Thursday, August 19, 2010

Lit Bits: Aug 19, 2010

From the recent medical literature...

1. Newer-Generation CT Is Highly Sensitive for Diagnosing Subarachnoid Hemorrhage

But don't put away those lumbar puncture trays just yet.

Older-generation computed tomography (CT) scanners proved too insensitive for a negative scan to rule out the diagnosis of subarachnoid hemorrhage (SAH), making lumbar puncture (LP) necessary in patients with negative scans. In a retrospective chart review, researchers evaluated the sensitivity of newer-generation multidetector CT scanners for diagnosing SAH in 499 patients with suspected SAH who were referred to a Dutch neurosurgical unit from 2000 through 2005.

All patients underwent head CT. Patients with negative CT scans underwent LP (12 hours after onset of symptoms), and cerebrospinal fluid (CSF) samples were analyzed for xanthochromia by spectrophotometry. Patients with positive scans underwent angiography. SAH was diagnosed in 296 patients, based on angiography or CSF findings. Overall, CT scanning had a sensitivity of 99.7% and a specificity of 100% for diagnosing SAH. Sensitivity was 100% for scans performed 1 to 5 days after symptom onset and 96% for those performed thereafter.

Comment: This study suffers from referral bias, with an extremely high proportion of patients ruling in for subarachnoid hemorrhage (almost 60%). Although newer-generation multidetector CT was highly sensitive, the authors note that CT alone should be used to exclude SAH only on days 1 to 3 after symptom onset and scans should be reviewed by a neuroradiologist or neurosurgeon. Although this study takes us a step closer to eliminating the need for lumbar puncture in patients with suspected SAH, keep those LP trays handy until these results are duplicated in a community emergency department setting.

— Diane M. Birnbaumer, MD, FACEP. Published in Journal Watch Emergency Medicine August 5, 2010. Citation: Cortnum S et al. Neurosurgery 2010;66:900.


2. 44-55-66-PM, a Mnemonic That Improves Retention of the Ottawa Ankle and Foot Rules: A Randomized Controlled Trial

Gravel L, et al. Acad Emerg Med. 2010;17:859–864.

Objectives:  Studies have suggested that poor knowledge of the Ottawa Ankle Rules (OAR) limits its clinical impact. This study evaluated the ability of a mnemonic to improve knowledge of the OAR.

Methods:  This was a single-blind randomized controlled trial performed among residents and medical students doing a pediatric emergency medicine rotation. At baseline, all participants were tested for their baseline knowledge of the OAR. The intervention was a standardized information sheet providing a mnemonic of the OAR (44-55-66-PM), while control subjects received its classic description. Block randomization (medical student vs. type of resident) was used. Each participant answered the same questionnaire at the end of rotation (3 weeks later) and via a Web-based survey 5 to 9 months postrandomization. Main outcome measures were knowledge of the components of the ankle rule based on a 13-item criterion grid and the foot rule based on a 10-item criterion grid. All questionnaires were marked at the end of the study by two reviewers blinded to the randomization. Discrepancies in final scores were resolved by consensus. Student’s t-test was performed to compare mean scores on the evaluation between groups using an intention-to-treat approach.

Results:  Among the 206 eligible participants, 96 medical students and 94 residents were recruited and agreed to participate. Primary outcomes were measured in 95% of the participants at 3 weeks postrandomization and in 72% on the long-term follow-up. Participants in both groups were similar with regard to baseline characteristics and prior knowledge of the OAR. Both groups showed improvement in their knowledge of the rule during the study period. At mid-term, knowledge of the OAR was similar for the ankle components (score for mnemonic 10.9; control 10.2; 95% confidence interval [CI] for difference = −0.3 to 1.7) and for the foot (mnemonic 7.6 vs. control 7.5; 95% CI for difference = −0.7 to 0.9). On the long term, randomization to the mnemonic was associated with a better knowledge of the OAR as demonstrated by a higher score for the ankle component (mnemonic 10.1 vs. control 8.9; 95% CI for difference = 0.6 to 1.8) and for the foot (mnemonic 7.8 vs. control 6.5; 95% CI for difference = 0.8 to 1.9).

Conclusions:  Mid-term knowledge of the OAR drastically improved for all participants of the study. The use of the mnemonic 44-55-66-PM was associated with a better long-term knowledge of the OAR among medical students and residents. The improvement in knowledge of the OAR among the control group highlights the importance of using controlled trials for studies evaluating knowledge transfer.

3. Which Antibiotic for Acute Exacerbations of COPD?

Ciprofloxacin offered no benefit over an old standby, trimethoprim-sulfamethoxazole.

Nouira S, et al. Clin Infect Dis 2010;51:143.

BACKGROUND. Although the use of antibiotics in the treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD) is largely accepted, controversy remains regarding whether the choice of antibiotic has any impact on outcome. Our aim was to compare the effects of the combination of trimethoprim and sulfamethoxazole and ciprofloxacin in patients treated for severe COPD exacerbation requiring mechanical ventilation.

METHODS. In a randomized, double-blind trial, we included 170 patients with an acute exacerbation of COPD requiring mechanical ventilation. Enrolled patients received trimethoprim-sulfamethoxazole (n = 85) or ciprofloxacin (n = 85) for 10 days. Main outcomes were hospital death and need for an additional course of antibiotics. Secondary outcomes were duration of mechanical ventilation, length of hospital stay, and exacerbation-free interval.

RESULTS. Combined hospital death and additional antibiotic prescription rates were similar in the 2 groups (16.4% vs 15.3% for trimethoprim-sulfamethoxazole group vs ciprofloxacin group; difference, 1.1%; 95% confidence interval [CI] -9.8% to 12.0%; P = .832). Hospital death occurred in 7 patients (8.2%) receiving trimethoprim-sulfamethoxazole and 8 patients (9.4%) receiving ciprofloxacin (difference, -1.2%; 95% CI, -9.7 to 7.3; P = .90). The need for an additional antibiotic course was observed in 8 patients in the trimethoprim-sulfamethoxazole group and 5 patients in the ciprofloxacin group (difference, 2.3%; 95% CI, -5.4 to 10.0; P = .549). The mean exacerbation-free interval (+/- standard deviation) was similar in both treatment groups (83 +/- 25 vs 79 +/- 22 for the trimethoprim-sulfamethoxazole group vs ciprofloxacin group; difference, 4 days; 95% CI, -15 to 19 days; P = .41). Duration of mechanical ventilation and hospital stay was not significantly different between the 2 groups.

CONCLUSIONS. In patients with acute exacerbation of COPD requiring mechanical ventilation, efficacy of trimethoprim-sulfamethoxazole was not inferior to ciprofloxacin.

4. The Relationship between the Emergent Primary PCI Quality Measure and Inpatient AMI Mortality

Khare RK, et al, Acad Emerg Med. 2010;17:793-800.

Background: In the setting of acute ST-segment elevation myocardial infarction (STEMI), reperfusion therapy with emergent primary percutaneous coronary intervention (PCI) significantly reduces mortality. It is unknown whether a hospital's performance on the Centers for Medicare & Medicaid Services (CMS) quality metric for time from patient arrival to angioplasty is associated with its overall hospital acute myocardial infarction (AMI) mortality rate.

Objectives: The objective of this study was to evaluate if hospitals with higher performance on the time-to-PCI quality measure are more likely to achieve lower mortality for patients admitted for any type of AMI.

Methods: Using merged 2006 data from the Nationwide Inpatient Sample (NIS), the American Hospital Association (AHA) annual survey, and CMS Hospital Compare quality indicator data, we examined 69,101 admissions with an International Classification of Diseases, Ninth Revision (ICD-9)-coded principal diagnosis of AMI in the 116 hospitals that reported more than 24 emergent primary PCI admissions in that year. Hospitals were categorized into quartiles according to percentage of admissions in 2006 that achieved the primary PCI timeliness threshold (time-to-PCI quality measure). Using a random effects logistic regression model of inpatient mortality, we examined the significance of the hospital time-to-PCI quality measure after adjustment for other hospital and individual patient sociodemographic and clinical characteristics.

Results: The unadjusted inpatient AMI mortality rate at the 27 top quartile hospitals was 4.3%, compared to 5.1% at the 32 bottom quartile (worst performing) hospitals. The risk-adjusted odds ratio (OR) of inpatient death was 0.83 (95% confidence interval [CI] = 0.72 to 0.95), or 17% lower odds of inpatient death, among patients admitted to hospitals in the top quartile for the time-to-PCI quality measure compared to the case if the hospitals were in the bottom 25th percentile.

Conclusions: Hospitals with the highest and second highest quartiles of time-to-PCI quality measure had a significantly lower overall AMI mortality rate than the lowest quartile hospitals. Despite the fact that a minority of all patients with AMI get an emergent primary PCI, hospitals that perform this more efficiently also had a significantly lower mortality rate for all their patients admitted with AMI. The time-to-PCI quality measure in 2006 was a potentially important proxy measure for overall AMI quality of care.

5. Getting Into Med School without Hard Sciences

By ANEMONA HARTOCOLLIS. Published: July 29, 2010. For generations of pre-med students, three things have been as certain as death and taxes: organic chemistry, physics and the Medical College Admission Test, known by its dread-inducing acronym, the MCAT.

So it came as a total shock to Elizabeth Adler when she discovered, through a singer in her favorite a cappella group at Brown University, that one of the nation’s top medical schools admits a small number of students every year who have skipped all three requirements.

Until then, despite being the daughter of a physician, she said, “I was kind of thinking medical school was not the right track for me.”

Ms. Adler became one of the lucky few in one of the best kept secrets in the cutthroat world of medical school admissions, the Humanities and Medicine Program at the Mount Sinai medical school on the Upper East Side of Manhattan.

The program promises slots to about 35 undergraduates a year if they study humanities or social sciences instead of the traditional pre-medical school curriculum and maintain a 3.5 grade-point average.

For decades, the medical profession has debated whether pre-med courses and admission tests produce doctors who know their alkyl halides but lack the sense of mission and interpersonal skills to become well-rounded, caring, inquisitive healers.

That debate is being rekindled by a study published on Thursday in Academic Medicine, the journal of the Association of American Medical Colleges. Conducted by the Mount Sinai program’s founder, Dr. Nathan Kase, and the medical school’s dean for medical education, Dr. David Muller, the peer-reviewed study compared outcomes for 85 students in the Humanities and Medicine Program with those of 606 traditionally prepared classmates from the graduating classes of 2004 through 2009, and found that their academic performance in medical school was equivalent.

Remainder of NYT article:
Acad Med (full-text free):

6. Wound Closure after 6 Hours Does Not Increase Infection Rates

Location of the wound was a more important predictor of infection than the time to closure.

Background: The dogma that traumatic wounds should not be sutured after 6 h is based on an animal experiment by P L Friedrich in 1898. There is no adequately powered prospective study on this cut-off of 6 h to confirm or disprove the dogma. The aim of this study was to provide evidence against the dogma that wounds should be sutured within 6 h after trauma.

Method: 425 patients were included in a prospective cohort study. Patients' wounds were closed, independent of time after trauma. All patients were seen after 7–10 days for removal of stitches and wound control on infection.

Results: Of the 425 patients, 17 were lost to follow-up. Of the remaining 408 patients, 45 had wounds older than 6 h after trauma. At follow-up 372 patients (91%) had no infection and 36 patients had redness of the suture sites or worse. 11 patients (2.7%) had general redness or pus. Of those with a wound older than 6 h, three of 45 (6.7%) wounds were infected, versus 30 of 363 (9.1%) in wounds younger than 6 h (p=0.59).

Conclusion: In everyday practice wounds are sutured regardless of elapsed time. Here an attempt was made to present the evidence for this daily routine, contrary to Friedrich's Dogma.

Editor’s note: For those who would like to read Friedrich’s original article, here’s the reference: Friedrich PL. Die aseptische Versorgung frischer Wunden, unter Mitteilung yon Their versUchen uber die auskeimungszeit yon Infectionserre gern in frischen Wunden. Arch. Klin. Chir. 1898;57:288. Full-text here:

7. Vast Majority of ED Visits Are Urgent, CDC Reports

Martha Kerr. August 12, 2010 — A report issued yesterday by the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, shows that the percentage of nonurgent visits to the nation's emergency departments (EDs) is low and that this number has been decreasing during the past several years, whereas the total number of visits is steadily increasing.

According to the latest CDC report, the "National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary," only 7.9% of all visits were nonurgent. This is down from 12.1% in 2006. Meanwhile, the total number of visits to EDs increased 23% between 1997 and 2007, with early indications pointing to a record high number of visits for 2008.

Infants younger than 12 months had the highest visit rate, at 88.5 visits per 100 infants. The second highest visit rate was by adults aged 75 years and older, with 62 visits per 100 people.

Approximately 15% of all visits were by the uninsured, and roughly 25% were by patients insured by either Medicaid or the State Children's Health Insurance Program.

Only 0.1% of patients died in the ED.

"We do an excellent job of stabilizing and treating our patients, but the persistent problems of overcrowding, ambulance diversion, and boarding admitted patients in the [ED] are not going away," Angela Gardner, MD, president of the American College of Emergency Physicians (ACEP), said in a statement. "We know from the Massachusetts experience that visits will continue to rise with health care reform. We also know that as Baby Boomers age, a tsunami of patients in need of emergency care is just around the corner. We need help and we need it now."

The report shows that 64.7% of all ED visits occurred outside regular business hours. "Most doctors' offices are open for around 45 hours a week, as opposed to the 168 hours a week [EDs] are open," Dr. Gardner said. "That nearly two-thirds of emergency patients came to the [ED] between 5 p.m. and 8 a.m. during the week or on weekends highlights the unpredictable nature of health emergencies."

Overall, 12.5% of patients were admitted as inpatients, 2.1% were admitted to an observation unit, and 1.8% were transferred to a different hospital.

Overcrowding was a significant issue, according to the 2007 report, with the primary contributor to the problem being delays in moving the sickest patients to inpatient beds. Admitted patients were often boarded in the EDs or hospital hallways for hours to days, Dr. Gardner said, resulting in overcrowding and diversion of incoming ambulances to other hospitals.

On a side note, ACEP points out that the CDC says "this is the last fully detailed report of its kind to be issued about [ED] visits." ACEP is asking the CDC to reconsider.

"It is essential to know what is happening in our [EDs] as we implement health care reform," Dr. Gardner said. "This report is rich in data about who our patients are, how old they are and why they are seeking care in the [ED]. From a planning perspective, this information is invaluable."

Full CDC report:

8. Clinical Outcomes of Children Treated with Intravenous Prochlorperazine for Migraine in a Pediatric ED

Trottier ED, et al. J Emerg Med. 2010;39:166-173.

Background: Prochlorperazine is the only treatment that has been studied so far in a randomized controlled trial and found to reduce pain at 1 h in children with migraine who presented to an emergency department (ED).

Objective: To evaluate the rate of treatment failure associated with prochlorperazine used in children with severe migraine in a pediatric ED.

Methods: This study was a retrospective chart review of patients younger than 18 years of age who visited the ED of a tertiary care pediatric hospital between November 2005 and June 2007. All patients diagnosed with migraine by the emergency physicians were included in the study. Charts were evaluated by a data abstractor blinded to the study hypothesis using a standardized datasheet. Inter-rater agreement was measured. Prochlorperazine treatment failure was defined as either administration of further rescue therapy, a hospitalization, or a return visit to the ED within 48 h for symptom recurrence or side effects from the medication.

Results: Prochlorperazine was administered in 92 episodes of migraine, including 43 confirmed by a pediatric neurologist; all received diphenhydramine to prevent akathisia. A total of 13 (14%) of these patients had a treatment failure: 8 patients received one or more further rescue therapies after the administration of prochlorperazine; 5 patients were hospitalized, including 3 who had received further rescue therapy; and 3 patients returned to the ED within 48 h due to symptom recurrence.

Conclusion: There was a treatment failure rate of 14% with the use of prochlorperazine in association with diphenhydramine for severe migraine in children seen in a pediatric ED.

9. Do retinal haemorrhages occur in infants with convulsions?

Curcoy AI, et al. Arch Dis Child. 2009 Nov;94(11):873-5.

AIM: To determine the prevalence of retinal haemorrhages in infants presenting with convulsions and admitted to hospital, and to consider whether this finding indicates shaken baby syndrome.

METHODS: Prospective study of children aged 15 days to 2 years admitted with a diagnosis of first convulsion over a 2-year period (May 2004-May 2006). All infants were examined by an experienced ophthalmologist using indirect ophthalmoscopy within 72 h of admission.

RESULTS: 182 of 389 children seen in the accident and emergency department were admitted and two were found to have retinal haemorrhages. Both children were eventually diagnosed as being abused.

CONCLUSIONS: Convulsions alone are unlikely to cause retinal haemorrhages in children under 2 years of age.

10. RICH and PRINCE Probe Prehospital Therapeutic Hypothermia after Cardiac Arrest

Reed Miller. August 9, 2010 (Melbourne, Australia) — Two studies published last week are shedding light on the possibilities and limitations of prehospital "brain cooling" after cardiac arrest. In the Rapid Infusion of Cold Hartmann's (RICH) study, paramedic cooling with a rapid infusion of a large volume of ice-cold intravenous fluid (Hartmann's solution) after resuscitation did not appear to improve the outcomes of cardiac arrest patients with ventricular fibrillation more than waiting until the patient reaches the hospital to begin cooling. In the second study, the Pre-Resuscitation Intranasal Cooling Effectiveness (PRINCE) trial, investigators showed significant reductions in time required to achieve therapeutic levels of cooling, using coolant gases and oxygen given directly into the nasal passages.

Both studies were published online in the August 2, 2010 issue of Circulation.

Previous studies have suggested that therapeutic hypothermia can improve outcomes in patients who suffer out-of-hospital cardiac arrests, but the question of whether prehospital cooling further boosts outcomes is not clear, RICH researchers Dr Stephen Bernard (Ambulance Victoria, Melbourne, Australia) and colleagues explain.

Remainder of the article:


11. Racial and Sex Differences in ED Triage Assessment and Test Ordering for Chest Pain, 1997–2006

Lopez L, et al. Acad Emerg Med. 2010;17:801–808.

Objectives:  This study assessed whether sociodemographic differences exist in triage assignment and whether these differences affect initial diagnostic testing in the emergency department (ED) for patients presenting with chest pain.

Methods: A nationally representative ED data sample for all adults (≥18 years) was obtained from the National Hospital Ambulatory Health Care Survey of EDs for 1997–2006. Weighted logistic regression was used to examine the associations between race and presenting symptom, triage assignment, and test ordering, adjusting for patient and hospital characteristics.

Results:  Over 10 years, an estimated 78 million visits to the ED presented with a complaint of chest pain. Of those presenting with chest pain, African Americans (odds ratio [OR] = 0.70; 99% confidence interval [CI] = 0.53 to 0.92), Hispanics (OR = 0.74; 99% CI = 0.51to 0.99), Medicaid patients (OR = 0.72; 99% CI = 0.54 to 0.94), and uninsured patients (OR = 0.65; 99% CI = 0.51 to 0.84) were less likely to be triaged emergently. African Americans (OR = 0.86; 99% CI = 0.70 to 0.99), Medicaid patients (OR = 0.70; 99% CI = 0.55 to 0.88), and uninsured patients (OR = 0.70; 99% CI = 0.55 to 0.89) were less likely to have an electrocardiogram (ECG) ordered. African Americans (OR = 0.69; 99% CI = 0.49 to 0.97), Medicaid patients (OR = 0.67; 99% CI = 0.47 to 0.95), and uninsured patients (OR = 0.66; 99% CI = 0.44 to 0.96) were less likely to have cardiac enzymes ordered. Similarly, African Americans and Hispanics were less likely to have a cardiac monitor and pulse oximetry ordered, and Medicaid and uninsured patients were less likely to have a cardiac monitor ordered.

Conclusions:  Persistent racial, sex, and insurance differences in triage categorization and basic cardiac testing exist. Eliminating triage disparities may affect “downstream” clinical care and help eliminate observed disparities in cardiac outcomes.

12. Success of a safe and simple algorithm to reduce use of CT pulmonary angiography in the ED

Stein EG, et al. AJR Am J Roentgenol. 2010;194:392-7.

OBJECTIVE: The purpose of our study was to determine whether the radiation exposure to patients with suspected pulmonary embolism (PE) could be decreased by safely increasing the use of ventilation-perfusion (V/Q) scanning and decreasing the use of CT pulmonary angiography (CTPA) through an educational intervention.

MATERIALS AND METHODS: Collaborative educational seminars were held among the radiology, nuclear medicine, and emergency medicine departments in December 2006 and January 2007 regarding the radiation dose and accuracies of V/Q scanning and CTPA for diagnosing PE. To reduce radiation exposure, an imaging algorithm was introduced in which emergency department patients with a clinical suspicion of PE underwent chest radiography. If the chest radiograph was normal, V/Q scanning was recommended, otherwise CTPA was recommended. We retrospectively tallied the number and results of CTPA and V/Q scanning and calculated mean radiation effective dose before and after the intervention. False-negative findings were defined as subsequent thromboembolism within 90 days.

RESULTS: The number of CTPA examinations performed decreased from 1,234 in 2006 to 920 in 2007, and the number of V/Q scans increased from 745 in 2006 to 1,216 in 2007. The mean effective dose was reduced by 20%, from 8.0 mSv in 2006 to 6.4 mSv in 2007 (p less than 0.0001). The patients who underwent CTPA and V/Q scanning in 2006 were of similar age. In 2007, the patients who underwent V/Q scanning were significantly younger. There was no significant difference in the false-negative rate (range, 0.8-1.2%) between CTPA and V/Q scanning in 2006 and 2007.

CONCLUSION: The practice patterns of physicians changed in response to an educational intervention, resulting in a reduction in radiation exposure to emergency department patients with suspected PE without compromising patient safety.

13. What’s Up with the “Vulnerable Atherosclerotic Plaque”? A Review of the Literature

Alsheikh-Ali AA, et al. Ann Intern Med 2010;153,

Full-text (free):

14. Mid-Arm Circumference Estimates Children's Weight in Emergencies

By Rob Goodier. NEW YORK (Reuters Health) Aug 06 - Doctors have developed a new tool for estimating school-age children's weight while treating them for trauma and other emergencies: a formula based on a mid-arm circumference measurement.

"This technique is intended as a 'rough estimate' in pediatric resuscitation, to better calculate appropriate drug doses," lead researcher Dr. Giles Cattermole at the Chinese University of Hong Kong told Reuters Health by email.

The formula is weight (kg) = (mid-arm circumference (cm) - 10) * 3.

According to a report published online July 12th in Resuscitation, this formula was at least as accurate as other methods when used for school-age children. And it may be more convenient than others, given that the arm is already exposed for measuring blood pressure and gaining venous access.

Dr. Cattermole and his team compared their new formula to three other techniques commonly used: estimates based on age, foot length and height using a color-coded Broselow tape.

In a study group of 1,391 children ages 1 to 11, the mid-arm circumference (MAC) measurement outperformed the other three parameters, both overall and in the oldest age group studied (9 to 11 years). In fact, 171 of the children were too tall for the Broselow tape.

The MAC correlation with weight was not statistically significant in the youngest group (1 to 5 years), however.

In no group was age or foot length the most accurate.

Multiple regression models showed that MAC was the most accurate method in the oldest group, and the Broselow height method was the most accurate in the youngest children. The two methods were similarly accurate in the 6-to-8-year-olds.

The study was population based, testing all the children in 14 schools and kindergartens who had their parents' permission to participate.

The MAC formula is simple and linear, the researchers say. It could become more nuanced using a color-coded tape system like the Broselow method, in which weight groups are categorized by color.


15. Images for the Emergency Physician

Complications of Otitis Media

16. Risk for Acute Bacterial Meningitis in Children with Complex Febrile Seizure

Bacterial meningitis is uncommon in children who present with a first complex febrile seizure.

In a retrospective chart review, researchers examined the rate of acute bacterial meningitis (ABM) in 526 otherwise healthy children (age range, 6–60 months) who presented with their first complex febrile seizure (focal seizures, duration over15 minutes, multiple seizures within 24 hours) to a tertiary care pediatric emergency department in Boston between 1995 and 2008.

A total of 156 children (29%) were pretreated with antibiotics. Of 340 patients (65%) who underwent lumbar puncture (LP), 14 (2.7%) had cerebrospinal fluid (CSF) pleocytosis (white blood cell count over 7 cells/µL). Three patients (0.9%) were diagnosed with ABM; two had Streptococcus pneumoniae in CSF culture and one, in whom LP was not successful, had S. pneumoniae in blood culture. One patient with ABM was nonresponsive at presentation, another had a bulging fontanelle and nuchal rigidity, and the third patient had two brief generalized seizures within 24 hours. Two patients with ABM presented before the introduction of the conjugate pneumococcal vaccine. Among the 161 (of 186) children who did not undergo LP and returned for follow-up, none had ABM.

Comment: Bacterial meningitis is uncommon in otherwise healthy children with a first complex febrile seizure. The authors concluded that "LP should be performed on the basis of clinical suspicion and additional signs and symptoms that are suggestive of meningitis." However, they do not provide specific suggestions about when to perform LP. The prevalence of acute bacterial meningitis in children who present with a first complex febrile seizure and no other signs and symptoms of meningitis is low. Thus, physicians could consider forgoing LP — after a period of observation — in well-appearing children without overt signs of meningitis whose neurological status returns to baseline.

— Howard Bauchner, MD, and Katherine Bakes, MD. Published in Journal Watch Pediatrics and Adolescent Medicine July 28, 2010. Citation: Kimia A et al. Pediatrics 2010;126:62.


17. New AHA/ASA Guidelines on Management of Spontaneous Intracerebral Hemorrhage

July 30, 2010 — The American Heart Association/American Stroke Association has released a new guideline on the management of spontaneous intracerebral hemorrhage (ICH).

ICH has long been recognized as one of the most severe forms of stroke, among the most devastating neurologic injuries, and the view of many has been that there is not much to be done for these patients, said lead study author Lewis B. Morgenstern, MD, from the University of Michigan, Ann Arbor.

"The clear message that we want to send with this guideline is that intracerebral hemorrhage is a very treatable disorder, with very guideline-concordant, aggressive critical care," Dr. Morgenstern told Medscape Medical News. "There's a lot of evidence in the guideline of things that are shown to be effective and improve outcome."

There's also a lot of evidence that if care is not aggressive, "outcome is very bad," he added. "So the hope of the writing committee is that clinicians will use this to guide their appropriate and aggressive treatment for patients who have intracerebral hemorrhage."

The guideline, which has been reviewed and the educational content affirmed by the American Academy of Neurology, as well as the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, was published online July 22 and will appear in the September issue of Stroke. The guideline applies only to spontaneous ICH, not ICH subsequent to trauma.

Remainder of the article:

Guidelines (free):

18. The Effect of Physician Triage on ED Length of Stay

Han JH, et al. J Emerg Med. 2010;39:227-233.

Background: Emergency Department (ED) overcrowding is a serious public health issue, but few solutions exist. Objectives: We sought to determine the impact of physician triage on ED length of stay for discharged and admitted patients, left-without-being-seen (LWBS) rates, and ambulance diversion.

Methods: This was a pre-post study performed using retrospective data at an urban, academic tertiary care, Level I trauma center. On July 11, 2005, physician triage was initiated from 1:00 p.m. to 9:00 p.m., 7 days a week. An additional physician was placed in triage so that the ED diagnostic evaluation and treatment could be started in waiting room patients. Using the hospital information system, we obtained individual patient data, ED and waiting room statistics, and diversion status data from a 9-week pre-physician triage (May 11, 2005 to July 10, 2005) and a 9-week physician triage (July 11, 2005 to September 9, 2005) period.

Results: We observed that overall ED length of stay decreased by 11 min, but this decrease was entirely attributed to non-admitted patients. No difference in ED length of stay was observed in admitted patients. LWBS rates decreased from 4.5% to 2.5%. Total time spent on ambulance diversion decreased from 5.6 days per month to 3.2 days per month.

Conclusion: Physician triage was associated with a decrease in LWBS rates, and time spent on ambulance diversion. However, its effect on ED LOS was modest in non-admitted ED patients and negligible in admitted patients.

19. Intranasal Medication Delivery for Children Reviewed

Laurie Barclay, MD. August 9, 2010 — The most frequent pediatric indications for intranasal medication delivery are pain control, anxiolysis, and seizure control, according to a review published online August 9 in Pediatrics. Other potential indications for intranasal medication delivery not reviewed in this article include the treatment of epistaxis, pretreatment before nasogastric tube insertion, and administration of naloxone for reversal of narcotic overdose.

"Intranasal delivery offers unique advantages that may allow more efficient use of resources, more rapid patient care, and higher patient and provider satisfaction," write Timothy R. Wolfe, MD, from University of Utah School of Medicine in Salt Lake City, and Darren A. Braude, MD, from the University of New Mexico School of Medicine in Albuquerque. "The highly vascularized nasal mucosa and the olfactory tissue in direct contact with the central nervous system allow nasally administered drugs to be rapidly transported into the bloodstream and brain, with onsets of action approaching that of intravenous therapy. First-pass drug metabolism via the liver is also avoided, resulting in high bioavailability of many medications."

Except for orally and intranasally administered medications, most formulations require a needle injection, which may be painful, anxiety-provoking, and time-consuming for staff, who must be trained in proper injection technique and who are exposed to the risks for needle stick injury. In comparison, intranasal delivery of medication is relatively painless, inexpensive, and easy to administer with minimal training.

Specific uses of intranasally delivered medications include the following:

• For pain control, fentanyl 1.5 to 2.0 μg/kg. This may be titrated every 15 minutes as needed. Patients should be monitored for respiratory depression. It may be appropriate to administer oral medications concurrently so that they take effect as the intranasal fentanyl effect wears off.
• For anxiolysis, midazolam 0.4 to 0.5 mg/kg. The concentrated form (5 mg/mL) should be used, because other concentrations may be ineffective when administered intranasally. The patient and family should be advised that a burning sensation may last for 30 seconds.
• For seizures, midazolam 0.2 mg/kg. As for anxiolysis, the concentrated form (5 mg/mL) should be used for intranasal delivery.

Intranasal opiates may be especially useful for minor fractures, large abrasions, burns, wound-dressing changes, extremity fractures, and other acutely painful conditions in children. For treatment of acute pain, intranasal opiates have been shown to be as effective as intravenous morphine and faster than intramuscular morphine.

Procedures in which light procedural sedation and anxiolysis may be achieved with intranasal medications include laceration repair, magnetic resonance imaging and computed tomography scans, burn-dressing changes, dental extractions, endoscopies, and central venous port access. Although intranasal midazolam is the most commonly studied drug in these settings, other options may include intranasal fentanyl, ketamine, sufentanil, dexmedetomidine, and combinations of these drugs.

Intranasal midazolam is effective for prolonged seizures because it easily and rapidly crosses the nasal mucosa and the blood-brain barrier, with similar efficacy to intravenous diazepam but faster onset because of the lack of need to start an intravenous line. Intranasal midazolam and lorazepam are also safe for treating seizures outside of the hospital setting, and intranasal midazolam may be a useful option for treating status epilepticus when intravenous access is not immediately available.

Specific considerations for administering intranasally delivered medications include the following:

• Deliver immediately to allow absorption while the airway is being supported.
• The nostril should be inspected for significant amounts of blood or mucous discharge that could limit absorption of a nasal medication. When these are present, alternative delivery options should be considered, or it may be appropriate to suction the nasal passage before medication delivery.
• Deliver half of the medication dose up each nostril, which doubles the available mucosal surface area (vs a single nostril) for drug absorption and increases the rate and amount of absorption.
• The most concentrated form available of the medication should be used, because dilute forms are less effective for intranasal delivery.
• The ideal volume for intranasal medication delivery is 0.2 to 0.3 mL of medication per nostril, and volume per nostril should not exceed 0.5 to 1.0 mL. Two separate doses may be used when a higher volume is needed, with a few minutes between doses to allow the first dose to absorb.

Adverse effects of nasal medications seldom occur. The most common adverse effect is transient nasal burning and irritation with midazolam. Except with high doses of intranasal sufentanil for induction during surgery, oversedation has not been reported for intranasal medications, including fentanyl or midazolam.

"Intranasal medication delivery is an effective method of delivering analgesia, anxiolysis, and anticonvulsants to pediatric patients," the review authors conclude. "In the properly selected patient, nasal administration can reduce time to medication delivery and onset, reduce medical staff resource use, eliminate needle-stick exposure risk, and eliminate pain from the injection, thereby leading to improved patient and parent satisfaction. Pediatricians, pediatric emergency physicians, and emergency medical services medical directors should consider adopting this delivery method for medications and indications that are appropriate to their practice setting."

Dr. Wolfe is affiliated with Wolfe Tory Medical, Inc, the maker of the MAD nasal drug delivery device. Dr. Braude has disclosed no relevant financial relationships.

Pediatrics. Published online August 9, 2010.

20. Straddling Patients on a Stretcher for CPR Works Fine

NEW YORK (Reuters Health) Jul 30 - Pumping on a patient's chest during CPR while the stretcher is moving works just fine, Chinese researchers have found.

By straddling patients on the stretcher, paramedics can get them to and from the ambulance while still doing cardiopulmonary resuscitation (CPR).

What hadn't been clear was how that precarious position would affect the quality of chest compressions if the paramedics didn't have the balance of a bull rider.

So the researchers, led by Dr. Zhou Yaxiong at West China Hospital of Sichuan University in Chengdu, had 20 medical students do chest compressions on a resuscitation dummy that measured the quality of their work. They would do compressions for one minute, both on the floor and on a moving stretcher.

When the researchers examined the data from the dummy, they found no difference in compression rate, depth or efficacy between the two positions. However, the students were able to start CPR about seven seconds earlier when they didn't have to mount the stretcher, and they said it was more comfortable on the floor.

In the report, the researchers thank the students for their "enthusiastic collaboration" and note that none of them fell off the stretcher.

In clinical terms: "Paramedics do not necessarily need to stop transporting the victims while external chest compression is in progress but can perform straddling external chest compression on a moving stretcher instead," the authors reported online July 20th in Resuscitation.

"By doing so, time for transporting victims to the emergency department to get advanced life support may be shortened."

Dr. Dana Edelson, associate chair of the CPR Committee at the University of Chicago, said the results were surprising.

"It goes against conventional wisdom that moving on a stretcher you would do CPR of the same quality as when you are on the floor," she told Reuters Health, adding that more research was needed to confirm the findings.

She stressed that it wasn't clear at this point that getting to the hospital sooner meant a better outcome. And the larger size of most Americans compared with Chinese might also make straddling patients a tougher job in the U.S.

"The general recommendation is still as far as possible to continue doing CPR at the scene and focus on doing the best CPR you can muster," she said.

In case you were wondering: Doing CPR while walking alongside a moving stretcher, instead of straddling the patient, doesn't work as well, according to previous studies.

It appears that mouth-to-mouth resuscitation - shown to be of limited value in another study last week - while straddling dummies on a moving stretcher has not yet been studied.

Resuscitation 2010. In press


21. Malpractice Threat to Physicians Pervasive, AMA Study Finds

Mark Crane. August 5, 2010 — More than 42% of physicians have been sued for medical malpractice at some point in their careers, and more than 20% were sued at least twice, according to a new American Medical Association (AMA) report.

An average of 95 claims were filed for every 100 physicians — almost 1 per physician — the AMA's Physician Practice Information survey of 5825 physicians, fielded in 2007 and 2008, found.

Despite the pervasive threat of litigation across 42 different specialties surveyed, two thirds of claims are dropped or dismissed, and physicians prevail 90% of the time in cases that go to trial, the study found. Still, the costs to physicians in terms of malpractice premiums and to the entire healthcare system resulting from the practice of defensive medicine are quite high. Average defense costs per claim range from a low of $22,000 among claims that are dropped or dismissed to a high of more than $100,000 for cases that go to trial.

"Even though the vast majority of claims are dropped or decided in favor of physicians, the understandable fear of meritless lawsuits can influence how and where physicians practice, when they retire, and how often they practice wasteful defensive medicine," AMA Immediate Past-President J. James Rohack, MD, told Medscape Medical News. "This litigious climate hurts patients' access to physician care at a time when the nation is working to reduce unnecessary healthcare costs.

"Unfortunately, there are no real surprises in this study for us," said Dr. Rohack, a cardiologist in Temple, Texas. "It reconfirms the need for a solution to our current tort system. If the nation is ever going to control the rise in healthcare costs, we have to eliminate wasteful defensive medicine spending."

Other highlights in the report include:

• Nearly 61% of physicians aged 55 years and older have been sued.
• There is wide variation in the effect of liability claims between specialties. The number of claims per 100 physicians was more than 5 times greater for general surgeons and obstetricians/gynecologists than it was for pediatricians and psychiatrists.
• Before they reach the age of 40 years, more than 50% of obstetricians/gynecologists have already been sued.
• Ninety percent of general surgeons aged 55 years and older have been sued.
"In any single year, being sued is a rare event. Only 5 percent of physicians had claims filed against them in that time frame. Over the length of a career, however, claims are much more common," the report found.

Using data compiled by the Physician Insurers Association of America, a group of physician-owned or physician-operated liability carriers, the AMA survey found:

• Sixty-five percent of claims were dropped, dismissed, or withdrawn; 25.7% were settled; 4.5% were decided by alternative dispute mechanism; and 5% were resolved by trial, with the defendant prevailing in 90% of those tried cases.
• Median indemnity payments were $200,000 for settled claims and $375,000 for tried claims.

Pediatricians and psychiatrists had the lowest incidence of claims. Less than 30% of physicians in either specialty were sued. General surgeons and obstetricians/gynecologists had the highest incidence of claims. Nearly 70% of physicians in those specialties were sued, and more than 200 career claims were filed for every 100 physicians.

Twice as many male physicians had been sued (47.5%) compared with female physicians (23.9%). Male physicians had more than twice as many career claims per 100 physicians, at 111 for men compared with 41 for women. There are several reasons for that disparity. Male physicians are concentrated in the specialties with the highest levels of claims, and female physicians are concentrated in those with the lowest levels. Women also are newer entrants into the medical workforce, so the men had a longer time period, or length of exposure, during which to accumulate claims. Male physicians also worked on average 5 more hours per week than women, resulting in greater exposure. Finally, male physicians were more likely to be practice owners than women.

Practice owners were about 14 percentage points more likely to be sued than employees (47.5% vs 33.4%) because owners incur claims from other physicians and employees of their practices.

The report concludes that the malpractice system "gets it wrong" in terms of compensation for medical errors on both sides of the equation. Citing a 2006 study (N Engl J Med. 2006;354:2024-2033), the report said 27% of claims involving errors were uncompensated. On the flip side, the same percentage of compensated claims did not involve a medical error.

The AMA cites its report to lobby for "proven medical liability reforms to lower health care costs and keep physicians caring for patients," especially caps on awards for pain and suffering. "The findings in this report validate the need for national and state medical liability reform to rein in our out-of-control system where lawsuits are a matter of when, not if, for physicians," said Dr. Rohack.

The AMA favors caps on awards for noneconomic damages. "We know they work," Dr. Rohack said. "Before the reforms in Texas in 2003, obstetricians, neurosurgeons, orthopaedists, and other high-risk specialists were leaving the state. Patients had to travel long distances to see these specialists."

Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change, based in Washington, DC, said the report shows that the threat faced by physicians, particularly in the high-risk specialties, is pervasive.

"We have long known that the medical liability system is a highly ineffective and inefficient mechanism to improve quality," Dr. Ginsburg said. "As the delivery system advances in the area of quality measurement, the crude and poorly targeted liability system seems to be even more inappropriate. In fact, the malpractice system is really obsolete in terms of improving quality and compensating victims."

Dr. Ginsburg argues that the AMA should "aim higher" in its reform efforts. Caps on awards are "a Band-Aid, not true reform. It may reduce the volume of claims and payouts through the system but doesn't improve quality. And the opposition to caps is so dug in that it may be impossible to achieve anyway.

"There are more ambitious proposals, such as granting safe harbors for care delivered in accord with accepted practice guidelines," he added. "Care delivered consistently with those guidelines should be protected." Pilot projects such as special health courts where judges experienced in malpractice cases choose their own experts and decide a case without a jury also are promising, he said.

Dr. Rohack said the AMA also favors these reforms but believes that caps on awards are a proven benefit to physicians.

The AMA Report: