From the recent medical literature...
1. Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter
Stiell IG, et al. CJEM 2010;12:181-191.
Abstract
Objective: There is no consensus on the optimal management of recent-onset episodes of atrial fibrillation or flutter. The approach to these conditions is particularly relevant in the current era of emergency department (ED) overcrowding. We sought to examine the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge patients with these arrhythmias.
Methods: This cohort study enrolled consecutive patient visits to an adult university hospital ED for recent-onset atrial fibrillation or flutter managed with the Ottawa Aggressive Protocol. The protocol includes intravenous chemical cardioversion, electrical cardioversion if necessary and discharge home from the ED.
Results: A total of 660 patient visits were included, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procainamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procainamide and 6.5 hours for those requiring electrical conversion.
Conclusion: This is the largest study to date to evaluate the Ottawa Aggressive Protocol, a unique approach to cardioversion for ED patients with recent-onset episodes of atrial fibrillation and flutter. Our data demonstrate that the Ottawa Aggressive Protocol is effective, safe and rapid, and has the potential to significantly reduce hospital admissions and expedite ED care.
2. Addressing Pain Complaints and Potential Drug-Seeking Behavior: Various Views
A. A Statewide Prescription Monitoring Program Affects Emergency Department Prescribing Behaviors
Baehren DF, et al. Ann Emerg Med. 2010;56:19-23.e3.
Study objective
Ohio recently instituted an online prescription monitoring program, the Ohio Automated Rx Reporting System (OARRS), to monitor controlled substance prescriptions within Ohio. This study is undertaken to identify the influence of OARRS data on clinical management of emergency department (ED) patients with painful conditions.
Methods
This prospective quasiexperimental study was conducted at the University of Toledo Medical Center Emergency Department during June to July 2008. Eligible participants included ED patients with painful conditions. Patients with acute injuries were excluded. After clinical evaluation, and again after presentation of OARRS data, providers answered a set of questions about anticipated pain prescription for the patient. Outcome measures included changes in opioid prescription and other potential factors that influenced opioid prescription.
Results
Among 179 participants, OARRS data revealed high numbers of narcotics prescriptions filled in the most recent 12 months (median 7; range 0 to 128). Numerous providers prescribed narcotics for patients (median 3 per patient; range 0 to 40). Patients had filled narcotics prescriptions at different pharmacies (mean [SD] 3.5 [4.4]). Eighteen providers are represented in the study. Four providers treated 63% (N=114) of the patients in the study. After review of the OARRS data, providers changed the clinical management in 41% (N=74) of cases. In cases of altered management, the majority (61%; N=45) resulted in fewer or no opioid medications prescribed than originally planned, whereas 39% (N=29) resulted in more opioid medication than previously planned.
Conclusion
The use of data from a statewide narcotic registry frequently altered prescribing behavior for management of ED patients with complaints of nontraumatic pain.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(09)01812-5/fulltext
B. Occupational Hazard: Playing the Fool with Potential Drug-Seekers
By Michael Kahn, MD. New York Times. June 7, 2010.
“Can you tolerate being bamboozled by your patients from time to time?”
I posed that question to a group of first-year psychiatric residents during a discussion of the perils of prescribing “feel good” medicines — anti-anxiety drugs like Xanax, in this case — to patients who might be lying to obtain them.
Xanax is one of a class of drugs known colloquially as “benzos” (benzodiazepines) that are safe and highly effective — but can also be addictive and have potential for abuse. The residents, in full “do no harm” mode, were focused on not fostering anyone’s drug habit.
“Everyone in the emergency room lies to get benzos,” one trainee remarked, as I recall.
Another said, “I’d give them one pill” to last until they could call their primary care provider, and a third said, “They need psychotherapy rather than medication.”
In short, the prevailing attitude was one of “they’ll have to pry that pill from my cold dead hands.” It made me wonder whether these budding psychiatrists might be working too hard to avoid being hoodwinked.
I think we underemphasize the prevalence of certain normal errors inherent in medical practice. Surgeons are fooled when they open an acutely painful abdomen only to find a normal appendix: in the days before CT scans, it was said that if that didn’t happen once in a while, you weren’t operating often enough. When in doubt, it was safer (and wiser) to operate than to risk a rupture and peritonitis, even if the diagnosis was “wrong.” Here was an error that wasn’t an error, but rather a predictable side effect of balancing known risks with imperfect information.
I suggest that we apply a similar principle to the prescribing of narcotic painkillers and anti-anxiety drugs. Let’s assume that it’s impossible not to be fooled at least some of the time — that when assessing patients’ sincerity, we should expect a certain rate of false positives.
Thus, when confronting patients who demand Xanax or morphine, doctors should worry less about defending their self-esteem and their lie-detection skills (after all, the most talented sociopaths are the ones most skilled at convincing others of their honesty) and more about what treatment is best for the patient.
Doing so doesn’t exempt the physician from exercising proper skepticism and clinical shrewdness. I still vividly remember being fooled by a patient who couldn’t have seemed more earnest about his need for narcotics to treat the pain from an accident that we were finally able to determine had never happened.
But even in that case, the cost was modest: two days of unnecessary narcotics for the patient and a survivable blow to my own estimation of my clinical acumen.
“It is better to suffer wrong than to do it,” Samuel Johnson wrote, “and happier to be sometimes cheated than not to trust.” Knowing that false positives are inevitable gives a statistical perspective to that wisdom — and frees the doctor from having to interrogate the patient like a criminal suspect.
To put it another way, I’d rather be taken for a sucker once in a while than know that my suspicion had denied someone legitimate help. Furthermore, excessive suspicion compromises empathy and compassion. It is draining to approach patients as possible adversaries who must be bested.
The rest of the article: http://www.nytimes.com/2010/06/08/health/08mind.html
C. Optimizing the Treatment of Pain in Patients with Acute Presentations
ACEP Policy Statement (July 2010)
Core Principles
1. The patient's self-report of pain is a critical component of a comprehensive pain assessment which includes clinical assessment and pain history and treatment. Pediatric patients, the elderly, and the cognitively impaired are patients at high risk of inadequate pain management.
2. Optimal pain treatment may be enhanced by acknowledging cultural differences in the expression of pain.
3. A comprehensive assessment, including the patient's self-report of pain, will allow clinicians to better evaluate the patient's experience. Improvement in function may be an important reference.
4. Evidence-based assessment and management techniques should guide pain management whenever possible.
5. Pain categorization: acute; an acute exacerbation of a recurring painful condition; chronic/persistent, and cancer pain are of help in choosing appropriate interventions. In addition to contemporaneous pharmacologic intervention, other pathways should be considered such as referral for long term pain management, case management or referral to social service for clinicians and/or centers available to provide long term pain management.
6. Analgesic management should begin as soon as possible when indicated. Diagnosis of the pain etiology should not delay administration of analgesics.
7. Providers must consider the special needs of patients with addictive disease to ensure adequate and safe delivery of analgesia.
8. Those individuals who appear to present with behaviors suggestive of addictive disease should be given a brief intervention and a referral for substance abuse treatment. Chronic repeat visits to non continuity of care providers can be addressed through social service interventions, care plans in conjunction with primary care physicians and analgesic contracts for emergency pain relief.
9. Aberrant behaviors do not equate with addictive disease and may indicate under-treatment of pain. Clinicians and nurses caring for patients experiencing acute and chronic pain may screen for addiction, bearing in mind that it is not the same as tolerance, physical dependence and pseudo-addiction. All patients should be treated appropriately for reports of pain, including those with addictive disease.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)00340-9/fulltext
3. Giving oxygen in acute myocardial infarction may raise death risk, Cochrane review concludes
Susan Mayor. BMJ 2010;340:c3227
A Cochrane systematic review has found no evidence that the routine practice of giving inhaled oxygen to patients with acute myocardial infarction is beneficial, and it may even increase mortality, it says. Its authors call for a large trial to be carried out urgently to provide a clear answer.
Oxygen is routinely given to patients with acute myocardial infarction, with clinical guidelines in most countries recommending its use in emergency care. The rationale is that this may improve oxygenation of the ischaemic myocardium and so reduce cardiac pain, infarct size, and consequent morbidity and mortality. However, previous studies have found insufficient evidence to determine whether oxygen had any effect on these outcomes.
The review analysed data from all trials meeting Cochrane criteria that randomised patients with suspected or proved acute myocardial infarction to inhaled oxygen (at normal pressure) or inhaled air within 24 hours of onset of symptoms (Cochrane Database of Systematic Reviews 2010;6:CD007160, doi:10.1002/14651858.CD007160.pub2). Other treatments were the same in both arms of each trial.
None of the three trials—which had a total of 387 patients—showed that inhaled oxygen improved clinical outcomes. Among the 14 patients who died, nearly three times as many had been given oxygen as air in both the intention to treat analysis (including all patients) (relative risk 2.9 (95% confidence interval 0.9 to 9.8)) and the analysis of patients with confirmed acute myocardial infarction (relative risk 3.0 (0.9 to 9.4)). However, the small number meant that this difference did not reach statistical significance.
There was no difference in analgesic use (used as a proxy for pain) between patients given oxygen and air (relative risk among patients with confirmed acute myocardial infarction 1.0 (0.83 to 1.2)).
The review authors, led by Juan Cabello, cardiologist and clinical epidemiologist at the Hospital General Universitario de Alicante, Alicante, Spain, said, "Current evidence neither supports nor clearly refutes the routine use of oxygen in patients with AMI [acute myocardial infarction]. The evidence that is available is suggestive of harm but lacks power, so this could be due to chance.
"A definitive randomised controlled trial is urgently required given the mismatch between trial evidence suggestive of possible harm from routine oxygen use and recommendations for its use in clinical practice guidelines," the group recommend.
They noted that as long ago as 1950 a study showed that giving pure oxygen through a face mask not only failed to reduce the duration of angina pain but also prolonged electrocardiographic changes indicative of acute myocardial infarction. "It is surprising that a definitive study to rule out the possibility that oxygen may do more harm than good has not been done," they said.
Part of the failure to fund such a study may be due to the strong belief that giving oxygen will reduce the oxygen deficit in ischaemic myocardial tissue, the group suggests.
Amanda Burls, a coauthor and senior clinical research fellow in the department of public health and primary health care at the University of Oxford, said, "Because there is the possibility that giving oxygen after a heart attack may be doing more harm than good—although we can’t say either way for certain—we are now seeking funding for a randomised controlled trial that should answer this question."
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20556775
Accompanying Cochrane editorial: http://www.thecochranelibrary.com/details/editorial/742329/Oxygen-therapy-in-acute-myocardial-infarction--too-much-of-a-good-thing--by-Dr-C.html
4. Most Patients with Stroke Symptoms Don't Get Prompt Brain Imaging
May 31, 2010 — Brain imaging is not being performed within the recommended 25 minutes in almost 80% of patients brought to emergency departments with acute stroke symptoms, a new study has found.
Having diabetes, arriving at the hospital by means other than ambulance, and being older, female, or African American were among the variables affecting this "door-to-imaging" time frame, the study determined.
"Imaging is a vitally important part of the evaluation of a stroke patient, and it's part of the process of administering tPA [tissue plasminogen activator], which is our only approved treatment for acute ischemic stroke," said lead researcher Adam G. Kelly, MD, assistant professor of neurology at the University of Rochester in New York. "If there are delays in imaging, that has potentially significant downstream effects on delays in tPA administration, and downstream of that, on the functional outcomes of stroke patients."
The study represents "an important intermediate step" in getting tPA administered more quickly, Dr. Kelly told Medscape Neurology. "We hope we have identified some overall trends, but also some specific populations that are having delays in their imaging."
The study was presented in Washington, DC, at the American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke 2010 Scientific Sessions.
National guidelines recommend that patients presenting with acute stroke undergo brain imaging within 25 minutes of arrival at an emergency department. Delays in such imaging can prevent or reduce the effect of stroke treatments, such as thrombolysis, the authors note.
For this study, investigators analyzed data on 221,538 patients from the Get With the Guidelines–Stroke program from 2003 to 2009. Launched in 2000, this program helps ensure continuous quality improvement in acute stroke treatment and ischemic stroke prevention. It focuses on protocols for care teams to ensure that patients are treated and discharged appropriately and provides insights into disparities in care delivery and trends in patient and disease characteristics.
Rates Low for All Stroke Categories
The study showed that brain imaging was performed within 25 minutes in only 21.6% of the 221,538 patients. The rates of brain imaging within this window were low for all stroke subtypes: 22.1% for ischemic stroke, 18.7% for subarachnoid hemorrhage, and 28.3% for intracerebral hemorrhage.
The median door-to-imaging time among all the patients — as well as among a subgroup of patients who were eventually diagnosed with ischemic stroke — was 57 minutes. "So we know that half the population had a scan done before 57 minutes and half had it done at more than 57 minutes," said Dr. Kelly.
The rates remained low but increased slightly — from 18.8% to 21.6% — from 2003 to 2009. "I frankly was hoping that it would have gone up more throughout those 7 years," said Dr. Kelly, adding that the rate actually dipped in 2008, but picked up again in 2009.
He pointed out that hospitals entered the program at different times of the study period. So although some hospitals might have had substantial improvement, that effect could have been "watered down" by hospitals new to the program, he said.
Dr. Kelly and his colleagues are planning a further analysis to see whether the number of years a hospital has been in the program affects door-to-imaging time for patients brought to its emergency department.
Independent Predictors
After adjusting for within-hospital clustering, researchers identified independent predictors of patients with ischemic stroke not receiving brain imaging within the 25-minute window. "Even though we'd like to know how we're doing with all patients presenting with acute stroke syndrome, we wanted to find specific predictors of quick or delayed imaging that are relevant to ischemic stroke patients because those are the folks we hope can benefit from tPA," explained Dr. Kelly.
There were 7 predictive factors for delayed brain imaging:
• Being older than 70 years of age. "Older people may be diagnosed as having delirium, an infection, dementia, or some other neurological disorder and therefore may not be evaluated as acutely for their stroke symptoms," speculated Dr. Kelly.
• Being female. "Men are at higher risk for strokes so the attention of emergency personnel toward stroke might be more heightened when they're taking care of male patients," said Dr. Kelly.
• Being African American. Because this population is at relatively high risk for stroke, it's difficult to explain why their door-to-imaging times would be delayed, noted Dr. Kelly.
• Having a history of diabetes, carotid stenosis, peripheral vascular disease, or smoking. Patients with diabetes were almost 23% less likely than nondiabetics to have their imaging completed within the 25-minute period, possibly because their stroke symptoms were "misattributed" to symptoms of severely high glucose levels or other diabetes-related symptoms, said Dr. Kelly.
• Arrival at the hospital by means other than ambulance. Patients arriving on their own were about 68% less likely than patients who arrived by emergency medical services (EMS) to receive prompt brain scans. "That goes to show that our public service message to get people to activate EMS when they have stroke symptoms is vitally important," stressed Dr. Kelly.
• Hospital being in the Northeast region of the United States. Again, there doesn't seem to be an obvious explanation for this result, given that this region not only has many hospitals but also dedicated stroke centers, said Dr. Kelly
• Symptom onset in another acute care or chronic care facility.
A history of atrial fibrillation/flutter was associated with a higher likelihood of brain imaging within 25 minutes, the authors note.
Although there is plenty of research on treatment delays in the prehospital phase — such as on why people don't notify EMS when they have stroke symptoms — this is one of the few studies looking at quality-of-care factors inside the hospital. "In terms of quality improvement, one of the things we clearly need to work on as a medical community is making sure that once people do hit the door, we're ready for them and that we have systems in place so we can get this evaluation done in a timely fashion," said Dr. Kelly.
Get With the Guidelines–Stroke is 1 of 4 programs geared to quality improvement in the areas of heart failure, coronary artery disease, and stroke. One or more of these hospital-based modules is being implemented in more than 1600 acute care hospitals across the United States. More than 2.2 million patient records have been entered into the patient database.
Discouraging Rates
Approached for a comment, Ralph L. Sacco, MD, MS, chair of the Department of Neurology at the University of Miami's Miller School of Medicine in Florida, and president-elect of the American Heart Association, said that although it is heartening that the number of scans within the recommended window are going up, "it's still discouraging that a larger number of patients are not getting acute brain imaging within 25 minutes."
Addressing the factors the study found to be predictive of more time to brain scans, Dr. Sacco noted that for women and older people, symptoms can be atypical or misinterpreted. As for the issue of arriving at hospital by means other than ambulance, Dr. Sacco said that hospitals respond differently when an ambulance arrives. "Ambulance personnel can push the right buttons; they probably have the right information and know they have a suspected stroke, so all of a sudden things move much more rapidly."
This research provides important information on where to make improvements in the system, Dr. Sacco told Medscape Neurology. "The study is beginning to identify predictors of where we could focus even more effort, for example people over age 70, women, and African Americans. Let's figure out why they're not getting their [computed tomography] scans as quickly and figure out ways we can alert people to perform better within the guidelines."
American Heart Association Quality of Care and Outcomes Research (AHA-QCOR) in Cardiovascular Disease and Stroke 2010 Scientific Sessions: Abstract 8. Presented May 20, 2010.
5. Accurate prediction of the needle depth required for successful lumbar puncture
Chong SY, et al. Amer J Emerg Med. 2010;28:603-606.
Introduction
The aim of this study is to formulate an accurate estimate of the spinal needle depth for a successful lumbar puncture in pediatric patients.
Methods
This is a prospective study of pediatric oncology patients who had lumbar punctures in the course of their treatment. The distance from skin entry point to the tip of the spinal needle was measured after lumbar punctures were performed. The relationship between the depth of needle insertion with weight, height, body surface area, body mass index, intervertebral space used, ethnicity, and sex of patient were studied. Predictive statistical models were used for the formulation of the ideal lumbar puncture needle depth.
Results
Two hundred seventy-nine patients who had nontraumatic lumbar punctures were studied. The patient characteristics were as follows: age, 0.5 to 15 years; weight, 7 to 63 kg; and height, 70 to 162 cm. Analysis using multiple regression tests with stepwise approach showed a strong relationship between the lumbar puncture needle depth and weight/height ratio. By using a predictive regression model, ideal depth of needle insertion (cm) = 10 [weight(kg)/height(cm)] + 1, with a regression coefficient r = 0.77.
Conclusion
This formula is accurate and practical with less complex calculations. However, further validation in a prospective study will be needed.
6. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial
Bleakley CM, et al. BMJ 2010;340:c1964
Objective: To compare an accelerated intervention incorporating early therapeutic exercise after acute ankle sprains with a standard protection, rest, ice, compression, and elevation intervention.
Design Randomised controlled trial with blinded outcome assessor.
Setting: Accident and emergency department and university based sports injury clinic.
Participants: 101 patients with an acute grade 1 or 2 ankle sprain.
Interventions: Participants were randomised to an accelerated intervention with early therapeutic exercise (exercise group) or a standard protection, rest, ice, compression, and elevation intervention (standard group).
Main outcome measures: The primary outcome was subjective ankle function (lower extremity functional scale). Secondary outcomes were pain at rest and on activity, swelling, and physical activity at baseline and at one, two, three, and four weeks after injury. Ankle function and rate of reinjury were assessed at 16 weeks.
Results: An overall treatment effect was in favour of the exercise group (P=0.0077); this was significant at both week 1 (baseline adjusted difference in treatment 5.28, 98.75% confidence interval 0.31 to 10.26; P=0.008) and week 2 (4.92, 0.27 to 9.57; P=0.0083). Activity level was significantly higher in the exercise group as measured by time spent walking (1.2 hours, 95% confidence interval 0.9 to 1.4 v 1.6, 1.3 to 1.9), step count (5621 steps, 95% confidence interval 4399 to 6843 v 7886, 6357 to 9416), and time spent in light intensity activity (53 minutes, 95% confidence interval 44 to 60 v 76, 58 to 95). The groups did not differ at any other time point for pain at rest, pain on activity, or swelling. The reinjury rate was 4% (two in each group).
Conclusion: An accelerated exercise protocol during the first week after ankle sprain improved ankle function; the group receiving this intervention was more active during that week than the group receiving standard care.
Intervention exercises with images: http://www.bmj.com/cgi/data/bmj.c1964/DC1/1
Full-text: http://www.bmj.com/cgi/content/full/340/may10_1/c1964
7. Placing Physician Orders at Triage: The Effect on Length of Stay
Russ S, et al. Ann Emerg Med. 2010;56:27-33.
Study objective
Emergency department (ED) crowding is a significant problem nationwide, and numerous strategies have been explored to decrease length of stay. Placing a physician in the triage area to rapidly disposition low-acuity patients and begin evaluations on more complex patients is one strategy that can be used to lessen the effect of ED crowding. The goal of this study is to assess the effect of order placement by a triage physician on length of stay for patients ultimately treated in a bed within the ED.
Methods
We conducted a pre-experimental study with retrospective data to evaluate patients with and without triage physician orders at a single academic institution. A matched comparison was performed by pairing patients with the same orders and similar propensity scores. Propensity scores were calculated with demographic and triage data, chief complaint, and ED capacity on the patient's arrival.
Results
During the 23-month study period, a total of 66,909 patients were sent to the waiting room after triage but still eventually spent time in an ED bed. A quarter of these patients (23%) had physician orders placed at triage. After a matched comparison, patients with triage orders had a 37-minute (95% confidence interval 34 to 40 minutes) median decrease in time spent in an ED bed, with an 11-minute (95% confidence interval 7 to 15 minutes) overall median increase in time until disposition.
Conclusion
Our study suggests that early orders placed by a triage physician have an effect on ED operations by reducing the amount of time patients spend occupying an ED bed.
8. Low-impact scenarios may account for two-thirds of blunt traumatic aortic rupture
P Sastry, et al. Emerg Med J 2010;27:341-344
Background: Traditionally, blunt traumatic aortic rupture (BTAR) is thought to be a high-velocity injury. It was hypothesised that BTAR has a higher than suspected incidence in low-speed accidents, with unique kinematic and demographic risk factors.
Methods: Using the UK Cooperative Crash Injury Study (CCIS) framework, impact profiling was undertaken for accidents involving BTAR. Equivalence Test Speed (ETS) was the parameter used to compare crash severity within comparable impact configurations, as it is a surrogate marker reflecting the net impact forces acting on the vehicle. ETS=40 mph (the threshold used for safety testing within the EURONCAP scheme) was used to delineate low-impact blunt traumatic aortic rupture (LIBTAR) cases, which were subsequently analysed for aetiological risk factors.
Results: 119 fully analysed cases of aortic injury were identified from a total of 16 444 cases reported to the UK CCIS between 1998 and 2007. 79 cases (66.4%) qualified as LIBTAR. Risk factors for LIBTAR were age over 60 (p less than 0.0001), lateral impact direction (OR 2.041, RR 1.99, p=0.003), and struck side seat position (OR 1.934, RR 1.885 p=0.101). Low-impact crash scenarios were found to represent more than 95% of UK road traffic accidents.
Conclusion: Low-impact collisions account for two thirds of fatal aortic injuries. Age over 60, lateral impacts and struck side seat position are predictive of LIBTAR. Low-impact cases were associated with minor (potentially subclinical) intimomedial injuries. Therefore, it is recommended that a higher index of suspicion of aortic injury is used in low-impact scenarios in the risk groups identified.
9. Cognitive and Social Effects of our iPhone Age
A. Your Brain on Computers: Hooked on Gadgets, and Paying a Mental Price
Matt Richtel. New York Times. June 6, 2010. Scientists say juggling e-mail, phone calls and other incoming information can change how people think and behave. They say our ability to focus is being undermined by bursts of information.
These play to a primitive impulse to respond to immediate opportunities and threats. The stimulation provokes excitement — a dopamine squirt — that researchers say can be addictive. In its absence, people feel bored.
The resulting distractions can have deadly consequences, as when cellphone-wielding drivers and train engineers cause wrecks. And for millions of people like Mr. Campbell, these urges can inflict nicks and cuts on creativity and deep thought, interrupting work and family life.
While many people say multitasking makes them more productive, research shows otherwise. Heavy multitaskers actually have more trouble focusing and shutting out irrelevant information, scientists say, and they experience more stress.
And scientists are discovering that even after the multitasking ends, fractured thinking and lack of focus persist. In other words, this is also your brain off computers.
Full-text: http://www.nytimes.com/2010/06/07/technology/07brain.html
B. An Ugly Toll of Technology: Impatience and Forgetfulness
By Tara Parker-Pope. New York Times. June 6, 2010.
Has high-speed Internet made you impatient with slow-speed children?
Do you sometimes think about reaching for the fast-forward button, only to realize that life does not come with a remote control?
If you answered yes to any of those questions, exposure to technology may be slowly reshaping your personality. Some experts believe excessive use of the Internet, cellphones and other technologies can cause us to become more impatient, impulsive, forgetful and even more narcissistic.
“More and more, life is resembling the chat room,” says Dr. Elias Aboujaoude, director of the Impulse Control Disorders Clinic at Stanford. “We’re paying a price in terms of our cognitive life because of this virtual lifestyle.”
Full-text: http://www.nytimes.com/2010/06/07/technology/07brainside.html
C. Mind Over Mass Media
By Steven Pinker. New York Times. June 10, 2010.
NEW forms of media have always caused moral panics: the printing press, newspapers, paperbacks and television were all once denounced as threats to their consumers’ brainpower and moral fiber.
So too with electronic technologies. PowerPoint, we’re told, is reducing discourse to bullet points. Search engines lower our intelligence, encouraging us to skim on the surface of knowledge rather than dive to its depths. Twitter is shrinking our attention spans.
But such panics often fail basic reality checks. When comic books were accused of turning juveniles into delinquents in the 1950s, crime was falling to record lows, just as the denunciations of video games in the 1990s coincided with the great American crime decline. The decades of television, transistor radios and rock videos were also decades in which I.Q. scores rose continuously.
For a reality check today, take the state of science, which demands high levels of brainwork and is measured by clear benchmarks of discovery. These days scientists are never far from their e-mail, rarely touch paper and cannot lecture without PowerPoint. If electronic media were hazardous to intelligence, the quality of science would be plummeting. Yet discoveries are multiplying like fruit flies, and progress is dizzying. Other activities in the life of the mind, like philosophy, history and cultural criticism, are likewise flourishing, as anyone who has lost a morning of work to the Web site Arts & Letters Daily can attest.
Critics of new media sometimes use science itself to press their case, citing research that shows how “experience can change the brain.” But cognitive neuroscientists roll their eyes at such talk. Yes, every time we learn a fact or skill the wiring of the brain changes; it’s not as if the information is stored in the pancreas. But the existence of neural plasticity does not mean the brain is a blob of clay pounded into shape by experience.
Experience does not revamp the basic information-processing capacities of the brain. Speed-reading programs have long claimed to do just that, but the verdict was rendered by Woody Allen after he read “War and Peace” in one sitting: “It was about Russia.” Genuine multitasking, too, has been exposed as a myth, not just by laboratory studies but by the familiar sight of an S.U.V. undulating between lanes as the driver cuts deals on his cellphone.
Full-text: http://www.nytimes.com/2010/06/11/opinion/11Pinker.html
10. Is Kayexalate Effective for Hyperkalemia, and Is It Safe?
Recent evidence fuels growing concerns about use of sodium polystyrene sulfonate with sorbitol.
Sodium polystyrene sulfonate (SPS; e.g., Kayexalate) has been used as an oral or rectal therapy for hyperkalemia since 1958 — before the FDA required drug manufacturers to prove efficacy and safety in 1962. SPS is an ion exchange resin that is thought to exchange sodium with potassium in the colon. Because constipation is a common complication, SPS is often mixed with sorbitol. In a clinical commentary, the authors reviewed the literature on SPS and sorbitol from the past 50 years and found no evidence of clinically significant lowering of serum potassium in patients with hyperkalemia. The strongest evidence for SPS efficacy is a drop in serum potassium of at least 0.4 mEq/L in 23 of 30 hyperkalemic patients (Circulation 1952; 5:747). A recent report described colonic necrosis in patients treated with SPS mixed with sorbitol (South Med J 2009; 102:493). In September 2009, the FDA issued a warning about concomitant use of SPS with sorbitol, although this combination is currently still available.
Comment: As a nephrologist who has used sodium polystyrene sulfonate for decades, I found this review startling. Although I was aware that the beneficial effect of SPS was, at best, slow and gradual, I was unaware about the risk for intestinal injury when SPS is combined with sorbitol. Fortunately, more rapid and effective measures are available to lower serum potassium in patients with hyperkalemia. These therapies include intravenous dextrose plus insulin, inhaled β-2 agonists, and sodium bicarbonate. On the basis of this commentary and literature review, I discourage prescribing SPS with sorbitol as a first-line therapy for hyperkalemia.
— F. Bruder Stapleton, MD. Published in Journal Watch Pediatrics and Adolescent Medicine June 9, 2010. Citation: Sterns RH et al. Ion-exchange resins for the treatment of hyperkalemia: Are they safe and effective? J Am Soc Nephrol 2010 May; 21:733.
11. Seven years of cyanide ingestions in the USA: critically ill patients are common, but antidote use is not
Bebarta VS, et al. Emerg Med J 2010; in print
Background: Cyanide is a common toxin in structural fires and a salt that is ingested for suicide. However, most studies have focused on the effects of inhaled cyanide. The objective of this study was to describe the incidence of cyanide ingestions, symptoms, cardiac arrest and antidotal therapy used as reported to all US poison centres over 7 years.
Methods: A retrospective review of cases over 7 years as reported to 61 poison centres in the USA was performed. Sole ingestions of cyanide were identified. A trained reviewer used a standard data collection sheet within a secured electronic database. Age, intent, clinical effects, treatments, antidotes and outcomes were recorded. One investigator audited a random sample of charts.
Results: Out of 1741 exposures, 435 ingestions were identified. Most were male (68%) and the mean age was 34 years (range 1 month–83 years). 45% of cases were intentional, most commonly as a suicide attempt. 8.3% of cases died and 9% (38/435) of patients had cardiac arrest or hypotension. 13% of all cases and 26% of cases arriving at a healthcare facility received an antidote. In 35% of cases of cardiac arrest or hypotension, and in 74% of intentional ingestions, antidotes were not given.
Conclusions: Suicide attempt was the most common reason for cyanide ingestion. Most of these patients died. Cardiac arrest or hypotension was common, but antidote use was not, particularly in critically ill patients. Research is needed to improve outcomes of cyanide-induced hypotension and cardiac arrest and to reduce barriers to antidote use.
12. Topical antacid therapy for capsaicin-induced dermal pain: a poison center telephone-directed study
Kim-Katz SY, et al. Amer J Emerg Med. 2010;28:596-602.
Purpose
The study aimed to assess the effects of topical antacids for treatment of capsaicin-induced dermal pain after exposure to capsaicin containing hot peppers, personal protection sprays, or topical creams.
Procedures
Participants of the study were California Poison Control System (CPCS) hotline callers 12 years or older with dermal pain from exposure to capsaicin-containing products or plants. Participants were instructed to apply a topical antacid and assessed for perceived pain (using a 0-10 scale) pre- and posttreatment. A positive response was defined as a sustained reduction of pain 33% or more within 30 minutes or achieving a pain score of 0 to 1.
Main findings
Of 93 eligible patients, 64 applied antacids and had outcome data available. Patients contacted the CPCS a median of 1 hour postexposure with a median initial pain score of 7.5/10. Thirty-six (56%) were exposed to unrefined (natural) peppers and 28 (44%) to refined capsaicin (eg, capsaicin-containing cream). Before calling the CPCS, 57 (89%) attempted at least one treatment. Forty-five (70%) reported positive response to antacid treatment as a 33% reduction in pain in 30 minutes (n = 17), a reduction in pain to a score of 0 to 1 (n = 3), or both (n = 25). A 33% reduction in pain within 30 minutes was associated with exposure to refined capsaicin (odds ratio, 3.37; 95% confidence interval, 0.98-11.66). Concomitant refined capsaicin exposure and early treatment (within 1 hour of symptoms) was associated with even greater odds of response (odds ratio, 5.4; 95% confidence interval, 1.4-21.2).
Conclusion
Topical application of antacids for capsaicin-induced pain is effective, particularly in early treatment of exposure to refined capsaicin.
13. A Prospective, Randomized Trial of Intravenous Prochlorperazine Versus Subcutaneous Sumatriptan in Acute Migraine Therapy in the Emergency Department
Kostic MA, et al. Ann Emerg Med. 2010;56:1-6.
Study objective
Intravenous (IV) prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the treatment of migraine patients presenting to the emergency department (ED).
Methods
In this randomized, double-blind, placebo-controlled trial, after providing written informed consent, patients presenting to the ED with a chief complaint of migraine received a 500-mL bolus of IV saline solution and either 10 mg prochlorperazine with 12.5 mg diphenhydramine IV plus saline solution placebo subcutaneously or saline solution placebo IV plus 6 mg sumatriptan subcutaneously. Pain intensity was assessed with 100-mm visual analog scales (visual analog scale at baseline and every 20 minutes for 80 minutes). The primary outcome was change in pain intensity from baseline to 80 minutes or time of ED discharge if subjects remained in the ED for fewer than 80 minutes after treatment. Sedation and nausea were assessed every 20 minutes with visual analog scale scales, and subjects were contacted within 72 hours to assess headache recurrence.
Results
Sixty-eight subjects entered the trial, with complete data for 66 subjects. Baseline pain scores were similar for the prochlorperazine/diphenhydramine and sumatriptan groups (76 versus 71 mm). Mean reductions in pain intensity at 80 minutes or time of ED discharge were 73 mm for the prochlorperazine/diphenhydramine group and 50 mm for those receiving sumatriptan (mean difference 23 mm; 95% confidence interval 11 to 36 mm). Sedation, nausea, and headache recurrence rates were similar.
Conclusion
IV prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the treatment of migraine.
14. Tranexamic acid cuts deaths in trauma patients at risk of major bleeding
Philip Wilson. BMJ 2010;340:c3214
Administering tranexamic acid to trauma patients at risk of major bleeding reduces all cause mortality as well as mortality from bleeding, a new trial has found.
World Health Organization figures give injury as the cause of 5.8 million deaths worldwide each year. The trial estimates that widespread adoption of tranexamic acid as a treatment for trauma could prevent 13 000 deaths a year in India, 12 000 in China, 2000 in the United States, and several hundred in the United Kingdom.
The trial included 20 000 adults in 40 countries. Trauma victims judged likely to need an early blood transfusion were randomly allocated to receive 1 g of tranexamic acid within eight hours of trauma, followed by 1 g administered intravenously over eight hours, or a matching placebo.
Tranexamic acid, an antifibrinolytic drug often used to prevent bleeding after surgery, reduced the number of deaths occurring in hospital within four weeks of the injury. All cause mortality was 14.5% among patients treated with tranexamic acid and 16% in the placebo group (relative risk 0.91 (95% confidence interval 0.85 to 0.97)). Tranexamic acid also reduced disability: 14.7% of patients in the treatment group and 13.3% in the placebo group had no disabilities at discharge (relative risk 1.11 (1.04 to 1.19)).
The research, reported online in the Lancet, found no corresponding increase in vascular occlusive events.
Ian Roberts, professor of epidemiology and public health at the London School of Hygiene and Tropical Medicine and one of the study’s authors, said that every year about 600 000 injured patients worldwide bleed to death.
He said, "Injuries may be accidental, for example road traffic crashes, or intentional, such as shootings, stabbings, or landmine injuries, and the majority of deaths occur soon after injury. Although most deaths from injuries are in developing countries, injury is a leading cause of death in young adults throughout the world.
"It’s important to remember that deaths from injuries are increasing around the world and that they usually involve young adults, often the main breadwinner in the family. The impact on the family is devastating."
Tranexamic acid is inexpensive, stable in heat, and available in generic forms, making it a practicable treatment in a wide range of healthcare settings.
Professor Roberts estimated the cost of the drug to be £6 (7.2; $8.9) a patient, saying that although a formal cost effectiveness evaluation is pending, the drug represents "one of the cheapest ways to save a life there is."
Tranexamic acid has previously been shown to reduce the need for blood transfusions in patients undergoing elective surgery.
The researchers conclude that "tranexamic acid should be available to doctors treating trauma patients in all countries, and this drug should be considered for inclusion on the WHO List of Essential Medicines."
The research was funded by the UK government through the health technology assessment programme of the National Institute for Health Research.
The health minister Frederick Howe said, "I am delighted that through the National Institute for Health Research the Department of Health has funded this research which shows that TXA [tranexamic acid] can be used safely on patients with recent, severe bleeding caused by injury.
"This is a great example of how important research can help the NHS save more lives and spread best practice around the world."
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20554319
J Watch Review: http://emergency-medicine.jwatch.org/cgi/content/full/2010/615/1
15. Thoracic electrical bioimpedance: a tool to determine cardiac versus non-cardiac causes of acute dyspnoea in the emergency department
Vorwerk C, et al. Emerg Med J 2010;27:359-363
Objectives: To determine whether cardiohaemodynamic parameters, using non-invasive thoracic electrical bioimpedance (TEB), can differentiate between cardiac and non-cardiac causes of acute breathlessness in adult emergency department (ED) patients.
Methods: A prospective cohort study of adult patients who presented with acute breathlessness to the ED of a large urban teaching hospital. Study patients had their cardiohaemodynamic parameters measured, using a TEB device. The patient’s hospital discharge diagnosis was used as the definitive diagnosis to determine whether the underlying cause of acute dyspnoea was cardiac or non-cardiac related. The definitive diagnosis was compared with the TEB data and the ED physician’s diagnosis.
Results: 52 patients were recruited into the study, of whom 51 had complete TEB data and were included in the analysis. There were statistically significant differences in cardiac output (6.2 vs 7.9, p less than 0.001), cardiac index (CI; 3.1 vs 4.4, p less than 0.001), systemic vascular resistance (1227 vs 933, p=0.002) and systemic vascular resistance index (2403 vs 1681, p less than 0.001) between the cardiac and non-cardiac cohort. CI was found to be an excellent discriminator (receiver operating characteristics area under the curve 0.906). The optimal diagnostic criterion for CI to distinguish between cardiac and non-cardiac dyspnoea was 3.2 l/min per square metre or less (positive likelihood ratio 7.9; negative likelihood ratio 0.14).
Conclusion: This study demonstrated that non-invasive TEB cardiohaemodynamic parameters can differentiate between cardiac and non-cardiac-related causes of dyspnoea in ED patients presenting with acute breathlessness. A large-scale trial is required to determine if TEB-derived cardiohaemodynamic information can aid ED clinicians in their early clinical decision-making and improve the care and outcome of patients with dyspnoea.
16. The (relative) accuracy of pulse oximetry in ED patients with severe sepsis and septic shock: a retrospective cohort study
Wilson BJ, et al. BMC Emergency Medicine 2010, 10:9
Background
Pulse oximetry is routinely used to continuously and noninvasively monitor arterial oxygen saturation (SaO2) in critically ill patients. Although pulse oximeter oxygen saturation (SpO2) has been studied in several patient populations, including the critically ill, its accuracy has never been studied in emergency department (ED) patients with severe sepsis and septic shock. Sepsis results in characteristic microcirculatory derangements that could theoretically affect pulse oximeter accuracy. The purposes of the present study were twofold: 1) to determine the accuracy of pulse oximetry relative to SaO2 obtained from ABG in ED patients with severe sepsis and septic shock, and 2) to assess the impact of specific physiologic factors on this accuracy.
Methods
This analysis consisted of a retrospective cohort of 88 consecutive ED patients with severe sepsis who had a simultaneous arterial blood gas and an SpO2 value recorded. Adult ICU patients that were admitted from any Calgary Health Region adult ED with a pre-specified, sepsis-related admission diagnosis between October 1, 2005 and September 30, 2006, were identified. Accuracy (SpO2 - SaO2) was analyzed by the method of Bland and Altman. The effects of hypoxemia, acidosis, hyperlactatemia, anemia, and the use of vasoactive drugs on bias were determined.
Results
The cohort consisted of 88 subjects, with a mean age of 57 years (19 - 89). The mean difference (SpO2 - SaO2) was 2.75% and the standard deviation of the differences was 3.1%. Subgroup analysis demonstrated that hypoxemia (SaO2 below 90) significantly affected pulse oximeter accuracy. The mean difference was 4.9% in hypoxemic patients and 1.89% in non-hypoxemic patients (p less than 0.004). In 50% (11/22) of cases in which SpO2 was in the 90-93% range the SaO2 was below 90%. Though pulse oximeter accuracy was not affected by acidoisis, hyperlactatementa, anemia or vasoactive drugs, these factors worsened precision.
Conclusions
Pulse oximetry overestimates ABG-determined SaO2 by a mean of 2.75% in emergency department patients with severe sepsis and septic shock. This overestimation is exacerbated by the presence of hypoxemia. When SaO2 needs to be determined with a high degree of accuracy arterial blood gases are recommended.
Full-text (free): http://www.biomedcentral.com/1471-227X/10/9
17. Improving Crotalidae polyvalent immune Fab reconstitution times
Quan AN, et al. Amer J Emerg Med. 2010;28:593-595.
Background
Crotalidae polyvalent immune Fab (CroFab) is used to treat rattlesnake envenomations in the United States. Time to infusion may be a critical factor in the treatment of these bites. Per manufacturer's instructions, 10 mL of sterile water for injection (SWI) and hand swirling are recommended for reconstitution. We wondered whether completely filling vials with 25 mL of SWI would result in shorter reconstitution times than using 10-mL volumes and how hand mixing compared to mechanical agitation of vials or leaving vials undisturbed.
Methods
Six sets of 5 vials were filled with either 10 mL or 25 mL. Three mixing techniques were used as follows: undisturbed; agitation with a mechanical agitator; and continuous hand rolling and inverting of vials. Dissolution was determined by observation and time to complete dissolution for each vial. Nonparametric 2-tailed P values were calculated.
Results
Filling vials completely with 25 mL resulted in quicker dissolution than using 10-mL volumes, regardless of mixing method (2-tailed P = .024). Mixing by hand was shorter than other methods (P less than .001). Reconstitution with 25 mL and hand mixing resulted in the shortest dissolution times (median, 1.1 minutes; range, 0.9-1.3 minutes). This appeared clinically important because dissolution times using 10 mL and mechanical rocking of vials (median, 26.4 minutes) or leaving vials undisturbed (median, 33.6 minutes) was several-fold longer.
Conclusion
Hand mixing after filling vials completely with 25 mL results in shorter dissolution times than using 10 mL or other methods of mixing and is recommended, especially when preparing initial doses of CroFab.
18. Factors Associated with Positive D-dimer Results in Patients Evaluated for Pulmonary Embolism
Kabrhel C, et al. Acad Emerg Med. 2010;17:589-597.
Objectives: Available D-dimer assays have low specificity and may increase radiographic testing for pulmonary embolism (PE). To help clinicians better target testing, this study sought to quantify the effect of risk factors for a positive quantitative D-dimer in patients evaluated for PE.
Methods: This was a prospective, multicenter, observational study. Emergency department (ED) patients evaluated for PE with a quantitative D-dimer were eligible for inclusion. The main outcome of interest was a positive D-dimer. Odds ratio (ORs) and 95% confidence intervals (CIs) were determined by multivariable logistic regression. Adjusted estimates of relative risk were also calculated.
Results: A total of 4,346 patients had D-dimer testing, of whom 2,930 (67%) were women. A total of 2,500 (57%) were white, 1,474 (34%) were black or African American, 238 (6%) were Hispanic, and 144 (3%) were of other race or ethnicity. The mean (±SD) age was 48 (±17) years. Overall, 1,903 (44%) D-dimers were positive. Model fit was adequate (c-statistic = 0.739, Hosmer and Lemeshow p-value = 0.13). Significant positive predictors of D-dimer positive included female sex; increasing age; black (vs. white) race; cocaine use; general, limb, or neurologic immobility; hemoptysis; hemodialysis; active malignancy; rheumatoid arthritis; lupus; sickle cell disease; prior venous thromboembolism (VTE; not under treatment); pregnancy and postpartum state; and abdominal, chest, orthopedic, or other surgery. Warfarin use was protective. In contrast, several variables known to be associated with PE were not associated with positive D-dimer results: body mass index (BMI), estrogen use, family history of PE, (inactive) malignancy, thrombophilia, trauma within 4 weeks, travel, and prior VTE (under treatment).
Conclusions: Many factors are associated with a positive D-dimer test. The effect of these factors on the usefulness of the test should be considered prior to ordering a D-dimer.
19. Ultrasound guidance for central venous catheter placement: results from the Central Line Emergency Access Registry Database
Balls A, et al. Amer J Emerg Med. 2010;28:561-567.
Background
Ultrasound guidance of central venous catheter (CVC) insertion improves success rates and reduces complications and is recommended by several professional and regulatory organizations.
Methods
This is a prospective observational study using data extracted from the Central Line Emergency Access Registry database, a multicenter online registry of CVC insertions from medical centers throughout the United States. We compared success rates with ultrasound and with the anatomic-landmark technique.
Results
A total of 1250 CVC placement attempts by emergency medicine residents during the study period were selected from the Central Line Emergency Access Registry database. Because a few attempts (n = 28) were made to place lines in either the left or right supraclavicular locations, data on these attempts were eliminated from the analysis. A total of 1222 CVC attempts from 5 institutions were analyzed. Successful placement on the first attempt occurred in 1161 (86%) cases and varied according to anatomic location. Ultrasound guidance was used in 478 (41%) of the initial attempts. The remainder of placements were presumably placed using the anatomic-landmark technique based on visible surface and palpatory subcutaneous structures. Overall successful placement rate did not vary according to the use of ultrasound guidance, nor did it vary at different anatomic sites. However, ultrasound was found to be significant for reducing the total number of punctures per attempt (P less than .02, t = 2.30).
Conclusions
Our study did not observe improved success with the use of ultrasound for CVC cannulation on the first attempt, but we did observe a reduced number of total punctures per attempt.
20. The impact of removing financial incentives from clinical quality indicators: longitudinal analysis of four Kaiser Permanente indicators
Lester H, et al. BMJ 2010;340:c1898
Objective: To evaluate the effect of financial incentives on four clinical quality indicators common to pay for performance plans in the United Kingdom and at Kaiser Permanente in California.
Design Longitudinal analysis.
Setting: 35 medical facilities of Kaiser Permanente Northern California, 1997-2007.
Participants: 2 523 659 adult members of Kaiser Permanente Northern California.
Main outcomes measures: Yearly assessment of patient level glycaemic control (HbA1c below 8%), screening for diabetic retinopathy, control of hypertension (systolic blood pressure below 140 mm Hg), and screening for cervical cancer.
Results: Incentives for two indicators—screening for diabetic retinopathy and for cervical cancer—were removed during the study period. During the five consecutive years when financial incentives were attached to screening for diabetic retinopathy (1999-2003), the rate rose from 84.9% to 88.1%. This was followed by four years without incentives when the rate fell year on year to 80.5%. During the two initial years when financial incentives were attached to cervical cancer screening (1999-2000), the screening rate rose slightly, from 77.4% to 78.0%. During the next five years when financial incentives were removed, screening rates fell year on year to 74.3%. Incentives were then reattached for two years (2006-7) and screening rates began to increase. Across the 35 facilities, the removal of incentives was associated with a decrease in performance of about 3% per year on average for screening for diabetic retinopathy and about 1.6% per year for cervical cancer screening.
Conclusion: Policy makers and clinicians should be aware that removing facility directed financial incentives from clinical indicators may mean that performance levels decline.
Full-text: http://www.bmj.com/cgi/content/full/340/may11_1/c1898
21. Personality traits of emergency physicians and paramedics
Pajonk F, et al. Emerg Med J. 2010: in print
Objective: Personality influences behaviour and decision-making. This may play a particular role in emergency medical personnel (EMP) dealing with critical situations. So far very little is known about personality traits that distinguish paramedics (PM) and emergency physicians (EP) from other medical staff.
Methods: A questionnaire including the ultra-short version of the Hamburg Personality Inventory (HPA) was distributed to EP, PM, medical doctors not practicing emergency medicine (MD) and medical students (MS).
Results: 274 EPs, 245 PMs, 48 MDs and 60 MSs returned the questionnaire. Four personality clusters in EPs and PMs were identified and to be found largely independent from demographic and job-related variables. For both groups one cluster revealed personality characteristics that seem particularly suitable for EMP (‘resilient crisis manager’). ‘Anxious’ and ‘insecure’ personality traits were found in two clusters in PMs and in one cluster in EPs. Mental health problems in the participants or their relatives or the experience of loss increased scores in the dimensions neuroticism and openness.
Conclusions: The personality characteristics of EPs and PMs are not homogenous and do not differ substantially from those of MDs and MSs. 50–70% of EMP can be characterised as ‘resilient and stable’, up to 30–40% as ‘anxious and insecure’. The presence of mental health problems in participants or their relatives or the experience of loss may lead to openness for new experiences and alternative behaviour or – on the other hand – may trigger feelings of insecurity and/or anxiety in emergency situations.
Saturday, June 26, 2010
Saturday, June 05, 2010
Lit Bits: June 5, 2010
From the recent medical literature...
1. Silent Pulmonary Embolism in Patients with Deep Venous Thrombosis: A Systematic Review
Stein PD, et al. Amer J Med. 2010;123:426-431.
Purpose
To determine, by systematic review of the literature, the prevalence of silent pulmonary embolism in patients with deep venous thrombosis.
Methods
Twenty-eight included published investigations were identified through PubMed. Studies were selected if methods of diagnosis of pulmonary embolism were described; if pulmonary embolism was stated to be asymptomatic; and if raw data were presented. Studies were stratified according to whether silent pulmonary embolism was diagnosed by a high-probability ventilation-perfusion lung scan using criteria from the Prospective Investigation of Pulmonary Embolism Diagnosis, computed tomography pulmonary angiography, or conventional pulmonary angiography (Tier 1), or by lung scans based on non-Prospective Investigation of Pulmonary Embolism Diagnosis criteria (Tier 2).
Results
Silent pulmonary embolism was diagnosed in 1665 of 5233 patients (32%) with deep venous thrombosis. This is a conservative estimate because many of the investigations used stringent criteria for the diagnosis of pulmonary embolism. The incidence of silent pulmonary embolism was higher with proximal deep venous thrombosis than with distal deep venous thrombosis. Silent pulmonary embolism seemed to increase the risk of recurrent pulmonary embolism: 25 of 488 (5.1%) with silent pulmonary embolism versus 7 of 1093 (0.6%) without silent pulmonary embolism.
Conclusion
Silent pulmonary embolism sometimes involved central pulmonary arteries. Because approximately one third of patients with deep venous thrombosis have silent pulmonary embolism, routine screening for pulmonary embolism may be advantageous.
Full-text (free): http://www.amjmed.com/article/PIIS0002934309011115/fulltext
2. β-Blockers OK for Chest Pain Associated with Recent Cocaine Use
Rangel C, et al. Arch Intern Med. 2010;170:874-879.
Background: Although β-blockers prevent adverse events after myocardial infarction, they are contraindicated when chest pain is associated with recent cocaine use. Recommendations against this use of β-blockers are based on animal studies, small human experiments, and anecdote. We sought to test the hypothesis that β-blockers are safe in this setting.
Methods: We performed a retrospective cohort study of consecutive patients admitted to the San Francisco General Hospital, San Francisco, California, with chest pain and urine toxicologic test results positive for cocaine, from January 2001 to December 2006. Mortality data were collected from the National Death Index.
Results: Of 331 patients with chest pain in the setting of recent cocaine use, 151 (46%) received a β-blocker in the emergency department. There were no meaningful differences in electrocardiographic changes, troponin levels, length of stay, use of vasopressor agents, intubation, ventricular tachycardia or ventricular fibrillation, or death between those who did and did not receive a β-blocker. After adjusting for potential confounders, systolic blood pressure significantly decreased a mean 8.6 mm Hg (95% confidence interval, 14.7-2.5 mm Hg) in those receiving a β-blocker in the emergency department compared with those who received their first β-blocker in the hospital ward (P = .006). Over a median follow-up of 972 days (interquartile range, 555-1490 days), after adjusting for potential confounders, patients discharged on a β-blocker regimen exhibited a significant reduction in cardiovascular death (hazard ratio, 0.29; 95% confidence interval, 0.09-0.98) (P = .047).
Conclusion: β-Blockers do not appear to be associated with adverse events in patients with chest pain with recent cocaine use.
3. FDA enlists doctors to help spot misleading drug advertisements
Janice Hopkins Tanne. BMJ 2010;340:c2594
The US Food and Drug Administration has launched a programme called "Bad Ad" to enlist doctors in reporting false or misleading drug advertising or promotions.
Drug company advertising, promotional materials, presentations at medical meetings, and presentations to individual doctors by sales representatives are supposed to be accurate and balanced. They should present the risks and the benefits of a drug, and they should not promote a drug for unapproved, or "off label," uses.
The FDA, however, has only a few dozen staff members to review hundreds of drug advertisements, brochures, and presentations that companies voluntarily submit to the agency, say the Associated Press news agency. And it has no way of knowing what drug company sales representatives say to doctors over dinner or in a chat at a meeting.
The "Bad Ad" educational programme "is designed to educate healthcare providers about the role they can play in helping the agency make sure that prescription drug advertising is truthful and not misleading," the FDA said.
The programme begins immediately and is administered by the agency’s division of drug marketing, advertising, and communication in the Center for Drug Evaluation and Research. The division regulates presentations by sales representatives, presentations at speaker programmes, radio and television advertising, and all written or printed prescription drug promotional material.
The idea, several news accounts say, came from former drug company sales representatives who now work for the FDA.
The FDA says common drug company violations are omitting or downplaying risk, overstating drug effectiveness, promoting unapproved uses, and misleading drug comparisons.
It gives three examples of violations: omitting risk when a speaker programme has a slide show that presents efficacy information but not risk information; when a drug company representative in the exhibit hall at a conference tells a doctor that a drug is effective for a non-approved use; and when a sales representative tells a doctor that a drug delivers rapid results in days when clinical trials have shown results are seen only weeks later.
Doctors who see or hear misleading information are asked to contact the FDA, which has set up a reporting telephone line. They can report anonymously, although the FDA encourages them to include contact information and evidence of the misleading promotion. "Whistleblowers" who have reported drug company misdeeds have received a part of the fine companies paid.
The FDA will also set up information booths at major medical conferences to educate doctors about possibly misleading pitches, Reuters reported. The FDA is also sending letters to about 33 000 healthcare providers about the campaign.
In a related issue, the not for profit Center for Digital Democracy sent a letter to Dr Margaret Hamburg, the FDA commissioner, asking the agency to consider placing restrictions on how drug and medical device companies can use websites and social media—which often have very short messages—to promote their products.
4. Safety of Assessment of Patients with Potential Ischemic Chest Pain in an Emergency Department Waiting Room: A Prospective Comparative Cohort Study
Scheuermeyer FX, et al. Ann Emerg Med. 2010; in press…
Editor’s Capsule Summary: Crowding can lead to delays in the evaluation and management of patients. Can selected emergency department (ED) patients complaining of chest pain safely receive some or all of their care in the waiting room?
There were no missed cases of acute coronary syndrome and no important complications in the
303 patients triaged to the waiting room. This study suggests that with careful triage and prompt physician assessment, waiting room management might be an adequate, albeit not optimal, means of managing low-risk chest pain patients when there are no monitored beds available in the ED.
Replication of this study with a larger number of subjects at multiple sites will be needed to establish exactly how safe this strategy is.
Full-text (free): http://www.annemergmed.com/webfiles/images/journals/ymem/fxscheuermeyer.pdf
5. Optimal Position for Pediatric Lumbar Puncture
Ultrasound measurement showed that sitting with hips flexed maximizes interspinous process distances in children.
Abo A et al. Pediatrics 2010 May; 125:e114
BACKGROUND Lumbar punctures are commonly performed in the pediatric emergency department. There is no standard, recommended, optimal position for children who are undergoing the procedure.
OBJECTIVE To determine a position for lumbar punctures where the interspinous space is maximized, as measured by bedside ultrasound.
METHODS A prospective convenience sample of children under age 12 was performed. Using a portable ultrasound device, the L3-L4 or L4-L5 interspinous space was measured with the subject in 5 different positions. The primary outcome was the interspinous distance between 2 adjacent vertebrae. The interspinous space was measured with the subject sitting with and without hip flexion. In the lateral recumbent position, the interspinous space was measured with the hips in a neutral position as well as in flexion, both with and without neck flexion. Data were analyzed by comparing pairwise differences.
RESULTS There were 28 subjects enrolled (13 girls and 15 boys) at a median age of 5 years. The sitting-flexed position provided a significantly increased interspinous space (P less than .05). Flexion of the hips increased the interspinous space in both the sitting and lateral recumbent positions (P less than .05). Flexion of the neck, did not significantly change the interspinous space (P = .998).
CONCLUSIONS The interspinous space of the lumbar spine was maximally increased with children in the sitting position with flexed hips; therefore we recommend this position for lumbar punctures. In the lateral recumbent position, neck flexion does not increase the interspinous space and may increase morbidity; therefore, it is recommended to hold patients at the level of the shoulders as to avoid neck flexion.
6. “Hospitalists Rock,” Says New York Times
By Jane Gross. New York Times. May 26, 2010. PHILADELPHIA — By the time Djigui Keita left the hospital for home, his follow-up appointment had been scheduled. Emergency health insurance was arranged until he could apply for public assistance. He knew about changes in his medication — his doctor had found less expensive brands at local pharmacy chains. And Mr. Keita, 35, who had passed out from dehydration, was cautioned to carry spare water bottles in the taxi he drove for a living.
Dr. Subha Airan-Javia spoke with a patient, Djigui Keita, and handled many details of his care, relieving the burden on family doctors who are pressed for time.
The hourlong briefing the home-bound patient received here at the Hospital of the University of Pennsylvania was orchestrated by a hospitalist, a member of America’s fastest-growing medical specialty. Over a decade, this breed of physician-administrator has increasingly taken over the care of the hospitalized patient from overburdened family doctors with less and less time to make hospital rounds — or, as in Mr. Keita’s case, when there is no family doctor at all.
Because hospitalists are on top of everything that happens to a patient — from entry through treatment and discharge — they are largely credited with reducing the length of hospital stays by anywhere from 17 to 30 percent, and reducing costs by 13 to 20 percent, according to studies in The Journal of the American Medical Association. As their numbers have grown, from 800 in the 1990s to 30,000 today, medical experts have come to see hospitalists as potential leaders in the transition to the Obama administration’s health care reforms, to be phased in by 2014.
Under the new legislation, hospitals will be penalized for readmissions, medical errors and inefficient operating systems. Avoidable readmissions are the costliest mistakes for the government and the taxpayer, and they now occur for one in five patients, gobbling $17.4 billion of Medicare’s current $102.6 billion budget.
Dr. Subha Airan-Javia, Mr. Keita’s hospitalist, splits her time between clinical care and designing computer programs to contain costs and manage staff workflow. The discharge process she walked Mr. Keita and his wife through can work well, or badly, with very different results. Do it safely and the patient gets better. Do it wrong, and he’s back on the hospital doorstep — with a second set of bills.
“Where we were headed was not a mystery to anyone immersed in health care,” said P. J. Brennan, the chief medical officer for the University of Pennsylvania’s hospitals. “We were getting paid to have people in the hospital and the part of that which was waste was under the gun. These young doctors, coming into a highly dysfunctional environment, had an affinity for working on processes and redesigning systems.”
The article continues here: http://www.nytimes.com/2010/05/27/us/27hosp.html
7. Researchers Explore the Benefits of Sleep--and the Problems with Sleep-Deprivation
SAN DIEGO—A panel of researchers with expertise in infant learning, adolescent drug use, aging, and memory convened for a symposium at the AAAS Annual Meeting, and as they described their research in detail, the conclusion was inescapable:
America, you need a nap.
“People are definitely sleep-deprived,” Sara Mednick, an assistant professor of psychiatry at the University of California, San Diego, said in a AAAS podcast.
"That sleep-deprivation is leading to increased risk for cardiovascular disease, depression, mood problems, weight gain, obesity, and diabetes. A lot of different health concerns seem to be helped by good sleep and damaged by poor sleep.”
More on recent sleep research: http://news.aaas.org/2010/0224this-story-could-put-you-to-sleep.shtml
8. Emergency Department Interruptions Adversely Affect Patient Satisfaction
Most physician interruptions are generated by other healthcare providers.
Jeanmonod R et al. Emerg Med J 2010 May; 27:376.
Objective: To explore the nature of interruptions that occur during clinical practice in the emergency department (ED). We determined the frequency, duration and type of interruptions that occurred. We then determined the impact on patient satisfaction of those interruptions occurring at the bedside.
Methods: This was a cohort study of ED physicians and physicians in training. Trained research associates were assigned to an individual provider during 4-hour blocks of time during day and evening shifts. The research associates recorded the activity that was interrupted, as well as the nature and the duration of the interruption. If the interruption occurred during the principal interaction with a patient, the patient's satisfaction score was recorded on a 10-point scale.
Results: Physicians were commonly interrupted in all clinical activities, but most frequently during reviewing of data (53%) and charting (50%). Bedside interruptions occurred 26% of the time, and had a negative impact on patient satisfaction. The majority of interruptions (60%) were initiated by another healthcare provider (physician or nurse). Interruptions only rarely resulted in a physician changing tasks before completion.
Conclusion: Interruptions occur commonly during all clinical activities in the ED, and are frequently generated by providers themselves. These have a negative impact on patient satisfaction. The direct impact on medical errors or on provider satisfaction has not been determined.
See related article: first entry here: http://drvinsonlitbits.blogspot.com/2010/05/lit-bits-may-21-2010.html
9. Randomized Clinical Trial of Propofol Versus Ketamine for Procedural Sedation in the Emergency Department
Miner JR, et al. Acad Emerg Med. 2010;17:604-611.
Objectives: The objective was to compare the occurrence of respiratory depression, adverse events, and recovery duration of propofol versus ketamine for use in procedural sedation in the emergency department (ED).
Methods: This was a randomized nonblinded prospective clinical trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were treated with intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients were randomized to receive either propofol 1 mg/kg IV followed by 0.5 mg/kg every 3 minutes as needed or ketamine 1.0 mg/kg IV followed by 0.5 mg/kg every 3 minutes as needed. Doses, vital signs, nasal end-tidal CO2 (ETCO2), and pulse oximetry were recorded. Subclinical respiratory depression was defined as a change in ETCO2 of greater than 10 mm Hg, an oxygen saturation of less than 92% at any time, or an absent ETCO2 waveform at any time. Clinical interventions related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure and had recall of the procedure. Physicians were asked to describe any adverse events or the occurrence of recovery agitation.
Results: One-hundred patients were enrolled; 97 underwent sedation and were included in the analysis. Fifty patients received propofol and 47 received ketamine. Subclinical respiratory depression was seen in 20 of 50 patients in the propofol group and 30 of 47 patients in the ketamine group (p = 0.019, effect size 22.8%; 95% CI = 4.0% to 43.6%). Clinical interventions related to respiratory depression were used in 26 of 50 propofol patients and 19 of 47 ketamine patients (p = 0.253, effect size = −13.7%; 95% CI = −33.8% to 6.4%). The median times of the procedures were 11 minutes (range = 4 to 33 minutes) for the ketamine group versus 10 minutes (range = 5 to 33 minutes) for the propofol group (p = 0.256). The median time to return to baseline mental status after the procedure was completed was 14 minutes (range = 2 to 47 minutes) for the ketamine group and 5 minutes (range = 1 to 32 minutes) for the propofol group (p less than 0.001). Pain during the procedure was reported by 3 of 50 patients in the propofol group and 1 of 47 patients in the ketamine group (effect size = −3.9%, 95% confidence interval [CI] = −11.9 to 4.1). Recall of some part of the procedure was reported by 4 of 50 patients in the propofol group and 6 of 47 patients in the ketamine group (effect size = 4.8%, 95% CI = −7.6% to 17.1%). Forty-eight of 50 procedures were successful in the propofol group and 43 of 47 in the ketamine group (p = 0.357, effect size = 0.3%; 95% CI = −7.8% to 8.4%). Recovery agitation was reported in 4 of 50 in the propofol group and 17 of 47 in the ketamine group (effect size = 28.2%, 95% CI = 12.4% to 43.9%).
Conclusions: This study detected a higher rate of subclinical respiratory depression in patients in the ketamine group than the propofol group. There was no difference in the rate of clinical interventions related to respiratory depression, pain, or recall of the procedure between the groups. Recovery agitation was seen more frequently in patients receiving ketamine than in those receiving propofol. The time to regain baseline mental status was longer in the ketamine group than the propofol group. This study suggests that the use of either ketamine or propofol is safe and effective for procedural sedation in the ED.
10. US heart association endorses active video games
Jeanne Lenzer. BMJ 2010;340:c2802
The American Heart Association announced that it has entered into a "strategic relationship" with Nintendo of America to endorse the company’s active video games, known as Wii.
The videos include titles such as Wii Tennis and Battalion Wars 2. Players gesture with hand-held devices that interact with the videos to simulate action, such as playing a sport or killing an opponent with a nunchuk.
The association endorsed the video games as part of its campaign against obesity, saying that 70% of US citizens don’t get adequate exercise. The association’s logo will be stamped on all Wii game packaging, indicating that it is a "healthy heart product," said Clyde Yancy, cardiologist and president of the American Heart Association.
Dr Yancy said that Nintendo has agreed to give a $1.5m (£1m; 1.2m) "gift" to the association, which he said will be used for "heart healthy messaging."
In late 2009, the association issued a news release stating that a study funded by Nintendo, found that playing some Wii games led to activity equal to moderate exercise, thereby helping to "prevent or improve obesity and lifestyle-related diseases." In February, the association reported that another study funded by Nintendo showed that some stroke patients could improve their fine and gross motor function by playing the games.
The endorsement has sparked criticism. During an interview on the popular television news programme, Good Morning, America, Richard Besser, former acting director of the Centers for Disease Control and Prevention and now medical commentator, asked Dr Yancy, whether he was concerned that the endorsement might damage the integrity of the association. Dr Yancy said that although the association accepted money from Nintendo, "The logo is not for sale" (http://abcnews.go.com/Health/HeartHealth/wii-worthy-american-heart-assn-endorsement/story?id=10663377).
Dr Besser said the association’s marketing documents show endorsements by the association are "proven to boost sales" of endorsed products, which translate into "big money for the heart association and big money for the manufacturers." Dr Besser commented, "Here you have a . . . medical association that sets standards for physical activity, that’s taking one and a half million dollars from a video game company; how will they be free to criticise that industry and its contribution to obesity?"
The association responded to a study cited by Dr Besser, which found that found only a small number of the games engaged children in moderate-intensity exercise (Pediatrics 2009, 124;2:763-71; doi:10.1542/peds.2008-2357), stating: "We agree that participating in an actual sport is usually more vigorous than active gaming. But active gaming compares very well with sitting on the couch" (www.newsroom.heart.org/index.php?s=43&item=1038).
Other critics focused on the endorsement of products by a single manufacturer. Technology expert, Jared Newman, wrote in the online computer journal PC World that the association "could be doing so much more with the active play concept. It could rate individual games based on the difficulty of their workouts. It could give advice on how to make the most of each exercise game . . . As it stands, the partnership between Nintendo and the [association] is a gimmick whose value barely exceeds the bullet points on the back of game boxes (www.pcworld.com/article/196507/nintendo_and_heart_association_team_up_fall_short.html).
11. Clinical Diagnostic Model for Predicting Serious Bacterial Infections in Febrile Children
The diagnostic model was more accurate than physician judgment.
Febrile illnesses in young children account for about 25 million medical visits annually in the U.S. The challenge for clinicians is distinguishing between viral illnesses and serious bacterial infections (SBIs) and deciding whether to initiate antibiotic treatment. Investigators prospectively tested the accuracy of a clinical diagnostic model for predicting SBI in 12,807 febrile children younger than 5 years who presented to one emergency department (ED) during the 2-year study (2004–2006). Cancer and transplant patients were excluded.
Clinicians recorded 40 signs and symptoms for 15,781 febrile illnesses and followed children until they had confirmed diagnoses or no fever for 24 hours. Children were classified with SBIs (i.e., urinary tract infection [UTI], pneumonia, or bacteremia), clinically diagnosed infections (e.g., otitis media, sinusitis, or cellulitis), or no bacterial infections using radiological and microbiological tests. The prevalences of UTI, pneumonia, and bacteremia were 3.4%, 3.4%, and 0.4%, respectively; antibiotics were prescribed at initial presentation in 67%, 69%, and 81% of children with these illnesses, respectively. Seventy-five percent of children with clinically diagnosed infections and 20% without identified infections received antibiotics. Osteomyelitis, septic arthritis, and meningitis were rare (less than 12 cases each) and, therefore, these data were not included in the diagnostic model.
Twenty-six clinical signs and symptoms were included in the logistic regression diagnostic model. The diagnostic accuracy of the model (reported as the area under the receiver operating characteristic curve) was 0.80 for UTI, 0.84 for pneumonia, and 0.88 for bacteremia. The strongest predictors of SBI were unwell appearance, elevated body temperature, reduced fluid intake, increased capillary refill time, and chronic disease.
Comment: Clinicians are continuously seeking a model or scoring system to help predict whether a young febrile child has a serious bacterial infection. In this ED study population, which might have a higher prevalence of SBI (7.2%) than in a primary care population, the diagnostic model was more accurate at ruling out SBI than was physician judgment (physicians prescribed antibiotics in only 70%–80% of SBI cases). Whether use of the model would have changed the decision-making process or patient outcomes is unknown. This model should be validated in other settings with lower prevalences of SBIs before it is implemented as a predictive tool.
— Robin Drucker, MD. Published in Journal Watch Pediatrics and Adolescent Medicine May 19, 2010. Citation: Craig JC et al. The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: Prospective cohort study of 15 781 febrile illnesses. BMJ 2010 Apr 20; 340:c1594. (http://dx.doi.org/10.1136/bmj.c1594)
12. The Root of the Problem: Emergency Physicians Struggle To Provide Dental Care When No One Else Will
Maryn McKenna. Ann Emerg Med. 2010;55:A17-A19.
Winters in Minneapolis are hard, and the winter of 2009-10 was harder than most. The snow came earlier than usual and lasted later, and periodic sleet storms and below-zero flash freezes left streets and sidewalks sheathed in long-lasting ice. In the emergency department (ED) of Hennepin County Medical Center, the public hospital for downtown Minneapolis, there was a constant stream of broken bones and severe sprains from frequent tumbles on the ice.
But there's another category of complaint that has kept Hennepin County Medical Center's emergency physicians even more busy than casting wrists and splinting ankles, one that they know will be a constant for their ED through spring, into summer and for the rest of the year: dental problems.
“We probably see numerous dental abscesses a day in the emergency department; we drain them for the most part ourselves or if they are complex we involve the oral surgery service,” said Cheryl Adkisson, MD, an associate professor of emergency medicine at University of Minnesota and an attending at Hennepin County Medical Center. “We get at least one serious enough to require hospitalization every month.”
Dr. Adkisson is in a unique position to appreciate the demands that dealing with nontraumatic dental emergencies places on Hennepin County Medical Center. She is also the hospital's director of hyperbaric medicine. Periodically, those patients with severe infections end up in her hyperbaric chamber—usually for treatment of necrotizing fasciitis that was sparked by infection spreading from a dental abscess.
The traffic through Hennepin County Medical Center's hyperbaric chamber is an extreme expression of a problem with which emergency physicians have become all too familiar. A persistent stream of dental disease is brought to EDs by adults who neglect their oral health or their children's because they cannot afford dental care or cannot find dentists who will accept Medicaid reimbursement.
These dental cases are deeply frustrating to emergency physicians, and not just for the obvious reason that they increase the patient load and, because they are likely to be triaged as low acuity, add to wait times as well. The most frustrating thing, physicians say, is that EDs do not provide what dental patients most need. Physicians can offer only the temporary fixes of a nerve block and an antibiotic prescription, knowing that, unless the patient can find a dentist, he or she will be back in the ED again.
“Myself, like every emergency physician in the country probably, I see patients every shift who come in with untreated caries, abscesses and pain,” said Michael Heller, MD, director of emergency ultrasonography at Beth Israel Medical Center in Manhattan. “I don't want to make the argument that they are choking the emergency department, but they are probably 1% to 2% of patients. But even in New York City, which has a lot of social services, it is very, very hard to find anywhere to send them.”
Public health authorities have been warning for a decade that the burden of dental disease in the population is significant and growing.
In 2000, the first-ever Surgeon General's report on the issue, Oral Health in America, warned that a “silent epidemic of oral diseases is affecting our most vulnerable citizens” and costing up to $60 billon a year in health care spending. Untreated dental caries, the report said, had become the most common disease of childhood, affecting 53 percent of children aged 6 to 8, 5 times more than are diagnosed with asthma.
That estimated disease burden confirmed what physicians at Boston University Medical Center recorded in their ED between 1998 and 2000. Puzzled by what seemed to be high rates of children complaining of long-standing pain and being diagnosed with significant dental abscesses, they did a study and found that 75% of their pediatric population had untreated dental caries. Similarly, a 2000 study by the University of Maryland Dental School of children in Maryland's Head Start program found 52% of them had untreated caries, and a 2002 study in the American Journal of Public Health found untreated caries in 25% of children entering kindergarten. Another study in the same journal found that when adults in Harlem were surveyed about their chief medical complaints, 30% named untreated dental problems as most important.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)00353-7/fulltext
13. Happiness May Come With Age, Study Says
By Nicholas Bakalar. New York Times. May 31, 2010
It is inevitable. The muscles weaken. Hearing and vision fade. We get wrinkled and stooped. We can’t run, or even walk, as fast as we used to. We have aches and pains in parts of our bodies we never even noticed before. We get old.
It sounds miserable, but apparently it is not. A large Gallup poll has found that by almost any measure, people get happier as they get older, and researchers are not sure why.
“It could be that there are environmental changes,” said Arthur A. Stone, the lead author of a new study based on the survey, “or it could be psychological changes about the way we view the world, or it could even be biological — for example brain chemistry or endocrine changes.”
The telephone survey, carried out in 2008, covered more than 340,000 people nationwide, ages 18 to 85, asking various questions about age and sex, current events, personal finances, health and other matters.
The survey also asked about “global well-being” by having each person rank overall life satisfaction on a 10-point scale, an assessment many people may make from time to time, if not in a strictly formalized way.
Finally, there were six yes-or-no questions: Did you experience the following feelings during a large part of the day yesterday: enjoyment, happiness, stress, worry, anger, sadness. The answers, the researchers say, reveal “hedonic well-being,” a person’s immediate experience of those psychological states, unencumbered by revised memories or subjective judgments that the query about general life satisfaction might have evoked.
The results, published online May 17 in the Proceedings of the National Academy of Sciences, were good news for old people, and for those who are getting old. On the global measure, people start out at age 18 feeling pretty good about themselves, and then, apparently, life begins to throw curve balls. They feel worse and worse until they hit 50. At that point, there is a sharp reversal, and people keep getting happier as they age. By the time they are 85, they are even more satisfied with themselves than they were at 18.
The rest of the essay: http://www.nytimes.com/2010/06/01/health/research/01happy.html
PubMed abstract: http://www.ncbi.nlm.nih.gov/pubmed/20479218
14. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis
Costelloe C, et al. BMJ 2010;340:c2096
Objective: To systematically review the literature and, where appropriate, meta-analyse studies investigating subsequent antibiotic resistance in individuals prescribed antibiotics in primary care.
Design Systematic review with meta-analysis.
Data sources: Observational and experimental studies identified through Medline, Embase, and Cochrane searches.
Review methods: Electronic searches using MeSH terms and text words identified 4373 papers. Two independent reviewers assessed quality of eligible studies and extracted data. Meta-analyses were conducted for studies presenting similar outcomes.
Results: The review included 24 studies; 22 involved patients with symptomatic infection and two involved healthy volunteers; 19 were observational studies (of which two were prospective) and five were randomised trials. In five studies of urinary tract bacteria (14 348 participants), the pooled odds ratio (OR) for resistance was 2.5 (95% confidence interval 2.1 to 2.9) within 2 months of antibiotic treatment and 1.33 (1.2 to 1.5) within 12 months. In seven studies of respiratory tract bacteria (2605 participants), pooled ORs were 2.4 (1.4 to 3.9) and 2.4 (1.3 to 4.5) for the same periods, respectively. Studies reporting the quantity of antibiotic prescribed found that longer duration and multiple courses were associated with higher rates of resistance. Studies comparing the potential for different antibiotics to induce resistance showed no consistent effects. Only one prospective study reported changes in resistance over a long period; pooled ORs fell from 12.2 (6.8 to 22.1) at 1 week to 6.1 (2.8 to 13.4) at 1 month, 3.6 (2.2 to 6.0) at 2 months, and 2.2 (1.3 to 3.6) at 6 months.
Conclusions: Individuals prescribed an antibiotic in primary care for a respiratory or urinary infection develop bacterial resistance to that antibiotic. The effect is greatest in the month immediately after treatment but may persist for up to 12 months. This effect not only increases the population carriage of organisms resistant to first line antibiotics, but also creates the conditions for increased use of second line antibiotics in the community.
15. Images in Emergency Medicine
An Adult Male With a Recreational Ankle Injury
http://www.annemergmed.com/article/S0196-0644(09)01262-1/fulltext
Young Man with Foreign-Body Sensation in the Right Eye
http://www.annemergmed.com/article/S0196-0644(09)01136-6/fulltext
16. External Validation of the Clinical Dehydration Scale for Children with Acute Gastroenteritis
Bailey B, et al. Acad Emerg Med. 2010;17:583–588.
Objectives: The objective was to validate the clinical dehydration scale (CDS) for children with gastroenteritis in a different pediatric emergency department (ED) from where it was initially derived and validated.
Methods: A prospective cohort study was performed in a tertiary care pediatric ED over a 1-year period. A sample of triage nurses were trained in applying the CDS. The CDS consists of four clinical characteristics (general appearance, eyes, mucous membranes, and tears), each of which are scored 0, 1, or 2 for a total score of 0 to 8, with 0 representing no dehydration; 1 to 4, some dehydration; and 5 to 8, moderate/severe dehydration. Children 1 month to 5 years of age with vomiting and/or diarrhea who had the CDS documented at triage and a final diagnosis of gastroenteritis, gastritis, or enteritis were enrolled. Exclusion criteria included a chronic disease, treatment with intravenous (IV) rehydration within the previous 24 hours, visit to the ED for the same illness in the 7 days prior to arrival, and diarrhea of more than 10 days' duration. The primary outcome was the length of stay (LOS) in the ED from the time of seeing a physician to discharge, analyzed with a Kruskal-Wallis test.
Results: From April 2008 to March 2009, 150 patients with a mean (±SD) age of 22 (±14) months (range = 4 months to 4 years) were enrolled. Fifty-six patients had no dehydration, 74 had some dehydration, and 20 had moderate/severe dehydration. The median LOS in the ED after being seen by a physician was significantly longer as children appeared more dehydrated according to the CDS: 54 minutes (interquartile range [IQR] = 26–175 minutes), 128 minutes (IQR = 25–334 minutes), and 425 minutes (IQR = 218–673 minutes) for the no, some, and moderate/severe dehydration groups, respectively (p less than 0.001).
Conclusions: The CDS has been further validated in children with gastroenteritis in a different pediatric center than the original one where it was developed. It is a good predictor of LOS in the ED after being seen by a physician.
17. No Benefit from Intravenous Alteplase When Given After 4.5 Hours of Stroke Onset
Risk for favorable outcomes decreases with increasing time to treatment from stroke onset, and, after 4.5 hours, alteplase treatment might increase mortality.
What is the optimal interval between stroke onset and intravenous recombinant tissue plasminogen activator (rt-PA) administration? Researchers conducted an updated analysis of pooled data from eight trials involving 3670 patients (median age, 68; age range, 19–101) who were randomized to receive rt-PA or placebo within 360 minutes of onset of stroke symptoms.
In multivariate logistic regression analysis, the odds of a favorable 3-month outcome (based on modified Rankin scale score, Barthel index score, and National Institutes of Health Stroke Scale score) were inversely related to time from onset of symptoms to rt-PA treatment, with no treatment benefit after about 270 minutes. Adjusted odds of favorable 3-month outcomes were 2.55 for 0–90 minutes, 1.64 for 91–180 minutes, 1.34 for 181–270 minutes, and 1.22 for 271–360 minutes. Adjusted odds of mortality increased with time to treatment, ranging from 0.78 for 0–90 minutes to 1.49 for 271–360 minutes. Large parenchymal bleeds occurred in 5.2% of rt-PA patients versus 1% of controls and were independent of time-to-treatment interval. The authors conclude that time from stroke onset to treatment should be minimized and that after 4.5 hours, "risk might outweigh benefit." An editorialist adds that, in large middle cerebral artery infarcts, "20 million additional neurons die every 10 min[utes] if reperfusion is not achieved."
Comment: These data suggest that the risk for favorable outcomes decreases by a factor of about two for every 90-minute delay in treatment from stroke onset and that after 4.5 hours, rt-PA treatment might increase mortality. Lytic therapy for acute stroke must be given at the earliest possible time. Extension of the window for treatment to 4.5 hours is not a license for delay; every minute counts.
— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine May 28, 2010. Citation(s): Lees KR et al. Time to treatment with intravenous alteplase and outcome in stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010 May 15; 375:1695. Saver JL and Levine SR. Alteplase for ischaemic stroke — Much sooner is much better. Lancet 2010 May 15; 375:1667.
18. Diagnostic Accuracy and Clinical Utility of Noninvasive Testing for Coronary Artery Disease
Weustink AC, et al. Ann Intern Med. 2010;152:630-639
Background: Computed tomography coronary angiography (CTCA) has become a popular noninvasive test for diagnosing coronary artery disease.
Objective: To compare the accuracy and clinical utility of stress testing and CTCA for identifying patients who require invasive coronary angiography (ICA).
Design: Observational study.
Setting: University medical center in Rotterdam, the Netherlands.
Patients: 517 patients referred by their treating physicians for evaluation of chest symptoms by using stress testing or ICA.
Intervention: Stress testing and CTCA in all patients.
Measurements: Diagnostic accuracy of stress testing and CTCA compared with ICA; pretest probabilities of disease by Duke clinical score; and clinical utility of noninvasive testing, defined as a pretest or posttest probability that suggests how to proceed with testing (no further testing if ≤5%, proceed with ICA if between 5% and 90%, and refer directly for ICA if ≥90%).
Results: Stress testing was not as accurate as CTCA; CTCA sensitivity approached 100%. In patients with a low (less than 20%) pretest probability of disease, negative stress test or CTCA results suggested no need for ICA. In patients with an intermediate (20% to 80%) pretest probability, a positive CTCA result suggested need to proceed with ICA (posttest probability, 93% [95% CI, 92% to 93%]) and a negative result suggested no need for further testing (posttest probability, 1% [CI, 1% to 1%]). Physicians could proceed directly with ICA in patients with a high (above 80%) pretest probability (91% [CI, 90% to 92%]).
Limitations: Referral and verification bias might have influenced findings. Stress testing provides functional information that may add value to that from anatomical (CTCA or ICA) imaging.
Conclusion: Computed tomography coronary angiography seems most valuable in patients with intermediate pretest probability of disease, because the test can distinguish which of these patients need invasive angiography. These findings need to be confirmed before CTCA can be routinely recommended for these patients.
19. Midazolam Trumps Diazepam for the Treatment of Status Epilepticus in Children and Young Adults: A Meta-analysis
McMullan J, et al. Acad Emerg Med. 2010; 17:575–582.
Background: Rapid treatment of status epilepticus (SE) is associated with better outcomes. Diazepam and midazolam are commonly used, but the optimal agent and administration route is unclear.
Objectives: The objective was to determine by systematic review if nonintravenous (non-IV) midazolam is as effective as diazepam, by any route, in terminating SE seizures in children and adults. Time to seizure cessation and respiratory complications was examined.
Methods: We performed a search of PubMed, Web of Knowledge, Embase, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, American College of Physicians Journal Club, Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature, and International Pharmaceutical Abstracts for studies published January 1, 1950, through July 4, 2009. English language quasi-experimental or randomized controlled trials comparing midazolam and diazepam as first-line treatment for SE, and meeting the Consolidated Standards of Reporting Trials (CONSORT)-based quality measures, were eligible. Two reviewers independently screened studies for inclusion and extracted outcomes data. Administration routes were stratified as non-IV (buccal, intranasal, intramuscular, rectal) or IV. Fixed-effects models generated pooled statistics.
Results: Six studies with 774 subjects were included. For seizure cessation, midazolam, by any route, was superior to diazepam, by any route (relative risk [RR] = 1.52; 95% confidence interval [CI] = 1.27 to 1.82). Non-IV midazolam is as effective as IV diazepam (RR = 0.79; 95% CI = 0.19 to 3.36), and buccal midazolam is superior to rectal diazepam in achieving seizure control (RR = 1.54; 95% CI = 1.29 to 1.85). Midazolam was administered faster than diazepam (mean difference = 2.46 minutes; 95% CI = 1.52 to 3.39 minutes) and had similar times between drug administration and seizure cessation. Respiratory complications requiring intervention were similar, regardless of administration route (RR = 1.49; 95% CI = 0.25 to 8.72).
Conclusions: Non-IV midazolam, compared to non-IV or IV diazepam, is safe and effective in treating SE. Comparison to lorazepam, evaluation in adults, and prospective confirmation of safety and efficacy is needed.
20. β-Blockers May Reduce Mortality and Risk of Exacerbations in Patients with Chronic Obstructive Pulmonary Disease
Rutten FH, et al. Arch Intern Med. 2010;170:880-887.
Background: Physicians avoid the use of β-blockers in patients with chronic obstructive pulmonary disease (COPD) and concurrent cardiovascular disease because of concerns about adverse pulmonary effects. We assessed the long-term effect of β-blocker use on survival and exacerbations in patients with COPD.
Methods: An observational cohort study using data from the electronic medical records of 23 general practices in the Netherlands. The data included standardized information about daily patient contacts, diagnoses, and drug prescriptions.
Results: In total, the study included 2230 patients 45 years and older with an incident or prevalent diagnosis of COPD between 1996 and 2006. The mean (SD) age of the patients with COPD was 64.8 (11.2) years at the start of the study, and 53% of the patients were male. During a mean (SD) follow-up of 7.2 (2.8) years, 686 patients (30.8%) died and 1055 (47.3%) had at least 1 exacerbation of COPD. The crude and adjusted hazard ratios with Cox regression analysis of β-blocker use for mortality were 0.70 (95% confidence interval [CI], 0.59-0.84) and 0.68 (95% CI, 0.56-0.83), respectively. The crude and adjusted hazard ratios for exacerbation of COPD were 0.73 (95% CI, 0.63-0.83) and 0.71 (95% CI, 0.60-0.83), respectively. The adjusted hazard ratios with the propensity score methods were even lower. Subgroup analyses revealed that patients with COPD but without overt cardiovascular disease had similar results.
Conclusion: Treatment with β-blockers may reduce the risk of exacerbations and improve survival in patients with COPD, possibly as a result of dual cardiopulmonary protective properties.
21. Response to NSAIDs Primarily Determined in First Week of Treatment
By Charlene Laino. BALTIMORE, Md -- May 15, 2010 -- In patients with osteoarthritis, the response to nonsteroidal anti-inflammatory drugs (NSAIDs) appears to be primarily determined in the first week of treatment, researchers said here at the 29th Annual Scientific Meeting of the American Pain Society (APS).
Researchers conducted a post hoc analysis of 2 identical, 12-week, double-blind, randomised studies comparing etoricoxib 60 mg/day, naproxen 1,000 mg/day, and placebo in a total of 997 patients with osteoarthritis of the knee or hip.
The percentage of patients achieving at least 15%, 30%, 50%, and 70% improvement in pain from baseline were calculated. To be considered an early responder, patients were required to achieve 3 or more days at these response levels during days 2 to 6 of the trial.
Kappa coefficients for agreement were computed for consistency across treatment groups.
As the response cutoff increased from 15% to 70%, the percentage of early responders being late responders decreased from 91% to 73%, and the percentage of responders converting to nonresponders increased from 9% to 27%.
The opposite pattern was observed for nonresponders: with higher cutoffs, the percentage of early responders being late responders increased from 44% to 71%, and the percentage of nonresponders switching to responders decreased from 56% to 29%.
Overall, kappa agreement between early and 12-week treatment response ranged from k = 0.32 to 0.37.
"Thus, the majority of patients, about 70%, who were nonresponders in the first week, whether they were on etoricoxib, naproxen, or placebo, were likely to remain nonresponders at later time points," said Arnold R. Gammaitoni, PharmD, Merck Research Laboratories, Rahway, New Jersey, on May 6. "These findings give clinicians some benchmarks to judge whether longer trials of therapy are likely to be of value."
1. Silent Pulmonary Embolism in Patients with Deep Venous Thrombosis: A Systematic Review
Stein PD, et al. Amer J Med. 2010;123:426-431.
Purpose
To determine, by systematic review of the literature, the prevalence of silent pulmonary embolism in patients with deep venous thrombosis.
Methods
Twenty-eight included published investigations were identified through PubMed. Studies were selected if methods of diagnosis of pulmonary embolism were described; if pulmonary embolism was stated to be asymptomatic; and if raw data were presented. Studies were stratified according to whether silent pulmonary embolism was diagnosed by a high-probability ventilation-perfusion lung scan using criteria from the Prospective Investigation of Pulmonary Embolism Diagnosis, computed tomography pulmonary angiography, or conventional pulmonary angiography (Tier 1), or by lung scans based on non-Prospective Investigation of Pulmonary Embolism Diagnosis criteria (Tier 2).
Results
Silent pulmonary embolism was diagnosed in 1665 of 5233 patients (32%) with deep venous thrombosis. This is a conservative estimate because many of the investigations used stringent criteria for the diagnosis of pulmonary embolism. The incidence of silent pulmonary embolism was higher with proximal deep venous thrombosis than with distal deep venous thrombosis. Silent pulmonary embolism seemed to increase the risk of recurrent pulmonary embolism: 25 of 488 (5.1%) with silent pulmonary embolism versus 7 of 1093 (0.6%) without silent pulmonary embolism.
Conclusion
Silent pulmonary embolism sometimes involved central pulmonary arteries. Because approximately one third of patients with deep venous thrombosis have silent pulmonary embolism, routine screening for pulmonary embolism may be advantageous.
Full-text (free): http://www.amjmed.com/article/PIIS0002934309011115/fulltext
2. β-Blockers OK for Chest Pain Associated with Recent Cocaine Use
Rangel C, et al. Arch Intern Med. 2010;170:874-879.
Background: Although β-blockers prevent adverse events after myocardial infarction, they are contraindicated when chest pain is associated with recent cocaine use. Recommendations against this use of β-blockers are based on animal studies, small human experiments, and anecdote. We sought to test the hypothesis that β-blockers are safe in this setting.
Methods: We performed a retrospective cohort study of consecutive patients admitted to the San Francisco General Hospital, San Francisco, California, with chest pain and urine toxicologic test results positive for cocaine, from January 2001 to December 2006. Mortality data were collected from the National Death Index.
Results: Of 331 patients with chest pain in the setting of recent cocaine use, 151 (46%) received a β-blocker in the emergency department. There were no meaningful differences in electrocardiographic changes, troponin levels, length of stay, use of vasopressor agents, intubation, ventricular tachycardia or ventricular fibrillation, or death between those who did and did not receive a β-blocker. After adjusting for potential confounders, systolic blood pressure significantly decreased a mean 8.6 mm Hg (95% confidence interval, 14.7-2.5 mm Hg) in those receiving a β-blocker in the emergency department compared with those who received their first β-blocker in the hospital ward (P = .006). Over a median follow-up of 972 days (interquartile range, 555-1490 days), after adjusting for potential confounders, patients discharged on a β-blocker regimen exhibited a significant reduction in cardiovascular death (hazard ratio, 0.29; 95% confidence interval, 0.09-0.98) (P = .047).
Conclusion: β-Blockers do not appear to be associated with adverse events in patients with chest pain with recent cocaine use.
3. FDA enlists doctors to help spot misleading drug advertisements
Janice Hopkins Tanne. BMJ 2010;340:c2594
The US Food and Drug Administration has launched a programme called "Bad Ad" to enlist doctors in reporting false or misleading drug advertising or promotions.
Drug company advertising, promotional materials, presentations at medical meetings, and presentations to individual doctors by sales representatives are supposed to be accurate and balanced. They should present the risks and the benefits of a drug, and they should not promote a drug for unapproved, or "off label," uses.
The FDA, however, has only a few dozen staff members to review hundreds of drug advertisements, brochures, and presentations that companies voluntarily submit to the agency, say the Associated Press news agency. And it has no way of knowing what drug company sales representatives say to doctors over dinner or in a chat at a meeting.
The "Bad Ad" educational programme "is designed to educate healthcare providers about the role they can play in helping the agency make sure that prescription drug advertising is truthful and not misleading," the FDA said.
The programme begins immediately and is administered by the agency’s division of drug marketing, advertising, and communication in the Center for Drug Evaluation and Research. The division regulates presentations by sales representatives, presentations at speaker programmes, radio and television advertising, and all written or printed prescription drug promotional material.
The idea, several news accounts say, came from former drug company sales representatives who now work for the FDA.
The FDA says common drug company violations are omitting or downplaying risk, overstating drug effectiveness, promoting unapproved uses, and misleading drug comparisons.
It gives three examples of violations: omitting risk when a speaker programme has a slide show that presents efficacy information but not risk information; when a drug company representative in the exhibit hall at a conference tells a doctor that a drug is effective for a non-approved use; and when a sales representative tells a doctor that a drug delivers rapid results in days when clinical trials have shown results are seen only weeks later.
Doctors who see or hear misleading information are asked to contact the FDA, which has set up a reporting telephone line. They can report anonymously, although the FDA encourages them to include contact information and evidence of the misleading promotion. "Whistleblowers" who have reported drug company misdeeds have received a part of the fine companies paid.
The FDA will also set up information booths at major medical conferences to educate doctors about possibly misleading pitches, Reuters reported. The FDA is also sending letters to about 33 000 healthcare providers about the campaign.
In a related issue, the not for profit Center for Digital Democracy sent a letter to Dr Margaret Hamburg, the FDA commissioner, asking the agency to consider placing restrictions on how drug and medical device companies can use websites and social media—which often have very short messages—to promote their products.
4. Safety of Assessment of Patients with Potential Ischemic Chest Pain in an Emergency Department Waiting Room: A Prospective Comparative Cohort Study
Scheuermeyer FX, et al. Ann Emerg Med. 2010; in press…
Editor’s Capsule Summary: Crowding can lead to delays in the evaluation and management of patients. Can selected emergency department (ED) patients complaining of chest pain safely receive some or all of their care in the waiting room?
There were no missed cases of acute coronary syndrome and no important complications in the
303 patients triaged to the waiting room. This study suggests that with careful triage and prompt physician assessment, waiting room management might be an adequate, albeit not optimal, means of managing low-risk chest pain patients when there are no monitored beds available in the ED.
Replication of this study with a larger number of subjects at multiple sites will be needed to establish exactly how safe this strategy is.
Full-text (free): http://www.annemergmed.com/webfiles/images/journals/ymem/fxscheuermeyer.pdf
5. Optimal Position for Pediatric Lumbar Puncture
Ultrasound measurement showed that sitting with hips flexed maximizes interspinous process distances in children.
Abo A et al. Pediatrics 2010 May; 125:e114
BACKGROUND Lumbar punctures are commonly performed in the pediatric emergency department. There is no standard, recommended, optimal position for children who are undergoing the procedure.
OBJECTIVE To determine a position for lumbar punctures where the interspinous space is maximized, as measured by bedside ultrasound.
METHODS A prospective convenience sample of children under age 12 was performed. Using a portable ultrasound device, the L3-L4 or L4-L5 interspinous space was measured with the subject in 5 different positions. The primary outcome was the interspinous distance between 2 adjacent vertebrae. The interspinous space was measured with the subject sitting with and without hip flexion. In the lateral recumbent position, the interspinous space was measured with the hips in a neutral position as well as in flexion, both with and without neck flexion. Data were analyzed by comparing pairwise differences.
RESULTS There were 28 subjects enrolled (13 girls and 15 boys) at a median age of 5 years. The sitting-flexed position provided a significantly increased interspinous space (P less than .05). Flexion of the hips increased the interspinous space in both the sitting and lateral recumbent positions (P less than .05). Flexion of the neck, did not significantly change the interspinous space (P = .998).
CONCLUSIONS The interspinous space of the lumbar spine was maximally increased with children in the sitting position with flexed hips; therefore we recommend this position for lumbar punctures. In the lateral recumbent position, neck flexion does not increase the interspinous space and may increase morbidity; therefore, it is recommended to hold patients at the level of the shoulders as to avoid neck flexion.
6. “Hospitalists Rock,” Says New York Times
By Jane Gross. New York Times. May 26, 2010. PHILADELPHIA — By the time Djigui Keita left the hospital for home, his follow-up appointment had been scheduled. Emergency health insurance was arranged until he could apply for public assistance. He knew about changes in his medication — his doctor had found less expensive brands at local pharmacy chains. And Mr. Keita, 35, who had passed out from dehydration, was cautioned to carry spare water bottles in the taxi he drove for a living.
Dr. Subha Airan-Javia spoke with a patient, Djigui Keita, and handled many details of his care, relieving the burden on family doctors who are pressed for time.
The hourlong briefing the home-bound patient received here at the Hospital of the University of Pennsylvania was orchestrated by a hospitalist, a member of America’s fastest-growing medical specialty. Over a decade, this breed of physician-administrator has increasingly taken over the care of the hospitalized patient from overburdened family doctors with less and less time to make hospital rounds — or, as in Mr. Keita’s case, when there is no family doctor at all.
Because hospitalists are on top of everything that happens to a patient — from entry through treatment and discharge — they are largely credited with reducing the length of hospital stays by anywhere from 17 to 30 percent, and reducing costs by 13 to 20 percent, according to studies in The Journal of the American Medical Association. As their numbers have grown, from 800 in the 1990s to 30,000 today, medical experts have come to see hospitalists as potential leaders in the transition to the Obama administration’s health care reforms, to be phased in by 2014.
Under the new legislation, hospitals will be penalized for readmissions, medical errors and inefficient operating systems. Avoidable readmissions are the costliest mistakes for the government and the taxpayer, and they now occur for one in five patients, gobbling $17.4 billion of Medicare’s current $102.6 billion budget.
Dr. Subha Airan-Javia, Mr. Keita’s hospitalist, splits her time between clinical care and designing computer programs to contain costs and manage staff workflow. The discharge process she walked Mr. Keita and his wife through can work well, or badly, with very different results. Do it safely and the patient gets better. Do it wrong, and he’s back on the hospital doorstep — with a second set of bills.
“Where we were headed was not a mystery to anyone immersed in health care,” said P. J. Brennan, the chief medical officer for the University of Pennsylvania’s hospitals. “We were getting paid to have people in the hospital and the part of that which was waste was under the gun. These young doctors, coming into a highly dysfunctional environment, had an affinity for working on processes and redesigning systems.”
The article continues here: http://www.nytimes.com/2010/05/27/us/27hosp.html
7. Researchers Explore the Benefits of Sleep--and the Problems with Sleep-Deprivation
SAN DIEGO—A panel of researchers with expertise in infant learning, adolescent drug use, aging, and memory convened for a symposium at the AAAS Annual Meeting, and as they described their research in detail, the conclusion was inescapable:
America, you need a nap.
“People are definitely sleep-deprived,” Sara Mednick, an assistant professor of psychiatry at the University of California, San Diego, said in a AAAS podcast.
"That sleep-deprivation is leading to increased risk for cardiovascular disease, depression, mood problems, weight gain, obesity, and diabetes. A lot of different health concerns seem to be helped by good sleep and damaged by poor sleep.”
More on recent sleep research: http://news.aaas.org/2010/0224this-story-could-put-you-to-sleep.shtml
8. Emergency Department Interruptions Adversely Affect Patient Satisfaction
Most physician interruptions are generated by other healthcare providers.
Jeanmonod R et al. Emerg Med J 2010 May; 27:376.
Objective: To explore the nature of interruptions that occur during clinical practice in the emergency department (ED). We determined the frequency, duration and type of interruptions that occurred. We then determined the impact on patient satisfaction of those interruptions occurring at the bedside.
Methods: This was a cohort study of ED physicians and physicians in training. Trained research associates were assigned to an individual provider during 4-hour blocks of time during day and evening shifts. The research associates recorded the activity that was interrupted, as well as the nature and the duration of the interruption. If the interruption occurred during the principal interaction with a patient, the patient's satisfaction score was recorded on a 10-point scale.
Results: Physicians were commonly interrupted in all clinical activities, but most frequently during reviewing of data (53%) and charting (50%). Bedside interruptions occurred 26% of the time, and had a negative impact on patient satisfaction. The majority of interruptions (60%) were initiated by another healthcare provider (physician or nurse). Interruptions only rarely resulted in a physician changing tasks before completion.
Conclusion: Interruptions occur commonly during all clinical activities in the ED, and are frequently generated by providers themselves. These have a negative impact on patient satisfaction. The direct impact on medical errors or on provider satisfaction has not been determined.
See related article: first entry here: http://drvinsonlitbits.blogspot.com/2010/05/lit-bits-may-21-2010.html
9. Randomized Clinical Trial of Propofol Versus Ketamine for Procedural Sedation in the Emergency Department
Miner JR, et al. Acad Emerg Med. 2010;17:604-611.
Objectives: The objective was to compare the occurrence of respiratory depression, adverse events, and recovery duration of propofol versus ketamine for use in procedural sedation in the emergency department (ED).
Methods: This was a randomized nonblinded prospective clinical trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were treated with intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients were randomized to receive either propofol 1 mg/kg IV followed by 0.5 mg/kg every 3 minutes as needed or ketamine 1.0 mg/kg IV followed by 0.5 mg/kg every 3 minutes as needed. Doses, vital signs, nasal end-tidal CO2 (ETCO2), and pulse oximetry were recorded. Subclinical respiratory depression was defined as a change in ETCO2 of greater than 10 mm Hg, an oxygen saturation of less than 92% at any time, or an absent ETCO2 waveform at any time. Clinical interventions related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure and had recall of the procedure. Physicians were asked to describe any adverse events or the occurrence of recovery agitation.
Results: One-hundred patients were enrolled; 97 underwent sedation and were included in the analysis. Fifty patients received propofol and 47 received ketamine. Subclinical respiratory depression was seen in 20 of 50 patients in the propofol group and 30 of 47 patients in the ketamine group (p = 0.019, effect size 22.8%; 95% CI = 4.0% to 43.6%). Clinical interventions related to respiratory depression were used in 26 of 50 propofol patients and 19 of 47 ketamine patients (p = 0.253, effect size = −13.7%; 95% CI = −33.8% to 6.4%). The median times of the procedures were 11 minutes (range = 4 to 33 minutes) for the ketamine group versus 10 minutes (range = 5 to 33 minutes) for the propofol group (p = 0.256). The median time to return to baseline mental status after the procedure was completed was 14 minutes (range = 2 to 47 minutes) for the ketamine group and 5 minutes (range = 1 to 32 minutes) for the propofol group (p less than 0.001). Pain during the procedure was reported by 3 of 50 patients in the propofol group and 1 of 47 patients in the ketamine group (effect size = −3.9%, 95% confidence interval [CI] = −11.9 to 4.1). Recall of some part of the procedure was reported by 4 of 50 patients in the propofol group and 6 of 47 patients in the ketamine group (effect size = 4.8%, 95% CI = −7.6% to 17.1%). Forty-eight of 50 procedures were successful in the propofol group and 43 of 47 in the ketamine group (p = 0.357, effect size = 0.3%; 95% CI = −7.8% to 8.4%). Recovery agitation was reported in 4 of 50 in the propofol group and 17 of 47 in the ketamine group (effect size = 28.2%, 95% CI = 12.4% to 43.9%).
Conclusions: This study detected a higher rate of subclinical respiratory depression in patients in the ketamine group than the propofol group. There was no difference in the rate of clinical interventions related to respiratory depression, pain, or recall of the procedure between the groups. Recovery agitation was seen more frequently in patients receiving ketamine than in those receiving propofol. The time to regain baseline mental status was longer in the ketamine group than the propofol group. This study suggests that the use of either ketamine or propofol is safe and effective for procedural sedation in the ED.
10. US heart association endorses active video games
Jeanne Lenzer. BMJ 2010;340:c2802
The American Heart Association announced that it has entered into a "strategic relationship" with Nintendo of America to endorse the company’s active video games, known as Wii.
The videos include titles such as Wii Tennis and Battalion Wars 2. Players gesture with hand-held devices that interact with the videos to simulate action, such as playing a sport or killing an opponent with a nunchuk.
The association endorsed the video games as part of its campaign against obesity, saying that 70% of US citizens don’t get adequate exercise. The association’s logo will be stamped on all Wii game packaging, indicating that it is a "healthy heart product," said Clyde Yancy, cardiologist and president of the American Heart Association.
Dr Yancy said that Nintendo has agreed to give a $1.5m (£1m; 1.2m) "gift" to the association, which he said will be used for "heart healthy messaging."
In late 2009, the association issued a news release stating that a study funded by Nintendo, found that playing some Wii games led to activity equal to moderate exercise, thereby helping to "prevent or improve obesity and lifestyle-related diseases." In February, the association reported that another study funded by Nintendo showed that some stroke patients could improve their fine and gross motor function by playing the games.
The endorsement has sparked criticism. During an interview on the popular television news programme, Good Morning, America, Richard Besser, former acting director of the Centers for Disease Control and Prevention and now medical commentator, asked Dr Yancy, whether he was concerned that the endorsement might damage the integrity of the association. Dr Yancy said that although the association accepted money from Nintendo, "The logo is not for sale" (http://abcnews.go.com/Health/HeartHealth/wii-worthy-american-heart-assn-endorsement/story?id=10663377).
Dr Besser said the association’s marketing documents show endorsements by the association are "proven to boost sales" of endorsed products, which translate into "big money for the heart association and big money for the manufacturers." Dr Besser commented, "Here you have a . . . medical association that sets standards for physical activity, that’s taking one and a half million dollars from a video game company; how will they be free to criticise that industry and its contribution to obesity?"
The association responded to a study cited by Dr Besser, which found that found only a small number of the games engaged children in moderate-intensity exercise (Pediatrics 2009, 124;2:763-71; doi:10.1542/peds.2008-2357), stating: "We agree that participating in an actual sport is usually more vigorous than active gaming. But active gaming compares very well with sitting on the couch" (www.newsroom.heart.org/index.php?s=43&item=1038).
Other critics focused on the endorsement of products by a single manufacturer. Technology expert, Jared Newman, wrote in the online computer journal PC World that the association "could be doing so much more with the active play concept. It could rate individual games based on the difficulty of their workouts. It could give advice on how to make the most of each exercise game . . . As it stands, the partnership between Nintendo and the [association] is a gimmick whose value barely exceeds the bullet points on the back of game boxes (www.pcworld.com/article/196507/nintendo_and_heart_association_team_up_fall_short.html).
11. Clinical Diagnostic Model for Predicting Serious Bacterial Infections in Febrile Children
The diagnostic model was more accurate than physician judgment.
Febrile illnesses in young children account for about 25 million medical visits annually in the U.S. The challenge for clinicians is distinguishing between viral illnesses and serious bacterial infections (SBIs) and deciding whether to initiate antibiotic treatment. Investigators prospectively tested the accuracy of a clinical diagnostic model for predicting SBI in 12,807 febrile children younger than 5 years who presented to one emergency department (ED) during the 2-year study (2004–2006). Cancer and transplant patients were excluded.
Clinicians recorded 40 signs and symptoms for 15,781 febrile illnesses and followed children until they had confirmed diagnoses or no fever for 24 hours. Children were classified with SBIs (i.e., urinary tract infection [UTI], pneumonia, or bacteremia), clinically diagnosed infections (e.g., otitis media, sinusitis, or cellulitis), or no bacterial infections using radiological and microbiological tests. The prevalences of UTI, pneumonia, and bacteremia were 3.4%, 3.4%, and 0.4%, respectively; antibiotics were prescribed at initial presentation in 67%, 69%, and 81% of children with these illnesses, respectively. Seventy-five percent of children with clinically diagnosed infections and 20% without identified infections received antibiotics. Osteomyelitis, septic arthritis, and meningitis were rare (less than 12 cases each) and, therefore, these data were not included in the diagnostic model.
Twenty-six clinical signs and symptoms were included in the logistic regression diagnostic model. The diagnostic accuracy of the model (reported as the area under the receiver operating characteristic curve) was 0.80 for UTI, 0.84 for pneumonia, and 0.88 for bacteremia. The strongest predictors of SBI were unwell appearance, elevated body temperature, reduced fluid intake, increased capillary refill time, and chronic disease.
Comment: Clinicians are continuously seeking a model or scoring system to help predict whether a young febrile child has a serious bacterial infection. In this ED study population, which might have a higher prevalence of SBI (7.2%) than in a primary care population, the diagnostic model was more accurate at ruling out SBI than was physician judgment (physicians prescribed antibiotics in only 70%–80% of SBI cases). Whether use of the model would have changed the decision-making process or patient outcomes is unknown. This model should be validated in other settings with lower prevalences of SBIs before it is implemented as a predictive tool.
— Robin Drucker, MD. Published in Journal Watch Pediatrics and Adolescent Medicine May 19, 2010. Citation: Craig JC et al. The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: Prospective cohort study of 15 781 febrile illnesses. BMJ 2010 Apr 20; 340:c1594. (http://dx.doi.org/10.1136/bmj.c1594)
12. The Root of the Problem: Emergency Physicians Struggle To Provide Dental Care When No One Else Will
Maryn McKenna. Ann Emerg Med. 2010;55:A17-A19.
Winters in Minneapolis are hard, and the winter of 2009-10 was harder than most. The snow came earlier than usual and lasted later, and periodic sleet storms and below-zero flash freezes left streets and sidewalks sheathed in long-lasting ice. In the emergency department (ED) of Hennepin County Medical Center, the public hospital for downtown Minneapolis, there was a constant stream of broken bones and severe sprains from frequent tumbles on the ice.
But there's another category of complaint that has kept Hennepin County Medical Center's emergency physicians even more busy than casting wrists and splinting ankles, one that they know will be a constant for their ED through spring, into summer and for the rest of the year: dental problems.
“We probably see numerous dental abscesses a day in the emergency department; we drain them for the most part ourselves or if they are complex we involve the oral surgery service,” said Cheryl Adkisson, MD, an associate professor of emergency medicine at University of Minnesota and an attending at Hennepin County Medical Center. “We get at least one serious enough to require hospitalization every month.”
Dr. Adkisson is in a unique position to appreciate the demands that dealing with nontraumatic dental emergencies places on Hennepin County Medical Center. She is also the hospital's director of hyperbaric medicine. Periodically, those patients with severe infections end up in her hyperbaric chamber—usually for treatment of necrotizing fasciitis that was sparked by infection spreading from a dental abscess.
The traffic through Hennepin County Medical Center's hyperbaric chamber is an extreme expression of a problem with which emergency physicians have become all too familiar. A persistent stream of dental disease is brought to EDs by adults who neglect their oral health or their children's because they cannot afford dental care or cannot find dentists who will accept Medicaid reimbursement.
These dental cases are deeply frustrating to emergency physicians, and not just for the obvious reason that they increase the patient load and, because they are likely to be triaged as low acuity, add to wait times as well. The most frustrating thing, physicians say, is that EDs do not provide what dental patients most need. Physicians can offer only the temporary fixes of a nerve block and an antibiotic prescription, knowing that, unless the patient can find a dentist, he or she will be back in the ED again.
“Myself, like every emergency physician in the country probably, I see patients every shift who come in with untreated caries, abscesses and pain,” said Michael Heller, MD, director of emergency ultrasonography at Beth Israel Medical Center in Manhattan. “I don't want to make the argument that they are choking the emergency department, but they are probably 1% to 2% of patients. But even in New York City, which has a lot of social services, it is very, very hard to find anywhere to send them.”
Public health authorities have been warning for a decade that the burden of dental disease in the population is significant and growing.
In 2000, the first-ever Surgeon General's report on the issue, Oral Health in America, warned that a “silent epidemic of oral diseases is affecting our most vulnerable citizens” and costing up to $60 billon a year in health care spending. Untreated dental caries, the report said, had become the most common disease of childhood, affecting 53 percent of children aged 6 to 8, 5 times more than are diagnosed with asthma.
That estimated disease burden confirmed what physicians at Boston University Medical Center recorded in their ED between 1998 and 2000. Puzzled by what seemed to be high rates of children complaining of long-standing pain and being diagnosed with significant dental abscesses, they did a study and found that 75% of their pediatric population had untreated dental caries. Similarly, a 2000 study by the University of Maryland Dental School of children in Maryland's Head Start program found 52% of them had untreated caries, and a 2002 study in the American Journal of Public Health found untreated caries in 25% of children entering kindergarten. Another study in the same journal found that when adults in Harlem were surveyed about their chief medical complaints, 30% named untreated dental problems as most important.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)00353-7/fulltext
13. Happiness May Come With Age, Study Says
By Nicholas Bakalar. New York Times. May 31, 2010
It is inevitable. The muscles weaken. Hearing and vision fade. We get wrinkled and stooped. We can’t run, or even walk, as fast as we used to. We have aches and pains in parts of our bodies we never even noticed before. We get old.
It sounds miserable, but apparently it is not. A large Gallup poll has found that by almost any measure, people get happier as they get older, and researchers are not sure why.
“It could be that there are environmental changes,” said Arthur A. Stone, the lead author of a new study based on the survey, “or it could be psychological changes about the way we view the world, or it could even be biological — for example brain chemistry or endocrine changes.”
The telephone survey, carried out in 2008, covered more than 340,000 people nationwide, ages 18 to 85, asking various questions about age and sex, current events, personal finances, health and other matters.
The survey also asked about “global well-being” by having each person rank overall life satisfaction on a 10-point scale, an assessment many people may make from time to time, if not in a strictly formalized way.
Finally, there were six yes-or-no questions: Did you experience the following feelings during a large part of the day yesterday: enjoyment, happiness, stress, worry, anger, sadness. The answers, the researchers say, reveal “hedonic well-being,” a person’s immediate experience of those psychological states, unencumbered by revised memories or subjective judgments that the query about general life satisfaction might have evoked.
The results, published online May 17 in the Proceedings of the National Academy of Sciences, were good news for old people, and for those who are getting old. On the global measure, people start out at age 18 feeling pretty good about themselves, and then, apparently, life begins to throw curve balls. They feel worse and worse until they hit 50. At that point, there is a sharp reversal, and people keep getting happier as they age. By the time they are 85, they are even more satisfied with themselves than they were at 18.
The rest of the essay: http://www.nytimes.com/2010/06/01/health/research/01happy.html
PubMed abstract: http://www.ncbi.nlm.nih.gov/pubmed/20479218
14. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis
Costelloe C, et al. BMJ 2010;340:c2096
Objective: To systematically review the literature and, where appropriate, meta-analyse studies investigating subsequent antibiotic resistance in individuals prescribed antibiotics in primary care.
Design Systematic review with meta-analysis.
Data sources: Observational and experimental studies identified through Medline, Embase, and Cochrane searches.
Review methods: Electronic searches using MeSH terms and text words identified 4373 papers. Two independent reviewers assessed quality of eligible studies and extracted data. Meta-analyses were conducted for studies presenting similar outcomes.
Results: The review included 24 studies; 22 involved patients with symptomatic infection and two involved healthy volunteers; 19 were observational studies (of which two were prospective) and five were randomised trials. In five studies of urinary tract bacteria (14 348 participants), the pooled odds ratio (OR) for resistance was 2.5 (95% confidence interval 2.1 to 2.9) within 2 months of antibiotic treatment and 1.33 (1.2 to 1.5) within 12 months. In seven studies of respiratory tract bacteria (2605 participants), pooled ORs were 2.4 (1.4 to 3.9) and 2.4 (1.3 to 4.5) for the same periods, respectively. Studies reporting the quantity of antibiotic prescribed found that longer duration and multiple courses were associated with higher rates of resistance. Studies comparing the potential for different antibiotics to induce resistance showed no consistent effects. Only one prospective study reported changes in resistance over a long period; pooled ORs fell from 12.2 (6.8 to 22.1) at 1 week to 6.1 (2.8 to 13.4) at 1 month, 3.6 (2.2 to 6.0) at 2 months, and 2.2 (1.3 to 3.6) at 6 months.
Conclusions: Individuals prescribed an antibiotic in primary care for a respiratory or urinary infection develop bacterial resistance to that antibiotic. The effect is greatest in the month immediately after treatment but may persist for up to 12 months. This effect not only increases the population carriage of organisms resistant to first line antibiotics, but also creates the conditions for increased use of second line antibiotics in the community.
15. Images in Emergency Medicine
An Adult Male With a Recreational Ankle Injury
http://www.annemergmed.com/article/S0196-0644(09)01262-1/fulltext
Young Man with Foreign-Body Sensation in the Right Eye
http://www.annemergmed.com/article/S0196-0644(09)01136-6/fulltext
16. External Validation of the Clinical Dehydration Scale for Children with Acute Gastroenteritis
Bailey B, et al. Acad Emerg Med. 2010;17:583–588.
Objectives: The objective was to validate the clinical dehydration scale (CDS) for children with gastroenteritis in a different pediatric emergency department (ED) from where it was initially derived and validated.
Methods: A prospective cohort study was performed in a tertiary care pediatric ED over a 1-year period. A sample of triage nurses were trained in applying the CDS. The CDS consists of four clinical characteristics (general appearance, eyes, mucous membranes, and tears), each of which are scored 0, 1, or 2 for a total score of 0 to 8, with 0 representing no dehydration; 1 to 4, some dehydration; and 5 to 8, moderate/severe dehydration. Children 1 month to 5 years of age with vomiting and/or diarrhea who had the CDS documented at triage and a final diagnosis of gastroenteritis, gastritis, or enteritis were enrolled. Exclusion criteria included a chronic disease, treatment with intravenous (IV) rehydration within the previous 24 hours, visit to the ED for the same illness in the 7 days prior to arrival, and diarrhea of more than 10 days' duration. The primary outcome was the length of stay (LOS) in the ED from the time of seeing a physician to discharge, analyzed with a Kruskal-Wallis test.
Results: From April 2008 to March 2009, 150 patients with a mean (±SD) age of 22 (±14) months (range = 4 months to 4 years) were enrolled. Fifty-six patients had no dehydration, 74 had some dehydration, and 20 had moderate/severe dehydration. The median LOS in the ED after being seen by a physician was significantly longer as children appeared more dehydrated according to the CDS: 54 minutes (interquartile range [IQR] = 26–175 minutes), 128 minutes (IQR = 25–334 minutes), and 425 minutes (IQR = 218–673 minutes) for the no, some, and moderate/severe dehydration groups, respectively (p less than 0.001).
Conclusions: The CDS has been further validated in children with gastroenteritis in a different pediatric center than the original one where it was developed. It is a good predictor of LOS in the ED after being seen by a physician.
17. No Benefit from Intravenous Alteplase When Given After 4.5 Hours of Stroke Onset
Risk for favorable outcomes decreases with increasing time to treatment from stroke onset, and, after 4.5 hours, alteplase treatment might increase mortality.
What is the optimal interval between stroke onset and intravenous recombinant tissue plasminogen activator (rt-PA) administration? Researchers conducted an updated analysis of pooled data from eight trials involving 3670 patients (median age, 68; age range, 19–101) who were randomized to receive rt-PA or placebo within 360 minutes of onset of stroke symptoms.
In multivariate logistic regression analysis, the odds of a favorable 3-month outcome (based on modified Rankin scale score, Barthel index score, and National Institutes of Health Stroke Scale score) were inversely related to time from onset of symptoms to rt-PA treatment, with no treatment benefit after about 270 minutes. Adjusted odds of favorable 3-month outcomes were 2.55 for 0–90 minutes, 1.64 for 91–180 minutes, 1.34 for 181–270 minutes, and 1.22 for 271–360 minutes. Adjusted odds of mortality increased with time to treatment, ranging from 0.78 for 0–90 minutes to 1.49 for 271–360 minutes. Large parenchymal bleeds occurred in 5.2% of rt-PA patients versus 1% of controls and were independent of time-to-treatment interval. The authors conclude that time from stroke onset to treatment should be minimized and that after 4.5 hours, "risk might outweigh benefit." An editorialist adds that, in large middle cerebral artery infarcts, "20 million additional neurons die every 10 min[utes] if reperfusion is not achieved."
Comment: These data suggest that the risk for favorable outcomes decreases by a factor of about two for every 90-minute delay in treatment from stroke onset and that after 4.5 hours, rt-PA treatment might increase mortality. Lytic therapy for acute stroke must be given at the earliest possible time. Extension of the window for treatment to 4.5 hours is not a license for delay; every minute counts.
— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine May 28, 2010. Citation(s): Lees KR et al. Time to treatment with intravenous alteplase and outcome in stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010 May 15; 375:1695. Saver JL and Levine SR. Alteplase for ischaemic stroke — Much sooner is much better. Lancet 2010 May 15; 375:1667.
18. Diagnostic Accuracy and Clinical Utility of Noninvasive Testing for Coronary Artery Disease
Weustink AC, et al. Ann Intern Med. 2010;152:630-639
Background: Computed tomography coronary angiography (CTCA) has become a popular noninvasive test for diagnosing coronary artery disease.
Objective: To compare the accuracy and clinical utility of stress testing and CTCA for identifying patients who require invasive coronary angiography (ICA).
Design: Observational study.
Setting: University medical center in Rotterdam, the Netherlands.
Patients: 517 patients referred by their treating physicians for evaluation of chest symptoms by using stress testing or ICA.
Intervention: Stress testing and CTCA in all patients.
Measurements: Diagnostic accuracy of stress testing and CTCA compared with ICA; pretest probabilities of disease by Duke clinical score; and clinical utility of noninvasive testing, defined as a pretest or posttest probability that suggests how to proceed with testing (no further testing if ≤5%, proceed with ICA if between 5% and 90%, and refer directly for ICA if ≥90%).
Results: Stress testing was not as accurate as CTCA; CTCA sensitivity approached 100%. In patients with a low (less than 20%) pretest probability of disease, negative stress test or CTCA results suggested no need for ICA. In patients with an intermediate (20% to 80%) pretest probability, a positive CTCA result suggested need to proceed with ICA (posttest probability, 93% [95% CI, 92% to 93%]) and a negative result suggested no need for further testing (posttest probability, 1% [CI, 1% to 1%]). Physicians could proceed directly with ICA in patients with a high (above 80%) pretest probability (91% [CI, 90% to 92%]).
Limitations: Referral and verification bias might have influenced findings. Stress testing provides functional information that may add value to that from anatomical (CTCA or ICA) imaging.
Conclusion: Computed tomography coronary angiography seems most valuable in patients with intermediate pretest probability of disease, because the test can distinguish which of these patients need invasive angiography. These findings need to be confirmed before CTCA can be routinely recommended for these patients.
19. Midazolam Trumps Diazepam for the Treatment of Status Epilepticus in Children and Young Adults: A Meta-analysis
McMullan J, et al. Acad Emerg Med. 2010; 17:575–582.
Background: Rapid treatment of status epilepticus (SE) is associated with better outcomes. Diazepam and midazolam are commonly used, but the optimal agent and administration route is unclear.
Objectives: The objective was to determine by systematic review if nonintravenous (non-IV) midazolam is as effective as diazepam, by any route, in terminating SE seizures in children and adults. Time to seizure cessation and respiratory complications was examined.
Methods: We performed a search of PubMed, Web of Knowledge, Embase, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, American College of Physicians Journal Club, Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature, and International Pharmaceutical Abstracts for studies published January 1, 1950, through July 4, 2009. English language quasi-experimental or randomized controlled trials comparing midazolam and diazepam as first-line treatment for SE, and meeting the Consolidated Standards of Reporting Trials (CONSORT)-based quality measures, were eligible. Two reviewers independently screened studies for inclusion and extracted outcomes data. Administration routes were stratified as non-IV (buccal, intranasal, intramuscular, rectal) or IV. Fixed-effects models generated pooled statistics.
Results: Six studies with 774 subjects were included. For seizure cessation, midazolam, by any route, was superior to diazepam, by any route (relative risk [RR] = 1.52; 95% confidence interval [CI] = 1.27 to 1.82). Non-IV midazolam is as effective as IV diazepam (RR = 0.79; 95% CI = 0.19 to 3.36), and buccal midazolam is superior to rectal diazepam in achieving seizure control (RR = 1.54; 95% CI = 1.29 to 1.85). Midazolam was administered faster than diazepam (mean difference = 2.46 minutes; 95% CI = 1.52 to 3.39 minutes) and had similar times between drug administration and seizure cessation. Respiratory complications requiring intervention were similar, regardless of administration route (RR = 1.49; 95% CI = 0.25 to 8.72).
Conclusions: Non-IV midazolam, compared to non-IV or IV diazepam, is safe and effective in treating SE. Comparison to lorazepam, evaluation in adults, and prospective confirmation of safety and efficacy is needed.
20. β-Blockers May Reduce Mortality and Risk of Exacerbations in Patients with Chronic Obstructive Pulmonary Disease
Rutten FH, et al. Arch Intern Med. 2010;170:880-887.
Background: Physicians avoid the use of β-blockers in patients with chronic obstructive pulmonary disease (COPD) and concurrent cardiovascular disease because of concerns about adverse pulmonary effects. We assessed the long-term effect of β-blocker use on survival and exacerbations in patients with COPD.
Methods: An observational cohort study using data from the electronic medical records of 23 general practices in the Netherlands. The data included standardized information about daily patient contacts, diagnoses, and drug prescriptions.
Results: In total, the study included 2230 patients 45 years and older with an incident or prevalent diagnosis of COPD between 1996 and 2006. The mean (SD) age of the patients with COPD was 64.8 (11.2) years at the start of the study, and 53% of the patients were male. During a mean (SD) follow-up of 7.2 (2.8) years, 686 patients (30.8%) died and 1055 (47.3%) had at least 1 exacerbation of COPD. The crude and adjusted hazard ratios with Cox regression analysis of β-blocker use for mortality were 0.70 (95% confidence interval [CI], 0.59-0.84) and 0.68 (95% CI, 0.56-0.83), respectively. The crude and adjusted hazard ratios for exacerbation of COPD were 0.73 (95% CI, 0.63-0.83) and 0.71 (95% CI, 0.60-0.83), respectively. The adjusted hazard ratios with the propensity score methods were even lower. Subgroup analyses revealed that patients with COPD but without overt cardiovascular disease had similar results.
Conclusion: Treatment with β-blockers may reduce the risk of exacerbations and improve survival in patients with COPD, possibly as a result of dual cardiopulmonary protective properties.
21. Response to NSAIDs Primarily Determined in First Week of Treatment
By Charlene Laino. BALTIMORE, Md -- May 15, 2010 -- In patients with osteoarthritis, the response to nonsteroidal anti-inflammatory drugs (NSAIDs) appears to be primarily determined in the first week of treatment, researchers said here at the 29th Annual Scientific Meeting of the American Pain Society (APS).
Researchers conducted a post hoc analysis of 2 identical, 12-week, double-blind, randomised studies comparing etoricoxib 60 mg/day, naproxen 1,000 mg/day, and placebo in a total of 997 patients with osteoarthritis of the knee or hip.
The percentage of patients achieving at least 15%, 30%, 50%, and 70% improvement in pain from baseline were calculated. To be considered an early responder, patients were required to achieve 3 or more days at these response levels during days 2 to 6 of the trial.
Kappa coefficients for agreement were computed for consistency across treatment groups.
As the response cutoff increased from 15% to 70%, the percentage of early responders being late responders decreased from 91% to 73%, and the percentage of responders converting to nonresponders increased from 9% to 27%.
The opposite pattern was observed for nonresponders: with higher cutoffs, the percentage of early responders being late responders increased from 44% to 71%, and the percentage of nonresponders switching to responders decreased from 56% to 29%.
Overall, kappa agreement between early and 12-week treatment response ranged from k = 0.32 to 0.37.
"Thus, the majority of patients, about 70%, who were nonresponders in the first week, whether they were on etoricoxib, naproxen, or placebo, were likely to remain nonresponders at later time points," said Arnold R. Gammaitoni, PharmD, Merck Research Laboratories, Rahway, New Jersey, on May 6. "These findings give clinicians some benchmarks to judge whether longer trials of therapy are likely to be of value."
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