Lit Bits: January 23, 2008

From the recent medical literature...

1. ED Patient Preferences for Boarding Locations When Hospitals Are at Full Capacity

Garson C, et al. Ann Emerg Med 2008;51:9-12.e3.

Intro: Emergency department (ED) crowding is a major public health crisis in the United States. A central cause for ED crowding is hospital crowding, which occurs when demand for inpatient beds outstrips supply. The practical question when hospitals are at full capacity is where admitted ED patients should wait until inpatient beds become available. The predominant strategy is to leave patients being admitted through the ED in the ED. High levels of ED boarding reduce the effective capacity of an ED to treat new patients and increase ED workload, especially for nurses who are required to provide inpatient care. Hospitals that have longer ED boarding times for admitted patients have been associated with poorer quality of care. One alternative to ED boarding is transferring admitted patients to inpatient hallways. One institution adopting this strategy reported increased revenue and decreased ambulance diversion. Boarding in inpatient hallways has been deemed acceptable by the New York Department of Health. We aimed to determine patient preferences for boarding location. Secondarily, we assessed patient expectations about what they consider a reasonable time to wait for an inpatient bed in the ED. We hypothesized that patients would prefer to board in inpatient hallways rather than ED hallways.

Methods: We surveyed adult ED patients during a 4-week period on preferences for boarding location. Patients were eligible if they were currently being admitted through the ED and had experienced at least 1 previous hospital admission to ensure knowledge of both the ED and inpatient locations. Patients were asked to choose whether they would rather board in an ED hallway or an inpatient hallway or whether they had no preference. Survey responses were hypothetical and did not affect care or bed placement. We tested whether patient demographics, survey location (ED room or ED hallway), admission service, timing to room placement, time to admission request, and time to survey administration were associated with survey responses.

Results: A total of 565 patients were approached; 87% consented to be interviewed. Of those consented, 88% of patients had been previously admitted, leaving 431 patients in the study group. A total of 64% (95% confidence interval [CI] 59% to 69%) had a preference for boarding location: 59% (95% CI 52% to 65%) preferred inpatient hallways and 41% (95% CI 35% to 48%) preferred ED hallways. Survey location, admission service, time to room placement, admission request, and survey administration were not associated with survey responses.

Conclusion: When hospitals are at full capacity, patients would rather board in inpatient hallways than ED hallways.

Associated editorial: Viccellio P. Customer Satisfaction Versus Patient Safety: Have We Lost Our Way? Ann Emerg Med. 2008;51:13-14. Full text (free):
http://www.annemergmed.com/article/PIIS0196064407014370/fulltext

2. White people get better pain relief in US emergency departments

Pletcher MJ, et al. JAMA 2008;299:70-8.

Total opioid prescribing is on the rise, from 23% of pain related visits in 1993 to 37% in 2005. This is in tune with the national standards and recommendations put forward in the 1990s, but the gap between ethnic groups has persisted. In 2005, for example, opioid prescribing rates were 40% for white people and 32% for all other people. Differences persisted after adjustment for pain severity and other confounders, and they were more pronounced in children and as the severity of pain increased.

The linked commentary (p 89) takes a global stand and says that adequate access to drugs for pain is unevenly distributed between rich and poor nations and between their rich and poor populations. Reasons include doctors' and patients' attitudes and misconceptions, supply and access barriers, legislation and regulation, and costs. In developed countries, for example, a typical monthly supply of morphine sulphate costs no more than $5.5 (£2.8; 3.7), but prices in developing countries can be as high as $180. The commentary ends by arguing that interventions to improve the treatment of pain should be a key public health priority worldwide.

JAMA Abstract: http://jama.ama-assn.org/cgi/content/abstract/299/1/70

3. Millions of Young People Abuse Cough and Cold Medicines

About 3.1 million teens and young adults (or 5% of U.S. youth) have used over-the-counter cough and cold medicines to get high, according to data from the 2006 National Survey on Drug Use and Health.

The study, released online, was conducted on people aged 12 to 25. Among other results:

# The most commonly misused products were NyQuil, Coricidin, and Robitussin.
# Among those who had abused cough and cold medicines, 82% had also used marijuana, 49% had used inhalants, and 44% had used hallucinogens, such as LSD, PCP, or Ecstasy.
# Whites were about three times as likely as blacks to misuse cough and cold medicines.
# Misuse was more common among girls than boys under age 18, and more common among boys than girls at older ages.

Substance Abuse & Mental Health Services Administration report (Free): http://oas.samhsa.gov/2k8/cough/cough.htm

4. ED Use of IV Procainamide for Patients with Acute A Fib or Flutter

Stiell IG, et al. Acad Emerg Med. 2007;14:1158-1164.

Objectives: Acute atrial fibrillation and flutter are very common arrhythmias seen in emergency department (ED) patients, but there is no consensus for their optimal management. The objective of this study was to examine the efficacy and safety of intravenous (IV) procainamide for acute atrial fibrillation or flutter.

Methods: This health records review included a consecutive cohort of ED patients with acute-onset atrial fibrillation or atrial flutter who received IV procainamide at one university hospital ED during a five-year period. The standard clinical protocol involved IV infusion of 1 g of procainamide over 60 minutes, followed by electrical cardioversion if necessary. A trained observer extracted data from the original clinical records. Outcome measurements included conversion to sinus rhythm, adverse events, and relapse up to seven days.

Results: The 341 study patients had a mean age of 63.9 years (SD ± 15.5 years), and 56.6% were male. The conversion rates were 52.2% (95% confidence interval = 47% to 58%) for 316 atrial fibrillation cases and 28.0% (95% confidence interval = 13% to 46%) for 25 atrial flutter cases. Mean dose given was 860.7 mg (SD ± 231.2 mg), and median time to conversion was 55 minutes. Adverse events occurred in 34 cases (10.0%): hypotension, 8.5%; bradycardia, 0.6%; atrioventricular block, 0.6%; and ventricular tachycardia, 0.3%. There were no cases of torsades de pointes, cerebrovascular accident, or death. Most patients (94.4%) were discharged home, but 2.9% of patients returned with a recurrence of atrial fibrillation within seven days.

Conclusions: This study of acute atrial fibrillation or flutter patients treated in the ED with IV procainamide suggests that this treatment is safe and effective in this setting. Procainamide should be prospectively compared with other ED strategies.

5. Studies in Septic Shock

A. Corticosteroids of No Apparent Benefit in Septic Shock

Corticosteroids do not improve survival in septic shock, regardless of the patient's responsiveness to corticotropin testing, according to an international study in the New England Journal of Medicine.

Using a randomized, double-blind, placebo-controlled design, researchers studied some 500 patients, half of whom received intravenous corticosteroids every 6 hours for 5 days, followed by 6 days of tapering; the others received placebo. At entry, about half the patients did not have a response to corticotropin challenge.

At the 28-day mark, neither the patients' treatment group nor their response to corticotropin testing made any difference in survival.

An editorialist calls the study "inadequately powered to detect a clinically important treatment effect," but comments that "it seems clear" that the corticotropin stimulation test is not useful in identifying patients who might benefit from corticosteroid therapy — views shared by the study's authors.

NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/short/358/2/111

B. Intensive Insulin Therapy, Pentastarch Resuscitation Linked to Adverse Events in Septic Shock

Patients with severe sepsis are at higher risk for adverse events when given intensive insulin therapy or pentastarch fluid resuscitation, according to a New England Journal of Medicine study.

Researchers studied some 540 patients, randomized to receive either intensive or conventional insulin therapy, along with either 10% pentastarch or modified Ringer's lactate for fluid resuscitation.

The study's safety monitoring board stopped the study early, "owing to an increased number of hypoglycemic events" among patients on intensive insulin therapy. The mortality rate at 28 days did not differ between the insulin groups.

In addition, there was a "significantly greater incidence of renal failure and a trend toward higher 90-day mortality" among those receiving pentastarch. The authors say that use of pentastarch and other low-molecular-weight hydroxyethyl starch solutions "should be avoided."

NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/abstract/358/2/125

6. Bronchodilator Therapy in Acute Decompensated Heart Failure Patients Without a History of COPD

Singer AJ, et al. Ann Emerg Med 2008;51:25-34.

Intro: Dyspnea is a common complaint among patients presenting to the emergency department (ED). Data from the National Hospital Ambulatory Medical Care survey indicate that shortness of breath was the sixth most common principal reason for ED visits. In 2003, 2.9 million ED visits for shortness of breath were reported.

The symptom of dyspnea is associated with a wide range of differential diagnoses. Chronic obstructive pulmonary disease and acute decompensated heart failure are among the most common and potentially serious causes of dyspnea. At patients’ initial presentation to the clinic, hospital, or ED, it is often difficult to determine whether their symptoms are the result of an acute exacerbation of chronic obstructive pulmonary disease or acute decompensated heart failure. Because these patients are often in clear distress, physicians may respond by treating for both conditions with a “shotgun” approach.

Inhaled bronchodilator agents are frequently used in the treatment of acute dyspnea. The actual use of bronchodilators in acute decompensated heart failure patients with or without pulmonary disease has not been well described in the literature. Some data suggest that bronchodilators may be harmful in patients with heart failure or ischemic heart disease. A better understanding of the association between inhaled bronchodilator use and clinical outcomes is needed among acute decompensated heart failure patients without chronic obstructive pulmonary disease.

Our objective was to evaluate the association between bronchodilator use and outcomes in acute decompensated heart failure patients without a history of chronic obstructive pulmonary disease, after adjusting for differences in baseline characteristics, severity of illness, and prognostic markers.

Methods: We conducted an analysis of the Acute Decompensated Heart Failure National Registry Emergency Module registry of patients with a principal discharge diagnosis of acute decompensated heart failure enrolled at 76 academic or community EDs. Dichotomous outcomes (mortality, ED discharges, ICU admission, ED IV vasodilator use, new dialysis, ED or in patient endotracheal intubation, ED BiPAP, and asymptomatic at discharge) in patients without a history of chronic obstructive pulmonary disease who were given bronchodilators were compared to those who were not given bronchodilators using logistic regression; odds ratios (ORs) and 95% confidence intervals (CIs) were calculated; and propensity score adjustments were made.

Results: Of the 10,978 patients enrolled, 7299 (66.5%) did not have a history of chronic obstructive pulmonary disease. Bronchodilators were administered by the EMS or in the ED to 2317 (21%) patients. Patients without chronic obstructive pulmonary disease given bronchodilators were more likely to receive ED IV vasodilators (28.4% vs. 16.9%; propensity adjusted OR 1.40 [95% CI 1.18-1.67]) and in-patient mechanical ventilation (6.0% vs. 2.4%; propensity adjusted OR 1.69 [95% CI 1.21-2.37]) than patients without chronic obstructive pulmonary disease who were not given bronchodilators. Hospital mortality in patients without chronic obstructive pulmonary disease was similar regardless of bronchodilator treatment (3.4% vs. 2.6%, propensity adjusted OR 1.02 [95% CI 0.67, 1.56]).

Conclusion: Many acute decompensated heart failure patients without a history of chronic obstructive pulmonary disease receive inhaled bronchodilators. Bronchodilator use was associated with a greater need for aggressive interventions and monitoring, and this may reflect an adverse effect of bronchodilators or it may be a marker for patients with more severe disease.

7. Delayed In-Hospital Defib Times Common

Almost a third of hospitalized patients requiring defibrillation receive it beyond the recommended 2-minute limit, according to a New England Journal of Medicine study. Researchers examined the outcomes of delayed defib in nearly 7000 patients included in a national database of resuscitative efforts. All patients had suffered arrest from ventricular arrhythmia. The median time to defib was 1 minute, but it took longer than 2 minutes for 30% of patients.

Black race, a noncardiac admitting diagnosis, small hospital size (under 250 beds), and occurrence after-hours or in unmonitored areas were all significantly associated with delayed defib. After adjustment for those factors, delayed defib was associated with a lower likelihood of survival to discharge and, among survivors, greater likelihood of major neurologic or functional disability.
An editorialist, urging the development of better monitoring technology and the installation of automated external defibrillators in each hospital room, concludes: "What are we waiting for?"

NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/short/358/1/9

8. Champagne: the safer choice for celebrations

Douglas RJ. BMJ 2007;335:1281

A 24 year old Australian rules football player presented to the emergency department complaining of a sensation of a foreign body stuck in his throat. The sensation was associated "with an inability to breathe properly." Earlier that day, when celebrating his team’s victory in the premiership, he had downed the remaining beer in the premiership cup, inadvertently swallowing a beer bottle cap.

Physical examination, radiography, and fibreoptic examination of the neck and throat were unremarkable. An anteroposterior chest radiogram showed a round metallic foreign body with scalloped edges at the level of the aortic arch (figure). Blood ethanol level was 0.109 g/100 ml. A beer bottle cap was retrieved via endoscopy later that evening, without complications.

Excessive alcohol consumption as a celebratory consequence of high profile sporting victories is well known. Oesophageal obstruction from a bottle cap, however, is rarely seen in emergency departments. In suspected cases, airways obstruction and injury should be rapidly excluded.

A comprehensive Medline search failed to elicit an example of oesophageal obstruction secondary to the ingestion of a champagne (or wine) cork. Since the 18th century, champagne has been the beverage of choice for celebrations and on current evidence should remain so.

9. Emergency Waits Get Dangerously Long in U.S. Study

WASHINGTON (Reuters) Jan 15 - Patients seeking urgent care in U.S. emergency rooms are waiting longer than in the 1990s, U.S. researchers reported on Tuesday.

They found a quarter of MI patients waited 50 minutes or more before seeing a doctor in 2004. Waits for all types of emergency department visits became 36% longer between 1997 and 2004, the team at Harvard Medical School reported.

Especially unsettling, people who had seen a triage nurse and been designated as needing immediate attention waited 40% longer -- from an average of 10 minutes in 1997 to an average 14 minutes in 2004, the researchers report in the journal Health Affairs.
Heart attack patients waited eight minutes in 1997 but 20 minutes in 2004, Dr. Andrew Wilper and colleagues found.

Dr. Wilper's team used U.S. Census survey and National Center for Health Statistics data for their study, which covered more than 92,000 emergency department visits. They used other surveys to calculate that the number of emergency room visits rose from 93.4 million in 1994 to 110.2 million in 2004. During the same time, 12% fewer hospitals operated emergency rooms, according to the American Hospital Association.

"EDs close because, in our current payment system, emergency patients are money-losers for hospitals," Dr. Wilper said in a statement.

Harvard's Dr. David Himmelstein, who worked on the study, also lobbies for some kind of national health care system. "One contributor to ED crowding is Americans' poor access to primary and preventive care, which could address medical issues before they become emergencies," Dr. Himmelstein said in a statement.

The American College of Emergency Physicians said the findings were not surprising.

"Emergency physicians have said for years that crowding and long wait times are hurting our patients -- insured and uninsured equally," ACEP president Dr. Linda Lawrence said in a statement. "Ever-lengthening waits are a frightening trend because any delays in care can make the difference between life and death for some patients. The number of emergency patients is increasing while the number of hospital beds continues to drop. It is a recipe for disaster."

10. Minor Leg Injuries Linked to Venous Thrombosis

January 14, 2008 — Minor injuries in the leg are associated with greater risk for venous thrombosis, according to the results of a large, population-based, case-control study reported in the January 14 issue of the Archives of Internal Medicine.

"Injuries increase the risk of venous thrombosis," write Karlijn J. van Stralen, MSc, from the Leiden University Medical Center in Leiden, the Netherlands, and colleagues. "So far, most research has focused on major injuries that are accompanied by other risk factors for venous thrombosis, such as plaster casts and surgery. We studied the association of venous thrombosis with common minor injuries, such as minor sural muscle ruptures and ankle sprains."

The Multiple Environmental and Genetic Assessment (MEGA) study of risk factors for venous thrombosis included 2471 consecutive patients with a first deep venous thrombosis (DVT) of the leg or pulmonary embolism (PE) and 3534 control subjects. Exclusion criteria were malignant neoplasms, surgery, and plaster cast or extended bed rest.

A minor injury in the 3 months preceding the venous thrombosis (patients) or completion of the questionnaire (controls) occurred in 289 patients (11.7%) and in 154 controls (4.4%). After adjustment for sex and age, venous thrombosis was associated with previous minor injury (adjusted odds ratio [aOR], 3.1; 95% confidence interval [CI], 2.5 - 3.8). The association was strongest for injuries during the 4-week period preceding thrombosis, and no association was evident before 10 weeks.

Minor injuries in the leg were more strongly associated with thrombosis (aOR, 5.1; 95% CI, 3.9 - 6.7), whereas minor injuries affecting other body parts were not associated with thrombosis. Factor V Leiden carriers with a leg injury had a 50-fold increased risk compared with noncarriers without injury (aOR, 49.7; 95% CI, 6.8 - 362.7).

"Minor injuries in the leg are associated with greater risk of venous thrombosis," the study authors write. "Because minor injuries are common, they could be major contributors to the occurrence of venous thrombosis."

Study limitations may include recall bias or referral bias.

"Many individuals with minor injuries will have contacted the general practitioner first," the authors conclude. "Therefore, there may be an important task for general practitioners to identify subjects who are at a high risk of developing venous thrombosis and subsequently to provide prophylactic measures."

The Netherlands Heart Foundation, the Dutch Cancer Foundation, and the Netherlands Organisation for Scientific Research supported this study. The authors have disclosed no relevant financial relationships.

Arch Intern Med. 2008;168:21-26.

11. A RCT of Prochlorperazine Versus Metoclopramide for Treatment of Acute Migraine

Friedman BW, et al. Ann Emerg Med 2008; in press.

Intro
A mounting body of evidence has demonstrated the efficacy of the antiemetic dopamine antagonists as primary parenteral treatment for acute migraine. These agents are at least as efficacious as parenteral triptans, dihyrdroergotamine, and nonsteroidals and are well tolerated. There is no consensus as to the optimal choice among the members of this class. However, metoclopramide and prochlorperazine are often used because, unlike other medications in their class, they do not cause significant orthostatic changes or require cardiac monitoring. Although previous trials have concluded that prochlorperazine is superior to metoclopramide for the treatment of acute migraine, the 10-mg dose of metoclopramide used in those studies may have been insufficient. The optimal dose of metoclopramide for the acute treatment of migraine is unknown because dose-finding studies have not been conducted. However, 20 mg of intravenous metoclopramide is efficacious and well tolerated.

There is substantial practice variation in the ED–based treatment of acute migraine. Two dozen parenteral agents, alone or in combination, are commonly used in US EDs. Yet, ED migraine care remains suboptimal. Incomplete pain relief, need for rescue medication, adverse medication effects, functional disability, and recurrence of headache after ED discharge continue to plague individuals with migraine, independent of the primary treatment. This study addressed the efficacy and tolerability of a 20-mg dose of metoclopramide versus a 10-mg dose of prochlorperazine, with the intent of helping emergency physicians decide whether one of these 2 dopamine antagonists is superior as a primary treatment for acute migraine.

Study objective
We compare prochlorperazine 10 mg intravenously versus metoclopramide 20 mg intravenously, both accompanied by 25 mg of intravenous diphenhydramine.

Methods
This was a randomized, double-blind, clinical trial comparing 2 parenteral dopamine antagonists. Both drugs were administered during 15 minutes with 25 mg intravenous diphenhydramine. Pain scores on a numeric rating scale were assessed at baseline, every 30 minutes for 2 hours, and by telephone 24 hours after discharge. The primary endpoint was the between-group difference in change in numeric rating scale from baseline to 1 hour postbaseline. Secondary endpoints included mean differences in change in numeric rating scale at 2 and 24 hours, headache relief, adverse effects, and desire to receive the same treatment for future migraines.

Results
Of 152 patients screened, 97 were eligible and 77 were randomized. The mean change in numeric rating scale scores at 1 hour was 5.5 and 5.2 in subjects receiving prochlorperazine and metoclopramide, respectively (difference=0.3; 95% confidence interval [CI] –1.0 to 1.6). Findings were similar at 2 hours and 24 hours. Forty-six percent (18/39) of prochlorperazine and 32% (12/38) of metoclopramide subjects reported adverse events (difference=15%; 95% CI –6% to 36%). Seventy-seven percent (26/34) of prochlorperazine and 73% (27/37) of metoclopramide subjects wanted to receive the same medication in future ED visits (difference=4%; 95% CI –16% to 24%).

Conclusion
Either prochlorperazine 10 mg intravenously or metoclopramide 20 mg intravenously, combined with diphenhydramine 25 mg intravenously, is an efficacious treatment for ED patients with acute migraine. Three quarters of subjects in both arms would want the same medication for their next migraine.

12. The Role of Oral Ondansetron in Children With Vomiting as a Result of Acute Gastritis/Gastroenteritis Who Have Failed Oral Rehydration Therapy: A RCT

Roslund G, et al. Ann Emerg Med. 2008; in press.

Study objective
We hypothesize that ondansetron will facilitate oral rehydration therapy in children with acute gastritis or acute gastroenteritis and mild to moderate dehydration who fail initial oral rehydration therapy. We hypothesize that subjects receiving ondansetron will tolerate oral rehydration and that a lower proportion will require intravenous hydration than subjects receiving placebo, with a clinically important difference of at least 30% when comparing 2 groups of patients presenting to the ED with acute gastritis/acute gastroenteritis. Secondarily, we hypothesize that subjects receiving ondansetron will have a lower proportion requiring admission, fewer episodes of vomiting and diarrhea, and fewer revisits.

Methods
This double-blind, placebo-controlled, prospective, randomized trial enrolled a convenience sample of subjects 1 to 10 years old, with acute gastritis or acute gastroenteritis, who failed oral rehydration therapy in the emergency department (ED). Subjects received a weight-based dose of ondansetron (0.15 mg/kg of the orally dissolving tablet) or placebo, and oral rehydration therapy was reattempted 30 minutes later. If a subject vomited or refused to drink, he or she was considered a failed oral rehydration therapy and received acute gastroenteritis. If a subject tolerated adequate oral rehydration therapy, he or she was discharged. Parents completed symptom diaries and were contacted by telephone for follow-up. We used the chi-square test to compare the proportions of subjects requiring acute gastroenteritis in each group.

Results
We enrolled 106 subjects: 51 received ondansetron and 55 received placebo. Eleven of 51 (21.6%; 95% confidence interval [CI] 11.3% to 35.3%) of subjects who received ondansetron required intravenous hydration and 30 of 55 (54.5%; 95% CI 40.6% to 68%) of placebo subjects required intravenous hydration (p less than 0.001) for a difference of 32.9% (95% CI 14.54% to 48.37%). Admission rates were 5.9% (3/51) with ondansetron and 12.7% (7/55) with placebo.

Conclusion
In subjects with acute gastritis/acute gastroenteritis and mild to moderate dehydration who failed initial oral rehydration therapy, the proportion of children who received intravenous hydration was smaller in the ondansetron group than in the placebo group.

13. ED Crowding Is Associated With Poor Care for Patients With Severe Pain

Pines JM, Hollander JE. Ann Emerg Med. 2008;51:1-5.

Study objective
We study the impact of emergency department (ED) crowding on delays in treatment and nontreatment for patients with severe pain.

Methods
We performed a retrospective cohort study of all patients presenting with severe pain to an inner-city, teaching ED during 17 months. Poor care was defined by 3 outcomes: not receiving treatment with pain medication while in the ED, a delay (more than 1 hour) from triage to first pain medication, and a delay (more than 1 hour) from room placement to first pain medication. Three validated crowding measures were assigned to each patient at triage. Logistic regression was used to test the association between crowding and outcomes.

Results
In 13,758 patients with severe pain, the mean age was 39 years (SD 16 years), 73% were black, and 64% were female patients. Half (49%) of the patients received pain medication. Of those treated, 3,965 (59%) experienced delays in treatment from triage and 1,319 (20%) experienced delays from time of room placement. After controlling for factors associated with the ED treatment of pain (race, sex, severity, and older age), nontreatment was independently associated with waiting room number (odds ratio [OR] 1.03 for each additional waiting patient; 95% confidence interval [CI] 1.02 to 1.03) and occupancy rate (OR 1.01 for each 10% increase in occupancy; 95% CI 0.99 to 1.04). Increasing waiting room number and occupancy rate also independently predicted delays in pain medication from triage (OR 1.05 for each waiting patient, 95% CI 1.04 to 1.06; OR 1.18 for each 10% increase in occupancy; 95% CI 1.15 to 1.21) and delay in pain medication from room placement (OR 1.02 for each waiting patient, 95% CI 1.01 to 1.03; OR 1.06 for each 10% increase in occupancy, 95% CI 1.04 to 1.08).

Conclusion
ED crowding is associated with poor quality of care in patients with severe pain, with respect to total lack of treatment and delay until treatment.

Full text (free): http://www.annemergmed.com/article/PIIS0196064407012978/fulltext

14. Medical myths: Sometimes even doctors are duped

Vreeman RC, et al. BMJ 2007;335:1288-1289.

Physicians understand that practicing good medicine requires the constant acquisition of new knowledge, though they often assume their existing medical beliefs do not need re-examination. These medical myths are a light hearted reminder that we can be wrong and need to question what other falsehoods we unwittingly propagate as we practice medicine. We generated a list of common medical or medicine related beliefs espoused by physicians and the general public, based on statements we had heard endorsed on multiple occasions and thought were true or might be true. We selected seven for critical review:

# People should drink at least eight glasses of water a day

# We use only 10% of our brains

# Hair and fingernails continue to grow after death

# Shaving hair causes it to grow back faster, darker, or coarser

# Reading in dim light ruins your eyesight

# Eating turkey makes people especially drowsy

# Mobile phones create considerable electromagnetic interference in hospitals.

We used Medline and Google to search for evidence to support or refute each of these claims. Because "proving a negative" can be challenging, we noted instances in which there was no evidence to support the claim.

Full-text: http://www.bmj.com/cgi/content/full/335/7633/1288?etoc

15. Beta-blockers Are Associated With Reduced Risk of AMI After Cocaine Use

Dattilo PB, et al. Ann Emerg Med 2008;51:117-125.

Background
Cocaine has many deleterious effects on the heart. The pharmacologic effects of cocaine include both alpha and beta receptor stimulation, as well as acute myocardial depression, which is not related to reduced coronary blood flow. Cocaine has also been associated with coronary artery spasm. This effect appears to be mediated by both alpha stimulation and a direct effect of cocaine on vascular smooth muscle. Because beta-adrenergic stimulation leads to vasodilatation of the coronary arteries, the safety of using beta-adrenergic blockers in patients with history of cocaine use has been questioned repeatedly. Lange et al presented evidence that beta-adrenergic blockade increases vasoconstriction when given after cocaine exposure, as measured physiologically by reduced coronary blood flow and increased coronary vascular resistance. Labetalol, which is a combined alpha-beta receptor-blocker, does not reduce cocaine-induced coronary vasoconstriction, whereas both nitroglycerin and verapamil are effective agents for this purpose. Case reports have also documented evidence for spasm of large coronary arteries in the genesis of myocardial infarction associated with cocaine use. These considerations have led to the recommendation that beta-adrenergic blocking agents not be used in patients with acute exposure to cocaine.

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.

16. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the ED with Acute Carbon Monoxide Poisoning

Wolf SJ, et al. Ann Emerg Med 2008;51:138-152.

This clinical policy focuses on critical issues concerning the management of adult patients presenting to the emergency department (ED) with acute symptomatic carbon monoxide (CO) poisoning. The subcommittee reviewed the medical literature relevant to the questions posed. The critical questions are:

Should hyperbaric oxygen (HBO2) therapy be used for the treatment of patients with acute CO poisoning; and

Can clinical or laboratory criteria identify CO-poisoned patients who are most or least likely to benefit from this therapy?

Recommendations are provided on the basis of the strength of evidence of the literature.

Full-text (free!): http://www.annemergmed.com/article/PIIS0196064407016691/fulltext

17. Validation of the Acute Heart Failure Index

Hsieh M, et al. Ann Emerg Med. 2008;51:37-44.

Introduction: Heart failure affects more than 5 million Americans, with more than 550,000 new cases diagnosed in the United States each year1 and 1 million admissions in 2004. Care of heart failure patients in the United States costs approximately $33.2 billion a year, with hospitalization accounting for $17.8 billion of that expense. Emergency department (ED) visits for evaluation of heart failure, the source for the majority of the hospital admissions for heart failure, increased 19% between 1992 and 2001.

Hospital admission rates for heart failure vary widely and in a manner not fully explained by disease severity. Acute care and emergency physicians often overestimate the probability of short-term death or severe complications for heart failure patients, with the higher estimates of risk translating into patient treatment in more intense care settings. An evidence-based clinical prediction rule could improve physician risk assessment and the appropriateness of initial site of treatment decisions. Additionally, such a rule could aid investigators studying heart failure populations, allowing accurate assessment of initial illness severity (particularly useful in observational or nonrandom assignment designs).

A rule to aid in assessing short-term risk was derived and is based on data readily available in the ED to identify heart failure patients who are at low risk of inpatient death or serious medical complications (less than 2% inpatient death or complications and 1% inpatient death). This could aid initial decision-making in the ED by limiting variation and inaccuracy in judging illness burden and risk of death or morbidity.

We sought to examine the performance of this clinical prediction rule, now called the Acute Heart Failure Index, in an independent group of patients with respect to inpatient death, serious medical complication before hospital discharge, and 30-day death.

Methods: We retrospectively studied a random cohort of 8,384 adult patients admitted to Pennsylvania hospitals in 2003 and 2004 with a diagnosis of heart failure as defined by primary discharge diagnosis codes. We reported the proportions of inpatient death, serious medical complications before discharge, and 30-day death in the patients identified as low risk by the prediction rule.

Results: The prediction rule classified 1,609 (19.2%) of the patients as low risk. Within this subgroup, there were 12 (0.7%; 95% confidence interval [CI] 0.3% to 1.2%) inpatient deaths, 28 (1.7%; 95% CI 1.1% to 2.4%) patients survived to hospital discharge after a serious complication, and 47 (2.9%; 95% CI 2.1% to 3.7%) patients died within 30 days of the index hospitalization.

Conclusion: This prediction rule identifies a group of admitted heart failure patients at low risk of inpatient mortal and nonmortal complications. Our validation findings suggest the rule could assist physicians in making site-of-care decisions for this patient population and aid in analyzing presenting illness burden in study populations.

The rules can be viewed here: http://www.pitt.edu/~hfpr/HF_tree_final_web.mht
An algorithm is also available: http://www.pitt.edu/~hfpr/

18. To Sit or Not to Sit?

Johnson RL, et al. Ann Emerg Med. 2008;51:188-193.e2.

Study objective
We prospectively examine whether provider posture (seated versus standing) influences patient and provider estimates of time spent at the bedside relative to actual time and patient perceptions of the provider-patient interaction.

Methods
A convenience sample of consenting adult patients presenting to an academic tertiary care emergency department between September 7, 2005, and September 25, 2005, were eligible for inclusion in this randomized, controlled trial. Providers (emergency medicine attending physicians, residents, physician assistants, and medical students) were randomly assigned to sit or stand during the initial encounter, after which, participants completed questionnaires about their perceptions of provider-patient interactions and time spent therein. Actual encounter length was measured. Data were analyzed to determine whether patient and provider perception differences existed, using a multilevel regression model that was adjusted for patient-level and provider-level covariates.

Results
Two hundred twenty-four consenting patients met inclusion criteria (239 approached; 15 excluded). Data from 36 providers were collected. The mean length of encounters in both study arms was 8.6 minutes (SD 4.8; range 1.5 to 34.1). Patients involved in seated interactions overestimated time providers spent performing initial encounters by an average of 1.3 minutes (SD 4.3 minutes), whereas patients involved in the standing interactions underestimated time by an average of 0.6 minutes (SD 4.3 minutes) (P=.001). Conversely, providers overestimated time spent with patients in both study arms (P=.85; mean [SD] 0.5 [3.6] versus 0.3 [3.2] minutes). Patient perceptions of the quality of patient-provider interactions were not affected by provider posture.

Conclusion
Although provider posture during the initial interaction affects patient perceptions of time spent at the bedside, it does not influence patient perception of the provider’s bedside manner, sense of caring, or understanding of the patient’s problem.

19. Assessment of hyperglycemia after calcium channel blocker overdoses involving diltiazem or verapamil

Levine M, et al. Crit Care Med. 2007;35:2071-5.

BACKGROUND: Overdoses of calcium channel blocker agents result in hyperglycemia, primarily due to the blockade of pancreatic L-type calcium channels and insulin resistance on the cellular level. The clinical significance of the hyperglycemia in this setting has not previously been described.

METHODS: This study is a retrospective review of all adult (age, 15 yrs or greater) patients with a discharge diagnosis of acute verapamil or diltiazem overdose at five university-affiliated teaching hospitals. The severity of overdose was assessed by determining whether a patient met the composite end points of in-hospital mortality, the necessity for a temporary pacemaker, or the need for vasopressors. We compared the initial and peak serum glucose concentrations with hemodynamic variables between patients who did and did not meet the composite end points.

RESULTS: A total of 40 patients met inclusion criteria, with verapamil and diltiazem accounting for 27 of 40 (67.5%) and 13 of 40 (32.5%) of the ingestions, respectively. For those patients who did and did not meet the composite end points, the median initial serum glucose concentrations were 188 (interquartile range, 143.5-270.5) mg/dL and 129 (98.5-156.5) mg/dL, respectively (p = .0058). The median peak serum glucose concentrations for these two groups were 364 (267.5-408.5) mg/dL and 145 (107.5-160.5) mg/dL, respectively (p = .0001). The median increase in blood glucose was 71.2% for those who met composite end points vs. 0% for those who did not meet composite end points (p = .0067). Neither the change in the median heart rate nor the change in systolic blood pressure was significantly different in any group.

CONCLUSION: Serum glucose concentrations correlate directly with the severity of the calcium channel blocker intoxication. The percentage increase of the peak glucose concentration is a better predictor of severity of illness than hemodynamic derangements. If validated prospectively, serum glucose concentration alone might be an indicator to begin hyperinsulinemia-euglycemia therapy.

20. Management of ED Patients With Primary Spontaneous Pneumothorax: Needle Aspiration or Tube Thoracostomy?

Zehtabchi S, et al. Ann Emerg Med. 2008;51:91-100.e1

Study objective: The emergency management of primary spontaneous pneumothorax is controversial. This evidence-based emergency medicine review evaluates the existing evidence about the efficacy and safety of needle aspiration in comparison to tube thoracostomy for management of primary spontaneous pneumothorax.

Methods: We searched MEDLINE, EMBASE, the Cochrane Library, and other databases. We selected studies for inclusion in the review if the authors stated that they had randomly assigned hemodynamically stable patients with no underlying lung disease to needle aspiration or tube thoracostomy. The outcome measures of interest included admission rate, length of hospital stay, recurrence rate, failure rate of the procedure, dyspnea score during or after the procedure, pain score during or after the procedure, and complications.

Results: Three randomized trials with acceptable quality standards met the inclusion criteria. There was no significant difference between needle aspiration and tube thoracostomy when outcomes of immediate failure, 1-week failure, risk of complication, and 1-year recurrence rate were measured. Only 2 trials reported the rate of hospitalization; needle aspiration was associated with lower rates of hospitalization in both trials: relative risks of 0.26 (95% confidence interval [CI] 0.17 to 0.39) and 0.51 (95% CI 0.36 to 0.74). Length of hospital stay was lower in the needle aspiration groups in all 3 trials, with mean differences of −2.15 days (95% CI −0.99 to −3.30), −2.10 days (95% CI −0.57 to −3.63), and −1.10 days (95% CI −2.28 to 0.08), respectively. Needle aspiration was associated with less analgesia requirement in one trial and lower pain scores in another.

Conclusion: The existing evidence indicates that needle aspiration is at least as safe and effective as tube thoracostomy for management of primary spontaneous pneumothorax. Additionally, needle aspiration carries the benefit of fewer hospital admissions and shorter length of hospital stay.

21. Educational Videos Drain Baby Brains

By Matt Kaplan. ScienceNOW Daily News.

Buyer beware: Videos aimed at improving infant and toddler language skills are not as beneficial for language learning as they claim to be, according to a new study. Rather than helping youngsters, such products may actually hurt their vocabularies.

Videos like Brainy Baby and Baby Einstein have been marketed to parents since 1997. They feature simple lessons in music, math, and vocabulary, and their makers tout them as important educational tools that will help young children build skills in each of these areas. But none of these claims has ever been verified, says Frederick Zimmerman, who studies the relationship between child development and the economy at the University of Washington, Seattle. "In many cases, the corporations making the educational videos are not even testing their own products," he says.

So Zimmerman and colleagues decided to test the videos themselves. The researchers interviewed the parents of more than 1000 U.S. children between the ages of 8 and 16 months, gathering information on the children's vocabulary and how frequently they watched videos like Baby Einstein. When the team controlled for factors such as socioeconomic status, race, and parental education, it found that Baby Einstein and his ilk are not the geniuses they're cracked up to be. For every hour per day spent watching the videos, children understood an average of six to eight fewer words than did those of the same age who did not watch them--a 17-percentile drop in vocabulary, the team reports online tomorrow in the Journal of Pediatrics. "There is no clear evidence of a benefit coming from these videos, and there is some suggestion of harm," says Zimmerman.

As for why the videos hurt vocabulary when they're supposed to help it, Zimmerman can only speculate. One possibility, he says, is that the videos simply pacify children without teaching them anything. "It's like empty calories for the mind," Zimmerman says. Meanwhile, children not watching the videos are reading, interacting with their parents, or building with blocks.

"The negative effect is a real surprise," says Rebecca Collins, a behavioral scientist at the RAND Corp. in Santa Monica, California. "There is so much consumption of these videos, and nobody has any idea how effective they are."