Saturday, June 26, 2010

Lit Bits: June 26, 2010

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.

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.

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.

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.

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):

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:

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):

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."


Accompanying Cochrane editorial:

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.

The aim of this study is to formulate an accurate estimate of the spinal needle depth for a successful lumbar puncture in pediatric patients.

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.

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.

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:

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.

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.

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.

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.


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.”


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.


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.

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.

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).

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).

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.

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.

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."


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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

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.

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.

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.

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.

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17. Improving Crotalidae polyvalent immune Fab reconstitution times

Quan AN, et al. Amer J Emerg Med. 2010;28:593-595.

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.

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.

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.

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.

Ultrasound guidance of central venous catheter (CVC) insertion improves success rates and reduces complications and is recommended by several professional and regulatory organizations.

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.

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).

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.


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.