Lit Bits: July 18, 2010

From the recent medical literature...

1. Typical Angina vs. Atypical Chest Pain

In patients presenting to an emergency department, presence and type of symptoms did not predict inducible myocardial ischemia.

Hermann LK, et al. Am J Cardiol. 2010;105:1561-4.

The present study was designed to assess the value of the presenting symptom of "typical" anginal pain, "atypical/nonanginal" pain, or the lack of chest pain in predicting the presence of inducible myocardial ischemia using cardiac stress testing in emergency department patients being evaluated for possible acute coronary syndrome.

We performed a retrospective observational study of adult patients who were evaluated for acute coronary syndrome in an emergency department chest pain unit. The presenting symptoms were obtained from a structured questionnaire administered before stress testing. Patient chest pain was categorized according to the presence of substernal chest pain or discomfort that was provoked by exertion or emotional stress and was relieved by rest and/or nitroglycerin. Chest pain was classified as "typical" angina if all 3 descriptors were present and "atypical" or "nonanginal" if less than 3 descriptors were present. All patients underwent serial biomarker and cardiac stress testing before discharge.

A total of 2,525 patients met the eligibility criteria. Inducible ischemia on stress testing was found in 33 (14%, 95% confidence interval 10% to 19%) of the 231 patients who had typical anginal pain, 238 (11%, 95% confidence interval 10% to 13%) of the 2,140 patients presenting with atypical/nonanginal chest pain, and 25 (16%, 95% confidence interval 11% to 22%) of the 153 patients who had no complaint of chest pain on presentation. Compared to patients with atypical or no chest pain, patients with typical chest pain were not significantly more likely to have inducible ischemia on stress testing (likelihood ratio +1.25, 95% confidence interval 0.89 to 1.78).

In conclusion, in our study, the patients who presented with "typical" angina were no more likely to have inducible myocardial ischemia on stress testing than patients with other presenting symptoms.

2. Dramatic Increase in ED Visits Resulting From Prescription Opioid Use

Deborah Brauser. June 29, 2010 — The estimated number of emergency department (ED) visits involving nonmedical use of prescription opioids increased by 111% during a 5-year period, according to a new study by researchers from the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA).

Oxycodone, hydrocodone, and methadone products were the opioid pain relievers most frequently involved in these visits, with increases of 152%, 123%, and 73%, respectively.

"These alarming findings provide 1 more example of how the misuse of prescription pain relievers is impacting lives and our health care system," said Pamela S. Hyde, JD, administrator of SAMSHA, Rockville, Maryland, in a statement. "This public health threat requires an all-out effort to raise awareness of the public about proper use, storage, and disposal of these powerful drugs."

"We urgently need to take action," echoed Thomas R. Frieden, MD, MPH, director of the CDC in Atlanta, Georgia, in the same statement. "ED visits involving non-medical use of these prescription drugs are now as common as ED visits for use of illicit drugs. These prescription medicines help many people, but we need to be sure they are used properly and safely."

The findings were reported jointly in a SAMHSA survey report and in the CDC's Morbidity and Mortality Weekly Report, published online June 17.

Important Public Health Issue

"This is something we've been tracking for a number of years, and it's been pretty clear that prescription drug use has been growing over time," Peter Delany, PhD, director of the Office of Applied Studies at SAMSHA, told Medscape Psychiatry. "This [study] was an opportunity for us to work with our partners at CDC to look at 5 years worth of data and to track trends.

"It was a real collaboration with our colleagues at CDC and we were very happy to do it as a joint project, especially because this is a critically important public health issue," added Dr. Delany.

The investigative team evaluated a "stratified, simple random sample" from 220 hospitals with 24-hour EDs between the years 2004 and 2008 from SAMHSA's Drug Abuse Warning Network ED system.

Nonmedical use of a prescription drug was defined as "taking a higher-than-recommended dose, taking a drug prescribed for another person, drug-facilitated assault, or documented misuse or abuse," according to the study authors.

Dramatic Increases

Results showed that the nonmedical use of prescription opioids rose significantly from 144,600 ED visits in 2004 to 305,900 visits in 2008 (P less than .001). It also increased by 29% just between the years 2007 and 2008.

In addition, ED visits during the 5-year period involving nonmedical oxycodone use rose significantly from 41,700 to 105,214 visits a year (P less than .001). Hydrocodone involvement rose from 39,844 to 89,051 visits, and methadone product involvement rose from 36,806 to 63,629 visits.

These increases "reflect, in part, substantial increases in the prescribing of these classes of drugs," the investigators write.

When researchers also looked at the estimated number of nonmedical benzodiazepine-related ED visits, they found an overall increase by 89% between 2004 and 2008 (from 143,500 to 271,700 visits; P = .01).

Individual benzodiazepines also showed significant rises in ED visits during the study period, including a 125% increase for alprazolam (P = .01), 107% increase for lorazepam (P = .006), 72% increase for clonazepam (P less than .001), and 70% increase for diazepam (P = .02). Benzodiazepines were involved in 26% of all opioid-related visits.

Age-specific rates of ED visits in 2008 showed a sharp increase for both opioids and benzodiazepines "after age 17 years, [peaking] in the 21 to 24 years age group, and [declining] after age 54 years," report the study authors. "The largest increases during 2004 to 2008 occurred among persons aged 21 to 29."

Although women had more benzodiazepine-related ED visits than men in 2008 (152,100 vs 119,600, respectively), the difference was not statistically significant.

"These findings indicate substantial, increasing morbidity associated with the nonmedical use of prescription drugs...despite recent efforts to control the problem," write the study authors. "Stronger measures to reduce the diversion of prescription drugs to nonmedical purposes are warranted."

Opportunity for Prevention and Education

"I think the number 1 takeaway is that this is an opportunity for [clinicians] to really think about these findings and then talk about them with their patients," said Dr. Delany. "It's also an opportunity for prevention and education. How do you store and dispose of medications when you don't need them anymore? These answers need to be given not just by the clinician who is prescribing medications but also by pharmacists and other health providers. Also, adults need to be aware of what's going on in their medicine cabinets, especially if there are [young people] in the household."

"The abuse of prescription drugs is our nation's fastest-growing drug problem. And this new study shows it is a problem that affects men and women, people under 21, and those over 21," said R. Gil Kerlikowske, director of the Office of National Drug Control Policy in Rockville, Maryland, in a statement.

"The newly released National Drug Control Strategy contains specific steps that all of us can take to address this issue," added Director Kerlikowske.

Dr. Delany noted that SAMHSA and the CDC plan on participating in more joint research partnerships. "There's a real commitment between my administrator and Dr. Frieden at CDC to keep building on the collaborations that we have done over the years.

"We're a behavioral health statistical unit while their researchers really look at health areas. So the ability to bring behavioral health and health together for these types of mainstream health issues is important, especially because they're both so intertwined," said Dr. Delany.

The study authors and commentators have disclosed no relevant financial relationships.

SAMHSA. "The DAWN Report — Trends in Emergency Department Visits Involving Nonmedical Use of Narcotic Pain Relievers." Released June 18, 2010. http://www.oas.samhsa.gov/2k10/DAWN016/OpioidED.htm

Morb Mortal Wkly Rep. "ED Visits Involving Nonmedical Use of Selected Prescription Drugs." Published online June 17, 2010. http://www.cdc.gov/mmwr/pdf/wk/mm5923.pdf

3. The Impact of Delays to Admission from the ED on Inpatient Outcomes

Huang Q, et al. BMC Emerg Med 2010, 10:16doi:10.1186/1471-227X-10-16

Background
We sought to determine the impact of delays to admission from the Emergency Department (ED) on inpatient length of stay (LOS), and IP cost.

Methods
We conducted a retrospective analysis of 13,460 adult (18 yrs and up) ED visits between April 1 2006 and March 30 2007 at a tertiary care teaching hospital with two ED sites in which the mode of disposition was admission to ICU, surgery or inpatient wards. We defined ED Admission Delay as ED time to decision to admit greater than 12 hours. The primary outcomes were IP LOS, and total IP cost.

Results
Approximately 11.6% (n=1558) of admitted patients experienced admission delay. In multivariate analysis we found that admission delay was associated with 12.4% longer IP LOS (95 % CI 6.6% - 18.5%) and 11.0% greater total IP cost (6.0% - 16.4%). We estimated the cumulative impact of delay on all delayed patients as an additional 2,183 inpatient days and an increase in IP cost of $2,109,173 at the study institution.

Conclusions
Delays to admission from the ED are associated with increased IP LOS and IP cost. Improving patient flow through the ED may reduce hospital costs and improve quality of care. There may be a business case for investments to reduce emergency department admission delays.

Full-text (free): http://www.biomedcentral.com/content/pdf/1471-227x-10-16.pdf

4. Is Computed Tomography Safe?

Rebecca Smith-Bindman, M.D. N Engl J Med. 2010;published online (10.1056/NEJMp1002530)

Ms. C., a 59-year-old schoolteacher, awoke on September 8, 2009, with facial paralysis. In a local emergency room [sic], she underwent computed tomographic (CT) and magnetic resonance imaging (MRI) brain scanning. The scans were normal, Bell's palsy was diagnosed, and the symptoms resolved over the next few weeks. Two weeks later, Ms. C. began losing her hair in a band-like distribution, and the following week she awoke with vertigo and confusion and returned to the emergency room, where repeat CT and MRI scans were normal. Fatigue, malaise, memory loss, and confusion began soon thereafter and have continued, making it difficult for her to work. Review of the first CT scan revealed that she had received a radiation dose to her brain of 6 Gy — approximately 100 times the dose from the average brain CT scan, 10 times the dose from the average brain-perfusion scan, and 3 times the daily dose of radiation treatment for brain cancer. Ms. C. is now a plaintiff in both a federal class-action lawsuit against a CT-scanner manufacturer and a state medical malpractice lawsuit. More than 378 patients in the United States have been identified as having received brain-perfusion scans with similar radiation overdoses, and the Food and Drug Administration (FDA) has issued a national advisory that hospitals should carefully check their CT protocols.

Radiation doses from CT scans are 100 to 500 times those from conventional radiography, depending on what part of the body is imaged. CT-machine manufacturers compete, in part, on the basis of image quality, which is directly associated with radiation dose (see figure). Technical advances such as increased imaging speed have led to new CT scanning techniques that have also boosted doses. For example, the brain-perfusion scan undergone by Ms. C. uses sophisticated techniques for assessing regional blood flow and, even when done correctly, delivers a dose 10 times that of a routine brain CT. Although such imaging techniques may have a role in diagnosis, there are few evidence-based guidelines regarding their appropriate use, and institutional use varies widely, reflecting physicians' preferences and manufacturers' promotion of these capabilities, rather than scientific evidence of improved clinical outcomes. Ms. C. not only received an accidental radiation overdose but also underwent a high-dose brain-perfusion CT when a much-lower-dose, routine head CT would have sufficed.

The rest of the article: Full-text (free): http://content.nejm.org/cgi/content/full/NEJMp1002530

5. Families Don't Trust Bad News from ICU Doctors

By Amy Norton. NEW YORK (Reuters Health) Jul 01 - Families of critically ill patients may often take a more optimistic view of their loved one's condition than doctors do, even when they are given a specific estimate of the chances of survival, a new study suggests.

A number of studies have found that doctors and family members frequently have different opinions on critically ill patients' odds of survival. This raises the question of whether doctors are effectively communicating their estimates of patients' prognosis.

Many experts now recommend that doctors try to give specific numeric estimates of a patient's chances of survival -- rather than "qualitative" information, such as telling families is it "very unlikely" that their loved one will survive.

So for the new study, researchers looked at whether the numeric and qualitative approaches differed in their effects on families' views.

The researchers had 169 family members of patients treated in one intensive care unit view videos that portrayed a doctor discussing a critically ill patient's prognosis with the family.

Half the family members viewed a hypothetical scenario in which the doctor told the family that their relative was "very unlikely" to survive and "very likely" to die. The doctor also said that if he did live, he would probably have to remain on a ventilator. The other half of the family members saw a video with the same scenario, with the exception that the doctor said the patient had a 10% chance of surviving and a 90% chance of dying.

In both cases, the researchers found, study participants came away with a more positive estimate of the hypothetical patient's prognosis than the doctor on the video had given.

They restated the doctor's estimates fairly accurately, but when asked for their own sense of the patient's chances of survival, study participants gave an average estimate of 26% after watching the video where the doctor had said survival was "very unlikely."

Even after viewing the video in which the doctor gave 10% survival odds, study participants still said the patient had, on average, a 22% chance of making it.

"The key finding is that many families don't take physicians' estimates at face value," said Dr. Douglas B. White, of the University of Pittsburgh Medical Center in Pennsylvania, who directed the study.

The findings, reported online June 10th in the American Journal of Respiratory and Critical Care Medicine, also suggest that effective communication with families is not just a matter of giving numeric estimates of the chances of survival, rather than qualitative ones.

This may mean, Dr. White said in an interview, that ICU doctors need to limit the amount of the information they convey, so that family members are less likely to be overwhelmed at a time when they are distraught. They could also try explicitly asking family members if they understood the information they were just given, he said.

Trust is another key issue, the researcher noted. ICU physicians are not the patient's or family's regular doctor, which means family members are being asked to trust the judgment of a stranger.

In this study, participants who reported relatively less trust in doctors also disagreed to a greater extent with the doctor's prognosis estimate in the video.

Dr. White said that it remains unclear exactly how ICU doctors can best establish a level of trust between themselves and family members in such a short and emotionally charged time frame.

Research also suggests that families take a number of factors into consideration, other than the doctor's judgment, when it comes to their own views of a loved one's chances of survival.

In an earlier study, Dr. White and his colleagues found that families of critically ill ICU patients only rarely relied on doctors' prognostication alone.

Instead, they often considered their perceptions of their loved one's strength and "will to live," his or her history of overcoming illness, and their own trust in optimism, intuition and faith.

As for how well doctors are able to estimate prognosis, research suggests they are "fairly accurate" when estimating the general odds of patients in a given situation surviving to hospital discharge, according to Dr. White. They are not as good, however, at predicting whether any one patient will live or die.

There is, Dr. White said, an "inherent uncertainty in medicine," and doctors need to convey that fact to family members as well.

http://ajrccm.atsjournals.org/cgi/content/abstract/201002-0262OCv1

Am J Respir Crit Care Med 2010.

6. Similar Results from Three Immobilization Techniques after Colles Fracture Reduction

Outcomes were similar at 8 weeks and at 6 months with circumferential casting, volar-dorsal splinting, and modified sugar-tong splinting.

Nonoperative immobilization of fractures can be accomplished by several methods, including circumferential casting, volar-dorsal splinting, and modified sugar-tong splinting. Researchers compared the efficacy of the three techniques in a prospective randomized study of 101 adult patients who presented to an emergency department (ED) in Vancouver, British Columbia, with closed isolated first-time distal radius fractures and who did not have neuromuscular deficit. Patients were randomized after successful reduction with procedural sedation in the ED.

Eighty-two percent of patients were available for follow-up assessment at 8 weeks, and 61% were available at 6 months. At both time points, rate of loss of anatomic position; disability of the arm, shoulder, and hand (DASH) scores; and median pain scores were similar among the three groups.

Comment: A common emergency medicine admonition is "don't put a circular cast on a fresh fracture" because of the risk for pressure syndromes. Yet circular casting is still used in some cases because it is believed to provide better immobilization than other techniques. This study failed to demonstrate better outcomes with casting, and risking compartment syndrome — even if the risk is small — is not advisable. Simple volar-dorsal or modified sugar-tong techniques are both acceptable forms of immobilization after reduction; circular casting adds risk but no benefit.
— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine July 9, 2010

Citation(s): Grafstein E et al. A prospective randomized controlled trial comparing circumferential casting and splinting in displaced Colles fractures. CJEM 2010 May; 12:192. http://www.cjem-online.ca/v12/n3/p192

7. Alarming Rise in Major Complications from Button Battery Ingestions

Ingestion of large button batteries, particularly lithium cells, accounts for the increase in poor outcomes.

To describe recent trends in button battery ingestions, investigators collected data from the National Poison Data System (NPDS; 56,535 cases reported during 1985–2009), the National Battery Ingestion Hotline (NBIH; 8161 cases during 1990–2008), and all 73 major (life-threatening or disabling) and 13 fatal cases ever reported in the medical literature or to the NBIH.

NPDS data showed no consistent trend in annual frequency of button battery ingestions. However, the proportion of major or fatal cases increased 6.7-fold between the first 3 years (1985–1987) and last 3 years (2007–2009). Children younger than 6 years accounted for 68% of NPDS cases and 62% of NBIH cases; all NBIH fatalities and 85% of major cases were in patients younger than 4 years. In logistic regression analysis of NBIH data, predictors of poor outcome were large battery diameter (20–25 mm; odds ratio, 24.6), age below 4 years (OR, 3.2), and ingestion of more than one battery (OR, 2.1).

During 2000–2009, 92% of major and fatal cases were from ingestion of 20-mm lithium cells. Injuries (e.g., severe burns, esophageal stenosis, bilateral vocal cord paralysis) occurred as soon as 2 hours after ingestion. Most major and fatal cases occurred in children less than 4 years old (92%) and were unwitnessed (56%), and many unwitnessed cases were initially misdiagnosed (46%). The authors present a management algorithm that recommends endoscopic removal of esophageal button batteries within 2 hours of ingestion.

Comment: These data are sobering. Physicians should keep button cells high on the list of differential diagnoses for any child who presents with airway obstruction or wheezing, drooling, vomiting, chest discomfort, difficulty swallowing or refusal to eat, or choking or coughing while eating or drinking. Once an esophageal button battery is identified, consultants must be mobilized for emergent removal.

— Katherine Bakes, MD. Published in Journal Watch Emergency Medicine June 25, 2010. Citation: Litovitz T et al. Emerging battery-ingestion hazard: Clinical implications. Pediatrics 2010 Jun; 125:1168.

8. Dorsal digital anaesthesia: one injection or two?

Cannon B, et al. Emerg Med J 2010;27:533-536.

Background: Digital nerve blocks (DNB) are performed frequently in the Emergency Department (ED). The aim of this study was to establish whether single injection subcutaneous digital nerve block (SDNB) is as effective as the traditional (two injection) digital nerve block (TDNB) for digital anaesthesia.

Method: Single blinded, prospective, randomised-controlled multicentre trial within Hampshire EDs. Patients ≥16 years attending the ED with fingertip injuries/infections (distal to the distal-interphalangeal joint) requiring a DNB were randomised to SDNB/TDNB groups. Outcome measures were: primary - successful anaesthesia; secondary - patient distress, clinician satisfaction (CS), complications.

Results: 76 patients were randomised. (37 received SDNB). At 5 min, more patients in the SDNB group (28/37, 76%) were adequately anaesthetised than in the TDNB group, (22/34, 65%). At 10 min, 33/37 (89%) of the SDNB group compared to 28/34 (82%) of the TDNB group were adequately anaesthetised. The mean (SD) of self-reported distress scores for the SDNB group were lower than those reported for the TDNB group, whereas the mean (SD) of CS scores for SDNB were higher than those reported for TDNB. Neither group reported complications from anaesthesia.

Conclusions: SDNB is as effective as TDNB. Outcome measures favoured SDNB, but only CS scores achieved statistical significance. Trial recruitment is much slower than anticipated. However, clinical practice has demonstrated that SDNB works and practice is already changing within the Hampshire region, with some departments adopting SDNB as standard practice. Therefore, the results are being presented now to allow clinicians to make an informed choice. Our results may also contribute to future metanalyses.

Editor’s note: Not compared was the one-shot transthecal block, which I find ‘handy’. For a good review, see Hart RG, et al. Transthecal digital block: an underutilized technique in the ED. Amer J Emerg Med. 2005;23:340-342. http://www.ajemjournal.com/article/S0735-6757(04)00267-0/abstract

9. Bedside Ultrasound Diagnosis of Clavicle Fractures in the Pediatric Emergency Department

Cross KP, et al. Acad Emerg Med. 2010;17:687–693.

Objectives: Clavicle fractures are among the most common orthopedic injuries in children. Diagnosis typically involves radiographs, which expose children to radiation and may consume significant time and resources. Our objective was to determine if bedside emergency department (ED) ultrasound (US) is an accurate alternative to radiography.

Methods: This was a prospective study of bedside US for diagnosing clavicle fractures. A convenience sample of children ages 1–18 years with shoulder injuries requiring radiographs was enrolled. Bedside US imaging and an unblinded interpretation were completed by a pediatric emergency physician (EP) prior to radiographs. A second interpreter, a pediatric EP attending physician with extensive US experience, determined a final interpretation of the US images at a later date. This final interpretation was blinded to both clinical and radiography outcomes. The reference standard was an attending radiologist's interpretation of radiographs. The primary outcome was the accuracy of the blinded US interpretation for detecting clavicle fractures compared to the reference standard. Secondary outcome measures included the interrater reliability of the unblinded bedside and the blinded physicians' interpretations and the FACES pain scores (range, 0–5) for US and radiograph imaging.

Results: One-hundred patients were included in the study, of whom 43 had clavicle fractures by radiography. The final US interpretation had 95% sensitivity (95% confidence interval [CI] = 83% to 99%) and 96% specificity (95% CI = 87% to 99%), and overall accuracy was 96%, with 96 congruent readings. Positive and negative predictive values (PPVs and NPVs, respectively) were 95% (95% CI = 83% to 99%) and 96% (95% CI = 87% to 99%), respectively. Interrater reliability (kappa) was 0.74 (95% CI = 0.60 to 0.88). FACES pain scores were available for the 86 subjects who were at least 5 years old. Pain scores were similar during US and radiography.

Conclusions: Compared to radiographs, bedside US can accurately diagnose pediatric clavicle fractures. US causes no more discomfort than radiography when detecting clavicle fractures. Given US's advantage of no radiation, pediatric EPs should consider this application.

10. New Study Finds 91% of Physicians Practice Defensive Medicine

Mark Crane. June 28, 2010 — The fear of being sued for medical malpractice is pervasive, leading 91% of physicians across all specialty lines to practice defensive medicine — ordering more tests and procedures than necessary to protect themselves from lawsuits — a new study finds.

A survey by researchers from Mount Sinai School of Medicine, New York City, also found that the same overwhelming percentage of physicians believe that tort reform measures to provide better protections against unwarranted malpractice suits are needed before any significant decrease in the ordering of unnecessary medical tests can be achieved.

Investigators questioned 2416 physicians from a variety of practice and specialty backgrounds in a survey conducted between June 25, 2009, and October 31, 2009. Their findings were published today in the June 28 issue of the Archives of Internal Medicine.
"Physicians feel they are vulnerable to malpractice lawsuits even when they practice competently within the standard of care," said Tara Bishop, MD, associate, Division of General Internal Medicine at Mount Sinai School of Medicine, and coauthor of the study, in a news release. "The study shows that an overwhelming majority of physicians support tort reform to decrease malpractice lawsuits and that unnecessary testing, a contributor to rising healthcare costs, will not decrease without it."

Physicians were asked to rate their level of agreement to 2 statements:

• "Doctors order more tests and procedures than patients need to protect themselves against malpractice suits," and
• "Unnecessary use of diagnostic tests will not decrease without protections for physicians against unwarranted malpractice suits."

There were no statistically significant differences between sex, geographic location, specialty category, or type of practice. The largest difference was that 92.6% of male physicians said they practice defensive medicine vs 86.5% of female physicians.

Although physicians in relatively low-risk specialties such as general internal medicine and pediatrics are much less likely to be sued for malpractice than obstetric/gynecologic specialists and emergency physicians, their fear is just as real, Dr. Bishop asserted in an interview with Medscape Medical News. "There's just a visceral response to the word 'malpractice,' " she said. "The entire medical community worries about being pulled into a lawsuit."

Determining the true costs of defensive medicine may be impossible because so many factors go into decisions about ordering tests, Dr. Bishop noted. Malpractice fears play a large role, but so does a desire to be thorough and careful. In a fee-for-service system that often rewards overuse, it is difficult to say how large a part defensive medicine plays in the decision to order a test.

A 2003 study by the US Department of Health and Human Services estimated the cost of defensive medicine at $60 billion a year, but the American Medical Association pegs it at $200 billion. A 2008 study by PricewaterhouseCoopers' Health Research Institute calculated the cost of defensive medicine at $210 billion per year, or 10% of all healthcare spending.

The new Mt. Sinai study coincides with several earlier surveys about how prevalent defensive medicine is. Some of the findings of those studies follow here.

• Ninety percent of physicians said they practice defensive medicine, according to a poll published in April by Jackson Healthcare, a medical staffing and information technology company. About three quarters of physicians surveyed said defensive medicine decreases patient access to healthcare and will exacerbate the growing physician shortage.
• A 2008 study by the Massachusetts Medical Society found that 83% of its physicians practice defensive medicine at a cost of at least $1.4 billion a year in that state alone. More than 20% of x-rays, computed tomography scans, magnetic resonance images, and ultrasounds; 18% of laboratory tests; 28% of specialty referrals; and 13% of hospital admissions were ordered for defensive purposes.
• A survey of 824 Pennsylvania physicians, published in 2005 in the Journal of the American Medical Association, found that 93% admit to risk-aversion tactics such as over-ordering tests, abandoning high-risk procedures, and avoiding the sickest of patients.

"We practice maximalist medicine to avoid missing any problem our clinical judgment tells us may be extremely remote," said Alan C. Woodward, MD, an emergency physician and past president of the Massachusetts Medical Society, to Medscape Medical News. Defensive medicine is rampant because "the threat of being sued is pervasive, and doctors simply don't trust the legal system."

In an invited commentary accompanying the Mt. Sinai study, Sen. Orrin G. Hatch (R-UT) acknowledged that consensus on Capitol Hill about tort reform "has been an elusive commodity" because of division and partisanship. "It is my hope that, as the American people see more evidence that they are paying for redundant and unuseful medical procedures, they will demand in larger numbers that real reforms be enacted to address this problem," Sen. Hatch writes. "That is what makes studies like the one by Bishop, et al., so important."

Arch Intern Med. 2010:170:1081-1084.

11. Population Trends in the Incidence and Outcomes of Acute Myocardial Infarction

Yeh RW, et al. N Engl J Med. 2010;362:2155-2165.

Background: Few studies have characterized recent population trends in the incidence and outcomes of myocardial infarction.

Methods: We identified patients 30 years of age or older in a large, diverse, community-based population who were hospitalized for incident myocardial infarction between 1999 and 2008. Age- and sex-adjusted incidence rates were calculated for myocardial infarction overall and separately for ST-segment elevation and non–ST-segment elevation myocardial infarction. Patient characteristics, outpatient medications, and cardiac biomarker levels during hospitalization were identified from health plan databases, and 30-day mortality was ascertained from administrative databases, state death data, and Social Security Administration files.

Results: We identified 46,086 hospitalizations for myocardial infarctions during 18,691,131 person-years of follow-up from 1999 to 2008. The age- and sex-adjusted incidence of myocardial infarction increased from 274 cases per 100,000 person-years in 1999 to 287 cases per 100,000 person-years in 2000, and it decreased each year thereafter, to 208 cases per 100,000 person-years in 2008, representing a 24% relative decrease over the study period. The age- and sex-adjusted incidence of ST-segment elevation myocardial infarction decreased throughout the study period (from 133 cases per 100,000 person-years in 1999 to 50 cases per 100,000 person-years in 2008, P less than 0.001 for linear trend). Thirty-day mortality was significantly lower in 2008 than in 1999 (adjusted odds ratio, 0.76; 95% confidence interval, 0.65 to 0.89).

Conclusions: Within a large community-based population, the incidence of myocardial infarction decreased significantly after 2000, and the incidence of ST-segment elevation myocardial infarction decreased markedly after 1999. Reductions in short-term case fatality rates for myocardial infarction appear to be driven, in part, by a decrease in the incidence of ST-segment elevation myocardial infarction and a lower rate of death after non–ST-segment elevation myocardial infarction.

12. Images in Emergency Medicine

Rattlesnake Envenomation
http://content.nejm.org/cgi/content/full/362/23/2212

Cutis Marmorata in Decompression Sickness
http://content.nejm.org/cgi/content/full/362/23/e67

Visible Peristalsis
http://content.nejm.org/cgi/content/full/362/24/e68

Radiologic Signs of Pneumoperitoneum
http://content.nejm.org/cgi/content/full/362/25/2410

Benign Paroxysmal Positional Vertigo
http://content.nejm.org/cgi/content/full/362/25/e70

Elderly Woman with Rectal Bleeding
http://www.annemergmed.com/article/S0196-0644(09)01282-7/fulltext

Woman with Leg Rash
http://www.annemergmed.com/article/S0196-0644(09)01448-6/fulltext


13. Predictors of important neurological causes of dizziness among patients presenting to the ED

Cheung C S K, et al. Emerg Med J 2010;27:517-521.

Objectives: Dizziness is a common presenting complaint in the emergency department (ED). This prospective study describes the incidence, causes and outcome of ED patients presenting with dizziness and tries to identify predictors of central neurological causes of dizziness.

Methods: Single-centre prospective observational study in a university teaching hospital ED in Hong Kong. All ED patients (≥18 years old) presenting with dizziness were recruited for 1 month. Symptoms, previous health, physical findings, diagnosis and disposition were recorded. The outcome at 3 months was evaluated using hospital records and telephone interviews. Follow-up was also performed at 55 months using computerised hospital records to identify patients with subsequent stroke and those who had died.

Results: 413 adults (65% female, mean 57 years) were recruited. The incidence of dizziness was 3.6% (413/11 319). Nausea and/or vomiting (46%) and headache (20%) were the commonest associated findings. Hypertension (33%) was the commonest previous illness. Central neurological causes of dizziness were found in 6% (23/413) of patients. Age 65 years or greater (OR=6.13, 95% CI 1.97 to 19.09), ataxia symptoms (OR=11.39, 95% CI 2.404 to 53.95), focal neurological symptoms (OR=11.78, 95% CI 1.61 to 86.29), and history of previous stroke (OR=3.89, 95% CI 1.12 to 13.46) and diabetes mellitus (OR=3.57, 95% CI 1.04 to 12.28) predicted central causes of dizziness.

Conclusions: Most dizzy patients had benign causes. Several clinical factors favoured a diagnosis of central neurological causes of dizziness.

14. Steroid Dosage and Route in Patients Admitted for Chronic Obstructive Pulmonary Disease

Oral low-dose use was associated with less treatment failure than was high-dose parenteral use.

Patients admitted for chronic obstructive pulmonary disease (COPD) usually receive systemic steroids, which have been associated with better outcomes in several prior randomized trials, but the best dose is still in question. Several major clinical practice guidelines recommend low-dose oral steroids.

In a retrospective cohort study, based on data from 414 U.S. hospitals, Massachusetts investigators compared outcomes in nearly 80,000 patients admitted for COPD to non–intensive care unit settings. About 74,000 received parenteral steroids (equivalent to a median dose of 600 mg of prednisone total for the first 2 days), and the rest received oral prednisone (median, 60 mg for the first 2 days). Treatment failure — defined as need for mechanical ventilation after the first 2 days, death, or readmission for COPD within 30 days — occurred in 11% of all patients.

In analyses adjusted for about 50 clinical and demographic variables, as well as propensity scores, treatment failure was 16% lower in patients who received oral low-dose steroids than in those who received parenteral steroids; length of stay and cost were about 10% lower in the low-dose group.

Comment: Although this study was retrospective, its sophisticated analyses convinced editorialists that the results should influence clinical practice and that a randomized controlled trial would be prohibitive in size and cost and is unnecessary. A worrisome secondary finding is that the vast majority of COPD patients received high-dose parenteral steroids, despite the contrary recommendations of major national and international guidelines — including those of the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

— Thomas L. Schwenk, MD. Published in Journal Watch General Medicine June 24, 2010.
Citation: Lindenauer PK et al. JAMA 2010;303:2359.

15. Are 2 smaller intravenous catheters as good as 1 larger intravenous catheter?

Li SF, et al. Amer J Emerg Med. 2010;28:724-727.

Objective: Using Poiseuille's law and standardized gauge sizes, an 18-gauge (g) intravenous catheter (IV) should be 2.5 times faster than a 20-g IV, but this is not borne out by observation, in vitro testing, and manufacturer's data. Our objective was to determine if the infusion rate of a single 18-g IV was equivalent to the infusion rate of two 20-g IVs.

Methods: This was a prospective study in healthy adult volunteers. Subjects simultaneously received 500 mL of normal saline via an 18-g IV in one arm and 500 mL of normal saline via two 20-g IVs in the other arm. We measured the rates of fluid administration. Paired Student's t test was used for comparison of the 2 arms of the study. We estimated that 18 trials were needed in sample size analysis.

Results: Eighteen trials were completed. The mean infusion rate for a single 18-g 500-mL IV administration was 35.6 mL/min (95% confidence interval [CI], 30.3-40.8), with manufacturer's rating being 105 mL/min. The mean infusion rate for two 20-g IVs was 41.3 mL/min (95% CI, 36.1-46.4), with manufacturer's rating being 120 mL/min. The rate of infusion via two 20-g IVs were statistically significantly faster than the single 18-g IV, with a mean difference in flow rate of 5.7 mL/min (95% CI, 1.3-10; P = .026).

Conclusion; In healthy volunteers, administration of intravenous fluids through two 20-g IVs is faster than a single 18-g IV, although both approaches are markedly slower than the manufacturer's estimates.

16. Are routine repeat chest x-rays before leaving the trauma room useful?

Lemmers M, et al. Emerg Med J 2010;27:522-525.

Background: Several guidelines advocate multiple chest x-rays during primary resuscitation of trauma patients. Some local hospital protocols include a repeat x-ray before leaving the trauma resuscitation room (TR). The purpose of this study was to determine the value of routine repeat x-rays.

Methods: One-year data of all radiological imaging in the TR were prospectively collected for all patients presenting to the TR of the hospital. The x-rays were counted and assessed and the findings were classified as either ‘new injury detected’, ‘presence of intervention devices’ or ‘deterioration of previously detected injury’.

Results: A total of 674 patients were included. More than 75% had two x-rays. Eight (2.1%) new injuries without clinical relevance were found on the repeat x-ray after an initial normal x-ray. 61 patients (9%) had a repeat x-ray to verify the effect of an intervention or position of devices. In 28 patients (22%) with two abnormal x-rays, newly diagnosed injuries (n=9) or deterioration of known injuries (n=19) were found. In 411 patients (81%) the results of the repeat x-ray had no clinical consequences.

Conclusion: This study indicates that routine repeat chest x-rays can be omitted in trauma patients whose initial chest x-ray is normal.

17. Normal Renal Ultrasound Might Obviate Need for Computed Tomography in Suspected Urolithiasis

Patients with normal renal ultrasound results had a low rate of urologic intervention within 90 days.

Edmonds ML, et al. CJEM 2010;12:201-206.

Objective: Computed tomography (CT) is an imaging modality used to detect renal stones. However, there is concern about the lifetime cumulative radiation exposure attributed to CT. Ultrasonography (US) has been used to diagnose urolithiasis, thereby avoiding radiation exposure. The objective of this study was to determine the ability of US to identify renal colic patients with a low risk of requiring urologic intervention within 90 days of their initial emergency department (ED) visit.

Methods: We completed a retrospective medical record review for all adult patients who underwent ED-ordered renal US for suspected urolithiasis over a 1-year period. Independent, double data extraction was performed for all imaging reports and US results were categorized as “normal,” “suggestive of ureterolithiasis,” “ureteric stone seen” or “disease unrelated to urolithiasis.” Charts were reviewed to determine how many patients underwent subsequent CT and urologic intervention.

Results: Of the 817 renal US procedures ordered for suspected urolithiasis during the study period, the results of 352 (43.2%) were classified as normal, and only 2 (0.6%) of these patients required urologic intervention. The results of 177 (21.7%) renal US procedures were suggestive of ureterolithiasis. Of these, 12 (6.8%) patients required urologic intervention. Of the 241 (29.5%) patients who had a ureteric stone seen on US, 15 (6.2%) required urologic intervention. The rate of urologic intervention was significantly lower in those with normal results on US (p less than 0.001) than in those with abnormal results on US.

Conclusion: A normal result on renal US predicts a low likelihood for urologic intervention within 90 days for adult ED patients with suspected urolithiasis.

18. The Importance of Being Timely (with regard to reperfusion)

In a population-based cohort with ST-segment-elevation myocardial infarction, time to reperfusion had a stronger effect than method of reperfusion on outcomes.

Lambert L, et al. JAMA. 2010;303:2148-55.

CONTEXT: Guidelines emphasize the importance of rapid reperfusion of patients with ST-elevation myocardial infarction (STEMI) and specify a maximum delay of 30 minutes for fibrinolysis and 90 minutes for primary percutaneous coronary intervention (PPCI). However, randomized trials and selective registries are limited in their ability to assess the effect of timeliness of reperfusion on outcomes in real-world STEMI patients.

OBJECTIVES: To obtain a complete interregional portrait of contemporary STEMI care and to investigate timeliness of reperfusion and outcomes.

DESIGN, SETTING, AND PATIENTS: Systematic evaluation of STEMI care for 6 months during 2006-2007 in 80 hospitals that treated more than 95% of patients with acute myocardial infarction in the province of Quebec, Canada (population, 7.8 million).

MAIN OUTCOME MEASURES: Death at 30 days and at 1 year and the combined end point of death or hospital readmission for acute myocardial infarction or congestive heart failure at 1 year by linkage to Quebec's medicoadministrative databases.

RESULTS: Of 1832 patients treated with reperfusion, 392 (21.4%) received fibrinolysis and 1440 (78.6%) received PPCI. Fibrinolysis was untimely (beyond 30 minutes) in 54% and PPCI was untimely (beyond 90 minutes) in 68%. Death or readmission for acute myocardial infarction or heart failure at 1 year occurred in 13.5% of fibrinolysis patients and 13.6% of PPCI patients. When the 2 treatment groups were combined, patients treated outside of recommended delays had an adjusted higher risk of death at 30 days (6.6% vs 3.3%; odds ratio [OR], 2.14; 95% confidence interval [CI], 1.21-3.93) and a statistically nonsignificant increase in risk of death at 1 year (9.3% vs 5.2%; OR, 1.61; 95% CI, 1.00-2.66) compared with patients who received timely treatment. Patients treated outside of recommended delays also had an adjusted higher risk for the combined outcome of death or hospital readmission for congestive heart failure or acute myocardial infarction at 1 year (15.0% vs 9.2%; OR, 1.57; 95% CI, 1.08-2.30). At the regional level, after adjustment, each 10% increase in patients treated within the recommended time was associated with a decrease in the region-level odds of overall 30-day mortality (OR, 0.80; 95% CI, 0.65-0.98).

CONCLUSION: Among patients in Quebec with STEMI, reperfusion delivered outside guideline-recommend delays was associated with significantly increased 30-day mortality, a statistically nonsignificant increase in 1-year mortality, and significantly increased risk of the composite of mortality or readmission for acute myocardial infarction or heart failure at 1 year.

19. Genomic Medicine — An Updated Primer

Feero WG, et al. N Engl J Med. 2010;362:2001-2011.

Remarkable advances have been made in understanding the human genome's contribution to health and disease since the first Genomic Medicine series was launched in the Journal in 2002… Completion of the Human Genome Project in 2003 was a major driver for the current period of biomedical discovery, and the pace continues to accelerate. This project spurred the development of innovations with extraordinary benefits. Initially, clinically useful discoveries derived from the Human Genome Project yielded improvements in "genetic medicine" — that is, the use of knowledge about single genes to improve the diagnosis and treatment of single-gene disorders. However, our increased understanding of the interactions between the entire genome and nongenomic factors that result in health and disease is paving the way for an era of "genomic medicine," in which new diagnostic and therapeutic approaches to common multifactorial conditions are emerging.

As a result of genomic discoveries, increasing numbers of clinical guidelines now suggest incorporating genomic tests or therapeutics into routine care. In some cases, the rapidity of translation has sparked debate regarding the level of evidence of clinical benefit needed to introduce new, and potentially costly, medical technologies. Although the effect of genomic discovery on the day-to-day practice of medicine has not been well quantified, it probably remains small in primary care and nonacademic settings as compared with, for example, oncology practice in an academic medical center. Regardless of where medicine is practiced, genomics is inexorably changing our understanding of the biology of nearly all medical conditions….

Given the diversity of the human species, there is no "normal" human genome sequence. We are all mutants. [Editor's note: My limited experience confirms that.]

Full-text (free): http://content.nejm.org/cgi/content/full/362/21/2001

20. Immediate β-Blockade in Patients with Myocardial Infarctions: Is There Evidence of Benefit?

Sinert R, et al. Ann Emerg Med. 2010; in press

Study Objective
The American Heart Association recommends the initiation of β-blockade to all patients with an ST-segment elevation myocardial infarction (STEMI) without contraindications to β-blocking agents. The present study seeks to systematically review the medical literature to determine the efficacy of treating STEMI patients with a β-blocker within the first 24 hours.

Methods
We searched databases for articles through MEDLINE with the PubMed interface and from 1966 through May 2009 and EMBASE from 1980 to August 2009 with the Ovid Technologies interface, using a search strategy derived from the following PICO (Patient-Intervention-Comparator-Outcome) clinical question: In patients presenting with STEMI (P), does immediate treatment with β-blockers (I) followed by standardized care beginning on day 2 or 3 compared with placebo or no treatment followed by standardized care on day 2 or 3 (C) reduce the risk of death, reinfarction, or cardiogenic shock (O)? The methodological quality of the studies was assessed.

Results
From more than 2,000 references identified in the search, only a single randomized trial met the inclusion criteria. There were no statistically significant differences in mortality; the relative risk for the combined endpoint (mortality and reinfarction) was 0.67 (95% confidence interval 0.44 to 1.03) at 6 days and 0.74 (95% confidence interval 0.53 to 1.06) at 6 weeks. Outcomes for cardiogenic shock were not reported.

Conclusion
Evidence from a single randomized trial failed to demonstrate a reduction in mortality or reinfarction with administration of β-blocker within the first 24 hours after STEMI.

21. U.S. Scores Dead Last Again in Healthcare Study

By Maggie Fox. WASHINGTON (Reuters) Jun 23 - Americans spend twice as much as residents of other developed countries on healthcare, but get lower quality, less efficiency and have the least equitable system, according to a report released on Wednesday.

The United States ranked last when compared to six other countries -- Britain, Canada, Germany, Netherlands, Australia and New Zealand, the Commonwealth Fund report found.

"As an American it just bothers me that with all of our know-how, all of our wealth, that we are not assuring that people who need healthcare can get it," Commonwealth Fund president Karen Davis told reporters in a telephone briefing.

Previous reports by the nonprofit Fund, which conducts research into healthcare performance and which promotes changes in the U.S. system, have been heavily used by policymakers and politicians pressing for healthcare reform.

Davis said she hoped health reform legislation passed in March would lead to improvements.

The current report uses data from nationally representative patient and physician surveys in seven countries in 2007, 2008, and 2009.

In 2007, health spending was $7,290 per person in the United States, more than double that of any other country in the survey.

Australians spent $3,357, Canadians $3,895, Germans $3,588, the Netherlands $3,837 and Britons spent $2,992 per capita on health in 2007. New Zealand spent the least at $2,454.

And yet Americans get less for their money, said the Commonwealth Fund's Cathy Schoen.

"We rank last on safety and do poorly on several dimensions of quality," Schoen told reporters. "We do particularly poorly on going without care because of cost. And we also do surprisingly poorly on access to primary care and after-hours care."

The report looks at five measures of healthcare -- quality, efficiency, access to care, equity and the ability to lead long, healthy, productive lives.

"On measures of quality the United States ranked 6th out of seven countries," the group said in a statement.

U.S. patients with chronic conditions were the most likely to say they got the wrong drug or had to wait to learn of abnormal test results.

Overall Britain, whose nationalized healthcare system was widely derided by opponents of U.S. healthcare reform, ranks second, the Commonwealth team found. The Netherlands ranked first.

"The findings demonstrate the need to quickly implement provisions in the new health reform law and stimulus legislation that focus on strengthening primary care, realigning incentives to reward higher quality and greater value, investing in preventive care, and expanding the use of health information technology," the report reads.

Critics of reports that show Europeans or Australians are healthier than Americans point to the U.S. lifestyle as a bigger factor than healthcare. Americans have higher rates of obesity than other developed countries, for instance.

"On the other hand, the other countries have higher rates of smoking," Davis countered. And Germany, for instance, has a much older population more prone to chronic disease.

Every other system covers all its citizens, the report noted and said the U.S. system, which leaves 46 million Americans or 15% of the population without health insurance, is the most unfair.

"The lower the performance score for equity, the lower the performance on other measures. This suggests that, when a country fails to meet the needs of the most vulnerable, it also fails to meet the needs of the average citizen," the report reads.

Cf: http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2010/Jun/Mirror-Mirror-Update.aspx