Lit Bits. May 25, 2009

From the recent medical literature...

0. Friendships and Health

In the quest for better health, many people turn to doctors, self-help books or herbal supplements. But they overlook a powerful weapon that could help them fight illness and depression, speed recovery, slow aging and prolong life: their friends.

Researchers are only now starting to pay attention to the importance of friendship and social networks in overall health. A 10-year Australian study found that older people with a large circle of friends were 22 percent less likely to die during the study period than those with fewer friends. A large 2007 study showed an increase of nearly 60 percent in the risk for obesity among people whose friends gained weight. And last year, Harvard researchers reported that strong social ties could promote brain health as we age.

“In general, the role of friendship in our lives isn’t terribly well appreciated,” said Rebecca G. Adams, a professor of sociology at the University of North Carolina, Greensboro. “There is just scads of stuff on families and marriage, but very little on friendship. It baffles me. Friendship has a bigger impact on our psychological well-being than family relationships.”

The rest of the article: http://www.nytimes.com/2009/04/21/health/21well.html

1. Dropping the Baton: A Qualitative Analysis of Failures During the Transition From Emergency Department to Inpatient Care

Horwitz LI, et al. Ann Emerg Med. 2009;53:701-710.e4

Study objective
We identify, describe, and categorize vulnerabilities in emergency department (ED) to internal medicine patient transfers.

Methods
We surveyed all emergency medicine house staff, emergency physician assistants, internal medicine house staff and hospitalists at an urban, academic medical center. Respondents were asked to describe any adverse events occurring because of inadequate communication between emergency medicine and the admitting physician. We analyzed the open-ended responses with standard qualitative analysis techniques.

Results
Of 139 of 264 survey respondents (53%), 40 (29%) reported that a patient of theirs had experienced an adverse event or near miss after ED to inpatient transfer. These 40 respondents described 36 specific incidents of errors in diagnosis (N=13), treatment (N=14), and disposition (N=13), after which patients experienced harm or a near miss event. Six patients required an upgrade in care from the floor to the ICU. Although we asked respondents to describe communication failures, analysis of responses identified numerous contributors to error: inaccurate or incomplete information, particularly of vital signs; cultural and professional conflicts; crowding; high workload; difficulty in accessing key information such as vital signs, pending data, ED notes, ED orders, and identity of responsible physician; nonlinear patient flow; “boarding” in the ED; and ambiguous responsibility for sign-out or follow-up.

Conclusion
The transfer of a patient from the ED to internal medicine can be associated with adverse events. Specific vulnerable areas include communication, environment, workload, information technology, patient flow, and assignment of responsibility. Systems-based interventions could ameliorate many of these and potentially improve patient safety.

Free full-text: http://www.annemergmed.com/article/S0196-0644(08)00795-6/fulltext

2. An aspirin a day…?

Aspirin is enormously useful as a secondary prophylactic for cardiovascular events including myocardial infarction and ischaemic stroke in patients with known arteriosclerotic disease. There has been concern, however, that aspirin can also increase haemorrhagic strokes and cause gastrointestinal bleeding. Whether the regular use of aspirin is effective in protecting against vascular disease in healthy individuals (primary prevention) is unclear. This study involving 95,000 individuals investigated the balance of positive and negative effects, and the results indicate no overwhelming difference. For individual patients, therefore, it depends on whether it is better to risk an MI or a gastrointestinal bleed.

The Lancet. 2009;373:1849–1860.

Abstract: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60503-1/abstract

3. New AHA/ASA Guidelines on TIA Management Released

May 8, 2009 — The American Heart Association (AHA)/American Stroke Association (ASA) has released new guideline documents for transient ischemic attacks (TIA).

The TIA document waspublished online May 7 and will appear in the June issue of Stroke.

New Definition of TIA

In the scientific statement examining the definition and evaluation of TIAs, the writing group points out that large cohort and population-based studies reported in the past 5 years have shown that the risk for stroke after a TIA is higher than previously thought. "Ten percent to 15% of patients have a stroke within 3 months, with half occurring within 48 hours," the group, chaired by J. Donald Easton, MD, professor and chair of the department of clinical neurosciences at Alpert Medical School of Brown University and the Rhode Island Hospital, in Providence, writes.

Accordingly, the authors recommend that TIAs be subject to the same urgent assessment and care given to acute strokes and, to that end, have changed the clinical definition of TIA. "We think a TIA should be treated as an emergency, just like a major stroke," Dr. Easton said in a news release from the AHA/ASA. "Because we know the high risk for a future stroke, this is a golden opportunity to prevent a catastrophic event."

The traditional clinical definition, dating to the mid-1960s, is "a sudden neurological deficit of presumed vascular origin lasting less than 24 hours." The new statement changes this definition to "a transient episode of neurological dysfunction caused by focal brain, spinal-cord, or retinal ischemia, without acute infarction."

The presence of infarction has been the main distinction between stroke and TIA, but the advent of more sensitive imaging of tissue damage using magnetic resonance imaging (MRI) has suggested that infarction with presumed TIAs may occur often.

"Research around the globe has shown that the arbitrary threshold based on duration of symptoms was too broad, because up to half of TIAs defined this way actually caused sustained brain injury according to an MRI," Dr. Easton noted.

4. D-Dimer Measurement to Determine Pneumonia Severity?

An admission D-dimer level less than 500 ng/mL was associated with low risk for death and major morbidity.

Chalmers JD, et al. Ann Emerg Med. 2009;53:633-38.

Study objective
Severity assessment is an important component of the management of community-acquired pneumonia. Clinicians are increasingly searching for biomarkers to aid in clinical decisions. Coagulation disorders can accompany severe pneumonia. We seek to investigate the association of D-dimer, a fibrinolysis biomarker, and 30-day mortality or the need for mechanical ventilation or vasopressor support in emergency department (ED) patients with community-acquired pneumonia.

Methods
We prospectively enrolled ED patients with community-acquired pneumonia between December 2005 and January 2008 in a convenience manner. We measured D-dimer level with the Vitek ImmunoDiagnostic Assay System. To assess clinical illness severity, both CURB65 and the Pneumonia Severity Index (Pneumonia Severity Index class) were calculated. Our primary outcomes were 30-day mortality and need for mechanical ventilation or vasopressor support.

Results
Of the 314 enrolled patients, 23.9% of patients had a D-dimer level less than 500 ng/mL on initial ED measurement, and 81.3% of these patients were in Pneumonia Severity Index class I to III. A D-dimer level of less than 500 ng/mL had a negative likelihood ratio of 0 (95% confidence interval 0 to 1.37) for 30-day mortality and 0.33 (95% confidence interval 0.09 to 1.27) for need for mechanical ventilation or vasopressor support. For 30-day mortality, the area under the receiver operator characteristic curve for D-dimer was similar to both CURB65 and Pneumonia Severity Index class. For mechanical ventilation or vasopressor support, the area under the receiver operator characteristic curve for D-dimer was lower than that for CURB65 but did not differ from that for Pneumonia Severity Index.

Conclusion
An admission D-dimer level less than 500 ng/mL is associated with low risk of short-term death and major morbidity in patients with community-acquired pneumonia.

5. Time to PCI: Is 90 Minutes Fast Enough?

Reduction in door-to-balloon time below 90 minutes translates to decreased mortality.

Current clinical guidelines set a door-to-balloon time goal of within 90 minutes for patients with ST-segment-elevation myocardial infarction (STEMI), but do further reductions in time improve outcomes? Researchers analyzed prospectively collected data from the American College of Cardiology National Cardiovascular Data Registry for 43,801 adult patients who presented with STEMI within 12 hours of symptom onset and underwent percutaneous coronary intervention (PCI) at more than 600 U.S. centers.

Median door-to-balloon time was 83 minutes (interquartile range, 62–109 minutes); nearly 60% of patients received intervention within 90 minutes of hospital arrival. Patients who had longer door-to-balloon times were older and had more comorbidities, including cardiogenic shock, than those who had shorter door-to-balloon times and were more likely to be women, not white, and to present after hours and on weekends.

The overall mortality rate was 4.6%. In logistic regression analysis, increasing times to PCI were associated with increasingly higher adjusted mortality rates as follows: 30 minutes, 3.0%; 60 minutes, 3.5%; 90 minutes, 4.3%; 120 minutes, 5.6%; 150 minutes, 7.0%. The researchers conclude that any delay in PCI portends higher mortality. They recommend that the standard for door-to-balloon time should be "as soon as possible," rather than within 90 minutes.

Comment: These results sound a clear warning that simply meeting the 90-minute standard isn’t good enough. Hospitals and emergency medical services systems should work together to deploy prehospital electrocardiography, activate the cath lab before arrival of patients with a prehospital electrocardiogram indicating STEMI, and establish prompt access to PCI 24/7 (JW Cardiol Oct 17 2007). Shaving even a few minutes off door-to-balloon time is likely to save lives!

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine May 20, 2009. Citation: Rathore SS et al. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: National cohort study. BMJ 2009 May 19; 338:b1807. (http://dx.doi.org/10.1136/bmj.b1807)

6. Randomized, Controlled Trial of Antibiotics in the Management of Community-Acquired Skin Abscesses in the Pediatric Patient

Study objective
Emergency department visits for skin and soft tissue infections are increasing with the discovery of community-acquired methicillin-resistant Staphylococcus aureus. Whether abscesses treated surgically also require antibiotics is controversial. There are no published pediatric randomized controlled trials evaluating the need for antibiotics in skin abscess management. We determine the benefits of antibiotics in surgically managed pediatric skin abscesses.

Methods
This was a double-blind, randomized, controlled trial. Pediatric patients were randomized to receive 10 days of placebo or trimethoprim-sulfamethoxazole after incision and draining. Follow-up consisted of a visit/call at 10 to 14 days and a call at 90 days. Primary outcome was treatment failure at the 10-day follow-up. Secondary outcome was new lesion development at the 10- and 90-day follow-ups. Noninferiority of placebo relative to trimethoprim-sulfamethoxazole for primary and secondary outcomes was assessed.

Results
One hundred sixty-one patients were enrolled, with 12 lost to follow-up. The failure rates were 5.26% (n=4/76) and 4.11% (n=3/73) in the placebo and antibiotic groups, respectively, yielding a difference of 1.15, with a 1-sided 95% confidence interval (CI) (1.15% to 6.8%). Noninferiority was established with an equivalence threshold of 7%. New lesions occurred at the 10-day follow-up: 19 on placebo (26.4%) and 9 on antibiotics (12.9%), yielding a difference of 13.5, with 95% 1-sided CI (13.5% to 24.3%). At the 3-month follow-up, 15 of 52 (28.8%) in the placebo group and 13 of 46 (28.3%) in the antibiotic group developed new lesions. The difference was 0.58, with 95% 1-sided CI (0.5% to 15.6%).

Conclusion
Antibiotics are not required for pediatric skin abscess resolution. Antibiotics may help prevent new lesions in the short term, but further studies are required.

Duong M, et al. Ann Emerg Med 2009; in press

7. Epinephrine Plus Dexamethasone May Reduce Hospitalizations for Children With Bronchiolitis

Laurie Barclay, MD. May 13, 2009 — Combined epinephrine plus dexamethasone treatment may significantly reduce hospital admissions in children with bronchiolitis seen in the emergency department, according to the results of a multicenter, double-blind, placebo-controlled trial reported in the May 14 issue of the New England Journal of Medicine.

"Although numerous studies have explored the benefit of using nebulized epinephrine or corticosteroids alone to treat infants with bronchiolitis, the effectiveness of combining these medications is not well established," write Amy C. Plint, MD, MSc, from Children's Hospital of Eastern Ontario in Ottawa, Canada, and colleagues. "The current study was undertaken in response to the continued controversy concerning the use of nebulized epinephrine and systemic corticosteroids in the treatment of bronchiolitis in infants and in recognition of the substantial burden that the care of infants with this disease adds to the health care system."

In this study, 800 infants aged 6 weeks to 12 months who were seen in the pediatric emergency department for bronchiolitis were randomly assigned to 1 of 4 groups. The epinephrine-dexamethasone group received 2 treatments of nebulized epinephrine (3 mL of epinephrine in a 1:1000 solution per treatment) and a total of 6 oral doses of dexamethasone (1.0 mg/kg of body weight in the emergency department and 0.6 mg/kg for an additional 5 days). The epinephrine-alone group received nebulized epinephrine and oral placebo, the dexamethasone-alone group received nebulized placebo and oral dexamethasone, and the placebo group received nebulized placebo and oral placebo. The main endpoint of the study was hospitalization within 7 days from the day when the child was first seen in the emergency department and enrolled.

All 4 groups were well balanced in baseline clinical characteristics. Hospitalization occurred by day 7 in 34 infants (17.1%) in the epinephrine-dexamethasone group, 47 (23.7%) in the epinephrine group, 51 (25.6%) in the dexamethasone group, and 53 (26.4%) in the placebo group. Compared with the placebo group, only the infants in the epinephrine-dexamethasone group were significantly less likely to be admitted by day 7 (relative risk, 0.65; 95% confidence interval, 0.45 - 0.95; P = .02), based on the unadjusted analysis. This result was no longer significant after adjustment for multiple comparisons (P = .07). No serious adverse events were observed.

"Among infants with bronchiolitis treated in the emergency department, combined therapy with dexamethasone and epinephrine may significantly reduce hospital admissions," the study authors write. "These results were not modified by RSV [respiratory syncytial virus] status, presence or absence of a history of atopy, or the severity or the duration of illness."

Limitations of this study include enrollment restricted to infants who had wheezing for the first time, limiting generalizability; infants enrolled at academic centers; failure of the study design to anticipate the synergism between epinephrine and dexamethasone; and multiple comparisons present in the factorial study design.

"Given the unexpected synergy we found between epinephrine and dexamethasone and the lack of any apparent benefit when either drug is used alone, our results should be considered exploratory," the study authors conclude. "Although some clinicians consider a trial of a bronchodilator to be standard therapy, published data show, at most, mild transient clinical benefits and no effect on the admission rate. Therefore, confirmation of our findings by a study powered specifically to compare combined epinephrine and dexamethasone therapy with placebo is needed."

In an accompanying editorial, Urs Frey, MD, PhD, from University Hospital of Bern in Bern, Switzerland, and Erika von Mutius, MD, MSc, from University Children's Hospital in Munich, Germany, note the small effect size of the study (11 infants would have to be treated to prevent 1 hospital admission).

"It does not seem practical to apply the treatment, especially considering the potential effects of high-dose corticosteroids on brain and lung development in such young children," Drs. Frey and von Mutius write. "We need to assess risk factors and symptom history and make sure that we identify and treat children with unremitting wheezing. In these children, particularly those presenting with signs of atopy, maintenance treatment can be initiated with inhaled corticosteroids, administered through an appropriate spacer, or with leukotriene-receptor antagonists."

N Engl J Med. 2009;360:2079-2089; 2130-2133.

8. CTA Safe and Effective to Rule Out ACS in Emergency Room for Low- to Moderate-Risk Patients--Cheaper Too

May 4, 2009 (Washington, DC and Boston, Massachusetts) - Another study looking at the use of coronary computed tomography angiography (CTA) in the emergency room has found that the imaging tool can rule out coronary artery disease (CAD) and acute coronary syndromes (ACS) in 50% of patients with a low to intermediate risk of disease [1]. While other studies have also supported a role for CTA in the ER, authors of this latest study, known as ROMICAT, say their series represents one of the largest studies to date and also extends the findings to a low- to intermediate-risk patient. Most emergency-room series have focused to date on low-risk patients only.

In all, 31 of 368 patients (8%) were found to have ACS on the basis of further testing, the authors, led by Dr Udo Hoffmann (Harvard Medical School, Boston, MA), note. "CT is not a good option in a group with a high prevalence of CAD/ACS, and we do not need to do CT in people who have too low a risk," Hoffman told heartwire . "But most people would agree that in a group like the one we have here, with an 8% event rate--this is exactly the segment in whom imaging should be performed."

The ROMICAT study is published in the May 5, 2009 issue of the Journal of the American College of Cardiology.

Hoffman et al used an observational cohort study design, enrolling only patients with normal initial troponin and a nonischemic electrocardiogram. A 64-slice CT angiogram was done before hospital admission, but patients and physicians were blinded to the CTA results, and any treatment decisions were made on the basis of positive troponin or unstable angina pectoris during hospitalization and/or a positive stress test. Patients were also followed for six months for major adverse cardiac events.

As Hoffman et al report, CTA found that 50% of patients had no CAD, 31% had nonobstructive disease, and 19% had inconclusive results or significant stenosis. When these findings were assessed according to ACS diagnosis by other tests postadmission, sensitivity and negative predictive value for ACS were both 100%--none of the patients without plaque on CTA had ACS. By contrast, specificity and positive predictive value were lower, at 17% and 54%, since some of the patients had plaque but no ACS. However, patients with ACS typically had more plaque than patients without, the authors note.

Average hospital stay for patients was 40 hours, the authors report--a cost and inconvenience to patients that could have been avoided had CT been used to determine patient care, Hoffman said. "If you look at it from the emergency-department point of view, it's important to identify as quickly as possible those whom you can send home. That will save a day in the hospital, as well as the troponin test and nuclear-perfusion imaging. If doctors can clear out those patients, they can spend more time with the people who need it."

Hoffman added that he and his colleagues are currently reviewing the CT angiograms of patients who were found to have CAD, to see whether there is anything CT can detect in terms of plaque morphology that could help determine which patients have ACS vs those who don't. "That's taking these findings from a patient level to a lesion level," he said.

In an accompanying editorial [2], Dr Mark A Hlatky (Stanford University School of Medicine, CA) calls ROMICAT a "promising development" for the use of coronary CTA in the emergency department. "A finding of normal coronary arteries will likely obviate additional tests and speed patient discharge to home and appears to be associated with a good short-term prognosis. A finding of some degree of coronary atherosclerosis might not, however, 'clear the air,' as further investigations are likely with either stress testing or invasive coronary angiography (or both)."

The question of whether hard clinical outcomes are actually changed by the use of CTA will require studies in which CT is actually used to direct the course of care in patients, Hlatky points out. In this study, he points out, 8% of patients were lost to follow-up, potentially because patients who had a poor clinical outcome were more difficult to contact. "Although the low rate of adverse cardiac events in the ROMICAT study is reassuring, larger studies with more complete follow-up will be needed to assess more fully the prognostic implication of a coronary CTA in the emergency department," he concludes.

Cost Savings With CTA?

In other recent CT news, researchers presented a similar, smaller study during the American Roentgen Ray Society 2009 Annual Meeting, in Boston, MA, but also factored in the costs of using CTA to rule out ACS in chest-pain patients vs the costs of standard care--typically cardiac enzyme tests and serial ECGs [3].

In their analysis, 50 out of 53 low-risk patients initially admitted with chest pain were negative on CTA (defined as less than 30% stenosis in any one coronary segment). These 50 were also found, subsequently, to have negative cardiac enzymes and negative ECGs. Standard-care charges were a mean of $7567 per patient. By comparison, the charges for CTA followed by observation in the hospital were calculated to be $6153, while CTA without observation was calculated at $4251. They also calculated differences in patient length of hospital stay based on diagnostic workup and found that CTA without and with observation would be significantly less than standard care (five hours, 14.3 hours, and 25.4 hours, respectively).

Lead author for the study, Dr Janet May (University of Washington, Seattle), explained that cardiac CT was added to the standard patient "workup," and patients continued through the regular pathway of patient care. As such, she says, "We were able to see the actual savings in both time and charges that would have occurred had we used cardiac CT instead of the standard of care. I do think the savings in length of stay are just as important as the dollars saved. The two go hand in hand."

No patients reported adverse events over six months' postdischarge, researchers noted, although May emphasized to heartwire that safety of using cardiac CT in low-risk emergency-department chest pain requires further documentation.

"We are working on publishing some one-year follow-up data from chest-pain patients who had CT in the emergency department that will show early, rapid discharge is a very safe practice when the CT showed no coronary artery disease," May noted.

[1] Hoffman U, Bamberg F, Chae CU, et al. Coronary computed tomography angiography for early triage of patients with acute chest pain. The ROMICAT (Rule Out Myocardial Infarction Using Computer-Assisted Tomography) trial. J Am Coll Cardiol 2009; 53:1642–50.

[2] Hlatky MA. Evaluating use of coronary computed tomography angiography in the emergency department. J Am Coll Cardiol 2009; 53:1651-1653.

[3] May JM, Shuman WP, Strote N, et al. Low-risk chest pain patients in the emergency department: negative 6- channel cardiac CT may reduce length of stay and hospital charges. American Roentgen Ray Society 2009 Annual Meeting; April 27, 2009; Boston, MA. Abstract 1, page 55.

9. NY Times Joins Us in Educating the Public about the Risk of Taking Antibiotics

“Stomach Bug Crystallizes an Antibiotic Threat” by Stuart Bradford, April 13, 2009

Earlier this year, Harold and Freda Mitchell of Como, Miss., both came down with a serious stomach bug. At first, doctors did not know what was wrong, but the gastrointestinal symptoms became so severe that Mrs. Mitchell, 66, was hospitalized for two weeks. Her husband, a manufacturing supervisor, missed 20 days of work.

A local doctor who had worked in a Veterans Affairs hospital recognized the signs of Clostridium difficile, a contagious and potentially deadly bacterium. Although the illness is difficult to track, health officials estimate that in the United States the bacteria cause 350,000 infections each year in hospitals alone, with tens of thousands more occurring in nursing homes. While the majority of cases are found in health care settings, 20 percent or more may occur in the community. The illness kills an estimated 15,000 to 20,000 people annually.

“It’s been the worst thing I’ve ever tried to get through in my life,” said Mrs. Mitchell, who remains weakened by the ordeal. “I really did think I was going to die.”

What is so frightening about C. difficile is that it is often spurred by antibiotics. The drugs wipe out the targeted illness, like a urinary tract or upper respiratory infection, but they also kill off large portions of the healthy bacteria that normally live in the digestive tract. If a person comes into contact with C. difficile, or already has it, the disruption to the beneficial bacteria creates an opportunity for the harmful bacteria to flourish.

The public health community has been sounding the alarm for years about the overuse of antibiotics and the emergence of “superbugs” — bacteria that have developed immunity to a wide number of antibiotics. But the C. difficile problem shows that the threat is not generalized or hypothetical, but immediate and personal.

“One of the things that we counsel consumers about is to make sure that an antibiotic is really necessary,” said Dr. Dale N. Gerding, an infectious disease specialist at the Stritch School of Medicine at Loyola University in Chicago. “There are many good reasons for taking an antibiotic, but an illness like sinusitis or bronchitis winds up being treated with antibiotics even though it will go away by itself anyway.”

Full-text: http://www.nytimes.com/2009/04/14/health/14well.html

10. New Antivenom Rapidly Resolves Neurotoxic Effects of Scorpion Sting in Children

May 15, 2009 — Results of a new randomized trial show that a scorpion-specific F(ab')2 antivenom rapidly resolved the clinical neuromotor syndrome and respiratory insufficiency associated with envenomation by the Centruroides scorpion among critically ill children.

Treatment also reduced the need for sedation with midazolam in these children and reduced circulating serum venom levels.

Completion of this trial was a challenge from a variety of standpoints, said lead author Leslie V. Boyer, MD, from the University of Arizona Health Sciences Center, in Tucson. The condition is relatively rare and the presentation emergent, the subjects are children, and the antivenom used in this trial, while commercially available in Mexico, where scorpion stings are a huge problem, had never been subjected to clinical trials.

Using a simple binary end point of resolution of the clinical neuromotor syndrome within 4 hours or not, Dr. Boyer and colleagues were able to answer the question after enrolling only 15 children. "There were people who thought it wouldn't work, but they were people who hadn't treated scorpion sting and didn't know what a vivid syndrome it is," Dr. Boyer told Medscape Neurology & Neurosurgery.

Their report appears in the May 14 issue of the New England Journal of Medicine (NEJM).

Sting of the Scorpion

Scorpions are carnivores, eating mostly insects but also small vertebrates, Dr. Boyer said. Various species have developed a "small arsenal" of different toxins, most of which are channel toxins. "The sodium-channel toxins are the most infamous for human envenomation, but there are chloride-, potassium-, and calcium-channel toxins that have been identified as well," she said.

The sting of the Centruroides sculpturatus contains a toxin that affects sodium channels in peripheral nerves, she said. The clinical presentation of the sting in a child who has received a large-per-kilogram dose includes violent neuromotor hyperactivity with stereotypical eye movements.

"It's often mistaken for a seizure, although it's not symmetric and not rhythmic," Dr. Boyer noted. "Physicians will see it and assume that the child is unconscious, but they're actually wide awake and just can't control themselves."

In addition to motor nerves, nerves that innervate the muscarinic system are also clearly involved, so the children sweat and drool, although the most dangerous effect is respiratory failure from the combination of aberrant movement in the muscles associated with respiration and the inability to clear the airway of excessive salivation. "When you put all these together, these kids can be critically ill, and without medical care, it can be fatal," she said.

The Centruroides scorpion is a big issue in Mexico, where there are about 250,000 reported stings each year. About 8000 stings are reported annually in Arizona, as well as some in New Mexico, Nevada, and, rarely, California.

There are no currently approved therapies for the treatment of scorpion envenomation, she said. Until 1999, Arizona used antivenom that was manufactured locally by Marilyn Bloom at Arizona State University, who had produced a goat-derived whole IgG preparation that predated the modern Food and Drug Administration, Dr. Boyer said. "When she retired, nobody would take the goats, and nobody would make the antivenom."

Because these stings are such a problem in Mexico, they began a collaboration with researchers there to study a different type of antivenom that is already used commercially. It is an F(ab')2 antivenom, in which the immunoglobulin molecule has been altered to remove the Fc portion of the molecule responsible for most allergic reactions.

In this randomized, double-blind study, 15 children between the ages of 6 months and 18 years admitted to the pediatric intensive care unit (ICU) received either the F(ab')2 antivenom or placebo. The primary end point was the resolution of the clinical syndrome within 4 hours of administration of study drug.

They found complete resolution of symptoms within 4 hours in all 8 treated patients, vs 1 of the 7 children who received placebo.

Children receiving the antivenom required less sedation with midazolam, which might facilitate earlier discharge from the ICU, and all had undetectable levels of circulating unbound venom, vs 1 patient in the placebo group.

There were no serum reactions in this study, but they point out that the small size of the study precludes an assessment of the safety, and larger trials will still be needed.

N Engl J Med. 2009;360:2090-2098.

11. Images in Emergency Medicine (Full-text Free)

Woman With Neck Pain

http://www.annemergmed.com/article/S0196-0644(08)01724-1/fulltext

Infant With Retained Urinary Catheter

http://www.annemergmed.com/article/S0196-0644(08)01725-3/fulltext

Blurry Vision and Abnormal Sweating

http://www.annemergmed.com/article/S0196-0644(08)01905-7/fulltext

Adult Male With Right Shoulder Pain

http://www.annemergmed.com/article/S0196-0644(08)01908-2/fulltext

Elderly Woman With Shortness of Breath

http://www.annemergmed.com/article/S0196-0644(08)02024-6/fulltext

A Man With Black Urine

http://www.annemergmed.com/article/S0196-0644(08)01976-8/fulltext

12. A Graphic Reanalysis of the NINDS Trial

Hoffman JR, Schriger DL. Ann Emerg Med. 2009; in press

Study objective
Reports of clinical trials typically present only a fraction of the available data, at times hampering interpretation of their meaning. The initial report of the National Institute of Neurologic Diseases and Stroke (NINDS) trials of tissue plasminogen activator in acute ischemic stroke is an example of this phenomenon.

Methods
We used the original data from the NINDS trials to create graphs showing the effect of treatment on neurologic function in all 624 individual patients in the trial. Our goal was to show detailed graphics of the 90-day outcomes, stratified on relevant confounders and effect modifiers.

Results
Final outcomes were highly dependent on stroke severity. In many graphs, the small difference between groups favored tissue plasminogen activator, particularly when baseline NIHSS score was between roughly 5 and 22. These differences diminish or disappear when 90-day change in NIHSS is graphed. Our graphs fail to support the time-is-brain hypothesis.

Conclusion
Our graphical method of presenting the NINDS trial results provides more detail than was conveyed in the original report and empowers readers to reach their own conclusions about the trial's meaning. Outcomes for placebo and treatment limbs are sufficiently similar that larger trials, conducted under the same conditions as the NINDS trial, are needed to determine which patients benefit from this therapy.

13. Women Less Likely to Receive Proper Out-Of-Hospital Treatment for Chest Pain

By Anthony J. Brown, MD. NEW YORK (Reuters Health) May 18 - Women with chest pain are less likely than their male counterparts to receive aspirin and other recommended therapies by emergency medical service (EMS) personnel, according to study findings presented Friday at the Society for Academic Emergency Medicine's annual conference in New Orleans.

"We expected to find no differences in treatments (by gender) because so much of ambulance care is subject to protocol," lead researcher Dr. Zachary Mesiel told Reuters Health. "In general, there is not as much discretion in how to treat patients in the prehospital arena compared to hospital or outpatient care." However, the findings showed that there was, in fact, a gender difference.

The good news is that no racial disparities in out-of-hospital care were seen, noted Dr. Mesiel, who is with the University of Pennsylvania School of Medicine. Prior studies have suggested that there might be.

The results stem from a study of 683 patients with chest pain who were brought by EMS to one of three Philadelphia hospitals in 2006 and 2007. The main outcome measures were how often the subjects received four recommended EMS interventions: aspirin, nitroglycerin, heart rhythm monitoring, and an intravenous line.

Women were less likely than men to receive aspirin (24% vs. 32%), nitroglycerin (26% vs. 33%), and an intravenous line (61% vs. 70%).

Among women, those with a confirmed MI in the ER were significantly less likely than those without an MI to have received the recommended EMS interventions. In fact, none of the women with MI had received aspirin in the field.

"We still don't know why men and women get different care for chest pain," Dr. Mesiel noted. "Some of the differences may be due to the way patients describe their symptoms or their preferences in how they want to be treated. On the other hand, some of the differences may be due to biases of the providers."

As for future research, Dr. Mesiel said that it remains to be determined whether the differences in pre-hospital care between men and women translate into different outcomes.

14. Is the Ordering of Imaging for Suspected Venous Thromboembolism Consistent With D-dimer Result?

Teismann NA, et al. Ann Emerg Med 2009; in press

Study objective
We assessed whether the ordering of imaging studies in patients with suspected venous thromboembolism was consistent with the results of D-dimer testing.

Methods
We performed a retrospective chart review of consecutive cases in which a D-dimer assay was performed at an urban academic emergency department during a 13-month period. Measurements included D-dimer result and results of imaging for venous thromboembolism. The primary outcome measure was the percentage of patients in each D-dimer category (positive or negative result with a cutoff value of 500 ng fibrinogen equivalent units/dL) who underwent subsequent imaging within 48 hours. We also report the results of the imaging studies obtained.

Results
A total of 553 D-dimer tests were ordered, with 266 (48.1%) negative and 287 (51.9%) positive results. Of patients with a negative D-dimer result, 37 (14%; 95% confidence interval [CI] 10% to 19%) underwent at least 1 imaging study. Of patients with a positive D-dimer result, 137 (48%; 95% CI 42% to 54%) did not undergo imaging.

Conclusion
Evaluation for venous thromboembolism occasionally proceeded despite a negative D-dimer result, whereas frequently no further evaluation occurred despite a positive result. These findings suggest that actual clinical practice differs from what is recommended by published algorithms that guide evaluation of patients with suspected venous thromboembolism.

15. The Safety of Emergency Care Systems: Results of a Survey of Clinicians in 65 US Emergency Departments (includes Kaiser Sacramento)

Magid DJ, et al. Ann Emerg Med. 2009;53:715-723.e1

Study objective
Well-functioning systems are critical to safe patient care, but little is known about the status of such systems in US health care facilities, including high-risk settings such as the emergency department (ED). The purpose of this study is to assess the degree to which EDs are designed, managed, and supported in ways that ensure patient safety.

Methods
This was a validated, psychometrically tested survey of clinicians working in 65 US EDs that assessed clinician perceptions about the EDs' physical environment, staffing, equipment and supplies, nursing, teamwork, safety culture, triage and monitoring, information coordination and consultation, and inpatient coordination.

Results
Overall 3,562 eligible respondents completed the survey (response rate=66%). Survey respondents commonly reported problems in 4 systems critical to ED safety: physical environment, staffing, inpatient coordination, and information coordination and consultation. ED clinicians reported that there was insufficient space for the delivery of care most (25%) or some (37%) of the time. Respondents indicated that the number of patients exceeded ED capacity to provide safe care most (32%) or some of the time (50%). Only 41% of clinicians indicated that most of the time specialty consultation for critically ill patients arrived within 30 minutes of being contacted. Finally, half of respondents reported that ED patients requiring admission to the ICU were rarely transferred from the ED to the ICU within 1 hour.

Conclusion
Reports by ED clinicians suggest that substantial improvements in institutional design, management, and support for emergency care are necessary to maximize patient safety in US EDs.

16. NHLBI Ends Enrollment in Trial of Hypertonic Saline for Traumatic Brain Injury

Laurie Barclay, MD. May 14, 2009 — The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) has stopped enrollment of patients with severe traumatic brain injury (TBI) into a Resuscitation Outcomes Consortium (ROC) trial testing the effects of hypertonic saline solutions given before arrival at the emergency department.

"The [ROC] is the largest research network to study real-world, prehospital interventions for cardiopulmonary arrest and traumatic injury leading to arrest," noted George Sopko, MD, program director in the NHLBI Division of Cardiovascular Science. "By conducting these studies through such a robust network, we can compare clinical interventions in meaningful ways and disseminate the results as quickly as possible, thus saving resources and providing information of immediate benefit to patients."

An independent data and safety monitoring board (DSMB) recommended stopping enrollment on the basis of an analysis of data from 1073 patients with TBI (about half of the total planned enrollment) who had been followed up for 6 months. This planned interim analysis suggested that hypertonic saline solutions offered no benefit over the standard treatment of normal saline, nor was there any difference in risks with the 2 treatments. Despite the absence of safety concerns, the board and the investigators decided that continuing to enroll new patients was unlikely to change the study outcome.

"Although hypertonic saline solutions showed promise for improving outcomes when used as quickly as possible after trauma, our findings do not support any significant benefit of hypertonic saline over standard saline in patients with either [TBI] or shock from excessive bleeding," coprincipal investigator and ROC Vice Chair for Trauma David Hoyt, MD, from the University of California, Irvine, said in a news release. "Although these findings are disappointing, they nonetheless provide major contributions to our understanding of emergency medical care."

According to the original trial design, previously enrolled patients will continue to be monitored through their 6-month follow-up visits.

In March, the NHLBI stopped a parallel study of hypertonic saline in trauma patients with hemorrhagic shock, also because interim analysis showed that hypertonic saline (with or without dextran) vs normal saline was not associated with improved survival.

The rationale for testing hypertonic saline in these trials was that compared with normal saline, it was thought to better compensate for blood loss, to reduce harmful inflammatory responses, and to prevent cerebral edema. Previous animal studies and smaller clinical trials suggested better outcomes in patients with TBI after use of hypertonic saline solution, which is currently approved and used in 14 European countries. The safety profile to date has been good, and some evidence suggests a potential survival benefit when hypertonic saline is given as early as possible after TBI.

Surprisingly, however, in the ROC hypertonic saline for hemorrhagic shock trial, 28-day mortality was no different with hypertonic saline alone or with dextran vs normal saline. The DSMB recommended early termination of the trial based on analyses of the interim data showing that deaths occurred earlier in the hypertonic saline groups, despite similar cumulative 28-day mortality between the hypertonic and normal saline groups.

In the hypertonic saline for TBI trial, analyses of 6-month follow-up data do not suggest a similar trend toward earlier deaths in the hypertonic saline vs normal saline group. Further analyses are underway, with publication anticipated in a peer-reviewed scientific journal.

"Improving treatment and survival of traumatic injury are critical public health problems," said NHLBI Director Elizabeth G. Nabel, MD. "While these study results did not show the expected benefit of one type of treatment, other findings by the resuscitation consortium researchers — and the hundreds of emergency and fire services teams they are working with — may lead to new life-saving intervention strategies."

17. Crowding Delays Treatment and Lengthens Emergency Department Length of Stay, Even Among High-Acuity Patients

McCarthy ML, et al. Ann Emerg Med. 2009; in press

Study objective: We determine the effect of crowding on emergency department (ED) waiting room, treatment, and boarding times across multiple sites and acuity groups.

Methods: This was a retrospective cohort study that included ED visit and inpatient medicine occupancy data for a 1-year period at 4 EDs. We measured crowding at 30-minute intervals throughout each patient’s ED stay. We estimated the effect of crowding on waiting room time, treatment time, and boarding time separately, using discrete-time survival analysis with time-dependent crowding measures (ie, number waiting, number being treated, number boarding, and inpatient medicine occupancy rate), controlling for patient demographic and clinical characteristics.

Results: Crowding substantially delayed patients’ waiting room and boarding times but not treatment time. During the day shift, when the number boarding increased from the 50th to the 90th percentile, the adjusted median waiting room time (range 26 to 70 minutes) increased by 6% to 78% (range 33 to 82 minutes), and the adjusted median boarding time (range 250 to 626 minutes) increased by 15% to 47% (range 288 to 921 minutes), depending on the site. Crowding delayed the care of high-acuity level 2 patients at all sites. During crowded periods (ie, 90%), the adjusted median waiting room times of high-acuity level 2 patients were 3% to 35% higher than during normal periods, depending on the site and crowding measure.

Conclusion: Using discrete-time survival analysis, we were able to dynamically measure crowding throughout each patient’s ED visit and demonstrate its deleterious

18. Evidence-Based Emergency Medicine Reviews (Full-text Free)

Clinical Prediction Rules to Stratify Short-Term Risk of Stroke Among Patients Diagnosed in the Emergency Department With a Transient Ischemic Attack

http://www.annemergmed.com/article/PIIS0196064408015886/fulltext

Is This Patient Clinically Depressed?

http://www.annemergmed.com/article/S0196-0644(08)00793-2/fulltext

Does This Patient With Diabetes Have Osteomyelitis of the Lower Extremity?

http://www.annemergmed.com/article/S0196-0644(08)00836-6/fulltext

Does This Child Have a Urinary Tract Infection?

http://www.annemergmed.com/article/S0196-0644(08)00846-9/fulltext

Continuing Education Meetings and Workshops: Effects on Professional Practice and Health Care Outcomes

http://www.annemergmed.com/article/S0196-0644(08)00849-4/fulltext

19. Neurocognitive Function of ED Patients With Mild Traumatic Brain Injury

Peterson SE, et al. Ann Emerg Med. 2009;53:796-803.e1

Study objective
We characterize the neurocognitive function of patients presenting to the emergency department (ED) with mild traumatic brain injury.

Methods
This prospective study took place at an urban, academic ED and Level I trauma center. Case patients consisted of a convenience sample of ED patients aged 18 to 59 years, presenting to the ED with mild traumatic brain injury and having a head computed tomography scan without traumatic abnormalities. Controls consisted of patients aged 18 to 59 years, presenting to the ED with an isolated, nondominant hand extremity injury. We excluded patients with multiple injuries and recent alcohol consumption. Subjects completed a computerized neurocognitive test battery (Immediate Post-concussion Assessment and Cognitive Testing). The primary measures were verbal memory, visual memory, and visual motor and reaction speed. We compared raw and age-normalized neurocognitive performance between case patients and controls by using nonparametric statistics.

Results
We included a total of 23 head-injured case patients and 31 non–head-injured controls. Case patients and controls exhibited similar raw (median 80.1 versus 85.0 points; difference in medians –4.9; P=.26) and age-normalized (31.9 versus 57.4 percentile; difference in medians –25.5; P=.12) verbal memory. Case patients and controls exhibited similar raw (64.6 versus 63.5; difference 1.1; P=.79) and age-normalized (20.8 versus 25.8 percentile; difference –5.0; P=.44) visual memory. Compared with controls, mild traumatic brain injury case patients demonstrated slower raw (31.6 versus 37.0 points; difference –5.4; P=.002) and age-normalized (17.1 versus 57.6 percentile; difference –40.5; P=.001) visual motor speed. Mild traumatic brain injury case patients exhibited slower raw (median 0.66 versus 0.60 seconds; difference 0.06; P=.01) and age-normalized (29.3 versus 42.8 percentile; difference –13.5; P=.009) reaction times.

Conclusion
In conclusion, compared with the non–head-injured patients, ED mild traumatic brain injury patients demonstrated subtle but discernible neurocognitive deficits.

20. The Association Between Transfer of Emergency Department Boarders to Inpatient Hallways and Mortality: A 4-Year Experience

Viccellio A, et al. Ann Emerg Med. 2009; in press

Study objective
We developed and implemented an institutional protocol aimed at reducing crowding by admitting boarded patients to hospital inpatient hallways. We hypothesized that transfer of admitted patients from the emergency department (ED) to inpatient hallways would be feasible and not create patient harm.

Methods
This was a retrospective cohort study in a suburban, academic ED with an annual census of 70,000. We studied consecutive patients admitted from our ED between January 2004 and January 2008. In 2001, a multidisciplinary team developed and implemented an institutional protocol in which admitted adult patients boarded in the ED were transferred to hospital inpatient hallways under select conditions. We extracted data from the electronic medical record system, measuring patient demographics, ED disposition (discharge, admit to floor, admit to hallway), ED length of stay, and inhospital mortality. We report ED length of stay, subsequent transfer to an ICU, and hospital mortality of patients admitted to standard and hallway inpatient beds.

Results
Of 55,062 ED patients admitted, there were 1,798 deaths. Of all admissions, 2,042 (4%) went to a hallway; 53,020 went to a standard bed. Patients admitted to standard and hallway beds were similar in age (median [interquartile range] 55 years [37 to 72 years] and 54 years [41 to 70 years], respectively) and sex (48.2% and 50% female patients, respectively). The median (interquartile range) times from ED triage to actual admission in patients admitted to standard and hallway beds were 426 minutes (306 to 600 minutes) and 624 (439 to 895 minutes) minutes, respectively (P less than .001). Median ED census at triage was lower for standard bed admissions than for hallway patients (44 [33 to 53] versus 50 [38 to 61], respectively, P less than .001). Inhospital mortality rates were higher among patients admitted to standard beds (2.6%; 95% confidence interval [CI] 2.5% to 2.7%) than among patients admitted to hallway beds (1.1%; 95% CI 0.7% to 1.7%). ICU transfers were also higher in the standard bed admissions (6.7% [95% CI 6.5% to 6.9%] versus 2.5% [95% CI 1.9% to 3.3%]).

Conclusion
Transfer of ED-boarded admitted patients to an inpatient hallway occurs during high ED census and waiting times for admission but does not appears to result in patient harm.

21. Randomized Trial of Computerized Quantitative Pretest Probability in Low-Risk Chest Pain Patients: Effect on Safety and Resource Use

Kline JA, et al. Ann Emerg Med. 2009;53:727-735.e1

Study objective
We hypothesize that the presentation of a quantitative pretest probability of acute coronary syndrome would safely reduce unnecessary resource use in low-risk emergency department (ED) chest pain patients.

Methods
Randomized controlled trial of adult patients with chest pain paired with their clinicians. Patients had neither obvious evidence of acute coronary syndrome nor obvious other reason for admission. Clinicans provided their unstructured point estimate for pretest probability before randomization. Clinicans and patients in the intervention group received a printout of pretest probability of acute coronary syndrome result displayed numerically and graphically. Controls received no printout. Patients were followed for 45 days for predefined criteria of acute coronary syndrome and efficacy endpoints. Endpoints were compared between groups, with 95% confidence intervals (CIs) for differences.

Results
Four hundred were enrolled, and 31 were excluded for cocaine use or elopement from care. The mean pretest probability estimates of acute coronary syndrome were 4 (SD 5%) from clinicians and 4 (SD 6%) from the computer. Safety and efficacy endpoints for controls (n=185) versus intervention patients (n=184) were as follows: (1) delayed or missed diagnosis of acute coronary syndrome: 1 of 185 versus 0 of 184 (95% CI for difference −2.8% to 15.0%); (2) hospital admission with no significant cardiovascular diagnosis, 11% versus 5% (−0.2% to 11%); (3) thoracic imaging imparting greater than 5 mSv radiation with a negative result, 20% versus 9% (95% CI for difference = 3.8% to 18.0%); (4) median length of stay, 11.4 hours versus 9.2 hours (95% CI for difference = −2.9 to 7.6 hours); (5) reported feeling “very satisfied” with clinician explanation of problem on follow-up survey, 38% versus 49% (95% CI for difference = 0.9% to 21.0%); (6) readmitted within 7 days, 11% versus 4% (95% CI for difference = 2.5% to 13.2%).

Conclusion
Presentation of a quantitative estimate of the pretest probability of acute coronary syndrome to clinicians and low-risk ED chest pain patients was associated with reduced resource use, without evidence of increased rate of premature discharge of patients with acute coronary syndrome.

22. Clinical Prediction Rules for Identifying Adults at Very Low Risk for Intra-abdominal Injuries After Blunt Trauma

Holmes JF, et al. Ann Emerg Med. 2009; in press

Study objective
We derive and validate clinical prediction rules to identify adult patients at very low risk for intra-abdominal injuries after blunt torso trauma.

Methods
We prospectively enrolled adult patients (≥18 years old) after blunt torso trauma for whom diagnostic testing for intra-abdominal injury was performed. In the derivation phase, we used binary recursive partitioning to create a rule to identify patients with intra-abdominal injury who were undergoing acute intervention (including therapeutic laparotomy or angiographic embolization) and a separate rule for identifying patients with any intra-abdominal injury present. We considered only clinical variables readily available with acceptable interrater reliability. The prediction rules were then prospectively validated in a separate cohort of patients.

Results
In the derivation phase, we enrolled 3,435 patients, including 311 (9.1%; 95% confidence interval [CI] 8.1% to 10.1%) with intra-abdominal injury and 109 (35.0%; 95% CI 29.7% to 40.6%) with intra-abdominal injury requiring acute intervention. In the validation study, we enrolled 1,595 patients, including 143 (9.0%; 95% CI 7.6% to 10.5%) with intra-abdominal injury. The derived rule for patients with intra-abdominal injuries who were undergoing acute intervention consisted of hypotension, Glasgow Coma Scale (GCS) score less than 14, costal margin tenderness, abdominal tenderness, hematuria level greater than or equal to 25 red blood cells/high powered field, and hematocrit level less than 30% and identified all 44 patients in the validation phase with intra-abdominal injury who were undergoing acute intervention (sensitivity 44/44, 100%; 95% CI 93.4% to 100%). The derived rule for the presence of any intra-abdominal injury consisted of GCS score less than 14, costal margin tenderness, abdominal tenderness, femur fracture, hematuria level greater than or equal to 25 red blood cells/high powered field, hematocrit level less than 30%, and abnormal chest radiograph result (pneumothorax or rib fracture). In the validation phase, the rule for any intra-abdominal injury present had the following test performance: sensitivity 137 of 143 (95.8%; 95% CI 91.1% to 98.4%), specificity 434 of 1,452 (29.9%; 95% CI 27.5% to 32.3%), and negative predictive value 434 of 440 (98.6%; 95% CI 97.1% to 99.5%).

Conclusion
These derived and validated clinical prediction rules can aid physicians in the evaluation of adult patients after blunt torso trauma. Patients without any of these variables are at very low risk for having intra-abdominal injury, particularly intra-abdominal injury requiring acute intervention, and are unlikely to benefit from abdominal computed tomography scanning.