Lit Bits: May 20, 2008

From the recent medical literature...

1. U.S. Hospital EDs Overwhelmed, One-Day Study Finds

By Maggie Fox. WASHINGTON (Reuters) May 06 - A 1-day snapshot of emergency room conditions at 34 U.S. hospitals shows they are all overwhelmed and none is prepared to handle a big event like a disaster or attack.

The report from the House of Representatives Oversight and Government Reform Committee, released to coincide with a hearing on Monday, shows emergency rooms in Washington and Los Angeles operating over capacity on an ordinary day. None could have handled a surge of new patients.

Henry Waxman, a California Democrat who heads the committee, used the report to illustrate why he opposes President George W. Bush's proposed cuts to the federal Medicaid program.

Bush says states need to pay more of the costs of maintaining emergency services and has proposed $18.2 billion in cuts to Medicaid over 5 years.

"The proposed Medicaid regulations will directly result in further reductions in hospital and ED (emergency department) capacity and, ironically, specifically target trauma centers and teaching hospitals -- the very institutions whose surge capacity we must maintain if they are to function in the time of disaster or terrorist attack," Dr. Roger Lewis of the University of California Los Angeles Medical Center told the hearing.

The survey included seven major cities -- New York, Los Angeles, Washington, Chicago, Houston, Denver and Minneapolis.

They were all inspected on Tuesday, March 25 at 4:30 p.m. local time.

"Both of the emergency rooms in the Level I trauma centers surveyed in Washington, D.C., were operating above capacity," the report reads. That means new patients must wait in hallways, waiting rooms or offices.

On average, the emergency rooms in all seven cities were 15 percent over capacity.

COMPARISONS TO MADRID

The report looked at what would happen if someone launched an attack equivalent to the 2004 bombing of commuter trains in Madrid that killed 191 people.

"After the Madrid attack, 966 victims were transported to 15 hospitals, and 270 victims arrived at a single hospital for emergency care," the report reads.

"Not one of the seven cities had sufficient treatment spaces in emergency rooms of their Level I trauma centers to handle the volume of victims seen at a single Madrid hospital."

And hospitals are not prepared for the most likely form of attack -- a suicide bomber, said Bruce Hoffman of Georgetown University.

Hoffman said suicide bombing victims often have multiple types of injuries: "penetration wounds from small projectiles that damage soft tissues and vital organs; fracture bone and sever arteries and nerves; blast effects on lungs, ear drums, and other organs, and severe burns."

"The best way to save as many lives as possible after a terrorist bombing or suicide attack is for physicians and other health care workers to undergo intensive training and preparation before an attack," he recommended.

Several of the experts told the committee the Medicaid cuts would not allow for such training and, in fact, stepped-up funding is needed.

2. Criteria Identified for Early ED Discharge of Children with Bronchiolitis

By Martha Kerr. NEW YORK (Reuters Health) May 02 - Pediatricians have identified specific criteria for safe, early discharge from the emergency department (ED) of small children with bronchiolitis.

The algorithm may avoid unnecessary hospitalization, Boston Children's Hospital researchers say in the April issue of Pediatrics.

"Few studies have investigated the lower end of the bronchiolitis severity spectrum," Dr. Jonathan M. Mansbach and colleagues note.

Physicians from 30 EDs participated in a prospective cohort study over two bronchiolitis seasons between 2004 and 2006. The study involved 1,456 children under the age of 2 years given a diagnosis of bronchiolitis in the ED, 837 of whom (57%) were discharged home from the ED.

Dr. Mansbach's team identified the following factors as predictive of safe discharge to home:

- at least 2 months of age;

- no history of intubation;

- a history of eczema;

- respiratory rates appropriate for age;

- no or mild retractions;

- initial oxygen saturation of 94% or greater;

- fewer albuterol or epinephrine treatments in the first hour; and

- adequate oral intake.

The importance of each factor varied somewhat according to age, but specific cut-points for respiratory rate and oxygen saturation have particular relevance, the investigators emphasize. They admit that the last two criteria - fewer albuterol or epinephrine treatments and adequate oral intake - require clinical judgment.

"These data are not for 'early discharge' (at this point)," Dr. Mansbach cautioned in an interview with Reuters Health. "Although I would be comfortable using these data, the next step is to see if the model works in other patient populations. In these future studies, we and other researchers should examine additional factors that may improve the low-risk model, such as the type of virus and genetic factors."

"To my knowledge there are no safe ED discharge criteria from the American Academy of Pediatrics or (implemented at) Children's Hospital of Boston," he added.

"These prospective, multicenter data define a group of children aged younger than 2 years with bronchiolitis that are safe for discharge to home from the ED. In practice, these results may help fast-track children at ED triage and reduce unnecessary admissions," Dr. Mansbach said. "Future work should delineate predictors of unnecessary hospitalizations and also validate the individual factors, the lowest-risk model and the potential beneficial effects of its use in patient care, health care costs and family satisfaction."

Pediatrics 2008;12:680-688.

3. Diagnostic (In)accuracy in Patients with Dyspnea

Natriuretic peptide testing adds diagnostic value to physician judgment in determining which dyspneic patients have congestive heart failure in the ED.

Green SM, et al. Arch Intern Med. 2008;168:741-748.

Background: Dyspnea is a common complaint in the emergency department (ED)and may be a diagnostic challenge. We hypothesized that diagnostic uncertainty in this setting is associated with adverse outcomes, and amino-terminal pro-B-type natriuretic peptide (NT-proBNP) testing would improve diagnostic accuracy and reduce diagnostic uncertainty.

Methods: A total of 592 dyspneic patients were evaluated from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) study. Managing physicians were asked to provide estimates from 0% to 100%of the likelihood of acutely destabilized heart failure (ADHF). A certainty estimate of either 20% or lower or 80% or higher was classified as clinical certainty, while estimates between 21% and 79% were defined as clinical uncertainty. Associations between clinical uncertainty, hospital length of stay, morbidity, and mortality were examined. The diagnostic value of clinical judgment vs NT-proBNP measurement was compared across categories of clinical certainty.

Results: Clinical uncertainty was present in 185 patients (31%), 103(56%) of whom had ADHF. Patients judged with clinical uncertainty had longer hospital length of stay and increased morbidity and mortality, especially those with ADHF. Receiver operating characteristic analysis of clinical judgment yielded an area under the curve (AUC) of 0.88in the clinical certainty group and 0.76 in the uncertainty group (P less than .001); NT-proBNP testing alone in these same groups had AUCs of 0.96 and 0.91, respectively. The combination of clinical judgment with NT-proBNP testing yielded improvements in AUC.

Conclusions: Among dyspneic patients in the ED, clinical uncertainty is associated with increased morbidity and mortality, especially in those with ADHF.The addition of NT-proBNP testing to clinical judgment may reduce diagnostic uncertainty in this setting.

4. Intra-articular lidocaine versus intravenous meperidine/diazepam in anterior shoulder dislocation: a randomised clinical trial

Moharari RS, et al. Emerg Med J. 2008;25:262-264.

Background: Anterior shoulder dislocation is one of the most common complaints of patients referred to emergency departments. Intravenous opiates and benzodiazepines are traditionally prescribed in order to relieve the pain in this group of patients; however, complications always pose a problem.

Objective: To compare the pain relief and complications following intra-articular lidocaine and intravenous meperidine/diazepam in patients with anterior shoulder dislocation.

Methods: 48 patients with non-habitual traumatic anterior dislocation of the glenohumoral joint admitted to Imam Khomeini hospital emergency department were enrolled in this randomised clinical trial. They were divided into two groups: one group of patients received intra-articular lidocaine 1%, while the other received intravenous meperidine and diazepam. Closed reduction using the countertraction–traction method was performed by a single person in all the patients. Utilising a 100 mm visual analogue scale, each patient’s pain was recorded before injection, before reduction, and after reduction.

Results: Mean pain (mm) recorded before injection, before reduction, and after reduction in the intra-articular lidocaine group was 84.3 (95% confidence interval (CI) 79.8 to 88.8), 52.6 (95% CI 45.2 to 60.1), and 27.3 (95% CI 19.9 to 34.7), respectively. The corresponding rates in the intravenous meperidine/diazepam group were 83.2 (95% CI 79.2 to 87.2), 57.9 (95% CI 53.8 to 62.0), and 23.9 (95% CI 18.9 to 28.8), respectively. Both groups demonstrated a similar significant decline in pain after injection (p less than 0.005). No severe complications were reported in either of the groups.

Conclusion: Intra-articular injection of lidocaine before closed reduction of anterior shoulder dislocation produces the same pain relief as intravenous meperidine and diazepam.

5. Adjunctive Atropine Is Unnecessary during Ketamine Sedation in Children

Brown L, et al. Acad Emerg Med. 2008;15:314-318.

Background: The prophylactic coadministration of atropine or other anticholinergics during dissociative sedation has historically been considered mandatory to mitigate ketamine-associated hypersalivation. Emergency physicians (EPs) are known to omit this adjunct, so a prospective study to describe the safety profile of this practice was initiated.

Objectives: To quantify the magnitude of excessive salivation, describe interventions for hypersalivation, and describe any associated airway complications.

Methods: In this prospective observational study of emergency department (ED) pediatric patients receiving dissociative sedation, treating physicians rated excessive salivation on a 100-mm visual analog scale and recorded the frequency and nature of airway complications and interventions for hypersalivation.

Results: Of 1,090 ketamine sedations during the 3-year study period, 947 (86.9%) were performed without adjunctive atropine. Treating physicians assigned the majority (92%) of these subjects salivation visual analog scale ratings of 0 mm, i.e., "none," and only 1.3% of ratings were 50 mm or greater. Transient airway complications occurred in 3.2%, with just one (brief desaturation) felt related to hypersalivation (incidence 0.11%, 95% confidence interval = 0.003% to 0.59%). Interventions for hypersalivation (most commonly suctioning) occurred in 4.2%, with no occurrences of assisted ventilation or intubation.

Conclusions: When adjunctive atropine is omitted during ketamine sedation in children, excessive salivation is uncommon, and associated airway complications are rare. Anticholinergic prophylaxis is not routinely necessary in this setting.

6. Misdiagnoses Caused in Part by Overconfidence

from WebMD. Salynn Boyles. April 30, 2008 — Most of the time a medical diagnosis is on point. But misdiagnoses do occur, and an overly confident doctor may be partly to blame, a new review suggests.

The rate of diagnostic error is as high as 15%, Eta S. Berner, EdD, and Mark L. Graber, MD, write in a special edition of The American Journal of Medicine dedicated to understanding and addressing diagnostic errors.

Physician overconfidence and a lack of feedback following a diagnosis are two important contributors to the problem, they note.

"When directly questioned, many clinicians find it inconceivable that their own error rate could be as high as the literature demonstrates," Berner and Graber write. "They acknowledge that diagnostic error exists, but believe the rate is very low, and that any errors are made by others who are less skillful or less careful." Berner says it is often the cases physicians perceive as routine and unchallenging that end up being misdiagnosed.

"With the hard cases, doctors generally seek out different opinions or turn to (computer-based) decision support tools," she tells WebMD.

Barriers to Patient Follow-up

In one of the newly published essays, Gordon D. Schiff, MD, of Chicago's Cook County Hospital addressed the barriers to the follow-up of patients in the real-world, clinical practice setting.

Not surprisingly, lack of time was at the top of his list, followed by fragmentation of care, the large number of symptoms for which there is no clear diagnosis, cost and managed care barriers, and physician defensiveness about critical feedback from peers.

"Learning and feedback are inseparable," Schiff writes. "The old tools (used by physicians) -- individual idiosyncratic systems to track patients, reliance on human memory, and patient adherence to or initiating of follow-up appointments -- are too unreliable to be depended upon to ensure high quality in modern diagnosis."

He calls for a systematic approach to link diagnoses with patient outcomes.

In a different essay, Mark Graber, MD, of the department of medicine at State University of New York at Stony Brook and VA Medical Center in Northport, N.Y., proposes new roles for patients that can help. One is to have the patient become a "watchdog for cognitive errors" by having doctors communicate to patients more about what diagnoses they are considering rather than just telling patients what tests to get or what medications to take. Sharing more information with patients can help patients be more active in checking for errors.

A second role is as a "watchdog for system-related errors" to help keep track of their own medical information such as test results and medication lists. By doing so, "the patient can play a valuable role in combating errors related to latent flaws in our healthcare systems and practices," Graber writes.

Berner adds that patients can help by questioning their doctors carefully during the diagnostic process, and, especially, letting them know when they might have made the wrong call. "If your doctor says you should be better in a week, and you aren't, call the office and let them know," she says, adding that a surprising number of patients do not do this.

Patients who aren't sure about their diagnosis should also ask their doctors what else their condition might be, she says. The simple suggestion was a major focus of the best-selling 2007 book How Doctors Think by Harvard Medical School physician Jerome Groopman.

In it Groopman writes that instead of being intimidated by their doctors, patients should ask questions like, "Is there anything that doesn't fit your diagnosis?" and "Is it possible that I may have more than one problem?" Mongerson tells WebMD that the point is not to put physicians on the defensive, but to explore all medical possibilities.

"After everything I went through I am still very high on doctors," he tells WebMD. "They are very dedicated people who work very hard and go through hell when they find out they have made a mistake. The problem is, they don't normally find out."

Full-text of this issue of Amer J Med: http://www.amjmed.com/issues/contents?issue_key=S0002-9343(08)X0007-5

Groopman’s How Doctors Think: http://www.amazon.com/How-Doctors-Think-Jerome-Groopman/dp/0547053649/

7. One-third of ED Angioedema Due to ACE Inhibitors

NEW YORK (Reuters Health) May 08 - Results of a study suggest that nearly one-third of angioedema seen in US emergency departments is caused by angiotensin-converting enzyme-inhibitor (ACEI) therapy.

And while most patients with ACEI-induced angioedema seen in the ED are treated and sent home, a subgroup of patients requires inpatient hospitalization for management of upper airway angioedema, Dr. Aleena Banerji from Massachusetts General Hospital, Boston and colleagues found.

They conducted a medical record review of ACEI-induced angioedema in patients who presented to five EDs in the United States over a median of 3 years.

They identified a total of 220 patients with ACEI-induced angioedema, which reflected 30% of all patients with angioedema who presented to the ED, the clinicians report. "The annual rate of visits for ACEI-induced angioedema was 0.7 per 10,000 ED visits."
Dr. Banerji and colleagues calculate that "the typical academic ED, with approximately 50,000 annual visits, might expect to see 11 patients with angioedema during a year, of which three to four cases would have been associated with ACEI."

Shortness of breath, lip and tongue swelling, and laryngeal edema were the most common presenting signs.

Fifty-eight percent of patients with ACEI-induced angioedema were sent home directly from the ED, whereas 12% were regular inpatient admissions, 11% were ICU admissions and 18% were admitted under observation status for less than 24 hours.

Pharyngeal swelling and respiratory distress were independent predictors of hospital admission and longer length of stay.

"Further research into the exact mechanism of ACEI-induced angioedema and development of novel treatment options is still needed," Dr. Banerji and colleagues conclude.

Ann Allergy Asthma Immunol 2008;100:327-332.

8. Discrepancies in US/European Guidelines on Antithrombotics for ACS

from Heartwire (WebMD): May 9, 2009 – Discrepancies in current recommendations on the use of various antithrombotics in the European and US guidelines for the treatment of acute coronary syndromes is causing confusion, some clinicians have suggested [1].

The editorial, published in the May 10, 2008 issue of the Lancet, is written by Drs John Eikelboom (Hamilton General Hospital, ON), Gordon Guyatt (CLARITY Research Group, Hamilton, ON), and Jack Hirsh (Henderson Research Centre, Hamilton, ON). They say that discrepancies on recommendations regarding enoxaparin and fondaparinux between US and European guidelines undermines confidence in the integrity of guideline development, and they suggest that in the future such discrepancies may be avoided if both committees met and debated differences between their recommendations and if they included nonconflicted methodologists to ensure that criteria for evidence quality were applied consistently.

They write: "The disagreements in the recommendations for enoxaparin and fondaparinux seem to stem from differences in both the interpretation of the trial data and from differences in the application of nearly identical criteria that were used by both committees to classify the evidence. Without an opportunity to review the reasoning behind each recommendation, it is difficult for readers to decide which recommendations to follow."

Eikelboom et al note that the American College of Cardiology (ACC)/American Heart Association (AHA) and the European Society of Cardiology (ESC) both updated their ACS guidelines last year [2,3]. "The committees reviewed the same research and used nearly identical criteria to rate the strength of the recommendations and to grade the quality of the evidence, but they interpreted the evidence for acute anticoagulant use differently and so reached different conclusions. Therefore, physicians who read recommendations from both the US and European societies might be confused."

They point out that the ACC/AHA gave enoxaparin and fondaparinux a class 1 rating for conservatively and invasively managed patients, implying that there is evidence or general agreement that the treatments are useful or effective. By contrast, the ESC gave enoxaparin a class 2 rating for conservatively and invasively managed patients, implying that there is conflicting evidence or divergence of opinion about the usefulness of enoxaparin, and did not recommend fondaparinux for patients undergoing urgent invasive procedures. "For clinicians, this is the most important area of disagreement between the guidelines, because it directly affects the choice of anticoagulant; unfortunately, it is also the hardest to explain," the authors state.

They suggest that the ACC/AHA must have placed greater weight than the ESC on the results of a meta-analysis that showed that enoxaparin compared with heparin reduced MI and did not increase bleeding. In contrast, the ESC seemed to place greater weight on the results of the SYNERGY trial (which showed that enoxaparin was as effective as heparin but was associated with more bleeding in invasively treated patients) and the OASIS-5 trial (which found that enoxaparin was as effective as fondaparinux but caused more bleeding and was associated with excess strokes and deaths at day 30).

Eikelboom et al note that the divergent recommendations for fondaparinux probably also reflect differences in the interpretation of the OASIS-5 trial, which showed an excess of catheter thrombosis in patients treated with fondaparinux undergoing PCI. This, they suggest, led the ESC not to recommend fondaparinux in invasively managed patients, "but the strong recommendation by the ACC/AHA for fondaparinux in invasively managed patients implies that they did not think the risk of catheter thrombosis to be an important issue, provided that a bolus dose of heparin is used at the time of the invasive procedure."

Clarifying the US Position

Chair of the AHC/AHA guidelines committee, Dr Jeffery Anderson (University of Utah, Salt Lake City), told heartwire that the Lancet editorial had somewhat misread the recommendations. He pointed out that although the ESC doesn't recommend fondaparinux for patients getting urgent revascularization, it has given the drug a 1A recommendation for delayed invasive therapy within three days. He added that the ACC/AHA recommendation for fondaparinux was for an invasive strategy within 48 hours, not an urgent strategy, and gives it a 1B, not a 1A, and it also specifies giving it with heparin.

"Thus, one could interpret the ACC/AHA guideline as being more conservative, not more liberal, for fondaparinux. The difference is the way 'early invasive' is defined. Reading the text carefully reveals similar concerns about catheter thrombosis by both societies, and neither advances fondaparinux particularly for invasive patients. So the editorial obviously doesn't fairly assess the very close overall agreement in the sense of both guidelines that is included in the text. However, OASIS-5 was a very large and well-done study that indicates fondaparinux as being successful for the overall efficacy and safety end points, regardless of strategy, despite the small excess of catheter thrombosis," Anderson commented.

Different Focuses on Benefit/Risk?

Dr Sanjay Kaul (Cedar Sinai Medical Center, Los Angeles) suggests that one reason for the discordant recommendations between the ACC/AHA and ESC guidelines is that the benefit/risk trade-off focuses only on efficacy outcomes in US guidelines but on both efficacy and safety in the European guidelines. "Thus, while enoxaparin gets a class 1A recommendation in the ACC/AHA guidelines (based only on equivalent efficacy with heparin), it is downgraded in the ESC guidelines (based on both equivalent efficacy but increased bleeding compared with heparin or fondaparinux)," he commented to heartwire.

"Ideally, guidelines must be written in a manner that communicates a clear, rational, and practical balance between clinically important magnitude of benefits and harms, not just statistically significant benefits," Kaul said. He adds: "Rigorous standardized analytical methodology that focuses on benefit/risk (and cost) assessment might also improve the quality of adjudication of evidence in guideline development."

In a recent discussion on theheart.org on differences between the US and European guidelines (sponsored by Sanofi-Aventis and Bristol-Myers Squibb), speakers noted that although enoxaparin and fondaparinux were not given such strong recommendations in the European guidelines, they were both used more extensively in Europe than they were in the US [4].

Dr Keith Fox (University of Edinburg, Scotland) said that fondaparinux was favored by some clinicians in the UK because it showed a mortality advantage over enoxaparin in OASIS-5; as it is not sufficient to be used alone in the cath lab, many centers use unfractionated heparin in the cath lab if patients have been pretreated with fondaparinux. But enoxaparin was still the most widely used agent in his center, Fox added.

Dr Charles Pollack (University of Pennsylvania School of Medicine, Philadelphia) said he was happy to use either enoxaparin or unfractionated heparin, both of which have class 1A recommendations in the US. He pointed out that there was very little use of fondaparinux in the US at present, probably because it was not yet approved for the ACS indication there. "Fondaparinux is attractive, but there is very little experience of this drug in the US, and we don't like the idea of having to give extra unfractionated heparin on top of it in the lab," he said.

Dr Giles Montalescot (Hospital La Pitie Salpetriere, Paris, France) concurred in this point. "We have moved away from using unfractionated heparin, and we put almost everyone on enoxaparin, as it covers all situations. If we use fondaparinux, we would have to bring back unfractionated heparin, but we don't use it anymore," he said. He added that his center does use fondaparinux in patients who it is known will not be going to the cath lab.

On the other option of bivalirudin, Pollack noted that it was not used much in the US to treat ACS patients and had not been approved yet for use outside the cath lab, although there were signs that it was now starting to move into the upstream setting.

1. Eikelboom J, Guyatt G and Hirsh J. Guidelines for anticoagulant use in acute coronary syndromes. Lancet 2008; 371: 1559-1561.
2. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2007; 50: e1–157.
3. Bassand JP, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: the task force for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes of the European Society of Cardiology. Eur Heart J 2007; 28: 1598–1660.
4. Lost in translation: US and European guidelines for the pharmacologic management of ACS. theheart.org. April 10, 2008. Available at http://www.theheart.org/article/846579.do

9. Awareness of Stroke Warning Symptoms Low in United States

Laurie Barclay, MD. May 9, 2008 — Stroke symptom awareness and recognition of the need to call 9-1-1 were low in the United States in 2005, with disparities seen by race/ethnicity, sex, and education level, according to the results of a study published in the May 9 issue of Morbidity and Mortality Weekly Report. The authors recommend that public health agencies, clinicians, and educators continue to stress the importance of learning to recognize stroke symptoms and the need to telephone 9-1-1 when someone appears to be having a stroke.

"A revised objective of Healthy People 2010 is to increase to 83% the proportion of persons who are aware of the warning symptoms of stroke and the need to telephone 9-1-1 immediately if someone appears to be having a stroke," write J. Fang, MD, from the National Center for Chronic Disease Prevention and Health Promotion, and colleagues. "To assess public awareness of stroke warning symptoms and the importance of seeking emergency care, [the Centers for Disease Control and Prevention] analyzed data from an optional module of the 2005 Behavioral Risk Factor Surveillance System (BRFSS) survey that was used in 13 states and the District of Columbia (DC). The results indicated that the percentages of respondents who recognized all five correct symptoms, identified an incorrect symptom, and recognized the need to telephone 9-1-1 was low; the percentage who met all three measures was 16.4%."

In the optional heart attack and stroke module of the BRFSS surveys of 13 states and DC in 2005, 71,994 respondents answered questions regarding stroke symptoms and how they would respond if they thought that someone was having a heart attack or stroke. Median response rate was 54.5% (range, 45.1% – 61.3%). Data were weighted to 2005 state population estimates and age-adjusted prevalence estimates, and 95% confidence intervals were calculated.

Awareness of stroke warning symptoms was 92.6% for sudden facial or limb numbness or weakness, particularly on 1 side; 86.5% for sudden confusion or speaking difficulty; 83.4% for sudden difficulty walking, dizziness, or loss of balance; 68.8% for sudden vision problem in 1 or both eyes; and 60.4% for severe headache with no apparent cause. All 5 stroke warning symptoms were correctly identified by 43.6% of respondents.

Sudden chest pain or discomfort, which is a warning symptom of a heart attack rather than stroke, was incorrectly identified as a warning symptom of stroke by 39.5% of respondents. Only 8.6% were aware of all stroke warning symptoms and knew that sudden chest pain is not a stroke warning sign.

Although 85.9% of respondents said they would call 9-1-1 if they thought someone was having a heart attack or stroke, only 16.4% were aware of all 5 stroke warning symptoms, knew that sudden chest pain is not a stroke warning symptom, and would call 9-1-1 if they thought that someone was having a heart attack or stroke.

Factors associated with increased awareness of stroke warning symptoms and the need to call 9-1-1 were white race (41.3%), female sex (41.5%), and higher educational levels (47.6% for college degree or more). Among states, the same measure ranged from 27.9% in Oklahoma to 49.7% in Minnesota.

An accompanying editorial notes that these 2005 results were not improved from the 2001 survey, although direct comparisons could not be made because the areas participating in the optional heart attack and stroke module were different.

Limitations of these findings are that BRFSS excludes households without landline telephones, lack of generalizability to the entire US population, substantial differences from the previously reported estimate from the 2001 National Health Interview Survey, and inability to determine whether participants who misidentified the incorrect stroke symptom did not know the correct answer or did not consider the question.

"Receiving treatment quickly after a stroke is critical to lowering the risk for disability and even death," the editorial concludes. "These findings indicate a need to increase awareness of stroke warning symptoms in the entire population, and particularly among blacks, Hispanics, men, and persons at lower education levels. In addition, increased education efforts in multiple languages might help improve awareness among non-English-speaking Hispanics and others."

MMWR Morb Mortal Wkly Rep. 2008;57(18):481–485.

10. Noninvasive Ventilation Outcomes in 2,430 Acute Decompensated Heart Failure Patients: An ADHERE Registry Analysis

Tallman TA, et al. Acad Emerg Med. 2008;15:355-362.

Objectives: Continuous or bilevel positive airway pressure ventilation, called noninvasive ventilation (NIV), is a controversial therapy for acute decompensated heart failure (ADHF). While NIV is considered safe and effective in patients with chronic obstructive pulmonary disease (COPD), clinical trial data that have addressed safety in ADHF patients are limited, with some suggestion of increased mortality. The objective of this study was to assess mortality outcomes associated with NIV and to determine if a failed trial of NIV followed by endotracheal intubation (ETI) (NIV failure) is associated with worse outcomes, compared to immediate ETI.

Methods: This was a retrospective analysis of the Acute Decompensated Heart Failure National Registry (ADHERE), which enrolls patients with treatment for, or with a primary discharge diagnosis of, ADHF. The authors compared characteristics and outcomes in four groups: no ventilation, NIV success, NIV failure, and ETI. One-way analysis of variance or Wilcoxon testing was performed for continuous data, and chi-square tests were used for categorical data. In addition, multivariable logistic regression was used to adjust mortality comparisons for risk factors.

Results: Entry criteria were met by 37,372 patients, of which 2,430 had ventilation assistance. Of the ventilation group, 1,688 (69.5%) were deemed NIV success, 72 (3.0%) were NIV failures, and 670 (27.6%) required ETI. The NIV failure group had the lowest O2 saturation (SaO2) (84 ± 16%), compared to either NIV success (89.6 ± 10%) or ETI (88 ± 13%; p = 0.017). ETI patients were more likely to receive vasoactive medications (p less than 0.001) than the NIV success cohort. When comparing NIV failures to ETI, there were no differences in treatment during hospitalization (p exceeded 0.05); other than that the NIV failure group more often received vasodilators (68.1% vs. 54.3%; p = 0.026). In-hospital mortality was 7.9% with NIV, 13.9% with NIV failure, and 15.4% with ETI. After risk adjustment, the mortality odds ratio for NIV failure versus ETI increased to 1.43, although this endpoint was not statistically significant.

Conclusions: In this analysis of ADHF patients receiving NIV to date, patients placed on NIV for ADHF fared better than patients requiring immediate ETI. Patients who failed NIV and required ETI still experienced lower mortality than those initially placed on ETI. Thus, while the ETI group may be more severely ill, starting therapy with NIV instead of immediate ETI will likely not harm the patient. When ETI is required, mortality and length of stay may be adversely affected. Since a successful trial of NIV is associated with improved outcomes in patients with ADHF, application of this therapy may be a reasonable treatment option.

11. Communicating risk to ED patients with chest pain

France J, et al. Emerg Med J 2008;25:276-278.

Background: The risks and benefits of thrombolytic therapy for acute myocardial infarction are usually discussed with patients before treatment. Numerous factors may make it difficult for a patient to understand these issues fully; one of these is the language doctors use to describe risk.

Study objective: To determine whether emergency department (ED) patients who experience chest pain have the same understanding of the frequency of side effects when expressed as percentages or in descriptive language (eg, "uncommon") as emergency medicine doctors.

Setting: The chest pain area of an urban ED.

Method: A short questionnaire survey was administered to both patients and ED doctors.

Results: Of the 50 patients recruited, 88% correctly understood data when presented as percentages. When patients were asked to identify the frequency of an "uncommon" and "rare" side effect only 22% and 18%, respectively, were able to do so. The corresponding results for the doctors were 70% (p less than 0.0001) and 54% (p = 0.0006). 39% of patients felt that there was no difference between these two verbal descriptors.

Conclusion: Patients understand side-effect frequencies when expressed as percentages. Patients have different understandings of the frequency of events to doctors when verbal descriptors are used. This lack of a shared understanding has implications for informed decision-making and we recommend that percentages are used to communicate risk in the ED.

12. Corticosteroids May Not Reduce Mortality in Children With Bacterial Meningitis

Laurie Barclay, MD. May 6, 2008 — In children with bacterial meningitis, adjuvant treatment with corticosteroids was not associated with a decreased risk for death or shorter hospital stay, according to the results of a retrospective cohort study reported in the May 7 issue of the Journal of the American Medical Association.

"In adults, adjuvant corticosteroids significantly reduce mortality associated with bacterial meningitis; however, in children, studies reveal conflicting results," write Jillian Mongelluzzo, from the Children's Hospital of Philadelphia in Pennsylvania, and colleagues. "Concerns over the use of corticosteroids relate to the potential for decreased cerebrospinal fluid (CSF) penetration of antibiotics and potential adverse effects of corticosteroids, namely gastrointestinal bleeding."

Between January 1, 2001, and December 31, 2006, a total of 2780 children were discharged with bacterial meningitis as their primary diagnosis from 27 US tertiary care children's hospitals that provide data to the Pediatric Health Information System's administrative database.

Primary outcomes were propensity scores, derived from patient demographics and baseline markers of illness severity, used to determine each child's likelihood of receiving adjuvant corticosteroids. Endpoints of time to death and time to hospital discharge were analyzed with propensity-adjusted Cox proportional hazards regression models stratified by age subgroups.

In the study cohort, 57% were boys; median age was 9 months (interquartile range, 0 - 6 years); Streptococcus pneumoniae was the most frequently identified causative organism; and 248 children (8.9%) received adjuvant corticosteroids.

The overall mortality rate was 4.2% (95% confidence interval [CI], 3.5% - 5.0%), with cumulative incidence of 2.2% at 7 days after admission and 3.1% at 28 days after admission. For any age group, adjuvant corticosteroid therapy was not associated with reduced mortality. The hazard ratio [HR] for children younger than 1 year was 1.09 (95% CI, 0.53 - 2.24), HR for age 1 to 5 years was 1.28 (95% CI, 0.59 - 2.78), and HR for children older than 5 years was 0.92 (95% CI, 0.38 - 2.25).

Time to hospital discharge was also unaffected by adjuvant corticosteroid use. Findings were not different in subgroups of children with pneumococcal or meningococcal meningitis or in those with a CSF culture performed at the admitting hospital.

"In this multicenter observational study of children with bacterial meningitis, adjuvant corticosteroid therapy was not associated with time to death or time to hospital discharge," the study authors write.

Limitations of this study include insufficient power to determine a difference in mortality when case fatality rates are low in children with bacterial meningitis; possibly unreliable discharge diagnosis coding for specific diseases or pathogens; measured and unmeasured residual confounding by indication for adjuvant corticosteroid therapy related to illness severity; and lack of data on specific clinical factors potentially associated with increased illness severity, such as the presence of cranial nerve palsy and hypothermia.

Other study limitations were relatively small numbers of patients included in various subgroups, making it likely that the study was underpowered to detect small but significant differences in these subgroups; inability to exclude the possibility of the benefit of adjuvant corticosteroid therapy for certain subpopulations of patients with bacterial meningitis; inability to determine the dose or timing of corticosteroid administration; and inability to determine the possible positive effects of adjuvant corticosteroid therapy on hearing loss or neurologic morbidity.

"Adjuvant corticosteroid use in the treatment of bacterial meningitis appears to be increasing," the study authors conclude. "A randomized trial is warranted to explore the possible benefit of adjuvant corticosteroid therapy on both morbidity and mortality in children with bacterial meningitis before such corticosteroid use becomes routine."

JAMA. 2008;299:2048-2055. Abstract: http://jama.ama-assn.org/cgi/content/abstract/299/17/2048

13. Spending Money on Others Promotes Happiness

Dunn EW, et al. Science 2008;319:1687-8.

Although much research has examined the effect of income on happiness, we suggest that how people spend their money may be at least as important as how much money they earn. Specifically, we hypothesized that spending money on other people may have a more positive impact on happiness than spending money on oneself. Providing converging evidence for this hypothesis, we found that spending more of one's income on others predicted greater happiness both cross-sectionally (in a nationally representative survey study) and longitudinally (in a field study of windfall spending). Finally, participants who were randomly assigned to spend money on others experienced greater happiness than those assigned to spend money on themselves.

14. Exodus of specialists from EDs raises concerns: Many consultants are unwilling to work nights and weekends or to care for uninsured patients.

Mary Engel, Los Angeles Times Staff Writer, April 25, 2008.

When Dr. Mark I. Langdorf began practicing emergency medicine more than 20 years ago, finding a specialist to help with a complicated case was easy. Newly minted surgeons and fledgling ear, nose and throat doctors would show up in the emergency room with boxes of doughnuts, hoping to pick up patients and build their practices.

Today, specialists not only have dumped the doughnuts, they've abandoned emergency rooms in droves. One more sign of a deteriorating safety net, their exodus is both a cause and a result of the backlogs that plague hospital emergency rooms across Southern California. Their dwindling numbers affect the uninsured and the insured alike.

"Calling 911 gets you a waiting room," said Langdorf, the emergency department director at UC Irvine Medical Center in Orange. "It doesn't get you an emergency doc, and it certainly doesn't get you a right to a medical specialist."

Emergency room doctors can take care of about 80% of the patients who go through their doors, Langdorf said. But 20% of patients need an orthopedic surgeon to set a badly busted leg, an ophthalmologist to treat a shattered eye or other experts. That can mean hours on the phone trying to find a specialist or arranging a transfer to a larger hospital.

Contrary to what many patients may assume, California hospitals don't directly employ physicians. Under a state law that seeks to limit hospital pressure on a doctor's professional judgment, hospitals contract with emergency physicians or physician groups, who do their own billing. (The law does not apply to university and county hospitals.)

In the past, specialists in private practice who wanted to be able to admit their patients to a hospital would seal the relationship by agreeing to be "on call" for emergencies. But today, plastic surgeons and some other specialists do more procedures in office settings than in hospitals. And hospitals' financial struggles have given specialists the upper hand; if told to take emergency calls, specialists can take their elective surgery patients to another hospital.

As a teaching hospital, UCI Medical Center -- like Harbor-UCLA and County-USC medical centers in Los Angeles County -- can draw on doctors in training from the full roster of specialties. That's not the case at community hospitals, the local non-teaching facilities that are far more numerous.

A 2006 survey by the American College of Emergency Physicians found that 73% of emergency departments in the United States had inadequate on-call coverage by specialist physicians.

"If the state of California's licensing and certification division came into our hospitals to examine whether we had all the specialists we say we do, they would shut down over half of the hospitals in Los Angeles County because we don't have coverage," said Jim Lott, executive vice president of the Hospital Assn. of Southern California.

The most obvious reason for the flight of specialists from emergency rooms is the surge of patients who have no medical insurance or who use Medi-Cal, which pays some of the lowest rates in the country. It has become virtually impossible for these patients to find specialists in private practice to treat them, so they turn as a last resort to the emergency room, which under federal law must treat them regardless of their ability to pay.

On-call specialists could grow even scarcer under state plans to shrink the budget deficit by cutting Medi-Cal payments 10% this summer.

Lott and others cite additional reasons for the exodus of specialists: patients who are often drunk or on drugs; the higher risk of being sued that comes from treating strangers instead of longtime patients; and insurance companies that tightly limit doctors' payments. And now that so many insured patients are in managed care plans, being on call is no guarantee that the doctor on call will be the one who provides follow-up care.

Such changes have led to an evolution in doctors' expectations.

"Many of these specialists are looking for a lifestyle that doesn't tie them to a hospital on evenings and weekends," Lott said. "Some of them you couldn't pay any amount of money to -- they just won't take the call." It has become common for some hospitals to pay stipends to specialists to be on call.

Full-text: http://www.latimes.com/news/local/la-me-er25apr25,1,5057682.story

15. Etiquette-Based Medicine

Kahn MW. N Engl J Med. 2008; 358:1988-1989.

Patients ideally deserve to have a compassionate doctor, but might they be satisfied with one who is simply well-behaved? When I hear patients complain about doctors, their criticism often has nothing to do with not feeling understood or empathized with. Instead, they object that "he just stared at his computer screen," "she never smiles," or "I had no idea who I was talking to." During my own recent hospitalization, I found the Old World manners of my European-born surgeon — and my reaction to them — revealing in this regard. Whatever he might actually have been feeling, his behavior — dress, manners, body language, eye contact — was impeccable. I wasn't left thinking, "What compassion." Instead, I found myself thinking, "What a professional," and even (unexpectedly), "What a gentleman." The impression he made was remarkably calming, and it helped to confirm my suspicion that patients may care less about whether their doctors are reflective and empathic than whether they are respectful and attentive.

I believe that medical education and postgraduate training should place more emphasis on this aspect of the doctor–patient relationship — what I would call "etiquette-based medicine." There have been many attempts to foster empathy, curiosity, and compassion in clinicians, but none that I know of to systematically teach good manners. The very notion of good manners may seem quaint or anachronistic, but it is at the heart of the mission of other service-related professions. The goals of a doctor differ in obviously important ways from those of a Nordstrom's employee, but why shouldn't the clinical encounter similarly emphasize the provision of customer satisfaction through explicit actions? A doctor who has trouble feeling compassion for or even recognizing a patient's suffering can nevertheless behave in certain specified ways that will result in the patient's feeling well treated. How could we implement an etiquette-based approach to patient care?

The success achieved by Peter Pronovost and colleagues in solving a different kind of complex problem — reducing the likelihood of central-line infections in critical care patients — provides a thought-provoking suggestion. Instead of taking an elaborate, "sophisticated" approach — say, tackling infections by developing more advanced antibiotics or clarifying the genetic basis for drug resistance — Pronovost et al. introduced a checklist to enforce the use of hand washing, thorough draping of the patient, and other tasks that could be easily performed. The results of this simple intervention were swift and dramatically effective. I would propose a similar approach to tackling the problem of patient satisfaction: that we develop checklists of physician etiquette for the clinical encounter. Here, for instance, is a possible checklist for the first meeting with a hospitalized patient:

1. Ask permission to enter the room; wait for an answer.

2. Introduce yourself, showing ID badge.

3. Shake hands (wear glove if needed).

4. Sit down. Smile if appropriate.

5. Briefly explain your role on the team.

6. Ask the patient how he or she is feeling about being in the hospital.

Such a checklist has the advantages of being clear, efficient to teach and evaluate, and easy for trainees to practice. It does not address the way the doctor feels, only how he or she behaves; it provides guidance for trainees whose bedside skills need the most improvement. The list can be modified to address a variety of clinical situations: explaining an ongoing workup, delivering bad news, preparing for discharge, and so forth.

Training for an etiquette-based approach to patient care would complement, rather than replace, efforts to train physicians to be more humane. Pedagogically, an argument could be made for etiquette-based medicine to take priority over compassion-based medicine. The finer points of patient care should be built on a base of good manners. Beginning pianists don't take courses in musicianship and artistic sensibility; they learn how to have proper posture at the piano and how to play scales and are expected to develop those higher-level skills through a lifetime of study and practice. I may or may not be able to teach students or residents to be curious about the world, to see things through the patient's eyes, or to tolerate suffering. I think I can, however, train them to shake a patient's hand, sit down during a conversation, and pay attention. Such behavior provides the necessary — if not always sufficient — foundation for the patient to have a satisfying experience.

Furthermore, it's simpler to change behavior than attitudes. Although reading medically relevant literary classics and writing reflection pieces (as is now done in many medical schools) may make some students more mature and humane, I wonder whether these exercises are most helpful for those students who arrive at medical school already in possession of those qualities to some degree. For many students, I suspect that these exercises may have a more limited effect, if only because they are too brief to allow the student to comprehend, practice, and master the intended values. It isn't easy to modify a person's character or outlook in a classroom; besides, clinical training is more effective when it resembles apprenticeship rather than graduate school. Trainees are likely to learn more from watching colleagues act with compassion than from hearing them discuss it.

Etiquette-based medicine would prioritize behavior over feeling. It would stress practice and mastery over character development. It would put professionalism and patient satisfaction at the center of the clinical encounter and bring back some of the elements of ritual that have always been an important part of the healing professions. We should continue our efforts to develop compassionate physicians, but let's not overlook the possibly more immediate benefits of emphasizing good behavior.

16. Stimulants for sale on the Internet: No need for the doctor

Schepis TS, et al. J Adoles Health 2008;42:458-65.

An analysis of the availability and portrayal of amphetamine-class prescriptions stimulants on the Internet demonstrated that adolescents were able to access these Schedule III stimulants without prescriptions and that much of the information on the effects of the agents was erroneous.

Intro
Central nervous system (CNS) stimulants are medications indicated for the treatment of attention-deficit hyperactivity disorder (ADHD), sleep disorders, and obesity. CNS stimulants that are properly administered provide much needed relief to adolescents suffering from the effects of these disorders. However, despite their beneficial effects, many CNS stimulants carry a high risk of misuse because their acute effects, which may include euphoria, increased energy and alertness, and decreased boredom and fatigue. The high potential for misuse is reflected in the fact that all stimulants are regulated under the Controlled Substances Act (CSA).

Concerns about the use of controlled stimulants have been increasing and have been particularly focused on diversion and misuse of these medications by adolescents and young adults. The Monitoring the Future Studies found that 8.6% of high school seniors and 6.7% of college students misused amphetamines in 2005, which were similar to previously established rates. In addition many children, adolescents, and young adults have been exposed to stimulant medication either directly or indirectly, often through peers. Stimulants are regularly prescribed in these age groups, with large increases in the number of prescriptions over the past two decades. To illustrate, Thomas et al found that adolescent stimulant use increased 208% from 1994 to 2002. Regular exposure to stimulants and their relative availability may make these medications appear safe and beneficial for all individuals, potentially resulting in misuse. Indeed 40% of teens believe potentially addictive prescription medications are “much safer” than their illicit counterparts.

Prescription stimulants are available from a variety of sources, including friends, family, and Internet retailers. The 2005 National Survey on Drug Use and Health found that 7.2% of stimulant misusers obtained stimulants most recently via the Internet, with both adolescents and young adults endorsing the Internet as a stimulant source. Purchases of medication from online sources has had unfortunate consequences beyond the risk of fostering addiction, including the dangerous substitution of antipsychotic agents for controlled sedatives or hypnotics that were ordered online. Thus adolescents and young adults appear to be putting themselves at notable risk through ordering and consuming medication from Internet retailers.

Fulltext: http://www.jahonline.org/article/S1054-139X(07)00641-6/fulltext

17. Age-Related Pulmonary Crackles May Interfere With Diagnosis of Heart Failure

Laurie Barclay, MD. May 12, 2008 — Characterizing age-related pulmonary crackles may facilitate diagnosis of heart failure in elderly patients, according to the results of a study reported in the May-June issue of the Annals of Family Medicine.

"The presence of age-related pulmonary crackles (rales) might interfere with a physician's clinical management of patients with suspected heart failure," write Hajime Kataoka, MD, from Nishida Hospital, and Osamu Matsuno, MD, from University Hospital, both in Oita, Japan. "We examined the characteristics of pulmonary crackles among patients with stage A cardiovascular disease (American College of Cardiology/American Heart Association heart failure staging criteria), stratified by decade, because little is known about these issues in such patients at high risk for congestive heart failure who have no structural heart disease or acute heart failure symptoms."

The investigators analyzed rales in 274 participants without comorbid pulmonary or other critical diseases who had normal heart structure (based on Doppler echocardiography) and function (B-type natriuretic peptide [BNP] less than 80 pg/mL) and normal lung results on chest radiographs.

The prevalence of crackles varied with age, ranging from 11% at ages 45 to 64 years (n = 97; 95% confidence interval [CI], 5% - 18%), to 34% at ages 65 to 79 years (n = 121; 95% CI, 27% - 40%), to 70% at ages 80 to 95 years (n = 56; 95% CI, 58% - 82%; P less than 0.001). The risk for audible crackles approximately tripled every 10 years after 45 years of age.

Logistic regression analysis showed that age was the only independent predictor of the presence or absence of pulmonary crackles and that leg venous insufficiency, leg edema, serum creatinine levels, and serum BNP levels were not associated with pulmonary crackles.

During follow-up of a mean duration of 11 ± 2.3 months, the short-term (within 3 months) reproducibility of crackles was 87% in 255 patients studied. Cardiovascular disease developed in 5 patients and pulmonary disease in 6 during follow-up.

Limitations of this study include definition of normal heart function based on plasma BNP levels, imprecise measurement of left ventricular diastolic function, use of only 1 index of Doppler-derived E/A ratio for the identification of diastolic dysfunction, highly selected patient group limiting generalizability of the findings, and disagreement among clinicians about the actual presence of crackles in individual patients.

"Recognition of age-related pulmonary crackles (rales) is important because such clinically unimportant crackles are so common among elderly patients that, without knowledge of this phenomenon, their existence might interfere with the physician's management of cardiopulmonary patients," the study authors write. "Characteristically, crackles in such patients are fine and are almost always restricted to an area localized to the lower quadrant of the lung field."

Ann Fam Med. 2008;6:239-245

18. Ketoacidosis Often Present at Diagnosis of Diabetes in US Youth

By Anthony J. Brown, MD. NEW YORK (Reuters Health) May 14 - Roughly one in four children and adolescents diagnosed with diabetes in the US present with ketoacidosis and these patients are more likely to be hospitalized than others, according to a report in the May issue of Pediatrics.

"The major finding is that nearly 30% of children with type 1 diabetes and 10% of those with type 2 diabetes in the United States today still present in potentially life-threatening ketoacidosis. We expected lower rates, given the recent increase in community recognition of childhood diabetes and improvements in treatment," lead author Dr. Arleta Rewers told Reuters Health.

"While poverty, barriers in access to care and lower parental educational attainment further increase the risk, over 20% of children from the most affluent families are diagnosed in ketoacidosis," Dr. Rewers, a researcher with the University of Colorado at Denver, added.

The Search for Diabetes in Youth Study involved 3666 patients who were diagnosed with diabetes before 20 years of age in selected US study areas from 2002 to 2004. A medical chart review was conducted for 2824 of the patients (77%) to determine the presence of ketoacidosis using standard criteria.

Overall, 25.5% of subjects presented with ketoacidosis, the report indicates. The prevalence decreased with age, ranging from 37.3% in children younger than 5 years to 14.7% in 15- to 19-year-olds.

About half of the patients were hospitalized at diagnosis. The proportion of hospitalized patients was much higher for those presenting with vs. without ketoacidosis: 93% vs. 41%.

On multivariate analysis, risk factors for a ketoacidosis presentation were lower family income, less desirable health insurance coverage, and lower parental education, the report shows.

"In light of the increasing incidence of diabetes in the US and worldwide, a high index of suspicion on the part of parents and health care providers may reduce the rates of ketoacidosis and the cost of initial diabetes care," Dr. Rewers said. "Early recognition of the classical triad of increased thirst, urination, and hunger with weight loss is essential."

Pediatrics 2008;121:e1258-e1266.

19. Factor VIIa Not Effective for Intracerebral Hemorrhage

Treatment with rFVIIa was not associated with improved 90-day neurologic outcomes.

In this phase 3 trial, recombinant activated factor VII (rFVIIa) reduced hematoma growth but did not improve clinical outcomes in patients with intracerebral hemorrhage.

Mayer SA, et al. New Engl J Med. 2008;358:2127-2137.

Abstract: http://content.nejm.org/cgi/content/short/358/20/2127

20. Understanding Prognostic Uncertainty

David J. Spiegelhalter, PhD, FRS, Statistical Laboratory, Centre for Mathematical Sciences, Cambridge, United Kingdom

I decided to put myself through the ARRIBA-Herz algorithm, developed by Krones et al, and notched up 10 points, corresponding to an 8% 10-year risk of a myocardial infarction (MI) or stroke, similar to the chance of drawing an ace out of a pack of cards. To me, this absolute risk is worrying, but that 8% is below average for my age is reassuring.

How best to assess odds for individual events? The standard way is to use historical data by essentially embedding a new individual in a population of similar people in whom the frequency of adverse events is known. This process requires some judgment: being told an event has happened 43 out of 43 times suggests that it is almost certain to happen next time, until I tell you the event is that the President of the United States is a white man. By embedding someone in a historical class, we are inevitably ignoring additional, potentially informative, personal information that could influence our odds.

Finally, we must decide on a way of communicating the risk, and we might look for guidance to a recent authoritative review of numerical, verbal, and graphic methods of individual risk communication in health. Lipkus identified some well-known biases—for example, risks reported as "10 out of 100" are generally perceived as higher than "1 out of 10"—but could not come up with any very firm conclusions as to the correct method for communicating risk…
Ann Family Med 2008;6:196-197.

Full-text (free): http://www.annfammed.org/cgi/content/full/6/3/196

21. More Free-standing EDs Open Away from Hospitals

Source: USA TODAY GERMANTOWN Md. Date: April 28, 2008

This commuter suburb near Washington, D.C., boasts new homes, shopping centers, plenty of traffic — and a state-of the-art 21-room emergency department tucked into an office complex.

Unlike most emergency departments, however, there are no patients awaiting transfer upstairs to a medical ward, because there is no medical ward.

The nearest hospital is about 8 miles away.

"A lot of people were skeptical" about the idea at first, says Robert Jepson, associate vice president of Adventist HealthCare, which owns both the nearby hospital and the free-standing emergency center.

High-tech emergency departments such as this one — staffed with doctors and nurses but often miles from a hospital — are increasing rapidly nationwide. The centers offer convenience to patients and can ease overcrowding in nearby hospital ERs. Yet, they also have spurred questions about their limited services, their ability to decrease the overall burden for area hospitals and their impact on health care spending.

The number of such facilities owned by hospitals or entrepreneurial doctors grew 23% from 2005 to 2006, jumping from 146 to 179, according to an American Hospital Association survey. About a dozen more are opening or in the planning stages in states such as Florida, Minnesota and Texas.

In September, a group of Houston doctors opened one in a shopping center next to a popular Mexican restaurant. It boasts posh waiting areas, wireless access and free coffee.

Another, owned by Mount Sinai Medical Center in Aventura, Fla., opened in January about a mile from rival Aventura Hospital and Medical Center.

The growth of stand-alone emergency departments comes amid continued overcrowding in hospital ERs and stiff competition among hospitals to expand their business in fast-growing suburbs.

The free-standing centers, open around the clock, often offer shorter wait times than hospital-based departments and can treat a variety of illnesses and problems, such as fevers, broken bones and serious cuts.

Yet, some experts, such as health care consultant Jim Unland, say that stand-alone ERs also can siphon patients with minor ailments away from lower-cost urgent care centers or doctors' offices, increasing costs to insurers and consumers. Urgent care centers differ from free-standing ERs because they usually are not open 24 hours and don't have the same level of high-tech equipment.

Ambulances generally won't bring the most critically ill to the stand-alone centers, including trauma patients and those having strokes or heart attacks. In Miami, ambulances won't bring patients to stand-alone ERs at all.

Patients who arrive on their own — the majority at most ERs — and need surgery or cardiac procedures must be rushed by ambulance to hospitals, a potential delay in treatment that worries some emergency service providers.

"We only transport to hospitals," says Elizabeth Calzadilla-Fiallo, spokeswoman for the Miami-Dade County Fire Rescue Department, which refuses to take patients to a newly opened center there. "If we transport to a stand-alone, and the patient actually needs more than the stand-alone can provide, you're compromising care."

Jepson and others say the centers provide the same high-level care given at hospital-based ERs and can handle just about any emergency, rapidly stabilizing patients, then sending them to a hospital for further treatment.

Heart attack patients who walk into the Germantown facility, for example, can be assessed quickly and sent by ambulance to the center's parent hospital, Jepson says.

Maryland lawmakers allowed the new center, which opened in 2006, after much debate. They're studying it and one other pilot project before deciding whether to permit more. In Florida, where there are at least four stand-alone centers, lawmakers adopted a moratorium on new facilities in 2007. Gov. Charlie Crist then vetoed the legislation.

"A lot of states are looking at them, partly out of fear that there is something less safe about them," says Juliet Rogers of Karlsberger Health Care Consulting Group in Ann Arbor, Mich. "These actually fill a need, but they are definitely controversial."

For the rest of the article, please visit:
http://www.usatoday.com/news/health/2008-04-24-emergency-rooms-stand-alone_N.htm

Lit Bits: May 3, 2008

From the recent medical literature...

1. What is the placebo worth? The doctor-patient relationship is a crucial part of its value

Spiegel D, Harrington A. BMJ 2008;336:967-968.

George Bernard Shaw described a miracle as "an event that creates faith." Belief is a powerful tool, and many factors influence it. A recent study testing pain relief from analgesics showed that merely telling people that a novel form of codeine they were taking (actually a placebo) was worth $2.50 (£1.25; 1.58) rather than 10 cents increased the proportion of people who reported pain relief from 61% to 85.4%. When the "price" of the placebo was reduced, so was the pain relief. A meta-analysis of decades of clinical trials proposed that the placebo effect was more hype than reality. However, the resulting backlash against it has had the implicit effect of clarifying what is best practice with regard to the placebo.

Hovering over much of the research is a practical question for clinicians—what does all this mean for patient care? In the accompanying randomised controlled trial, Kaptchuk and colleagues undertake a dismantling approach to the examination of placebo effects.4 In 262 adults with irritable bowel syndrome, they examined the effects of placebo acupuncture in circumstances that involved observation only (evaluating a "Hawthorne effect"), sham acupuncture alone, and an enriched relationship with the treating doctor along with the sham procedure. The proportion of patients who reported moderate or substantial improvement on the irritable bowel syndrome global improvement scale was 3% in the observation group, 20% in the procedure alone group, and 37% in the augmented intervention group (P less than 0.001 for trend).

Clearly the group with the greatest relief of symptoms was the one that received not only sham acupuncture but 45 minutes of quality contact with a clinician. This contact involved questions about the patient’s symptoms and beliefs about them, a "warm, friendly manner," empathy, and communication of confidence and positive expectations. In contrast, the doctor-patient relationship in the sham acupuncture only group sounds like a caricature of procedure based medicine practised under strict time limitations: the practitioners explained that this was "a scientific study" and they had been instructed not to talk about it with patients.

Global improvement scores were higher and quality of life and amelioration in symptom severity were almost doubled in people receiving augmented care, which raises some interesting questions. Perhaps the ratcheting down of the time that doctors spend with patients and our modern overemphasis on drugs and procedures is "penny wise and pound foolish." Patients might respond better to real as well as placebo interventions if they were associated with a good doctor-patient relationship. Although the increased time and concern may enhance the effects of the placebo, it also changes the context of associations with the treatment—the doctor may enhance the effect of the sham needle, but the needle also becomes a reminder of the enriched relationship.

That this study chose to evaluate placebo effects associated with an unconventional treatment raises further interesting questions. It is already widely assumed by sceptics that most if not all of the benefit of "alternative" or integrative medicine comes from the placebo effect. It is then assumed that demonstration of a powerful placebo effect, without proving a specific effect, is enough to consign the treatment to the realm of quackery.

But what if we asked a different question? Is it possible that the alternative medical community has tended historically to understand something important about the experience of illness and the ritual of doctor-patient interactions that the rest of medicine might do well to hear? Many people may be drawn to alternative practitioners because of the holistic concern for their wellbeing they are likely to experience, and many may also experience appreciable placebo responses. Why shouldn’t we try to understand what alternative practitioners know and do, as this may help explain why so many patients are prepared to pay to be treated by them, even when many of the treatments are unproven?

In seeking such understanding we should think about the conditions for which patients often seek alternative treatment, and what that might teach us. Patients with irritable bowel syndrome have a chronic condition that can deeply affect their quality of life. They usually have a story to tell about their suffering and want it to be heard, and an empathetic ear may be just what they need. Both the emotional and physical needs of a patient needing emergency surgery, however, might be very different. Such patients might well have a strong placebo response to a calm, orderly, high-tech hospital environment and a kind but focused doctor who does not stop long to chat but instead brings his or her full attention to the pressing business at hand.

Whatever the specifics, the take home message is clear. We treat patients in a social and psychophysiological context that can either improve or, alas, worsen outcome. The meanings and expectations created by the interactions of doctors and patients matter physically, not just subjectively. Recent brain imaging research on pain and the placebo effect has shown functional connectivity between specific brain regions that process attention (the anterior cingulate gyrus) and pain (periaqueductal grey), involving endogenous opiate receptors. Techniques such as hypnosis improve a range of objective symptoms of irritable bowel syndrome and produce subjective reductions in distress. The word "placebo" is Latin for "I will please." On the basis of these and related studies, it seems fair to conclude that a good doctor-patient relationship can tangibly improve patients’ responses to treatment, placebo or otherwise.

2. Removable Splints May Be as Good as Casts for Minor Wrist Fractures in Children

Anthony J. Brown, MD. April 25, 2008 — A review of trial data suggests that removable splints offer a more tolerable, but equally effective alternative to casts in treating minor fractures of the wrist in children.

A review of 10 randomized or quasi-randomized trials involving 827 children suggests that removable splints, either plastic or plaster, generally keep the fractures aligned as well as casts, but with greater comfort and less restriction, allowing children to bathe and participate in other activities.

The findings, which appear in the April 16th online issue of The Cochrane Library, also suggest that above-elbow casts are no better than less-restrictive below-elbow casts. Arm position in above-elbow casts had no effect on the risk of deformity, according to the results of one trial.

Percutaneous wire fixation helps prevent fracture redisplacement, three trials found, but it is unclear if this intervention actually improves function.

"There are minor, or buckle, fractures of the wrist, particularly in toddlers and preschool infants, which are currently being over-treated with a plaster cast and clinical follow-up," lead author Dr. Alwyn Abraham, an orthopedic surgeon with Leicester Royal Infirmary in the UK, said in a statement. "Provided these are accurately diagnosed in an emergency department, these minor fractures can be treated with a removable splint. Removal can be done at home with no further follow-up."

However, according to Dr. Leon Benson, spokesman for the American Academy of Orthopaedic Surgeons, the ability to remove these splints, which makes them more comfortable and may help patients avoid a clinic visit, is also their biggest problem.

"Yes, you can treat a child's buckle fracture with a splint, but I don't," Dr. Benson said in a statement. "In my experience, a child under 10 is not going to keep a splint on, and who is going to take responsibility for that fact — the doctor? And, given that fact, what parent wants to sit on pins and needles waiting for it to happen when a safe plaster casts insures it won't?"

Cochrane Database Syst Rev. Published online April 16, 2008.

3. Is Screening Radiography Necessary to Detect Retained Foreign Bodies in Adequately Explored Superficial Glass-Caused Wounds?

Weinberger LN, et al. Ann Emerg Med. 2008;51:666-667.

The Bottom Line

According to the available evidence, from 0.6% to 4.3% of superficial wounds have retained foreign body detected by radiography after adequate exploration or visualization. Because there is no standard definition of what constitutes a superficial wound, physician discretion is advised to make this determination. If a 4% miss rate would not be acceptable in your practice environment, then all glass-caused wounds, including superficial wounds that may be adequately explored and completely visualized, require routine radiography. Particular caution should be exercised in wounds with foreign body sensation, with head or foot location, and caused by motor vehicle collision or puncture because these may be associated with retained foreign body. Because wounds are a common cause for malpractice litigation in emergency medicine, a large prospective trial with standardized, well-defined variables would be needed to more definitively answer this question.

4. Legislation would require California hospitals to frequently assess conditions of EDs

Source: The American College of Emergency Physicians (http://www.acep.org)

Date: April 07, 2008. California's Daily Breeze (4/8, Evans) reports that State Assemblyman Ted Lieu (D-El Segundo) has introduced "Assembly Bill 2207, [which] would require hospitals to assess the condition of their" emergency departments (EDs) "every three hours, and take corrective measures immediately." Should the ED be "full, the hospital would have to move patients into other areas of its facility until conditions improve." Under the legislation, "[h]ospitals would also be allowed to move patient beds into hallways, a practice that is currently allowed only under the most extreme crowding conditions." Dr. Irv Edwards, former president of the American College of Emergency Physicians, said that EDs "have become makeshift holding wards for patients who often wait hours to be moved or treated, which further compounds crowding."

For more information, please visit: http://www.dailybreeze.com/ci_8846706

5. Role of Bedside Transvaginal Ultrasonography in the Diagnosis of Tubo-ovarian Abscess in the ED

Adhikari S, et al. J Emerg Med 2008;34:429-433.

Tubo-ovarian Abscess (TOA) is a complication of pelvic inflammatory disease (PID) requiring admission, i.v. antibiotics and, possibly, aspiration or surgery. The purpose of this study was to describe the role of emergency department (ED) bedside transvaginal ultrasonography (US) in the diagnosis of TOA.

This was a retrospective review of non-pregnant ED patients presenting with pelvic pain who were diagnosed with TOA using bedside transvaginal US. ED US examinations were performed by emergency medicine residents and ultrasound-credentialed attending physicians within 1 h after clinical assessment. ED US logs were reviewed for the diagnosis of TOA. Medical records were reviewed for risk factors, medical and sexual history, physical examination findings, laboratory results, additional diagnostic testing, hospital course, and a discharge diagnosis of TOA by the admitting gynecology service.

A total of 20 patients with TOA were identified over a 3-year period. Ages ranged from 14 to 45 years (mean 27 years). Seven (35%) patients reported a prior history of PID or sexually transmitted disease, and 1 (5%) was febrile. All had lower abdominal tenderness and 9 (45%) had cervical motion or adnexal tenderness. The sonographic abnormalities included 14 (70%) with a complex adnexal mass, 5 (25%) with echogenic fluid in the cul-de-sac, and 3 (15%) patients with pyosalpinx. The discharge diagnosis was TOA by the admitting gynecology service for all patients.

Our study illustrates the limitations of clinical criteria in diagnosing TOA and supports the use of bedside US when evaluating patients with pelvic pain and symptoms that do not meet classic Centers for Disease Control and Prevention criteria for PID.

6. Physician Clinical Impression Does Not Rule Out Spontaneous Bacterial Peritonitis in Patients Undergoing ED Paracentesis

Chinnock, et al. Ann Emerg Med. 2008; in press.

Clinical bottom line: Peritoneal fluid analysis should be done routinely after all ED paracentesis because detection of spontaneous bacterial peritonitis by clinical means is poor and the incidence is significant.

Introduction
Diagnostic paracentesis is an important emergency department (ED) procedure in evaluating for spontaneous bacterial peritonitis in the patient with ascites. In addition, therapeutic paracentesis is a mainstay of treatment for ameliorating the discomfort associated with large-volume ascites. Although many patients have their therapeutic paracentesis performed in a scheduled outpatient clinic setting, an increasingly large number of patients without access to primary or specialty care are coming to the ED for therapeutic paracentesis. In the outpatient clinic ED setting, 2 studies examining asymptomatic patients presenting for a therapeutic paracentesis showed a combined 2.5% incidence of spontaneous bacterial peritonitis (defined as absolute neutrophil count over 250 cells/mm3) in 545 patients. This low incidence of spontaneous bacterial peritonitis in the outpatient setting contrasts with that observed in the hospitalized patient.

Studies have demonstrated a 12% incidence of spontaneous bacterial peritonitis in patients admitted with decompensated cirrhosis and an 18% incidence in patients admitted with hepatic encephalopathy. It is unknown where the ED patient presenting for paracentesis fits in this spectrum; therefore, the role of routine ascites fluid analysis for spontaneous bacterial peritonitis in the ED patient is less clear. Because mortality is 20% even in treated spontaneous bacterial peritonitis patients, it is important not to miss the diagnosis. To our knowledge, no studies exist that examine which patients who present to the ED might be safe candidates for therapeutic paracentesis without ascites fluid analysis. The aim of this study, therefore, is to prospectively determine whether patient clinical characteristics or physician assessment of likelihood of spontaneous bacterial peritonitis is highly sensitive for the detection of spontaneous bacterial peritonitis and thus could reliably rule out spontaneous bacterial peritonitis in the ascites patient.

Methods
We conducted a prospective, observational study of ED patients with ascites undergoing paracentesis. Predefined clinical characteristics including historical features and ED vital signs were recorded. Each patient was assessed by 2 separate, blinded physicians for severity of abdominal tenderness and overall clinical suspicion for spontaneous bacterial peritonitis. The primary outcome measures were sensitivity, specificity, and likelihood ratios (LR) of the individual clinical characteristics and the physician assessments. Spontaneous bacterial peritonitis was defined by absolute neutrophil count greater than 250 cells/mm3 or positive fluid culture result.

Results
There were 285 separate physician assessments in 144 patients enrolled with complete data. Spontaneous bacterial peritonitis was diagnosed in 17 (11.8%) patients. Physician clinical impression had a sensitivity of 76% (95% confidence interval [CI] 62% to 91%) and specificity of 34% (95% CI 28% to 40%) for the detection of spontaneous bacterial peritonitis. The lowest negative LR was associated with the presence of any abdominal pain or tenderness (negative LR=0.4); however, the presence of pain/tenderness was also observed in 85% of patients without spontaneous bacterial peritonitis. Six patients (4.2%) with spontaneous bacterial peritonitis had at least 1 physician assessment of little to no risk for spontaneous bacterial peritonitis, and 3 of the 6 subsequently died during their hospitalization.

Conclusion
Clinical characteristics and physician assessment were insufficient in the diagnosis or exclusion of spontaneous bacterial peritonitis in the ED patient undergoing diagnostic or therapeutic paracentesis. This finding supports routine laboratory fluid analysis after ED paracentesis.

7. Absorbable Sutures for Repair of Pediatric Facial Lacerations

Cosmetic outcomes with absorbable sutures are similar to those with nonabsorbable sutures.

Absorbable sutures offer several advantages over nonabsorbable sutures — including ease of use, less skin reactivity, and lower cost — but their use in children has not been well studied. In a prospective, randomized trial, researchers compared the two types of sutures for repair of acute pediatric facial lacerations of 1 to 5 cm. Patients were excluded if the lacerations had irregular borders, resulted from mammalian bites, were contaminated, occurred more than 8 hours before presentation, or could be repaired with a topical adhesive.

Children (age range, 1–18 years) were randomized to wound closure with either 5–0 or 6–0 fast-absorbing surgical gut or nonabsorbable nylon. At 3-month follow-up, wounds were photographed, and three pediatric emergency physicians who were blinded to group assignment assessed cosmetic appearance (the primary outcome) using a 100-mm continuous cosmesis visual analog scale (VAS; with a score of 100 representing the best scar). A between-group difference of 15 mm was defined as being clinically important. Wounds were assessed at 5 to 7 days for infection (defined as requirement for systemic antibiotics) and dehiscence (defined as requirement for additional sutures).

Overall, 23 of 49 patients in the absorbable-suture group and 24 of 39 in the nonabsorbable-suture group completed the study. Baseline demographic and wound characteristics were similar between the two groups and between patients who did and did not complete follow-up. At 3 months, mean VAS scores between the absorbable-suture and nonabsorbable-suture groups differed by only 1.4 mm (92.3 mm and 93.7 mm). Correlation among the blinded observers was good (r=0.42). Two patients, both in the absorbable-suture group, had wound dehiscence. No wound infections occurred.

Comment: The study fell short of its target sample size of 27 patients in each group completing the study; thus, it did not have adequate power to detect a true difference in primary outcome. However, that the two suture strategies are equivalent is very likely, at least for highly vascular facial wounds. Absorbable sutures do not require subsequent visits for removal, and fears that they might increase wound inflammation seem to be unfounded. EPs should consider absorbable sutures to be a reasonable option for repair of pediatric facial lacerations that are not amenable to topical adhesives.

— Jill M. Baren, MD. Published in Journal Watch EM April 25, 2008. Citation: Luck RP et al. Pediatr Emerg Care 2008;24:137.

8. Nesiritide: A Costly Placebo for Decompensated HF Patients

Acutely Decompensated Heart Failure in a County ED: A Double-Blind Randomized Controlled Comparison of Nesiritide Versus Placebo Treatment

Miller AH, et al. Ann Emerg Med 2008;51: 571-578.

Conclusion: Administration of nesiritide for acutely decompensated congestive heart failure in a county ED was no better than standard therapy alone for return to the ED or hospitalization at 30 days.

Abstract: http://www.annemergmed.com/article/S0196-0644(07)01852-5/abstract

9. Glucose Monitoring: Not Productive?

Self-monitoring of glucose levels in type 2 diabetes fails on two counts: It has no effect on clinical outcomes, and it lowers quality of life, according to two BMJ studies.

One study comprised nearly 200 people with newly diagnosed disease not requiring insulin. They were randomized either to glucose monitoring or no monitoring. After a year, the groups showed no differences in glycated hemoglobin or self-reported hypoglycemic episodes. Depression scores were higher among the monitored group, however.

The second study evaluated cost data from some 450 patients randomized either to standard care, or to "less intensive" self-monitoring, or to "more intensive" monitoring. After a year, costs were significantly higher in the monitored groups, and quality-of-life scores were lower. Clinical outcomes did not differ among groups.

An editorialist, citing the axiom that interventions should be tested before introduction to practice, writes: "Self-monitoring of blood glucose in type 2 diabetes provides an example of the difficulties that arise if this principle is not followed."

BMJ article on clinical efficacy of glucose monitoring (Free): http://www.bmj.com/cgi/content/full/bmj.39534.571644.BE
BMJ article on cost effectiveness of glucose monitoring (Free): http://www.bmj.com/cgi/content/full/bmj.39526.674873.BE

10. Am I Passing MRSA to My Patients?

A literature review finds that healthcare workers play a role in MRSA transmission, and the authors make screening recommendations.

Methicillin-resistant Staphylococcus aureus (MRSA) has become ubiquitous in emergency departments, but the role of healthcare workers in its transmission is unclear. To assess likelihood of MRSA colonization, infection, and transmission among healthcare workers, researchers performed a comprehensive literature search and identified 127 investigations involving 33,318 screened healthcare workers.

Only 18 studies failed to detect MRSA in healthcare workers. Inadequate hand-washing, chronic skin diseases, and having worked in countries with endemic MRSA were identified as risk factors for MRSA carriage. The overall MRSA carriage rate was 4.6%, and most colonization was on the hands or in the nasopharynx of affected healthcare workers. Of these carriers, 5.1% had clinical infections. Healthcare-worker transmission of MRSA to patients was deemed likely in 63 of 68 studies (93%) that performed genotyping. Transmission occurred from both transiently and persistently colonized workers. Eight studies documented transmission to workers’ family members. According to data from one systematic review, nasal mupirocin led to MRSA eradication in 91% of 143 treated workers within 48 to 96 hours.

Although acknowledging that the cost might be prohibitive, the authors recommend healthcare-worker screening, especially for all staff during outbreak investigations, for all new employees, and for all staff on high-risk units (e.g., intensive care units, burn units, and surgical wards). In cases of eradication failure or frequent relapses, the authors recommend testing household contacts (including pets) and home environments.

Comment: Not only can we become colonized or infected with MRSA from our patients, but also we can infect them and even become the source of community MRSA clusters. Healthcare personnel have an essential responsibility for meticulous attention to hand hygiene before and after every patient contact and proper adherence to contact precautions. Both are critical to stopping the rampant spread of MRSA.

— Kristi L. Koenig, MD. Published in Journal Watch EM April 18, 2008. Citation: Albrich WC and Harbarth S. Lancet Infect Dis 2008;8:289.

11. Serum D-Dimer is a Sensitive Test for the Detection of Acute Aortic Dissection: A Pooled Meta-Analysis

Marill KA. J Emerg Med. 2008;34:367-376.

Acute aortic dissection is a rare but devastating condition with high mortality. Unfortunately, there is no sensitive screening indicator of disease in common use. The objective of this study was to assess the sensitivity and utility of the serum D-dimer as a test for acute aortic dissection.
A pooled analysis was performed of all original research studies testing the sensitivity of serum D-dimer for acute aortic dissection. A search of MEDLINE, EMBASE, and the Cochrane Register using the terms “aortic dissection” and “d-dimer” was made of all English language publications. All original reports of consecutively enrolled patients with acute aortic dissection and a measured serum D-dimer were included. Case reports were excluded. A value of 0.5 microgram per milliliter was defined as the threshold for a positive D-dimer. The primary outcome was the pooled sensitivity of the D-dimer test for acute aortic dissection.

There were 21 original reports of patients with acute aortic dissection and D-dimer measurements. Eleven studies were included and a total of 349 acute aortic dissection patients were described. The sensitivity of the D-dimer test was 327/349, 94% (95% confidence interval 91–96), and the point estimate was essentially unchanged in a sensitivity analysis, 183/192, 95% (95% confidence interval 91–98). Specificity ranged from 40% to 100%.

Serum D-dimer is sensitive for acute aortic dissection and potentially represents a useful test for patients who present with a low likelihood of this disease.

12. Bacteremia in Previously Hospitalized Patients: Prolonged Effect From Previous Hospitalization and Risk Factors for Antimicrobial-Resistant Bacterial Infections

Chen SY, et al. Ann Emerg Med. 2008;51:639-646.

Study objective
Patients who came from the community but were recently discharged from the hospital have a higher risk of contracting antimicrobial-resistant bacterial infections. Our objectives are to determine the time from previous hospital discharge that affects subsequent antimicrobial susceptibility pattern and risk factors for antimicrobial-resistant infection in bacteremia in recently discharged patients.

Methods
Excluding patients of hospital-acquired, patients with regular health care–associated exposure, and patients whose previous hospitalization was not at our hospital, a total of 789 nonduplicated bacteremia episodes from community adult patients were enrolled in a 1-year study period. Antimicrobial-resistant bacteria, including multidrug-resistant Gram-negative bacilli, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci causing bacteremia, were logistically analyzed according to different posthospitalization periods (3 to 90 days, 91 to 180 days, 181 to 360 days, and no hospitalization in the past 360 days) to identify the independent effect from previous hospitalization on subsequent antimicrobial-resistant bacteremia.

Results
Of the 789 bacteremia patients, the proportion of antimicrobial-resistant bacteremia is 14.6% (95% confidence interval [CI] 9.8% to 19.4%) for 3 to 90 days, 9.6% (95% CI 1.6% to 17.6%) for 91 to 180 days, and 6.4% (95% CI 0% to 13.4%) for 181 to 360 days since last hospitalization and 1.0% (95% CI 0.1% to 1.9%) for no hospitalization within the last 360 days. Risk of antimicrobial-resistant bacteremia decreased monthly after discharge by an odds ratio of 0.83 (95% CI 0.76 to 0.90) (P less than 0.01). Previous carriage of antimicrobial-resistant bacteria in the past 360 days and previous stay at ICU in the past 180 days were independent risk factors for antimicrobial-resistant bacteremia in previously hospitalized patients.

Conclusion
Previous hospitalization affects the antimicrobial susceptibility of subsequent bacteremia up to 360 days after hospital discharge. Presence of risk factors for antimicrobial-resistant bacteremia in previously hospitalized patients may help emergency physicians in selecting empirical antimicrobial agents and prompting infection control precautions.

13. A Decision Rule for Predicting Bacterial Meningitis in Children with Cerebrospinal Fluid Pleocytosis When Gram Stain Is Negative or Unavailable

Bonsu BK, et al. Acad Emerg Med. 2008;15:437-444.

Objectives: Among children with cerebrospinal fluid (CSF) pleocytosis, the task of separating aseptic from bacterial meningitis is hampered when the CSF Gram stain result is unavailable, delayed, or negative. In this study, the authors derive and validate a clinical decision rule for use in this setting.

Methods: This was a review of peripheral blood and CSF test results from 78 children (less than 19 years) presenting to Children’s Hospital Columbus from 1998 to 2002. For those with a CSF leukocyte count of more than 7/μL, a rule was created for separating bacterial from viral meningitis that was based on routine laboratory tests, but excluded Gram stain. The rule was validated in 158 subjects seen at the same site (Columbus, 2002–2004) and in 871 subjects selected from a separate site (Boston, 1993–1999).

Results: One point each (maximum, 6 points) was assigned for leukocytes above 597/μL, neutrophils above 74%, glucose below 38 mg/dL, and protein above 97 mg/dL in CSF and for leukocytes above 17,000/mL and bands to neutrophils above 11% in peripheral blood. Areas under receiver-operator-characteristic curves (AROCs) for the resultant score were 0.98 for the derivation set and 0.90 and 0.97, respectively, for validation sets from Columbus and Boston. Sensitivity and specificity pairs for the Boston data set were 100 and 44%, respectively, at a score of 0 and 97 and 81% at a score of 1. Likelihood ratios (LRs) increased from 0 at a score of 0 to 40 at a score of 4 or more.

Conclusions: Among children with CSF pleocytosis, a prediction score based on common tests of CSF and peripheral blood and intended for children with unavailable, negative, or delayed CSF Gram stain results has value for diagnosing bacterial meningitis.

14. Neurosurgical Consultation: A Must for Suspected CSF Shunt Malfunction

The shunt series and CT scanning have low sensitivity for detecting shunt malfunction.

Mater A, et al. CJEM 2008;10:131-5

Objective: Cerebrospinal fluid (CSF) shunt malfunction is one of the most common life-threatening neurosurgical conditions. In the emergency department (ED), imaging techniques to identify shunt malfunction include the shunt series (SS) and CT scanning of the head. We sought to determine the test characteristics of the SS and CT scan for identifying children with shunt malfunction.

Methods: We retrospectively reviewed the medical records of children with a CSF shunt who presented to our tertiary care pediatric emergency department and received an SS during a 2-year period from Jan. 1, 2001, to Dec. 31, 2002. A pediatric neuroradiologist reviewed all SS and CT scans. We defined shunt malfunction as present if the child underwent operative shunt revision.

Results: We identified 437 ED visits by 280 children. Forty-seven SS were read as abnormal. A CT scan was performed in 386 (88.3%) cases and 80 were abnormal. Shunt malfunction was identified in 131 (30.0%) children. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio of the SS for identifying cases of shunt malfunction were 30.0%, 95.8%, 72.3%, 75.1%, 7.1 and 0.7, respectively; for the CT scan, they were 61.0%, 82.7%, 64.5%, 80.5%, 3.5 and 0.5, respectively.

Conclusion : La sensitivité de la neuroimagerie est faible quand il s'agit de diagnostiquer un dysfonctionnement de shunt. Une consultation neurochirurgicale est nécessaire si l'on soupçonne cliniquement un tel dysfonctionnement, malgré les résultats normaux de l'imagerie.

Or if you prefer English: Neuroimaging has a low sensitivity for identifying shunt malfunction. Neurosurgical consultation should be sought if shunt malfunction is clinically suspected, despite normal imaging.

15. Are racial disparities in ED analgesia improving? Yes!

Quazi S, et al. Amer J Emerg Med. 2008;26:462-464.

Objective
Ethnic disparities in emergency department (ED) analgesic use have been noted previously; the purpose of this study was to determine if current ED practice has been altered subsequent to the widespread recognition of these inequalities.

Methods
Using data from the National Hospital Ambulatory Care Survey, we analyzed ED analgesic treatment with respect to race for the complaints of headache (HA) and long bone fractures (LBF) for 1995 to 1999 (period A) and compared that with data for 2000 to 2003 (period B). We compared the use of “any analgesics” and “opioids” among blacks, whites, and Hispanics.

Results
For both HA and LBF, improvements over time were noted in all 3 ethnic subgroups. A statistically significant increase was documented in the treatment of HA among Hispanics using any analgesia (71.3% vs 80.8%, P = .011). Although individual differences between the 2 periods in the LBF cohort were not statistically significant for any of the 3 ethnic groups, there was an overall improvement noted when combining all ethnicities: among all patients treated for LBF, 66% received some analgesic and 42.8% received opioid analgesia during period A vs 75% and 51%, respectively, during period B (all P < .001). Furthermore, in the latest study period, there were no differences in the frequency of analgesic administration for LBF with respect to race (blacks, 43%; whites, 48%; Hispanics, 43.8%; P > .1).

Conclusion
There is evidence that previously described racial inequalities in analgesic use have decreased over time.

16. Inadequate provision of postintubation anxiolysis and analgesia in the ED

Bonomo JB, et al. Amer J Emerg Med. 2008;26:469-472.

Introduction
Patients intubated in the emergency department (ED) often have extended ED stays. We hypothesize that ED intubated patients receive inadequate postintubation anxiolysis and analgesia after rapid sequence induction (RSI).

Methods
This was a retrospective cohort study of every adult intubated in a tertiary-care ED (July 2003-June 2004). Patients were included if they underwent RSI, remained in the ED for more than 30 minutes post intubation, and survived to admission. Presuming a mean patient weight of 70 kg, we defined adequacy of anxiolysis and analgesia on the provision postintubation of weight-based doses of lorazepam (0.77 mg/h) or midazolam (4.2 mg/h) and fentanyl (35 μg/h), referenced from pharmaceutical texts. Demographic data, time in ED, and dosage of each medication given were abstracted. The proportion, with 95% confidence intervals (CIs), of patients receiving inadequate anxiolysis and analgesia were computed.

Results
One hundred seventeen patients met the inclusion criteria. Mean time in the ED was 4.2 hours (SD ± 3.1 hours). Thirty-nine patients received no anxiolytic (33%, CI 25%-43%), and 62 received no analgesic (53%, CI 44%-62%). Twenty-three patients received neither anxiolytic nor analgesic (20%, CI 13%-28%). Of 70 patients given postintubation vecuronium, 67 received either no or inadequate anxiolysis or analgesia (96%, CI 87%-99%). Overall, 87 of 117 patients received no or inadequate anxiolysis (74%, CI 65%-82%); and 88 of 117 received no or inadequate analgesia (75%, CI 66%-83%).

Conclusion
Patients undergoing RSI in the ED frequently receive inadequate postintubation anxiolysis and analgesia.

17. Evidence Behind the 4-Hour Rule for Initiation of Antibiotic Therapy in Community-Acquired Pneumonia

Yu KT, et al. Ann Emerg Med. 2008;51: 651-662.e2.

Study objective
US regulatory authorities mandate delivery of antibiotics within 4 hours of arrival for patients being admitted to the hospital with community-acquired pneumonia. This evidence-based emergency medicine review examines the scientific evidence pertaining to this requirement.

Methods
We searched MEDLINE, EMBASE, the Cochrane Library, other databases, and bibliographies. We selected articles allowing comparison of inpatient or 30-day mortality among patients receiving early versus delayed antibiotics. We prospectively categorized studies according to whether they were retrospective or prospective and whether they adjusted for severity with the Pneumonia Severity Index. We evaluated the precision with which the interval to initiation of antibiotic therapy was defined and the compliance of retrospective studies with standard reporting criteria for chart reviews.

Results
We identified 13 observational studies reporting comparative outcomes in patients receiving early versus delayed antibiotic initiation, of which 10 allowed calculation of our primary outcome. Of the 4 prospective studies, 1 allowed severity adjustment using the Pneumonia Severity Index score. Among the retrospective studies, definition of time to antibiotic therapy was frequently imprecisely defined, and compliance with standard reporting criteria for chart review was scanty in the subgroup lacking severity adjustment. Odds ratios (ORs) for mortality varied widely. One methodologically weak study reported a large benefit of early antibiotics (OR for mortality antibiotics within 4 hours versus greater than 4 hours 0.24; 95% confidence interval [CI] 0.08 to 0.71). The one study that used prospective enrollment and severity adjustment using the Pneumonia Severity Index observed a contrary result (adjusted OR for mortality, antibiotics within 4 hours versus greater than 4 hours 1.99; 95% CI 1.22 to 13.45). Results from studies reporting an 8-hour cutoff also varied in magnitude and direction of effect.

Conclusion
Evidence from observational studies fails to confirm decreased mortality with early administration of antibiotics in stable patients with community-acquired pneumonia. Although timely administration of antibiotics to patients with confirmed community-acquired pneumonia should be encouraged, an inflated sense of priority of the 4-hour time frame is not justified by the evidence.

18. The Anatomic Relationship of Femoral Vein to Femoral Artery in Euvolemic Pediatric Patients by Ultrasonography: Implications for Pediatric Femoral Central Venous Access

Warkentine FH, et al. Acad Emerg Med. 2008;15:426-430.

Background: Knowledge of the femoral vein (FV) anatomy in pediatric patients is important in the selection of appropriate size central line catheters as well as the approach to central venous access. This knowledge may avoid potential complications during central line access.

Objectives: To describe the relationship of the FV to the femoral artery (FA). To measure FV diameter and FV depth using ultrasonography (US) in newborns, infants, and children up to 9 years of age.

Methods: This study was a prospective descriptive study at a tertiary care children’s hospital. A convenience sample of euvolemic children was enrolled aged 0–9 years presenting to an urban pediatric emergency department. All patients underwent a standardized US evaluation using a Sonosite Titan bedside machine by a single emergency physician. The FA and FV were identified by four criteria: relative positions, FV compressibility, FV enlargement by Valsalva maneuver, and absence of FV pulsatility. The position of the FV relative to the FA was described as being completely overlapped by the FA, having partial (less than 50%) overlap by the FA, and having no overlap by the FA. The FV depth was measured from the skin to the superior border of the vein using the US machine’s caliper function.

Results: A total of 84 patients were studied. The FV was found to be completely overlapped by the FA in 8% of subjects and partially overlapped by the FA in 4% of subjects. The mean FV diameter ranged from 4.5 mm in young infants to 10.8 mm in patients 9 years of age. The mean FV depth ranged from 6.5 mm in neonates to 11.2 mm in patients 9 years of age.

Conclusions: External landmarks were not always predictive of internal anatomy. The FV was completely or partially overlapped by the FA in 12% of cases. Thus, visualization of femoral vessels should be recommended prior to attempting pediatric femoral central venous access.

19. The Impact of Arm Position on the Measurement of Orthostatic Blood Pressure

Guss, DA, et al. J Emerg Med. 2008;34:377-382.

Blood pressure is a standard vital sign in patients evaluated in an Emergency Department. The American Heart Association has recommended a preferred position of the arm and cuff when measuring blood pressure. There is no formal recommendation for arm position when measuring orthostatic blood pressure. The objective of this study was to assess the impact of different arm positions on the measurement of postural changes in blood pressure.

This was a prospective, unblinded, convenience study involving Emergency Department patients with complaints unrelated to cardiovascular instability. Repeated blood pressure measurements were obtained using an automatic non-invasive device with each subject in a supine and standing position and with the arm parallel and perpendicular to the torso. Orthostatic hypotension was defined as a difference of 20 or more mm Hg systolic or 10 or more mm Hg diastolic when subtracting standing from supine measurements. There were four comparisons made: group W, arm perpendicular supine and standing; group X, arm parallel supine and standing; group Y, arm parallel supine and perpendicular standing; and group Z, arm perpendicular supine and parallel standing. There were 100 patients enrolled, 55 men, mean age 44 years. Four blood pressure measurements were obtained on each patient.

The percentage of patients meeting orthostatic hypotension criteria in each group was: W systolic 6% (95% CI 1%, 11%), diastolic 4% (95% CI 0%, 8%), X systolic 8% (95% CI 3%, 13%), diastolic 9% (95% CI 3%, 13%), Y systolic 19% (95% CI 11%, 27%), diastolic 30% (95% CI 21%, 39%), Z systolic 2% (95% CI 0%, 5%), diastolic 2% (95% CI 0%, 5%). Comparison of Group Y vs. X, Z, and W was statistically significant (p less than 0.0001).

Arm position has a significant impact on determination of postural changes in blood pressure. The combination of the arm parallel when supine and perpendicular when standing may significantly overestimate the orthostatic change. Arm position should be held constant in supine and standing positions when assessing for orthostatic change in blood pressure.

20. Do Patients with AMI Benefit from Treatment with Clopidogrel?

Worster A, et al. J Emerg Med. 2008;34:479-483.

Case
A 49-year-old man presents to your Emergency Department with a 2-h history of chest pain upon awakening that morning. The electrocardiogram demonstrates an acute anterior myocardial infarction (MI). The patient is given aspirin and considered for thrombolytic therapy. Percutaneous coronary intervention (PCI) is currently not available at your institution and a transfer will take at least 2 h to complete.

Clinical Question
In this patient with acute anterior MI, would the addition of clopidogrel improve outcomes such as death, recurrent MI, or infarct-related coronary artery occlusion without increasing the risk of major bleeding?

Context
Although clear benefits have been achieved with PCI in acute ST-elevation MI (STEMI), not all Emergency Department patients have access or are eligible. These patients likely have access to fibrinolytic therapy. Approximately 20% of patients treated with fibrinolytic therapy for STEMI will fail to achieve initial adequate reperfusion of the infarct-related coronary artery. This results in a two-fold increase in mortality rates. A three-fold increase in mortality is seen after reocclusion of the artery. Reocclusion occurs in up to 8% of patients during their admission. Platelet activation and aggregation occur after plaque rupture in acute MI and contribute to the formation and growth of the coronary-artery thrombosis. The effectiveness of platelet inhibitors in the treatment of acute MI was first demonstrated in a large-scale clinical trial (ISIS-2) in 1988 using ASA (acetylsalicylic acid). Clopidogrel, an adenosine diphosphate-receptor antagonist, also inhibits the activation and aggregation of platelets. In fact, it has been shown to prevent death and ischemic complications in a variety of patients with coronary artery disease, including patients with symptomatic atherosclerotic disease, with unstable angina, with MI without ST-segment elevation (NSTEMI), and in those who have undergone percutaneous coronary intervention.

Evidence Search
Using PubMed clinical queries, category: therapy, and scope: narrow, the keywords “Clopidogrel Myocardial Infarction Fibrinoly*” were entered and 19 items were displayed. Two clinical trial abstracts (CLARITY and COMMIT) were acquired and appraised.

Conclusion
Physicians should strongly consider the addition of clopidogrel (as well as aspirin) for patients with acute myocardial infarction receiving fibrinolytic therapy as well as those receiving PCI. This makes sense from pathophysiologic and pharmacologic points of view and, most importantly, is supported by these two recent, large, randomized controlled trials demonstrating clinical benefit without a significant increase in adverse events. Because surgeons may be reluctant to take clopidogrel-treated patients to CABG, it would be wise for emergency physicians to fully understand their practice environment preference on this issue.

Commentary by Peter Rosen, MD

Although I appreciate the analysis and conclusions of the authors of this article, I still have some reservations about accepting the conclusions without some caveats. First of all, no evidence is worthwhile until the reader has integrated it into a personal clinical experience. What I mean by this caveat is that each physician has memorable clinical cases that must be used to modify the conclusions that other physicians are trying to promulgate. The conclusions in this article are based in part on a large multicenter study from China [COMMIT]. My experience with multicenter studies in the United States is that there are no two centers whose practices are identical. Therefore, without more knowledge of who runs the intensive care unit and Cardiac Care Unit, how the diagnosis of myocardial infarction is established, and what are the individual hospital complications of the drug, it is hard to compare to US institutions, where the culture and system of care is quite different from China, for example.

Secondly, in the COMMIT study, we are not given a description of variance in the types of myocardial infarction between the study and the control groups. For example, if the study group had a larger incidence of inferior wall infarction, the built-in bias of the population studies would hide a large difference in complications of the therapy.

Thirdly, I remain skeptical about the reported hemorrhagic complication rates. I doubt many cardiovascular surgeons will now believe they do not need to delay CABG for at least 5 days on clopidogrel-treated patients. Furthermore, because the need for CABG is almost always discovered during PCI, a patient who had just received clopidogrel in the Emergency Department would likely not be taken for emergency surgery. Delaying the decision to administer clopidogrel, therefore, to the immediate post-PCI period makes the most sense.

Finally, and this is a criticism of virtually all the reperfusion studies from any country, there is nowhere that one can determine the exact hospital mortality of the myocardial infarction population. We know from studies before reperfusion that inferior wall infarction had, at worst, about a 10% mortality, whereas anterior wall infarctions had a mortality that in some studies approached 50%. All the perfusion studies reported a decrease in mortality, but if the decrease was from 30% to 20% for inferior wall, and from 50% to 40% for anterior, we would want to know why the control mortalities are so high. Similarly, in these studies on platelet inhibition, if the mortalities decrease, but are still higher than untreated infarction patients, perhaps we need to understand whether we are looking at the real parameters of difference.

There is no way to be totally confident of clinical evidence; we must do the best we can to interpret, analyze, and improve our practice. The best approach is still thoughtful analysis measured against true clinical experience.

COMMIT: Chen ZM, Jiang LX, Chen YP, et al. COMMIT (Clopidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005;366:1607–1621.

CLARITY: Sabatine MS, Cannon CP, Gibson CM, et al.. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med. 2005;352:1179–1189.

21. Energy drinks contain dangerous amounts of caffeine

Nagajothi N, et al. Amer J Med. 2008;121:e3-e4.

A 23-year-old woman with no medical history was brought to the hospital for palpitations and chest tightness shortly after consuming a GNC Speed Shot and a Mountain Dew.

On arrival, she looked anxious with a blood pressure of 120/55 mm Hg and heart rate of 219 beats/min. Physical examination and laboratory workup were unremarkable. Her electrocardiogram showed a narrow complex tachycardia with a ventricular rate of 219 beats/min. Carotid sinus massage and Valsalva maneuvers were unsuccessful in terminating the tachycardia. On administration of 6 mg of adenosine by rapid intravenous push, she converted to normal sinus rhythm.

Many "energy drinks" contain excessive amounts of caffeine, sometimes several times the amount contained in a cup of coffee. It is important for the public to be more aware of the potential adverse effects of these energy drinks, alone or in combination with other caffeine-containing products, because fatal and serious events have been reported.

Full-text: http://www.amjmed.com/article/S0002-9343(07)01186-2/fulltext