Lit Bits. June 23, 2009

From the recent medical literature...

1. ED crowding mainly due to lack of inpatient beds

The American Hospital Association

Lack of access to inpatient beds is the main reason for continued hospital emergency department crowding, according to a report released yesterday by the Government Accountability Office. The GAO found that the average wait time to see a physician in the ED – one measure of crowding – increased from 46 minutes in 2003 to 56 minutes in 2006, while the percentage of visits in which wait time exceeded recommended time frames for patients with immediate (less than 1 minute) and emergent (within 1 to 14 minutes) acuity levels increased from 37.5% in 2003 for both to 73.9% and 50.4% respectively in 2006. “Emergency rooms are a critical component of our nation’s health care safety net,” said Sen. Max Baucus (D-MT), who requested the report. He called the findings “unacceptable” and reiterated the need for comprehensive health care reform.

To view the report: http://www.gao.gov/new.items/d09347.pdf

2. Stroke After TIA: How Likely and How Soon?

Risk for stroke within 24 hours after TIA was 5% in this large population-based study.

Urgent intervention after transient ischemic attack (TIA) is highly effective for preventing recurrent stroke. Most guidelines recommend neurological evaluation within 24 hours after symptom onset, yet some patients with TIA have strokes within that 24-hour period. As part of a prospective study of all strokes and TIAs in a population of 91,106 individuals in Oxfordshire, U.K. (the Oxford Vascular Study), researchers assessed the risk for stroke within 24 hours after a first TIA and the predictive value of the ABCD2 risk scoring system.

Among 488 patients with first TIAs from 2002 to 2007, the risk for stroke was 1.2% within 6 hours, 2.0% within 12 hours, and 5.1% within 24 hours. Of the 59 strokes that occurred within 30 days after TIA, 25 (42%) occurred within the first 24 hours. Nineteen of the 25 patients who had strokes within 24 hours had ABCD2 scores 5. Risk for stroke within 24 hours after TIA was 2.0% in patients with ABCD2 scores 4, 6.5% with scores of 5, 11.8% with scores of 6, and 33.0% with scores of 7. Similarly, patients with scores 5 had greater risk for stroke than those with lower scores within 6 hours (2.6% vs. 0.3%) and within 12 hours (4.7% vs. 0.3%).

Comment: The finding of a substantial rate of stroke within 24 hours after presentation with TIA underscores the need for healthcare workers to educate patients to seek emergency care if they have symptoms of stroke, even if they are minor or resolved, and for primary care physicians to quickly refer patients for emergent evaluation. Although stroke risk correlates with the ABCD2 score, even patients in the lowest risk ABCD2 group have a 2% risk for stroke within 24 hours, which is sufficient to warrant emergent evaluation.

— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine June 1, 2009
Citation: Chandratheva A et al. Population-based study of risk and predictors of stroke in the first few hours after a TIA. Neurology 2009 Jun 2; 72:1941.

3. Body of lies: Patients aren't 100% honest with doctors

Karen Ravn, the Los Angeles Times, June 8, 2009

When patients aren't truthful, misled doctors may give a wrong diagnosis or treatment.

Bill Moore of Pacific Grove was barely in his 20s when he found out he had cholesterol trouble.

This was bad news for Moore because his father had died of a heart attack at 45 and because, as he told his doctor, Moore was eating all the right stuff.

The doctor prescribed cholesterol-lowering medication, and a subsequent test showed the drug was working very well. Too well.

His doctor was very surprised, Moore says. "I told him I must be unique. I must have a unique body composition." But the truth was Moore had fed his doctor a false written record of his eating habits before beginning the drug -- reporting vegetables and salads that had never been on his menu, and not reporting all the hamburgers and pizzas that had.

Only when he started on the cholesterol drug did he finally begin eating the way he'd been claiming to eat all along. It was that change combined with the drug that made his cholesterol levels plunge.

Inaccurate information can do more than confuse a doctor. It can lead to misinterpreted symptoms, overlooked warning signs, flawed diagnoses and treatments -- potentially endangering a patient's health, even life.

Still, doctors know that at least some of the time, at least some of their patients overstate, understate, embellish, omit, or otherwise stray from a straight and thorough reporting.

"Everybody lies at some point," says Dr. Sharon Parish, a professor of clinical medicine at Albert Einstein College of Medicine in New York City who practices at Montefiore Medical Center. They do it out of embarrassment, to please the doctor, to avoid a lecture.

But doctors and patient advocates agree that in most cases, when patients lie, they're pretty much asking for trouble. Even when telling the truth is unappealing, "getting into a lying relationship with your physician is really far more perilous," says Peter Clarke, director of the Center for Health and Medical Communication at USC and co-author of the 1998 book "Surviving Modern Medicine."

An early lesson

That patients lie is one of the basics doctors learn in medical school. Of 1,500 responders to a 2004 online survey by WebMD, 45% admitted they hadn't always told it exactly like it was -- with 13% saying they had "lied," and 32% saying they had "stretched the truth."

Not included in those figures would be patients who "lie" without knowing they do so by withholding information because it slips their mind or they have no idea it could be useful. (Maybe Aunt Agnes would gladly tell about the time she snored so loud she woke the neighbors if she knew that a diagnosis of sleep apnea could depend on it.)

In the WebMD survey, 38% of respondents said they lied about following doctors' orders and 32% about diet or exercise. Doctor reports bear this out.

"Patients are strongly motivated to have their doctors think they're good patients," says Dr. Steven Hahn, professor of clinical medicine at Albert Einstein College and an internist at Jacobi Medical Center in New York City.

It's hard to make a good impression when you're on an examining table in a flimsy, open-backed gown -- a fact that might make lying that much more tempting. But even fully clothed, talking face to face across a desk, a patient cedes authority to the doctor. And people generally like to please those in authority, says Emanuel Maidenberg, clinical professor of psychiatry at UCLA.

Patients also are prone to lying about the fact that they engage in social taboos, things their doctor might not approve of. In the WebMD survey, 22% lied about smoking, 17% about sex, 16% about drinking and 12% about recreational drug use.

"When you're studying psychiatry, you're taught that if a patient says, 'I use cocaine once a month,' you figure it's twice a month," says Dr. Robert Klitzman, professor of clinical psychiatry at Columbia University. "We were taught to double."

Patients lie because they don't want to be judged, embarrassed or misunderstood. They lie about pursuing alternative health remedies because they disagree with their doctor or because they think an item is none of their doctor's business.

The rest of the article: http://www.latimes.com/features/health/la-he-lying8-2009jun08,0,2605423.story

4. The Incremental Benefit of a Shortness-of-breath Biomarker Panel in Emergency Department Patients with Dyspnea

Singer AJ, et al. Acad Emerg Med. 2009;16:488–494.

Objectives: The objective was to determine the incremental benefit of a shortness-of-breath (SOB) point-of-care biomarker panel on the diagnostic accuracy of emergency department (ED) patients presenting with dyspnea.

Methods: Adult ED patients at 10 U.S. EDs with SOB were included. The physician's estimates of the pretest clinical probability of heart failure (HF), acute myocardial infarction (MI), and pulmonary embolism (PE) were recorded using deciles (0%–100%). Blood samples were analyzed using a SOB point-of-care biomarker panel (troponin I, myoglobin, creatinine kinase-myocardial band isoenzyme [CK-MB], D-dimer, and B-type natriuretic peptide [BNP]). Thirty-day follow-up for MI, HF, and PE was performed. Data were analyzed using logistic regression and receiver operating characteristics (ROC) curve analysis.

Results: Of 301 patients, the mean (±standard deviation [SD]) age was 61 (±18) years; 56% were female, 58% were white, and 38% were African American. Diagnoses included MI (n = 54), HF (n = 91), and PE (n = 16) in a total of 129 (43%) of the patients. High pretest clinical certainty (80% and up) identified 60 of these 129 (46.5%) cases. The SOB point-of-care biomarker panel identified 66 additional cases of MI (n = 24), HF (n = 31), and PE (n = 11). The overall adjusted sensitivity for any diagnosis was increased from 65% to 70% with the addition of the SOB point-of-care biomarker panel (difference = 5%, 95% CI = −1.1% to 11%) while specificity was increased from 82% to 83% (difference = 1%, 95% CI = −4% to 7%). The model containing pretest probability and the results of the SOB panel had an area under the curve (AUC) of 83.4% (95% CI = 78.4% to 88.5%), which was not significantly better than the AUC of 80.4% (95% CI = 75.1% to 85.7%) for clinical probability alone.

Conclusions: The addition of the SOB panel of markers did not improve the AUC for diagnosing the combined set of clinical conditions. Using the disease-specific SOB biomarkers increased the sensitivity on a disease-by-disease basis; however, specificity was reduced.

5. New Guidelines on Young Athletes’ Concussions Stir Controversy

By ALAN SCHWARZ. New York Times: June 7, 2009. New guidelines for the care of youth athletes who sustain concussions are causing controversy among brain-injury experts, reigniting the debate over whether strict rules regarding concussions can actually leave athletes at greater risk for injury.

An international panel of neurologists, updating their recommendations on concussion care in the May issue of The British Journal of Sports Medicine, said that any athlete 18 or younger who was believed to have sustained a concussion during a game or practice should never be allowed to return to the playing field the same day. The group had previously said that such athletes could return if cleared by a doctor or certified athletic trainer, but now contend that such determinations are too difficult and dangerous for same-day return to be considered safe.

Other doctors, many of whom work the sidelines of high school athletic events, said they feared the effects of such strictness. They predicted that athletes would respond by hiding their injuries from coaches and trainers even more than they are already known to do, leaving them at risk for a second and more dangerous concussion.

The panel’s recommendation to remove all players suspected of concussion has no direct influence on rules governing United States youth sports, which are generally made at the state and local levels. But it does spotlight how some attempts to improve concussion-related safety can instead compromise it, a paradox encountered at levels as high as the N.F.L.

“So many bad decisions are made when trying to assess whether a player is symptomatic or not,” said Dr. Robert Cantu, an author of the guidelines who is also a director of the Neurological Sports Injury Center at Brigham & Women’s Hospital in Boston. “We know that an unacceptable number of kids are being sent back while symptomatic, and sometimes with devastating effects. The majority believe that the bullet should be bitten, and not let a kid go back into the same contest.”

But Dr. Bob Sallis, a past president of the American College of Sports Medicine and a longtime sideline doctor in Southern California, said he saw the recommendation as a step backward.

“More kids will be hurt seriously because of this, either by players not admitting they might have gotten a concussion or coaches encouraging them not to be up front about their symptoms, whether subtly or overtly,” Sallis said.

Asked how the guidelines could have any influence on league rules throughout the country — in Iowa, for example — Sallis said: “It does put the people in Iowa in scrutiny. When a kid gets hurt, they’ll get sued and be told, why didn’t you follow those guidelines?”

High school athletes in nine primary sports sustained an estimated 137,000 concussions in the 2007-8 school year, according to a study conducted by the Center for Injury Research and Policy at Nationwide Children’s Hospital in Columbus, Ohio. Football had the most, with more than 70,000, followed by girls soccer (24,000), boys soccer (17,000) and girls basketball (7,000). These were only reported concussions; more were almost certainly sustained but went unrecognized or ignored.

“Sometimes, postconcussion symptoms can be delayed for hours or even days, like difficulty sleeping or concentrating,” Cantu said. “It’s a clinical decision that’s difficult or sometimes damn near impossible to be made on the sideline, and we aren’t doing a very good job at it. Athletes, even when assessed by qualified people, seem to be returning to contests prematurely or when symptomatic — an unacceptable number of cases.”

The panel also emphasized the importance of not just physical rest for players found to have a concussion, but cognitive rest as well. It said that teenagers should be kept from activities ranging from schoolwork to video games and text messaging while recovering from a concussion.
“That is the No. 1 management issue in our clinic — how do we manage the cognitive activity that stresses that brain’s abnormal metabolism?” said Gerry Gioia, the chief of pediatric neuropsychology at Children’s National Medical Center in Washington. “Studying for an algebra exam, reading a lengthy text, sitting in a classroom for an hour and a half trying to keep notes and keep up — it extends recovery, it feels miserable to the kid, and it’s misunderstood by the school and public.”

6. AHA/ASA Science Advisory Recommends Use of tPA Between 3 and 4.5 Hours After Stroke

Susan Jeffrey. May 28, 2009 — A new science advisory from the American Heart Association (AHA)/American Stroke Association (ASA) has given the green light to the use of tissue plasminogen activator (tPA) to treat acute ischemic stroke between 3 and 4.5 hours after symptom onset.

However, the advisory, published online May 28 in Stroke, still emphasizes that time is of the essence when it comes to treatment of stroke.

"Although a longer time window for treatment has been tested formally, delays in evaluation and initiation of therapy should be avoided," the authors stress. The writing group is chaired by Gregory J. del Zoppo, MD, from the University of Washington, in Seattle.

ECASS 3

The advisory updates the current guidelines mainly on the basis of findings from the European Cooperative Acute Stroke Study 3 (ECASS 3), which showed a benefit from thrombolytic therapy in patients treated between 3 and 4.5 hours after symptom onset. Exclusion criteria for that trial — which followed exclusions mandated by European regulatory authorities for the approval of tPA there — now become exclusion criteria for these new recommendations.

"The eligibility criteria for treatment in this time period are similar to those treated at earlier time periods, with any 1 of the following additional exclusion criteria: patients older than 80 years, those taking oral anticoagulants with an international normalized ratio [INR] of ≤ 1.7, those with a baseline National Institutes of Health Stroke Scale score greater than 25, or those with both a history of stroke and diabetes," the authors write. For this later time period, all patients receiving oral anticoagulants are excluded, regardless of their INR, they note.

"The efficacy of intravenous treatment with [recombinant tissue plasminogen activator] rtPA within 3 to 4.5 hours after stroke in patients with these exclusion criteria is not well established and requires further study," the document states. In addition, the relative utility of rtPA in this time window to other methods of recanalization such as thrombus dissolution or approval is considered "not well established."

Ancillary care for patients receiving tPA In this expanded window should be similar to what has been established in the current 2007 American Heart Association Stroke Council Guidelines, the authors note.

"These recommendations, which are based on peer-reviewed publications, should be reevaluated after the results of regulatory agency review of detailed, non–publicly available data are known," they conclude.

Do Not Hesitate to Treat

Asked for comment on the new advisory, Ralph Sacco, MD, from the Miller School of Medicine at the University of Miami, in Florida, and president-elect of the AHA, pointed out that on the basis of ECASS 3, the guidelines in Europe have already changed.

"The European Stroke Organization was quick to change the guidelines," Dr. Sacco said. "I think the American Heart Association has been more cautious about widening the window. One of our concerns is that we don't want people to hesitate, and if you all of a sudden widen the window, some people may feel they have a little more time, both patients waiting to call or healthcare professionals waiting to give tPA," he said.

"First and foremost to us is, the earlier you treat, the better; the earlier you recognize the symptoms, the better; and that's the only concern — that if we widen the window, will we lose some patients giving it later rather than earlier?"

This may allow many physicians to be more comfortable at least in treating those who arrive late in the already-approved 3-hour time window, he added.

Phillip B. Gorelick, MD, from the University of Illinois College of Medicine at Chicago, was a reviewer on the new science advisory. "There are several key factors to keep in mind when contemplating administration of intravenous tPA, given the AHA/ASA advisory," he told Medscape Neurology & Neurosurgery. "One, treatment should not be delayed if it can be given sooner than the 3- to 4.5-hour time window."

In addition, the exclusions outlined above will also apply, he noted. "The advisory does not address the role of intra-arterial rtPA administration or the use of mechanical or other clot-extraction devices in the 3- to 4.5-hour time window," Dr. Gorelick said. "The role of these latter treatments in light of the expanded time-window advisory will need to be addressed in subsequent AHA/ASA guidelines on acute stroke therapy and in subsequent research."

The American Heart Association/American Stroke Association statement notes that the association receives funding "primarily from individuals and foundations, and corporations (including pharmaceutical, device manufacturers, and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing science content. Revenues from pharmaceutical and device corporations are disclosed at www.americanheart.org/corporatefunding ."

Dr. Del Zoppo reports no disclosures. Disclosure information for other members of the writing group and reviewers are included in the advisory.

Stroke. Published online May 28, 2009.

7. Obama Open to Reining in Medical Suits

By SHERYL GAY STOLBERG and ROBERT PEAR. New York Times, June 15, 2009

WASHINGTON — The American Medical Association has long battled Democrats who oppose protecting doctors from malpractice lawsuits. But during a private meeting at the White House last month, association officials said, they found one Democrat willing to entertain the idea: President Obama.

In closed-door talks, Mr. Obama has been making the case that reducing malpractice lawsuits — a goal of many doctors and Republicans — can help drive down health care costs, and should be considered as part of any health care overhaul, according to lawmakers of both parties, as well as A.M.A. officials.

It is a position that could hurt Mr. Obama with the left wing of his party and with trial lawyers who are major donors to Democratic campaigns. But one Democrat close to the president said Mr. Obama, who wants health legislation to have broad support, views addressing medical liability issues as a “credibility builder” — in effect, a bargaining chip that might keep doctors and, more important, Republicans, at the negotiating table.

The rest of the article: http://www.nytimes.com/2009/06/15/health/policy/15health.html

8. Slower infusion of metoclopramide decreases the rate of akathisia

Regan LA, et al. Amer J Emerg Med. 2009;27:475-480.

Objective
We investigated the difference in incidence of acute akathisia related to the rate of infusion in patients receiving metoclopramide for acute nausea, vomiting, or migraine headache in the emergency department (ED).

Methods
Randomized, prospective, double-blind clinical trial of patients aged 18 years and older who were to receive intravenous metoclopramide for the treatment of nausea, vomiting, or headache were eligible. Patients were excluded if they were taking medications that might mimic or mask akathisia, had a movement disorder, renal insufficiency, or were unable or unwilling to consent. Pregnant women and prisoners were also excluded. Subjects were randomized to receive 1 of 2 accepted metoclopramide administration regimens. The regimens included 10 mg of metoclopramide administered either as a 2-minute bolus (BG) or as a slow infusion for 15 minutes (IG). All patients received a normal saline placebo at the opposite rate to maintain blinding. The main outcome was development of akathisia noted at 60 minutes after drug administration as measured either with The Prince Henry Hospital akathisia rating scale or by sudden unexplained departure from the ED during treatment.

Results
One hundred twenty-seven patients were eligible for the study. Fifty-nine patients met exclusion criteria. Of the remaining 68 patients, 36 were randomized to the BG and 32 were randomized to the IG. In the BG, 11.1% of patients developed akathisia compared with 0% in the IG (P = .026). Four patients developed akathisia based on the scale and 2 departed suddenly from the ED.

Conclusions
Slower infusion of metoclopramide reduces the incidence of akathisia.

9. Your Body Is a Wonderland ... of Bacteria

By Stephanie Pappas. ScienceNOW Daily News, 28 May 2009.

Where can you find your skin's most diverse community of bacteria? Not in a sweaty armpit or linty belly button. According to a new survey of the bacterial ecosystem that covers us, the diversity hot spot of the body's exterior is the forearm. And the surprises don't end there.
Microbes that live in and on our bodies outnumber our own cells 10 to one, but researchers have only recently begun to catalog the residents on our skin. Traditionally, scientists identified human skin bacteria by swabbing volunteers and culturing the samples, but those results skewed toward microbes that grow well in the lab. Thanks to ever-evolving gene-sequencing technology, scientists can now use microbial RNA to identify organisms. With these techniques, researchers have found an unexpectedly wide variety of bacteria on human skin (Science, 23 May 2008, p. 1001). But no one had ever systematically compared bacterial colonies from different areas on the human body.

To do so, scientists from the National Human Genome Research Institute in Bethesda, Maryland, recruited 10 volunteers and asked them to wash with mild soap for 1 week. Then, after 24 hours without bathing, the volunteers arrived at the lab, where researchers swabbed and scraped their skin in 20 places--everywhere from the nostril to the navel to that bane of low-rise jeans aficionados, the gluteal crease. The team analyzed ribosomal RNA from the samples and classified the microbes based on their genomes.

The researchers found about 1000 species total, which were fairly consistent from person to person; it turns out we all have similar tenants in our noses and on our backs. The number suggests that our skin is as variegated as our guts, which house anywhere from 500 to 1000 bacterial species. The team also found vast differences across the skin, according to the study published in tomorrow's issue of Science. Contrary to what acne-prone teenagers might expect, oily areas such as the forehead and scalp are actually less diverse than dry areas such as the forearm (though one is enough for grief: Propionibacterium acnes thrives in oily spots). The most barren region was behind the ear, with a median diversity of 15 species. In comparison, the forearm teemed with a median 44 species. A follow-up with five of the volunteers months later found that bacterial makeup changed little over time.

Why some neighborhoods are more varied than others is unknown. It could be because of skin properties such as hair or oil, exposure to bacteria, or some combination. As for the forearm, geneticist and co-author Julia Segre speculates that exposed arms make a good landing pad for bacteria. Contrasted with how we clean our hands, we rarely lather up our forearms. Whatever the reason, the research shows that location matters. "This paper really highlights that the skin is an ecosystem and that the bacteria that live on our skin are not homogenous," says Segre.

The research "could contribute to explaining why certain skin diseases appear at certain sites of the body and not others," says dermatologist Richard Gallo of the University of California, San Diego. "It's a straightforward description of something that needed to be described." The next step, Segre says, is to investigate the relationship between microbial ecosystems and diseases such as eczema and psoriasis.

10. Frequency of Acute Coronary Syndrome in Patients with Normal Electrocardiogram Performed during Presence or Absence of Chest Pain

Turnipseed SD, et al. Acad Emerg Med. 2009;16:495–499.

Objectives: The authors hypothesized that patients with active chest pain at the time of a normal electrocardiogram (ECG) have a lower frequency of acute coronary syndrome (ACS) than patients being evaluated for chest pain but with no active chest pain at the time of a normal ECG. The study objective was to describe the association between chest pain in patients with a normal ECG and the diagnosis of ACS.

Methods: This was a prospective observational study of emergency department (ED) patients with a chief complaint of chest pain and an initial normal ECG admitted to the hospital for chest pain evaluation over a 1-year period. Two groups were identified: patients with chest pain during the ECG and patients without chest pain during the ECG. Normal ECG criteria were as follow: 1) normal sinus rhythm with heart rate of 55–105 beats/min, 2) normal QRS interval and ST segment, and 3) normal T-wave morphology or T-wave flattening. "Normal" excludes pathologic Q waves, left ventricular hypertrophy, nonspecific ST-T wave abnormalities, any ST depression, and discrepancies in the axis between the T wave and the QRS. Patients' initial ED ECGs were interpreted as normal or abnormal by two emergency physicians (EPs); differences in interpretation were resolved by a cardiologist. ACS was defined as follows: 1) elevation and characteristic evolution of troponin I level, 2) coronary angiography demonstrating more than 70% stenosis in a major coronary artery, or 3) positive noninvasive cardiac stress test. Chi-square analysis was performed and odds ratios (ORs) are presented.

Results: A total of 1,741 patients were admitted with cardiopulmonary symptoms; 387 met study criteria. The study group comprised 199 males (51%) and 188 females (49%), mean age was 56 years (range, 25–90 years), and 106 (27%) had known coronary artery disease (CAD). A total of 261 (67%) patients experienced chest pain during ECG; 126 (33%) patients experienced no chest pain during ECG. There was no difference between the two groups in age, sex, cardiac risk factors, or known CAD. The frequency of ACS for the total study group was 17% (67/387). There was no difference in prevalence of ACS based on the presence or absence of chest pain (16% or 42/261 vs. 20% or 25/126; OR = 0.77, 95% confidence interval = 0.45 to 1.33, p = 0.4).

Conclusions: Contrary to our hypothesis concerning patients who presented to the ED with a chief complaint of chest pain, our study demonstrated no difference in the frequency of acute coronary syndrome between patients with chest pain at the time of acquisition of a normal electrocardiogram and those without chest pain during acquisition of a normal electrocardiogram.

11. Images in Emergency Medicine

Spider Bite
http://www.annemergmed.com/article/S0196-0644(08)02059-3/fulltext

Male With Left Neck Pain
http://www.annemergmed.com/article/S0196-0644(08)02193-8/fulltext

12. ED Pulmonary Embolism D-Dimer Screening Not Following Guidelines

By David Douglas. NEW YORK (Reuters Health) Jun 17 - Despite established clinical guidelines that suggest how D-dimer testing results should guide CT evaluation of patients with suspected pulmonary emboli (PE), emergency department (ED) use of such testing is not well-standardized, according to researchers.

"Any time a patient gets a CT scan there is a radiation dose," lead investigator Dr. Michael T. Corwin said in a statement. "The evaluation of patients with suspected PE should include D-dimer and CT testing in a more standardized fashion so that we can save patients from having unnecessary CT scans."

Dr. Corwin and his colleagues at the Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, note in the May issue of the American Journal of Roentgenology that in current accepted clinical practice, in patients with low clinical probability for PE, a D-dimer test is performed; if it is negative, the patient has no further workup. If it is positive, patients have a CT.

The researchers retrospectively reviewed data on more than 5300 patients who underwent either a D-dimer test or a multidetector CT (MDCT) examination.

"42% of patients had a positive D-dimer exam and did not have a CT scan," Dr. Corwin stated. "Current protocols suggest that those patients should have had a scan."

"MDCT was performed in 7% of patients with negative D-dimer results," he added, "and the same protocols suggest that those patients should not have undergone a scan."

"Our study shows that the evaluation of ER patients for the diagnosis of pulmonary embolism does not follow established clinical guidelines," Dr. Corwin told Reuters Health.

He added: "We hope that our results bring awareness to this and lead to stricter adherence to these guidelines. This is turn, may reduce the number of unnecessary CT examinations, thereby reducing the radiation exposure to these patients."

Am J Roentgenol 2009;192:1295-1323.

13. Adherence to Healthy Lifestyle Habits in US Adults, 1988-2006

King DE, et al. Amer J Med 2009;122:528-534.

Background
Lifestyle choices are associated with cardiovascular disease and mortality. The purpose of this study was to compare adherence to healthy lifestyle habits in adults between 1988 and 2006.

Methods
Analysis of adherence to 5 healthy lifestyle trends (5 or more fruits and vegetables/day, regular exercise more than 12 times/month, maintaining healthy weight [body mass index 18.5-29.9 kg/m2], moderate alcohol consumption [up to 1 drink/day for women, 2/day for men] and not smoking) in the National Health and Nutrition Examination Survey 1988-1994 were compared with results from the National Health and Nutrition Examination Survey 2001-2006 among adults aged 40-74 years.

Results
Over the last 18 years, the percent of adults aged 40-74 years with a body mass index 30 kg/m2 or more has increased from 28% to 36% (P less than .05); physical activity 12 times a month or more has decreased from 53% to 43% (P less than .05); smoking rates have not changed (26.9% to 26.1%); eating 5 or more fruits and vegetables a day has decreased from 42% to 26% (P less than .05), and moderate alcohol use has increased from 40% to 51% (P less than .05). Adherence to all 5 healthy habits has gone from 15% to 8% (P less than .05). Although adherence to a healthy lifestyle was lower among minorities, adherence decreased more among non-Hispanic Whites over the period. Individuals with a history of hypertension/diabetes/cardiovascular disease were no more likely to be adherent to a healthy lifestyle than people without these conditions.

Conclusions
Generally, adherence to a healthy lifestyle pattern has decreased during the last 18 years, with decreases documented in 3 of 5 healthy lifestyle habits. These findings have broad implications for the future risk of cardiovascular disease in adults.

14. The association between physician risk tolerance and imaging use in abdominal pain

Pines JM, et al. Amer J Emerg Med. 2009;27:552-557.

Objective
We sought to determine the impact of 3 validated scales of physician risk behavior on imaging use in emergency department (ED) patients with abdominal pain.

Methods
We performed a prospective cohort study of nonpregnant ED patients with acute, nontraumatic abdominal pain and then administered 3 instruments (a risk-taking subscale of the Jackson Personality Index, the stress from uncertainty scale, and a malpractice fear scale) to attending physicians who had evaluated these patients and made decisions regarding abdominal imaging. Outcomes were the use of abdominal pelvic computed tomography (CT) and any imaging use (CT, ultrasound, or abdominal plain film). Hierarchical logistic regression was used to determine the effect of risk scales on abdominal imaging use.

Results
Of 838 patients with acute abdominal pain, 487 (58%) received imaging studies; 395 (47%) received an CT, 111 (13%) ultrasound, and 122 (15%) an abdominal plain film. Both CT and any imaging use were lower among the physicians who were least risk-averse as measured by the risk-taking subscale (highest quartiles vs 3 lower quartiles). In adjusted analysis, probability of CT in the least risk-averse group was 35% (95% confidence interval [CI], 28%-44%) compared to 50% (95% CI, 45%-54%) among more risk-averse physicians, and the probability of any imaging was 53% (95% CI, 44%-61%) compared to 64% (95% CI, 61%-68%). Malpractice fear and stress due to uncertainty were not predictive of imaging use.

Conclusion
Self-reported physician risk-taking behavior predicts the use of imaging in ED patients with abdominal pain, whereas malpractice fear and stress due to uncertainty do not.

15. Outpatient Management of Primary Spontaneous Pneumothorax in the Emergency Department of a Community Hospital Using a Small-bore Catheter and a Heimlich Valve

Hassani B, et al. Acad Emerg Med. 2009;16:513–518.

Objectives: The objective was to assess the effectiveness of a small-bore catheter (8F) connected to a one-way Heimlich valve in the emergency department (ED)-based outpatient management of primary spontaneous pneumothorax (PSP).

Methods: The authors conducted a structured chart audit in a retrospective case series of patients with PSP who were treated with a small-bore (8F) catheter and a Heimlich valve who were seen in the ED of a community hospital between April 2000 and March 2005. To be eligible, patients had to be available for a telephone interview. Main outcomes were success of treatment (sustained, complete lung reexpansion), admission, and surgical intervention rates. Secondary outcomes included number of chest x-rays (CXRs), number of visits to the ED, treatment duration, complications, and recurrence rates.

Results: The authors identified 62 discrete episodes of PSP in 50 patients, with a mean (±standard deviation [SD]) age of 25.5 ± 10.5 years (range = 14–53 years). In 50 of 62 episodes (81%, 95% confidence interval [CI] = 70.8% to 90.5%), patients were discharged directly from the ED. Patients were admitted to the hospital at some point for treatment in 27/62 episodes (43.5%, 95% CI = 31.2% to 55.9%). Surgery was performed for acute treatment failure in 17 episodes. Ultimately, 19 patients, who accounted for 21 of 62 episodes (33.9%, 95% CI = 22.1% to 45.6%), had surgery at some point in the study. Mean (±SD) time to admission for those patients initially discharged from the ED was 2.9 (±2.01) days (95% CI = 1.9 to 3.8 days). There were no serious complications from treatment; the minor complication rate (misplacement or dislodging of the chest tube) was 22.6% (95% CI = 12.2% to 33.0%). No association was found between the size of pneumothorax and treatment failure.

Conclusions: This study suggests that the initial management of PSP with a small-bore catheter and Heimlich valve can easily be performed by emergency physicians in the community hospital setting and appears safe. A larger study systematically comparing this approach with alternative therapies is needed.

16. Asthma Education Intervention Reduces Emergency Department Visits

NEW YORK (Reuters Health) Jun 18 - Asthma education aimed at asthmatic children and their caretakers who present to the emergency department for acute asthma exacerbations may help lower the risk of future visits and hospitalizations, according to findings published in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration.

"Asthma management for children results in substantial costs," lead author Dr. Michelle Boyd, of Royal Children's Hospital, Herston, Australia, and colleagues write. "There is evidence to suggest that hospital admissions could be reduced with effective education for parents and children about asthma and its management."

To further investigate, the researchers conducted a systematic review of the literature using the Cochrane Airways Group Trials Register, which includes data from MEDLINE, EMBASE and other databases. Included in the analysis were randomized controlled trials of asthma education for children who had attended the emergency department for asthma, with or without hospitalization, within the previous 12 months.

Educational interventions included teaching patients how to monitor their breathing flow; showing patients the importance of early response to symptoms before they escalate into an asthma emergency; and teaching the caretakers the importance of making environmental changes in the home, such as removing allergens and asthma triggers.

A total of 38 studies involving 7843 children were included in the analysis. Significantly reduced risks of subsequent emergency department visits (RR 0.73) and hospitalizations (RR 0.79) were observed in the educational intervention groups compared with the control groups. Educational interventions also lowered the risk of unscheduled doctor visits (RR 0.68).

"We could not find evidence of statistically significant effects on measures of FEV1, PEF, rescue medication use, quality of life or symptoms; very few studies contributed data to these outcomes and interpreting this apparent lack of finding is difficult," Dr. Boyd's team explains.

Withdrawal rates from the educational intervention did not differ significantly between the intervention and control groups, "indicating that education following an acute exacerbation of asthma is no more or less acceptable for children and their carers compared with usual follow-up."

The authors suggest that an educational intervention may be especially useful for young asthma patients with a history of emergency department visits; these patients may have more severe disease and may not have the skills to effectively manage it.

Cochrane Database Syst Rev 2009.

17. Outcomes After Intravenous Opioids in Emergency Patients: A Prospective Cohort Analysis

O'Connor AB, et al. Acad Emerg Med. 2009;16:477–487.

Objectives: Pain management continues to be suboptimal in emergency departments (EDs). Several studies have documented failures in the processes of care, such as whether opioid analgesics were given. The objectives of this study were to measure the outcomes following administration of intravenous (IV) opioids and to identify clinical factors that may predict poor analgesic outcomes in these patients.

Methods: In this prospective cohort study, emergency patients were enrolled if they were prescribed IV morphine or hydromorphone (the most commonly used IV opioids in the study hospital) as their initial analgesic. Patients were surveyed at the time of opioid administration and 1 to 2 hours after the initial opioid dosage. They scored their pain using a verbal 0–10 pain scale. The following binary analgesic variables were primarily used to identify patients with poor analgesic outcomes: 1) a pain score reduction of less than 50%, 2) a postanalgesic pain score of 7 or greater (using the 0–10 numeric rating scale), and 3) the development of opioid-related side effects. Logistic regression analyses were used to study the effects of demographic, clinical, and treatment covariates on the outcome variables.

Results: A total of 2,414 were approached for enrollment, of whom 1,312 were ineligible (658 were identified more than 2 hours after IV opioid was administered and 341 received another analgesic before or with the IV opioid) and 369 declined to consent. A total of 691 patients with a median baseline pain score of 9 were included in the final analyses. Following treatment, 57% of the cohort failed to achieve a 50% pain score reduction, 36% had a pain score of 7 or greater, 48% wanted additional analgesics, and 23% developed opioid-related side effects. In the logistic regression analyses, the factors associated with poor analgesia (both less than 50% pain score reduction and postanalgesic pain score of ≥7) were the use of long-acting opioids at home, administration of additional analgesics, provider concern for drug-seeking behavior, and older age. An initial pain score of 10 was also strongly associated with a postanalgesic pain score of 7 or greater. African American patients who were not taking opioids at home were less likely to achieve a 50% pain score reduction than other patients, despite receiving similar initial and total equianalgesic dosages. None of the variables we assessed were significantly associated with the development of opioid-related side effects.

Conclusions: Poor analgesic outcomes were common in this cohort of ED patients prescribed IV opioids. Patients taking long-acting opioids, those thought to be drug-seeking, older patients, those with an initial pain score of 10, and possibly African American patients are at especially high risk of poor analgesia following IV opioid administration.

18. Cephalosporins in Patients with Penicillin Allergy: Use Them . . . but Be Careful

Patients with penicillin allergy are not necessarily allergic to cephalosporins.

Use of cephalosporins for treatment of pediatric infections is limited because of concern about cross-reactivity in patients with penicillin allergy. In an industry-supported review, researchers examined the evidence from 44 studies on cephalosporin cross-reactivity in patients allergic to penicillin (J Am Pharm Assoc 2008; 48:530).

About 10% of patients in the general population report allergic responses to penicillin and the reported risk for anaphylactic reaction to cephalosporins ranges from 1:1000 to 1:1,000,000, but this risk is increased fourfold in patients with penicillin allergy. Characteristics of adverse drug reactions (immunologic, nonimmunologic, duration, severity) are key to distinguishing allergic from nonallergic adverse reactions. The reported frequency of cross-reactivity between cephalosporins and penicillin is 7% to 18%, but the authors cite recent data that suggest that the incidence of true allergic reactions is lower because much of the evidence was based on nonallergic adverse reactions or in vitro studies, rather than on clinically relevant immune-mediated reactions. Further, improved manufacturing processes have removed contaminants from penicillins and cephalosporins that might have caused cross-reactivity reactions. First-generation cephalosporins are associated with higher risk for cross-reactivity than later-generation agents due to changes in the chemical structure.

Clear contraindications to use of cephalosporins include history of penicillin-associated type I anaphylaxis reactions associated with the presence of IgE antibodies, Stevens-Johnson syndrome, toxic epidermal necrolysis, angioedema, interstitial nephritis, vasculitis, serum sickness, hemolytic anemia, neutropenia, and thrombocytopenia.

Comment: The good news is that patients with penicillin allergy are not necessarily allergic to cephalosporins. The bad news is that some cross-reactivity exists. Clinicians need to evaluate risk based on history and diagnostic testing. The most important factors to assess when considering the use of cephalosporins in penicillin-allergic patients is the nature and extent of previous allergic reactions and the type of cephalosporin to be used. When cephalosporin use is necessary in life-threatening situations, skin testing and drug-challenge desensitization might be appropriate. Fortunately, the risk for cross-reactivity with third- and fourth-generation cephalosporins is very low, and reasonable treatment alternatives exist.

— William P. Kanto, Jr., MD. Published in Journal Watch Pediatrics and Adolescent Medicine May 27, 2009

19. The Limited Utility of Routine Cardiac Stress Testing in Emergency Department Chest Pain Patients Younger Than 40 Years

Hermann LK, et al. Ann Emerg Med. 2009;54:12-16.

Study objective
This is a study designed to evaluate the utility of routine provocative cardiac testing in low-risk young adult (younger than 40 years) patients evaluated for an acute coronary syndrome in an emergency department (ED) setting.

Methods
This was a retrospective observational study of patients aged 23 to 40 years who were evaluated for acute coronary syndrome in an ED-based chest pain unit from March 2004 to September 2007. All patients had serial cardiac biomarker testing to rule out myocardial infarction and then underwent provocative cardiac testing to identify the presence of myocardial ischemia. Patients were excluded from the study if they had known coronary artery disease, had ECG findings diagnostic of myocardial infarction or ischemia, or self-admitted, or tested positive for cocaine use.

Results
Of the 220 patients who met inclusion criteria, 6 patients (2.7%; 95% confidence interval 1% to 5.8%) had positive stress test results. Among these 6 patients, 4 underwent subsequent coronary angiography that demonstrated no obstructive coronary disease, suggesting the initial provocative study was falsely positive. For the remaining 2 patients, no diagnostic angiography was performed. Discounting the patients who had negative angiography results, only 2 of 220 study patients (0.9%; 95% confidence interval 0.1% to 3.2%) had a provocative test result that was positive for myocardial ischemia.

Conclusion
In our study, a combination of age younger than 40 years, nondiagnostic ECG result, and 2 sets of negative cardiac biomarker results at least 6 hours apart identified a patient group with a very low rate of true-positive provocative testing. Routine stress testing added little to the diagnostic evaluation of this patient group and was falsely positive in all patients who consented to diagnostic coronary angiography (4 of 6 cases).

20. Nebulized Lidocaine Before Nasogastric Tube Insertion in Children Causes Distress

This treatment is not a viable option in young children.

Nasogastric tubes often are inserted in children without analgesia or local anesthesia. In a randomized, double-blind, placebo-controlled trial, investigators in Australia assessed the efficacy of nebulized lidocaine for reducing pain and distress during this procedure in children aged 1 to 5 years. In adults, nebulized lidocaine has been shown to have less systemic absorption and a potentially better safety profile than topical lidocaine.

Thirty-eight children received 2% lidocaine (4 mg/kg) or saline administered via nebulizer for 5 minutes. The procedures were filmed, and each of six phases was scored independently by an emergency department attending physician and a nurse practitioner using the Face, Legs, Activity, Cry, and Consolability (FLACC) procedural pain scale (the primary outcome measure). A FLACC score of 10 indicates maximal distress; a difference of 2 points was considered clinically significant.

Eighteen patients in each group completed the study; more boys were in the lidocaine group, but otherwise the groups were similar at baseline. The range of FLACC scores varied widely during the different phases in both groups. Median scores in the lidocaine and placebo groups were highest during nebulization (6.3 and 6.0, respectively) and nasogastric tube insertion (9.8 and 9.5, respectively). Scores did not differ significantly between groups during any phase. Immediately after the procedure, ED nurses rated the overall pain of insertion on a visual analog scale as being lower in the lidocaine group. Adverse events included one endotracheal insertion in each group and one failed insertion in each group; none of these events resulted in harm.

Comment: The study was terminated early, before the intended 52 subjects were enrolled, because of concern about the level of patient distress during nebulization. Although adults may tolerate topical anesthetic administered via nebulizer, clearly young children do not. Therefore, nebulized lidocaine is not a viable treatment option for young children. This study highlights the importance of evaluating therapies in children and not simply extrapolating safety and efficacy from studies in adults.

— Jill M. Baren, MD, MBE, FACEP, FAAP. Published in Journal Watch Emergency Medicine June 19, 2009. Citation: Babl FE et al. Does nebulized lidocaine reduce the pain and distress of nasogastric tube insertion in young children? A randomized, double-blind, placebo-controlled trial. Pediatrics 2009 Jun; 123:1548.

21. Ultrasound Helps Confirm Pediatric Intubation, but Should Not Be Used Alone

By David Douglas. NEW YORK (Reuters Health) Jun 16 - Diaphragmatic ultrasound is showing promise in determining endotracheal tube positioning in pediatric emergency department patients, but more study is needed before it is considered equivalent to chest radiography, Ohio-based researchers report in the June issue of Pediatrics

"The general clinical implication of our study is for the feasibility of ultrasound as a diagnostic tool in pediatric emergency medicine," lead investigator Dr. Benjamin T. Kerrey told Reuters Health. "There is a growing body of literature to support several different applications of ultrasound for our patients. Our study adds to that literature in a generally positive way."

Dr. Kerrey and colleagues at Cincinnati Children's Hospital Medical Center observe that estimates of misplacement of endotracheal tubes in such patients range as high as 40%.

To compare ultrasound and chest radiography as placement aids, the team studied 127 pediatric emergency department inpatients evaluated by both techniques. There were no esophageal intubations, but in 24 patients (19%) chest radiography showed that the tube was in the mainstem bronchus.

Radiography and ultrasound agreed on placement in 94 patients with tracheal placement and 12 with mainstem bronchial placement, thus giving an overall agreement of 0.83. Ultrasound had a sensitivity for tracheal placement of 0.91 and a specificity for mainstem intubation of 0.50.

The ultrasound approach provided rapid results, taking a median of 8 minutes less than radiography. The results were also highly reproducible. In 33 of 34 re-evaluated sonograms, a separate blinded sonographer came to the same conclusions as the original sonographer.

"Although I cannot recommend diaphragmatic ultrasound be used 'as is' to confirm an intubation," concluded Dr. Kerrey, "I feel our findings are promising and warrant further investigation."

Pediatrics 2009;123:e1039-e1044.