From the recent medical literature...
1. Drive-Through Emergency Care May Be Feasible for Pandemics
Laurie Barclay, MD. January 26, 2010 — A drive-through model may be a feasible approach to emergency care during a pandemic, or even in other circumstances in which emergency care is needed, according to the results of a study published online January 13 in the Annals of Emergency Medicine.
"The most important message is that a drive-through medical clinic is not only a feasible model, but may be a preferred type of alternative care center," lead author Eric A. Weiss, MD, from the Stanford University School of Medicine in California, said in a news release. "It can expedite and facilitate seeing large numbers of patients while mitigating the spread of infectious diseases by providing a social distancing mechanism. And it not only can be used during a pandemic, but also would be an excellent strategy for bioterrorism, or for other emerging infectious disease events."
The investigators performed a full-scale exercise to determine the feasibility of a drive-through influenza clinic, as well as to measure throughput times of simulated patients, carbon monoxide levels of staff, and disposition decisions of participant physicians. Patient scenarios for the drive-through influenza clinic were created from medical records of 38 patients with influenza-like illness treated in the Stanford Hospital emergency department during the initial H1N1 outbreak in April 2009.
Mock patients were screened by a nurse in a parking garage near the hospital. Those who were relatively stable were directed into a lane for the drive-through clinic. Severely ill patients were triaged to the emergency department.
Nurses measured vital signs at 2 triage stations in the garage, and at a third station patients stepped outside their cars for a complete physical examination conducted in heated, draped-off areas. Mock medications and prescriptions were dispensed at a discharge station. Crash carts were available, and golf carts equipped with stretchers and resuscitation equipment circled the parking garage.
Total median length of stay was 26 minutes. Physicians taking part in the exercise were 100% accurate in identifying those patients who were admitted and discharged during the real ED visit (95% confidence interval, 91% - 100%), and they had no significant increases in carboxyhemoglobin.
"The drive-through model is a feasible alternative to a traditional walk-in [emergency department] or clinic and is associated with rapid throughput times," the study authors write. "It provides a social distancing strategy, using the patient's vehicle as an isolation compartment to mitigate person-to-person spread of infectious diseases."
Limitations of this study include use of a simulated environment involving dedicated staff and actors waiting in their cars, with historical data and pertinent examination findings listed on a data card. Another limitation was a possible Hawthorne effect. In addition, drive-through "patients" were all English speaking in this scenario, and starting the simulation and timing with the system empty may have produced artificially short lengths of stay.
Limitations of the drive-through model include lack of air conditioning and heating and a lack of bathrooms.
"You don't have the delays inherent in having to turn over a fixed number of rooms, waiting for patients to be discharged, having to change linens," Dr. Weiss concluded. "We developed a general drive-through plan for all the hospitals in the county. It's essentially a playbook that shows how to set up one of these centers at your own hospital."
Ann Emerg Med. Published online January 13, 2010.
2. Recent Caffeine Ingestion Reduces Adenosine Efficacy in the Treatment of Paroxysmal Supraventricular Tachycardia
Cabalag MS, et al. Acad Emerg Med. 2010;17:44-49.
Objectives: Caffeine, an adenosine receptor blocker, should theoretically reduce adenosine efficacy in the treatment of paroxysmal supraventricular tachycardia (SVT). We aimed to determine the effect of recent caffeine ingestion on the likelihood of reversion of SVT with adenosine.
Methods: This was a multicenter, case–control study of adult patients with SVT treated with adenosine between September 2007 and July 2008. The primary endpoint was reversion to sinus rhythm (SR) after a 6-mg adenosine bolus, as a function of recent (within 2, 4, 6, and 8 hours) caffeine ingestion. Caffeine ingestion data were collected using a self-administered questionnaire.
Results: Of 68 patients enrolled, 52 (76.5%, 95% confidence interval [CI] = 64.4% to 85.6%) reverted after a 6-mg adenosine bolus. There were no significant differences in age, sex, or daily caffeine ingestion between patients who did and did not revert (p greater than 0.05). However, as a group, patients who did not revert had recently ingested significantly more caffeine (p less than 0.05). If caffeine had been ingested less than 2 or 4 hours before the adenosine bolus, the odds of reversion to SR were significantly reduced (odds ratio [OR] = 0.18, 95% CI = 0.04 to 0.93; and OR = 0.14, 95% CI = 0.04 to 0.49, respectively). If caffeine had been ingested less than 6 or 8 hours before the adenosine, the odds of reversion were not reduced (OR = 0.31, 95% CI = 0.09 to 1.02; and OR = 0.31, 95% CI = 0.09 to 1.08, respectively).
Conclusions: Ingestion of caffeine less than 4 hours before a 6-mg adenosine bolus significantly reduces its effectiveness in the treatment of SVT. An increased initial adenosine dose may be indicated for these patients.
3. Outcomes for Patients with ST-Elevation Myocardial Infarction in Hospitals With and Without Onsite Coronary Artery Bypass Graft Surgery: The New York State Experience
Hannan EL, et al. Circulation 2009;2:519-527.
Background— The benefit of primary percutaneous coronary interventions (P-PCI) for patients with ST-elevation myocardial infarction (STEMI) has been well documented. However, controversy still exists as to whether PCI should be expanded to hospitals without coronary artery bypass graft surgery.
Methods and Results— Patients who were discharged after PCI for STEMI between January 1, 2003, and December 12, 2006, in P-PCI centers (hospitals with no coronary artery bypass graft surgery, and PCI only for patients with STEMI) were propensity matched with patients in full service centers, and mortality and subsequent revascularization rates were compared. For patients undergoing PCI, there were no differences for in-hospital/30-day mortality (2.3% for P-PCI centers versus 1.9% for full service centers [P=0.40]), emergency coronary artery bypass graft surgery immediately after PCI (0.06% versus 0.35%, P=0.06), 3-year mortality (7.1% versus 5.9%, P=0.07), or 3-year subsequent revascularization (23.8% versus 21.5%, P=0.52). P-PCI centers had a lower same/next day coronary artery bypass graft rate (0.23% versus 0.69%, P=0.046) and higher repeat target vessel PCI rates (12.1% versus 9.0%, P=0.003). For patients with STEMI who did not undergo PCI, P-PCI centers had higher in-hospital mortality (28.5% versus 22.3%; adjusted odds ratio, 1.38; 95% CI, 1.10 to 1.75).
Conclusions— No differences between P-PCI centers and full service centers were found in in-hospital/30-day mortality, the need for emergency surgery, 3-year mortality or subsequent revascularization, but P-PCI centers had higher repeat target vessel PCI rates and higher mortality rates for patients who did not undergo PCI. P-PCI centers should be monitored closely, including the monitoring of patients with STEMI who did not undergo PCI.
Full-text (free): http://circinterventions.ahajournals.org/cgi/content/full/2/6/519
4. Does the Early Administration of Beta-blockers Improve the In-hospital Mortality Rate of Patients Admitted with Acute Coronary Syndrome?
Brandler E, et al. Acad Emerg Med 2010:17:1-10.
Objectives: Beta-blockade is currently recommended in the early management of patients with acute coronary syndromes (ACS). This was a systematic review of the medical literature to determine if early beta-blockade improves the outcome of patients with ACS.
Methods: The authors searched the PubMed and EMBASE databases for randomized controlled trials from 1965 through May 2009 using a search strategy derived from the following PICO formulation of our clinical question: Patients included adults (18+ years) with an acute or suspected myocardial infarction (MI) within 24 hours of onset of chest pain. Intervention included intravenous or oral beta-blockers administered within 8 hours of presentation. The comparator included standard medical therapy with or without placebo versus early beta-blocker administration. The outcome was the risk of in-hospital death in the intervention groups versus the comparator groups. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. In-hospital mortality rates were compared using a forest plot of relative risk (RR; 95% confidence interval [CI]) between beta-blockers and controls. Statistical analysis was done with Review Manager V5.0.
Results: Eighteen articles (total N = 72,249) met the inclusion/exclusion criteria. For in-hospital mortality, RR = 0.95 (95% CI, 0.90–1.01). In the largest of these studies (n = 45,852), a significantly higher rate (p less than 0.0001) of cardiogenic shock was observed in the beta-blocker (5.0%) versus control group (3.9%).
Conclusions: This systematic review failed to demonstrate a convincing in-hospital mortality benefit for using beta-blockers early in the course of patients with an acute or suspected MI.
5. Introducing a Clinical Practice Guideline Using Early CT in the Diagnosis of Scaphoid and Other Fractures.
Pincus S, et al. West J Emerg Med. 2009;10:227-32.
OBJECTIVE: We developed and implemented clinical practice guideline (CPG) using computerized tomography (CT) as the initial imaging method in the emergency department management of scaphoid fractures. We hypothesized that this CPG would decrease unnecessary immobilization and lead to earlier return to work.
METHODS: This observational study evaluated implementation of our CPG, which incorporated early wrist CT in patients with "clinical scaphoid fracture": a mechanism of injury consistent with scaphoid fracture, anatomical snuff box tenderness, and normal initial plain x-rays. Outcome measures were the final diagnosis as determined by orthopaedic review of the clinical and imaging data. Patient outcomes included time to return to work and patient satisfaction as determined by telephone interview at ten days.
RESULTS: Eighty patients completed the study protocol in a regional emergency department. In this patient population CT detected 28 fractures in 25 patients, including six scaphoid fractures, five triquetral fractures, four radius fractures, and 13 other related fractures. Fifty-three patients had normal CT. Eight of these patients had significant ongoing pain at follow up and had an MRI, with only two bone bruises identified. The patients with normal CTs avoided prolonged immobilization (mean time in plaster 2.7 days) and had no or minimal time off work (mean 1.6 days). Patient satisfaction was an average 4.2/5.
CONCLUSION: This CPG resulted in rapid and accurate management of patients with suspected occult scaphoid injury, minimized unnecessary immobilization and was acceptable to patients.
Full-text (free): http://www.escholarship.org/uc/item/6098v3k6
6. ACEP's Ethics Committee: Gifts to Emergency Physicians From Industry
Ann Emerg Med. 2010;55:230.
The practice of the pharmaceutical and medical device industries to give gifts to physicians has come under increasing scrutiny in recent years. Prominent professional associations have issued reports recommending a ban on accepting gifts from industry. Many US academic medical centers have implemented policies prohibiting acceptance by physicians, other health care professionals, and trainees, of any gifts from industry representatives. The leading trade associations of the pharmaceutical and medical device industries have adopted revised guidelines for interaction with health care professionals that impose new voluntary restrictions on the practice of giving gifts.
Opponents of the practice of giving and accepting gifts cite neurobiological and psychosocial evidence that even small favors may create a subliminal sense of gratitude or loyalty that can influence physicians' medical treatment choices. The American College of Emergency Physicians believes that treatment choices should be based on an impartial assessment of the benefits, risks, and costs of the treatment for the patient, and not on a physician's relationship with industry representatives. For this reason, acceptance of gifts from the biomedical industry should be carefully limited, as detailed below.
The remainder of the statement can be found here: http://www.annemergmed.com/article/S0196-0644(09)01738-7/fulltext
7. Complications and Death at the Start of the New Academic Year: Is There a July Phenomenon?
Inaba K, et al. J Trauma 2010;68:19-22.
Background: The “July Phenomenon” refers to the propensity for increased errors to occur with new housestaff, as they assume new responsibilities at the beginning of the academic year. The purpose of this study was to examine the impact of the new residents presenting in July at a high volume Level I Academic Trauma Center.
Methods: The trauma registry at the Los Angeles County + University of Southern California Medical center was retrospectively reviewed to identify all injured patients admitted over a 5-year period ending in December 2006. All Morbidity and Mortality reports for the study period were reviewed to extract deaths and any complications classified as preventable or potentially preventable. Patients admitted in the first 2 months (July to August) of the academic year were compared with those treated at the end of the academic year (May to June). Baseline clinical and demographic characteristics were compared, and the rates of preventable and potentially preventable deaths and complications were determined for each of these groups.
Results: During the 5-year study period, 24,302 injured patients were admitted. Of those, 8,151 were admitted during the period from May to August with 4,030 (49.4%) at the beginning of the academic year (July to August) and 4,121 (50.6%) at the end of the academic year (May to June). Overall, the average age was 35.1 ± 17.7 years, 77% were men with an Injury Severity Score of 8.4 ± 9.7 and 24.2% penetrating injury rate. When examining mortality, after adjustment for differences between the two groups, there was no difference between patients admitted at the beginning or at the end of the academic year (adjusted odds ratio [95% confidence interval]: 1.1 [0.8, 1.5], p = 0.52). However, when compared with the patients treated for their injuries in May to June, those treated at the beginning of the academic year had a significantly higher rate of preventable and potentially preventable complications (adjusted odds ratio [95% confidence interval]: 1.9 [1.1, 3.2], p = 0.013).
Conclusions: At an academic Level I trauma center, admission at the beginning of the academic year was associated with an increased risk of errors resulting in preventable and potentially preventable complications; however, these errors did not impact mortality. Specific errors associated with this increased rate of preventable complications warrant further investigation.
8. Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax after Blunt Trauma
Wilkerson RG, et al. Acad Emerg Med. 2010;17:11-17.
Objectives: Supine anteroposterior (AP) chest radiographs in patients with blunt trauma have poor sensitivity for the identification of pneumothorax. Ultrasound (US) has been proposed as an alternative screening test for pneumothorax in this population. The authors conducted an evidence-based review of the medical literature to compare sensitivity of bedside US and AP chest radiographs in identifying pneumothorax after blunt trauma.
Methods: MEDLINE and EMBASE databases were searched for trials from 1965 through June 2009 using a search strategy derived from the following PICO formulation of our clinical question: patients included adult (18 + years) emergency department (ED) patients in whom pneumothorax was suspected after blunt trauma. The intervention was thoracic ultrasonography for the detection of pneumothorax. The comparator was the supine AP chest radiograph during the initial evaluation of the patient. The outcome was the diagnostic performance of US in identifying the presence of pneumothorax in the study population. The criterion standard for the presence or absence of pneumothorax was computed tomography (CT) of the chest or a rush of air during thoracostomy tube placement (in unstable patients). Prospective, observational trials of emergency physician (EP)-performed thoracic US were included. Trials in which the exams were performed by radiologists or surgeons, or trials that investigated patients suffering penetrating trauma or with spontaneous or iatrogenic pneumothoraces, were excluded. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. Data analysis consisted of test performance (sensitivity and specificity, with 95% confidence intervals [CIs]) of thoracic US and supine AP chest radiography.
Results: Four prospective observational studies were identified, with a total of 606 subjects who met the inclusion and exclusion criteria. The sensitivity and specificity of US for the detection of pneumothorax ranged from 86% to 98% and 97% to 100%, respectively. The sensitivity of supine AP chest radiographs for the detection of pneumothorax ranged from 28% to 75%. The specificity of supine AP chest radiographs was 100% in all included studies.
Conclusions: This evidence-based review suggests that bedside thoracic US is a more sensitive screening test than supine AP chest radiography for the detection of pneumothorax in adult patients with blunt chest trauma.
9. Exploring Emergency Physician–Hospitalist Handoff Interactions: Development of the Handoff Communication Assessment
Apker J, et al. Ann Emerg Med. 2010;55:161-170.
Study objective
We develop and evaluate the Handoff Communication Assessment, using actual handoffs of patient transfers from emergency department to inpatient care.
Methods
This was an observational qualitative study. We derived a Handoff Communication Assessment tool, using categories from discourse coding described in physician-patient communication, previous handoff research in medicine, health communication, and health systems engineering and pilot data from 3 physician-hospitalist handoffs. The resulting tool consists of 2 typologies, content and language form. We applied the tool to a convenience sample of 15 emergency physician-to-hospitalist handoffs occurring at a community teaching hospital. Using discourse analysis, we assigned utterances into categories and determined the frequency of utterances in each category and by physician role.
Results
The tool contains 11 content categories reflecting topics of patient presentation, assessment, and professional environment and 11 language form categories representing information-seeking, information-giving, and information-verifying behaviors. The Handoff Communication Assessment showed good interrater reliability for content (kappa=0.71) and language form (kappa=0.84). We analyzed 742 utterances, which provided the following preliminary findings: emergency physicians talked more during handoffs (67.7% of all utterances) compared with hospitalists (32.3% of all utterances). Content focused on patient presentation (43.6%), professional environment (36%), and assessment (20.3%). Form was mostly information-giving (90.7%) with periodic information-seeking utterances (8.8%) and rarely information-verifying utterances (0.4%). Questions accounted for less than 10% of all utterances.
Conclusion
We were able to develop and use the Handoff Communication Assessment to analyze content and structure of handoff communication between emergency physicians and hospitalists at a single center. In this preliminary application of the tool, we found that emergency physician–to-hospitalist handoffs primarily consist of information giving and are not geared toward question-and-answer events. This critical exchange may benefit from ongoing analysis and reformulation.
Full-text (free): http://www.annemergmed.com/article/PIIS0196064409015595/fulltext
10. A Randomized Clinical Trial to Reduce Patient Prehospital Delay to Treatment in Acute Coronary Syndrome
Dracup K, et al. Circulation. 2009;2:524-532.
Background— Delay from onset of acute coronary syndrome (ACS) symptoms to hospital admission continues to be prolonged. To date, community education campaigns on the topic have had disappointing results. Therefore, we conducted a clinical randomized trial to test whether an intervention tailored specifically for patients with ACS and delivered one-on-one would reduce prehospital delay time.
Methods and Results— Participants (n=3522) with documented coronary heart disease were randomized to experimental (n=1777) or control (n=1745) groups. Experimental patients received education and counseling about ACS symptoms and actions required. Patients had a mean age of 67±11 years, and 68% were male. Over the 2 years of follow-up, 565 patients (16.0%) were admitted to an emergency department with ACS symptoms a total of 842 times. Neither median prehospital delay time (experimental, 2.20 versus control, 2.25 hours) nor emergency medical system use (experimental, 63.6% versus control, 66.9%) was different between groups, although experimental patients were more likely than control to call the emergency medical system if the symptoms occurred within the first 6 months following the intervention (P=0.036). Experimental patients were significantly more likely to take aspirin after symptom onset than control patients (experimental, 22.3% versus control, 10.1%, P=0.02). The intervention did not result in an increase in emergency department use (experimental, 14.6% versus control, 17.5%).
Conclusions— The education and counseling intervention did not lead to reduced prehospital delay or increased ambulance use. Reducing the time from onset of ACS symptoms to arrival at the hospital continues to be a significant public health challenge.
11. Ultrasound detection of guidewire position during central venous catheterization
Stone MB, et al. Amer J Emerg Med. 2010;28:82-84.
Introduction
Ultrasound guidance decreases complications of central venous catheter (CVC) placement, but risks of arterial puncture and inadvertent arterial catheter placement exist. Ultrasound-assisted detection of guidewire position in the internal jugular vein could predict correct catheter position before dilation and catheter placement.
Methods
Ultrasound examinations were performed in an attempt to identify the guidewire before dilation and catheter insertion in 20 adult patients requiring CVC placement. Central venous pressures were measured after completion of the procedure.
Results
Guidewires were visible within the lumen of the internal jugular vein in all subjects. Central venous pressures confirmed venous placement of catheters. Ultrasound visualization of the guidewire predicted venous CVC placement with 100% sensitivity (95% confidence interval 80-100%) and 100% specificity (95% confidence interval 80%-100%).
Conclusions
Ultrasound reliably detects the guidewire during CVC placement and visualization of the wire before dilation and catheter insertion may provide an additional measure of safety during ultrasound-guided CVC placement.
12. The clinical differentiation of cerebellar infarction from common vertigo syndromes.
Nelson JA, Viirre E. West J Emerg Med. 2009;10:273-7.
This article summarizes the emergency department approach to diagnosing cerebellar infarction in the patient presenting with vertigo. Vertigo is defined and identification of a vertigo syndrome is discussed. The differentiation of common vertigo syndromes such as benign paroxysmal positional vertigo, Meniere's disease, migrainous vertigo, and vestibular neuritis is summarized. Confirmation of a peripheral vertigo syndrome substantially lowers the likelihood of cerebellar infarction, as do indicators of a peripheral disorder such as an abnormal head impulse test. Approximately 10% of patients with cerebellar infarction present with vertigo and no localizing neurologic deficits. The majority of these may have other signs of central vertigo, specifically direction-changing nystagmus and severe ataxia.
Full-text (free): http://www.escholarship.org/uc/item/6gt0d3x7
13. Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access
Dargin JM, et al. Amer J Emerg Med. 2010;28:1-7.
Objectives
We determined the survival and complications of ultrasonography-guided peripheral intravenous (IV) catheters in emergency department (ED) patients with difficult peripheral access.
Methods
This was a prospective, observational study conducted in an academic hospital from April to July of 2007. We included consecutive adult ED patients with difficult access who had ultrasonography-guided peripheral IVs placed. Operators completed data sheets and researchers examined admitted patients daily to assess outcomes. The primary outcome was IV survival more than 96 hours. As a secondary outcome, we recorded IV complications, including central line placement. We used descriptive statistics, univariate survival analysis with Kaplan Meier, and log-rank tests for data analysis.
Results
Seventy-five patients were enrolled. The average age was 52 years. Fifty-three percent were male, 21% obese, and 13% had a history of injection drug use. The overall IV survival rate was 56% (95% confidence interval, 44%-67%) with a median survival of 26 hours (interquartile range [IQR], 8-61). Forty-seven percent of IVs failed within 24 hours, most commonly due to infiltration. Although 47 (63%) operators reported that a central line would have been required if peripheral access was unobtainable, only 5 (7%; 95% confidence interval, 2%-15%) patients underwent central venous catheterization. Only 1 central line was placed as a result of ultrasonography-guided IV failure. We observed no infectious or thrombotic complications.
Conclusion
Despite a high premature failure rate, ultrasonography-guided peripheral IVs appear to be an effective alternative to central line placement in ED patients with difficult access.
14. Breath Alcohol Analyzer Mistakes Methanol Poisoning for Alcohol Intoxication
Caravati EM, et al. Ann Emerg Med. 2010;55:198-200.
Breath alcohol analyzers are used to detect ethanol in motorists and others suspected of public intoxication. One concern is their ability to detect interfering substances that may falsely increase the ethanol reading.
A 47-year-old-man was found in a public park, acting intoxicated. A breath analyzer test (Intoxilyzer 5000EN) measured 0.288 g/210 L breath ethanol, without an interferent noted. In the emergency department, the patient admitted to drinking HEET Gas-Line antifreeze, which contains 99% methanol. Two to three hours after ingestion, serum and urine toxicology screen results were negative for ethanol and multiple other substances. His serum methanol concentration was 589 mg/dL, serum osmolality 503 mOsm/kg, osmolar gap 193 mOsm/kg, and anion gap 17 mmol/L. The patient was treated with intravenous ethanol, fomepizole, and hemodialysis without complication.
This is a unique clinical case of a breath alcohol analyzer reporting methanol as ethanol. Intoxilyzer devices have been shown to indicate some substances (acetone) as interferents in humans but not methanol. Increased serum concentrations of methanol can be reported as ethanol by a commonly used breath alcohol analyzer, which can result in a delayed diagnosis or misdiagnosis and subsequent methanol toxicity if antidotal treatment is not administered in a timely manner.
15. Two Studies Validating the ABCD2 Score for Predicting Early Disabling Ischemic Stroke Risk after TIA in the ED
A. A Multicenter Evaluation of the ABCD2 Score's Accuracy for Predicting Early Ischemic Stroke in Admitted Patients With Transient Ischemic Attack
Asimos AW, et al. Ann Emerg Med. 2010;55:201-210.e5.
Study objective
We evaluate, in admitted patients with transient ischemic attack, the accuracy of the ABCD2 (age [A], blood pressure [B], clinical features [weakness/speech disturbance] [C], transient ischemic attack duration [D], and diabetes history [D]) score in predicting ischemic stroke within 7 days.
Methods
At 16 North Carolina hospitals, we enrolled a prospective, nonconsecutive sample of admitted patients with transient ischemic attack and with no stroke history, presenting within 24 hours of transient ischemic attack symptom onset. We conducted a medical record review to determine ischemic stroke outcomes within 7 days. According to a modified Rankin Scale Score, strokes were classified as disabling (greater than 2) or nondisabling (2 or less).
Results
During a 35-month period, we enrolled 1,667 patients, of whom 373 (23%) received a diagnosis of an ischemic stroke within 7 days. Eighteen percent (69/373) of all strokes were disabling. We were unable to calculate an ABCD2 score in 613 patients (37%); however, our imputed analysis indicated this did not significantly alter results. The discriminatory power of the ABCD2 score was modest for ischemic stroke in 7 days (c statistic 0.59), and fair for disabling ischemic stroke within 7 days (c statistic 0.71). Patients characterized as low risk according to ABCD2 score (3 or less) were at low risk for experiencing a disabling stroke within 7 days, with a negative likelihood ratio of 0.16 (95% confidence interval [CI] 0.04 to 0.64) with missing values excluded and 0.34 (95% CI 0.15 to 0.76) when missing values were imputed.
Conclusion
Our analysis suggests the best application of the ABCD2 score may be to identify patients at low risk for an early disabling ischemic stroke. Further study of the ability to determine an ABCD2 score in all patients is needed, along with validation in a large, consecutive population of patients with transient ischemic attack.
B. Validating the ABCD2 Score for predicting stroke risk after TIA in the ED
Ong ME, et al. Amer J Emerg Med. 2010;28:44-48.
Objectives
The aim of the study was to validate the use of the ABCD2 score for the prediction of stroke after transient ischemic attack (TIA) in patients presenting to the emergency department (ED). The ABCD2 scoring is based on 5 factors as follows: age of at least 60 years; blood pressure of at least 140/90 mm Hg; clinical features such as unilateral weakness and speech impairment alone; duration of at least 60 minutes or 10 to 59 minutes; and diabetes.
Methods
The authors conducted a retrospective observational study of all patients presented to the ED for TIA, as diagnosed by the attending emergency physicians, for a 2-year period. Sensitivity, specificity, and negative predictive value (NPV) were calculated for risk of stroke at 2, 7, 30, and 90 days after presentation.
Results
From January 1, 2005, to December 31, 2006, there were 470 patients diagnosed with TIA at the ED. Mean age was 61.0 years (SD, 13.2), with 63.3% males. Age of at least 60 years, unilateral weakness, and duration of at least 60 minutes were found to be significant predictors of stroke at 2 days. An admission rule based on an ABCD2 score of at least 4 showed sensitivity of 86.4% and NPV of 91.7% for stroke at 7 days. Admission based on a score of at least 3 showed sensitivity of 96.6% and NPV of 96.1%. Admission rate was 69.1% and. 83.6%, respectively.
Conclusion
The ABCD2 rule showed good sensitivity and NPV for stroke at 7 days. However, NPV was not 100%, and there would still be patients being discharged from the ED and returning with a stroke if this cutoff was implemented in our setting.
16. Molar pregnancy in the emergency department.
Masterson L, et al. West J Emerg Med. 2009;10:295-6.
A 15-year-old female presented to the emergency department with complaints of vaginal bleeding. She was pale, anxious, cool and clammy with tachycardic, thready peripheral pulses and hemoglobin of 2.4g/dL. Her abdomen was gravid appearing, approximately early to mid-second trimester in size. Pelvic examination revealed 2 cm open cervical os with spontaneous discharge of blood, clots and a copious amount of champagne-colored grapelike spongy material. After 2L boluses of normal saline and two units of crossmatched blood, patient was transported to the operating room. Surgical pathology confirmed a complete hydatidiform mole.
Full-text (free): http://www.escholarship.org/uc/item/569107db
17. Diagnostic Accuracy of Emergency Doppler Echocardiography for Identification of Acute Left Ventricular Heart Failure in Patients with Acute Dyspnea: Comparison with Boston Criteria and N-terminal Prohormone Brain Natriuretic Peptide
Nazerian P, et al. Acad Emerg Med. 2010;17:18-26.
Objectives: Echocardiography is a fundamental tool in the diagnosis of acute left ventricular heart failure (aLVHF). However, a consultative exam is not routinely available in every emergency department (ED). The authors investigated the diagnostic performance of emergency Doppler echocardiography (EDecho) performed by emergency physicians (EPs) for the diagnosis of aLVHF in patients with acute dyspnea.
Methods: A convenience sample of acute dyspneic patients was evaluated. For each patient, the Boston criteria score for heart failure was calculated, and N-terminal prohormone brain natriuretic peptide (NT-proBNP) and EDecho were contemporaneously performed. Four investigators, after a limited echocardiography course, performed EDechos and evaluated for a "restrictive" pattern on pulsed Doppler analysis of mitral inflow and reduced left ventricular (LV) ejection fraction. The final diagnosis, established after reviewing all patient clinical data except NT-proBNP and EDecho results, served as the criterion standard.
Results: Among 145 patients, 64 (44%) were diagnosed with aLVHF. The median time needed to perform EDecho was 4 minutes. Pulsed Doppler analysis was feasible in 125 patients (84%). The restrictive pattern was more sensitive (82%) and specific (90%) than reduced LV ejection fraction and more specific than the Boston criteria and NT-proBNP for the diagnosis of aLVHF. Considering noninterpretable values of the restrictive pattern and uncertain values ("gray areas") of Boston criteria (between 4 and 7) and of NT-proBNP (between 300 and 2,200 pg/mL) as false results, the accuracy of the restrictive pattern in the overall population was 75%, compared with accuracy of 49% for both NT-proBNP and Boston criteria.
Conclusions: EDecho, particularly pulsed Doppler analysis of mitral inflow, is a rapid and accurate diagnostic tool in the evaluation of patients with acute dyspnea.
18. Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures
Beaudoin FL, et al. Amer J Emerg Med. 2010;28:76-81.
Objectives
The primary objective of this study was to determine the feasibility of ultrasound-guided femoral nerve blocks in elderly patients with hip fractures in the emergency department (ED). The secondary objective was to examine the effectiveness of this technique as an adjunct for pain control in the ED.
Methods
This prospective observational study enrolled a convenience sample of 13 patients with hip fractures. Ultrasound-guided femoral nerve block was performed on all participants. To determine feasibility, time to perform the procedure, number of attempts, and complications were measured. To determine effectiveness of pain control, numerical rating scores were assessed at baseline and at 15 minutes, 30 minutes, and hourly after the procedure for 4 hours. Summary statistics were calculated for feasibility measures. Wilcoxon matched-pairs signed-rank tests and Friedman analysis of variance test were used to compare differences in pain scores.
Results
The median age of the participants was 82 years (range, 67-94 years); 9 were female. The median time to perform the procedure was 8 minutes (range, 7-11 minutes). All procedures required only one attempt; there were no complications. After the procedure, there were 44% and 67% relative decreases in pain scores at 15 minutes (P ≤ .002) and at 30 minutes (P ≤ .001), respectively. Pain scores were unchanged from 30 minutes to 4 hours after the procedure (P ≤ .77).
Conclusions
Ultrasound-guided femoral nerve blocks are feasible to perform in the ED. Significant and sustained decreases in pain scores were achieved with this technique.
19. “So, Doctor, What's So Bad About Being Fat?” Combating the Obesity Epidemic in the United States
Alpert JS. Amer J Med. 2010;123:1-2.
Each week, many of my middle-aged patients ask me the question cited above. Obesity has become so commonplace in the United States that thin, healthy individuals are becoming the exception rather than the rule. With the rising prevalence and incidence of obesity in our society, patients have begun seeing this state of body habitus as the norm rather than the exception. “What's the matter with being a little overweight, doc; everyone in my family is fat, so why not me?”
In response, I deliver my “fat” talk. In this sermonette on obesity, I stress the many increased health risks that overweight individuals incur: atherosclerosis, hypertension, gallstones, diabetes, colonic adenomas, degenerative joint disease, sleep apnea, deep venous thrombosis, and pulmonary embolism, among others. I try to communicate to my obese patients the importance of modest and gradual weight loss as compared with the cycle of rapid weight loss and equally rapid weight gain that is so common in our society. “Bouncing your weight up and down may even put you at greater risk for heart disease,” I continue, hoping that my message will take root in the patient's mind. “Regular exercise such as daily walking is a great help in losing weight. Try to cut back on portion size, simple carbohydrates such as sugar and products made with white flour, as well as saturated fat in your diet. Would you like to speak with one of our dieticians?”
My daily preaching often goes unheeded and leads me and my internal medicine colleagues to become cynical about the possibility of ever convincing our patients to lose weight. This is, unfortunately, the price to be paid in a society that gratifies itself with every type of food taken in excess combined with widespread physical inactivity.
The rest of the essay: http://www.amjmed.com/article/S0002-9343(09)00711-6/fulltext
20. Non-traumatic urologic emergencies in men: a clinical review.
Kessler CS, Bauml J. West J Emerg Med. 2009;10:281-7.
Although true urologic emergencies are extremely rare, they are a vital part of any emergency physician's (EP) knowledge base, as delays in treatment lead to permanent damage. The four urologic emergencies discussed are priapism, paraphimosis, testicular torsion, and Fournier's gangrene. An overview is given for each, including causes, pathophysiology, diagnosis, treatment, and new developments. The focus for priapism is on diagnosis and distinguishing high-flow from low-flow forms, as the latter requires emergent treatment. For paraphimosis, we describe various methods of relieving the stricture, from manual reduction to surgery in extreme cases. For testicular torsion, the most important factor in salvaging the testicle is decreasing time to treatment. This is accomplished through experience and understanding which signs and symptoms strongly suggest it, so that time-consuming tests are avoided. Lastly, Fournier's gangrene is potentially fatal. While aggressive medical and surgical therapy will improve chances of survival and outcome, it is vital for the emergency department (ED) physician to diagnose Fournier's. It often presents in the elderly, immunocompromised, or those with depressed mental status. The goal of this paper is to arm EPs with information to recognize urological emergencies and intervene quickly to preserve tissue, fertility, and life.
Full-text (free): http://www.escholarship.org/uc/item/2cj981j1
21. ED antibiotic use for acute respiratory illnesses since pneumonia performance measure inception
Fee C, et al. Amer J Emerg Med. 2010;28:23-31.
Objective
The study aimed to determine if emergency department (ED)–administered antibiotics for patients discharged home with nonpneumonia acute respiratory tract infections (ARIs) have increased since national pneumonia performance measure implementation, including antibiotic administration within 4 hours of arrival.
Methods
Design: Time series analysis. Setting: Six university and 7 Veterans Administration EDs participating in the Improving Antibiotic Use for Acute Care Treatment (IMPAACT) trial (randomized educational intervention to reduce antibiotics for bronchitis). Participants: Randomly selected adult (age older than 18 years) ED visits for acute cough, diagnosed with nonpneumonia ARIs, discharged home during winters (November-February) of 2003 to 2007. Main outcome: Time trend in ED-administered antibiotics, adjusted for patient demographics, comorbidities, vital signs, ED length of stay, IMPAACT intervention status, geographic region, Veterans Administration/university setting, and site and provider level clustering.
Results
Six thousand four hundred seventy-six met study criteria. Three hundred ninety-four (6.1%) received ED-administered antibiotics. Emergency department–administered antibiotics did not increase across the study period among all IMPAACT sites (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.76-1.01) after adjusting for age, congestive heart failure history, temperature higher than 100°F, heart rate more than 100, blood cultures obtained, diagnoses, and ED length of stay. The ED-administered antibiotic rate decreased at IMPAACT intervention (OR, 0.80; 95% CI, 0.69-0.93) but not nonintervention sites (OR, 1.04; 95% CI, 0.91-1.19). Adjusted proportions receiving ED-administered antibiotics were 6.1% (95% CI, 2.7%-13.2%) for 2003 to 2004; 4.8% (95% CI, 2.2%-10.0%) for 2004 to 2005; 4.6% (95% CI, 2.7%-7.8%) for 2005 to 2006; and 4.2% (95% CI, 2.2%-8.0%) for 2006 to 2007.
Conclusions
Emergency department–administered antibiotics did not increase for patients with acute cough discharged home with nonpneumonia ARIs since pneumonia antibiotic timing performance measure implementation in these academic EDs.
Friday, January 29, 2010
Sunday, January 17, 2010
Lit Bits: Jan 17, 2010
From the recent medical literature...
1. Ranking 37th — Measuring the Performance of the U.S. Health Care System
Posted by NEJM • January 6th, 2010 •
Christopher J.L. Murray, M.D., D.Phil., and Julio Frenk, M.D., Ph.D., M.P.H.
Evidence that other countries perform better than the United States in ensuring the health of their populations is a sure prod to the reformist impulse. The World Health Report 2000, Health Systems: Improving Performance, ranked the U.S. health care system 37th in the world1 — a result that has been discussed frequently during the current debate on U.S. health care reform.
The conceptual framework underlying the rankings2 proposed that health systems should be assessed by comparing the extent to which investments in public health and medical care were contributing to critical social objectives: improving health, reducing health disparities, protecting households from impoverishment due to medical expenses, and providing responsive services that respect the dignity of patients. Despite the limitations of the available data, those who compiled the report undertook the task of applying this framework to a quantitative assessment of the performance of 191 national health care systems. These comparisons prompted extensive media coverage and political debate in many countries. In some, such as Mexico, they catalyzed the enactment of far-reaching reforms aimed at achieving universal health coverage. The comparative analysis of performance also triggered intense academic debate, which led to proposals for better performance assessment.
Despite the claim by many in the U.S. health policy community that international comparison is not useful because of the uniqueness of the United States, the rankings have figured prominently in many arenas. It is hard to ignore that in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy.3 These facts have fueled a question now being discussed in academic circles, as well as by government and the public: Why do we spend so much to get so little?
The rest of the article: http://healthcarereform.nejm.org/?p=2610
2. Cardiac Arrest: Cardiovert, Compress, Cool, ... and Cath?
Amal Mattu, MD.
In recent decades, numerous therapies have been promoted as great advances in the treatment of primary cardiac arrest: epinephrine, high-dose epinephrine, vasopressin, lidocaine, amiodarone, electrical defibrillation, biphasic defibrillation, induced hypothermia, and so on. The initial literature on these "miracle cures" has always looked promising. However, when attempts at validating these early studies were made or when meaningful outcomes (eg, hospital discharge with good neurologic function) were evaluated, most of these therapies fell short and eventually lost favor in the literature. Currently, only 3 therapies have emerged as truly beneficial in terms of meaningful outcomes: rapid defibrillation of ventricular fibrillation/pulseless ventricular tachycardia, good chest compressions (with less emphasis on early airway interventions and minimizing interruptions), and induced hypothermia.
Given that the majority of cases of primary cardiac arrest are associated with acute coronary syndromes, it seems reasonable to assume that urgent coronary angiography and percutaneous coronary intervention (PCI) would be associated with improved outcomes in patients with return of spontaneous circulation (ROSC) after cardiac arrest. Recent studies have demonstrated this to be true for patients with electrocardiogram (ECG) evidence of ST-segment elevation myocardial infarction (STEMI) either before or after resuscitation. However, it is well-known that the ECG is far from perfect at demonstrating evidence of acute MI. Therefore, use of the ECG to determine which patients should undergo urgent PCI might potentially lead to many patients missing out on beneficial therapy. Can coronary angiography and PCI improve the outcomes of resuscitated patients without definite evidence of STEMI? Reynolds and colleagues attempted to answer this question.
Reynolds JC, et al. Coronary Angiography Predicts Improved Outcome Following Cardiac Arrest: Propensity-adjusted Analysis. J Intensive Care Med. 2009;24:179-186
Summary
The authors performed a chart review of resuscitated patients in cardiac arrest between 2005 and 2007. They evaluated an assortment of parameters including acute ischemic ECG changes (new left bundle branch block or STEMI), presenting rhythm, neurologic status, and outcome. A good outcome was defined as discharge home or to an acute rehabilitation facility. Of the 241 patients they reviewed, 40% received coronary angiography. Significant disease (defined as 70% stenosis or greater in at least 1 coronary artery) was identified in 69% of patients, including 57% of patients without any ischemic changes on ECG. Of the patients who received coronary angiography and PCI, 54% experienced a good clinical outcome compared with 25% of patients not receiving coronary angiography. A propensity-adjusted analysis was used to account for the nonrandomized nature of the study. The authors determined that improved survival and good outcome were associated with coronary angiography regardless of the presence of new left bundle branch block or STEMI, and also regardless of presenting rhythm or neurologic status immediately after resuscitation.
Viewpoint
Reynolds' study further supports previously published reports encouraging urgent catheterization for survivors of cardiac arrest regardless of ECG evidence of STEMI. Recent publications also show that therapeutic hypothermia can be used safely in these patients during and after PCI without producing delays in time to balloon inflation.
The significance of this new literature cannot be overstated. If further studies confirm these findings, it would strongly argue for enormous changes in prehospital systems of care. All survivors of primary cardiac arrest would be recommended for immediate transport to hospitals that have the capability of performing urgent PCI in conjunction with therapeutic hypothermia. Based on the current literature, it certainly seems advisable that emergency healthcare practitioners who care for resuscitated victims of primary cardiac arrest should engage in conversations with cardiology consultants and urge them to take an aggressive approach to PCI in these patients.
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19321536
3. Santa Claus: a public health pariah?
Grills NJ, et al. BMJ 2009;339:b5261
Santa Claus is a well known and loved character, but Nathan Grills and Brendan Halyday question whether he is a healthy role model
Santa Claus long ago displaced the Virgin Mary and baby as the most unmistakable Christmas iconography. A recent study among hospital inpatients concluded that awareness of Santa was near universal. Given Santa’s fame, he has considerable potential to influence individual and societal behaviour—and not necessarily for good. Santa is a late adopter of evidence based behaviour change and continues to sport a rotund sedentary image. But this is not the only example where Santa’s behaviour and public image are at odds with contemporary accepted public health messages.
Eric Schlosser and Morgan Spurlock have both described how McDonald’s used Ronald McDonald to target their products at children by creating an association between McDonald’s food and happy times. Spurlock showed how Ronald McDonald was more highly recognised than the American president or the Pope. Interestingly, Schlosser documents that among American schoolchildren Santa Claus was the only fictional character more highly recognised than than Ronald McDonald.
If Ronald McDonald can be so effective at selling burgers to children, we might expect Santa to be equally effective at selling other goods. After all, it was Santa’s advertising potential that reincarnated simple Saint Nicholas into the glory of a universally recognised icon. Santa’s contemporary image was cemented by the Coca-Cola advertisements that began in the 1930s. By the mid-1950s Santa had become the leading sales consultant for numerous other companies and products. Today, he is one of the biggest sellers at Christmas and appears in adverts on television, the internet, billboards, and shop fronts.
Public health needs to be aware of what giant multinational capitalists realised long ago: that Santa sells, and sometimes he sells harmful products. Several countries, like the UK, limit what can be advertised to children. Since Santa is a childhood icon should we prevent him from selling products such as alcohol and unhealthy foods?
Furthermore, Santa has a growing impact on international public health. Like Coca-Cola, Santa has become a major export item to the developing world. Countries such as India are increasing celebrating the Christmas festival. The potential for Santa’s growing acclaim to be misused may even be greater in countries where there is less regulation of advertising.
Obesity
Epidemiologically there is a correlation between countries that venerate Santa Claus and those that have high levels of childhood obesity. Although given the various confounders it is premature to conclude causality, there is a temporal pathway whereby Santa promotes a message that obesity is synonymous with cheerfulness and joviality. Rear Admiral Galson, acting US surgeon general in 2007, commented, "It is really important that the people who kids look up to as role models are in good shape, eating well and getting exercise. It is absolutely critical." He went on to explain that Santa should slim down.
To create a supportive environment for Santa’s dieting we should cease the tradition of leaving Santa cookies, mince pies, and milk, brandy, or sherry. This is bad not only for Santa’s waistline but for parental obesity. When Santa is full, Dad is a willing helper. Maybe we should encourage Santa (and his helpers) to share the carrots and celery sticks commonly left for Rudolf. Santa might also be encouraged to adopt a more active method to deliver toys—swapping his reindeer for a bike or simply walking or jogging.
The rest of the article: http://www.bmj.com/cgi/content/full/339/dec16_1/b5261
4. Geriatric Population Becoming Bigger Part of Emergency Department Mix
NEW YORK (Reuters Health) Dec 18 - Traffic in US emergency departments has increased significantly in the last decade, with geriatric patients leading the way, new research from Texas shows.
Dr. K. Tom Xu and colleagues, from Texas Tech University Health Sciences Center in Lubbock, extracted emergency department utilization data from the Medical Expenditure Panel Survey for the period 1996 to 2005.
During that period, they report in the Annals of Emergency Medicine for December, the total number of non-institutionalized individuals who used emergency department services in the US increased from 34.2 million to 40.8 million. That is, the proportion of emergency department users in the US population rose from 12.7% to 13.8%.
The authors did not report specific percentages for various age groups and subpopulations, but they "found that emergency department users had become older and (included more of) those who perceived themselves to be in poor or fair physical health, with and without population adjustment," they write in their report.
"The key observation in this study is that the composition of patients seen in emergency rooms has been changing over time," Dr. Xu told Reuters Health.
"People tend to associate ERs with traumas, injuries, accidents, poisoning, overdose and other dramatic events," Dr. Xu said. "In reality, a larger portion of patients seen in emergency rooms are those with chronic diseases and poor overall health."
The study, he added, also confirms earlier findings that the poor and the uninsured "are not the main contributing factors to emergency room crowding in recent years."
In addition to older adults and those in poor health, subpopulations that showed significantly increasing levels of emergency department use after population adjustment included blacks, people with only Medicare insurance, those with multiple types of insurance, those within 100% to 199% of the federal poverty line and those with at least one inpatient stay.
Some subpopulations that showed decreasing levels of emergency department use: women, Hispanics, uninsured individuals, people with private insurance only, and patients at greater than or equal to 200% of the federal poverty line.
"The aging population will create additional challenges in the training of future emergency physicians and in the reform of the nation's health care system," Dr. Xu said.
"This study will not change practice but will help those planning the kinds of emergency department resources that will be needed in the future."
Ann Emerg Med 2009;54:805-810.
5. Evidence based merriment
Isaacs S, et al. BMJ 2009;339:b5098
Background
Medical humour has a long history, but is short on evidence. The ancient Greeks introduced the world to bodily fluids called the four humours. You would think that a philosophy based on blood, choler, phlegm, and melancholy was no laughing matter.
What is the evidence that medical humour benefits staff or patients? We performed a systematic revue, but it was not funny. We propose a randomised controlled trial of medical humour.
Pilot study
The Royal Flying Doctor Service funded a pilot study. Hospital staff completed a standardised questionnaire about the role of humour in their department.
The department of surgery expressed an interest in side-splitting jokes.
The ophthalmology department insisted that all patients should have a slit lamp examination for aqueous and vitreous humour.
The gastroenterology department wanted to ban sick jokes and toilet humour.
The allergy department warned of the hazards of severe joke allergy. At least one child has suffered a severe allergic reaction to a shaggy dog story, while cat allergy predisposes to cataplexy. However, the most feared condition is anaphylaxis to puns, which can only be treated with outrageously expensive adrenaline syringes, called Epipuns. The State Department of Allergy and Over-reaction has recommended that all children with pun anaphylaxis carry Epipuns and that jokes are banned from nursery schools. The child must also bring to school a letter from their parents guaranteeing that they have not been told any jokes at home in the last 24 hours.
The hospital administration warned that black humour contravenes health department policy on racial discrimination and punch-lines are forbidden under department guidelines on bullying in the workplace.
Study design
Doctors will be randomised to an intervention group who will tell random jokes to children on the paediatric wards or a self control group who will be asked to save their jokes for their own long suffering children at home. Here is a random joke. "Two cannibals ate a clown doctor. One cannibal asked the other, did that taste funny to you?"
The responses of joke recipients will be screened. Their facial contours will be examined for increases in creases. Mirth will be measured in grins per milli-titter, gigglebytes, or smiles per hour. Belly laughs are expressed in units called Hertz. Laughter delayed for greater than 30 seconds is not classified as humour. He who laughs last, thinks slowest.
Statistics
The data will be massaged and tickled and subjected to a Student’s t-hee test with a funnel plot to see if the jokes come out funnelly.
Ethics approval
The proposed trial will be submitted to the Institutional Ethics and Deforestation Committee, which requires 47 double spaced, single sided copies of the trial protocol. The protocol must be on the ethics committee application form, which can be completed in less than a month by anyone with an IQ over 130 and advanced degrees in information technology and communication.
The ethics form needs to be countersigned by the Head of Department, the Head of Department’s Head of Clinical Stream, the Clinical Superintendent, the Chief Executive Officer and the Minister for Health.
Conclusion
We call for a randomised fairly controlled trial of humour. Humour is a serious matter and should not be taken lightly.
6. Is Contrast Needed for CT Diagnosis of Acute Appendicitis?
This systematic review showed that helical CT without contrast is sufficiently sensitive and specific for diagnosing acute appendicitis.
Hlibczuk V. Ann Emerg Med. 2010:55:51-59.
Study objective
We seek to determine the diagnostic test characteristics of noncontrast computed tomography (CT) for appendicitis in the adult emergency department (ED) population.
Methods
We conducted a search of MEDLINE, EMBASE, the Cochrane Library, and the bibliographies of previous systematic reviews. Included studies assessed the diagnostic accuracy of noncontrast CT for acute appendicitis in adults by using the final diagnosis at surgery or follow-up at a minimum of 2 weeks as the reference standard. Studies were included only if the CT was completed using a multislice helical scanner. Two authors independently conducted the relevance screen of titles and abstracts, selected studies for the final inclusion, extracted data, and assessed study quality. Consensus was reached by conference, and any disagreements were adjudicated by a third reviewer. Unenhanced CT test performance was assessed with summary receiver operating characteristic curve analysis, with independently pooled sensitivity and specificity values across studies.
Results
The search yielded 1,258 publications; 7 studies met the inclusion criteria and provided a sample of 1,060 patients. The included studies were of high methodological quality with respect to appropriate patient spectrum and reference standard. Our pooled estimates for sensitivity and specificity were 92.7% (95% confidence interval 89.5% to 95.0%) and 96.1% (95% confidence interval 94.2% to 97.5%), respectively; the positive likelihood ratio=24 and the negative likelihood ratio=0.08.
Conclusion
We found the diagnostic accuracy of noncontrast CT for the diagnosis of acute appendicitis in the adult population to be adequate for clinical decisionmaking in the ED setting.
Full-text: http://www.annemergmed.com/article/S0196-0644(09)01140-8/fulltext
7. Steroids May Effectively Relieve Pain of Acute Pharyngitis
Laurie Barclay, MD. January 15, 2010 — Steroids are effective as adjuvant therapy in relieving pain in acute pharyngitis, according to the results of a systematic review reported in the January/February issue of the Annals of Family Medicine.
"A major treatment goal for patients complaining of sore throat is to relieve pain and alleviate difficulties in swallowing," write Katrin Korb, MD, from the University of Goettingen in Germany, and colleagues. "The anti-inflammatory action of steroids might be effective to relieve symptoms caused by inflammation and has been studied in other upper respiratory tract infections. Steroids might, therefore, represent a useful clinical option to meet patients' needs."
The purpose of this review was to summarize evidence from randomized controlled trials (RCTs) that assessed the efficacy of adjuvant therapy with corticosteroids to relieve the pain of acute pharyngitis. After searching MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews for RCTs published between 1966 and December 2008, 2 reviewers evaluated the quality of each identified article and summarized the data.
Of 8 identified RCTs enrolling a total of 806 ambulatory patients, 5 enrolled adult patients and 3 enrolled children. Compared with placebo, steroid use (dexamethasone, betamethasone, or prednisone) was associated with statistically significant faster reduction of pain or complete pain relief in all identified RCTs. Most participants had been treated with antibiotics at least initially. Although use of acetaminophen or other analgesic medication was permitted in all studies, this factor was not always controlled. There were no serious adverse effects.
"Steroids are effective in relieving pain in acute pharyngitis," the study authors write. "Although no serious adverse effects were observed, the benefits have to be balanced with possible adverse drug effects. There are safe and effective over-the-counter medications to relieve throat pain."
Limitations of this systematic review include possible publication bias favoring studies finding steroids to be beneficial, possible recall bias, and limitations inherent in the included studies. Specific drugs used, dosing and administration, and outcome measures all varied among the included trials.
"Most patients received concomitant antibiotics; however, reducing the prescription of antibiotics for generally benign upper respiratory tract infection is a public health goal," the review authors conclude. "We therefore recommend further studies to establish both the safety of steroids without antibiotic coverage and the additional benefits of steroids when used with regular administration of over-the-counter analgesic medications."
Ann Fam Med. 2010;8:58-63. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20065280
8. For Migraine in the ED, Prochlorperazine Is Better Than Sumatriptan
NEW YORK (Reuters Health) Jan 12 - For patients in the emergency department (ED) with migraine, IV prochlorperazine with diphenhydramine is more effective than subcutaneous sumatriptan, a small prospective trial suggests.
Both prochlorperazine (Compazine) and sumatriptan (Imitrex) are effective for migraine, Dr. Mark A. Kostic, at the Medical College of Wisconsin, Milwaukee, and co-investigators note. However, little is known about how the two compare, they point out in the Annals of Emergency Medicine for January 4.
Their double-blind, placebo-controlled trial included 66 consecutive ED patients, ages 18 to 50, with "typical" migraine diagnosed on the basis of International Headache Society criteria.
Patients were randomly assigned either to subcutaneous sumatriptan 6 mg (n = 34) or to prochlorperazine 10 mg plus diphenhydramine 12.5 mg (to control akathisia) in 500 mL IV saline (n = 32). Because the trial was blinded, each patient also received a sham treatment along with the assigned therapy.
Patients were asked to assess pain and adverse effects every 20 minutes until 80 minutes or emergency department discharge, whichever came first. At baseline, there were no important differences between the groups, according to the authors.
Prochlorperazine was associated with more rapid and significantly greater reduction in pain intensity on a 100-mm visual analog scale (mean decrease in pain intensity 73 mm vs 50 mm with sumatriptan).
Both groups reported similar degrees of sedation. Prochlorperazine-treated patients had less nausea, but the difference was not statistically significant.
Dr. Kostic's team concludes, "The IV prochlorperazine with diphenhydramine route is not only more efficient and more effective but also less expensive."
Ann Emerg Med 2010; publication pending. Abstract: http://www.annemergmed.com/article/S0196-0644(09)01794-6/abstract
9. Lying obliquely—a clinical sign of cognitive impairment: cross sectional observational study
Kraft P, et al. BMJ 2009;339:b5273
Objective: To determine if failure to spontaneously orient the body along the longitudinal axis of a hospital bed when asked to lie down is associated with cognitive impairment in older patients.
Design Cross sectional observational study.
Setting: Neurology department of a university hospital in Germany.
Participants: Convenience sample of 110 older (60 years) inpatients with neurological conditions and 23 staff neurologists.
Main outcome measures: The main outcome measure was the association between the angle of the body axis and the results of three cognitive screening tests (mini-mental state examination, DemTect, and clock drawing test). Staff doctors were shown photographs of a model taken at a natural viewing able to determine their subjective perspective of what constitutes oblique.
Results: 110 neurological inpatients (mean age 70.9 (SD 6.8) years) were included after exclusions. Evidence of cognitive impairment was found in 34, with scores indicating dementia in eight, according to the mini-mental state examination, and in 11 according to the DemTect. Across all patients, the mean angular deviation of the body axis from the longitudinal axis of the bed (range 0-23 degrees) correlated linearly with the mini-mental state examination (r=–0.480), DemTect (r=–0.527), and the clock drawing test (r=–0.552) scores (P less than 0.001 for all), even after removing age as a covariate. Overall, 90% of staff neurologists considered a minimal body angle of 7 degrees to be oblique. Angular deviation of at least 7 degrees predicted cognitive impairment according to the three different tests, with specificities between 89% and 96% and sensitivities between 27% and 50%.
Conclusion: Clinicians might suspect cognitive impairment in mobile older inpatients with neurological disorders who spontaneously position themselves obliquely when asked to lie on a bed.
Full-text: http://www.bmj.com/cgi/content/full/339/dec16_3/b5273
10. Does This Patient Have Irritable Bowel Syndrome?
Rational Clinical Exam Review by Annals of Emergency Medicine
Sherbino J. Ann Emerg Med. 2010;55:117-119.
Full-text: http://www.annemergmed.com/article/S0196-0644(09)00112-7/fulltext
11. Effect of listening to Nellie the Elephant during CPR training on performance of chest compressions by lay people: randomised crossover trial
L Rawlins, et al. BMJ 2009;339:b4707
Objectives: To determine whether listening to music during cardiopulmonary resuscitation (CPR) training increases the proportion of lay people delivering chest compressions of 100 per minute.
Design Prospective randomised crossover trial.
Setting: Large UK university.
Participants: 130 volunteers (81 men) recruited on an opportunistic basis. Exclusion criteria included age under 18, trained health professionals, and cardiopulmonary resuscitation (CPR) training within the past three months.
Interventions: Volunteers performed three sequences of one minute of continuous chest compressions on a skill meter resuscitation manikin accompanied by no music, repeated choruses of Nellie the Elephant (Nellie), and That’s the Way (I like it) (TTW) according to a pre-randomised order.
Main outcome measures: Rate of chest compressions delivered (primary outcome), depth of compressions, proportion of incorrect compressions, and type of error.
Results: Median (interquartile range) compression rates were 110 (93-119) with no music, 105 (98-107) with Nellie, and 109 (103-110) with TTW. There were significant differences within groups between Nellie v no music and Nellie v TTW (P less than 0.001) but not no music v TTW (P=0.055). A compression rate of between 95 and 105 was achieved with no music, Nellie, and TTW for 15/130 (12%), 42/130 (32%), and 12/130 (9%) attempts, respectively. Differences in proportions were significant for Nellie v no music and Nellie v TTW (P less than 0.001) but not for no music v TTW (P=0.55). Relative risk for a compression rate between 95 and 105 was 2.8 (95% confidence interval 1.66 to 4.80) for Nellie v no music, 0.8 (0.40 to 1.62) for TTW v no music, and 3.5 (1.97 to 6.33) for Nellie v TTW. The number needed to treat for listening to Nellie v no music was 5 (4 to 10)—that is, the number of cardiac arrests required during which lay responders listen to Nellie to facilitate one patient receiving compressions at the correct rate (v no music) would be between four and 10. A greater proportion of compressions were too shallow when participants listened to Nellie v no music (56% v 47%, P=0.022).
Conclusions: Listening to Nellie the Elephant significantly increased the proportion of lay people delivering compression rates at close to 100 per minute. Unfortunately it also increased the proportion of compressions delivered at an inadequate depth. As current resuscitation guidelines give equal emphasis to correct rate and depth, listening to Nellie the Elephant as a learning aid during CPR training should be discontinued. Further research is required to identify music that, when played during CPR training, increases the proportion of lay responders providing chest compressions at both the correct rate and depth.
Full-text: http://www.bmj.com/cgi/content/full/339/dec11_2/b4707
For the tune, consult YouTube
12. Portrait of a Multitasking Mind: What happens when you try to do three things at once?
By Naomi Kenner and Russell Poldrack. Scientific American. Dec 2009.
Productive, or spinning wheels? Researchers are examining the psychology of quickly shifting attention
Are you a media multitasker? We know you're reading a blog, but what else are you doing right now? Take a quick inventory: Are you also listening to music? Monitoring the progress of a sports game on TV? Emailing your co-worker? Texting your friend? On hold with tech support? If your inventory has revealed a multitasking lifestyle, you are not alone. Media multitasking is increasingly common, to the extent that some have dubbed today’s teens "Generation M."
People often think of the ability to multitask as a positive attribute, to the degree that they will proudly tout their ability to multitask. Likewise it’s not uncommon to see job advertisements that place “ability to multitask” at the top of their list of required abilities. Technologies such as smartphones cater to this idea that we can (and should) maximize our efficiency by getting things done in parallel with each other. Why aren’t you paying your bills and checking traffic while you’re driving and talking on the phone with your mother? However, new research by EyalOphir, Clifford Nass, and Anthony D. Wagner at Stanford University suggests that people who multitask suffer from a problem: weaker self-control ability.
The researchers asked hundreds of college students fill out a survey on their use of 12 different types of media. Students reported not only the number of hours per week that they used each type of media, but also rated how often they used each type of media simultaneously with each other type of media. The researchers created a score for each person that reflected how much their lifestyle incorporated media-multitasking.
They then recruited people who had scores that were extremely high or low and asked them perform a series of tests designed to measure the ability to control one's attention, one's responses, and the contents of one's memory. They found that the high- and low- media-multitasking groups were equally able to control their responses, but that the heavy media-multitasking group had difficulties, compared to the low media-multitasking group, when asked to ignore information that was in the environment or in their recent memory. They also had greater trouble relative to their counterparts when asked to switch rapidly between two different tasks. This last finding was surprising, because psychologists know that multitasking involves switching rapidly between tasks rather than actually performing multiple tasks simultaneously.
It seems that chronic media-multitaskers are more susceptible to distractions. In contrast, people who do not usually engage in media-multitasking showed a greater ability to focus on important information. According to the researchers, this reflects two fundamentally different strategies of information processing. Those who engage in media-multitasking more frequently are "breadth-biased," preferring to explore any available information rather than restrict themselves. AsLin Lin at the University of North Texas puts it in a review of the article, they develop a habit of treating all information equally. On the other extreme are those who avoid breadth in favor of information that is relevant to an immediate goal.
So what does this mean for you, reading this blog while checking your stocks and playing solitaire? Are you in trouble? Should you curb your media congestion? Not necessarily. Breadth-bias may still serve a purpose in our media-heavy society. While the researchers focused on a type of control known as "top-down" attention, meaning that control is initiated by higher-level mental processes such as cognition in service of a specific goal, they suggest that heavy media-multitaskers might be better at "bottom-up" attention. In this type of control, cues from the external world drive your attention through lower-level mental processes such as perception and habit. In our fast-paced and technologically advancing society, it may be that having a single goal on which to focus our efforts is a luxury. We may often be better served by a control strategy that is cued by the demands of our surroundings. Look around yourself - do you see notes and to-do lists? Piles of objects meant to remind you about tasks and goals? These sorts of reminders are a great way to take advantage of bottom-up attentional control, and this type of control might in fact be more influential in our lives than we realize.
Abstract: http://www.pnas.org/content/106/37/15583
13. What is the Degree and Duration of Risk for DVT and PE in Post-op Patients?
Sweetland S, et al. BMJ 2009;339:b4583.
The risk of deep vein thrombosis and pulmonary embolism after surgery is substantially increased in the first 12 postoperative weeks, and varies considerably by type of surgery. An estimated 1 in 140 middle aged women undergoing inpatient surgery in the UK will be admitted with venous thromboembolism during the 12 weeks after surgery (1 in 45 after hip or knee replacement and 1 in 85 after surgery for cancer), compared with 1 in 815 after day case surgery and only 1 in 6200 women during a 12 week period without surgery.
Full-text (free): http://www.bmj.com/cgi/content/full/339/dec03_1/b4583
14. ARREST Finds Link Between Chest Compressions and VF Recurrence During CPR
January 5, 2010 (Amsterdam, Netherlands) — Results from the ongoing Amsterdam Resuscitation Study (ARREST) showing a causal relationship between CPR chest compressions and ventricular fibrillation (VF) underscore the need for defibrillators that can accurately monitor the patients' heart rhythm during chest compressions, according to researchers [1].
In their analysis published online December 30, 2009 in Circulation: Arrhythmia and Electrophysiology, in patients treated by first responders for out-of-hospital cardiac arrest, immediate resumption of chest compressions following defibrillation leads to earlier recurrence of ventricular fibrillation.
"Until this publication, the general idea was that chest compressions cannot cause refibrillation, and we have clearly shown beyond a doubt that it is not just coincidence but . . . a true relation between the moment we start chest compression and the fact that refibrillation occurs," study coauthor Dr Rudolph Koster (University of Amsterdam, the Netherlands) told heartwire .
The study included patients treated by first responders with external defibrillators in North Holland presenting with VF as their initial rhythm. The responders tracked ECG and impedance signals. Only 136 out of the initial 361 patients considered for the study met the inclusion criteria. Patients were randomized to two different resuscitation techniques. For half of the patients, following a defibrillation shock, the responders performed postshock analysis and checked the patient's pulse before resuming chest compressions, as suggested in the 2000 resuscitation guidelines. In the other half of the patients in the study, responders resumed chest compressions as soon as possible after defibrillation, as recommended in the 2005 guidelines.
In the group treated under the 2000 guidelines, rescuers resumed compressions an average of 30 seconds (range 21 to 39 seconds) after the first defibrillator shock that successfully terminated VF. In the group treated under 2005 guidelines, compressions were resumed an average of eight seconds (range seven to nine seconds) after the shock (p less than 0.001).
VF recurred, on average, after 40 seconds (range 21 to 76 seconds ) in the delayed-compressions group vs 21 seconds (range 10 to 80 seconds) in the immediate-compressions group (p=0.001). The time interval between start of the compressions and the recurrence of VF was six (range 0 to 67) and eight (range three to 61) seconds, respectively (p=0.88). The hazard ratio for VF recurrence during the first two seconds of CPR vs the hazard of VF in the period prior to resumption of compressions was 15.5, but after eight seconds of compressions, the hazard of VF recurrence was similar to the hazard of VF prior to resumption of compressions.
VF Recurrence Doesn't Diminish Value of Compressions
The link between VF recurrence and chest compressions does not diminish their value, Koster emphasized. Previous research, reported by heartwire , shows that minimizing interruptions in compressions improves the patient's chances of survival. "It was never our intention to suggest that we would not do chest compressions . . . because we are sure that chest compressions, even after defibrillation, are needed to get the patient back from cardiac arrest to a perfusing and pulsating rhythm," Koster said. "What we identified was that these chest compressions have an adverse effect. . . . You may need more and more repeated defibrillations, because the recurrence of ventricular fibrillation does occur at a high rate."
So the ideal solution, Koster explained, would be a defibrillator that can continue to accurately track a patient's heart rhythm during chest compressions so that the responder knows when VF has recurred and can deliver another shock almost immediately. However, the compressions interfere with the device's ability to monitor the heart rhythm and detect VF, so the responders have to halt compressions for about 30 seconds in order to get a "clean signal."
"Many times paramedics believe they can look at the heart rhythm while chest compressions are going on, but we think that's not true. You need an automated filtering technique to make a reliable judgment possible."
Clinical Trials of Defibrillators With Signal Filters on the Horizon
Koster expects that very soon, several external defibrillator manufacturers will be introducing devices that are able to "filter" the distortion caused by compressions and provide a clean signal within a few seconds of a chest compression. With that device, the responders could charge the defibrillator while performing the chest compressions and then, if the patient goes into VF, take their hands off the chest for about two seconds and deliver a shock from the defibrillator before immediately resuming chest compressions again, Koster said. "Then the interruption [in compressions] is so minimal compared with what is happening now many times, where interruptions are up to 20 to 30 seconds, which is really not a good thing. But only two seconds of interruption may be a very good compromise" between immediately shocking the heart, which may retrigger VF, and a long interruption in chest compressions, which could reduce the patient's chances of survival.
Koster said he knows of at least one company that may begin clinical trials of defibrillators with this type of signal filter within 2010. Unfortunately, the technology will probably not be sufficiently tested in time to be incorporated in the new resuscitation guidelines that are scheduled to be published in October 2010, according to Koster, who is one of the experts developing the new guidelines.
15. Crack Research: Good news about knuckle cracking
One man's long, noisy, asymmetrical adventure gets him a high five
By Steve Mirsky. Scientific American. Dec 2009. The latest physical anthropology research indicates that the human evolutionary line never went through a knuckle-walking phase. Be that as it may, we definitely entered, and have yet to exit, a knuckle-cracking phase. I would run out of knuckles (including those on my feet) trying to count how many musicians wouldn’t dream of playing a simple scale without throwing off a xylophone-like riff on their knuckles first. But despite the popularity of this practice, most known knuckle crackers have probably been told by some expert—whose advice very likely began, “I’m not a doctor, but ...”—that the behavior would lead to arthritis.
One M.D. convincingly put that amateur argument to rest with a study published back in 1998 in the journal Arthritis & Rheumatism entitled “Does Knuckle Cracking Lead to Arthritis of the Fingers?” The work of sole author Donald Unger was back in the news in early October when he was honored as the recipient of this year’s Ig Nobel Prize in Medicine.
The Igs, for the uninitiated, are presented annually on the eve of the real Nobel Prizes by the organization Improbable Research for “achievements that first make people laugh, and then make them think.” In Unger’s case, I thought about whether his protocol might be evidence that he is obsessive-compulsive. From his publication: “For 50 years, the author cracked the knuckles of his left hand at least twice a day, leaving those on the right as a control. Thus, the knuckles on the left were cracked at least 36,500 times, while those on the right cracked rarely and spontaneously.”
Unger undertook his self and righteous research because, as he wrote, “During the author’s childhood, various renowned authorities (his mother, several aunts and, later, his mother-in-law [personal communication]) informed him that cracking his knuckles would lead to arthritis of the fingers.” He thus used a half-century “to test the accuracy of this hypothesis,” during which he could cleverly tell any unsolicited advice givers that the results weren’t in yet.
The article continues: http://www.scientificamerican.com/article.cfm?id=crack-research&sc=WR_20091217
16. Can Comparative-Effectiveness Research Be a Physician's Best Friend?
January 9, 2010 — As healthcare reform legislation grinds its way through Congress, 2 articles published online January 6 in the New England Journal of Medicine (NEJM) advocate for one of its touchiest provisions — comparative-effectiveness research (CER).
In theory, CER sounds like a calm, academic subject: evaluate different treatment options for a given illness — drug A vs drug B, or drug A vs surgery — and determine which does a better job of reducing morbidity and mortality. You also can go a step further and compare these treatment options in terms of risks or cost-effectiveness: Does drug B outperform drug A by a 2% margin but cost 3 times as much? Experts say such research is in short supply, leading to poorer clinical outcomes and runaway costs.
However, talk of government-sponsored CER pushes hot buttons in medicine and American society alike, being called "rationing" and "government takeover of medicine." For proof, consider what happened when the US Preventive Services Task Force announced last November that, based on the scientific evidence it weighed, it no longer recommends mammograms for women aged 40 through 49 years. The task force also recommended that women aged 50 years and older no longer receive annual mammograms but, instead, get them every other year. Public outcry and pushback from several medical societies and expert groups like the American Cancer Society swayed Senate Democrats to rewrite their pending healthcare reform legislation to guarantee mammogram coverage.
If Congress enacts healthcare reform, more such medical recommendations could roil Americans. That's because reform bills passed by the House and Senate (which have yet to be reconciled) call for the creation of a CER entity that would question the value of many trusted procedures and treatments. These provisions come on top of economic stimulus legislation passed in early 2009 that pumps $1.1 billion into CER and establishes a new federal bureaucracy to manage it. The government would not conduct CER itself by and large but would instead fund the work of academic investigators.
NEJM Authors Bolster Support for CER
Individual physicians and medical societies approach CER with varying degrees of enthusiasm, cautious support, and downright fear and loathing. The 2 recent NEJM articles seek to bolster support for this controversial discipline. Two professors at Weill Cornell Medical College, New York City, write in an article titled "Health Care Reform and the Need for Comparative-Effectiveness Research" that CER is "physicians' first line of defense against blind cost containment." Furthermore, it could spur drug and medical device manufacturers "to develop products that really matter."
"I think CER is the physician's best friend," coauthor Alvin Mushlin, MD, professor and chair of the Department of Public Health at Weill Cornell, told Medscape Medical News.
Similarly, the other NEJM article, titled "Comparative Effectiveness and Health Care Spending — Implications for Reform," warns that without a shift to best-bang-for-the-buck services identified by CER, cost-cutting alone could produce worse health outcomes.
"If we can induce hospitals and health plans to improve efficiency and not just cut costs, then health costs in the United States will come down and outcomes will improve," write coauthors Milton Weinstein, PhD, a professor of health policy and management at the Harvard School of Public Health, Boston, Massachusetts, and Jonathan Skinner, PhD, a professor of economics at Dartmouth Medical School, Hanover, New Hampshire.
Give Physicians Scientific Findings, Not Recommendations
Both the ACP and the AMA agree that a government-sponsored CER body should forgo recommendations, much less mandates, on how physicians should practice medicine. For one thing, private insurers and government programs like Medicare are tempted to turn such recommendations into binding policies that may arbitrarily deny patients coverage for needed care, explained the AMA's Dr. Rohack.
"Look at vaccines," Dr. Rohack told Medscape Medical News. "The federal Advisory Committee on Immunization Practices recommends what vaccines should be administered, and insurers key off that to determine what they'll pay for."
The fracas over mammograms last year occurred at the intersection of recommendation and insurance coverage, noted health-policy analyst Dennis Smith from the Heritage Foundation, a conservative think tank. "The essential benefit package in the [original] Senate reform bill was supposed to include preventive services recommended by the US Preventive Services Task Force. So if you didn't meet the [task force] criteria, you wouldn't get your mammogram paid for."
Dr. Rohack also pointed to the problem of inflexible application of CER. A study that identifies the best way to treat a particular medical condition may have excluded patients older than 65 years, for example. A payer may then decide to cover that treatment, but not for anyone older than 65 years, he said.
It's sufficient, said Dr. Rohack, to give CER findings to physicians and patients and let them make the final decision on medical care. "Physicians by training try to use evidence-based science to do what's best for patients," he said. "If there is a gray zone, they'll rely on history, experience, and local practice styles. And there are gray zones."
Dr. Rushlin at Weill Cornell Medical College agrees with Dr. Rohack that merely publishing CER findings without adding recommendations will benefit healthcare.
"We need to get started incorporating information from CER into the public debate on healthcare. It can be a very positive step in the right direction," he said. "When you put the evidence on the table, it illuminates the discussion. It doesn't eliminate the discussion. That's healthy."
From N Engl J Med.
Selker HP, Wood AJJ: Industry Influence on Comparative-Effectiveness Research Funded through Health Care Reform. http://content.nejm.org/cgi/content/full/361/27/2595
Weinstein MC, Skinner JA. Comparative Effectiveness and Health Care Spending — Implications for Reform. http://content.nejm.org/cgi/content/extract/NEJMsb0911104
Mushlin AI, Ghomrawi H. Health Care Reform and the Need for Comparative-Effectiveness Research. http://content.nejm.org/cgi/content/extract/NEJMp0912651
17. Observed Behaviors of Subjects During Informed Consent for an Emergency Department Study
Baren J, et al. Ann Emerg Med. 2009;55:9-14.
Study objective
To determine emergency department patients' behaviors during informed consent for an intimate partner violence survey.
Methods
We conducted a cross-sectional study during administration of informed consent. Research assistants recorded whether informed consent was read, time spent reading it, whether questions were asked, and whether the patients took a copy of the form that was handed to them. Results are reported as percentage of frequency of occurrence.
Results
Of 1,609 patients approached for the intimate partner violence study, 1,312 (82%) patients participated. After verbal description of the study, 53% of patients read the informed consent but only 13% spent more than 2 minutes doing so. Only 20% of patients asked questions and less than half (49%) accepted a copy of the form when it was handed to them.
Conclusion
Patients who participated in an intimate partner violence study did not spend a lot of time reading the consent document, asked few questions, and did not take the copy of the consent form with them. Future studies of the current consent process should determine whether it provides adequate human subjects protections in a manner desired by the patient.
Full-text: http://www.annemergmed.com/article/PIIS0196064409015613/fulltext
18. A New Culprit for Pharyngitis in Adolescents
A gram-negative anaerobe that causes Lemierre syndrome has become a common cause of pharyngitis.
Guideline recommendations for the management of pharyngitis vary from doing nothing, to treating patients with positive test results (rapid or culture), to treating empirically. Current guidelines focus on infections with group A streptococcus, because, although the disease is self-limiting, it can cause substantial complications, most notably rheumatic fever (JW Pediatr Adolesc Med Apr 1 2009).
A recent surge in complicated cases of pharyngitis, particularly in adolescents, prompted more-elaborate microbiological testing. DNA analysis revealed that the gram-negative anaerobe, Fusobacterium necrophorum, is as common as group A strep in this age group. An estimated 1 in 400 cases of F. necrophorum pharyngitis progresses to complications, including abscess, septicemia with septic pulmonary emboli, and Lemierre syndrome, which is a septic thrombophlebitis of the internal jugular vein. In case series of patients with F. necrophorum pharyngitis, death — an almost unknown complication of group A strep pharyngitis — has been reported in 2% to 5% of patients, along with a substantial morbidity rate of 10%.
The organism is not sensitive to macrolides, which are recommended for suspected strep pharyngitis in penicillin-allergic patients. Penicillin or a cephalosporin remains the first treatment choice for adolescents and young adults with pharyngitis, and the addition of clindamycin is indicated for those with evidence of sepsis or neck swelling. Clindamycin should be the primary treatment in penicillin-allergic patients.
Comment: The differential diagnosis of pharyngitis in adolescents and young adults includes group A strep, mononucleosis, and acute HIV infection and should now also include F. necrophorum, both at initial presentation and in cases that have not resolved in the usual 5-day interval from onset. Any clinical indicator of bacteremia indicates the need for admission (at least to an observation unit), blood cultures, and antibiotic coverage for F. necrophorum pending culture results.
— J. Stephen Bohan, MD, MS, FACP, FACEP. Published in Journal Watch Emergency Medicine January 15, 2010. Citation: Centor RM. Expand the pharyngitis paradigm for adolescents and young adults. Ann Intern Med 2009 Dec 1; 151:812.
19. In Praise of the Physical Examination
Verghese A, et al. BMJ 2009;339:b5448
If an alien anthropologist were to visit a modern teaching hospital, "it" might conclude that, judging by where doctors spend most of their time, the business of an internal medicine service takes place around computer terminals. The alien might assume that the virtual construct of the patient, or the "iPatient", is more important than the flesh and blood human being occupying the bed.
But the alien would be wrong—patients are what medical care is all about. Yet the electronic medical record and advanced imaging technology have not only seduced doctors away from the bedside but also devalued the importance of their role there. Indeed, intensive care units exist where consultants conduct their "rounds" on the patients and adjust ventilator settings and drugs via telemetry.
These trends have left educators and trainees in internal medicine in two camps when it comes to the merits of the bedside examination. In the first camp are those who pine for the old days, bemoan the loss of clinical bedside diagnostic skills, and complain that no one knows Traube’s space or Kronig’s isthmus. In the second camp are those who say good riddance and point out that evidence based studies show that many physical signs are useless; some might even argue that examining the patient is just a waste of time.
We believe that the truth is somewhere in between....
For the remainder of the essay, cf: http://www.bmj.com/cgi/content/full/339/dec16_3/b5448
20. C-Reactive Protein Level Predicts SBI in Febrile Neonates
In well-appearing neonates with fever without a source, CRP measured more than 12 hours after fever onset was a better predictor of severe bacterial infection than ANC or WBC.
Bressan S, et al. Pediatr Infect Dis J. 2009;
OBJECTIVES: To assess the diagnostic accuracy of white blood cell count (WBC), absolute neutrophil count (ANC), and C-reactive protein (CRP) in detecting severe bacterial infections (SBI) in well-appearing neonates with early onset fever without source (FWS) and in relation to fever duration.
METHODS: An observational study was conducted on previously healthy neonates 7 to 28 days of age, consecutively hospitalized for FWS from less than 12 hours to a tertiary care Pediatric Emergency Department, over a 4-year period. Laboratory markers were obtained upon admission in all patients and repeated 6 to 12 hours from admission in those with normal values on initial determination. Sensitivity, specificity, positive and negative likelihood ratios, and receiver operating characteristic analysis were carried out for primary and repeated laboratory examinations.
RESULTS: Ninety-nine patients were finally studied. SBI was documented in 25 (25.3%) neonates. Areas under receiver operating characteristic curves were 0.78 (95% CI, 0.69-0.86) for CRP, 0.77 (95% CI, 0.67-0.85) for ANC and 0.59 (95% CI, 0.49-0.69) for WBC. Sixty-two patients presented normal laboratory markers on initial determination. Of these, 58 successfully underwent repeated blood examination more than 12 hours from fever onset. Five of them had an SBI. The area under curve calculated for repeated laboratory tests showed better values, respectively of 0.99 (95% CI, 0.92-1) for CRP, 0.85 (95% CI, 0.73-0.93) for ANC and 0.79 (95% CI, 0.66-0.88) for WBC.
CONCLUSIONS: In well-appearing neonates with early onset FWS, laboratory markers are more accurate and reliable predictors of SBI when performed more than 12 hours of fever duration. ANC and especially CRP resulted better markers than the traditionally recommended WBC.
21. Images in Emergency Medicine
Man With Right Arm Weakness
http://www.annemergmed.com/article/S0196-0644(09)00525-3/fulltext
Adult Female With Shoulder Pain
http://www.annemergmed.com/article/S0196-0644(09)01434-6/fulltext
1. Ranking 37th — Measuring the Performance of the U.S. Health Care System
Posted by NEJM • January 6th, 2010 •
Christopher J.L. Murray, M.D., D.Phil., and Julio Frenk, M.D., Ph.D., M.P.H.
Evidence that other countries perform better than the United States in ensuring the health of their populations is a sure prod to the reformist impulse. The World Health Report 2000, Health Systems: Improving Performance, ranked the U.S. health care system 37th in the world1 — a result that has been discussed frequently during the current debate on U.S. health care reform.
The conceptual framework underlying the rankings2 proposed that health systems should be assessed by comparing the extent to which investments in public health and medical care were contributing to critical social objectives: improving health, reducing health disparities, protecting households from impoverishment due to medical expenses, and providing responsive services that respect the dignity of patients. Despite the limitations of the available data, those who compiled the report undertook the task of applying this framework to a quantitative assessment of the performance of 191 national health care systems. These comparisons prompted extensive media coverage and political debate in many countries. In some, such as Mexico, they catalyzed the enactment of far-reaching reforms aimed at achieving universal health coverage. The comparative analysis of performance also triggered intense academic debate, which led to proposals for better performance assessment.
Despite the claim by many in the U.S. health policy community that international comparison is not useful because of the uniqueness of the United States, the rankings have figured prominently in many arenas. It is hard to ignore that in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy.3 These facts have fueled a question now being discussed in academic circles, as well as by government and the public: Why do we spend so much to get so little?
The rest of the article: http://healthcarereform.nejm.org/?p=2610
2. Cardiac Arrest: Cardiovert, Compress, Cool, ... and Cath?
Amal Mattu, MD.
In recent decades, numerous therapies have been promoted as great advances in the treatment of primary cardiac arrest: epinephrine, high-dose epinephrine, vasopressin, lidocaine, amiodarone, electrical defibrillation, biphasic defibrillation, induced hypothermia, and so on. The initial literature on these "miracle cures" has always looked promising. However, when attempts at validating these early studies were made or when meaningful outcomes (eg, hospital discharge with good neurologic function) were evaluated, most of these therapies fell short and eventually lost favor in the literature. Currently, only 3 therapies have emerged as truly beneficial in terms of meaningful outcomes: rapid defibrillation of ventricular fibrillation/pulseless ventricular tachycardia, good chest compressions (with less emphasis on early airway interventions and minimizing interruptions), and induced hypothermia.
Given that the majority of cases of primary cardiac arrest are associated with acute coronary syndromes, it seems reasonable to assume that urgent coronary angiography and percutaneous coronary intervention (PCI) would be associated with improved outcomes in patients with return of spontaneous circulation (ROSC) after cardiac arrest. Recent studies have demonstrated this to be true for patients with electrocardiogram (ECG) evidence of ST-segment elevation myocardial infarction (STEMI) either before or after resuscitation. However, it is well-known that the ECG is far from perfect at demonstrating evidence of acute MI. Therefore, use of the ECG to determine which patients should undergo urgent PCI might potentially lead to many patients missing out on beneficial therapy. Can coronary angiography and PCI improve the outcomes of resuscitated patients without definite evidence of STEMI? Reynolds and colleagues attempted to answer this question.
Reynolds JC, et al. Coronary Angiography Predicts Improved Outcome Following Cardiac Arrest: Propensity-adjusted Analysis. J Intensive Care Med. 2009;24:179-186
Summary
The authors performed a chart review of resuscitated patients in cardiac arrest between 2005 and 2007. They evaluated an assortment of parameters including acute ischemic ECG changes (new left bundle branch block or STEMI), presenting rhythm, neurologic status, and outcome. A good outcome was defined as discharge home or to an acute rehabilitation facility. Of the 241 patients they reviewed, 40% received coronary angiography. Significant disease (defined as 70% stenosis or greater in at least 1 coronary artery) was identified in 69% of patients, including 57% of patients without any ischemic changes on ECG. Of the patients who received coronary angiography and PCI, 54% experienced a good clinical outcome compared with 25% of patients not receiving coronary angiography. A propensity-adjusted analysis was used to account for the nonrandomized nature of the study. The authors determined that improved survival and good outcome were associated with coronary angiography regardless of the presence of new left bundle branch block or STEMI, and also regardless of presenting rhythm or neurologic status immediately after resuscitation.
Viewpoint
Reynolds' study further supports previously published reports encouraging urgent catheterization for survivors of cardiac arrest regardless of ECG evidence of STEMI. Recent publications also show that therapeutic hypothermia can be used safely in these patients during and after PCI without producing delays in time to balloon inflation.
The significance of this new literature cannot be overstated. If further studies confirm these findings, it would strongly argue for enormous changes in prehospital systems of care. All survivors of primary cardiac arrest would be recommended for immediate transport to hospitals that have the capability of performing urgent PCI in conjunction with therapeutic hypothermia. Based on the current literature, it certainly seems advisable that emergency healthcare practitioners who care for resuscitated victims of primary cardiac arrest should engage in conversations with cardiology consultants and urge them to take an aggressive approach to PCI in these patients.
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19321536
3. Santa Claus: a public health pariah?
Grills NJ, et al. BMJ 2009;339:b5261
Santa Claus is a well known and loved character, but Nathan Grills and Brendan Halyday question whether he is a healthy role model
Santa Claus long ago displaced the Virgin Mary and baby as the most unmistakable Christmas iconography. A recent study among hospital inpatients concluded that awareness of Santa was near universal. Given Santa’s fame, he has considerable potential to influence individual and societal behaviour—and not necessarily for good. Santa is a late adopter of evidence based behaviour change and continues to sport a rotund sedentary image. But this is not the only example where Santa’s behaviour and public image are at odds with contemporary accepted public health messages.
Eric Schlosser and Morgan Spurlock have both described how McDonald’s used Ronald McDonald to target their products at children by creating an association between McDonald’s food and happy times. Spurlock showed how Ronald McDonald was more highly recognised than the American president or the Pope. Interestingly, Schlosser documents that among American schoolchildren Santa Claus was the only fictional character more highly recognised than than Ronald McDonald.
If Ronald McDonald can be so effective at selling burgers to children, we might expect Santa to be equally effective at selling other goods. After all, it was Santa’s advertising potential that reincarnated simple Saint Nicholas into the glory of a universally recognised icon. Santa’s contemporary image was cemented by the Coca-Cola advertisements that began in the 1930s. By the mid-1950s Santa had become the leading sales consultant for numerous other companies and products. Today, he is one of the biggest sellers at Christmas and appears in adverts on television, the internet, billboards, and shop fronts.
Public health needs to be aware of what giant multinational capitalists realised long ago: that Santa sells, and sometimes he sells harmful products. Several countries, like the UK, limit what can be advertised to children. Since Santa is a childhood icon should we prevent him from selling products such as alcohol and unhealthy foods?
Furthermore, Santa has a growing impact on international public health. Like Coca-Cola, Santa has become a major export item to the developing world. Countries such as India are increasing celebrating the Christmas festival. The potential for Santa’s growing acclaim to be misused may even be greater in countries where there is less regulation of advertising.
Obesity
Epidemiologically there is a correlation between countries that venerate Santa Claus and those that have high levels of childhood obesity. Although given the various confounders it is premature to conclude causality, there is a temporal pathway whereby Santa promotes a message that obesity is synonymous with cheerfulness and joviality. Rear Admiral Galson, acting US surgeon general in 2007, commented, "It is really important that the people who kids look up to as role models are in good shape, eating well and getting exercise. It is absolutely critical." He went on to explain that Santa should slim down.
To create a supportive environment for Santa’s dieting we should cease the tradition of leaving Santa cookies, mince pies, and milk, brandy, or sherry. This is bad not only for Santa’s waistline but for parental obesity. When Santa is full, Dad is a willing helper. Maybe we should encourage Santa (and his helpers) to share the carrots and celery sticks commonly left for Rudolf. Santa might also be encouraged to adopt a more active method to deliver toys—swapping his reindeer for a bike or simply walking or jogging.
The rest of the article: http://www.bmj.com/cgi/content/full/339/dec16_1/b5261
4. Geriatric Population Becoming Bigger Part of Emergency Department Mix
NEW YORK (Reuters Health) Dec 18 - Traffic in US emergency departments has increased significantly in the last decade, with geriatric patients leading the way, new research from Texas shows.
Dr. K. Tom Xu and colleagues, from Texas Tech University Health Sciences Center in Lubbock, extracted emergency department utilization data from the Medical Expenditure Panel Survey for the period 1996 to 2005.
During that period, they report in the Annals of Emergency Medicine for December, the total number of non-institutionalized individuals who used emergency department services in the US increased from 34.2 million to 40.8 million. That is, the proportion of emergency department users in the US population rose from 12.7% to 13.8%.
The authors did not report specific percentages for various age groups and subpopulations, but they "found that emergency department users had become older and (included more of) those who perceived themselves to be in poor or fair physical health, with and without population adjustment," they write in their report.
"The key observation in this study is that the composition of patients seen in emergency rooms has been changing over time," Dr. Xu told Reuters Health.
"People tend to associate ERs with traumas, injuries, accidents, poisoning, overdose and other dramatic events," Dr. Xu said. "In reality, a larger portion of patients seen in emergency rooms are those with chronic diseases and poor overall health."
The study, he added, also confirms earlier findings that the poor and the uninsured "are not the main contributing factors to emergency room crowding in recent years."
In addition to older adults and those in poor health, subpopulations that showed significantly increasing levels of emergency department use after population adjustment included blacks, people with only Medicare insurance, those with multiple types of insurance, those within 100% to 199% of the federal poverty line and those with at least one inpatient stay.
Some subpopulations that showed decreasing levels of emergency department use: women, Hispanics, uninsured individuals, people with private insurance only, and patients at greater than or equal to 200% of the federal poverty line.
"The aging population will create additional challenges in the training of future emergency physicians and in the reform of the nation's health care system," Dr. Xu said.
"This study will not change practice but will help those planning the kinds of emergency department resources that will be needed in the future."
Ann Emerg Med 2009;54:805-810.
5. Evidence based merriment
Isaacs S, et al. BMJ 2009;339:b5098
Background
Medical humour has a long history, but is short on evidence. The ancient Greeks introduced the world to bodily fluids called the four humours. You would think that a philosophy based on blood, choler, phlegm, and melancholy was no laughing matter.
What is the evidence that medical humour benefits staff or patients? We performed a systematic revue, but it was not funny. We propose a randomised controlled trial of medical humour.
Pilot study
The Royal Flying Doctor Service funded a pilot study. Hospital staff completed a standardised questionnaire about the role of humour in their department.
The department of surgery expressed an interest in side-splitting jokes.
The ophthalmology department insisted that all patients should have a slit lamp examination for aqueous and vitreous humour.
The gastroenterology department wanted to ban sick jokes and toilet humour.
The allergy department warned of the hazards of severe joke allergy. At least one child has suffered a severe allergic reaction to a shaggy dog story, while cat allergy predisposes to cataplexy. However, the most feared condition is anaphylaxis to puns, which can only be treated with outrageously expensive adrenaline syringes, called Epipuns. The State Department of Allergy and Over-reaction has recommended that all children with pun anaphylaxis carry Epipuns and that jokes are banned from nursery schools. The child must also bring to school a letter from their parents guaranteeing that they have not been told any jokes at home in the last 24 hours.
The hospital administration warned that black humour contravenes health department policy on racial discrimination and punch-lines are forbidden under department guidelines on bullying in the workplace.
Study design
Doctors will be randomised to an intervention group who will tell random jokes to children on the paediatric wards or a self control group who will be asked to save their jokes for their own long suffering children at home. Here is a random joke. "Two cannibals ate a clown doctor. One cannibal asked the other, did that taste funny to you?"
The responses of joke recipients will be screened. Their facial contours will be examined for increases in creases. Mirth will be measured in grins per milli-titter, gigglebytes, or smiles per hour. Belly laughs are expressed in units called Hertz. Laughter delayed for greater than 30 seconds is not classified as humour. He who laughs last, thinks slowest.
Statistics
The data will be massaged and tickled and subjected to a Student’s t-hee test with a funnel plot to see if the jokes come out funnelly.
Ethics approval
The proposed trial will be submitted to the Institutional Ethics and Deforestation Committee, which requires 47 double spaced, single sided copies of the trial protocol. The protocol must be on the ethics committee application form, which can be completed in less than a month by anyone with an IQ over 130 and advanced degrees in information technology and communication.
The ethics form needs to be countersigned by the Head of Department, the Head of Department’s Head of Clinical Stream, the Clinical Superintendent, the Chief Executive Officer and the Minister for Health.
Conclusion
We call for a randomised fairly controlled trial of humour. Humour is a serious matter and should not be taken lightly.
6. Is Contrast Needed for CT Diagnosis of Acute Appendicitis?
This systematic review showed that helical CT without contrast is sufficiently sensitive and specific for diagnosing acute appendicitis.
Hlibczuk V. Ann Emerg Med. 2010:55:51-59.
Study objective
We seek to determine the diagnostic test characteristics of noncontrast computed tomography (CT) for appendicitis in the adult emergency department (ED) population.
Methods
We conducted a search of MEDLINE, EMBASE, the Cochrane Library, and the bibliographies of previous systematic reviews. Included studies assessed the diagnostic accuracy of noncontrast CT for acute appendicitis in adults by using the final diagnosis at surgery or follow-up at a minimum of 2 weeks as the reference standard. Studies were included only if the CT was completed using a multislice helical scanner. Two authors independently conducted the relevance screen of titles and abstracts, selected studies for the final inclusion, extracted data, and assessed study quality. Consensus was reached by conference, and any disagreements were adjudicated by a third reviewer. Unenhanced CT test performance was assessed with summary receiver operating characteristic curve analysis, with independently pooled sensitivity and specificity values across studies.
Results
The search yielded 1,258 publications; 7 studies met the inclusion criteria and provided a sample of 1,060 patients. The included studies were of high methodological quality with respect to appropriate patient spectrum and reference standard. Our pooled estimates for sensitivity and specificity were 92.7% (95% confidence interval 89.5% to 95.0%) and 96.1% (95% confidence interval 94.2% to 97.5%), respectively; the positive likelihood ratio=24 and the negative likelihood ratio=0.08.
Conclusion
We found the diagnostic accuracy of noncontrast CT for the diagnosis of acute appendicitis in the adult population to be adequate for clinical decisionmaking in the ED setting.
Full-text: http://www.annemergmed.com/article/S0196-0644(09)01140-8/fulltext
7. Steroids May Effectively Relieve Pain of Acute Pharyngitis
Laurie Barclay, MD. January 15, 2010 — Steroids are effective as adjuvant therapy in relieving pain in acute pharyngitis, according to the results of a systematic review reported in the January/February issue of the Annals of Family Medicine.
"A major treatment goal for patients complaining of sore throat is to relieve pain and alleviate difficulties in swallowing," write Katrin Korb, MD, from the University of Goettingen in Germany, and colleagues. "The anti-inflammatory action of steroids might be effective to relieve symptoms caused by inflammation and has been studied in other upper respiratory tract infections. Steroids might, therefore, represent a useful clinical option to meet patients' needs."
The purpose of this review was to summarize evidence from randomized controlled trials (RCTs) that assessed the efficacy of adjuvant therapy with corticosteroids to relieve the pain of acute pharyngitis. After searching MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews for RCTs published between 1966 and December 2008, 2 reviewers evaluated the quality of each identified article and summarized the data.
Of 8 identified RCTs enrolling a total of 806 ambulatory patients, 5 enrolled adult patients and 3 enrolled children. Compared with placebo, steroid use (dexamethasone, betamethasone, or prednisone) was associated with statistically significant faster reduction of pain or complete pain relief in all identified RCTs. Most participants had been treated with antibiotics at least initially. Although use of acetaminophen or other analgesic medication was permitted in all studies, this factor was not always controlled. There were no serious adverse effects.
"Steroids are effective in relieving pain in acute pharyngitis," the study authors write. "Although no serious adverse effects were observed, the benefits have to be balanced with possible adverse drug effects. There are safe and effective over-the-counter medications to relieve throat pain."
Limitations of this systematic review include possible publication bias favoring studies finding steroids to be beneficial, possible recall bias, and limitations inherent in the included studies. Specific drugs used, dosing and administration, and outcome measures all varied among the included trials.
"Most patients received concomitant antibiotics; however, reducing the prescription of antibiotics for generally benign upper respiratory tract infection is a public health goal," the review authors conclude. "We therefore recommend further studies to establish both the safety of steroids without antibiotic coverage and the additional benefits of steroids when used with regular administration of over-the-counter analgesic medications."
Ann Fam Med. 2010;8:58-63. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20065280
8. For Migraine in the ED, Prochlorperazine Is Better Than Sumatriptan
NEW YORK (Reuters Health) Jan 12 - For patients in the emergency department (ED) with migraine, IV prochlorperazine with diphenhydramine is more effective than subcutaneous sumatriptan, a small prospective trial suggests.
Both prochlorperazine (Compazine) and sumatriptan (Imitrex) are effective for migraine, Dr. Mark A. Kostic, at the Medical College of Wisconsin, Milwaukee, and co-investigators note. However, little is known about how the two compare, they point out in the Annals of Emergency Medicine for January 4.
Their double-blind, placebo-controlled trial included 66 consecutive ED patients, ages 18 to 50, with "typical" migraine diagnosed on the basis of International Headache Society criteria.
Patients were randomly assigned either to subcutaneous sumatriptan 6 mg (n = 34) or to prochlorperazine 10 mg plus diphenhydramine 12.5 mg (to control akathisia) in 500 mL IV saline (n = 32). Because the trial was blinded, each patient also received a sham treatment along with the assigned therapy.
Patients were asked to assess pain and adverse effects every 20 minutes until 80 minutes or emergency department discharge, whichever came first. At baseline, there were no important differences between the groups, according to the authors.
Prochlorperazine was associated with more rapid and significantly greater reduction in pain intensity on a 100-mm visual analog scale (mean decrease in pain intensity 73 mm vs 50 mm with sumatriptan).
Both groups reported similar degrees of sedation. Prochlorperazine-treated patients had less nausea, but the difference was not statistically significant.
Dr. Kostic's team concludes, "The IV prochlorperazine with diphenhydramine route is not only more efficient and more effective but also less expensive."
Ann Emerg Med 2010; publication pending. Abstract: http://www.annemergmed.com/article/S0196-0644(09)01794-6/abstract
9. Lying obliquely—a clinical sign of cognitive impairment: cross sectional observational study
Kraft P, et al. BMJ 2009;339:b5273
Objective: To determine if failure to spontaneously orient the body along the longitudinal axis of a hospital bed when asked to lie down is associated with cognitive impairment in older patients.
Design Cross sectional observational study.
Setting: Neurology department of a university hospital in Germany.
Participants: Convenience sample of 110 older (60 years) inpatients with neurological conditions and 23 staff neurologists.
Main outcome measures: The main outcome measure was the association between the angle of the body axis and the results of three cognitive screening tests (mini-mental state examination, DemTect, and clock drawing test). Staff doctors were shown photographs of a model taken at a natural viewing able to determine their subjective perspective of what constitutes oblique.
Results: 110 neurological inpatients (mean age 70.9 (SD 6.8) years) were included after exclusions. Evidence of cognitive impairment was found in 34, with scores indicating dementia in eight, according to the mini-mental state examination, and in 11 according to the DemTect. Across all patients, the mean angular deviation of the body axis from the longitudinal axis of the bed (range 0-23 degrees) correlated linearly with the mini-mental state examination (r=–0.480), DemTect (r=–0.527), and the clock drawing test (r=–0.552) scores (P less than 0.001 for all), even after removing age as a covariate. Overall, 90% of staff neurologists considered a minimal body angle of 7 degrees to be oblique. Angular deviation of at least 7 degrees predicted cognitive impairment according to the three different tests, with specificities between 89% and 96% and sensitivities between 27% and 50%.
Conclusion: Clinicians might suspect cognitive impairment in mobile older inpatients with neurological disorders who spontaneously position themselves obliquely when asked to lie on a bed.
Full-text: http://www.bmj.com/cgi/content/full/339/dec16_3/b5273
10. Does This Patient Have Irritable Bowel Syndrome?
Rational Clinical Exam Review by Annals of Emergency Medicine
Sherbino J. Ann Emerg Med. 2010;55:117-119.
Full-text: http://www.annemergmed.com/article/S0196-0644(09)00112-7/fulltext
11. Effect of listening to Nellie the Elephant during CPR training on performance of chest compressions by lay people: randomised crossover trial
L Rawlins, et al. BMJ 2009;339:b4707
Objectives: To determine whether listening to music during cardiopulmonary resuscitation (CPR) training increases the proportion of lay people delivering chest compressions of 100 per minute.
Design Prospective randomised crossover trial.
Setting: Large UK university.
Participants: 130 volunteers (81 men) recruited on an opportunistic basis. Exclusion criteria included age under 18, trained health professionals, and cardiopulmonary resuscitation (CPR) training within the past three months.
Interventions: Volunteers performed three sequences of one minute of continuous chest compressions on a skill meter resuscitation manikin accompanied by no music, repeated choruses of Nellie the Elephant (Nellie), and That’s the Way (I like it) (TTW) according to a pre-randomised order.
Main outcome measures: Rate of chest compressions delivered (primary outcome), depth of compressions, proportion of incorrect compressions, and type of error.
Results: Median (interquartile range) compression rates were 110 (93-119) with no music, 105 (98-107) with Nellie, and 109 (103-110) with TTW. There were significant differences within groups between Nellie v no music and Nellie v TTW (P less than 0.001) but not no music v TTW (P=0.055). A compression rate of between 95 and 105 was achieved with no music, Nellie, and TTW for 15/130 (12%), 42/130 (32%), and 12/130 (9%) attempts, respectively. Differences in proportions were significant for Nellie v no music and Nellie v TTW (P less than 0.001) but not for no music v TTW (P=0.55). Relative risk for a compression rate between 95 and 105 was 2.8 (95% confidence interval 1.66 to 4.80) for Nellie v no music, 0.8 (0.40 to 1.62) for TTW v no music, and 3.5 (1.97 to 6.33) for Nellie v TTW. The number needed to treat for listening to Nellie v no music was 5 (4 to 10)—that is, the number of cardiac arrests required during which lay responders listen to Nellie to facilitate one patient receiving compressions at the correct rate (v no music) would be between four and 10. A greater proportion of compressions were too shallow when participants listened to Nellie v no music (56% v 47%, P=0.022).
Conclusions: Listening to Nellie the Elephant significantly increased the proportion of lay people delivering compression rates at close to 100 per minute. Unfortunately it also increased the proportion of compressions delivered at an inadequate depth. As current resuscitation guidelines give equal emphasis to correct rate and depth, listening to Nellie the Elephant as a learning aid during CPR training should be discontinued. Further research is required to identify music that, when played during CPR training, increases the proportion of lay responders providing chest compressions at both the correct rate and depth.
Full-text: http://www.bmj.com/cgi/content/full/339/dec11_2/b4707
For the tune, consult YouTube
12. Portrait of a Multitasking Mind: What happens when you try to do three things at once?
By Naomi Kenner and Russell Poldrack. Scientific American. Dec 2009.
Productive, or spinning wheels? Researchers are examining the psychology of quickly shifting attention
Are you a media multitasker? We know you're reading a blog, but what else are you doing right now? Take a quick inventory: Are you also listening to music? Monitoring the progress of a sports game on TV? Emailing your co-worker? Texting your friend? On hold with tech support? If your inventory has revealed a multitasking lifestyle, you are not alone. Media multitasking is increasingly common, to the extent that some have dubbed today’s teens "Generation M."
People often think of the ability to multitask as a positive attribute, to the degree that they will proudly tout their ability to multitask. Likewise it’s not uncommon to see job advertisements that place “ability to multitask” at the top of their list of required abilities. Technologies such as smartphones cater to this idea that we can (and should) maximize our efficiency by getting things done in parallel with each other. Why aren’t you paying your bills and checking traffic while you’re driving and talking on the phone with your mother? However, new research by EyalOphir, Clifford Nass, and Anthony D. Wagner at Stanford University suggests that people who multitask suffer from a problem: weaker self-control ability.
The researchers asked hundreds of college students fill out a survey on their use of 12 different types of media. Students reported not only the number of hours per week that they used each type of media, but also rated how often they used each type of media simultaneously with each other type of media. The researchers created a score for each person that reflected how much their lifestyle incorporated media-multitasking.
They then recruited people who had scores that were extremely high or low and asked them perform a series of tests designed to measure the ability to control one's attention, one's responses, and the contents of one's memory. They found that the high- and low- media-multitasking groups were equally able to control their responses, but that the heavy media-multitasking group had difficulties, compared to the low media-multitasking group, when asked to ignore information that was in the environment or in their recent memory. They also had greater trouble relative to their counterparts when asked to switch rapidly between two different tasks. This last finding was surprising, because psychologists know that multitasking involves switching rapidly between tasks rather than actually performing multiple tasks simultaneously.
It seems that chronic media-multitaskers are more susceptible to distractions. In contrast, people who do not usually engage in media-multitasking showed a greater ability to focus on important information. According to the researchers, this reflects two fundamentally different strategies of information processing. Those who engage in media-multitasking more frequently are "breadth-biased," preferring to explore any available information rather than restrict themselves. AsLin Lin at the University of North Texas puts it in a review of the article, they develop a habit of treating all information equally. On the other extreme are those who avoid breadth in favor of information that is relevant to an immediate goal.
So what does this mean for you, reading this blog while checking your stocks and playing solitaire? Are you in trouble? Should you curb your media congestion? Not necessarily. Breadth-bias may still serve a purpose in our media-heavy society. While the researchers focused on a type of control known as "top-down" attention, meaning that control is initiated by higher-level mental processes such as cognition in service of a specific goal, they suggest that heavy media-multitaskers might be better at "bottom-up" attention. In this type of control, cues from the external world drive your attention through lower-level mental processes such as perception and habit. In our fast-paced and technologically advancing society, it may be that having a single goal on which to focus our efforts is a luxury. We may often be better served by a control strategy that is cued by the demands of our surroundings. Look around yourself - do you see notes and to-do lists? Piles of objects meant to remind you about tasks and goals? These sorts of reminders are a great way to take advantage of bottom-up attentional control, and this type of control might in fact be more influential in our lives than we realize.
Abstract: http://www.pnas.org/content/106/37/15583
13. What is the Degree and Duration of Risk for DVT and PE in Post-op Patients?
Sweetland S, et al. BMJ 2009;339:b4583.
The risk of deep vein thrombosis and pulmonary embolism after surgery is substantially increased in the first 12 postoperative weeks, and varies considerably by type of surgery. An estimated 1 in 140 middle aged women undergoing inpatient surgery in the UK will be admitted with venous thromboembolism during the 12 weeks after surgery (1 in 45 after hip or knee replacement and 1 in 85 after surgery for cancer), compared with 1 in 815 after day case surgery and only 1 in 6200 women during a 12 week period without surgery.
Full-text (free): http://www.bmj.com/cgi/content/full/339/dec03_1/b4583
14. ARREST Finds Link Between Chest Compressions and VF Recurrence During CPR
January 5, 2010 (Amsterdam, Netherlands) — Results from the ongoing Amsterdam Resuscitation Study (ARREST) showing a causal relationship between CPR chest compressions and ventricular fibrillation (VF) underscore the need for defibrillators that can accurately monitor the patients' heart rhythm during chest compressions, according to researchers [1].
In their analysis published online December 30, 2009 in Circulation: Arrhythmia and Electrophysiology, in patients treated by first responders for out-of-hospital cardiac arrest, immediate resumption of chest compressions following defibrillation leads to earlier recurrence of ventricular fibrillation.
"Until this publication, the general idea was that chest compressions cannot cause refibrillation, and we have clearly shown beyond a doubt that it is not just coincidence but . . . a true relation between the moment we start chest compression and the fact that refibrillation occurs," study coauthor Dr Rudolph Koster (University of Amsterdam, the Netherlands) told heartwire .
The study included patients treated by first responders with external defibrillators in North Holland presenting with VF as their initial rhythm. The responders tracked ECG and impedance signals. Only 136 out of the initial 361 patients considered for the study met the inclusion criteria. Patients were randomized to two different resuscitation techniques. For half of the patients, following a defibrillation shock, the responders performed postshock analysis and checked the patient's pulse before resuming chest compressions, as suggested in the 2000 resuscitation guidelines. In the other half of the patients in the study, responders resumed chest compressions as soon as possible after defibrillation, as recommended in the 2005 guidelines.
In the group treated under the 2000 guidelines, rescuers resumed compressions an average of 30 seconds (range 21 to 39 seconds) after the first defibrillator shock that successfully terminated VF. In the group treated under 2005 guidelines, compressions were resumed an average of eight seconds (range seven to nine seconds) after the shock (p less than 0.001).
VF recurred, on average, after 40 seconds (range 21 to 76 seconds ) in the delayed-compressions group vs 21 seconds (range 10 to 80 seconds) in the immediate-compressions group (p=0.001). The time interval between start of the compressions and the recurrence of VF was six (range 0 to 67) and eight (range three to 61) seconds, respectively (p=0.88). The hazard ratio for VF recurrence during the first two seconds of CPR vs the hazard of VF in the period prior to resumption of compressions was 15.5, but after eight seconds of compressions, the hazard of VF recurrence was similar to the hazard of VF prior to resumption of compressions.
VF Recurrence Doesn't Diminish Value of Compressions
The link between VF recurrence and chest compressions does not diminish their value, Koster emphasized. Previous research, reported by heartwire , shows that minimizing interruptions in compressions improves the patient's chances of survival. "It was never our intention to suggest that we would not do chest compressions . . . because we are sure that chest compressions, even after defibrillation, are needed to get the patient back from cardiac arrest to a perfusing and pulsating rhythm," Koster said. "What we identified was that these chest compressions have an adverse effect. . . . You may need more and more repeated defibrillations, because the recurrence of ventricular fibrillation does occur at a high rate."
So the ideal solution, Koster explained, would be a defibrillator that can continue to accurately track a patient's heart rhythm during chest compressions so that the responder knows when VF has recurred and can deliver another shock almost immediately. However, the compressions interfere with the device's ability to monitor the heart rhythm and detect VF, so the responders have to halt compressions for about 30 seconds in order to get a "clean signal."
"Many times paramedics believe they can look at the heart rhythm while chest compressions are going on, but we think that's not true. You need an automated filtering technique to make a reliable judgment possible."
Clinical Trials of Defibrillators With Signal Filters on the Horizon
Koster expects that very soon, several external defibrillator manufacturers will be introducing devices that are able to "filter" the distortion caused by compressions and provide a clean signal within a few seconds of a chest compression. With that device, the responders could charge the defibrillator while performing the chest compressions and then, if the patient goes into VF, take their hands off the chest for about two seconds and deliver a shock from the defibrillator before immediately resuming chest compressions again, Koster said. "Then the interruption [in compressions] is so minimal compared with what is happening now many times, where interruptions are up to 20 to 30 seconds, which is really not a good thing. But only two seconds of interruption may be a very good compromise" between immediately shocking the heart, which may retrigger VF, and a long interruption in chest compressions, which could reduce the patient's chances of survival.
Koster said he knows of at least one company that may begin clinical trials of defibrillators with this type of signal filter within 2010. Unfortunately, the technology will probably not be sufficiently tested in time to be incorporated in the new resuscitation guidelines that are scheduled to be published in October 2010, according to Koster, who is one of the experts developing the new guidelines.
15. Crack Research: Good news about knuckle cracking
One man's long, noisy, asymmetrical adventure gets him a high five
By Steve Mirsky. Scientific American. Dec 2009. The latest physical anthropology research indicates that the human evolutionary line never went through a knuckle-walking phase. Be that as it may, we definitely entered, and have yet to exit, a knuckle-cracking phase. I would run out of knuckles (including those on my feet) trying to count how many musicians wouldn’t dream of playing a simple scale without throwing off a xylophone-like riff on their knuckles first. But despite the popularity of this practice, most known knuckle crackers have probably been told by some expert—whose advice very likely began, “I’m not a doctor, but ...”—that the behavior would lead to arthritis.
One M.D. convincingly put that amateur argument to rest with a study published back in 1998 in the journal Arthritis & Rheumatism entitled “Does Knuckle Cracking Lead to Arthritis of the Fingers?” The work of sole author Donald Unger was back in the news in early October when he was honored as the recipient of this year’s Ig Nobel Prize in Medicine.
The Igs, for the uninitiated, are presented annually on the eve of the real Nobel Prizes by the organization Improbable Research for “achievements that first make people laugh, and then make them think.” In Unger’s case, I thought about whether his protocol might be evidence that he is obsessive-compulsive. From his publication: “For 50 years, the author cracked the knuckles of his left hand at least twice a day, leaving those on the right as a control. Thus, the knuckles on the left were cracked at least 36,500 times, while those on the right cracked rarely and spontaneously.”
Unger undertook his self and righteous research because, as he wrote, “During the author’s childhood, various renowned authorities (his mother, several aunts and, later, his mother-in-law [personal communication]) informed him that cracking his knuckles would lead to arthritis of the fingers.” He thus used a half-century “to test the accuracy of this hypothesis,” during which he could cleverly tell any unsolicited advice givers that the results weren’t in yet.
The article continues: http://www.scientificamerican.com/article.cfm?id=crack-research&sc=WR_20091217
16. Can Comparative-Effectiveness Research Be a Physician's Best Friend?
January 9, 2010 — As healthcare reform legislation grinds its way through Congress, 2 articles published online January 6 in the New England Journal of Medicine (NEJM) advocate for one of its touchiest provisions — comparative-effectiveness research (CER).
In theory, CER sounds like a calm, academic subject: evaluate different treatment options for a given illness — drug A vs drug B, or drug A vs surgery — and determine which does a better job of reducing morbidity and mortality. You also can go a step further and compare these treatment options in terms of risks or cost-effectiveness: Does drug B outperform drug A by a 2% margin but cost 3 times as much? Experts say such research is in short supply, leading to poorer clinical outcomes and runaway costs.
However, talk of government-sponsored CER pushes hot buttons in medicine and American society alike, being called "rationing" and "government takeover of medicine." For proof, consider what happened when the US Preventive Services Task Force announced last November that, based on the scientific evidence it weighed, it no longer recommends mammograms for women aged 40 through 49 years. The task force also recommended that women aged 50 years and older no longer receive annual mammograms but, instead, get them every other year. Public outcry and pushback from several medical societies and expert groups like the American Cancer Society swayed Senate Democrats to rewrite their pending healthcare reform legislation to guarantee mammogram coverage.
If Congress enacts healthcare reform, more such medical recommendations could roil Americans. That's because reform bills passed by the House and Senate (which have yet to be reconciled) call for the creation of a CER entity that would question the value of many trusted procedures and treatments. These provisions come on top of economic stimulus legislation passed in early 2009 that pumps $1.1 billion into CER and establishes a new federal bureaucracy to manage it. The government would not conduct CER itself by and large but would instead fund the work of academic investigators.
NEJM Authors Bolster Support for CER
Individual physicians and medical societies approach CER with varying degrees of enthusiasm, cautious support, and downright fear and loathing. The 2 recent NEJM articles seek to bolster support for this controversial discipline. Two professors at Weill Cornell Medical College, New York City, write in an article titled "Health Care Reform and the Need for Comparative-Effectiveness Research" that CER is "physicians' first line of defense against blind cost containment." Furthermore, it could spur drug and medical device manufacturers "to develop products that really matter."
"I think CER is the physician's best friend," coauthor Alvin Mushlin, MD, professor and chair of the Department of Public Health at Weill Cornell, told Medscape Medical News.
Similarly, the other NEJM article, titled "Comparative Effectiveness and Health Care Spending — Implications for Reform," warns that without a shift to best-bang-for-the-buck services identified by CER, cost-cutting alone could produce worse health outcomes.
"If we can induce hospitals and health plans to improve efficiency and not just cut costs, then health costs in the United States will come down and outcomes will improve," write coauthors Milton Weinstein, PhD, a professor of health policy and management at the Harvard School of Public Health, Boston, Massachusetts, and Jonathan Skinner, PhD, a professor of economics at Dartmouth Medical School, Hanover, New Hampshire.
Give Physicians Scientific Findings, Not Recommendations
Both the ACP and the AMA agree that a government-sponsored CER body should forgo recommendations, much less mandates, on how physicians should practice medicine. For one thing, private insurers and government programs like Medicare are tempted to turn such recommendations into binding policies that may arbitrarily deny patients coverage for needed care, explained the AMA's Dr. Rohack.
"Look at vaccines," Dr. Rohack told Medscape Medical News. "The federal Advisory Committee on Immunization Practices recommends what vaccines should be administered, and insurers key off that to determine what they'll pay for."
The fracas over mammograms last year occurred at the intersection of recommendation and insurance coverage, noted health-policy analyst Dennis Smith from the Heritage Foundation, a conservative think tank. "The essential benefit package in the [original] Senate reform bill was supposed to include preventive services recommended by the US Preventive Services Task Force. So if you didn't meet the [task force] criteria, you wouldn't get your mammogram paid for."
Dr. Rohack also pointed to the problem of inflexible application of CER. A study that identifies the best way to treat a particular medical condition may have excluded patients older than 65 years, for example. A payer may then decide to cover that treatment, but not for anyone older than 65 years, he said.
It's sufficient, said Dr. Rohack, to give CER findings to physicians and patients and let them make the final decision on medical care. "Physicians by training try to use evidence-based science to do what's best for patients," he said. "If there is a gray zone, they'll rely on history, experience, and local practice styles. And there are gray zones."
Dr. Rushlin at Weill Cornell Medical College agrees with Dr. Rohack that merely publishing CER findings without adding recommendations will benefit healthcare.
"We need to get started incorporating information from CER into the public debate on healthcare. It can be a very positive step in the right direction," he said. "When you put the evidence on the table, it illuminates the discussion. It doesn't eliminate the discussion. That's healthy."
From N Engl J Med.
Selker HP, Wood AJJ: Industry Influence on Comparative-Effectiveness Research Funded through Health Care Reform. http://content.nejm.org/cgi/content/full/361/27/2595
Weinstein MC, Skinner JA. Comparative Effectiveness and Health Care Spending — Implications for Reform. http://content.nejm.org/cgi/content/extract/NEJMsb0911104
Mushlin AI, Ghomrawi H. Health Care Reform and the Need for Comparative-Effectiveness Research. http://content.nejm.org/cgi/content/extract/NEJMp0912651
17. Observed Behaviors of Subjects During Informed Consent for an Emergency Department Study
Baren J, et al. Ann Emerg Med. 2009;55:9-14.
Study objective
To determine emergency department patients' behaviors during informed consent for an intimate partner violence survey.
Methods
We conducted a cross-sectional study during administration of informed consent. Research assistants recorded whether informed consent was read, time spent reading it, whether questions were asked, and whether the patients took a copy of the form that was handed to them. Results are reported as percentage of frequency of occurrence.
Results
Of 1,609 patients approached for the intimate partner violence study, 1,312 (82%) patients participated. After verbal description of the study, 53% of patients read the informed consent but only 13% spent more than 2 minutes doing so. Only 20% of patients asked questions and less than half (49%) accepted a copy of the form when it was handed to them.
Conclusion
Patients who participated in an intimate partner violence study did not spend a lot of time reading the consent document, asked few questions, and did not take the copy of the consent form with them. Future studies of the current consent process should determine whether it provides adequate human subjects protections in a manner desired by the patient.
Full-text: http://www.annemergmed.com/article/PIIS0196064409015613/fulltext
18. A New Culprit for Pharyngitis in Adolescents
A gram-negative anaerobe that causes Lemierre syndrome has become a common cause of pharyngitis.
Guideline recommendations for the management of pharyngitis vary from doing nothing, to treating patients with positive test results (rapid or culture), to treating empirically. Current guidelines focus on infections with group A streptococcus, because, although the disease is self-limiting, it can cause substantial complications, most notably rheumatic fever (JW Pediatr Adolesc Med Apr 1 2009).
A recent surge in complicated cases of pharyngitis, particularly in adolescents, prompted more-elaborate microbiological testing. DNA analysis revealed that the gram-negative anaerobe, Fusobacterium necrophorum, is as common as group A strep in this age group. An estimated 1 in 400 cases of F. necrophorum pharyngitis progresses to complications, including abscess, septicemia with septic pulmonary emboli, and Lemierre syndrome, which is a septic thrombophlebitis of the internal jugular vein. In case series of patients with F. necrophorum pharyngitis, death — an almost unknown complication of group A strep pharyngitis — has been reported in 2% to 5% of patients, along with a substantial morbidity rate of 10%.
The organism is not sensitive to macrolides, which are recommended for suspected strep pharyngitis in penicillin-allergic patients. Penicillin or a cephalosporin remains the first treatment choice for adolescents and young adults with pharyngitis, and the addition of clindamycin is indicated for those with evidence of sepsis or neck swelling. Clindamycin should be the primary treatment in penicillin-allergic patients.
Comment: The differential diagnosis of pharyngitis in adolescents and young adults includes group A strep, mononucleosis, and acute HIV infection and should now also include F. necrophorum, both at initial presentation and in cases that have not resolved in the usual 5-day interval from onset. Any clinical indicator of bacteremia indicates the need for admission (at least to an observation unit), blood cultures, and antibiotic coverage for F. necrophorum pending culture results.
— J. Stephen Bohan, MD, MS, FACP, FACEP. Published in Journal Watch Emergency Medicine January 15, 2010. Citation: Centor RM. Expand the pharyngitis paradigm for adolescents and young adults. Ann Intern Med 2009 Dec 1; 151:812.
19. In Praise of the Physical Examination
Verghese A, et al. BMJ 2009;339:b5448
If an alien anthropologist were to visit a modern teaching hospital, "it" might conclude that, judging by where doctors spend most of their time, the business of an internal medicine service takes place around computer terminals. The alien might assume that the virtual construct of the patient, or the "iPatient", is more important than the flesh and blood human being occupying the bed.
But the alien would be wrong—patients are what medical care is all about. Yet the electronic medical record and advanced imaging technology have not only seduced doctors away from the bedside but also devalued the importance of their role there. Indeed, intensive care units exist where consultants conduct their "rounds" on the patients and adjust ventilator settings and drugs via telemetry.
These trends have left educators and trainees in internal medicine in two camps when it comes to the merits of the bedside examination. In the first camp are those who pine for the old days, bemoan the loss of clinical bedside diagnostic skills, and complain that no one knows Traube’s space or Kronig’s isthmus. In the second camp are those who say good riddance and point out that evidence based studies show that many physical signs are useless; some might even argue that examining the patient is just a waste of time.
We believe that the truth is somewhere in between....
For the remainder of the essay, cf: http://www.bmj.com/cgi/content/full/339/dec16_3/b5448
20. C-Reactive Protein Level Predicts SBI in Febrile Neonates
In well-appearing neonates with fever without a source, CRP measured more than 12 hours after fever onset was a better predictor of severe bacterial infection than ANC or WBC.
Bressan S, et al. Pediatr Infect Dis J. 2009;
OBJECTIVES: To assess the diagnostic accuracy of white blood cell count (WBC), absolute neutrophil count (ANC), and C-reactive protein (CRP) in detecting severe bacterial infections (SBI) in well-appearing neonates with early onset fever without source (FWS) and in relation to fever duration.
METHODS: An observational study was conducted on previously healthy neonates 7 to 28 days of age, consecutively hospitalized for FWS from less than 12 hours to a tertiary care Pediatric Emergency Department, over a 4-year period. Laboratory markers were obtained upon admission in all patients and repeated 6 to 12 hours from admission in those with normal values on initial determination. Sensitivity, specificity, positive and negative likelihood ratios, and receiver operating characteristic analysis were carried out for primary and repeated laboratory examinations.
RESULTS: Ninety-nine patients were finally studied. SBI was documented in 25 (25.3%) neonates. Areas under receiver operating characteristic curves were 0.78 (95% CI, 0.69-0.86) for CRP, 0.77 (95% CI, 0.67-0.85) for ANC and 0.59 (95% CI, 0.49-0.69) for WBC. Sixty-two patients presented normal laboratory markers on initial determination. Of these, 58 successfully underwent repeated blood examination more than 12 hours from fever onset. Five of them had an SBI. The area under curve calculated for repeated laboratory tests showed better values, respectively of 0.99 (95% CI, 0.92-1) for CRP, 0.85 (95% CI, 0.73-0.93) for ANC and 0.79 (95% CI, 0.66-0.88) for WBC.
CONCLUSIONS: In well-appearing neonates with early onset FWS, laboratory markers are more accurate and reliable predictors of SBI when performed more than 12 hours of fever duration. ANC and especially CRP resulted better markers than the traditionally recommended WBC.
21. Images in Emergency Medicine
Man With Right Arm Weakness
http://www.annemergmed.com/article/S0196-0644(09)00525-3/fulltext
Adult Female With Shoulder Pain
http://www.annemergmed.com/article/S0196-0644(09)01434-6/fulltext
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