Lit Bits: February 19, 2009

From the recent medical literature...

1. Intl Stroke Conference (ICS) 2009: Stroke Patients Arriving Within "Golden Hour" More Likely to Get tPA

Susan Jeffrey. February 19, 2009 (San Diego, California) — A greater proportion of patients who arrive at the hospital in the first 60 minutes after symptom onset — the so-called "golden hour" — receive thrombolytic therapy than those who arrive later, new data from the Get With The Guidelines-Stroke (GWTG-S) quality-improvement program shows.

In this analysis, 12% of all ischemic stroke patients seen at 100 GWTG-S hospitals arrived within 1 hour of symptom onset, and 27.1% of these were treated with tissue plasminogen activator (tPA) vs 12.9% of those arriving between 1 and 3 hours after onset.

However, Jeffery L. Saver, MD, from the University of California, Los Angeles Stroke Center, pointed out that golden-hour patients also had door-to-needle (DTN) times that were about 20 minutes longer than those arriving later, and only about 20% were treated within 60 minutes of arrival.

"These findings support greater public-education efforts to increase the proportion of patients arriving in the first 60 minutes after symptom onset and a revamping of our hospital's performance-improvement activities to shorten the DTN times in patients who've done their part in arriving in the first 60 minutes, to make sure we do our part and get drug started for them in the next 60 minutes," Dr. Saver concluded.

He presented their findings here at the American Stroke Association International Stroke Conference 2009.

Benefit Strongly Time Dependent

The benefit of intravenous (IV) tPA in acute ischemic stroke is strongly time dependent, Dr. Saver said. Therapeutic yield of treatment is maximal in the first minutes after stroke and declines steadily during the first 3 hours. "Every minute that goes by without treatment, 2 million nerve cells die," he said. "Every 10 minutes that goes by without tPA, 1 fewer patient experiences benefit from tPA."

Patients who present within the first 60 minutes after symptom onset have the greatest opportunity for benefit from treatment, but these patients have not been well characterized. "That's why we undertook this study," Dr. Saver said.

They used the GWTG-S registry, a national database of acute strokes treated at participating hospitals in the United States. From 905 participating hospitals, a total of 517,000 stroke and transient ischemic attack patients were entered in the database between April 2003 and December 2007. After excluding those who did not arrive directly at the emergency department by ambulance or private vehicle, those having hemorrhagic strokes, and patients for whom a time of symptom onset could not be documented, they were left with 106,924 patients for this analysis.

Of these, 28.3% arrived at the hospital within 60 minutes of symptom onset; the mean onset-to-door time for these patients was 39.9 minutes.

Although most patient characteristics examined were to some extent statistically significant, 2 factors stood out; National Institutes of Health Stroke Scale (NIHSS) score, which was higher in those arriving earlier (8 for those arriving within 60 minutes vs 4 in those arriving after 3 hours), and arrival by ambulance, which was the case in 79% of those arriving in the golden hour, vs 55% of those arriving after 3 hours.

Overall, 11.8% of all ischemic stroke patients arriving directly at the hospital with a documented onset time were treated with IV tPA, vs 5% of those without a documented onset of symptoms. The mean onset-to-door time in patients who received tPA was 56 minutes, and the mean DTN time was 84 minutes.

Those arriving within the golden hour were much more likely than those arriving later to receive thrombolysis, Dr. Saver said.

The frequency of delivery of tPA was 27.1% of the golden-hour patients vs 12.9% in the 1-to-3 hour patients (P less than .0001).

However, those arriving earlier also had longer DTN times. Patients who arrived at the hospital within the first hour had a mean DTN time of 90.6 minutes, compared with 76.7 minutes for those arriving between 1 and 3 hours after symptom onset. Only 18.3% of these patients who arrived within 60 minutes of symptom onset had a DTN time under the recommended target of 60 minutes.

There was a "modest increase" of about 1.2% per year over time in the number of golden-hour patients being treated within 60 minutes, from 12.8% in 2003 to 19.5% in 2007; this improvement did not appear to be related to length of participation in the GWTG-S program, he noted.

Having More Time Should Not Mean Taking More Time

After his presentation, Dr. Saver was asked about what might explain the longer times to treatment among those who arrived earlier. Although they plan to look at this issue further in this data set, he pointed out that doctors might take the opportunity for a longer informed-consent process when they have more time.

Furthermore, during a press conference here, Dr. Saver speculated that this potential problem of using the time for deliberation may worsen over time, given the results of ECASS 3 reported last fall that showed thrombolytic therapy was safe and effective up to 4.5 hours after symptom onset.

"I think for the providers, focusing the attention on how well your health system is performing by focusing on door-to-needle time for treatment, rather than the onset-to-treatment time or the maximal permitted time, is the way to go," Dr. Saver said. "We're trying to emphasize a door-to-needle time of 60 minutes."

Arthur Pancioli, MD, professor and vice chair of emergency medicine at the University of Cincinnati, in Ohio, moderated a press conference here where this paper was presented. He pointed out that while there is a benefit to treatment, there are also serious risks associated with thrombolytic therapy, including a 6.4% risk of hemorrhage, "even if you're doing it right."

While it is still clearly the right thing to do, he said, "that would give you pause . . . but what you cannot do is pause, and that's the hard part.

"We're caught in a situation where you have to be fast, and you have to do it well."

The study was funded by the American Heart Association PRT Outcomes Research Center and the National Institutes of Health-National Institute of Neurological Disorders and Stroke. Dr. Saver reports he is an investigator in the NIH CLEAR, IMS-3, and the MR-RESCUE trials.

International Stroke Conference 2009: Abstract 31. Presented February 18, 2009.

2. Urgent Care for TIA and Minor Stroke Reduces Disability and Costs: EXPRESS

Susan Jeffrey. February 5, 2009 — A new analysis from the EXPRESS trial, which showed that urgent aggressive intervention after a transient ischemic attack (TIA) or minor stroke cut the 90-day risk for recurrent stroke by 80%, now confirms this strategy reduces fatal and nonfatal stroke as well as disability, hospital admission days, and costs by the same magnitude.

"In contrast to most medical treatments or interventions, which cost money but do some good, this intervention would actually save much more money than it costs to implement," Peter M. Rothwell, FMedSci, from John Radcliffe Hospital, in Oxford, the United Kingdom, told Medscape Neurology & Neurosurgery.

The results, from the Early Use of Existing Preventive Strategies for Stroke (EXPRESS) trial, are published online February 5 ahead of print in the March issue of Lancet Neurology.

EXPRESS Intervention After TIA

After a TIA or minor stroke, the risk for recurrent stroke within 7 days is between 8% and 10%, the authors write.

The EXPRESS trial was a prospective, population-based study looking at the effect of early assessment and treatment of TIA or minor stroke by comparing outcomes in two 30-month periods before and after implementation of a "no-appointment-necessary" clinic where patients could be seen within 24 hours of the event and preventive treatments, including antiplatelet therapy and statins, could begin immediately.

Full-text here: http://www.medscape.com/viewarticle/587884

3. Prescribe prednisolone alone for Bell’s palsy diagnosed within 72 hours of symptom onset

Madhok V, et al. BMJ 2009;338:b255.

The clinical problem
Bell’s palsy affects 11 to 40 people per 100, 000 population each year, and although most patients recover, as many as 30% are left with facial disfigurement and pain. Uncertainty surrounds the most commonly used treatments, corticosteroids and antiviral agents: two Cochrane reviews examining their effectiveness concluded that there were unsatisfactory data to determine definitive treatment.However, on the basis of a more recent randomised controlled trial of prednisolone and aciclovir for early Bell’s palsy, we now propose that prednisolone should be prescribed immediately on diagnosis and that aciclovir either alone or in combination does not confer any benefit.

The evidence for change
The treatment of Bell’s palsy has been an area of clinical uncertainty in terms of whether to treat with corticosteroid or antiviral therapy. Two separate Cochrane reviews in 2004 examined the effectiveness of corticosteroids and antiviral agents in patients with Bell’s palsy. The first Cochrane review included three randomised controlled trials with 117 patients, and the second review included two randomised control trials with 200 patients. Each review concluded that the data were unsatisfactory for determining definitive treatment. Following these two reviews, England’s National Institute for Health Research commissioned a randomised controlled trial within primary care to look at the effectiveness of prednisolone and aciclovir in treating early Bell’s palsy. This trial included twice as many patients as did the Cochrane reviews, thereby reducing the selection bias found in hospital based studies.

In this newly commissioned trial, over a two year period 752 patients with symptoms suggestive of Bell’s palsy were referred from primary care to 17 hospital based receiving centres in Scotland to be assessed within 72 hours of symptom onset. Altogether, 551 patients met the inclusion criteria and were randomised twice, resulting in four study groups. Each group received a combination of two preparations: prednisolone plus placebo; aciclovir plus placebo; prednisolone plus aciclovir; or two placebo capsules. Facial nerve function was the primary outcome and was assessed using the House-Brackmann scale, with quality of life, appearance, and pain as secondary outcomes (table).

Prednisolone provides an effective treatment for Bell’s palsy—the number needed to treat (NNT) for one additional person to experience full facial function being six and eight at three and nine months respectively.

Barriers to change
Effective dissemination of this new knowledge on how the best to treat Bell’s palsy is needed. This article and others in review publications such as the Drug and Therapeutics Bulletin (http://dtb.bmj.com/cgi/content/abstract/46/7/53), together with the incorporation of the new findings into the online resource Map of Medicine (www.nhs.uk/Conditions/Bells-palsy/Pages/Treatment.aspx?url=Pages/what-is-it.aspx), will enable these findings to be more widely known. This will make it more likely that patients receive corticosteroids within three days of the onset of symptoms.

How should we change our practice?
Prednisolone should be prescribed as first line treatment in patients diagnosed with Bell’s palsy within 72 hours of onset. Corticosteroids alone are easy for patients to take, are well tolerated, and now have clear supporting evidence. They are also more cost effective, with the daily dose of 50 mg (25 mg twice daily) of prednisolone costing £0.52 compared with £0.70 for 2 g (400 mg five times daily) of aciclovir; patients are recommended to take a 10 day course. Corticosteroids are contraindicated in patients with systemic infection. It remains to be seen if other antiviral agents, such as valaciclovir, have any benefit in the treatment of Bell’s palsy in primary care.

Methods
We searched Medline and the Cochrane Library to identify published randomised controlled trials and systematic reviews that assessed the efficacy of steroids and antivirals in the treatment of Bell’s palsy. We also consulted widely among specialists and generalists, as well as drug companies, to identify relevant published evidence. A single recent study dominates the current evidence base as the largest randomised control trial providing the best supportive evidence on management of the early stages for patients presenting in primary care

Key points

Prednisolone given within 72 hours of onset of Bell’s palsy increases the chance of complete recovery at three and nine months

Combining the antiviral aciclovir with prednisolone confers no additional benefit

Prednisolone is easy to take, well tolerated, and cheap

4. Parental Preferences for Boarding Locations When a Children's Hospital Exceeds Capacity

Guthrie BD, et al. Ann Emerg Med 2009; in press

Study objective
Our objective is to determine parental preferences for boarding locations when a children's hospital is at full capacity. We also assess parental interest in transfer to a general hospital when a children's hospital is experiencing crowding.

Methods
Eligible patients were surveyed within 24 hours of admission. Surveys were completed in emergency department (ED) and inpatient areas. Previous admission was not required; children with chronic illnesses were included. Parents were asked whether they would prefer their child to board in an ED hallway or inpatient hallway or whether they had no preference. Parents were also asked the maximum acceptable waiting time for an inpatient bed and whether they would prefer to be transferred to another hospital should the children's hospital not have a bed available. Responses were hypothetical and confidential and did not affect care.

Results
A total of 382 patients met enrollment criteria and 359 (94%) were enrolled; 58.8% (95% confidence interval [CI] 53.5% to 63.9%) preferred boarding on inpatient hallways, 11.1% (95% CI 8.2% to 15.0%) preferred ED hallways, and 30.1% (95% CI 25.4% to 35.2%) had no preference. Seventy percent (95% CI 65.2% to 74.9%) of parents preferred to wait at a children's hospital despite crowding. Most parents believed that the maximum acceptable waiting time was less than or equal to 3 hours.

Conclusion
Parents of pediatric patients prefer boarding on inpatient hallways over ED hallways. The majority of parents prefer to remain at a children's hospital despite crowded conditions, but some parents may be amenable to transfer. These results may help institutions develop strategies to improve patient satisfaction when hospital capacity is exceeded.

5. ISC 2009: Misdiagnosis of Young Stroke Patients Not Uncommon

Caroline Cassels. February 19, 2009 (San Diego, California) — It is not uncommon for young adults with stroke to be misdiagnosed during initial presentation to the emergency department, particularly if they experience an infarct in their posterior circulation.

New research presented here at the American Stroke Association International Stroke Conference 2009 shows an overall misdiagnosis rate of 14% among adults under the age of 50 years.

"In these individuals, we also found there was a strong trend among the very youngest patients — those under age 35 — to have an even greater chance of misdiagnosis," principal investigator Seemant Chaturvedi, MD, from Wayne State University, in Detroit, Michigan, told Medscape Neurology.

Dr. Chaturvedi said his own anecdotal experience and that of some of his colleagues led them to look into the issue of misdiagnosis in young stroke patients.

"I think we've all seen young patients who, even though they have presented to the emergency department early after symptom onset, do not receive the proper diagnosis. When that happens, patients are deprived of the opportunity to receive [tissue plasminogen activator] tPA or interventional stroke therapy, so we decided to look at this issue in a more systematic way," he said.

Inner-Ear Disorder Diagnosed in 50%

The researchers reviewed data on 57 patients aged 16 to 50 years enrolled since 2001 in the Young Stroke Registry at the Comprehensive Stroke Center at Wayne State University.

With an average age of 34 years, 8 patients — 4 males and 4 females — were misdiagnosed with conditions including alcohol intoxication, migraine, vertigo, and inner-ear disorder.

Of these, half were diagnosed with an inner-ear disorder, including labyrinthitis or peripheral vertigo, and subsequently ended up being diagnosed with stroke in the brain stem or cerebellum. One 18-year-old patient diagnosed with alcohol intoxication also ended up with a diagnosis of posterior cerebral artery stroke.

Of the misdiagnosed cases, 7 of the 8 presented within 3 hours to the emergency department. Of these, said Dr. Chaturvedi, 3 would have been considered good candidates for thrombolysis.

A Diagnostic Challenge

Diagnosing posterior stroke can be challenging, said Dr. Chaturvedi.

"There are a number of neural pathways in the brain stem that can affect different functions, including strength, coordination, speech, eye movements, hearing, and swallowing. So to a nonspecialist, it can be challenging to tease out which of these are serious and which are benign," he said.

Nevertheless, he added, the presenting signs and symptoms in these misdiagnosed patients were not atypical.

"It may be that physicians are just not expecting stroke [in these young patients]. A lot of the presentations were classic for stroke, but for whatever reason, they just weren't recognized as such," he said.

Dr. Chaturvedi said the study highlights the need for efforts to increase awareness among the public and clinicians that stroke can occur in young people. He estimated that in the United States there are approximately 10,000 to 15,000 strokes in individuals under the age of 45 years annually.

"I think I would recommend that doctors consider a diagnosis of stroke in patients who present with acute neurologic deficits, regardless of age. It is particularly important in patients who present with dizziness to evaluate patients' gait, speech, and eye movements before concluding their condition is benign."

Dr. Chaturvedi said his future research will examine potential differences between misdiagnosis rates in designated and undesignated stroke centers.

International Stroke Conference 2009: Abstract 33. Presented February 18, 2009.

6. Postreduction Management of First-Time Traumatic Anterior Shoulder Dislocations

McNeil NJ. Ann Emerg Med. 2009; in press.

The shoulder is the most commonly dislocated joint. The overall sex- and age-adjusted incidence of initial traumatic shoulder dislocation is 8.2 per 100,000 person-years in the United States. For the past 2,000 years, immobilization in internal rotation has been performed after reduction. In a 2004 survey of British Trauma Society members, 93% immobilize anterior shoulder dislocations postreduction in internal rotation. Despite this, the recurrence rate after an initial dislocation ranges between 20% and 50%.The rate is 50% to 64% in patients younger than 30 years. It is unclear whether the duration of immobilization has any effect on the recurrence rate. The traumatic lesion found in 94% to 97% of initial shoulder dislocations is called the Bankart lesion. It consists of a detachment of the inferior glenohumeral ligament–labrum complex from the glenoid and is the main determinant of acquired shoulder instability after shoulder dislocation. Anterior shoulder dislocations evaluated after reduction by arthroscopy and magnetic reonance imaging (MRI) showed better reduction of the labrum in external rotation than in internal rotation. There is also MRI evidence of healing in the reduced position after immobilization for 3 weeks in external rotation. We reviewed the available evidence to determine the optimal method of immobilization of a first-time traumatic anterior shoulder dislocation.

Search Strategy
An Ovid MEDLINE (1950 to present) search was performed by using “shoulder dislocation” in the title and keywords (immobilization or immobilisation or “external rotation” or recurrence), with no limits. This search yielded 230 articles. Bibliographic references found in these articles were also examined to identify pertinent literature. Articles dealing with operative treatment were excluded. Cadaveric and MRI outcome studies were also excluded as a result of their low level of evidence-based medicine. Five original research articles were identified that addressed the optimal method of immobilization after traumatic anterior shoulder dislocations.

The Bottom Line
The currently available evidence suggests that the immobilization of a first-time traumatic shoulder dislocation in external rotation for 3 weeks reduces the risk of recurrent dislocation. There is little to no evidence that immobilization in internal rotation has any effect on recurrence. Shoulder dislocations with a nondisplaced fracture of the greater tuberosity have a decreased risk of recurrence. It would be within the standard of care to immobilize first-time traumatic anterior shoulder dislocations without a fracture of the greater tuberosity in external rotation

7. New Guidelines on Management of Aneurysmal Subarachnoid Hemorrhage

January 22, 2009 — New guidelines on the management of aneurysmal subarachnoid hemorrhage (aSAH) have been released by the American Heart Association/American Stroke Association.

Mortality associated with aSAH is high, about 45% in the first 30 days after a rupture, Dr. Bederson said. Still, he notes, "The majority of aneurysms do not rupture, and as much as 1% of the population dies of old age with a small, unruptured aneurysm."
SAH is frequently misdiagnosed, in up to 12% of cases. For the initial evaluation of headache, CT scanning for suspected SAH is "strongly recommended," followed by lumbar puncture if the CT is negative. A standard management protocol for the evaluation of patients with headaches and other symptoms that may potentially relate to SAH does not currently exist and should be developed.

Early vs later treatment of the aneurysm reduces the risk for rebleeding after SAH, and so early surgery is "reasonable and probably indicated in the majority of cases," the authors write.

Medical measures to prevent rebleeding include blood-pressure monitoring and control and bed rest, although these should be part of a broader strategy with more definitive measures. A short course of antifibrinolytics may be considered prior to definitive treatment.

To reduce poor outcomes associated with vasospasm, the authors "strongly recommend" use of oral nimodipine. The value of other calcium antagonists remains uncertain, they note. Treatment begins with early management of the ruptured aneurysm, they add; "in most cases maintaining normal circulating blood volume and avoiding hypovolemia is probably indicated."

Another "reasonable" approach to symptomatic vasospasm is volume expansion with induction of hypertension and hemodilution, so-called "triple-H therapy," the authors note. "Alternatively, cerebral angioplasty and/or selective intra-arterial vasodilator therapy may also be reasonable, either following, or together with, or in the place of, triple-H therapy, depending on the clinical scenario."

The relationship between hypertension and aSAH is "uncertain," they conclude, but management of blood pressure to prevent other clinical problems is recommended. Quitting smoking is "reasonable," they note, "although the evidence for this association is indirect."

Screening for unruptured aneurysms in high-risk populations is of "uncertain value," they conclude. Noninvasive imaging may be used for such screening, "but catheter angiography remains the 'gold standard' when it is clinically imperative to know if an aneurysm exists."

Full-text: http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.108.191395v1.pdf

8. Respiratory Syncytial Virus Infection May Cause Substantial Morbidity in Young Children

Laurie Barclay, MD. February 4, 2009 — Respiratory syncytial virus (RSV) infection in young children is linked with substantial morbidity in US children in both inpatient and outpatient settings, according to results from a surveillance study reported in the February 5 issue of the New England Journal of Medicine.

"The primary role of [RSV] in causing infant hospitalizations is well recognized, but the total burden of RSV infection among young children remains poorly defined," write Caroline Breese Hall, MD, from the University of Rochester School of Medicine and Dentistry in New York, and colleagues.

"The Centers for Disease Control and Prevention (CDC) initiated the New Vaccine Surveillance Network...a prospective, population-based inpatient and outpatient surveillance for acute respiratory infections among children under 5 years of age in 2000 in Nashville and Rochester, New York, and in 2003 in Cincinnati," the authors write. "The aim of our study was to determine the population-based burden of RSV infection among hospitalized children and outpatients in emergency departments and primary care settings."

This prospective, population-based surveillance study of acute respiratory infections among children younger than 5 years took place in 3 US counties. Hospitalized children were enrolled from 2000 through 2004, and outpatients in emergency departments and pediatric offices were enrolled from 2002 through 2004. Culture and reverse-transcriptase polymerase chain reaction were used to diagnose RSV infection. Parents and medical record review provided clinical data. The investigators calculated population-based rates of hospitalization linked to RSV infection and determined approximate rates of RSV-associated outpatient visits.

RSV infections occurred in 919 (18%) of 5067 children enrolled in the study. From November through April, RSV was associated with 20% of hospitalizations, 18% of emergency department visits, and 15% of office visits for acute respiratory infections. For children younger than 6 months, average annual hospitalization rates were 17 per 1000 vs 3 per 1000 children younger than 5 years. Prematurity and young age were independent risk factors for hospitalization; most of the hospitalized children had no comorbid illnesses.

Among children younger than 5 years, estimated rates of RSV-associated office visits were 3 times those in emergency departments. Although outpatients had moderately severe RSV-associated illness, only 3% of the illnesses were diagnosed as being caused by RSV.

"RSV infection is associated with substantial morbidity in U.S. children in both inpatient and outpatient settings," the study authors write. "Most children with RSV infection were previously healthy, suggesting that control strategies targeting only high-risk children will have a limited effect on the total disease burden of RSV infection.... On the basis of our findings, we estimate that among children under the age of 5 years, RSV infection results in approximately 1 of 334 hospitalizations, 1 of 38 visits to an emergency department, and 1 of 13 visits to a primary care office each year in the United States."

This study was supported by cooperative agreements with the CDC. Some of the authors report various financial relationships with MedImmune, Astellas, GlaxoSmithKline, Merck, Pfizer, and/or Wyeth.

N Engl J Med. 2009;360:588–598.

9. New Class of Drugs for Acute Migraine

Telcagepant, a calcitonin gene-related peptide antagonist, is as effective as zolmitriptan, with fewer adverse effects.

Migraine headache is commonly treated with triptans (serotonin-receptor agonists), but, because these agents are associated with side effects (such as chest discomfort, dizziness, and throat tightness), they are poorly tolerated by some patients and contraindicated in those with cardiovascular disease. Telcagepant is a new calcitonin gene-related peptide antagonist that lacks the vasoconstrictor effects of triptans. In a randomized, controlled, double-blind, parallel-treatment trial funded by the maker of telcagepant, 1380 adult patients (mean age, 42; 85% female) with acute migraine received one of four oral treatments: telcagepant (160 mg or 300 mg), zolmitriptan (5 mg), or placebo. The study was conducted at 81 outpatient primary care and headache centers in Europe and the U.S.

Patients were excluded if they had cardiovascular disease or uncontrolled hypertension or had used selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, or propranolol within 1 month before the screening visit. Patients recorded headache pain severity (none, mild, moderate, or severe) and presence or absence of phonophobia, photophobia, and nausea at baseline; every 30 minutes for 3 hours; and at 4, 6, 8, and 24 hours.

Telcagepant 300 mg and zolmitriptan 5 mg were similarly effective, and both were superior to telcagepant 150 mg and placebo for pain relief; pain freedom; and absence of phonophobia, photophobia, and nausea. No deaths and only one serious adverse event (in a placebo recipient) were reported. Adverse events were significantly more common in the zolmitriptan group than in the other three groups.

Comment: An editorialist suggests that the proof of efficacy of telcagepant — the first of a new class of drugs — "marks a new era in migraine therapy." If approved by the FDA (the manufacturer plans to file a new drug application in 2009) and other regulatory agencies, telcagepant and its future congeners show promise as effective alternatives to triptans. This new drug might be another important step toward the goal of minimizing or eliminating emergency department visits by patients with chronic migraine syndromes.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emerg Med January 16, 2009.
Citation: Ho TW et al. Lancet 2008 Dec 20; 372:2115.

10. Etomidate Induction Does Not Increase Mortality in Septic Patients

Neither mortality nor hospital length of stay differed between septic patients who received etomidate and those who received other agents for rapid sequence intubation.

Tekwani KL, et al. Acad Emerg Med. 2009;16:11-14.
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19055676

11. Mortality Rates Vary Among Trauma Centers

NEW YORK (Reuters Health) Feb 03 - Even after controlling for injury severity, mortality rates vary significantly across similarly designated trauma centers, according to a report in the January issue of the Archives of Surgery.

"Our results imply that the quality of trauma care is not consistent across similarly designated trauma centers despite the use of the designation process," the authors say.

Dr. Shahid Shafi from the University of Texas Southwestern Medical School, Dallas, and colleagues measured mortality rates at 15 designated Level 1 and 2 trauma centers in Texas, after controlling for injury severity and other patient characteristics.

In a logistic regression analysis, age, mechanism of injury, Injury Severity Score, initial systolic blood pressure, and Glasgow Coma Scale scores measured in the emergency department and individual trauma centers independently predicted mortality, the researchers report.

Compared with the best-performing center, 8 of the other 14 trauma centers had significantly worse odds of survival, while the remaining 6 had similar odds of survival.

"The current criteria used in the designation process may not measure all of the resources needed to achieve best possible survival rates," the investigators speculate. "Alternatively, it is possible that the factors that do influence outcome are not measured by the designation process."

"Either way," they add, "it appears that the designation process could be improved if the factors associated with differences in outcome can be identified and included in the process."

Arch Surg 2009;144:64-68.

12. TRIAD II: Do Living Wills Have an Impact on Pre-Hospital Lifesaving Care?

Mirarchi FL, et al. J Emerg Med. 2009;36:105-115.

Background: Living wills accompany patients who present for emergent care. To the best of our knowledge, no studies assess pre-hospital provider interpretations of these instructions.

Objectives: Determine how a living will is interpreted and assess how interpretation impacts lifesaving care.

Design setting: Three-part survey administered at a regional emergency medical system educational symposium to 150 emergency medical technicians (EMTs) and paramedics. Part I assessed understanding of the living will and do-not-resuscitate (DNR) orders. Part II assessed the living will's impact in clinical situations of patients requiring lifesaving interventions. Part III was similar to part II except a code status designation (full code) was incorporated into the living will.

Results: There were 127 surveys completed, yielding an 87% response rate. The majority were male (55%) and EMTs (74%). The average age was 44 years and the average duration of employment was 15 years. Ninety percent of respondents determined that, after review of the living will, the patient's code status was DNR, and 92% defined their understanding of DNR as comfort care/end-of-life care. When the living will was applied to clinical situations, it resulted in a higher proportion of patients being classified as DNR as opposed to full code (Case A 78% vs. 22%, respectively; Case B 67% vs. 33%, respectively; Case C 63% vs. 37%), respectively. With the scenarios presented, this DNR classification resulted in a lack of or a delay in lifesaving interventions. Incorporating a code status into the living will produced statistically significant increases in the provision of lifesaving care. In Case A, intubation increased from 15% to 56% (p less than 0.0001); Case B, defibrillation increased from 40% to 59% (p less than 0.0001); and Case C, defibrillation increased from 36% to 65% (p less than 0.0001).

Conclusions: Significant confusion and concern for patient safety exists in the pre-hospital setting due to the understanding and implementation of living wills and DNR orders. This confusion can be corrected by implementing clearly defined code status into the living will.

13. Should the Digital Rectal Examination Be a Part of the Trauma Secondary Survey?

Hankin AD, et al. Ann Emerg Med. 2009;53:208-212.

The Bottom Line
In our review of the literature on the utility of digital rectal examination in the trauma evaluation, we found 7 studies appropriate for inclusion. Of these, 3 studies were prospective, involving data collection completed by members of the trauma team, and 4 were retrospective reviews. Limitations present in all included studies are the lack of randomization, lack of independent confirmation of digital rectal examination findings, and lack of blinding because the physician performing and recording the digital rectal examination findings was aware of the results of the rest of the trauma evaluation in all cases. However, lack of blinding would be expected to result in a bias toward a higher proportion of true positives and true negatives than would be present in a fully blinded study.

The consistency of the findings is compelling. All studies found that the digital rectal examination performed poorly as a screening test, with sensitivities ranging from 0% to 50% and with consistently high false-positive and false-negative rates. Two studies that compared the statistical characteristics of digital rectal examination with the rest of the physical examination found that inclusion of the digital rectal examination did not improve the predictive value of the other components of a typical trauma examination.

Nevertheless, there remain some situations in the setting of trauma in which the digital rectal examination may be a valuable part of the trauma evaluation (as suggested by Porter and Ursic), including in patients with evidence of penetrating trauma in the vicinity of the rectum, in cases in which the presence of neurologic injury is neither completely supported nor refuted by the clinical findings, and before pharmacologic paralysis. This selective approach to the use of digital rectal examination is supported by the strong positive likelihood ratios found in these studies, which ranged from 5.1 to 33.

Cf. Porter and Ursic: Digital rectal examination for trauma: does every patient need one?. Am Surg. 2001;67:438–441. http://www.ncbi.nlm.nih.gov/pubmed/11379644

14. Images in Emergency Medicine

a. Elderly Man With Upper Lip Swelling
Link: http://www.annemergmed.com/article/S0196-0644(08)00829-9/fulltext

b. Bilateral Knee Deformity Following a Fall
Link: http://www.annemergmed.com/article/S0196-0644(08)00835-4/fulltext

15. Below-Knee Cast Best for Rapid Recovery From Ankle Sprain

Barbara Boughton. February 13, 2009 — A 10-day period of immobilization in a below-knee cast or Aircast results in a more rapid recovery from ankle sprain compared with the current clinical practice of mobilization after a severe ankle sprain, according to a randomized controlled trial reported in the February 14 issue of The Lancet.

In a trial of 584 patients treated at 8 emergency departments across the United Kingdom, support with tubular compression bandage was compared with a below-knee cast, Aircast brace, and Bledsoe boot, and outcomes were assessed at 3 and 9 months.

Only the below-knee cast resulted in significantly better ankle function as well as improvements in pain, symptoms, and activity at 3 months. While the Aircast brace did not show any benefits in lessening pain or symptoms or patient activity, it produced a significant improvement in ankle function when compared with tubular compression bandage at 3 months.

"Contrary to popular clinical opinion, a period of immobilization was the most effective strategy for promoting rapid recovery. This was achieved best by the application of a below-knee cast," write Sarah E. Lamb, DPhil, from the Warwick Clinical Trials Unit, Medical School, University of Warwick, Coventry, United Kingdom, and colleagues. "The Aircast brace was a suitable alternative to below-knee casts. Results for the Bledsoe boot were disappointing, especially in view of the substantial additional cost of this device. Tubular compression bandage, which is currently the most commonly used of all the supports investigated, was, consistently the worst treatment."

The researchers conclude that below-knee cast is a better choice for clinicians treating severe ankle sprains than tubular compression bandage because it aids recovery, lessens symptoms, and helps patients return to normal function. These advantages are especially important in treating severe ankle sprain because the condition can result in severe incapacity and lingering symptoms for months or years, according to the study authors. They recommend a below-knee cast as the first-choice treatment for severe ankle sprain, because of the range of benefits seen in the study.

When compared with tubular compression bandage, the below-knee cast resulted in a 9% mean difference in ankle function at 3 months (95% confidence interval [CI], 2.4% – 15.0%) in the study. There was an 8% mean difference in quality of ankle function when the Aircast brace was compared with tubular compression bandage (95% CI, 1.8% – 14.2%).

The 3-month results are especially important in assessing the relative strengths of different treatments because most recovery from severe ankle sprains occurs within the first 6 months, according to the researchers.

The study found that there was little difference between any of the 4 treatments when patients were assessed at 9 months.

In an accompanying editorial, Jay Hertel, PhD, from the University of Virginia in Charlottesville, notes that the study's findings are likely to be viewed as controversial, because established clinical consensus on ankle sprains have emphasized functional treatment rather than immobilization. He also points out that the authors did not report on the incidence of recurrent ankle sprains in the 4 groups, which could have illuminated the long-term clinical benefits of below-knee casting.

Other limitations of the study were that the researchers were not able to measure long-term compliance with the supports accurately, except by patient self-report, and the presence of a 3-day delay before randomization in order to confirm injury severity and allow initial swelling to decrease before using a support.

Yet Dr. Hertel notes that the findings of the study are both provocative and compelling. "The results of the study call into question the current standard of aggressive functional treatment of patients recovering from acute ankle sprains," he writes.

Lancet. 2009;373:524-525, 575–581.

16. Does 16 Detector CT Improve Detection of Subarachnoid Hemorrhage?

A retrospective review was performed of patients presenting to the emergency department (ED) with symptoms suggestive of subarachnoid hemorrhage and in whom the final diagnosis was non-traumatic subarachnoid hemorrhage. Results of 16 Detector computed tomography (CT) scan, angiogram, and spinal fluid analysis were reviewed.

Of 61 patients entered in the study, one patient did not have subarachnoid hemorrhage identified by 16 detector CT but had a positive lumbar puncture and an aneurysm confirmed by cerebral angiography. In conclusion, 16 detector CT did not improve detection of non-traumatic subarachnoid hemorrhage compared to studies using single detector CT.

Lourenco AP, et al. J Emerg Med 2009;36:171-175.

17. Secondhand smoke raises risk of dementia

British researchers found that exposure to secondhand smoke can raise a person's risk of developing dementia by 44%. The study of more than 4,800 nonsmokers who were over age 50, published in the journal BMJ.com, also showed the risk increased with the amount of exposure

BMJ 2009;338:b462.

Abstract: http://www.bmj.com/cgi/content/abstract/338/feb12_2/b462

18. A Critical Comparison of Clinical Decision Instruments for Computed Tomographic Scanning in Mild Closed Traumatic Brain Injury in Adolescents and Adults

Stein SC, et al. Ann Emerg Med. 2009;53:180-188.

Study objective
A number of clinical decision aids have been introduced to limit unnecessary computed tomographic scans in patients with mild traumatic brain injury. These aids differ in the risk factors they use to recommend a scan. We compare the instruments according to their sensitivity and specificity and recommend ones based on incremental benefit of correctly classifying patients as having surgical, nonsurgical, or no intracranial lesions.

Methods
We performed a secondary analysis of prospectively collected database from 7,955 patients aged 10 years or older with mild traumatic brain injury to compare sensitivity and specificity of 6 common clinical decision strategies: the Canadian CT Head Rule, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies, the New Orleans, the National Emergency X-Radiography Utilization Study II (NEXUS-II), the National Institute of Clinical Excellence guideline, and the Scandinavian Neurotrauma Committee guideline. Excluded from the database were patients for whom the history of trauma was unclear, the initial Glasgow Coma Scale score was less than 14, the injury was penetrating, vital signs were unstable, or who refused diagnostic tests. Patients revisiting the emergency department within 7 days were counted only once.

Results
The percentage of scans that would have been required by applying each of the 6 aids were Canadian CT head rule (high risk only) 53%, Canadian (medium & high risk) 56%, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies 56%, New Orleans 69%, NEXUS-II 56%, National Institute of Clinical Excellence 71%, and the Scandinavian 50%. The 6 decision aids' sensitivities for surgical hematomas could not be distinguished statistically (P greater than .05). Sensitivity was 100% (95% confidence interval [CI] 96% to 100%) for NEXUS-II, 98.1% (95% CI 93% to 100%) for National Institute of Clinical Excellence, and 99.1% (95% CI 94% to 100%) for the other 4 clinical decision instruments. Sensitivity for any intracranial lesion ranged from 95.7% (95% CI 93% to 97%) (Scandinavian) to 100% (95% CI 98% to 100%) (National Institute of Clinical Excellence). In contrast, specificities varied between 30.9% (95% CI 30% to 32%) (National Institute of Clinical Excellence) and 52.9% (95% CI 52% to 54) (Scandinavian).

Conclusion
NEXUS-II and the Scandinavian clinical decision aids displayed the best combination of sensitivity and specificity in this patient population. However, we cannot demonstrate that the higher sensitivity of NEXUS-II for surgical hematomas is statistically significant. Therefore, choosing which of the 2 clinical decision instruments to use must be based on decisionmakers' attitudes toward risk.

NEXUS-II Review
The study identified eight criteria that were independently and highly associated with intracranial injuries. These include:

evidence of significant skull fracture
scalp hematoma
neurologic deficit
altered level of alertness
abnormal behavior
coagulopathy
persistent vomiting
age 65 or more

The study showed that patients who did not have any of the above criteria were unlikely to have significant injuries revealed by CT imaging and could therefore be safely discharged following a thorough evaluation without the use of CT.

Source: Mower et al. Developing a Decision Instrument to Guide Computed Tomographic Imaging of Blunt Head Injury Patients. Journal of Trauma-Injury Infection & Critical Care. 2005;59:954-959.

19. Post-Transient Ischemic Attack Early Stroke Stratification: The ABCD2 Prognostic Aid

Carpenter CR, et al. J Emerg Med. 2009;36:194-200.

Abstract
Background: In many patients, transient ischemic attack (TIA) precedes stroke. Prompt recognition of TIA patients who are at increased short-term risk for stroke may facilitate efficient resource utilization and improved patient outcomes. Three prognostic decision aids have been derived and validated to empower emergency physicians to stratify TIA patients for 2-day stroke risk based upon information readily available at the bedside.

Clinical Question: Can a TIA stratification tool predict short-term stroke risk?

Evidence Review: Two relevant tool derivation studies and one validation study were selected from an evidence search and a structured review.

Results: The three tools reveal similar prognostic capabilities, although the ABCD2 prognostic guide may be slightly superior. A proposal scoring system for TIA patients at low risk for stroke within 90 days is presented.

Conclusion: Stroke risk stratification is possible with a simple prediction rule.

Commentary: The ABCD2 rule and any subsequent improved rule will need to undergo implementation studies to ensure that such rules have an important impact on the resulting morbidity and mortality of TIA patients due to subsequent stroke, and assess the impact of using such rules in busy EDs.

ABCD2 Rule Review

Risk Factor Points
Age over 60 years 1
Blood pressure over 140/90 1
Clinical features
Unilateral weakness 2
Language disturbance w/o weakness 1
Diabetes 2
Duration more than 60 min 2
Duration 10–59 min 1
Duration less than 10 min 0

A score of 0 was associated with a 0% 90-day stroke risk, whereas a score of 1 had a 1–3% 90-day risk. The 2-day stroke risk for ABCD2 score 1 or less was 0%, but for a score of 2, the 2-day stroke risk was 1–2%. The authors advocate for an ABCD2 score of 3 or less as “low risk,” although ED patients in California had a 2–3% 2-day stroke risk with a score of 3 (10/438 suffered a stroke) and an ABCD2 score 6 or greater as high risk.

20. Imaging strategies for low-back pain: systematic review and meta-analysis

Chou R, et al. Lancet 2009;373 (9662):463-472.

Background
Some clinicians do lumbar imaging routinely or in the absence of historical or clinical features suggestive of serious low-back problems. We investigated the effects of routine, immediate lumbar imaging versus usual clinical care without immediate imaging on clinical outcomes in patients with low-back pain and no indication of serious underlying conditions.

Methods
We analysed randomised controlled trials that compared immediate lumbar imaging (radiography, MRI, or CT) versus usual clinical care without immediate imaging for low-back pain. These trials reported pain or function (primary outcomes), quality of life, mental health, overall patient-reported improvement (based on various scales), and patient satisfaction in care received. Six trials (n=1804) met inclusion criteria. Study quality was assessed by two independent reviewers with criteria adapted from the Cochrane Back Review Group. Meta-analyses were done with a random effects model.

Findings
We did not record significant differences between immediate lumbar imaging and usual care without immediate imaging for primary outcomes at either short-term (up to 3 months, standardised mean difference 0·19, 95% CI −0·01 to 0·39 for pain and 0·11, −0·29 to 0·50 for function, negative values favour routine imaging) or long-term (6—12 months, −0·04, −0·15 to 0·07 for pain and 0·01, −0·17 to 0·19 for function) follow-up. Other outcomes did not differ significantly. Trial quality, use of different imaging methods, and duration of low-back pain did not affect the results, but analyses were limited by small numbers of trials. Results are most applicable to acute or subacute low-back pain assessed in primary-care settings.

Interpretation
Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.

Funding
American Pain Society.