Lit Bits: Aug 21, 2009

From the recent medical literature...

1. Fever in a Vaccinated Child? Hold the Blood Cultures

Routine blood cultures are not necessary for febrile children older than 3 months.

During the past decade, children have received routine vaccinations against Haemophilus influenzae type b and pneumococcus, and, as a result, the rate of serious bacterial infections (SBIs) caused by these organisms has plummeted. This change mandates review of the approach to evaluation and treatment of febrile children. These authors studied 68 infants younger than 3 months with either home or emergency department temperatures 100.4°F and 917 children aged 3 to 24 months with ED temperatures 102.3°F who presented to the ED of a tertiary care center in San Diego in 2003. Children younger than 3 months underwent an extensive standardized work-up, and older children underwent testing based on physician discretion.

Overall, 129 children (13%) had 132 cases of SBI (82 cases of pneumonia, 45 of urinary tract infection, and 5 of bacteremia). No white blood cell (WBC) count cutoff predicted SBI. However, the subset of children younger than 3 months was too small to adequately assess the accuracy of WBC counts in this age group. Nonpathogenic bacteria were identified in 4.9% of the 690 blood cultures obtained.

Comment: With the widespread use of the pneumococcal and H. influenzae type b vaccines, most serious bacterial illnesses in children now are either pneumonia or urinary tract infections. Most febrile children older than 3 months have viral syndromes, and routine blood cultures are not suggested by any guideline. However, this small study suggests that bacteremia does occur, infrequently. Clinicians should continue to exercise judgment about when to obtain blood cultures and complete blood cell counts, remembering that children are more susceptible than adults to bacteremia and that blood cultures should not be routinely obtained for febrile vaccinated children older than 3 months (JW Emerg Med Apr 17 2009).

— Diane M. Birnbaumer, MD, FACEP. Published in Journal Watch Emergency Medicine August 14, 2009. Citation: Rudinsky SL et al. Serious bacterial infections in febrile infants in the post–pneumococcal conjugate vaccine era. Acad Emerg Med 2009;16:585.

2. Door-to-Balloon Times Improve, But Other Aspects of AMI Care Lag Behind

August 12, 2009 (Durham, North Carolina) — Hospitals that offer PCI for AMI have improved their door-to-balloon times, but they have not been as successful at improving other care performance measures, such as referring patients for cardiac rehabilitation or counseling them to stop smoking, investigators report in the August 10/24, 2009 issue of the Archives of Internal Medicine.

Hospitals need to pay attention to all aspects of the care they provide their AMI patients and not focus solely on shortening door-to-balloon times, lead author Dr Tracy Y Wang (Duke Clinical Research Institute, Durham, NC) told heartwire. "Door-to-balloon time is a great quality metric, but it's only one of several. This study highlights the fact that we're doing great at one thing, but it doesn't mean that we can neglect everything else. We need to focus on the whole process of care, rather than just focus on that one particular aspect of quality improvement."

Commenting on this study for heartwire, Dr Paul W Armstrong (University of Alberta, Edmonton) said, "The authors have provided readers with a useful reminder that outcomes of STEMI patients are influenced by a host of things, not all of which were measured in this study, and that a single metric or preoccupation with door-to-balloon times may be misleading."

Everything in Between, and Thereafter

Wang and colleagues analyzed 101 hospitals participating in the American Heart Association Get With the Guidelines program and correlated door-to-balloon time improvement from 2005 to 2007 with changes in the composite Centers for Medicare and Medicaid Services/Joint Commission on Accreditation of Healthcare Organizations (CMS/JCAHO) core measure performance and in-hospital mortality.

The CMS/JCAHO core measures include aspirin at admission and discharge, beta-blocker use at admission and discharge, ACE inhibitors and angiotensin-receptor blocker use at discharge if ejection fraction is less than 40%, time to fibrinolysis of less than 30 minutes, and smoking-cessation counseling.

Wang and her group also evaluated each hospital's performance of American College of Cardiology/American Heart Association (ACC/AHA) guideline-recommended performance measures, which included in-hospital low-density-lipoprotein assessment, lipid-lowering therapy use at discharge, clopidogrel use at discharge, cardiac rehabilitation referral, and dietary and weight management counseling for patients with a body-mass index greater than 25 kg/m2.

A total of 43 678 patients were treated for AMI between 2005 and 2007. Over this time, mean door-to-balloon times decreased from 101 minutes to 87 minutes (p less than 0.001). The hospitals, which included teaching hospitals and surgical facilities, were more likely to show a greater improvement in door-to-balloon time if they were smaller, nonteaching, and had higher door-to-balloon times to begin with.

The composite CMS/JCAHO scores improved significantly between early and late periods, increasing from a mean of 93.4% to 96.4% (p less than 0.001), and the composite ACC/AHA scores also improved, from 82.0% to 84.2% (p less than 0.001).

However, there was no significant correlation between improved door-to-balloon times and CMS/JCAHO or ACC/AHA scores, even after multivariable adjustment for differences in patient characteristics.

In-hospital mortality was 5.1% in the early period and 4.7% in the later period (p=0.09), but there was no significant association between improvements in door-to-balloon times and changes in mortality. However, in a secondary analysis, there was a suggestion of reduced mortality in the hospitals that improved both door-to-balloon time and CMS/JCAHO performance.

"If you improved only one measure alone, you wouldn't impact mortality very much, but if you improved both door-to-balloon time and the other care process measures, you would see a significant impact on mortality," commented Wang.

Shaving off 14 Minutes a "Modest" Improvement

To heartwire, Armstrong pointed out that the study is missing key information, including the overall time from symptom onset to actual achievement of effective myocardial perfusion.

"Speedy reperfusion is much more likely to affect outcome when patients present within the first two to three hours, than later when they are at the 'flat portion' of the time-efficacy curve," Armstrong said. "The overall improvement in door-to-balloon times was quite modest, 14 minutes, from 101 to 87 minutes, and this means that nearly half of all the patients were still beyond guideline recommendations of 90 minutes. Since we do not know where in time these patients are within the 12-hour window of the study, and other key information is missing, we can only affirm that we need to do better in shortening the overall time from when patients start having symptoms to when they are effectively reperfused with whatever strategy is employed and combine it with attention to the many other components of care that affect outcome."

3. Probiotic Effects on Cold and Influenza-Like Symptom Incidence and Duration in Children

Leyer GJ, et al. Pediatrics 2009;124:e172-e179.

OBJECTIVE: Probiotic consumption effects on cold and influenza-like symptom incidence and duration were evaluated in healthy children during the winter season.

METHODS: In this double-blind, placebo-controlled study, 326 eligible children (3–5 years of age) were assigned randomly to receive placebo (N = 104), Lactobacillus acidophilus NCFM (N = 110), or L acidophilus NCFM in combination with Bifidobacterium animalis subsp lactis Bi-07 (N = 112). Children were treated twice daily for 6 months.

RESULTS: Relative to the placebo group, single and combination probiotics reduced fever incidence by 53.0% (P = .0085) and 72.7% (P = .0009), coughing incidence by 41.4% (P = .027) and 62.1% (P = .005), and rhinorrhea incidence by 28.2% (P = .68) and 58.8% (P = .03), respectively. Fever, coughing, and rhinorrhea duration was decreased significantly, relative to placebo, by 32% (single strain; P = .0023) and 48% (strain combination; P less than .001). Antibiotic use incidence was reduced, relative to placebo, by 68.4% (single strain; P = .0002) and 84.2% (strain combination; P less than .0001). Subjects receiving probiotic products had significant reductions in days absent from group child care, by 31.8% (single strain; P = .002) and 27.7% (strain combination; P less than .001), compared with subjects receiving placebo treatment.

CONCLUSION: Daily dietary probiotic supplementation for 6 months was a safe effective way to reduce fever, rhinorrhea, and cough incidence and duration and antibiotic prescription incidence, as well as the number of missed school days attributable to illness, for children 3 to 5 years of age.

4. A Regional System of Stroke Care Provides Thrombolytic Outcomes Comparable With the NINDS Stroke Trial

LaMonte MP, et al. Ann Emerg Med. 2009;54:319-327.

Study objective
Administration of tissue plasminogen activator (tPA) for acute ischemic stroke remains controversial in community practice. Well-organized hierarchic systems of acute stroke care have been proposed to link community hospitals to comprehensive stroke centers. We report safety and functional outcomes in patients treated with tPA in our regional emergency stroke network and compare them with results reported from the trial conducted by the National Institute of Neurological Disorders and Stroke (NINDS).

Methods
Through a statewide communications and transport network, our brain attack center gives emergency medicine staff in the state and surrounding area immediate access to stroke specialists. The team provides consultation about the administration of tPA for ischemic stroke, using the NINDS protocol. Consultations, treatment, and outcomes are documented in our database.

Results
From 1996 to 2005, the brain attack center completed 2,670 consultations and diagnosed 1,788 patients with ischemic stroke. Two hundred forty patients (9% of all consultations; 13.4% of those with acute ischemic stroke) received tPA. Percentages of patients with symptomatic intracranial hemorrhage and 3-month modified Rankin scale scores less than or equal to 1, compared with those in the NINDS trial, were as follows: 3.3% versus 6.4% and 53% versus 43% (P=.04). Mortality rates were 13% (network) versus 17% (NINDS).

Conclusion
During a 9-year period, an emergency medicine network with stroke consultants achieved patient outcomes comparable to those reported from the NINDS trial. These results indicate that the NINDS tPA protocol is applicable to community practice, with the support of a university-based brain attack center.

Full-text (free!): http://www.annemergmed.com/article/PIIS0196064408017861/fulltext

5. Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular Outcomes

Chandra A, et al. Acad Emerg Med. 2009;16:740–748.

Objectives: The value of unstructured physician estimate of risk for disease processes, other than acute coronary syndrome (ACS), has been demonstrated. The authors sought to evaluate the predictive value of unstructured physician estimate of risk for ACS in emergency department (ED) patients without obvious initial evidence of a cardiac event.

Methods: This was a post hoc secondary analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospectively collected multicenter data registry of patients over the age of 18 years presenting to the ED with symptoms of ACS between 1999 and 2001. In this registry, following patient history, physical exam, and electrocardiogram (ECG), the unstructured treating physician estimate of risk was recorded. A 30-day follow-up and a medical record review were used to determine rates of adverse cardiac events, death, myocardial infarction (MI), or revascularization procedure. The analysis included all patients with nondiagnostic ECG changes, normal initial biomarkers, and a non-MI initial impression from the registry and excluded those without complete data or who were lost to follow-up. Data were stratified by unstructured physician risk estimate: noncardiac, low risk, high risk, or unstable angina.

Results: Of 15,608 unique patients in the registry, 10,145 met inclusion/exclusion criteria. Patients were defined as having unstable angina in 6.0% of cases; high risk, 23.5% of cases; low risk, 44.2%; and noncardiac, 26.3% of cases. Adverse cardiac event rates had an inverse relationship, decreasing from 22.0% (95% confidence interval [CI] = 18.8% to 25.6%) for unstable angina, 10.2% (95% CI = 9.0% to 11.5%) for those stratified as high risk, 2.2% (95% CI = 1.8% to 2.6%) for low risk, and to 1.8% (95% CI = 1.4% to 2.4%) for noncardiac. The relative risk (RR) of an adverse cardiac event for those with an initial label of unstable angina compared to those with a low-risk designation was 10.2 (95% CI = 8.0 to 13.0). The RR of an event for those with a high-risk initial impression compared to those with a low-risk initial impression was 4.7 (95% CI = 3.8 to 5.9). The risk of an event among those with a low-risk initial impression was the same as for those with a noncardiac initial impression (RR = 0.83, 95% CI = 0.6 to 1.2).

Conclusions: In ED patients without obvious initial evidence of a cardiac event, unstructured emergency physician (EP) estimate of risk correlates with adverse cardiac outcomes.

6. Ruling Out Abdominal Organ Injury in Children with Blunt Trauma

A new clinical score identified nearly all children with abdominal organ injury after trauma.

History and physical exam provide limited information for detecting intra-abdominal injury in children with blunt abdominal trauma. A reliable method for identifying children who require abdominal computed tomography (CT) would decrease radiation and contrast exposure and improve efficiency of care. In a prospective observational study, these authors used clinical data for 147 consecutive children with blunt abdominal trauma who were admitted to a Swedish tertiary care hospital to develop a decision rule for excluding intra-abdominal organ injuries.

All patients underwent extensive laboratory testing and abdominal ultrasound for assessment of renal artery Doppler flow by a radiologist; patients with abnormal laboratory or ultrasound findings underwent abdominal CT. The Blunt Abdominal Trauma in Children (BATiC) score assigns points as follows:

•4 points for an abnormal Doppler evaluation of the renal arteries on abdominal ultrasound

•2 points each for abdominal pain, signs of peritoneal irritation on physical exam, hemodynamic instability, aspartate aminotransferase (AST) over 60 IU/L, and alanine aminotransferase (ALT) over 25 IU/L

•1 point each for peripheral white blood cell count over 9.5 g/L, lactate dehydrogenase above 330 IU/L, lipase over 30 IU/L, and creatinine over 50 µg/L

Overall, 31 patients (21%) were diagnosed with abdominal organ injury. A BATiC score 7 had a 97% negative predictive value for abdominal organ injury. Two patients with scores 7 had injuries (1 splenic, 1 renal) that were detected by CT performed to evaluate persistent abdominal pain 24 hours after admission; neither required intervention.

Comment: The BATiC score is a promising clinical decision rule. If the method is validated in large prospective multicenter studies, its use could decrease exposure to contrast CT and increase detection of abdominal organ injuries in children with blunt abdominal trauma. Larger studies in other settings would also help determine which children with blunt abdominal trauma are eligible for use of the rule. Fine-tuning might eliminate colinear predictors, such as AST and ALT, and nonspecific indicators, such as the peripheral white blood cell count.

— Daniel J. Pallin, MD, MPH. Published in Journal Watch Emergency Medicine July 17, 2009. Citation: Karam O et al. Blunt abdominal trauma in children: A score to predict the absence of organ injury. J Pediatr 2009 Jun; 154:912

7. Correlation of sonographic measurements of the internal jugular vein with central venous pressure

Donahue SP, et al. Amer J Emerg Med. 2009;27:851-855.

Determination of volume status is crucial in treating acutely ill patients. This study examined bedside ultrasonography of the internal jugular vein (IJV) to predict central venous pressure (CVP).

Ultrasonography was performed on 34 nonventilated patients with monitored CVPs. The IJV was measured during the respiratory cycle and with the patient in different positions. Mean IJV diameter in patients with CVP less than 10 cm H2O was 7.0 mm (95% confidence interval [CI], 5.7-8.3) vs 12.5 mm (95% CI, 11.2-13.8) in patients with CVP of 10 cm H2O and greater. Measurement of end expiratory diameter with the patient supine had the highest correlation coefficient: 0.82 (95% CI). There was strong agreement among ultrasonographers: correlation coefficient, 0.92 (95% CI).

This pilot study shows promise that ultrasonography of the IJV can be a noninvasive tool to predict CVP. Measurement of end expiratory diameter in supine patients exhibited a high correlation to CVP.

8. A Feasibility Study of the Sensitivity of Emergency Physician Dysphagia Screening in Acute Stroke Patients

Turner-Lawrence DE, et al. Ann Emerg Med. 2009;54:344-348.e1.

Study objective
To determine the sensitivity of dysphagia screening by emergency physicians on acute stroke patients.

Methods
To develop a 2-tiered dysphagia screen and performed it on a convenience sample of acute stroke patients. Tier 1 examined voice quality, swallowing complaints, facial asymmetry, and aphasia. Tier 2 involved a water swallow test, with evaluation for swallowing difficulty, voice quality compromise, and pulse oximetry desaturation (2% or more). We classified patients passing both tiers as “low risk” and compared the screen's sensitivity to a formal assessment by speech language pathologists. To assess reproducibility, we performed 2 consecutive, blinded ED screens on a convenience sample of 32 patients.

Results
During 16 months, we enrolled a convenience sample of 103 patients, excluding 19 patients from data analysis for lack of a stroke discharge diagnosis (n=11), an incomplete speech language pathologist evaluation within 24 hours (n=7), or pneumonia on emergency department (ED) chest radiography (n=1). Of the 84 remaining patients, speech language pathologists identified dysphagia in 48. The sensitivity of the ED dysphagia screen was 96% (95% confidence interval [CI] 85% to 99%), with a negative likelihood ratio of 0.08 (95% CI 0.02 to 0.3). Reproducibility testing yielded a kappa for the overall screen result of 0.9 (95% CI 0.9-1.0) and a simple agreement of 97%.

Conclusion
Preliminary data on the sensitivity and reliability of our ED dysphagia screening tool are promising. The simple screen provides an easy way for emergency physicians to identify acute stroke patients eligible for early oral medications and nutrition. Further validation and refinement of our screen are needed before its widespread adoption.

9. Antibiotic Use in Children with Otitis Media Increases Risk for Recurrence

Another reason to wait and see

Clinicians often prescribe antibiotics for treatment of uncomplicated acute otitis media (AOM) in children despite lack of evidence for improved outcomes. To examine the effects of antibiotic treatment on recurrence of AOM, investigators in the Netherlands surveyed parents of 240 children (age range, 6 months to 2 years) about 3 years after the children had participated in a multicenter, randomized, double-blind trial of amoxicillin (40 mg/kg/day in 3 doses) or placebo for treatment of AOM (JW Emerg Med Apr 1 2000). Seventy percent of parents returned questionnaires.

Parents reported at least one episode of AOM since the 6-month posttreatment follow-up visit significantly more often in the amoxicillin group than in the placebo group (63% vs. 43%). Even after adjustment for confounding factors, children in the amoxicillin group had 2.5 times the risk for recurrence. In sensitivity analysis among children who were not prescribed antibiotics during the 6 months after randomized treatment, the adjusted odds ratio for recurrence was 4.4. Ear, nose, and throat surgery was less likely in the amoxicillin group (21% vs. 30%). The authors note that wide confidence intervals limit interpretation of the results and caution that the findings cannot be generalized to children with underlying disease or who live in underresourced conditions.

Comment: One more nail in the coffin for antibiotic use in simple otitis media! This practice increases risk for colonization with resistant pathogens and recurrent infections in individual children and contributes to antibiotic resistance in the general population. In uncomplicated cases, reassure parents that resolution without antibiotics is the rule, not the exception, and try a "wait-and-see prescription," rather than immediately starting unnecessary antibiotics.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine August 7, 2009. Citation: Bezáková N et al. Recurrence up to 3.5 years after antibiotic treatment of acute otitis media in very young Dutch children: Survey of trial participants. BMJ 2009 Jun 30; 338:b2525. (http://dx.doi.org/10.1136/bmj.b2525)

10. Who’s Likely to Have a Problem with Ketamine?

A. Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department: An Individual-Patient Data Meta-analysis of 8,282 Children

Green SM, et al. Ann Emerg Med. 2009;54:158-168.e4

Study objective
Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events.

Methods
We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events.

Results
In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose ≥2.5 mg/kg or total dose ≥5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class ≥3), and the choice of intravenous versus intramuscular route.

Conclusion
Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Full-text (free): http://www.annemergmed.com/article/PIIS0196064408020842/fulltext

B. Predictors of Emesis and Recovery Agitation With Emergency Department Ketamine Sedation: An Individual-Patient Data Meta-Analysis of 8,282 Children

Study objective
Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies.

Methods
We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events.

Results
In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of 2.5 mg/kg or more or a total dose of 5.0 mg/kg or more), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (less than 3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation.

Conclusion
Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.

11. Patient Satisfaction as a Function of Emergency Department Previsit Expectations

Toma G, et al. Ann Emerg Med. 2009;54:360-367.e6.

Study objectives
This study measures the effect of meeting emergency department (ED) patients' expectations for diagnostic and therapeutic interventions on patient satisfaction.

Methods
This was a cross-sectional study of consecutive patients during block enrollment periods surveyed at the beginning and end of their ED visits. On arrival patients or their surrogates were surveyed about the specific interventions they expected during their visit. After completion of ED care, they were surveyed about their level of satisfaction with the entire encounter, assessment of their provider's interpersonal skills, impression of time spent waiting in the ED, and perceived waiting time. Satisfaction was assessed with categorical responses. The degree of concordance of interventions expected and interventions provided was analyzed to determine their effect on overall ED visit satisfaction.

Results
Nine hundred eighty-seven patients presented during enrollment periods, 821 met inclusion criteria, and complete data were collected on 504 patient encounters. Twenty-nine percent had no previsit expectations of diagnostic or therapeutic interventions, 24% had a single reported expectation, 47% had multiple intervention expectations. After adjusting for potential confounders, we could not demonstrate a relationship between fulfillment of expectations and satisfaction. We did find a very strong relationship between highly ranked provider interpersonal skills and ED satisfaction (probability ratio of being “very satisfied” 8.6; 95% confidence interval 4.7 to 15.6). Other factors associated with high ED encounter satisfaction were adequate explanations for waiting times and perception of total time in the ED.

Conclusion
Overall satisfaction was strongly correlated with patient's assessment of the physician's interpersonal skills and was not correlated with whether the physician had met expectations about diagnostic and therapeutic interventions.

Full-text (free!): http://www.annemergmed.com/article/S0196-0644(09)00104-8/fulltext

12. Optimal Depth of Chest Compressions in Children

Following the American Heart Association recommendation for compression to a depth of one third to one half of chest thickness could lead to overcompression in children.

Braga MS, et al. Pediatrics 2009;124:e69-e74.

OBJECTIVE: Pediatric consensus-driven cardiopulmonary resuscitation guidelines target chest compression (CC) depths of one third to one half anterior-posterior (AP) chest depth. Estimates for this target as assessed by computed tomography (CT) measurements of internal and external AP chest dimensions could direct future pediatric cardiopulmonary resuscitation guidelines.

METHODS: A total of 280 consecutive chest CT scans in permuted blocks of 20 for each of 14 age divisions between 0 and 8 years were reconstructed and analyzed. External and internal AP depths were measured at midsternum, and residual chest depth was calculated at simulated one-third and one-half AP compressions.

RESULTS: After a simulated compression calculation, one-half external AP depth CC would result in residual internal depth of less than 10 mm for 94% (263 of 280) of children 3 months to 8 years. For a one-third external AP CC, only 0.4% (1 of 280) of children 3 months to 8 years had a calculated residual internal chest depth less than 10 mm.

CONCLUSIONS: By using CT reconstruction estimates of chest dimensions across the developmental spectrum from 0 to 8 years of age, we demonstrated that a simulated CC targeting approximately one-third external AP chest depth seems radiographically appropriate for children aged 3 months to 8 years, whereas simulated CC targeting approximately one-half external AP chest depth seems radiographically to be too deep, resulting in residual internal chest depth of less than 10 mm for most patients of this age.

13. A comparison of the palatability of flavored oral contrasts

Arya R, et al. Amer J Emerg Med. 2009;27:847-850.

Objective
The aim of this study was to compare the taste of computed tomography (CT) oral contrast diluted with various flavored drinks.

Methods
We performed a prospective, blinded, controlled trial in healthy adult volunteers. Subjects were assigned to ingest four 250-mL aliquots of oral contrast media diluted in water, Crystal Light Lemonade (Kraft Food, Northfield, Ill), Tropical Punch Kool-Aid (Kraft Food), and Tropicana orange juice (Pepsi Bottling Company, Sommers, NY) in random order; and the taste of the solution was measured with a 100-mm visual analogue scale and 5-point Likert scale from very worst to best. Between-group comparison of the taste scores was performed with repeated-measures analysis of variance and pairwise t tests. The study had 80% power to detect an effect size 0.75 SDs.

Results
There were 23 subjects; mean (SD) age was 33 (7.7) and 30% were female. The mean (SD) taste scores were water 12 (5), lemonade 37 (21), Kool-Aid 44 (20), and orange juice 40 (20) (P less than .05). The proportion of subjects completely ingesting the contrast in water (65%) was significantly less than that with other 3 study solutions (100% each, P less than .001).

Conclusions
Dilution of oral contrast media with lemonade, fruit punch, or orange juice is tastier than with water. The choice of the specific juice used to dilute the oral contrast should be individualized based on patient preferences and availability.

14. Rebound Symptoms After Stopping PPIs

The findings are pertinent for patients who take PPIs unnecessarily.

Reimer C, et al. Gastroenterol 2009;137:80-87.e1.

Background & Aims
Rebound acid hypersecretion (RAHS) has been demonstrated after 8 weeks of treatment with a proton-pump inhibitor (PPI). If RAHS induces acid-related symptoms, this might lead to PPI dependency and thus have important implications.

…Conclusions
PPI therapy for 8 weeks induces acid-related symptoms in healthy volunteers after withdrawal. This study indicates unrecognized aspects of PPI withdrawal and supports the hypothesis that RAHS has clinical implications.

Full-text (free): http://www.gastrojournal.org/article/PIIS0016508509005228/fulltext

15. Urine dipstick useless to rule out rhabdomyolysis in patients with suspected heat injury

Young SE, et al. Amer J Emerg Med. 2009;27:875-877.

Background
Heat injury is a common, potentially life-threatening medical condition. In austere or mass-casualty conditions an easy to use, sensitive screening test could be a valuable tool to care providers and evacuation planners.

Objective
The objective of the study was to determine if a simple urine dipstick test for blood is sensitive for detection of rhabdomyolysis in the suspected heat injury patient.

Material and Methods
A convenience sample of patients presenting to a military community hospital Emergency Department during summer months with a presenting complaint consistent with suspected heat injury had urine dipstick testing performed for blood and compared with the results of formal urinalysis and serum creatine kinase.

Results
60 patients were enrolled in the study, seven had creatine kinase levels greater than 1000U/L, 14 had levels greater than 500U/L, and 26 had levels greater than 250 U/L. Using 1000U/L, urine dipstick testing had a sensitivity of 14% and a specificity of 85%.

Conclusions
Urine dipstick testing for blood is not a useful screening test for rhabdomyolysis in patients suspected to have significant heat injury.

16. Clinical and ECG Effects of Escitalopram (aka Lexapro) Overdose

Van Gorpab F, et al. Ann Emerg Med. 2009;54:404-408.

Study objective
We investigate the clinical effects of escitalopram overdose and determine the risk of QT prolongation and serotonin toxicity.

Methods
A review of escitalopram overdoses to a clinical toxicology unit was undertaken. Patient demographics, details of the ingestion, clinical effects, including evidence of serotonin toxicity, complications (arrhythmias and seizures), ICU admission, and length of stay were obtained. QT and QRS intervals were manually measured on ECGs by using a standardized approach. In a subgroup of 34 prospectively recruited patients, escitalopram was detected in blood from 33 patients. Medians and interquartile ranges (IQR) were reported, and QT versus pulse rate was plotted on a QT nomogram to investigate QT prolongation.

Results
Median ingested dose in the 79 presentations was 140 mg (IQR 75 to 260 mg; range 20 to 560 mg), and escitalopram was the only drug ingested or all coingested drugs were nontoxic in 46 cases. Median length of stay for patients receiving clinically important coingestants was 19 hours (IQR 9 to 33 hours) compared with that of patients receiving escitalopram alone (median 12 hours; IQR 7 to 19 hours). Serotonin toxicity occurred in 7 of the 46 escitalopram-alone ingestions (15%) but in only 1 of the 33 patients coingesting other medications. Common features were inducible clonus and hyperreflexia. Central nervous system depression and ICU admission were rare in escitalopram-alone overdoses compared with those in cases with sedative coingestants. Bradycardia (pulse rate below 60 beats/min) occurred in 11 cases (14%) and an abnormal QT–HR pair in 11 (14%), which was associated with normal or slow pulse rates. There were no deaths, seizures, or arrhythmias.

Conclusion
Major manifestations of escitalopram overdose were serotonin toxicity, QT prolongation, and bradycardia. The study suggests a potential for cardiac arrhythmias in escitalopram overdose.

17. Facebook requests can be dilemma for physicians

Physicians with Facebook pages may have patients who ask to be accepted as a "friend" on the social network site. The request can create a dilemma; the physician doesn't want to be rude and refuse, but also may be wary about giving a patient access to personal information. As one physician wrote in the New England Journal of Medicine, the debate over crossing personal-professional boundaries has taken a different shape in a new medium.

Sachin H. Jain. Practicing Medicine in the Age of Facebook. N Engl J Med. 2009;361:649-651.

Full-text (free!): http://content.nejm.org/cgi/content/full/361/7/649

18. Is Chest CT Overused in Children After Blunt Trauma?

Neither chest x-rays nor CT scout films missed findings in patients who needed immediate surgery.

Markel TA et al. J Trauma 2009;67:23.

Background: There is a growing concern that computed tomography (CT) is being unnecessarily overused for the evaluation of pediatric patients. The purpose of this study was to analyze the trends and utility of chest CT use compared with chest X-ray (CXR) for the evaluation of children with blunt chest trauma.

Methods: A 4-year retrospective review was performed for pediatric patients who underwent chest CT within 24 hours of sustaining blunt trauma at a Level-I trauma center. Trends in the use of CT and CXR were documented, and results of radiology reports were analyzed and compared with clinical outcomes.

Results: Three hundred thirty-three children, mean age 11 years, had chest CTs, increasing from 5.5% in 2001-2002 to 10.5% in 2004-2005 (p less than 0.001). Conversely, in those children who underwent chest CT, the rate of initial CXR use decreased from 84% to 56% during the same period (p less than 0.001). Twenty percent of chest CTs had significant positive findings. Six patients underwent emergency surgery for cardiac or arterial injuries, and all demonstrated abnormal findings on CXR or CT scout imaging. When compared with the CT, only 5% of initial CXRs falsely reported normal findings that may have altered management.

Conclusions: CT use in children has increased rapidly for the initial evaluation of chest trauma, whereas CXR use has decreased. Despite this trend, CXR remains an acceptable screening tool to analyze which patients may require CT evaluation. A multidisciplinary approach is warranted to develop guidelines that standardize the use of CT and thereby decreases unnecessary radiation exposure to pediatric patients.

19. Emergency physicians report infrequent use of α-blockade for the treatment of ureteral stones

Chan CW, et al. Amer J Emerg Med. 2009;27:776-778.

We sought to determine how frequently tamsulosin is used by emergency physicians (EPs) for the treatment of patients with ureteral stones, and examine factors influencing its use.

Basic Procedures
We distributed online and paper surveys to 240 EPs in five states in the United States. Surveys asked the length of time in practice, the type of hospital setting, and the self-reported frequency of tamsulosin use by quartile.

Findings
A total of 103 EPs (43%) responded to the survey. The majority (60%, 95% CI 51% to 69%) reported the use of tamsulosin in fewer than 25% of patients presenting with ureteral stones, and many (27%, 95% CI 20% to 36%) had not heard of the use of tamsulosin for urinary-stone passage. Practice in a county hospital was associated with infrequent tamsulosin use (p=.02).

Conclusions
Despite evidence that alpha-blockade may be beneficial (see below) to patients presenting to the emergency department with ureteral stones, this approach is still used inconsistently by EPs.

20. Tamsulosin Unhelpful for Ureteral Stones in the ED: A Randomized, Controlled Trial

Ferre RM, Ann Emerg Med. 2009;54:432-439.e2.

Study objective
The α-adrenergic antagonist tamsulosin hydrochloride has become an increasingly common adjunct in the treatment of ureteral calculi; however, its efficacy in a general emergency department (ED) population has not been investigated.

Methods
We conducted a randomized, controlled trial of adult ED patients with distal ureteral calculi diagnosed by computed tomography scan. Patients were randomized to receive either a 10-day course of ibuprofen and oxycodone plus tamsulosin or ibuprofen and oxycodone alone. The primary outcome measure was successful spontaneous ureteral stone expulsion at 14 days. Secondary outcomes included time to stone passage, self-reported pain scores, number of colicky pain episodes, unscheduled return ED/primary care visits, number of days of missed work/usual function, amount of analgesic used, and adverse events.

Results
Eighty subjects were enrolled in the study, with 77 completing the trial. Mean stone size was 3.6 mm (95% confidence interval [CI] 3.4 to 3.9). Successful spontaneous stone expulsion at 14 days was similar between the groups, with 27 (77.1%) subjects in the tamsulosin group and 24 (64.9%) subjects in the standard therapy group reporting spontaneous stone passage, a difference of 12% (95% CI –8.4% to 32.8%). At 2-, 5-, and 14-day follow-up, there were no clinically important (or statistically significant) differences between the groups for any secondary outcome measure. No adverse events were reported in either group.

Conclusion
In this cohort of adult ED patients with distal ureteral calculi, treatment with tamsulosin did not substantially improve any of the studied outcome measures compared with treatment with ibuprofen and oxycodone alone.

21. Is female sex associated with ED delays to diagnosis of appendicitis in the computed tomography era?

Donlan SM, et al. Amer J Emerg Med. 2009;27:856-858.

Background
Historically, females had delays to definitive diagnosis of appendicitis when compared to males. In this current millennium, appendicitis is now most commonly diagnosed by computed tomography (CT) in the emergency department (ED) rather than at surgery.

Objective
The aim of the study was to assess if female gender is still associated with delays to diagnosis of appendicitis in the CT era.

Methods
A retrospective cohort analysis of adult patients with appendicitis at a university teaching hospital ED was conducted. Inclusion criteria was age of more than 18 years and an International Classification of Diseases, Ninth Revision (ICD-9), diagnosis of appendicitis. Patients were excluded from analysis if they were pregnant, no CT scan was obtained in the ED, or had incomplete outcome data.

Results
One hundred thirty-seven patients met inclusion criteria; 65 female, 72 males. Time from triage to CT order was 138 minutes in females and 95 minutes in males (P = .0012). Time from initial physician evaluation to CT order was 45 minutes in females and 28 minutes in males (P = .0012). Nonclassic symptoms were more common in females and pelvic evaluation did not delay the CT order.

Conclusion
Female gender is still associated with delays to CT acquisition and diagnosis of appendicitis.