Wednesday, October 29, 2008

Lit Bits: Oct 29, 2008

From the recent medical literature...

1. Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke

Hacke W, et al. N Engl J Med. 2008;359:1317-1329.

Background: Intravenous thrombolysis with alteplase is the only approved treatment for acute ischemic stroke, but its efficacy and safety when administered more than 3 hours after the onset of symptoms have not been established. We tested the efficacy and safety of alteplase administered between 3 and 4.5 hours after the onset of a stroke.

Methods: After exclusion of patients with a brain hemorrhage or major infarction, as detected on a computed tomographic scan, we randomly assigned patients with acute ischemic stroke in a 1:1 double-blind fashion to receive treatment with intravenous alteplase (0.9 mg per kilogram of body weight) or placebo. The primary end point was disability at 90 days, dichotomized as a favorable outcome (a score of 0 or 1 on the modified Rankin scale, which has a range of 0 to 6, with 0 indicating no symptoms at all and 6 indicating death) or an unfavorable outcome (a score of 2 to 6 on the modified Rankin scale). The secondary end point was a global outcome analysis of four neurologic and disability scores combined. Safety end points included death, symptomatic intracranial hemorrhage, and other serious adverse events.

Results: We enrolled a total of 821 patients in the study and randomly assigned 418 to the alteplase group and 403 to the placebo group. The median time for the administration of alteplase was 3 hours 59 minutes. More patients had a favorable outcome with alteplase than with placebo (52.4% vs. 45.2%; odds ratio, 1.34; 95% confidence interval [CI], 1.02 to 1.76; P=0.04). In the global analysis, the outcome was also improved with alteplase as compared with placebo (odds ratio, 1.28; 95% CI, 1.00 to 1.65; P less than 0.05). The incidence of intracranial hemorrhage was higher with alteplase than with placebo (for any intracranial hemorrhage, 27.0% vs. 17.6%; P=0.001; for symptomatic intracranial hemorrhage, 2.4% vs. 0.2%; P=0.008). Mortality did not differ significantly between the alteplase and placebo groups (7.7% and 8.4%, respectively; P=0.68). There was no significant difference in the rate of other serious adverse events.

Conclusions: As compared with placebo, intravenous alteplase administered between 3 and 4.5 hours after the onset of symptoms significantly improved clinical outcomes in patients with acute ischemic stroke; alteplase was more frequently associated with symptomatic intracranial hemorrhage.

Related Medscape Articles:

ECASS 3: Thrombolysis Beneficial Up to 4.5 Hours After Acute Ischemic Stroke

A Long, Difficult Path

In an editorial accompanying the article, Patrick Lyden, MD, from the University of California, San Diego, points out that the results of ECASS 3, like the National Institute for Neurological Disorders and Stroke trial that established the efficacy of tPA in stroke treatment, was robust across multiple endpoints, and showed efficacy for treatment despite an increased rate of hemorrhage. Based on this, he writes, "one cannot help wondering why thrombolytic therapy has travelled such a long, difficult path to wider clinical use."

The inclusion and exclusion criteria for ECASS 3 were broad, and in general, patients who present with an acute stroke will qualify for treatment, he writes. When collected properly, the evidence consistently shows that one-third of patients with stroke come to an emergency department within the appropriate time window and satisfy the criteria for thrombolytic therapy, Dr. Lyden writes.

"The frequently quoted statistic that only 4% of all patients with stroke receive rt-PA [recombinant tissue plasminogen activator] must be viewed as an important indictment of our health care system and of the field of neurology in particular," he asserts. "The patients are coming in but we are not."

Policies and procedures should be instituted to ensure that patients are promptly identified and treated, quality outcome data must be used to select and designate treatment centers of excellence for patients with acute stroke, and patients should be diverted to these centers, Dr. Lyden concludes. "The public expects no less, and given the past decade of distortion of the NINDS [National Institute for Neurological Disorders and Stroke] study findings and delay in implementing thrombolytic therapy for acute stroke, we have not a minute to lose."

Full-text of this Medscape article:

ECASS 3 Gets a Warm Welcome From the Stroke Community

Joseph Broderick, MD, from the University of Cincinnati, in Ohio, and a primary investigator of the National Institute of Neurological Disorders and Stroke (NINDS) trial that first established efficacy of tPA in stroke, told Medscape Neurology & Neurosurgery that, in his view, the ECASS 3 results are the most important to the field of stroke treatment since the NINDS results were published some 13 years ago.

However, like the ECASS 3 researchers and others, he too is concerned that physicians will take more time if they think they have it. "Unfortunately with physicians, sometimes the more time you have, the more you kind of drag your feet or you want to do another test, and what I worry about is that people will be treated later when it's clear that this is a very time-dependent therapy."

“What I worry about is that people will be treated later, and it's clear that this is a very time-dependent therapy.”

He said the efficacy in ECASS 3 was similar to that seen in the NINDS trial, although he noted that the ECASS 3 population was a much less severely affected group. "I think their median [National Institutes of Health Stroke Scale] NIHSS score was 9 to 10 as opposed to 14 in the NINDS trial, which is a big difference," he said. "That's why their mortality is extraordinarily low, around 8%, whereas in the [NINDS] trial, the mortality with placebo was 21% and with tPA it was 17%, so you're talking about half the mortality rate, but that reflects the lesser severity of the strokes."

The findings, then, do not provide information on the patients excluded from the trial, Dr. Broderick said. Still, he added, "It's just a great event that builds upon the positive momentum. I still think reperfusion is what it's all about, but reperfusion within a certain time window."

During his presentation, Dr. Hacke acknowledged this limitation for the generalizability of their results but pointed out that the inclusion criteria for the ECASS 3 study were identical to the labeling of tPA for Europe, except for the time window. "So we were not responsible as the investigators that the age limit ended at 80. We were also not responsible that there was exclusion of patients who had had a prior stroke and were diabetic, but that's what we had to do."

Full-text of Medscape article:

2. Study Dispels Some Myths about Uninsured Patients Presenting to ED

By Anthony J. Brown, MD. NEW YORK (Reuters Health) Oct 21 - Contrary to what many people believe, uninsured patients are not a primary cause of the overcrowding that is seen in US emergency departments (EDs), new research indicates. By contrast, the assumption that increasing numbers of uninsured patients are presenting to EDs is, in fact, true.

"There is a commonly held belief that uninsured patients abuse the ED, coming in for 'non-urgent' complaints, are overwhelming the system. This is simply not true," lead author Dr. Manya F. Newton told Reuters Health. "Crowding in the ED is highly multifactorial (this includes an increased amount of ED use by everyone, fewer EDs, fewer inpatient beds, and many other problems). People without insurance tend to use the ED less than any other group and when they present they tend to be sicker/more acutely ill."

Dr. Newton, a researcher with the University of Michigan, Ann Arbor, noted that "this is the first paper to critically examine unsupported statements in the peer reviewed literature concerning uninsured patients in the ED and compare these statements to the current data on the subject."

In searching MEDLINE from 1950 through September 19, 2008, the research team identified 127 studies that looked at the medical and surgical care of uninsured adult patients in emergency settings. Assumptions identified in these studies were then tested against supporting data in various data sets and in peer-reviewed literature.

Overall, 53 studies had one or more assumptions (mean = 3) about uninsured ED patients, according to the report in the Journal of the American Medical Association for October 22/29.

The assumptions that increasing numbers of uninsured patients are presenting to the ED and that uninsured patients lack access to primary care were both found to be accurate. Likewise, the belief that ED care is more expensive than office-based care for both uninsured and insured patients was also true.

Unsupported assumptions include the beliefs that uninsured patients are the main cause of ED overcrowding, uninsured ED patients have less acute conditions than insured patients, and that uninsured patients use the ED mostly for convenience.

"We have a crisis in the ED and we have a crisis with the uninsured, but it is crucial that we do not assume that the latter is causing the former," Dr. Newton emphasized. "If we attempt to solve ED overcrowding by creating policies based on inaccurate assumptions, common knowledge, or what 'everybody knows,' we will waste limited resources, fail to address the root causes of the problem, and potentially increase the barriers to care faced by 47 million uninsured Americans."

JAMA 2008;300:1914-1924.

3. Antibiotic-Associated Adverse Events Often Require Emergency Care

Laurie Barclay, MD. October 17, 2008 — Antibiotic-associated adverse events, particularly allergic reactions, lead to many emergency department visits, according to the results of a study reported in the September 15 issue of Clinical Infectious Diseases.

"Drug-related adverse events are an underappreciated consequence of antibiotic use, and the national magnitude and scope of these events have not been studied," write Nadine Shehab, from the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, and colleagues. "Our objective was to estimate and compare the numbers and rates of emergency department (ED) visits for drug-related adverse events associated with systemic antibiotics in the United States by drug class, individual drug, and event type."

Using data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project from 2004 to 2006, the investigators analyzed drug-related adverse events. These were linked with outpatient prescriptions identified from national sample surveys of ambulatory care practices, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey from 2004 to 2005.

On the basis of 6614 cases thus identified, the investigators estimated that the annual rate of visits to US EDs for adverse events related to systemic antibiotics was 142,505 visits (95% confidence interval [CI], 116,506 - 168,504 visits). Among all ED visits for drug-related adverse events, antibiotics were thought to be causally related in 19.3%.

Allergic reactions were most often implicated in ED visits for antibiotic-associated adverse events (78.7% of visits; 95% CI, 75.3% - 82.1% of visits). The most common culprits regarding allergic reactions were penicillins (36.9% of visits; 95% CI, 34.7% - 39.2% of visits) and cephalosporins (12.2%; 95% CI, 10.9% - 13.5%).

Of frequently prescribed antibiotics, sulfonamides and clindamycin were linked to the highest rate of ED visits (18.9 ED visits per 10,000 outpatient prescription visits [95% CI, 13.1 - 24.7 ED visits per 10,000 outpatient prescription visits] and 18.5 ED visits per 10,000 outpatient prescription visits [95% CI, 12.1 - 25.0 ED visits per 10,000 outpatient prescription visits], respectively).

Sulfonamides were linked to a significantly higher rate of moderate to severe allergic reactions vs all other antibiotic classes (4.3% [95% CI, 2.9% - 5.8%] vs 1.9% [95% CI, 1.5% - 2.3%]). Compared with all other antibiotic classes, sulfonamides and fluoroquinolones were linked to a significantly higher rate of neurologic or psychiatric complaints and/or findings (1.4% [95% CI, 1.0% - 1.7%] vs. 0.5% [95% CI, 0.4% - 0.6%]).

"Antibiotic-associated adverse events lead to many ED visits, and allergic reactions are the most common events," the study authors write. "Minimizing unnecessary antibiotic use by even a small percentage could significantly reduce the immediate and direct risks of drug-related adverse events in individual patients."

Limitations of this study include focus on drug-related adverse events diagnosed in EDs, with failure to include all antibiotic-associated adverse events; inability to account for unreported events and events identified in clinicians' offices or other healthcare settings; difficulty in detecting rare and less well-recognized events and events with subacute onset; analysis of drug-related adverse event conditions and outcomes limited to cases in which only drugs from a single antibiotic class were implicated in the adverse event; and inclusion only of events that were attributed to antibiotics and not to other types of drugs.

"Communicating the risks of antibiotic-associated adverse events can become an important strategy in efforts to promote judicious antibiotic use," the study authors conclude.

In an accompanying editorial, Jeffrey A. Linder, from Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, notes that antibiotic prescription by US clinicians greatly exceeds guidelines recommendations.

"The decision and discussion about antibiotic prescribing should focus on benefits and risks for the individual patient," Dr. Linder writes. "For most acute respiratory tract infections, antimicrobial resistance is irrelevant. For an individual patient, the risks are greater than the benefits, and the discussion should stop there."

The CDC supported this study.

Clin Infect Dis. 2008;47:735-743, 744-746.

4. Subdissociative-dose Ketamine versus Fentanyl for Analgesia during Propofol Procedural Sedation: A Randomized Clinical Trial

Messenger DW, et al. Acad Emerg Med. 2008;15:1–10.

Objectives: The authors sought to compare the safety and efficacy of subdissociative-dose ketamine versus fentanyl as adjunct analgesics for emergency department (ED) procedural sedation and analgesia (PSA) with propofol.

Methods: This double-blind, randomized trial enrolled American Society of Anesthesiology (ASA) Class I or II ED patients, aged 14–65 years, requiring PSA for orthopedic reduction or abscess drainage. Subjects received 0.3 mg/kg ketamine or 1.5 μg/kg fentanyl intravenously (IV), followed by IV propofol titrated to deep sedation. Supplemental oxygen was not routinely administered. The primary outcomes were the frequency and severity of cardiorespiratory events and interventions, rated using a composite intrasedation event rating scale. Secondary outcomes included the frequency of specific scale component events, propofol doses required to achieve and maintain sedation, times to sedation and recovery, and physician and patient satisfaction.

Results: Sixty-three patients were enrolled. Of patients who received fentanyl, 26/31 (83.9%) had an intrasedation event versus 15/32 (46.9%) of those who received ketamine. Events prospectively rated as moderate or severe were seen in 16/31 (51.6%) of fentanyl subjects versus 7/32 (21.9%) of ketamine subjects. Patients receiving fentanyl had 5.1 (95% confidence interval [CI] = 1.9 to 13.6; p less than 0.001) times the odds of having a more serious intrasedation event rating than patients receiving ketamine. There were no significant differences in secondary outcomes, apart from higher propofol doses in the ketamine arm.

Conclusions: Subdissociative-dose ketamine is safer than fentanyl for ED PSA with propofol and appears to have similar efficacy.

5. The Effect of Clinical Experience on the Error Rate of Emergency Physicians

Berk WA, et al. Ann Emerg Med. 2008;52:497-501.

Study objective
We assess the effect of emergency physicians' clinical experience on the propensity to commit a patient care error.

Seven years of data from a single emergency department's peer review activities were reviewed for all patient care errors made by emergency physicians. Emergency physician clinical experience was defined as years since completion of residency training during the year each error was made. A repeated-measures log-linear model was constructed that predicted error count and the rate of errors over time, with a correction for number of patients treated by each physician.

Of 829 cases reviewed during 7 years, there were 374 emergency physician errors identified. Mean emergency physician experience was 8.1±8.6 years. Emergency physicians with experience of 1.5 years or more were less likely to make an error (relative risk [RR]=0.66; 95% confidence interval [CI] 0.48 to 0.91) than those who were less experienced. Errors were not associated with emergency physician age (RR=1.01; 95% CI 0.99 to 1.03) or sex (RR=1.29; 95% CI 0.93 to 1.79).

Emergency physicians with less than 1.5 years of clinical experience may be more likely to commit errors than more experienced emergency physicians.

6. Prediction of Outcome in Subarachnoid Hemorrhage

In predicting risks for vasospasm, delayed infarction, and poor outcome after aneurysmal subarachnoid hemorrhage, the modified Fisher scale has advantages over the traditional Fisher scale.

After aneurysm rupture, the amount of blood in the subarachnoid cisterns on the initial CT scan predicts the risk for vasospasm. Clinicians have traditionally estimated this risk via a scale described by C.M. Fisher and colleagues in 1980. In initial studies, two newer scales — the Claassen and modified Fisher scales — had improved prognostic yield. The modified Fisher scale incorporates any intraventricular hemorrhage (IVH); the Claassen scale incorporates bilateral IVH. In this retrospective, single-center study, investigators compared the prognostic performance of the three scales in 237 consecutive patients with aneurysmal subarachnoid hemorrhage.

Compared with the traditional Fisher scale, the newer scales had more-linear associations with risks for symptomatic vasospasm and for delayed radiologic infarctions. The newer scales also had better interobserver agreement. Scores on the modified Fisher scale, unlike on the other two, were associated incrementally with risk for poor functional outcome at 6 weeks. Presence of IVH was not associated significantly with symptomatic vasospasm or with delayed infarction but did predict worse functional outcome.

Comment: The two newer radiologic scales modify the traditional Fisher scale by combining the amount of subarachnoid hemorrhage and the presence of IVH in their grading systems. Thus, they achieve more-linear and more-accurate associations with vasospasm risk. In this study population, IVH was so common (nearly 70% of cases) that the study might have been underpowered to detect a stronger association between IVH and vasospasm. Nonetheless, the new scales performed better than did the traditional Fisher scale. Moreover, these findings highlight that the scales predict functional prognosis, although they were designed to assess the risk for vasospasm only. Overall, the modified Fisher scale appears to offer the best prognostic performance.

— Alejandro Rabinstein, MD. Published in Journal Watch Neurology October 28, 2008. Citation:
Kramer AH et al. J Neurosurg 2008 Aug; 109:199.

7. Child Abuse Often Overlooked in Emergency Department

October 28, 2008 (Chicago, Illinois) — At least one third of children diagnosed with abuse had at least 1 visit to the emergency department before diagnosis, according to a new study.

The results were presented here at the American College of Emergency Physicians 2008 Scientific Assembly.

This is among the first studies looking at emergency-department use before the diagnosis of child abuse. Child abuse is often overlooked in the emergency department, according to the researchers from Oregon Health & Science University, in Portland. The researchers have been taking a close look at people who use emergency departments frequently.

In this study, administrative data were gathered on patients younger than 18 years who visited 23 Oregon emergency departments between February 2001 to August 2005. The hospitals ranged from small rural facilities to urban medical centers. When patients were diagnosed with abuse, demographic characteristics, the number of visits before the diagnosis, and the type of injuries were noted. Of the 286,066 pediatric patients, 399 were diagnosed with abuse.

Of those diagnosed as having experienced child abuse, 53% were girls, and 20% were infants (younger than 1 year), 15% were toddlers (1 to 2 years), 14% were preschool age (3 to 5 years), 24% were school age (6 to 12 years), and 28% were teenagers (13 to 17 years). Of the infants diagnosed with abuse, 49% had previous visits for injury. Of the overall injuries, 70% were to the head, face, and neck.

"I was not surprised by the overall number of visits for abuse, but I was surprised by the number of previous visits by these patients for which abuse was not a recorded diagnosis," lead author Esther K. Choo, MD, told Medscape Emergency Medicine. She is a clinical instructor and research fellow at the Center for Policy and Research in Emergency Medicine at Oregon Health & Science University. "Thirty percent of children eventually diagnosed with child abuse did not have the diagnosis recorded until at least their second visit, and 7% had 3 or more visits before receiving the diagnosis of abuse."

"This study highlights the importance of screening for and identifying in the chart suspicious or confirmed child abuse," said Paula Oldeg, MD, clinical instructor in emergency medicine at Rush Medical College and attending physician in the emergency department of West Suburban Medical Center, in Oak Park, Illinois, who attended the presentation. "Based on the results of this study, it seems that if these patients are identified, appropriate referrals can be made," and further abuse might be prevented, she said.

Dr. Choo pointed out that emergency-department visits might be a missed opportunity, especially for identifying abuse in infants. The study also indicates that once child abuse is recognized, repeat emergency-department visits are unlikely.

As a result of the study, Dr. Choo believes that, although individual physicians should maintain constant vigilance about abuse, they cannot fix the problem alone. Policy makers need to consider the resources in the healthcare system that can best assist clinicians in detecting and addressing family violence, she said.

The study was funded by the National Heart, Lung, and Blood Institute, the Robert Wood Johnson Foundation, and the Oregon Office for Health Policy and Research.

American College of Emergency Physicians (ACEP) 2008 Scientific Assembly: Abstract 113. Presented October 27, 2008.

8. Images in Emergency Medicine

a. Man with Progressive Dyspnea

b. Infant with Vomiting and Weight Loss

9. Kaiser Study Finds that Use of a Fan During Sleep Reduces Risk of SIDS

The theory is that the moving air dispels the carbon dioxide buildup that can occur when the expelled breath air isn't moving away from the baby's face.

Coleman-Phox K, et al. Arch Pediatr Adolesc Med. 2008;162:963-968

Objective: To examine the relation between room ventilation during sleep and risk of sudden infant death syndrome (SIDS).

Design: Population-based case-control study.

Setting: Eleven California counties.

Participants: Mothers of 185 infants with a confirmed SIDS diagnosis and 312 randomly selected infants matched on county of residence, maternal race/ethnicity, and age.

Intervention: Fan use and open window during sleep.

Main Outcome Measure: Risk of SIDS.

Results: Fan use during sleep was associated with a 72% reduction in SIDS risk (adjusted odds ratio [AOR], 0.28; 95% confidence interval [CI], 0.10-0.77). The reduction in SIDS risk seemed more pronounced in adverse sleep environments. For example, fan use in warmer room temperatures was associated with a greater reduction in SIDS risk (AOR, 0.06; 95% CI, 0.01-0.52) compared with cooler room temperatures (0.77; 0.22-2.73). Similarly, the reduction associated with fan use was greater in infants placed in the prone or side sleep position (AOR, 0.14; 95% CI, 0.03-0.55) vs supine (0.84; 0.21-3.39). Fan use was associated with a greater reduction in SIDS risk in infants who shared a bed with an individual other than their parents (AOR, 0.15; 95% CI, 0.01-1.85) vs with a parent (0.40; 0.03-4.68). Finally, fan use was associated with reduced SIDS risk in infants not using pacifiers (AOR, 0.22; 95% CI, 0.07-0.69) but not in pacifier users (1.99; 0.16-24.4). Some differences in the effect of fan use on SIDS risk did not reach statistical significance.

Conclusion: Fan use may be an effective intervention for further decreasing SIDS risk in infants in adverse sleep environments.

10. Three Hours of Follow-Up Is Sufficient for Asymptomatic Penetrating Thoracic Trauma

Plain films at 6 hours did not detect any pneumothoraces or hemothoraces that were not seen at presentation or at 3 hours.

Penetrating thoracic trauma is termed "asymptomatic" if the patient has no symptoms, signs, or radiographic findings of intrathoracic injury, but delayed pneumothorax or hemothorax occurs in about 3% of such patients and usually necessitates tube thoracostomy. Patients with asymptomatic thoracic penetrating trauma usually are observed and undergo repeat chest radiography after 6 hours. However, findings from two studies suggest that 3 hours is sufficient for follow-up (Surg Gynecol Obstet 1992; 175:249).

In a prospective study, researchers compared chest radiography findings at 3 and 6 hours after presentation in patients who presented to a single emergency department within 2 hours after asymptomatic penetrating thoracic trauma (anatomic boundaries of injury: clavicles and base of the neck, superiorly; inferior costal margin and iliac crests, inferiorly). Supine anteroposterior chest radiographs were obtained at presentation, and upright posterioanterior and lateral chest radiographs were obtained at 3 and 6 hours. Patients with worrisome clinical or laboratory findings or findings of pneumothorax or hemothorax on the initial radiograph were excluded.

Of 100 patients who met inclusion criteria, 75% were men, 75% had stab wounds, and 25% had gunshot wounds. The average ED stay was 8.8 hours. Two patients had findings of pneumothorax on the 3-hour film; both patients underwent tube thoracostomy. No new cases of pneumothorax or hemothorax were detected on the 6-hour films. Patient charges, including the cost of radiographs and continuous pulse oximetry monitoring, were US$2802 for the 3-hour observation period and $4521 for the 6-hour period.

Comment: In the three studies published to date (including this study) that compared chest radiography findings at 3 and 6 hours, 8 of the combined total of 304 patients (2.6%) developed pneumothoraces within 3 hours, and no patients developed pneumothoraces or hemothoraces within the next 3 hours. The inherent value of a 3-hour follow-up chest radiography policy is that the stay is shortened, thereby relieving ED overcrowding, and associated healthcare costs are reduced considerably. Moreover, this approach limits radiation exposure, a matter of increasing concern. Some authors have advocated for the use of chest computed tomography (CT) at presentation, with immediate discharge if the scan is negative. However, that approach is a poor alternative because thoracic CT transmits 8 mSv of ionizing radiation — an amount that is 400 times the radiation dose of a two-view chest radiograph and is equivalent to 3 years of background radiation in the U.S. Finally, the evolving role of ED ultrasound, such as the extended FAST examination, and its ability to identify pneumothorax remain to be determined.

— John A. Marx, MD, FAAEM, FACEP. Published in Journal Watch Emergency Medicine October 10, 2008. Citation: Seamon MJ et al. J Trauma 2008 Sep; 65:549.

11. Surprise, Surprise: ED Crowding Adversely Affects Patient Satisfaction

Dissatisfaction lasts throughout entire hospital stay.

Pines JM, et al. Acad Emerg Med. 2008;15:825–831.

Objectives: The objective was to study the association between factors related to emergency department (ED) crowding and patient satisfaction.

Methods: The authors performed a retrospective cohort study of all patients admitted through the ED who completed Press-Ganey patient satisfaction surveys over a 2-year period at a single academic center. Ordinal and binary logistic regression was used to study the association between validated ED crowding factors (such as hallway placement, waiting times, and boarding times) and patient satisfaction with both ED care and assessment of satisfaction with the overall hospitalization.

Results: A total of 1,501 hospitalizations for 1,469 patients were studied. ED hallway use was broadly predictive of a lower likelihood of recommending the ED to others, lower overall ED satisfaction, and lower overall satisfaction with the hospitalization (p less than 0.05). Prolonged ED boarding times and prolonged treatment times were also predictive of lower ED satisfaction and lower satisfaction with the overall hospitalization (p less than 0.05). Measures of ED crowding and ED waiting times predicted ED satisfaction (p less than 0.05), but were not predictive of satisfaction with the overall hospitalization.

Conclusions: A poor ED service experience as measured by ED hallway use and prolonged boarding time after admission are adversely associated with ED satisfaction and predict lower satisfaction with the entire hospitalization. Efforts to decrease ED boarding and crowding might improve patient satisfaction.

12. In ‘Sweetie’ and ‘Dear,’ a Hurt for the Elderly

Heidi Schumann for The New York Times. October 6, 2008. Professionals call it elderspeak, the sweetly belittling form of address that has always rankled older people: the doctor who talks to their child rather than to them about their health; the store clerk who assumes that an older person does not know how to work a computer, or needs to be addressed slowly or in a loud voice. Then there are those who address any elderly person as “dear.”

“People think they’re being nice,” said Elvira Nagle, 83, of Dublin, Calif., “but when I hear it, it raises my hackles.”

Now studies are finding that the insults can have health consequences, especially if people mutely accept the attitudes behind them, said Becca Levy, an associate professor of epidemiology and psychology at Yale University, who studies the health effects of such messages on elderly people.

“Those little insults can lead to more negative images of aging,” Dr. Levy said. “And those who have more negative images of aging have worse functional health over time, including lower rates of survival.”

In a long-term survey of 660 people over age 50 in a small Ohio town, published in 2002, Dr. Levy and her fellow researchers found that those who had positive perceptions of aging lived an average of 7.5 years longer, a bigger increase than that associated with exercising or not smoking. The findings held up even when the researchers controlled for differences in the participants’ health conditions.

In her forthcoming study, Dr. Levy found that older people exposed to negative images of aging, including words like “forgetful,” “feeble” and “shaky,” performed significantly worse on memory and balance tests; in previous experiments, they also showed higher levels of stress.

Despite such research, the worst offenders are often health care workers, said Kristine Williams, a nurse gerontologist and associate professor at the University of Kansas School of Nursing.

To study the effects of elderspeak on people with mild to moderate dementia, Dr. Williams and a team of researchers videotaped interactions in a nursing home between 20 residents and staff members. They found that when nurses used phrases like “good girl” or “How are we feeling?” patients were more aggressive and less cooperative or receptive to care. If addressed as infants, some showed their irritation by grimacing, screaming or refusing to do what staff members asked of them.

The researchers, who will publish their findings in The American Journal of Alzheimer’s Disease and Other Dementias, concluded that elderspeak sent a message that the patient was incompetent and “begins a negative downward spiral for older persons, who react with decreased self-esteem, depression, withdrawal and the assumption of dependent behaviors.”

Dr. Williams said health care workers often thought that using words like “dear” or “sweetie” conveyed that they cared and made them easier to understand. “But they don’t realize the implications,” she said, “that it’s also giving messages to older adults that they’re incompetent.”

“The main task for a person with Alzheimer’s is to maintain a sense of self or personhood,” Dr. Williams said. “If you know you’re losing your cognitive abilities and trying to maintain your personhood, and someone talks to you like a baby, it’s upsetting to you.”

She added that patients who reacted aggressively against elderspeak might receive less care.

For people without cognitive problems, elderspeak can sometimes make them livid. When Sarah Plummer’s pharmacy changed her monthly prescription for cancer drugs from a vial to a contraption she could not open, she said, the pharmacist explained that the packaging was intended to help her remember her daily dose.

“I exploded,” Ms. Plummer wrote to a New York Times blog, The New Old Age, which asked readers about how they were treated in their daily life.

“Who says I don’t take my medicine as prescribed?” wrote Ms. Plummer, 61, who lives in Champaign, Ill. “I am alive right now because I take these pills! What am I supposed to do? Hold it with vice grips and cut it with a hack saw?’”

She added, “I believed my dignity and integrity were being assaulted.”


13. Early Goal-Directed Therapy for Sepsis: Show Me the Data!

A meta-analysis of randomized sepsis trials showed mortality benefit with early goal-directed therapy.

The validity of various aspects of early goal-directed therapy (EGDT) for patients with severe sepsis and septic shock has been challenged in non–peer-reviewed publications. Researchers conducted a meta-analysis of randomized controlled trials in adult patients with sepsis; eligible trials described the resuscitative protocol used to achieve predetermined hemodynamic endpoints and included control groups of patients who received standard care. The primary endpoint in the meta-analysis was mortality. Assessment of trial quality included evaluation of diagnostic criteria for patient selection and internal validity.

Of 903 reports identified in a comprehensive search, 29 were chosen for complete manuscript review, and 9 (involving a total of 1001 patients) were eligible for inclusion in the final analysis. Overall, mortality was significantly lower in patients who received resuscitation directed by quantitative endpoints than in those who received standard care (odds ratio, 0.64; 95% confidence interval, 0.43–0.96). Analysis of predefined subgroups of patients who received endpoint-directed resuscitation early (6 studies) demonstrated lower mortality with this procedure (OR, 0.50; 95% CI, 0.37–0.69). However, no mortality benefit resulted from late (more than 24 hours) resuscitation (OR, 1.16; 95% CI, 0.60–2.22). The results remained consistent in sensitivity analyses. Because the early endpoint-based resuscitation strategy had such a clear effect on mortality, the investigators performed a post hoc sensitivity analysis to determine whether any specific study had a disproportionate influence on the overall results; as each study was excluded and data from the remaining studies were reanalyzed, the significant mortality benefit of early goal-directed resuscitation remained consistent.

Comment: This meta-analysis showed a dramatic mortality benefit from early resuscitation that was targeted to achieve specified physiologic goals. The authors conclude that the data strongly support the Surviving Sepsis Campaign recommendations for EGDT in septic patients. Large multicenter studies evaluating the benefits of EGDT, including various individual components, currently are under way or nearing completion. Until those results are available, clinicians resuscitating patients with sepsis syndrome are well advised to embrace the principles of EGDT, which are supported by more than 14 peer-reviewed publications.

— Tiffany M. Osborn, MD. Published in Journal Watch EM October 3, 2008. Citation:
Jones AE et al. Crit Care Med 2008 Oct; 36:2734.

14. Olanzapine versus Droperidol for the Treatment of Primary Headache in the ED

It’s a tie.

Hill CH, at al. Acad Emerg Med. 2008;15:806–811.
Objectives: The objective was to determine if there is a difference in pain relief or frequency and severity of side effects in emergency department (ED) patients with primary headache treated with either intramuscular (IM) olanzapine or IM droperidol.

Methods: This was a prospective, randomized nonblinded clinical trial of adult ED patients undergoing treatment for suspected primary headache. Consenting patients were randomized to receive either droperidol 5 mg IM or olanzapine 10 mg IM. Prior to receiving treatment, patients were asked to complete a 100-mm visual analog scale (VAS) describing their pain and a 4-point verbal rating scale (VRS) describing their pain as none, mild, moderate, or severe. Patients also completed a 100-mm VAS describing their level of nausea. Pain and nausea measurements were repeated 30 and 60 minutes after medication administration. Patients also completed the Barnes Akathisia Scale (BAS) 30 and 60 minutes after medication administration. Descriptive statistics were used as appropriate. Pain relief was compared both in terms of the decrease in VAS scores and in the proportion of patients who reported moderate or severe pain whose report later changed to mild or no pain.

Results: One-hundred patients were enrolled; 13 were withdrawn before administration of the study medication, 8 in the droperidol group and 5 in the olanzapine group, leaving 87 patients for analysis. Forty-two patients received droperidol and 45 received olanzapine. In the droperidol group, 35/40 (87.5%) patients who had reported moderate or severe pain at baseline reported mild or no pain at 60 minutes. In the olanzapine group, 38/44 (86.4%) reported this change (p = 0.89). The mean percent change from baseline VAS pain score at 60 minutes was −37% (95% CI = −84% to 11%) for droperidol and −37% (95% CI = −64% to 10%) for olanzapine (p = 0.30). The mean percent change from baseline for the VAS nausea score was −59% (95% CI = −70% to −47%) for droperidol and −64% (95% CI = −77% to −51%) for olanzapine (p = 0.83). There was no difference in any report of akathisia by the BAS between the groups (p = 0.63).

Conclusions: Both olanzapine and droperidol are effective treatments for primary headaches in the ED. No significant differences were found between the medications in terms of pain relief, antiemetic effect, or akathisia. Olanzapine may be used to treat primary headache and it is an effective alternative to droperidol.

15. Morphine analgesia in patients with acute appendicitis: a randomised double-blind clinical trial (again)

Amoli HA, et al. Emerg Med J 2008;25:586-589.

Background: The administration of analgesics to patients with acute abdominal pain due to acute appendicitis is controversial. A study was undertaken to assess the analgesic effect of morphine in patients with acute appendicitis.

Methods: A randomised double-blind clinical trial was conducted in Sina hospital, a general teaching hospital, from January 2004 to March 2005. Patients scheduled for appendectomy were randomised to receive 0.1 mg/kg morphine sulfate or saline (0.9%) to a maximum dose of 10 mg over a 5 min period. Patients were examined by surgeons not involved in their care before and after drug administration and their pain intensity and signs were recorded at each visit. The physicians were also asked to indicate their own treatment plan. The main outcome measures were pain intensity using a visual analogue scale (VAS) and signs of acute appendicitis. A favourable reduction in VAS score was defined as a change of greater than 13 mm.

Results: Of the 71 patients enrolled in the study, 35 were allocated to receive morphine and 36 to receive placebo. One patient left the hospital before receiving morphine. No significant differences were seen between the two groups with regard to age, sex and initial VAS score. A more favourable change in VAS score was reported in the morphine group with a significantly greater reduction in the median VAS score than in the placebo group. Morphine administration did not cause significant changes in patients’ signs or in the physicians’ plans or diagnoses. No adverse events were seen in either group.

Conclusion: Morphine can reduce pain in patients with acute appendicitis without affecting diagnostic accuracy.

16. Procedures Can Be Learned on the Web: A Randomized Study of Ultrasound-guided Vascular Access Training

Chenkin J, et al. Acad Emerg Med. 2008;15:949–954.

Objectives: Web-based learning has several potential advantages over lectures, such as anytime–anywhere access, rich multimedia, and nonlinear navigation. While known to be an effective method for learning facts, few studies have examined the effectiveness of Web-based formats for learning procedural skills. The authors sought to determine whether a Web-based tutorial is at least as effective as a didactic lecture for learning ultrasound-guided vascular access (UGVA).

Methods: Participating staff emergency physicians (EPs) and junior emergency medicine (EM) residents with no UGVA experience completed a precourse test and were randomized to either a Web-based or a didactic group. The Web-based group was instructed to use an online tutorial and the didactic group attended a lecture. Participants then practiced on simulators and live models without any further instruction. Following a rest period, participants completed a four-station objective structured clinical examination (OSCE), a written examination, and a postcourse questionnaire. Examination results were compared using a noninferiority data analysis with a 10% margin of difference.

Results: Twenty-one residents and EPs participated in the study. There were no significant differences in mean OSCE scores (absolute difference = −2.8%; 95% confidence interval [CI] = −9.3% to 3.8%) or written test scores (absolute difference = −1.4%; 95% CI = −7.8% to 5.0%) between the Web group and the didactic group. Both groups demonstrated similar improvements in written test scores (26.1% vs. 25.8%; p = 0.95). Ninety-one percent (10/11) of the Web group and 80% (8/10) of the didactic group participants found the teaching format to be effective (p = 0.59).

Conclusions: Our Web-based tutorial was at least as effective as a traditional didactic lecture for teaching the knowledge and skills essential for UGVA. Participants expressed high satisfaction with this teaching technology. Web-based teaching may be a useful alternative to didactic teaching for learning procedural skills.

17. When to Suspect Abuse in Children with Fractures

Results of a meta-analysis suggest that about 70% of rib fractures and 50% of humeral fractures result from abuse.

Kemp AM, et al. BMJ 2008;337:a1518


Skeletal fractures are diagnosed in up to a third of children who have been investigated for physical abuse. The fractures are often occult, and they occur in infants and toddlers who cannot give a causal explanation. Children who have been physically abused represent a small proportion of the total number of childhood fractures. Most children who sustain fractures do so from falls, motor vehicle crashes, or other non-abusive trauma. In addition, a small group of children are more susceptible to fractures owing to underlying conditions that contribute to bone fragility. All health professionals who see children should be able to recognise the characteristics of fractures resulting from abuse and initiate child protection investigations where necessary, to prevent further injury that could be fatal. In reality, the possibility of child abuse is often overlooked in clinical practice.

We systematically reviewed the published world literature to answer the question "what features differentiate fractures resulting from abuse from those sustained from other causes?" We aimed to identify indicators that can help clinicians to identify cases of suspected child abuse when a child presents with a fracture for which the cause cannot be confirmed. We explore the strengths and limitations of the current evidence base and make recommendations for future research in this field. We anticipate that this review will enable the development of evidence based clinical guidelines. It will also contribute to the knowledge and understanding of the scientific evidence that expert medical witnesses are expected to have to support their opinion in the family and criminal courts.

Excerpt from Abstract

Results: In total, 32 studies were included. Fractures resulting from abuse were recorded throughout the skeletal system, most commonly in infants (<1 year) and toddlers (between 1 and 3 years old). Multiple fractures were more common in cases of abuse. Once major trauma was excluded, rib fractures had the highest probability for abuse (0.71, 95% confidence interval 0.42 to 0.91). The probability of abuse given a humeral fracture lay between 0.48 (0.06 to 0.94) and 0.54 (0.20 to 0.88), depending on the definition of abuse used. Analysis of fracture type showed that supracondylar humeral fractures were less likely to be inflicted. For femoral fractures, the probability was between 0.28 (0.15 to 0.44) and 0.43 (0.32 to 0.54), depending on the definition of abuse used, and the developmental stage of the child was an important discriminator. The probability for skull fractures was 0.30 (0.19 to 0.46); the most common fractures in abuse and non-abuse were linear fractures. Insufficient comparative studies were available to allow calculation of a probability of abuse for other fracture types.

Conclusion: When infants and toddlers present with a fracture in the absence of a confirmed cause, physical abuse should be considered as a potential cause. No fracture, on its own, can distinguish an abusive from a non-abusive cause. During the assessment of individual fractures, the site, fracture type, and developmental stage of the child can help to determine the likelihood of abuse. The number of high quality comparative research studies in this field is limited, and further prospective epidemiology is indicated.

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18. Is Hospital Admission and Observation Required after a Normal Abdominal Computed Tomography Scan in Children with Blunt Abdominal Trauma?

No. Send them home.

Awasthi S, et al. (UC Davis). Acad Emerg Med. 2008;15:895–899.

Objectives: The objective was to determine if hospital admission of children with blunt abdominal trauma for observation of possible intraabdominal injury (IAI) is necessary after a normal abdominal computed tomography (CT) scan in the emergency department (ED).

Methods: The authors conducted a prospective observational cohort study of children less than 18 years of age with blunt abdominal trauma who underwent an abdominal CT scan in the ED. Abdominal CT scans were obtained with intravenous contrast but no oral contrast. The decision to hospitalize the patient was made by the attending emergency physician (EP) with the trauma or pediatric surgery teams. An abnormal abdominal CT scan was defined by the presence of any visualized IAI or findings suggestive of possible IAI (e.g., intraperitoneal fluid without solid organ injury). Patients were followed to determine if IAI was later diagnosed and the need for acute therapeutic intervention if IAI was present.

Results: A total of 1,295 patients underwent abdominal CT, and 1,085 (84%) patients had normal abdominal CT scans in the ED and make up the study population. Seven-hundred thirty-seven (68%) were hospitalized, and 348 were discharged to home. None of the 348 patients discharged home and 2 of the 737 hospitalized patients were identified with an IAI after a normal initial abdominal CT. The IAIs in patients with normal initial CT scans included a 10-year-old with a mesenteric hematoma and serosal tear at laparotomy and a 10-year-old with a perinephric hematoma on repeat CT. Neither underwent specific therapy. The negative predictive value (NPV) of a normal abdominal CT scan for IAI was 99.8% (95% confidence interval [CI] = 99.3% to 100%).

Conclusions: Children with blunt abdominal trauma and a normal abdominal CT scan in the ED are at very low risk of having a subsequently diagnosed IAI and are very unlikely to require a therapeutic intervention. Hospitalization of children for evaluation of possible undiagnosed IAI after a normal abdominal CT scan has a low yield and is generally unnecessary.

19. Is Traditional Reading of the Bedside Chest Radiograph Appropriate To Detect Intraatrial Central Venous Catheter Position?

Wirsing M, et al. Chest. 2008;134:527-533.

Background: Traditionally, the positioning of central venous catheters (CVCs) outside the right atrium (RA) in patients receiving intensive care is determined by surrogate landmarks on bedside chest radiographs (CXRs). The validity of this method was examined by comparing readings of radiologists with the results of transesophageal echocardiography (TEE).

Methods: Prospective study at university hospital. Two hundred thirteen adults scheduled for cardiothoracic surgery were randomized to right or left internal jugular vein catheterization under ECG guidance. One senior radiologist and two radiologists in training independently read the CXRs, and determined whether the CVC tip ended in the RA and measured the vertical distance from the CVC tip to the carina (TC-distance).

Results: Two hundred twelve CVC tips could be identified by TEE. Only left-sided CVCs (n = 5) ended in the upper RA (2.4%). Three of those patients were shorter than 160 cm. Specificity was 94% for senior radiologist, 44% for the first radiologist in training, and 60% for the second radiologist in training. The TC-distance of intraatrial catheters was 39, 55, 59, 80, and 83 mm, respectively. Thus, a TC-distance 55 mm ensured extraatrial tip position in four of five intraatrial CVCs (80%, p = 0.002). The TC-distance of extraatrial catheters ranged from – 26 to 102 mm.

Conclusions: Reading of a bedside CXR alone is not very accurate to identify intraatrial CVC tip position. TC-distance is a helpful marker, and its specificity is as good as that of an experienced radiologist if a cutoff value of 55 mm is chosen.

20. Empiric Antibiotic Therapy for Sepsis Patients: Monotherapy With β-Lactam or β-Lactam Plus an Aminoglycoside?

Sinert R, et al. Ann Emerg Med. 2008;557-560.

The objective of this review is to examine the efficacy of monotherapy with β-lactam antibiotics versus the standard β-lactam-aminoglycoside antibiotic combination in treatment of sepsis, with regard to all-cause mortality and an estimation of the rate of adverse effects with each treatment.

The authors concluded that in sepsis patients there is no difference in overall mortality between monotherapy or combination therapy. The addition of an aminoglycoside only increased the risk of nephrotoxicity. The authors concluded that a broad-spectrum antibiotic β-lactam required less modification than a narrow-spectrum β-lactam with aminoglycoside combination. No specific infection or disease was identified in which the addition of an aminoglycoside to a broad-spectrum β-lactam antibiotic therapy provided an advantage.