baertlein. LOS ANGELES (Reuters) Dec 06 - The rate of visits to U.S. hospital emergency rooms by senior citizens grew faster than that of any other age group between 1993 and 2003, straining the country's already overcrowded emergency care system, according to a study published on Wednesday. The research from George Washington University also found the rate of emergency room visits by older blacks was rising at an alarming rate.

The reasons behind seniors' accelerated visit rates were not immediately clear. Researchers said the trend could have been driven by health-care advances that have resulted in people living longer with chronic medical issues. It could also have been related to difficulty finding timely primary care, they said.

"Seniors are using the emergency department more and more frequently, and given the needs of this population and the nature of their medical problems, the current state of overcrowding is likely to continue to escalate dramatically," said Dr. Mary Pat McKay, a study co-author from the George Washington University Medical Center in Washington.

The researchers, who published their findings in the Annals of Emergency Medicine, said a review of hospital data from 1993 to 2003 showed a 34% increase in emergency room visits by people aged 65 to 74. By comparison, there was little change in visit rates among people younger than the age of 21 from 1993 to 2003. The rate of visits was up 19% for individuals aged 22 to 49 and 16% for people aged 50 to 64.

The authors said seniors' additional emergency room visits did not appear to be driven by frivolous complaints.

Dr. McKay said she was surprised the data showed a widening gap between the rates of black and white seniors seeking emergency care. Emergency visits by black patients aged 65 to 74 rose by the greatest rate, nearly doubling during the 11-year study period to 77 visits per 100 persons. In comparison, the visit rate among whites of the same age group was up 26% to 36 visits per 100 persons.

"That there is a racial disparity didn't surprise me. What surprised me is that it's getting worse," she said. The study's authors said more research was needed to pinpoint the reasons driving the differences. They said the higher prevalence of diabetes and hypertension in the black community may be a factor. They also noted that nearly twice as many young blacks lack health insurance -- a problem that worsens among the poor.

People who were uninsured before becoming eligible for the U.S. government's Medicare health coverage at age 65 are more likely to have serious health problems if they could not afford to get needed care for chronic illnesses.

Whatever the cause, the study's authors estimated that visits by people aged 65 to 74 could nearly double to 11.7 million by 2013 from 6.4 million in 2003 if the trend in emergency room visit rates continues.

"The system is broken and the point of the study is that it's going to get worse," said Dr. McKay.

8. False-Positives in the PCI Era: Roughly 1 in 10 Patients Sent to Cath Lab Unnecessarily

Shelley Wood. from Heartwire — a professional news service of WebMD. December 21, 2007 — Having emergency-room physicians diagnose ST-segment-elevation MI (STEMI) and "activate" cardiac cath labs directly — cutting out the delay associated with seeing a cardiologist — is a key recommendation for efforts to trim door-to-balloon times for patients with STEMI. But a new analysis suggests that this strategy may lead to false-positive activation of cath labs anywhere from 9% to 14% of the time.

Writing in the December 19, 2007 issue of the Journal of the American Medical Association, Dr David M Larson (Ridgeview Medical Center, Waconia, MN) and colleagues point out that hospitals planning and budgeting for strategies to cut door-to-balloon times will need to take into account this relatively common and unavoidable consequence of direct cath-lab activation [1].

To heartwire, Larson, an emergency room (ER) physician, commented that he thinks a false-positive rate somewhere in the region of what they found is appropriate. In the thrombolytic era, he notes, the false-positive rate of patients who received lytics and later were found not to have a myocardial infarction (MI; by cardiac biomarkers) was about 10%; false-positive rates in the percutaneous coronary intervention (PCI) era have not previously been reported, with or without door-to-balloon time-saving strategies. Larson also thinks that while hospitals should always strive to reduce the rates of patients being sent to the cath lab unnecessarily, there needs to be a balance.

"There are a lot of cases that are in the gray zone," he said. "If you're more specific, and you decrease the rate of false positives, you're probably going to increase your rate of false negatives. It's a trade-off."

Larson et al reviewed all cases of suspected STEMI patients presenting to the Minneapolis Heart Institute or transferred from one of 30 community hospitals — a total of 1345 patients between March 2003 and November 2006. In all cases, emergency-department staff, on the basis of electrocardiogram (ECG) results, activated the cath lab at the tertiary hospital before transferring patients for angiography. In the authors' subsequent review, however, 14% of patients were found to have no culprit coronary artery and 9.5% had no significant coronary artery disease. Of those with no coronary artery disease (CAD), 38% had positive cardiac biomarkers, pointing to myocarditis (31%), stress cardiomyopathy (31%), or STEMI confirmed by cardiac magnetic resonance imaging (MRI) — in some of these patients, angiography did not pave the way for PCI but was at least an appropriate diagnostic test. In all, just 9.2% of patients had both negative cardiac biomarkers and no culprit artery, which the authors say believe is likely the "true measure" of unnecessary cath-lab activation in this study.

Sometimes you do need to slow down

In an accompanying editorial, Dr Frederick A Masoudi (Denver Health Medical Center, CO) points out that the push in recent years to reduce door-to-balloon times may have the unintended consequence of increasing false-positive rates [2]. "In the case of primary PCI, the view of quality should extend beyond the time to treatment to include patient selection and ultimately to outcomes," he writes. To reduce the number of false positives that arise from overly zealous efforts to shorten door-to-balloon times, false-positive rates could, like door-to-balloon times, be a measure in the overall assessment of hospital performance.

Larson agrees: "There's so much emphasis on door-to-balloon time and time to reperfusion; I think sometimes we have to realize that there are cases where we need to slow down and maybe get another ECG or an echocardiogram and not penalize people for slower door-to-balloon times in those cases. When you're looking at quality, it's not just the process measures like time to treatment, it's patient selection as well. If one hospital has a false-positive rate of 25% and the standard in the community is 10%, you have to take a closer look at that."

But Larson also believes there is "always room for improvement." In his study, roughly 2% of electrocardiograms were "overread," resulting in patients heading to the cath lab unnecessarily. Better education would help reduce this problem, and centers with higher rates of false positives could perhaps be targeted for this kind of education, Larson suggests. He also notes that many patients who undergo an urgent diagnostic catheterization and are not found to have occlusive disease are patients who would likely have ended up undergoing angiography at a later date anyhow and, in some cases, may at least be less at risk from an invasive catheterization than if they underwent unnecessary fibrinolytic therapy: for example, patients having a dissection or who have pericarditis.

Larson also emphasized that the results should not be interpreted to mean that a cardiologist should see each and every patient with presumed STEMI in the emergency room—bypassing the cardiologist has proved key to improving door-to-balloon times. "There should always be the opportunity, on questionable cases, to get more data, get help from a cardiologist if necessary, have someone else look at the ECG, without penalizing somebody for having a slower door-to-balloon time. But I don't think we should change the whole system: most of the cases — 90% — are clear-cut. You don't want to hurt the whole system because of the remaining 10% of patients."

Know your rates

Also commenting on the study for heartwire, senior author and cardiologist Dr Timothy Henry (Abbott Northwestern Hospital, Minneapolis, MN) noted that this study "sets a benchmark."

"Everyone talks about false positives, but no one knows what their rates are or what the rates should be," he said. "If your false-positive rate is 2% or 5%, you're doing something wrong and you're missing patients. But if your false-positive rate is 25%, you need to be talking to people about what you could do differently. . . . The most important thing is that everyone should know what their own rate is. We've been so focused on reducing door-to-balloon times that we've forgotten about some of these other things."

[1] Larson, DM, Menssen KM, Sharkey SW, et al. "False-positive" cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA. 2007;298:2754-2760. Abstract:
[2] Masoudi FA. Measuring the quality of primary PCI for ST-segment elevation myocardial infarction. Time for balance. JAMA. 2007;298:2790-2791.

9. Adjuvant Dexamethasone Ineffective in ED Treatment of Migraine

NEW YORK (Reuters Health) Dec 07 - For patients presenting to the emergency department with acute migraine, adding intravenous dexamethasone to standard treatment provides little added benefit, although it might be useful for patients with migraine lasting longer than 72 hours.

These are the findings of a study conducted by Dr. Benjamin W. Friedman of the department of emergency medicine at Montefiore Medical Center, Bronx, New York, and colleagues and published in the November 27 issue of Neurology.

In the study, 205 patients presenting to the emergency department with acute migraine were randomized in a double-blind fashion to dexamethasone 10 mg IV or placebo. All were given 20 mg metoclopramide and 25 mg diphenhydramine IV, plus other analgesic medications as needed.

According to Dr. Friedman and colleagues, there were no significant between-group differences in the percentage of patients who achieved the primary outcome -- headache-free state in the emergency department and for 24 hours and no headache-related functional impairment after emergency department discharge.

The persistent pain-free outcome was achieved in 25% of dexamethasone-treated patients and 19% of placebo-treated patients (p = 0.34). The "no functional impairment" outcome was achieved in 67% and 59%, respectively (p = 0.20).

In the small subgroup of 45 patients with migraine lasting more than 72 hours, 38% randomized to dexamethasone were persistently pain free at 24 hours compared with 13% randomized to placebo (p = 0.06). "While not quite significant, these data suggest that dexamethasone merits further study in this subgroup," Dr. W. J. Becker from the University of Calgary in Alberta, Canada, and Dr. R. J. Kryscio of the University of Kentucky in Lexington write in an editorial accompanying the study.

Neurology 2007;69:2034-2035,2038-2044.

10. ED Visits for Adverse Drug Events in Elders Hinge on Commonly Prescribed Drugs

Drugs commonly prescribed to the elderly cause more serious adverse effects than drugs identified as "always potentially inappropriate" for them, according to an Annals of Internal Medicine study.

Federal researchers examined 2 years of nationally representative data on emergency room visits for adverse drug effects and compared the implicated drugs with their prescribing frequencies in databases detailing outpatient visits.

Drugs considered "always potentially inappropriate" for the elderly (according to the Beers criteria) accounted for roughly 4% of the ER visits for adverse drug events. The risk for ER visits due to the most commonly implicated drugs — warfarin, insulin, and digoxin (not "always potentially inappropriate") — was some 35 times higher than that for drugs rated always potentially inappropriate.

The authors conclude their findings "suggest that there may be considerable opportunity to reduce [these adverse effects] through interventions that improve the use of anticoagulants, antidiabetic agents, and narrow therapeutic index medications."

Annals of Internal Medicine article (Free):

List of Beers criteria drugs (Free):

11. CT Pulmonary Angiography and V/Q Lung Scans Similarly Accurate for Excluding PE

Computed tomographic pulmonary angiography (CTPA) rules out pulmonary embolism as accurately as ventilation-perfusion (V/Q) lung scanning, JAMA reports.

In a multicenter, noninferiority trial, some 1400 adults (mostly outpatients) with a high likelihood of pulmonary embolism based on clinical criteria and D-dimer testing were randomized to CTPA or V/Q scanning. More CTPA patients than V/Q patients were diagnosed with venous thromboembolism (19% vs. 14%) and subsequently received anticoagulation therapy. The rest of the patients, in whom pulmonary embolism was considered excluded, did not receive treatment.

During 3 months' follow-up, the primary outcome — the proportion of patients who developed symptomatic pulmonary embolism or proximal deep venous thrombosis after pulmonary embolism was initially excluded — did not differ significantly between the groups (CTPA, 0.4%; V/Q, 1.0%).

The authors note that some of the excess emboli initially found with CTPA could be clinically unimportant, possibly leading to unnecessary anticoagulation.

JAMA article (Free):

12. FDA Approves Voluven for Loss of Blood Volume Related to Surgery

The FDA has approved the blood volume expander Voluven, an isotonic saline solution containing a synthetic starch. In clinical trials, Voluven was comparable to other approved volume expanders, including the starch solution hetastarch (Hespan) during orthopedic surgery and an albumin-based product during pediatric surgery.

Jesse L. Goodman, director of the FDA's Center for Biologics Evaluation and Research, says the approval offers "an alternative blood volume product that is safe and effective in a wide range of age groups."

FDA alert (Free):

13. Excuse me! The etiquette of sneezing in surgical masks

Granville-Chapman J, et al. BMJ 2007;335:1293

Sneezing etiquette and the efficacy of masks in the operating theatre remain a subject of debate. Standard teaching dictates that one must face the wound when sneezing, so that droplets escape backwards, via the sides of the mask. A literature search found no clear demonstration of this principle.

We therefore tested the hypothesis that one should face the wound when sneezing into a surgical mask in theatre.

Method: A surgeon wearing a surgical mask (Kimberley Clark Healthcare) was encouraged to sneeze by inhaling finely ground pepper. A small reservoir of water was held in the floor of the mouth to improve the appearance of the droplets on the photographs. All photographs were taken by the medical photography department in a dark room with a dark background, using a Kodak DCS Pro SLR camera (ISO 160, 13.5MP resolution, RAW format) and a Nikon Micro-Nikkor 55mm F2.8 lens. A Sony HVL56AM flashgun was strobed (1/32 power, 2 sec, 10Hz). Images were converted into TIFF files and then sharpened slightly on Adobe Photoshop.

Results (see article for images:
Fig 1 shows the droplet spray from a sneeze without a mask. Fig 2 shows slight droplet spray escaping from the sides of the mask. Fig 3 shows there is also little spray escaping anteriorly. On close inspection, however, a few droplets can be seen escaping inferiorly on to the surgeon’s upper chest. None of our photographs showed substantial numbers of droplets passing behind the head of the surgeon.

Discussion: The doctrine of facing the wound when sneezing seems logical. Our study does not, however, support this hypothesis. A few droplets of spray escaped sideways, but no substantial numbers passed behind the surgeon’s head. Our photographs show that the most important visible escape of spray comes from below the mask on to the surgeon’s chest. We therefore recommend that surgeons should follow their instincts when sneezing during operations.

14. Strategies Reduce Return ED Visits for Asthma

By Will Boggs, MD. NEW YORK (Reuters Health) Dec 24 - Preprinted order sheets and access to a pediatrician are among strategies that can reduce the rate of return visits to the emergency department for children with asthma, according to a report in the December issue of Pediatrics.

"Standard order sets are an effective and inexpensive way to 1) ensure that all children with asthma receive timely and evidence-based care for asthma in emergency departments, and 2) reduce 'bouncebacks' to the Emergency Department," Dr. Astrid Guttmann from the Institute for Clinical Evaluative Sciences, Ontario, Canada told Reuters Health.

Dr. Guttmann and colleagues describe current asthma management strategies for children used by emergency departments in the province of Ontario, and which strategies have an impact on 72-hour return visits by children.

Asthma management strategies were distributed across all hospital types, the authors report, but small community hospitals generally had lower adoption rates of all strategies than did large community hospitals and academic hospitals.

Two strategies -- the availability of a pediatrician for consultation and the use of a standard, preprinted order sheet -- were associated with significantly reduced return visits. Employing both these strategies was associated with a 36% reduction in return-visit rates, the report indicates.

"This study cannot identify the specific components of these order sheets that account for their effectiveness," the investigators say, "but the timely use of evidence-based medications is likely to be an important component, given its consistent appearance in all of them."

"We think the evidence is compelling enough to move ahead with implementing asthma order sets for emergency departments, but we are considering studying order sets for other common conditions seen in emergency departments in a trial and collecting data about what processes are improved," Dr. Guttmann said.

Pediatrics 2007;120:e1402-e1409.

15. What Do Non-ischemic Transient Neurologic Attacks Portend?

Sudden attacks of neurologic dysfunction that do not qualify as transient ischemic attacks are not harmless, according to a JAMA study.

Dutch researchers followed some 6000 subjects aged 55 or older for over 10 years. By the end of follow-up, those who'd suffered a TIA (also called a focal transient neurologic attack) and those who'd suffered a nonfocal attack (i.e., one not attributable to the dysfunction of a single arterial territory of the brain) had roughly similar clinical courses. Relative to those subjects without any neurologic attacks, the hazard ratio for subsequent stroke among those with TIAs was 2.14; among those with nonfocal attacks, the HR was 1.56; and among those with attacks showing both focal and nonfocal characteristics, the HR was 2.48 (but these patients were rare).

The authors say their results "challenge the strong but unfounded conviction that nonfocal [transient attacks] are harmless." An editorialist recommends applying the same diagnostic and treatment regimens, short of hospitalization, in both focal and nonfocal attacks.

JAMA Abstract:

16. Hypertension Poorly Controlled in Patients with Cardiovascular Comorbidities

Blood pressure control rates among patients with comorbid cardiovascular conditions, such as heart failure, dyslipidemia, and diabetes, are "disappointing," according to a study and editorial in Archives of Internal Medicine.

Using federal health and nutrition survey data, researchers estimated that roughly one-third of U.S. adults suffer from hypertension, and among those with cardiovascular comorbidities, that proportion approaches three-quarters. Despite higher treatment rates among patients with comorbid conditions, their hypertension — particularly systolic hypertension — remains less controlled than that among patients without comorbidities. The authors say their results suggest "an urgent need for intensified efforts at improved treatment and control."

An editorialist writes that physicians may simply be unaware of the importance of following guideline recommendations, may find them too onerous in terms of the time and expense needed for compliance, or may simply be skeptical that recommendations will hold up over time.

Archives of Internal Medicine article (Free abstract; full text requires subscription):

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 Express) (Free PDF):

17. “Pimp my slang.” A guide to some medical neologisms

Keeley PW. BMJ 2007;335:1295

Struggling to understand what your colleagues are saying?

One of the principal virtues of English is its malleability and easy incorporation of new words, and new meanings for old ones. The language has been constantly changing, enriched by each wave of immigration and by exposure to other languages, most notably during the days of the British Empire.[1]

The rate of change has accelerated recently with the advent of electronic media. Coupled with this has been the development of urban slang, tracked by online publications such as the Urban Dictionary[2] New terms can be derived from existing words or from popular culture (especially film, television, and the internet). Just as doctors need to familiarise themselves with new words arising from new concepts and technologies they need to keep up with changing usages and slang.

But it can be hard,[3] particularly for those who don’t recognise the references. Here is a small selection of new terms in current use. I would be delighted to hear of more. (No personal inventions, please.)

404 moment
The point in a ward round when-despite all efforts to look through the notes or access electronic systems-a particular result cannot be located. (From the world wide web error message "404 document not found.")

The pleasantly decorated and furnished palatial offices of trust management or the dean.

The flurry of pointless emails and paperwork that emanate from the adminosphere.

The (usually vain) attempt to answer the question, "How long have I got, doc?"

A session of mutual recrimination during which a multidisciplinary team attempts to apportion blame for some particularly egregious error.

Disco biscuits
E, ecstasy, or methylenedioxymethamphetamine (MDMA) - a class A drug under the Misuse of Drugs Act 1971. Commonly used as a recreational drug by clubbers. An emergency doctor might say: "The man in cubicle 3 looks like he’s taken one too many disco biscuits."

A combination of broad spectrum antibiotics, thiazide diuretics, and nebulised bronchodilators (with or without corticosteroids) prescribed to elderly patients admitted to UK hospitals between October and March.

A patient presenting to accident and emergency with an injury with a bizarre explanation. (After the former Baywatch actor David Hasselhoff, who suffered a freak injury when he hit his head on a chandelier while shaving. The broken glass severed four tendons as well as an artery in his right arm, which required immediate surgery.[4])

It’s like . . .
The opening words of every medical or nursing student sentence. Just ignore.

Jack Bauer
A doctor still up and working after 24 hours on the job—now something of a rarity but will be recognised by older clinicians. Usually a bit tetchy:

Colleague: Going for lunch, Jack?

JB: (shouts) "THERE ISN’T TIME!" (From the lead character in the television series 24.)]

The lateral movement of the head to an angle of 45° to the vertical by a palliative care nurse specialist. It is intended to convey sympathy and understanding. (Mac from Macmillan nurse—a specialist palliative care nurse—and tilt.)

Mini me
A trainee or medical student who emulates their senior colleague a little too much but doesn’t say a lot. Can be very annoying. (From the character in the Austin Powers films.)

Expendable member of a team. (After Ringo Starr, drummer with the Beatles. John, Paul, and George went on to successful solo careers. Ringo did the voiceover for Thomas the Tank Engine.)

Search and rescue
The medical middle grader allocated to look after the patients dotted in non-medical wards.

The holding forth with expressive hand gestures by a consultant on a subject on which he or she has little knowledge. (Concatenation of testicle and gesticulate.)

Ward 101
The source of referrals that fills the recipient with dread. (From room 101, which contained all the deepest fears of the protagonist in George Orwell’s novel 1984.)

[1] Bragg M. The adventure of English. London: Sceptre, 2004.
[2] Urban dictionary.
[3] Fox AT, Fertleman M, Cahill P, Palmer RD. Medical slang in British hospitals. Ethics Behav 2003;13:173-89.
[4] Hasselhoff in chandelier accident. BBC News Online 2006 Jun 30.

18. More Support for Chest-Compression-Only Resuscitation for Out-of-Hospital Cardiac Arrest

Steve Stiles. from Heartwire — a professional news service of WebMD. December 18, 2007 — Two observational studies published online December 10, 2007 in Circulation concluded that the conventional method of cardiopulmonary resuscitation (CPR) that calls for mouth-to-mouth assisted ventilation is no more effective than a chest-compression-only approach [1,2]. The findings support a good deal of international research supporting use of the latter method, which is less complicated and may be more appealing to potential bystander rescuers.

In their retrospective analysis of almost 10,000 cases of bystander resuscitation for cardiac arrest in which one or the other method was used [1], Katarina Bohm (Karolinska Institute, South General Hospital Stockholm, Sweden) and colleagues saw no significant difference in the odds that the victim would survive to be hospitalized or in one-month survival.

The findings support the use of the "simpler version of CPR," which can be especially useful "in dispatcher-assisted CPR and in cases involving elderly bystanders, in which the simplest algorithm is probably also the best," the group writes.

They point to "two large, independent, prospective, randomized trials" comparing the two methods that are ongoing in the US, Finland, and Sweden. "We therefore suggest waiting for the results of these randomized trials before starting any new discussion to change guidelines."

In the longer-term prospective study of about 4900 cases of witnessed out-of-hospital arrests by Dr Taku Iwami (National Cardiovascular Center, Suita, Japan) and associates [2], the chances of one-year survival with "favorable" neurologic outcomes was similarly increased with either method, compared with no bystander resuscitation — by 72% using the compression-only or "cardiac-only" technique, and by 57% with standard CPR.

"If cardiac-only resuscitation is simply as effective as conventional CPR, is there any reason to change lay CPR programs to focus on cardiac-only resuscitation? Perhaps," the group writes.

"Conventional CPR is a complex psychomotor task, and it typically is provided for less than 25% of out-of-hospital arrests," observe Iwami et al. "Specific educational campaigns to teach cardiac-only resuscitation may increase the rate of bystander CPR and improve the quality of cardiac-only resuscitation, thereby improving survival from out-of-hospital cardiac arrest.

Dr Gordon A Ewy (University of Arizona College of Medicine, Tucson), a longtime advocate of chest-compression-only resuscitation [3], who wasn't associated with either study, said that no randomized trial is needed for the technique to be recommended.

He pointed out to heartwire that the most current guidelines, published in 2005 [4], had updated the conventional-CPR recommended ratio from 15 chest compressions to two ventilations to 30 chest compressions to two ventilations. Whether 15 or 30 compressions, he said, the guidelines were based on consensus, not data.

But Ewy's group recently published data in a pig model suggesting that the continuous-compression technique, which he calls "cardiocerebral resuscitation," yields better outcomes than 30:2 CPR [5]. That, combined with the abundant supporting observational data, he said, showed that bystander CPR improves survival, and survival is better using the compression-only method.

"There's no question in my mind that the guidelines need to change, and they need to change now," Ewy said.

In Bohm et al's analysis of 8902 cases of out-of-hospital standard CPR and 1145 cases of compression-only resuscitation, 19.6% and 20% of patients, respectively, made it to the hospital alive; the adjusted odds ratio (OR) for CPR vs chest-compression-only was 1.03 (95% confidence interval [CI], 0.86 - 1.23). The one-month survival rates were 7.2% for standard CPR and 6.7% for the simpler technique (adjusted OR, 1.18 [95% CI, 0.89 - 1.56]).

In the prospective, population-based study of 4902 witnessed cardiac arrests in Japan, there were 783 cases in which bystanders performed conventional CPR and 544 in which only chest compressions were used; there were no bystander attempts in the remainder. Excluding arrests lasting greater than 15 minutes, the one-year rate of survival with favorable neurologic outcomes was 4.1% for standard CPR, 2.5% for no resuscitation (OR 1.57 [95% CI, 0.95 - 2.60]), and 4.3% for compression only (OR 1.72 [95% CI, 1.01 - 2.95]).

Ewy, like Iwami et al, observes that regardless of inherent efficacy, the compression-only method is likely to save more lives than standard CPR, if only because it's more likely to be carried out. "People are afraid of getting an infection, or they just don't like doing mouth-to-mouth on a stranger, or they don't know how or are afraid they'll do harm. For whatever reason, it's being done in only one out of five cases in certain societies, and two out of five in others," according to Ewy. "And if you just call 911 and don't do anything until the paramedics get there, you might as well sign the patient's death certificate."

The Ministry of Education, Science, Sports, and Culture, Japan, and the Ministry of Health, Labor, and Welfare, Japan, supported the study by Iwami and colleagues. The study authors have disclosed no relevant financial relationships.

[1] Bohm K, Rosenqvist M, Herlitz J, et al. Survival is similar after standard treatment and chest compression only in out-of-hospital bystander cardiopulmonary resuscitation. Circulation. Published online before print December 10, 2007.
[2] Iwami T, Kawamura T, Hiraide A, et al. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest. Circulation. Published online before print December 10, 2007.
[3] Be a lifesaver with continuous chest compression CPR tutorial. University of Arizona Sarver Heart Center. Available at
[4] ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2005; 112:IV1-IV203.
[5] Ewy GA, Zuercher M, Hilwig RW, et al. Improved neurological outcome with continuous chest compressions compared with 30:2 compressions-to-ventilations cardiopulmonary resuscitation in a realistic swine model of out-of-hospital cardiac arrest. Circulation 2007; 116:2525-2530.

19. What Initial Dose of Aspirin Is Right for STEMI Patients?

from Heartwire — a professional news service of WebMD. December 20, 2007 (Durham, NC) – An initial dose of 162-mg aspirin may be as effective as and perhaps safer than 325 mg for the acute treatment of ST-elevation MI (STEMI), a new study suggests [1].

The study, published online in Circulation on December 17, 2007, was conducted by a group led by Dr Jeffrey Berger (Duke Clinical Research Institute, Durham, NC). They explain that aspirin therapy is a cornerstone in the immediate treatment of STEMI and that much of the data supporting its use comes from the ISIS-2 trial, which showed that a 162.5-mg dose reduced five-week vascular mortality by 23%, which led to an ACC/AHA class 1, level of evidence A, recommendation for this dose. In contrast, use of a 325-mg dose of aspirin has a class 1, level of evidence C, recommendation, due to a paucity of data on this dose.

Berger et al point out that despite these recommendations, the most common initial dose of aspirin in the US has been 325 mg. They note that there has been only a single randomized trial that compared initial aspirin doses among those receiving fibrinolytic therapy, but that trial stopped early after enrolling only 162 patients. They therefore conducted a retrospective analysis of two large STEMI fibrinolytic trials, GUSTO I and GUSTO III, with a combined database of 56 080 STEMI patients, to assess immediate aspirin dose (162 vs 325 mg) and short-term outcomes after STEMI.

Results showed that 24.4% of patients (11 828) received an initial aspirin dose of 325 mg, and 75.6% (36 594) received 162 mg. There was no significant difference between the two doses in terms of mortality or other cardiac events at 24 hours or at seven and 30 days.

But the 325-mg dose was associated with a significant increase in the risk of moderate or severe bleeding compared with the 162-mg dose (OR 1.14; 95% CI 1.05–1.24; p less than 0.003).

Berger et al write: "Our data are consistent with prior aspirin studies that have shown similar efficacy and increased bleeding risk with a higher aspirin dose. The present study extends these findings and demonstrates that even the initial dose of aspirin may have clinical implications and therefore should not be overlooked. Our study raises the hypothesis that lowering the initial dose of aspirin from 325 to 162 mg may substantially lower the risk of bleeding without loss of efficacy."

The authors acknowledge that there are several limitations to this study, including the fact that it was a post hoc analysis of prospectively collected data from two clinical trials in which the dose of aspirin was not randomized or stipulated in the study protocol. Despite this, they say that the data do suggest that for the first dose of aspirin, 162 mg may be as effective as and safer than 325 mg for the acute treatment of STEMI. "This higher associated bleeding risk reinforces the importance of finding the lowest effective aspirin dose as an important goal in each clinical setting," they conclude.

Berger JS, Stebbins A, Granger CB, et al. Initial aspirin dose and outcome among ST-elevation myocardial infarction patients treated with fibrinolytic therapy. Circulation 2007;

20. US has highest dissatisfaction with health care

Bob Roehr, Washington, DC (from BMJ 2007;335:956). The United States is the nation most dissatisfied with its healthcare system, while the Dutch are the most satisfied, an international survey has found.

The study, of 12,000 adults in seven industrialised countries (Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States), was conducted by the US health policy charity the Commonwealth Fund. The results were released last month at a news conference in Washington, DC, that involved a panel of health ministers and other representatives from several of the countries.

Just 16% of respondents in the US said that minor changes in health care are needed, while 34% said the system needed to be rebuilt completely. Among Dutch respondents 42% said that minor changes in health care are needed and only 9% thought that the system needed to be rebuilt completely. About a quarter of respondents in the four British Commonwealth countries thought their systems needed only minor tinkering; large majorities thought they needed fundamental changes or complete rebuilding. In the UK 26% said that the healthcare system needed only minor changes, 57% said fundamental changes were needed, and 15% said the system needed complete rebuilding.

"On out of pocket costs, the US is again an outlier, with almost a third reporting paying $1000 or more each year," said Cathy Schoen, one of the authors of the study. Americans with health insurance often have a high deductible threshold before coverage begins, or they must make a co-payment for visits to doctors or for prescriptions.

Ms Schoen said that, across all the countries, participants who had a "medical home" (a family doctor they use regularly) were the "least likely to report problems of coordination of care." The study found that in all the countries about a third of the patients reported that information arising from their visits to emergency departments or from stays in hospital was not reported back to the medical home.

Health Affairs 2007;26:w717-w734; Abstract:

21. Comparison of energy expenditure in adolescents when playing new generation and sedentary computer games: cross sectional study

Graves L, et al. BMJ 2007;335:1282-1284

Objective: To compare the energy expenditure of adolescents when playing sedentary and new generation active computer games.

Design: Cross sectional comparison of four computer games.

Setting: Research laboratories.

Participants: Six boys and five girls aged 13-15 years.

Procedure: Participants were fitted with a monitoring device validated to predict energy expenditure. They played four computer games for 15 minutes each. One of the games was sedentary (XBOX 360) and the other three were active (Wii Sports).

Main outcome measure: Predicted energy expenditure, compared using repeated measures analysis of variance.

Results: Mean (standard deviation) predicted energy expenditure when playing Wii Sports bowling (190.6 (22.2) kJ/kg/min), tennis (202.5 (31.5) kJ/kg/min), and boxing (198.1 (33.9) kJ/kg/min) was significantly greater than when playing sedentary games (125.5 (13.7) kJ/kg/min) (P less than 0.001). Predicted energy expenditure was at least 65.1 (95% confidence interval 47.3 to 82.9) kJ/kg/min greater when playing active rather than sedentary games.

Conclusions: Playing new generation active computer games uses significantly more energy than playing sedentary computer games but not as much energy as playing the sport itself. The energy used when playing active Wii Sports games was not of high enough intensity to contribute towards the recommended daily amount of exercise in children.