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."