Sunday, November 22, 2009

Lit Bits: Nov 22, 2009

From the recent medical literature...

1. Induced Hypothermia After VF Cardiac Arrest Improves Outcomes

Hypothermia led to significantly better survival rates and neurological outcomes in patients with ventricular fibrillation but not in those with other initial rhythms.

Despite evidence that induced hypothermia therapy after cardiac arrest improves neurological outcomes and survival, cooling protocols have not been widely implemented. In a retrospective observational study, researchers compared outcomes in consecutive patients with out-of-hospital cardiac arrest who were resuscitated in the 2 years before (204 patients) and the 2 years after (287) implementation of a therapeutic hypothermia protocol at a teaching hospital in Seattle. Patients with severe infection, active bleeding, or nonintact skin from recent burns or who were in a persistent vegetative state prior to cardiac arrest were excluded.

Patients in the hypothermia group were cooled with ice packs, cooling blankets, or cooling pads and received intravenous vecuronium and diazepam. Temperature was measured with an esophageal probe; the goal of 32°C–34°C was achieved in 65% of patients. Passive rewarming commenced after 24 hours of cooling.

Rates of survival to hospital discharge were significantly higher in the hypothermia group than in the control group among patients with an initial rhythm of ventricular fibrillation (VF) (54% vs. 39%) but did not differ among patients with other rhythms. Similarly, the rate of favorable neurological outcomes was significantly higher in the hypothermia group than in the control group among patients with VF (35% vs. 15%).

Comment: Although a greater incidence of witnessed arrests in the hypothermia group (66%) than in the control group (57%) might have skewed the results, the findings suggest that cardiac arrest patients with an initial rhythm of VF might benefit from therapeutic cooling. Based on this and previous outcome studies and on other studies showing that induced hypothermia in the emergency department is feasible, it is time for EDs (and some emergency medical services systems) to implement hypothermia protocols for comatose survivors of cardiac arrest.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch EM November 6, 2009. Citation: Don CW et al. Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest: A retrospective before-and-after comparison in a single hospital. Crit Care Med 2009 Sep 16; [e-pub ahead of print]. (

2. Capsule Endoscopy in ED Hastens Treatment of Upper GI Bleeding

By Anthony J. Brown, MD. NEW YORK (Reuters Health) Oct 26 - Use of real time capsule endoscopy in the emergency room can rapidly identify patients with upper gastrointestinal bleeding who require urgent treatment, according to study findings presented this week at the American College of Gastroenterology annual meeting in San Diego.

"A positive capsule endoscopy test, defined as visualization of a bleeding lesion, red blood or coffee grounds, (was) highly correlated with high-risk stigmata at endoscopy," senior researcher Dr. Moshe Rubin, from New York Hospital Queens, told Reuters Health. "We were surprised at the accuracy of capsule endoscopy in this small study."

Using capsule endoscopy, he added, "we may able to improve patient rapidly identifying those at high risk who need urgent endoscopic care."

The study featured 24 patients with a history of upper GI bleeding who were randomized to capsule endoscopy or standard clinical evaluation following admission to the emergency room.

Intravenous metoclopramide was given within 10 minutes after the capsule was swallowed. Images were evaluated in real-time at the bedside and then again later after download. Patients with positive findings received endoscopic treatment within 6 hours, whereas those without bleeding and control subjects underwent endoscopic assessment within 24 hours.

Seven of the 12 patients in the capsule endoscopy group had positive findings. In all, seven stigmata of bleeding were confirmed at endoscopy. In 6 of the 7, the actual lesion was identified either during bedside image viewing or upon download review, the researchers report.

Of the 5 patients with negative findings on capsule images, 4 had no bleeding stigmata at endoscopy and 1 had comorbidities that precluded endoscopy. Capsule endoscopy-positive patients had a significantly shorter time to endoscopy than did controls: 2.5 vs. 8.9 hours (p = 0.029).

No patient died, and blood transfusion requirements and length of stay were comparable in the two groups. A capsule was retained in one patient with a strictured esophagus, but it was retrieved with endoscopy.

"We need to validate these findings in a larger trial that we are planning," Dr. Rubin said. "In a follow up study, we will use capsule endoscopy to segregate high-risk patients who need urgent intervention from low-risk patients who can potentially be treated more conservatively, and then assess outcomes."

3. ED Waiting Times Increasing in US

Percentage of US Emergency Department Patients Seen Within the Recommended Triage Time: 1997 to 2006

Horwitz LI, et al. Arch Intern Med. 2009;169:1857-1865.

Background The wait time to see a physician in US emergency departments (EDs) is increasing and may differentially affect patients with varied insurance status and racial/ethnic backgrounds.

Methods Using a stratified random sampling of 151 999 visits, representing 539 million ED visits from 1997 to 2006, we examined trends in the percentage of patients seen within the triage target time by triage category (emergent, urgent, semiurgent, and nonurgent), payer type, and race/ethnicity.

Results The percentage of patients seen within the triage target time declined a mean of 0.8% per year, from 80.0% in 1997 to 75.9% in 2006 (P less than .001). The percentage of patients seen within the triage target time declined 2.3% per year for emergent patients (59.2% to 48.0%; P less than .001) compared with 0.7% per year for semiurgent patients (90.6% to 84.7%; P less than .001). In 2006, the adjusted odds of being seen within the triage target time were 30% lower than in 1997 (odds ratio, 0.70; 95% confidence interval, 0.55-0.89). The adjusted odds of being seen within the triage target time were 87% lower (odds ratio, 0.13; 95% confidence interval, 0.11-0.15) for emergent patients compared with semiurgent patients. Patients of each payment type experienced similar decreases in the percentage seen within the triage target over time (P for interaction = .24), as did patients of each racial/ethnic group (P = .05).

Conclusions The percentage of patients in the ED who are seen by a physician within the time recommended at triage has been steadily declining and is at its lowest point in at least 10 years. Of all patients in the ED, the most emergent are the least likely to be seen within the triage target time. Patients of all racial/ethnic backgrounds and payer types have been similarly affected.

4. Ultrasound Detects Central Line Placement and Postprocedure Pneumothorax

Chest x-ray missed 2 of 4 pneumothoraces and 1 of 25 misplaced catheter tips that were detected by bedside ultrasound.

Vezzani A et al. Crit Care Med 2009 Oct 12.

Objective: To determine the usefulness of ultrasound to evaluate central venous catheter misplacements and detection of pneumothorax, thus obviating postprocedural radiograph. After the insertion of a central venous catheter, chest radiograph is usually obtained to ensure correct positioning of the catheter tip and detect postprocedural complications.

Measurements and Main Results: A prospective study of 111 consecutive central venous catheter procedures, using a landmark technique, was conducted in an adult intensive care unit. At the end of the procedure, a B-mode ultrasonography was first performed to assess catheter position and detect pneumothorax. Then, contrast enhanced ultrasonography was used to facilitate visualization of catheter tip, avoiding unknown right atrium positioning or artifacts. A postprocedural chest radiograph was obtained for all patients and was considered as a reference technique. Right atrium positioning was detected in 19 patients by ultrasonography, and an additional six by contrast enhanced ultrasonography. Combining ultrasonography and contrast enhanced ultrasonography yielded a 96% sensitivity and 93% specificity in detecting catheter misplacement. Concordance was 95% and [kappa] value was 0.88 (p less than .001). Pneumothorax was detected in four patients by ultrasonography and in two by chest radiograph (concordance = 98%). The mean time required to perform ultrasonography plus contrast enhanced ultrasonography was 10 +/- 5 mins vs. 83 +/- 79 mins for chest radiograph (p less than .05).

Conclusions: The close concordance between ultrasonography plus contrast enhanced ultrasonography and chest radiograph justifies the use of sonography as a standard technique to ensure the correct positioning of the catheter tip and to detect pneumothorax after central venous catheter cannulation to optimize use of hospital resources and minimize time consumption and radiation. Chest radiograph will be necessary when sonographic examination is impossible to perform by technical limitations.

5. Updated Guidelines for the Care of Children in EDs

This joint policy statement provides a highly useful roadmap for standardizing emergency care of children in community EDs.

American Academy of Pediatrics et al. Pediatrics 2009;124:1233-1243.

Full-text (free):

6. Cervical Collar, Physical Therapy, or "Wait and See" for Recent-Onset Cervical Radiculopathy?

Pain scores were significantly lower in the collar and physical therapy groups.

Kuijper B et al. BMJ 2009 Oct 7; 339:b3883.


7. A Comparison of Parental and Nursing Assessments of Level of Illness or Injury in a Pediatric Emergency Department

Kestner V, et al., Pediatric Emergency Care. 2009;25:633-635.

Background: The 5-tier Emergency Severity Index (ESI) score is a well-accepted, validated triage tool with good interrater reliability. Parental perception of illness severity has not been compared to ESI score.

Objective: This study compares parental assessment of severity of illness to triage nurse acuity.

Design: Prospective and descriptive.

Setting: Large, urban pediatric emergency department (ED).

Participants: Parents/guardians of patients younger than 18 years.

Intervention: The triage nurse assigned an ESI score, and the parent/guardian assigned all patients a severity score on a scale of 1 to 5 (1, most sick and 5, least sick). Mean severity scores were compared between the groups.

Results: There were 142 participants with a mean patient age of 6.15 years. The mean participant and nurse severity scores were 3.01 and 3.35, respectively, with an intraclass correlation coefficient of 0.203 (P = 0.008). Most frequently, the parent/guardian and triage nurse assigned the same score (n = 44, 31%). Seventy-six percent of the parent/guardian scores were within 1 point of the triage nurse score.

Conclusions: Close agreement exists between parent/guardian and nurse ESI scores, illustrating objectivity in parent/guardian assessments. This study provides a springboard for future studies regarding ED use after educating families on ED triage.

8. Interobserver agreement in the interpretation of computed tomography in acute pulmonary embolism

Costantino G, Amer J Emerg Med. 2009;27:1109-1111.

Multidetector computed tomography (MDCT) is one of the best diagnostic tools for the diagnosis of pulmonary embolism (PE). However, differences in MDCT interpretation, depending on the operator personal expertise, is an important factor that could interfere with the right diagnosis and, consequently, with the more adequate and well-timed therapy.

The aim of the present study was to evaluate the interobserver agreement in the interpretation of MDCT for the diagnosis of acute PE.

On a blind basis, 4 radiologists with different expertise in CT interpretation evaluated 46 different MDCT executed for acute PE. They had to verify the presence or absence of PE and, in the positive case, localize (right-left) and quantify (massive, segmentarian or subsegmentarian) it. The interobserver concordance was expressed using the Cohen K statistic.

The mean concordance between the 4 operators was high (0.82; range, 0.68-0.95). Ruling out the massive PE cases, the mean concordance over the other cases was only moderate (0.47; range, 0.16-0.84).

We found a very good interobserver agreement in MDCT evaluation for the diagnosis of massive PE, whereas we observed a lower concordance in regard to segmentarian and subsegmentarian PE. In the case of negative or nonmassive PE diagnosis, a second evaluation of the CT performed by an expert CT radiologist would probably be effective to decrease the CT evaluation error.

9. Compress the Chest: Better CPR Improves Survival from Out-of-Hospital Cardiac Arrest

Implementation of the 2005 AHA CPR guidelines that focus on uninterrupted chest compressions nearly doubled the odds of survival among patients with out-of-hospital cardiac arrest.

In 2005, the American Heart Association (AHA) released updated evidence-based guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, but does adherence to the revised protocol improve outcomes? Investigators compared rates of survival from out-of-hospital cardiac arrest among 606 adult patients treated before and 1021 treated after implementation of the 2005 AHA guidelines in a single large emergency medical services system.

Review of a convenience sample of 69 electronic electrocardiogram recordings showed significant improvement in CPR quality after guideline implementation, including improvements in mean chest-compression rate, proportion of time that patients received chest compressions, and median preshock and postshock pause times for compressions. Unadjusted rates of survival to hospital discharge were significantly higher after implementation of the guidelines than before (9.4% vs. 6.1%). Among patients with witnessed arrest whose initial rhythm was ventricular fibrillation on EMS arrival, survival rates improved significantly from 24% (19 of 78) before implementation to 30% (34 of 112) after. Multivariate regression analysis that adjusted for initial rhythm, sex, arrest location, and witnessed arrest showed 1.8 greater odds of survival in the postintervention period.

Comment: The promising results of this large study suggest the AHA was on the right track with its renewed focus on basic CPR, including the importance of providing uninterrupted chest compressions.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine October 23, 2009. Citation: Sayre MR et al. Impact of the 2005 American Heart Association cardiopulmonary resuscitation and emergency cardiovascular care guidelines on out-of-hospital cardiac arrest survival. Prehosp Emerg Care 2009;13:469.

10. Methohexital Beats Pentobarbital for Head CT Sedation in Children

Chun TH et al. Pediatr Emerg Care 2009 Oct; 25:648.

Objectives: To determine if there are differences in the duration of sedation between pediatric emergency department (PED) patients receiving methohexital and PED patients receiving pentobarbital for the purpose of obtaining a head computed tomographic (CT) scan.

Methods: Retrospective cohort study of PED patients receiving either methohexital or pentobarbital for a sedated head CT. Data were collected on patient demographics and medical condition, indications for head CT, duration of sedation, medication dosage, and medication adverse events. Primary analyses investigated whether there were differences between the 2 groups. Secondary analysis determined whether the need for additional sedative doses contributed to observed differences between groups.

Results: The patients receiving methohexital completed their head CT more quickly and needed less total sedation monitoring than those receiving pentobarbital. The need for additional doses of medication does not appear to be responsible for the observed difference. Adverse medication events were minor and comparable between groups.

Conclusions: Methohexital may be superior to pentobarbital for the purpose of sedating PED patients for head CT.

11. Anticholinergic Drugs and Acute Urinary Retention

Risk is highest during the first several weeks of treatment.

Martín-Merino E et al. J Urol 2009 Oct; 182:1442.


12. Doctors' Lack of Respect Weighs on the Obese

October 29, 2009 — Heavier patients get less respect from doctors, raising concerns about the impact on the quality of care, new research indicates.

Scientists reporting in the November issue of the Journal of General Internal Medicine say they found that the higher a patient’s body mass index (BMI), the less respect their doctors had for them.

Mary Margaret Huizinga, MD, MPH, of Johns Hopkins University School of Medicine and lead author of the study, says she came up with the idea for the research from her experiences working in a weight loss clinic.

She says that patients who'd visit would, by the time they left, “be in tears, saying 'no other physician talked with me like this before,'" and had failed to listen.

“Many patients felt like because they were overweight, they weren’t receiving the type of care other patients received,” she says in a news release.

She and colleagues looked at data on 238 patients and 40 physicians. The average BMI of the patients was 32.9.

A person with a BMI of 25 to 29.9 is considered overweight, and 30 or greater obese.

In the study, patients and physicians filled out questionnaires about a doctor’s visit. They were asked questions about their attitudes and perceptions of one another at the end of their encounter. Physicians were asked to rate the level of respect they had for each patient compared to “the average patient” on a 5-point scale.

The patients for whom doctors expressed low respect, on average, had a higher BMI than patients for whom the physicians had high respect, the researchers report. The researchers note that the findings don’t show a cause/effect relationship between BMI and physician respect. Their study also didn’t investigate patients’ health outcomes.

Huizinga writes that respect is critical because some patients may avoid the health care system altogether. In other research, physician respect has been linked to more information being provided by the physician during a patient visit. She says more research is needed “to really understand how physician attitudes toward obesity affect quality of care for those patients."

“If a doctor has a patient with obesity and has low respect for that person, is the doctor less likely to recommend certain types of weight loss programs or to send her for cancer screening?” Huizinger asks. “We need to understand these things better.”

SOURCES: News release, Johns Hopkins University School of Medicine.

Huizinga, M., Journal of General Internal Medicine, November 2009.

13. Divorce Risk Higher When Wife Gets Sick

By TARA PARKER-POPE. NY Times. Nov 12, 2009.

When Dr. Marc Chamberlain, a Seattle oncologist, was treating his brain cancer patients, he noticed an alarming pattern. His male patients were typically receiving much-needed support from their wives. But a number of his female patients were going it alone, ending up separated or divorced after receiving a brain tumor diagnosis.

Dr. Chamberlain, chief of the neuro-oncology division at the Fred Hutchinson Cancer Research Center, had heard similar stories from his colleagues. To find out if these observations were based in fact, he embarked on a study with Dr. Michael J. Glantz of the University of Utah Huntsman Cancer Institute and colleagues from three other institutions who began to collect data on 515 patients who received diagnoses of brain tumors or multiple sclerosis from 2001 through 2006.

The results were surprising. Women in the study who were told they had a serious illness were seven times as likely to become separated or divorced than men with similar health problems, according to the report published in the journal Cancer.
The remainder of the NY Times article:

The abstract of the study:

14. Intranasal Naloxone Is Effective for Opioid Overdose

Time from patient contact to clinical response was the same with intranasal and intravenous naloxone.

Robertson TM, et al. Prehospital Emerg Care 2009;13:512-515.

Objective. To compare the prehospital time intervals from patient contact and medication administration to clinical response for intranasal (IN) versus intravenous (IV) naloxone in patients with suspected narcotic overdose.

Methods. This was a retrospective review of emergency medical services (EMS) and hospital records, before and after implementation of a protocol for administration of intranasal naloxone by the Central California EMS Agency. We included patients with suspected narcotic overdose treated in the prehospital setting over 17 months, between March 2003 and July 2004. Paramedics documented dose, route of administration, and positive response times using an electronic record. Clinical response was defined as an increase in respiratory rate (breaths/min) or Glasgow Coma Scale score of at least 6. Main outcome variables included time from medication to clinical response and time from patient contact to clinical response. Secondary variables included numbers of doses administered and rescue doses given by an alternate route. Between-group comparisons were accomplished using t-tests and chi-square tests as appropriate.

Results. One hundred fifty-four patients met the inclusion criteria, including 104 treated with IV and 50 treated with IN naloxone. Clinical response was noted in 33 (66%) and 58 (56%) of the IN and IV groups, respectively (p = 0.3). The mean time between naloxone administration and clinical response was longer for the IN group (12.9 vs. 8.1 min, p = 0.02). However, the mean times from patient contact to clinical response were not significantly different between the IN and IV groups (20.3 vs. 20.7 min, p = 0.9). More patients in the IN group received two doses of naloxone (34% vs. 18%, p = 0.05), and three patients in the IN group received a subsequent dose of IV or IM naloxone.

Conclusions. The time from dose administration to clinical response for naloxone was longer for the IN route, but the overall time from patient contact to response was the same for the IV and IN routes. Given the difficulty and potential hazards in obtaining IV access in many patients with narcotic overdose, IN naloxone appears to be a useful and potentially safer alternative.

15. Subarachnoid Hemorrhage Might Be a Common Cause of Out-of-Hospital Cardiac Arrest

In this Japanese study, 16% of survivors of out-of-hospital cardiac arrest had subarachnoid hemorrhage.

Inamasu J, et al. Resuscitation 2009;80:977-980.

Aneurysmal subarachnoid haemorrhage (SAH) is a relatively common cause of out-of-hospital cardiac arrest (OHCA). Early identification of SAH-induced OHCA with the use of brain computed tomography (CT) scan obtained immediately after resuscitation may help emergency physicians make therapeutic decision as quickly as they can.

During the 4-year observation period, brain CT scan was obtained prospectively in 142 witnessed non-traumatic OHCA survivors who remained haemodynamically stable after resuscitation. Demographics and clinical characteristics of SAH-induced OHCA survivors were compared with those with “negative” CT finding.

Brain CT scan was feasible with an average door-to-CT time of 40.0min. SAH was found in 16.2% of the 142 OHCA survivors. Compared with 116 survivors who were negative for SAH, SAH-induced OHCA survivors were significantly more likely to be female, to have experienced a sudden headache, and trended to have achieved return of spontaneous circulation (ROSC) prior to arrival in the emergency department less frequently. Ventricular fibrillation (VF) was significantly less likely to be seen in SAH-induced than SAH-negative OHCA (OR, 0.06; 95% CI, 0.01–0.46). Similarly, Cardiac Trop-T assay was significantly less likely to be positive in SAH-induced OHCA (OR, 0.08; 95% CI, 0.01–0.61).

Aneurysmal SAH causes OHCA more frequently than had been believed. Immediate brain CT scan may particularly be useful in excluding SAH-induced OHCA from thrombolytic trial enrollment, for whom the use of thrombolytics is contraindicated. The low VF incidence suggests that VF by itself may not be a common cause of SAH-induced OHCA.

16. Combination of epinephrine and dexamethasone may reduce hospitalization in children with bronchiolitis

Frohna JG, et al. J Pediatrics 2009;155:761-762.

Identifying effective treatments for children with bronchiolitis has proven elusive. In part, this is due to the heterogenous cause of wheezing, which can range from episodic wheezing (often caused by viral infections) to multifactorial wheezing that can be triggered by a variety of factors and often resulting in asthma. A meta-analysis showed limited short-term benefit from epinephrine, and it is well known that children with asthma respond to corticosteroids. Plint et al were surprised to find a synergistic effect between epinephrine and dexamethasone, which reduced the frequency of hospitalization for children in this study. In addition, there are likely many factors that influence the decision to hospitalize a child, such as the distance to the hospital, the ability of the parents to care for their ill child, and the availability of health care resources. While a number needed to treat of 11 to prevent 1 hospitalization might be appealing, there are several caveats to these results. First, the dose of corticosteroids used in this study is quite high, and there is still limited knowledge of potential risks associated with this treatment. Second, when the authors adjusted their results for the multiple comparisons that were made, the difference in hospitalization was no longer statistically significant. One area of future research would be to look at the subgroups of infants who respond better to corticosteroids and look for possible biomarkers that may even include virus identification techniques. Although we await follow-up studies to provide stronger evidence, it is prudent to provide supportive care and close monitoring for children with an initial episode of wheezing. Monitoring these infants in the general pediatrician's office does not require high-tech medicine—just some relatively straightforward clinical algorithims.


17. The Oblique View: An Alternative Approach for Ultrasound-Guided Central Line Placement

Phelan M, et al. Amer J Emerg Med. 2009;37:403-408.

Background: Numerous studies have shown significant benefits of using real-time ultrasonography for central line intravenous access. Traditionally, the ultrasound probe is placed along the short axis of the vein to visualize and direct needle placement. This view has some limitations, particularly being able to visualize the needle tip. Some practitioners place the ultrasound probe in the long axis of the vessel to direct needle placement, allowing better visualization of the needle entering the vein, but this does not allow visualization of relevant anatomic structures.

Objectives: We describe an alternative means to obtain ultrasound-guided vascular access using an oblique axis rather than the traditional short-axis approach.

Discussion: This view allows better visualization of the needle shaft and tip but also offers the safety of being able to visualize all relevant anatomically significant structures at the same time and in the same plane. This orientation is halfway between the short and long axis of the vessel, allowing visualization of the needle as it enters the vessel. This capitalizes on the strengths of the long axis while optimizing short-axis visualization of important structures during intravenous line placement.

Conclusion: Ultrasound-guided vascular access can be obtained in a variety of ways. We describe a technique that is used by some experienced ultrasound users but that has never been fully described in the literature. This technique for obtaining ultrasound-guided vascular access offers another option for attempting ultrasound-guided vascular access that has the potential to improve success rates and minimize complications associated with intravenous access.

18. CT-STAT: CT Angiography Rules Out CAD Faster and Cheaper Than Standard Care

Michael O'Riordan. November 18, 2009 (Orlando, Florida) — The use of coronary computed tomography (CT) angiography in the emergency room can successfully triage at-risk chest-pain patients and can do so faster and less expensively than standard diagnostic testing, according to the results of a new study.

"I think the reassurance is that both strategies are very safe," said lead investigator Dr James Goldstein (William Beaumont Hospital, Royal Oak, MI). "We've chosen a chosen a low-risk population--we don't want anybody to go home with a heart attack. We already know that the standard of care is a very fine strategy, and we've gotten very good at evaluating chest pain, but it is cumbersome and expensive."

Although the use of CT to rule out coronary artery disease should not be used in all patients, especially those with manifest ischemia, electrocardiogram abnormalities, or elevations in enzymatic biomarkers, among low-risk patients, "wisely and prudently applied," CT angiography is a powerful addition to the armamentarium of clinicians, said Goldstein.

The results of the study, known as the Computed Tomographic Angiography for the Systematic Triage of Acute Chest Pain Patients to Treatment (CT-STAT) trial, were presented today at the American Heart Association 2009 Scientific Sessions.

The remainder of the essay:

19. Prophylactic Acetaminophen Blunts Immunogenicity of Childhood Vaccinations

Routine prophylactic use of acetaminophen at the time of childhood immunizations should be reconsidered.

Prymula R et al. Lancet 2009; 374:1339.


20. Kubler-Ross’ Stages of Grief: Maybe Not so Cut-and-Dried

In 1969 the psychiatrist Elizabeth Kubler-Ross wrote one of the most influential books in the history of psychology, On Death and Dying. It exposed the heartless treatment of terminally-ill patients prevalent at the time. On the positive side, it altered the care and treatment of dying people. On the negative side, it postulated the now-infamous five stages of dying—Denial, Anger, Bargaining, Depression, and Acceptance (DABDA), so annealed in culture that most people can recite them by heart. The stages allegedly represent what a dying person might experience upon learning he or she had a terminal illness. “Might” is the operative word, because Kübler-Ross repeatedly stipulated that a dying person might not go through all five stages, nor would they necessarily go through them in sequence. It would be reasonable to ask: if these conditions are this arbitrary, can they truly be called stages?

Many people have contested the validity of the stages of dying, but here we are more concerned with the supposed stages of grief which derived from the stages of dying. As professional grief recovery specialists, we contend that the theory of the stages of grief has done more harm than good to grieving people. Having co-authored three books on the impact of death, divorce, and other losses, and having worked directly with over 100,000 grieving people during the past 30 years, our reasons for disputing the stages of grief theory are predicated on the horror stories we’ve heard from thousands of grieving people who’ve told us how they’d been harmed by them.
Friedman R, et al. The Myth of the Stages of Dying, Death and Grief. Skeptic. 2008;13:37-41.