Monday, September 21, 2009

Lit Bits: Sept 21, 2009

From the recent medical literature...

1. Validated Rules May Predict Children at Very Low Risk for Brain Injury After Head Trauma

Laurie Barclay, MD. September 18, 2009 — Validated prediction rules might help identify children at very low risk for brain injury after head trauma, according to the results of a study published online September 14 in The Lancet.

"CT imaging of head-injured children has risks of radiation-induced malignancy," write Nathan Kuppermann, from University of California, Davis Medical Center in Sacramento, and colleagues from the Pediatric Emergency Care Applied Research Network. "Our aim was to identify children at very low risk for clinically important traumatic brain injuries (ciTBI) for whom CT might be unnecessary."

The study sample consisted of 42,412 patients younger than 18 years of age with Glasgow Coma Scale scores of 14 or 15 who presented at 25 North American emergency departments within 24 hours of head trauma. The investigators derived and validated age-specific prediction rules for ciTBI, defined as death from traumatic brain injury, neurosurgery, intubation for longer than 24 hours, or hospital admission for 2 or more nights.

Among children younger than 2 years of age, 8502 were in the derivation population and 2216 in the validation population, and among children 2 years of age and older, there were 25,283 and 6411, respectively. CT scans were performed in 14,969 children (35.3%); 376 children (0.9%) were diagnosed with ciTBIs and 60 (0.1%) underwent neurosurgery.

For children younger than 2 years, the prediction rule was normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 seconds, nonsevere injury mechanism, no palpable skull fracture, and acting normally according to the parents. In the validation population, this rule had a negative predictive value for ciTBI of 1176/1176 (100.0%; 95% confidence interval [CI], 99.7 - 100.0) and a sensitivity of 25/25 (100%; 95% CI, 86.3 - 100·0). This low-risk group consisted of 167 (24.1%) of 694 CT-imaged patients younger than 2 years of age.

For children 2 years of age and older, the prediction rule was normal mental status, no loss of consciousness, no vomiting, nonsevere injury mechanism, no signs of basilar skull fracture, and no severe headache. This rule had a negative predictive value of 3798/3800 (99.95%; 95% CI, 99.81 - 99.99) and a sensitivity of 61/63 (96.8%; 95% CI, 89.·0 - 99.6). Of 2223 CT-imaged patients 2 years of age and older, 446 (20.1%) were in this low-risk group.

"Neither rule missed neurosurgery in validation populations," the study authors write. "These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated."

Using these prediction rules, CT scans and the attendant radiation exposure could be eliminated in 1 in 4 children younger than 2 years and in 1 in 5 children older than 2 years presenting with head trauma.

Limitations of this study include lack of CT scans on all patients and lack of assessment of long-term neurocognitive outcomes.

"Application of these rules could limit CT use, protecting children from unnecessary radiation risks," the study authors conclude. "Furthermore, these rules provide the necessary data to assist clinicians and families in CT decision making after head trauma."

In an accompanying Comment, Patricia C. Parkin, MD, and Jonathon L. Maguire, MD, from the Hospital for Sick Children, University of Toronto Faculty of Medicine in Ontario, note that decision aids offer structured presentations of options and outcomes.

"Many decisions, even in acute-care settings, are sensitive to patients' values and preferences," Drs. Parkin and Maguire write. "Perhaps as this field moves forward to assessment of the effect of the rules on physicians' behavior and clinical outcomes (impact analysis), clinicians and investigators might consider involving patients in the decision-making process. Then, when asking the question 'should my head-injured child have a CT scan?', parents can weigh the probability of a clinically important traumatic brain injury with the probability of harm from ionizing radiation from the CT scan."

The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services, funded this study. The study authors and editorialists have disclosed no relevant financial relationships.


2. Multitasking Muddles the Mind?

By Constance Holden. ScienceNOW Daily News. 25 August 2009

Bad news for people who like to text their BFFs while surfing the Web for some new shoes and watching the latest episode of Project Runway. Scientists who've conducted what they say is the first-ever study of chronic multitaskers found that cognitive performance declines when people try to pay attention to many media channels at once.

Although media multitasking has become more and more prevalent, no one knows how chronic media immersion affects cognitive functioning. So a team headed by psychologist Eyal Ophir of Stanford University in Palo Alto, California, identified 19 "heavy media multitaskers" (HMMs) and 22 "light media multitaskers" (LMMs) among a group of students based on how often they reported simultaneously using media such as television, cell phones, computer games, and videos.

The researchers then gave subjects in the two groups tests to see how well they could sift relevant information from the environment, filter out irrelevant information in their memories, and quickly switch between cognitive tasks. One filtering test, for example, required viewers to note changes in red rectangles while ignoring changes in blue rectangles in the same pictures. In the task-switching experiment, participants were presented with images of paired numbers and letters and had to switch back and forth between classifying the numbers as even or odd and classifying the letters as vowels or consonants.

The HMMs did worse than the LMMs across the board. Surprisingly, says co-author and sociologist Clifford Nass, "They're bad at every cognitive control task necessary for multitasking." They were more easily distracted by irrelevant stimuli, and although their memories were no worse than those of the LMMs, they had more difficulty in selecting stored information that was relevant to the task at hand. In one filtering test, for example, the LMMs took 323 milliseconds to discern the correct answer, but the HMMs averaged 400 milliseconds.

Nass says the study has a disturbing implication in an age when more and more people are simultaneously working on a computer, listening to music, surfing the Web, texting, or talking on the phone: Access to more information tools is not necessarily making people more efficient in their intellectual chores. Also disconcerting, he notes, is that "people who chronically multitask believe they're good at it." The findings are reported this week in the Proceedings of the National Academy of Sciences.

Daphne Bavelier, a cognitive scientist at the University of Rochester in New York state, says the research presents a puzzle about the brain's ability to learn from experience. Bavelier has discovered that people who play action video games get better at the kind of task-switching those games require. In contrast, Bavelier says, the poor performance of multitaskers in the new study suggests that more experience doesn't always translate to improved performance.

It's still not clear, however, that multitasking really scrambles the brain. It's also possible that people with poor filtering and attentional abilities are more prone to multitasking to begin with. Anthony Wagner, a psychologist in the Stanford group, says he suspects that constant jumping among different media offers instant rewards that reinforce "exploratory" behavior at the expense of the ability to concentrate on a particular task.

Want more on how the brain works? See John Medina, Brain Rules: 12 Principles for Surviving and Thriving at Work, Home, and School (Seattle: Pear Press, 2008). Amazon See also the book’s webpage

3. Opioids May Be Unnecessary Adjuncts to Proposal

Randomized Clinical Trial of Propofol With and Without Alfentanil for Deep Procedural Sedation in the Emergency Department

Miner JR, et al. Acad Emerg Med. 2009;16:825–834.

Objectives: The objectives were to compare the efficacy, occurrence of adverse events, and recovery duration of propofol with and without alfentanil for use in procedural sedation in the emergency department (ED).

Methods: This was a randomized nonblinded prospective trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were given intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients received 1 mg/kg propofol either with or without a supplemental dose of 10 μg/kg alfentanil for deep procedural sedation. Doses, vital signs, nasal end-tidal CO2 (ETCO2), pulse oximetry, and bispectral electroencephalographic (EEG) analysis scores were recorded. Subclinical respiratory depression was defined as a change in ETCO2 of greater than 10 mmHg, an oxygen saturation of less than 92% at any time, or an absent ETCO2 waveform at any time. Clinical events related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure or had recall of the procedure.

Results: A total of 150 patients were enrolled; 146 underwent sedation and were included in the analysis. Seventy-four patients received propofol, and 71 received propofol with alfentanil. No clinically significant complications were noted. Subclinical respiratory depression was seen in 24/74 patients in the propofol group and 30/71 patients in the propofol/alfentanil group (effect size = 9.8%, 95% CI = –5.8% to 25.5%). Clinical signs of respiratory depression included an increase in supplemental oxygen use in 25 of the 74 propofol patients and 31 of the 71 propofol/alfentanil patients (effect size 9.9%, 95% CI = –5.9% to 25.7%), the use of bag-valve mask apparatus in seven patients in the propofol group and 12 in the propofol/alfentanil group (effect size = 5.6%, 95% CI = –3.5% to 18.4%), airway repositioning in 13 propofol patients and 20 propofol/alfentanil patients (effect size = 10.6%, 95% CI = –3.0% to 24.2%), and stimulation to induce breathing in 11 propofol patients and 20 propofol/alfentanil patients (effect size = 13.3%, 95% CI = 0.1% to 26.5%). The total time of the procedure was longer for the alfentanil/propofol group (median = 11 minutes, range = 5–22 minutes) than for the propofol group (median = 9 minutes, range = 1 to 43 minutes; effect size = 1.93 minutes, 95% CI = 0.73 to 2.58, p = 0.02). Pain during the procedure was reported by 10 of the 74 patients in the propofol group and 7 of the 71 patients in the propofol/alfentanil group (effect size = 4.5%, 95% CI = –6.8% to 14.1%). Recall of some part of the procedure was reported by 12 patients in the propofol group and 9 in the propofol/alfentanil group (effect size = 3.5%, 95% CI = –7.9% to 15.0%). All procedures were successfully completed.

Conclusions: The use of supplemental alfentanil with propofol for procedural sedation did not result in a difference in reported pain or recall immediately after the procedure. There was an increase in the proportion of patients who required stimulation to induce respiration during the procedure in patients who received propofol with supplemental alfentanil. The addition of supplemental opioid to procedural sedation with propofol does not appear beneficial.

4. Most Mistakes in the Emergency Department Caused by Human Error

Fran Lowry. September 17, 2009 — Most of the mistakes in the emergency department (ED) that have the potential to compromise patient safety are caused by human error, according to a study published online September 18 in BMC Emergency Medicine.

"[EDs] are challenging hospital settings with regard to patient safety. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety," Marleen Smits, MD, from the Netherlands Institute for Health Services Research, Utrecht, and colleagues write. "This can only be achieved if interventions tackle the dominant underlying causes."

The aim of this study was to examine the nature and causes of unintended events in EDs and the relationship between type of event and causal factor structure.

The study evaluated medical errors in the EDs of 10 hospitals in the Netherlands (1 university hospital, 3 tertiary teaching hospitals, and 6 general hospitals) for 8 to 10 weeks. ED staff members were asked to report all unintended events, no matter how trivial or commonplace, that could have harmed or did harm a patient.

A total of 522 events were reported, ranging from 46 to 71 per ED, for an average of 52 reports. Most of the reports (85%) were made by nurses; resident physicians or consultants reported 13% of the unintended events, and clerical staff reported 2%. The reporter was directly involved in 83% of the unintended events. Most occurred during daytime hours (44%); 34% occurred during evening and night, and for 22% of the unintended events, the time of occurrence was unknown or unspecified by the reporter.

Most errors occurred during medical examinations or lab tests (36%). More than half of the unintended events (56%) had consequences for the patient, and in 45% of these instances, the patient suffered some inconvenience, such as prolonged waiting time. One third of patients received suboptimal care, such as a delay in starting antibiotic treatment. The consequences of error were more severe in the 8% of patients who required an extra intervention, the 6% of patients who suffered pain, and the 3% of patients who suffered a physical injury, Dr. Smits and colleagues write.

Most root causes of error were human (60%), followed by organizational (25%) and technical (11%) causes. Nearly half of the root causes could be attributed to other departments either in or outside of the hospital.

In citing limitations to their study, the investigators note that, because the reporting was not anonymous, it is possible that certain mistakes were underreported. "This may have biased the results towards the reporting of less significant events, events without consequences for the patient, and errors originating in other departments, because these are 'safer' to report."

In addition, most errors were reported by nurses, and therefore the study results give information about events that are mainly related to nursing care and less to care by residents and specialists in the ED.

Although the majority of errors had no consequences for the patient or resulted in only minor inconveniences, their accumulated effect on patient well-being is likely to be large, the authors write. They conclude: "Event reporting gives insight into diverse unintended events. The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments."

Dr. Smits and colleagues have disclosed no relevant financial relationships.

BMC Emerg Med. 2009;9:16

5. More Disturbing News About Prehospital Trauma Intubation

Prehospital intubation failed in 31% of trauma patients in a large urban trauma system.

Cobas MA, et al. Anesth Analg 2009 Aug; 109:489.

BACKGROUND: Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI.

METHODS: A prospective observational study was conducted evaluating trauma patients who had emergency prehospital airway management and were admitted during the period between August 2003 and June 2006. The PHI was considered a failure if the initial assessment determined improper placement of the endotracheal tube or if alternative airway management devices were used as a rescue measure after intubation was attempted.

RESULTS: One-thousand-three-hundred-twenty patients had emergency airway interventions performed by an anesthesiologist upon arrival at the trauma center. Of those, 203 had been initially intubated in the field by emergency medical services personnel, with 74 of 203 (36%) surviving to discharge. When evaluating the success of the intubation, 63 of 203 (31%) met the criteria for failed PHI, all of them requiring intubation, with only 18 of 63 (29%) surviving to discharge. These patients had rescue airway management provided either via Combitube® (n = 28), Laryngeal Mask Airway® (n = 6), or a cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not. Several other variables, including age, gender, weight, mechanism of injury, presence of facial injuries, and emergency medical services were not correlated with an increased incidence of failed intubations.

CONCLUSION: This prospective study showed a 31% incidence of failed PHI in a large metropolitan trauma center. We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.

6. Intervention for Non–ST-Segment-Elevation Acute Coronary Syndromes: What Difference Does a Day Make?

Interventions performed immediately or deferred to the next working day resulted in similar outcomes.

The advantages of invasive over conservative strategies for managing non–ST-segment-elevation acute coronary syndromes (NSTEACS) are established, but the optimal timing of intervention is undetermined. To find out whether immediate catheterization compared with delayed intervention reduces incident MI, investigators in France randomized 352 patients hospitalized for NSTEACS to undergo interventional treatment either immediately upon admission or on the next working day (8–60 hours after enrollment).

Median time from randomization to sheath insertion was 70 minutes in the immediate-intervention group and 21 hours in the delayed-intervention group. The primary endpoint, peak troponin level during hospitalization, did not differ significantly between the two strategies (median peak levels, 2.1 ng/mL and 1.7 ng/mL in the immediate- and delayed-intervention groups, respectively). The rate of the composite of death, MI, and urgent revascularization at 1 month also did not differ significantly between the two groups (13.7% and 10.2%, respectively). However, median hospital stay was significantly shorter with the immediate strategy than with the delayed strategy (55 hours vs. 77 hours).

Comment: These findings suggest that in patients with non–ST-segment-elevation acute coronary syndromes, immediate versus delayed intervention does not result in increased MI rates, as defined by peak troponin levels. Accordingly, rapid or urgent intervention appears to be appropriate in unstable patients, whereas logistical and cost concerns may factor into decisions about whether to defer intervention in stable patients.

— Beat J. Meyer, MD. Published in Journal Watch Cardiology September 16, 2009. Citation:
Montalescot G et al. Immediate vs delayed intervention for acute coronary syndromes: A randomized clinical trial. JAMA 2009 Sep 2; 302:947.

7. Useful Clinical Aphorisms to Practice By

“Clinical aphorisms that have proved useful for me during more than 30 years of inpatient and outpatient attending at 4 US medical schools”

Alpert JS. Amer J Med. 2009;122:700-701;789-790.

Rule 1: Common things occur commonly. I make this point continuously to medical students and residents. Sometimes young clinicians will suggest an unusual diagnosis for a patient with the hope of being the only doctor to make the correct diagnosis. More experienced clinicians believe the correct diagnosis is usually something common. For example, consider a patient with an enlarged spleen. In North America, splenomegaly rarely results from entities such as primary lymphoma of the spleen or malaria. Rather, splenomegaly is often caused by portal hypertension or mononucleosis. One of my first, and best, residents during my internship told me “If it looks like a horse, whinnies like a horse, and smells like a horse, don't expect a zebra to appear” (Stone N, MD, personal communication, 1970).

Rule 2: Common sense occurs uncommonly. This aphorism is usually attributed to Voltaire. Over the years, I have seen many violations of this important rule in clinical medicine. Physicians should exercise common sense before ordering tests or performing therapeutic interventions. Examples abound in support of this rule. Recently, I saw a 60-year-old diabetic woman in my office. She had been admitted to our hospital several weeks earlier with a single bout of rest angina. Her cardiac catheterization revealed modest coronary arterial stenoses, and she was placed on medical therapy with brand name medications by another cardiologist: a statin, an angiotensin receptor blocker, and clopidogrel. Subsequently, I first saw her in my office. At that time, she and her family told me that they had paid more than $500 for 1 month's supply of the medicines that had been prescribed in the hospital. I quickly altered her regimen to include generic forms of a statin and an angiotensin-converting enzyme inhibitor, as well as 325 mg of aspirin. These new generic prescriptions would cost the patient less than $20 per month. Common sense should have been used earlier by the inpatient attending physician simply by informing the patient that generic brands cost less than brand name pharmaceuticals. As noted by Harvey Cushing (1869-1939), “Three-fifths of the practice of medicine depends on common sense, knowledge of people and of human reactions.” I would add knowledge of the patient's ability to pay for the medicines prescribed.

Rule 3: The less a procedure is indicated the more likely that its use will be accompanied by complications. This rule advises clinicians to ensure that every procedure or test ordered has a reasonable probability of altering patient management. An example of this aphorism in practice involved a healthy 55-year-old man without coronary heart disease risk factors. He became anxious when a neighbor had an acute myocardial infarction. His doctor suggested that he undergo a coronary calcium computed tomography scan. This test revealed modest coronary calcifications. The patient became more anxious when he heard the results of his computed tomography scan, and he convinced his physician that he needed a coronary angiogram. The angiogram was unremarkable, but the catheterization resulted in a large groin hematoma and pseudoaneurysm that required vascular surgical repair. If I had been involved in this patient's initial care, reassurance or, at most, a Bruce protocol electrocardiographically monitored exercise test, would have been my approach.

Rule 4: Listen between the lines.
Rule 5: Seven minutes is an inadequate amount of time to spend on a patient visit.
Rule 6: Practicing good medicine requires a triad of equal doses of hard work, kindness, and honesty.
Rule 7: No individual has a monopoly on truth.
Rule 8: Obtaining informed consent from a patient for a procedure can help or hurt the patient.
Rule 9: Physician, heal thyself.
Rule 10: Respect your fellow health care workers; they are your most important clinical asset.
Rule 11: Admission to an intensive care unit in a tertiary care hospital can be a harrowing experience for the patient.
Rule 12: True, true, and unrelated.
Rule 13: The enemy of good is perfect.
Rule 14: Physician error is often the result of overconfidence.
Rule 15: It is a privilege to practice medicine.

Full-texts (free):

8. Switch to Part D Limits Access to Psychiatric Medications, Increases ED Use

Caroline Cassels. September 9, 2009 — The switch from Medicaid drug coverage to Medicare Part D has restricted access to psychiatric medications and contributed to a subsequent high rate of emergency room visits among patients with mental health disorders, new research suggests.

A study conducted at Harvard Medical School in Boston, Massachusetts, shows that since January 2006, when the switch occurred, 44% of psychiatric patients reported difficulties in accessing medications. In addition, the likelihood of visiting an emergency department was significantly higher for psychiatric patients who experienced a medication access problem than for those who did not (odds ratio, 1.75; mean P = .003).

"We were surprised by the high rate of reports of access problems — 44% of patients reported some type of access issue, and that's a pretty large number, even allowing for the fact that it is a relatively new initiative and you would expect a certain amount of miscommunication and confusion," lead author Haiden Huskamp, PhD, told Medscape Psychiatry.

The study is published in the September issue of Psychiatric Services.

Utilization Management

It is estimated that approximately one third of individuals dually eligible for Medicare and Medicaid benefits have a mental disorder. For these individuals, said Dr. Huskamp, pharmacotherapy is a key element of their treatment.

The authors point out that "dual eligibles" received coverage for prescription drugs through the Medicaid program in which patients paid little or none of the cost of their medications

However, under the Medicare Prescription Drug Improvement and Modernization Act of 2003, drug coverage for this population was shifted from Medicaid to the new Medicare Part D program, and all of these individuals were randomly assigned to a private Part D plan with associated premiums and other utilization management tools including prior authorization and stepped care.

"The creation of Part D represented an important switch for dually eligible patients. Now instead of getting their drugs from Medicaid, patients had to get their medications through private Part D plans, which had different coverage policies and restrictions," said Dr. Huskamp.

Dr. Huskamp added her group was particularly concerned about the potential effect of this policy change on the dually eligible psychiatric population.

"This is a particularly vulnerable population, and there was some concern that switching to a Part D plan that may have restrictions on the medications they were taking could have implications for the quality of care they received. So we wanted to look and see what was happening in this particular group," said Dr. Huskamp.

Drugs Not Covered or Approved

For the study, the researchers randomly sampled psychiatrists from the American Medical Association's Physicians Masterfile who reported on experiences of 1 dually eligible patient in the 9 to 12 months after Part D implementation.

Each psychiatrist was randomly assigned 1 of 21 start days and times to report on the next dually eligible patients treated during the psychiatrist's last typical work week. Information on patients' sociodemographics, treatment setting, diagnosis, clinical characteristics, and ability to access medication was gathered.

The researchers also obtained information on emergency department visits related to participants' psychiatric illness, as well as any psychiatric hospitalizations since January 1, 2006. A total of 908 patients were included in the final study sample. Of these 57% were women and 62% were between 41 and 64 years old. Almost two thirds had a diagnosis of either schizophrenia or bipolar disorder.

Overall, 400 individuals (44%) had some type of problem accessing their medications. Investigators found that 318 individuals (35%) were unable to access clinically indicated refills or new prescriptions because the drugs were not covered or approved.

In addition, 170 individuals (19%) were stable on a clinically desired or indicated medication but switched to a different drug because refills were not covered or approved, and 200 participants (22%) had problems accessing medications because of copayments.

Compared with a matched sample of dually eligible patients whose medication access was not disrupted, those with difficulty accessing their medication were more likely to incur a visit to the hospital emergency department related to their psychiatric illness.

It may be, said Dr. Huskamp, that switching from Medicaid to Part D had some unanticipated and unintended negative effects including the possibility of negative clinical outcomes, as indicated by a high rate of emergency room visits and increased health costs for non-drug-related health services.

"I think our study provides a red flag that some attention needs to be devoted to this issue. We need to examine the Part D data (which are currently not publicly available) so we can take a detailed look at utilization patterns and health outcomes for this population," said Dr. Huskamp.

"Certainly emergency department use is an indicator that things are not going well for patients, but having more concrete measures would be helpful to get a clearer understanding of how this policy change has affected patients' mental health status and functioning," she added.

Psychiatr Serv. 2009;60:1169–1174.

9. Aspiration vs. Chest Tube for Spontaneous Pneumothorax: No Difference in Outcome

NEW YORK (Reuters Health) Sep 10 - For primary spontaneous pneumothorax in adults, percutaneous aspiration and standard chest tube drainage have similar outcomes, according to an abstract of a report from the Cochrane Database of Systematic Reviews.

The abstract appears in the September issue of the Annals of Emergency Medicine, in the journal's Evidence-Based Emergency Medicine section.

"The management of primary spontaneous pneumothorax is controversial, with bodies such as the American College of Chest Physicians recommending formal chest tube drainage for patients requiring intervention, (and) the British Thoracic Society recommending simple percutaneous aspiration as the primary management strategy," section editor Dr. John W. Hafner, of the University of Illinois College of Medicine at Peoria, told Reuters Health.

The abstract is based on a Cochrane Review titled "Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults," written in 2007 by Abel Wakai and colleagues. That report reviewed studies published through 2006.

Of 1735 reports of randomized trials initially identified by the researchers as potentially relevant, only one, involving 60 patients, met all the criteria for study design and quality.

In this one trial, there was no significant difference in the immediate success rate for simple percutaneous aspiration compared with intercostal chest tube drainage (relative risk (RR)=0.93).

Similarly, there were no significant differences between the two approaches in rates of early failure at 1 week (RR=1.12), 1-year success (RR=1.02), length of hospital stay (mean group difference, 1.09 days), or pleurodesis by thoracoscopic talc poudrage within a year (RR=0.95).

Simple percutaneous aspiration did reduce patients' number of hospitalizations (RR=0.52).

"Widespread use of simple percutaneous aspiration (for) primary spontaneous pneumothorax could limit more invasive chest tube placement that requires hospitalization and increased healthcare costs," Dr. Hafner said.

"Unfortunately," he added, "due to the small size of the single study in the review, the general application of these results remains in question and requires further study with a larger study sample."

Ann Emerg Med 2009;54:458-460.

10. FDA Adds Boxed Warning to Injectable Promethazine

September 16, 2009 — The US Food and Drug Administration (FDA) is requiring manufacturers of the injectable form of promethazine hydrochloride to add a boxed warning to the drug's labeling that highlights the risk of serious tissue injury if the drug is administered incorrectly.

"Intravenous administration of promethazine can cause severe tissue injury, including gangrene, requiring fasciotomy, skin graft, and/or amputation," according to information for healthcare professionals posted on the FDA Web site. In addition, "Severe tissue injury can occur from perivascular extravasation, unintentional intra-arterial injection, and intraneuronal or perineuronal infiltration."

The preferred route of administration is deep intramuscular injection. Subcutaneous and intra-arterial injection are contraindicated.

Based on these known risks, the FDA advises clinicians to “effectively communicate” the risk of severe tissue injury to the patient when promethazine is administered intravenously.

In an alert sent today from MedWatch, the FDA's safety information and adverse event reporting program, the FDA also advises healthcare professionals to monitor patients who have received promethazine via contraindicated routes of administration for signs and symptoms of potential tissue injury, including burning or pain at the site of injection, phlebitis, swelling, and blistering. And if a patient complains of pain during injection, administration should cease immediately.

The FDA is also requiring a revision in the Dosage and Administration section of the drug's labeling to highlight "specific recommendations for the maximum concentration (25 mg/mL) and rate of administration (25 mg/min) when intravenous administration of promethazine is required." The 50 mg/mL is for deep intramuscular injection only, and the intravenous line should be checked to ensure it is properly functioning with a rate of 25 mg per minute.

Promethazine hydrochloride injection, USP, first introduced to the market in 1956, is approved for a variety of uses including allergic reactions, sedation, motion sickness, nausea and vomiting associated with anesthesia and surgery, and as an adjunct to analgesics for control of postoperative pain.

Current prescribing information for promethazine does contain information on the risk of tissue injury, but it was not highlighted in a boxed warning.

More information can be found on the FDA Web site.

11. Antivirals Slightly Shorten Duration of Seasonal Flu in Children

Treatment was well tolerated and slightly reduced transmission to household contacts.

Children may shed influenza virus longer than adults and are a main source of spread to household contacts. To examine the effect of antiviral treatment in children, researchers performed a meta-analysis of seven randomized controlled trials of neuraminidase inhibitors for outpatient treatment of seasonal influenza and postexposure prophylaxis in children aged 12 years or younger.

Two trials evaluated outpatient treatment with oseltamivir and two with zanamivir within 36 or 48 hours of onset of influenza-like symptoms. In a total of 1766 children (1243 with confirmed and 523 with suspected influenza), treatment reduced median time to symptom resolution, return to normal activities, or both by 0.5 to 1.5 days; reductions were statistically significant in one oseltamivir trial and one zanamivir trial. Recovery was significantly faster in children with confirmed influenza than in those with suspected influenza.

Three trials evaluated 10-day courses of oseltamivir (1 trial) or zanamivir (2 trials) for postexposure prophylaxis in 863 children. Treatment was associated with an 8% decrease in the incidence of symptomatic influenza (number needed to treat to prevent 1 additional case, 13). Compliance was high — 97% of children took more than 8 of the 10 doses of zanamivir and 90% took all 10 doses of oseltamivir. Both drugs were well tolerated; however, the incidence of vomiting was 5% higher with oseltamivir than with placebo. No deaths were reported.

Comment: This meta-analysis suggests that neuraminidase inhibitors are well tolerated in children and that they slightly reduce symptom duration and household transmission of seasonal influenza. Whether these data apply to the 2009 influenza A (H1N1) virus pandemic is not clear. Given that H1N1 disease has been mild so far in otherwise healthy children older than age 5 years, neuraminidase inhibitors cannot be recommended for routine outpatient treatment in low-risk children older than 5 years with uncomplicated suspected 2009 H1N1 influenza (JW Pediatr Adolesc Med Aug 21 2009).

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine September 4, 2009. Citation: Shun-Shin M et al. Neuraminidase inhibitors for treatment and prophylaxis of influenza in children: Systematic review and meta-analysis of randomised controlled trials. BMJ 2009 Aug 10; 339:b3172. (

12. Combined Corticosteroid and Antiviral Treatment for Bells Palsy: Two Big Reviews

A. A Systematic Review and Meta-analysis

de Almeida JR, et al. JAMA. 2009;302:985-993.

Context: New evidence has emerged regarding the use of corticosteroids and antiviral agents in Bell palsy.

Objective: To estimate the association of corticosteroids and antiviral agents with the risk of unsatisfactory facial recovery in patients with Bell palsy.

Data Sources: The search included MEDLINE, EMBASE, CENTRAL, PsychInfo, CINAHL, Web of Science, PAPERSFIRST, PROCEEDINGSFIRST, and PROQUEST to identify studies up to March 1, 2009.

Study Selection and Data Extraction: Eligible studies were randomized controlled trials comparing treatment with either corticosteroids or antiviral agents with a control and measuring at least 1 of the following outcomes: unsatisfactory facial recovery (4 months), unsatisfactory short-term recovery (6 weeks to 4 months), synkinesis and autonomic dysfunction, or adverse effects. Two reviewers extracted data on study characteristics, methods, and outcomes. Disagreement was resolved by consensus.

Results: Eighteen trials involving 2786 patients were eligible. Regression analysis identified a synergistic effect when corticosteroids and antiviral agents were administered in combination compared with alone (odds ratio for interaction term, 0.54 [95% confidence interval {CI}, 0.35-0.83]; P = .004). Meta-analysis using a random-effects model showed corticosteroids alone were associated with a reduced risk of unsatisfactory recovery (relative risk [RR], 0.69 [95% CI, 0.55-0.87]; P = .001) (number needed to treat to benefit 1 person, 11 [95% CI, 8-25]), a reduced risk of synkinesis and autonomic dysfunction (RR, 0.48 [95% CI, 0.36-0.65]; P less than .001) (number needed to treat to benefit 1 person, 7 [95% CI, 6-10]), and no increase in adverse effects. Antiviral agents alone were not associated with a reduced risk of unsatisfactory recovery (RR, 1.14 [95% CI, 0.80-1.62]; P = .48). When combined with antiviral agents, corticosteroids were associated with greater benefit (RR, 0.48 [95% CI, 0.29-0.79]; P = .004) than antiviral agents alone. When combined with corticosteroids, antiviral agents were associated with greater risk reduction of borderline significance compared with corticosteroids alone (RR, 0.75 [95% CI, 0.56-1.00]; P = .05).

Conclusions: In Bell palsy, corticosteroids are associated with a reduced risk of unsatisfactory recovery. Antiviral agents, when administered with corticosteroids, may be associated with additional benefit.

B. The benefits of steroids versus steroids plus antivirals for treatment of Bell’s palsy: a meta-analysis

Quant EC, et al. BMJ 2009;339:b3354

Objective: To determine whether steroids plus antivirals provide a better degree of facial muscle recovery in patients with Bell’s palsy than steroids alone.
Design Meta-analysis.

Data sources: PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for studies published in all languages from 1984 to January 2009. Additional studies were identified from cited references.

Selection criteria: Randomised controlled trials that compared steroids with the combination of steroids and antivirals for the treatment of Bell’s palsy were included in this study. At least one month of follow-up and a primary end point of at least partial facial muscle recovery, as defined by a House-Brackmann grade of at least 2 (complete palsy is designated a grade of 6) or an equivalent score on an alternative recognised scoring system, were required.

Review methods: Two authors independently reviewed studies for methodological quality, treatment regimens, duration of symptoms before treatment, length of follow-up, and outcomes. Odds ratios with 95% confidence intervals were calculated and pooled using a random effects model.

Results: Six trials were included, a total of 1145 patients; 574 patients received steroids alone and 571 patients received steroids and antivirals. The pooled odds ratio for facial muscle recovery showed no benefit of steroids plus antivirals compared with steroids alone (odds ratio 1.50, 95% confidence interval 0.83 to 2.69; P=0.18). A one study removed analysis showed that the highest quality studies had the greatest effect on the lack of difference between study arms shown by the odds ratio. Subgroup analyses assessing causes of heterogeneity defined a priori (time from symptom onset to treatment, length of follow-up, and type of antiviral studied) showed no benefit of antivirals in addition to that provided by steroids.

Conclusions: Antivirals did not provide an added benefit in achieving at least partial facial muscle recovery compared with steroids alone in patients with Bell’s palsy. This study does not, therefore, support the routine use of antivirals in Bell’s palsy. Future studies should use improved herpes virus diagnostics and newer antivirals to assess whether combination therapy benefits patients with more severe facial paralysis at study entry.

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13. Rapid Urine Chlamydia Test for Males Is Highly Sensitive

When tested on first-void urine samples, a new rapid chlamydia test had a sensitivity of 82%.

Nadala E-C et al. BMJ 2009 Jul 28; 339:b2655.

Conclusions: The performance of the new Chlamydia Rapid Test with first void male urine samples indicates that it would be an effective diagnostic tool for chlamydial infection in men. The availability of test results within an hour allows for immediate treatment and contact tracing, potentially reducing the risks of persistent infection and onward transmission. The test could also provide a simple and reliable alternative to nucleic acid amplification assays for testing of male urine in chlamydial screening programmes in high prevalence settings.

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14. Time to Abandon the "Shotgun Approach" to Syncope Evaluation

Many unnecessary and costly tests are obtained to evaluate elders with syncope.

Syncope is common, challenging, and expensive; it accounts for 1% to 3% of all U.S. emergency department visits and about 6% of inpatient admissions, with an estimated annual healthcare cost of US$2.5 billion. Most causes of syncope are benign, but the diagnostic challenge is to identify those that are life-threatening, particularly cardiovascular causes. Despite thorough and costly work-ups, syncope etiology remains undetermined in 40% of patients after their initial evaluations.

Researchers at Yale University performed a retrospective cohort study in 2106 consecutive older patients (age, 65) who were admitted with syncope. The investigators reviewed how often various diagnostic tests were ordered and how often such results helped to establish the etiology of syncope or affected diagnosis and management. They calculated the cost per test that affected diagnosis or management and whether use of the San Francisco Syncope Rule (SFSR; Ann Emerg Med 2004; 43:224) resulted in improved cost efficiency or diagnostic yield.

Postural blood pressure measurement (i.e., orthostatics), performed in only 38% of cases, affected diagnosis and management in about 25% of patients and identified syncope etiology in 15% to 21% of syncopal episodes; it returned the highest diagnostic yield and was the most cost-effective test ($17–$21). Cardiac enzymes, head computed tomography (CT) scans, carotid ultrasound (US), and electroencephalography (EEG) had little effect on diagnosis or management (less than 5%); rarely helped determine syncope etiology (less than 2%); and were among the least cost-effective tests: EEG ($33,000), head CT ($25,000), cardiac enzymes ($22,000), and carotid US ($20,000). Use of the SFSR led to higher diagnostic yield and better cost-effectiveness for most cardiac tests.

Comment: These findings underscore the importance of prioritizing diagnostic testing based on an initial standard evaluation, which should include a complete history and physical examination (including orthostatic blood pressure measurements and an electrocardiogram). Neurological tests (i.e., head magnetic resonance imaging or CT, EEG, and carotid US) shouldn't be performed, unless a neurological disease or event is suspected, based on the initial evaluation.

I am confident that the results of this study could be replicated in a variety of clinical settings. Although "shot gunning" multiple tests might reassure patients that they are getting the best care money can buy, we must take more financial stewardship of our resources, follow evidence-based guidelines, and be willing to live with some diagnostic uncertainty. Our healthcare system and economy can no longer support indiscriminate ordering of tests. More studies should be designed to evaluate cost-effectiveness, and those results should be incorporated into clinical guidelines.

— Aaron J. Calderon, MD, FACP. Published in Journal Watch Hospital Medicine August 31, 2009. Citation: Mendu ML et al. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med. 2009;169:1299.

15. Unenhanced CT May Assist in Diagnosis of Children with Flank Pain

Laurie Barclay, MD. September 14, 2009 — Unenhanced computed tomography (UCT) plays an important role in diagnosing children with flank pain, according to the results of a retrospective study reported in the September issue of Pediatrics.

"Urolithiasis can cause acute abdominal or flank pain, and its incidence is increasing," write Andre C. Persaud, MD, from Akron Children's Hospital in Akron, Ohio, and colleagues. "With increases in the use of UCT for diagnosis, additional predictors that can aid clinicians in management are needed....The objective of this study was to identify factors that predict the presence of urolithiasis detected with...UCT in children."

Between January 2002 and December 2005, a total of 339 eligible patients younger than 21 years presented to the emergency department at Akron Children's Hospital and underwent UCT of the abdomen. Mean age of those with positive results on UCT for urolithiasis was 14.4 years; 72 patients (66%) were girls. A standardized form was used to abstract data regarding demographics, clinical presentation, diagnosis, treatment, and disposition. Factors associated with urolithiasis were identified with use of univariate and logistic regression analyses.

UCT detected 110 cases of urolithiasis in 95 individual patients. Initial urinalysis results were negative for blood in 17 cases of urolithiasis (15%). Of the 110 stones detected, 57 (51.8%) were ureteral, 26 (23.6%) were renal, and 4 (3.6%) were in the bladder. Among children in whom UCT did not reveal a stone, UCT did lead to potentially significant, alternative diagnoses in 23 children (10%).

Positive predictors of urolithiasis were a history of urolithiasis, a history of nausea and vomiting, flank pain on examination, and more than 2 red blood cells per high-power field seen on urine microscopic examination. Factors inversely associated with urolithiasis on UCT scans were a history of fever or dysuria and costovertebral angle tenderness on physical examination.

"UCT plays an important role in the diagnostic evaluation of children with flank pain," the study authors write. "Approximately 15% of children with urolithiasis do not have hematuria."

Limitations of this study include retrospective design, data limited to the information reported in the electronic charts, and UCT results interpreted by a single radiologist without set guidelines.

"A history of urolithiasis, nausea and vomiting, flank pain on examination, and hematuria are positively associated with urolithiasis in children," the study authors conclude. "Fever, dysuria, and costovertebral angle tenderness are inversely associated with urolithiasis....The relative cost and potential radiation risks of UCT must be balanced against its high sensitivity in depicting calculi, rapid results, and ability to reveal alternate pathologic conditions."

The study authors have disclosed no relevant financial relationships.

Pediatrics. 2009;124:888-894. Abstract:

16. More Details on Corticosteroids for Bacterial Meningitis

This meta-analysis of published randomized, placebo-controlled trials suggests that the adjunctive administration of corticosteroids is beneficial in the treatment of adolescents and adults with acute bacterial meningitis in patient populations similar to those seen in high-income countries and in areas with a low prevalence of human immunodeficiency virus infection.

Assiri AM et al. Mayo Clin Proc 2009 May; 84:403.

17. "Spin" Not Uncommon in Negative RCTs, Study Shows

Shelley Wood. September 14, 2009 (Vancouver, British Columbia) — French researchers who set out to classify, then quantify the amount of "spin" in publications of negative randomized controlled trials say that the language used in and around the numbers themselves may frequently serve to sugar-coat negative results. Dr Isabelle Boutron (University Paris Descartes, France), who presented the results of the study during the 2009 International Congress on Peer Review and Biomedical Publication, said "spin" in reports of negative randomized controlled trials is by no means rare.

In randomized controlled trials, the "data should speak for themselves," she said during her presentation. The problem, however, is that scientists are rarely neutral about the results of their trial and consciously or unconsciously may try to portray their findings in a rosier light, often in the hopes of expediting publication, advancing their own careers, or even profiting financially. The aim of Boutron et al's study was to get a sense of just how often scientists may be "spinning" their findings, with spin defined as presenting or discussing the results in such a way as to convince the reader that an experimental treatment is beneficial, despite a nonstatistically significant difference for the primary end point.

Boutron and colleagues searched all two-arm randomized controlled trials indexed in PubMed in December 2006, ultimately identifying a total of 72 negative randomized controlled trials. They also developed a scoring system for identifying spin, based on linguistic choices and on instances when authors put particular emphasis on statistically significant results outside the primary end point (including within-group comparisons, subgroup analyses, and secondary outcomes), or interpreted results as demonstrating "comparable effectiveness" or "equivalence." Two independent reviewers then scored the papers, and reached a consensus for individual components of each of the papers.

Overall, evidence of spin was present in 18% of study titles, rising to 29% in the results, 43% in the discussions, and 50% in the conclusions. More than 40% of publications had spin in at least two of the three sections of the main text. Taking a closer look at the conclusions specifically, Boutron et al found that 33% of abstracts contained a "high level" of spin, defined as no acknowledgement of the negative primary outcome, no expression of uncertainty, and no recommendation to study the issue further in another trial. By contrast, a high level of spin was slightly less common in the conclusions of the full article.

Speaking with heartwire, Boutron emphasized that she hopes her work can ultimately be used to help authors write more objectively, and to also assist editors, reviewers, and readers.

"I think we should be reading articles differently," she said. "We should be really careful about the way people present and conclude their articles. And for academics, they should be very careful about the way they write articles. I often work with principle investigators in writing their articles, and I always need to calm them down, because they believe that their treatments work and they try to frame the results in a specific way."

An initial hurdle, she added, is for journal editors to think more critically about the discussion and conclusion sections of articles. "Sometimes the trials are very good and they have very straightforward ways of reporting their results and methods, but the interpretation of the results will be wrong. . . . This is an area where people aren't focusing too much; they're not looking at the discussion, they are looking at the results, and whether the statistical methods were well done, did they do the randomization correctly, etc. But for the discussion and interpretation, probably because it's subjective, people are afraid to look at it. . . . I think the journals need to take a tougher stand."

18. Comparison of GlideScope Video Laryngoscopy Versus Direct Laryngoscopy Intubation in the ED

Platts-Mills TF, et al. Acad Emerg Med. 2009;16:866–871.

Objectives: The first-attempt success rate of intubation was compared using GlideScope video laryngoscopy and direct laryngoscopy in an emergency department (ED).

Methods: A prospective observational study was conducted of adult patients undergoing intubation in the ED of a Level 1 trauma center with an emergency medicine residency program. Patients were consecutively enrolled between August 2006 and February 2008. Data collected included indication for intubation, patient characteristics, device used, initial oxygen saturation, and resident postgraduate year. The primary outcome measure was success with first attempt. Secondary outcome measures included time to successful intubation, intubation failure, and lowest oxygen saturation levels. An attempt was defined as the introduction of the laryngoscope into the mouth. Failure was defined as an esophageal intubation, changing to a different device or physician, or inability to place the endotracheal tube after three attempts.

Results: A total of 280 patients were enrolled, of whom video laryngoscopy was used for the initial intubation attempt in 63 (22%) and direct laryngoscopy was used in 217 (78%). Reasons for intubation included altered mental status (64%), respiratory distress (47%), facial trauma (9%), and immobilization for imaging (9%). Overall, 233 (83%) intubations were successful on the first attempt, 26 (9%) failures occurred, and one patient received a cricothyrotomy. The first-attempt success rate was 51 of 63 (81%, 95% confidence interval [CI] = 70% to 89%) for video laryngoscopy versus 182 of 217 (84%, 95% CI = 79% to 88%) for direct laryngoscopy (p = 0.59). Median time to successful intubation was 42 seconds (range, 13 to 350 seconds) for video laryngoscopy versus 30 seconds (range, 11 to 600 seconds) for direct laryngoscopy (p less than 0.01).

Conclusions: Rates of successful intubation on first attempt were not significantly different between video and direct laryngoscopy. However, intubation using video laryngoscopy required significantly more time to complete.

19. Images in EM

Adult Female With Weakness and Chills

20. US Clinicians Underrecognize Abdominal Migraine in Children

Daniel M. Keller, PhD. September 14, 2009 (Philadelphia, Pennsylvania) — Abdominal migraine may represent up to 15% of pediatric gastrointestinal patients who experience idiopathic recurrent abdominal pain, if results presented here at the 14th International Headache Congress are representative.

Although the condition is well recognized in Europe, it is underdiagnosed in the United States, according to investigator Donald Lewis, MD, professor and chairman of the Department of Pediatrics at Eastern Virginia Medical School and senior vice president for academic affairs at Children's Hospital of the King's Daughters in Norfolk, Virginia.

Children with recurrent abdominal pain use significant amounts of healthcare resources, he said, and the condition can lead to dysfunction and disability that may interfere with school, family, and social activities.

Dr. Lewis told Medscape Neurology that abdominal migraine is classified as one of the period syndromes of childhood that are precursors to migraine. "If you track those kids [for] long through adolescence, most of them grow up to have migraine," he said.

Belly Pain a Cardinal Feature

Dr. Lewis, a pediatric neurologist, explained that abdominal migraine is characterized by episodes of moderate to severe midline, periumbilical, or poorly localized pain lasting for 1 to 72 hours with nausea, anorexia, pallor, and occasionally headache. "But headache is not one of the cardinal features. It's episodes of belly pain," he emphasized. The condition was included in the 2004 International Classification of Headache Disorders and recognized by the 2006 Rome III criteria for functional gastrointestinal disorders as a well-defined type of recurrent abdominal pain.

Through chart reviews, Dr. Lewis and colleagues assessed patients with recurrent abdominal pain in the hospital's pediatric gastroenterology clinic to define the proportion of patients who might fulfill the International Classification of Headache Disorders 2004 criteria for abdominal migraine. Eligible subjects were girls (41%) or boys (59%) who were 1 to 21 years old and who did not have a known diagnosis of causes of chronic abdominal pain. Of an initial cohort of 600 children, 458 met the inclusion criteria. Twenty children (4.4%) met the International Classification of Headache Disorders 2004 diagnostic criteria, with an additional 11% having probable abdominal migraine (documentation lacking for 1 or more diagnostic criterion).

"So we have this large subset of children who are languishing with a vague diagnosis in [gastrointestinal] clinics who most likely have abdominal migraine," Dr. Lewis said. Making the correct diagnosis of abdominal migraine means the spectrum of migraine medications will become available to these children, he added.

Migraine prophylactic medications and acute treatments for migraine attacks are available and efficacious for abdominal migraine. Because the study was solely demographic, it did not test medication efficacy, but Dr. Lewis said the European literature has documented the efficacy of these treatments.

He speculated that abdominal migraine is underrecognized in the United States because physicians have not been taught about it. The message about the existence of the condition is especially relevant to pediatric gastroenterologists and general pediatricians. Dr. Lewis suggested that pediatricians might better refer such patients to pediatric neurologists instead of to gastroenterologists. Informed families, too, may alert their physicians if their child has recurring symptoms consistent with a diagnosis of abdominal migraine, especially if a parent, particularly the mother, has a migraine condition, as migraine is often inherited.

Background of Episodic Abdominal Pain

Brian McGeeney, MD, MPH, assistant professor of neurology at Boston University, Massachusetts, who was not involved in the study, told Medscape Neurology that in his clinical experience with adults, abdominal migraine is a real entity. "They seem to have a background of episodic abdominal pain in childhood more than one would expect by chance," he said.

"Posters like this should really heighten the awareness of this unusual syndrome to adult neurologists as well as pediatricians." Knowing a patient's childhood history of abdominal symptoms may be one more clue in the diagnosis of adult migraine.

Although abdominal migraine may be a precursor to and temporally linked with later migraine, for Dr. McGeeney, a strong indication that abdominal migraine is really a form of migraine is that it often responds to a broad range of migraine prophylactic medications.

14th International Headache Congress: Abstract PO222. Presented Saturday, September 12, 2009.