Friday, January 29, 2010

Lit Bits: Jan 29, 2010

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.

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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.

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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:

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.

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.

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.

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.

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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.

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.

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.

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%).

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.

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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.

We determined the survival and complications of ultrasonography-guided peripheral intravenous (IV) catheters in emergency department (ED) patients with difficult peripheral access.

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

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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.

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.

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.

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).

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.

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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.

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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.

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.

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.

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.

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.