Lit Bits: Oct 28, 2010

From the recent medical literature...

1. The New 2010 CPR and Advanced Cardiac Care Guidelines Hit the Press This Month

Guideline highlights (32 page pdf—the place to start): http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf

Guidelines in 17 parts (for the academic details): http://circ.ahajournals.org/content/vol122/18_suppl_3/

Quick summary: 2010 AHA Guidelines: The ABCs of CPR Rearranged to "CAB"

Emma Hitt, PhD. October 20, 2010 — Chest compressions should be the first step in addressing cardiac arrest. Therefore, the American Heart Association (AHA) now recommends that the A-B-Cs (Airway-Breathing-Compressions) of cardiopulmonary resuscitation (CPR) be changed to C-A-B (Compressions-Airway-Breathing).

The changes were documented in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, published in the November 2 supplemental issue of Circulation: Journal of the American Heart Association, and represent an update to previous guidelines issued in 2005.

"The 2010 AHA Guidelines for CPR and ECC [Emergency Cardiovascular Care] are based on the most current and comprehensive review of resuscitation literature ever published," note the authors in the executive summary. The new research includes information from "356 resuscitation experts from 29 countries who reviewed, analyzed, evaluated, debated, and discussed research and hypotheses through in-person meetings, teleconferences, and online sessions ('webinars') during the 36-month period before the 2010 Consensus Conference."

According to the AHA, chest compressions should be started immediately on anyone who is unresponsive and is not breathing normally. Oxygen will be present in the lungs and bloodstream within the first few minutes, so initiating chest compressions first will facilitate distribution of that oxygen into the brain and heart sooner; starting with "A" rather than "C" adds another 30 critical seconds.

"For more than 40 years, CPR training has emphasized the ABCs of CPR, which instructed people to open a victim's airway by tilting their head back, pinching the nose and breathing into the victim's mouth, and only then giving chest compressions," noted Michael R. Sayre, MD, coauthor and chairman of the AHA's Emergency Cardiovascular Care Committee, in an AHA written release. "This approach was causing significant delays in starting chest compressions, which are essential for keeping oxygen-rich blood circulating through the body," he added.

The new guidelines also recommend that during CPR, rescuers increase the speed of chest compressions to a rate of at least 100 times a minute. In addition, compressions should be made more deeply into the chest, to a depth of at least 2 inches in adults and children and 1.5 inches in infants.

Persons performing CPR should also avoid leaning on the chest so that it can return to its starting position, and compression should be continued as long as possible without the use of excessive ventilation.

9-1-1 centers are now directed to deliver instructions assertively so that chest compressions can be started when cardiac arrest is suspected.

The new guidelines also recommend more strongly that dispatchers instruct untrained lay rescuers to provide Hands-Only CPR (chest compression only) for adults who are unresponsive, with no breathing or no normal breathing.

Other Key Recommendations

Other key recommendations for healthcare professionals performing CPR include the following:

• Effective teamwork techniques should be learned and practiced regularly.
• Quantitative waveform capnography, used to measure carbon dioxide output, should be used to confirm intubation and monitor CPR quality.
• Therapeutic hypothermia should be part of an overall interdisciplinary system of care after resuscitation from cardiac arrest.
• Atropine is no longer recommended for routine use in managing and treating pulseless electrical activity or asystole.

Pediatric advanced life support guidelines emphasize organizing care around 2-minute periods of continuous CPR. The new guidelines also discuss resuscitation of infants and children with various congenital heart diseases and pulmonary hypertension.

The authors of the guidelines have disclosed no relevant financial relationships.

Circulation. 2010;122[suppl 3]:S640-S656.

2. Five Intriguing Presentations at the ACEP 2010 Scientific Assembly

a. ED Imaging, Testing Rises, Increasing Length of Stay

Nancy A. Melville. October 7, 2010 (Las Vegas, Nevada) — A significant increase in imaging and diagnostic testing in the emergency department (ED) is leading to longer stays and is likely having a direct effect on ED overcrowding, according to research presented here at the American College of Emergency Physicians 2010 Scientific Assembly.

A retrospective study looking at ED trends with data from the National Hospital Ambulatory Medical Care Survey found that the rates of imaging tests such as magnetic resonance imaging (MRI) and computed tomography (CT) scans in the ED were as much as 3 times higher in 2007 than in 1998, and obtaining the tests was associated with longer ED stays. The rate of procedures to treat conditions remained steady.

"In the past decade, the odds of getting a treatment in the emergency department have been flat, while the odds of having a test there have increased," said Keith E. Kocher, MD, lead author and clinical instructor at the University of Michigan's Department of Emergency Medicine Injury Research Center, in Ann Arbor.

"The intensity of that testing has also increased, and this activity is associated with a longer length of stay," he said. "So we're probably contributing to crowing conditions with our activity."

The study found that among the more than 1.1 billion ED visits between 1998 and 2007, about 432 million (39.1%) involved 1 of 3 diagnostic tests (complete blood count [CBC], urinalysis, or electrocardiogram); 462 million (41.9%) involved an imaging study such as x-ray, ultrasonography, CT scan, or MRI; 280 million (25.3%) involved dispensing 3 or more medications; and 410 million (37.1%) involved 1 of 7 treatment procedures (cardiopulmonary resuscitation, endotracheal intubation, intravenous [IV] fluids, bladder catheterization, nasogastric tube placement, wound care, or orthopedic care).

The adjusted odds ratio (OR) of obtaining at least 1 of the 3 diagnostic tests in 2007, relative to 1998, was 1.15 (95% confidence interval [CI], 1.04 - 1.28); the OR of obtaining an imaging study was 1.15 (95% CI, 1.07 - 1.23); and the OR of dispensing 3 or more medications was 1.37 (95% CI, 1.21 - 1.56).

The remainder of the article: http://www.medscape.com/viewarticle/730084

b. Prolonged Wait Times for Primary Care a Key Reason Parents Use ED

Nancy A. Melville. October 6, 2010 (Las Vegas, Nevada) — The undesirable prospect of a long day in their primary care provider (PCP)'s waiting room drives many parents of sick children to opt for their local hospital's emergency department (ED), according to research presented here at the American College of Emergency Physicians 2010 Scientific Assembly.

Researchers surveyed 436 parents or caregivers of children brought to a community teaching hospital between December 2009 and March 2010. They found that nearly half of children presenting to the ED during regular office hours represented "avoidable" visits made by families that had access to PCPs.

As many as 96% of caregivers had PCPs, but the majority (58%) did not know their PCP's hours, and 24% could not even recall the PCP's name.

The study found that 63% of caregivers cited prolonged wait times at their PCP's office as the reason they came to the ED. Significant associations were made between avoidable visits and young age of the child (P = .04) and not knowing the PCP's office hours (P = .007).

"Prolonged wait times in PCP offices and lack of knowledge of office hours are significant contributors to avoidable ED visits," said Vaishali Bansilal, MD, from the Brooklyn Hospital Center, in New York, and a coauthor of the study.

"It's clear that merely assigning a PCP does not reduce avoidable emergency department use unless caregivers are appropriately educated to access their services," Dr. Bansilal reported.

The study defined avoidable ED visits as cases in which "the patient's initial complaint, medical history, presenting signs and symptom, work-up or therapy given in the ED, and discharge diagnosis indicated that immediate care was not required within 12 hours." An unavoidable ED visit was defined as all patients who did not fall into the avoidable category.

The results indicated that as many as 45% of visits (n = 196) were considered avoidable.

"The results showed that avoidable ED visits occur in nearly half the children presenting to the ED during office hours, despite having a PCP," Dr. Bansilal said.

Overcrowding in EDs remains a critical issue, but the determination of what constitutes an avoidable visit has been a point of contention, according to Jill M. Baren, MD, director of pediatric emergency medicine education in the Department of Emergency Medicine at the Hospital of the University of Pennsylvania in Philadelphia, and moderator of the session at which Dr. Bansilal presented the study findings.

"Categorizing emergency department visits as avoidable really shouldn't be done in a retrospective fashion," said Dr. Baren.

Such characterizations can fail to take into account a host of legitimate factors that steer a caregiver to the ED, she explained.

"When people seek emergency care, particularly parents, they often truly believe their child could have a life-threatening issue."

"Despite this, do the results of this study mean that we should keep allowing these behaviors? No, but the implications are such that we need to do a better job of educating people about what an emergency is and to give them realistic alternatives for timely and accessible care," she asserted.

"Don't be lulled into a false sense of security that assigning a primary care doctor results in better access, as this study illustrates," Dr. Baren cautioned.

Dr. Bansilal and Dr. Baren have disclosed no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2010 Scientific Assembly: Abstract 9. Presented September 28, 2010.

c. OTC Pediatric Dosing Cups Often Marked to Give Inaccurate Doses

Nancy A. Melville. October 6, 2010 (Las Vegas, Nevada) — Cups to measure pediatric liquid medication dose, commonly sold with over-the-counter medications, often are marked inaccurately, potentially providing a larger dose than is intended or recommended, according to research presented here at the American College of Emergency Physicians 2010 Scientific Assembly.

Researchers independently measured 2.5 and 5.0 mL doses of water and medication according to markings on 7 over-the-counter medication dose cups, and then poured the contents into a standard 10 mL graduated cylinder and recorded the measurement.

Overall, the results on the accurate cylinder showed measurements that were an average of 0.33 mL greater than the measuring cup (95% confidence interval [CI], 0.15 - 0.52; P = .0012).

When water was tested against the cylinder for all 7 dosing cups, the cylinder measurement was 0.63 mL more than the dosing cup (95% CI, 0.42 - 0.86; P less than .0001).

Lead author Allison M. Tadros, MD, assistant professor and assistant residency director of emergency medicine at West Virginia University School of Medicine in Morgantown, noted that the inaccuracies occurred in the careful context of a scientific study; in the hands of actual users, the measurements could be even more inaccurate.

"We were taking our time and being careful, but we all know that in the context of treating a screaming child at 3 in the morning, most are not taking the time to really measure accurately."

For the study, Dr. Tadros and a colleague were blinded to each other's measurements. The investigators did not significantly differ in their measurements (average bias, −0.1 mL; 95% limits of agreement, −0.6 - 0.8; P = .15).

When the researchers excluded the 2 most accurate dosing cups from the analysis, the average difference was 0.54 mL for medication (95% CI, 0.37 - 0.72; P less than .0001) and 0.91 mL for water (95% CI, 0.73 - 1.10; P less than .0001).

One cup studied measured an average of 1.15 mL more of the medication than the cylinder. With water, the difference averaged 1.05 mL more than the cylinder.

Dr. Tadros said that the type of dosing cup and the color of the medicine made a difference.

"We found that some of the cups were embossed with the measurements, instead of printed, and it was much harder to make the measurement on the embossed cup. If the medication was clear, measuring was also more difficult."

She noted that a study in 2008 asked volunteers to measure 5 mL of acetaminophen (Tylenol) in a dosing cup. When the researchers pulled the medicine into a syringe, and they found that, on average, they were getting 6.3 mL instead of 5 mL.

For a 1-time dose, the discrepancies might not have a clinical significance, but they could be problematic in longer-term use, Dr. Tadros noted.

"The numbers may seem low, but keep in mind that some of them are being dosed multiple times a day," she said. "So it could be more of a clinical consequence over the course of a day or several days, when you're giving more medication than you should with every dose."

The study sheds light on potentially important flaws in the dosing measurements on pediatric medication cups, but the clinical implications of the discrepancies remain to be seen, according to Jill M. Baren, MD, director of pediatric emergency medicine education in the Department of Emergency Medicine at the Hospital of the University of Pennsylvania in Philadelphia, and moderator of the session at which Dr. Tadros presented her findings.

"This is the first study to raise the point that inaccurate dosing of medication using over-the-counter medicine cups can occur. However, at this point, we can't really say with certainty that this translates to anything clinically meaningful. This study was not designed to demonstrate that," said Dr. Baren.

"The researchers suggest that prior studies have shown that parents already tend to err on the side of giving more liquid. Therefore, discrepancies in a small child could have potential clinical ramifications," she added.

Dr. Tadros and Dr. Baren have disclosed no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2010 Scientific Assembly: Abstract 2. Presented September 28, 2010.

d. Out-of-Hospital Hypothermia With Cold Saline Nearly Doubles Survival of Cardiac Arrest Patients

Nancy A. Melville. October 4, 2010 (Las Vegas, Nevada) — When emergency medical services added induced hypothermia with cold saline to standard postresuscitation care, the survival rate of patients with a return of spontaneous circulation in the field nearly doubled, according to a study presented here at the American College of Emergency Physicians 2010 Scientific Assembly.

Researchers evaluated the hospital discharge summaries of survivors of out-of-hospital return of spontaneous circulation before and after the introduction of a new protocol for therapeutic hypothermia.

According to their results, overall survival before the protocol was implemented was 17.2%, whereas after it was implemented, overall survival was 28.8%, with an adjusted odds ratio of 1.9 (95% confidence interval [CI], 1.2 - 3.1).

Importantly, survival rates improved from the before to the after groups for all initial rhythms, including ventricular fibrillation (VF)/ventricular tachycardia (VT) (41.8% vs 54.5%), pulseless electrical activity (PEA) (4.4% vs 16.1%), and asystole (3.8% vs 10.1%). The best survival outcomes were seen for VF/VT, which had an adjusted odds ratio of 8.6 (95% CI, 5.5 - 13.3).

"It was very encouraging that we saw a trend toward an improvement in survival in each rhythm," said Brent Myers, MD, a coauthor on the study and medical director for the Wake County EMS System, headquartered in Raleigh, North Carolina.

Even more encouraging, he said, was the finding that there were no statistically significant differences in the before and after groups in the proportion of patients with a good neurologic outcome. Previous studies have indicated that patients at risk for ischemic brain injuries might have better outcomes if treated with therapeutic hypothermia.

"The outcome measure for the study was primarily discharge from the hospital, but the more important question is whether the [Pittsburgh Cerebral Performance Categories] scores at the time of discharge indicated that the patient was neurologically intact," he said.

"At the time of discharge, 3 of 4 patients in both arms were neurologically intact, but we just doubled the survival rate in the hypothermia group and still had a very robust number of patients who left the hospital," he said. "So we were very happy that these individuals were not left in a persistent vegetative state."

The study comprised 227 patients in the before group and 413 in the after group; baseline characteristics were similar in both groups, including mean age (65.9% vs 65.2%), male sex (52.1% vs 59.6%), mean response interval from 911 call to first arriving unit (5.6 vs 5.6 minutes), and VF/VT rhythm (35.0% vs 38.4%).

Dr. Myers noted that, contrary to some assumptions, age did not strongly affect the chance of survival with therapeutic hypothermia.

"We found in the odds ratio of survival that age does affect survival, but the decrease in survival is small," he noted, adding that increasing age was not significantly associated with survival.

According to Brian J. O'Neil, MD, moderator of the session, the study offers some impressive survival statistics for therapeutic hypothermia.

"I wasn't surprised with the VF/VT patients, but I was very surprised with the recovery rate of the PEA and asystole patients, he said. "These are among the best outcomes in the country."

He said hospitals might have various reasons for not establishing a therapeutic hypothermia protocol, but the benefits clearly outweigh the costs.

"I have heard all of the reasons, including [that it is] too much of a capital expenditure and too labor-intensive, but they are weak arguments," said Dr. O'Neil, associate chair of research and director of basic science research at Wayne State University School of Medicine, in Detroit, Michigan.

"Ice and cooling blankets cost nothing and the cost and labor to care for nursing home patients makes these arguments short-sighted."

Dr. Myers has disclosed no relevant financial relationships, although one member of the research team was on the Physio-Control EMS Fellowship during the project. Dr. O'Neil reports receiving grant support and being on the speakers board for Medivance, maker of the Arctic Sun therapeutic temperature management product.

American College of Emergency Physicians (ACEP) 2010 Scientific Assembly: Abstract 13. Presented September 28, 2010.

e. Blood Tests for Occult Bacteremia in Infants: Useless

By Frederik Joelving. LAS VEGAS (Reuters Health) Sep 29 - If an infant or young child in the emergency department has a fever but looks fine, there is no point testing for occult bacteremia, researchers reported yesterday at the annual meeting of the American College of Emergency Physicians in Las Vegas.

In their meta-analysis involving more than 11,000 infants in the "post-vaccine era," the prevalence of occult bacteremia was only 0.38%. Babies in the study were between two months and three years old.

"Because testing at this prevalence is only likely to generate false results, clinicians should acknowledge the success of vaccines as well as the inadequacy of (acute phase reactant) tests and stop testing well-appearing infants save urine," co-author Dr. Yashwant Chathampally, of the University of Texas HSC at Houston, told Reuters Health by e-mail.

Dr. Chathampally and colleagues found sensitivities and specificities for white blood cell counts and other acute phase reactant tests ranged from 77% to 86% and 57% to 78%, respectively.

Given the low prevalence of bacteremia, that means the positive predictive value never goes beyond 3%, while the negative predictive value is nearly 100%.

"Continued testing with acute phase reactants will actually only increase misidentification," said Dr. Samuel J Prater in his presentation.

In an interview with Reuters Health, Dr. Prater, of Texas Children's Hospital in Houston, added that blood testing is widespread in young infants, despite guidelines to the contrary.

"Our conclusion is that blood testing is no longer useful in the well-appearing infant aged two months and older," he said. "These tests are more likely to misclassify these infants, resulting in excess cost and antibiotic exposure."

Dr. Alfred Sacchetti, of the American College of Emergency Physicians, advises that doctors let febrile children go home if a thorough exam comes up empty, although he recommends close follow-up during the next 24 hours.

"The gist of the article was, your clinical judgment is just as good as doing these blood tests," Dr. Sacchetti, chief of emergency services at Our Lady of Lourdes Medical Center in Camden, New Jersey, told Reuters Health.

Since the 1980s, he has been giving lectures on occult bacteremia, but over the years -- first with the Hib vaccine, then the pneumococcal vaccine -- they have become shorter and shorter.

"Now it's down to one slide," he said. "It's a virus!"

3. Prehospital Oxygen: Is More Always Better?

Prehospital administration of high-flow oxygen to patients with chronic obstructive pulmonary disease was associated with significantly higher mortality than administration of oxygen titrated to a saturation of 88% to 92%.

Researchers in Australia randomized 405 prehospital patients with suspected chronic obstructive pulmonary disease (COPD) to receive standard high-flow oxygen via a nonrebreather mask at 8 to 10 L/minute or oxygen via nasal cannula titrated to a pulse oximetry reading of 88% to 92%. All patients received bronchodilators and steroids.

Prehospital and in-hospital mortality was significantly lower in the titrated oxygen group than in the high-flow oxygen group among all patients (4% vs. 9%; relative risk, 0.42) and among the 214 patients with confirmed COPD (2% vs. 9%; RR, 0.22). Length of hospital stay, ventilation requirements, and arterial blood gas measurements within 30 minutes of emergency department arrival (obtained in only 11% of patients) were similar between treatment groups. In patients with confirmed COPD, those who received titrated oxygen were significantly less likely to experience hypercapnia with respiratory acidosis than were those who received high-flow oxygen.

Comment: We agree with editorialists, who assert that titration to an oxygen saturation of 88% to 92% represents a new "gold standard" for prehospital management of patients with suspected COPD and that "further trials of high concentration oxygen in this condition would not be ethical."

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine October 19, 2010. Citation(s): Austin MA et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: Randomised controlled trial. BMJ 2010 Oct 18; 341:c5462. (http://www.bmj.com/content/341/bmj.c5462.full); O'Driscoll BR and Beasley R. Avoidance of high concentration oxygen in chronic obstructive pulmonary disease. BMJ 2010 Oct 18; 341:c5549. (http://dx.doi.org/10.1136/bmj.c5549).

4. Vascular Events Rare After ED Presentation with Dizziness

By Will Boggs, MD. NEW YORK (Reuters Health) Oct 12 - Patients who come to the emergency department (ED) with dizziness or vertigo rarely go on to develop vascular events after discharge, according to a September 19th online report in Annals of Emergency Medicine.

But while the overall risk of major vascular events is low, "we have less information on whether there are important subsets of patients that are at significantly higher or lower risk," Dr. Anthony S. Kim from University of California, San Francisco, told Reuters Health in an email.

He said that having a better understanding of each patient's evaluation in the ED and how their symptoms would impact their risk would in turn help with discharge instructions.

Dr. Kim and colleagues studied 31,159 ED patients who were discharged home with a primary diagnosis of dizziness or vertigo. In the 6 months after the initial ED visit, 274 patients died and 332 were hospitalized with a major vascular event, for a cumulative incidence of a major vascular event or death of 0.93%, a cumulative incidence of cardiovascular events of 0.32%, and a cumulative incidence of cerebrovascular events of 0.63%.

The incidence of cerebrovascular events was highest in the first month (30.2 cases per 10,000 person-months) and decreased to 6.5 cases per 10,000 person-months thereafter.

On the other hand, the incidence of cardiovascular events per 10,000 person-months was relatively stable throughout the follow-up period, ranging from 9.0 cases in the first month to 10.6 cases thereafter.

Advancing age and male sex were significant risk factors for adverse vascular outcomes, as was a discharge diagnosis of dizziness (as opposed to vertigo).

Based on predictions of the multivariable model, the 180-day risk of stroke would be 3.1% for an 85-year-old white man discharged with the diagnosis of vertigo or dizziness, but only 0.22% for a 35-year-old white woman.

"We are comparing detailed information from medical histories, neurological examinations, and diagnostic tests for dizzy ED patients who were later diagnosed with stroke" and those who were not, Dr. Kim said. "In particular, we are interested in the value of head CT imaging for these patients, given ongoing concerns about medical radiation exposure and the generally poor sensitivity of this test for the types of strokes that usually cause dizziness symptoms. Our goal is to use these data to develop better ways to identify groups of high- and low-risk patients right from the Emergency Department."

"A better understanding of these risks could create opportunities to both improve efficiency and to improve patient outcomes by targeting extensive workups and therapeutic interventions to the most appropriate patients," he said.

Ann Emerg Med. Posted online September 19, 2010. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20855127

5. Ask Patients about Care Experience, Not Satisfaction, to Measure Quality

Robert Lowes. October 13, 2010 — Asking patients about specific aspects of their care experience rather than their overall level of satisfaction is a more accurate way to compare the quality of medical practices and individual physicians, according to a study published yesterday in the BMJ.

Improved survey questions in the BMJ study, however, still allowed patient characteristics and random error to account for the lion's share of variability in the scores that practices and physicians received.

The study is timely, given the increasing use of patient surveys to help set physician compensation, as in pay-for-performance programs. The new healthcare reform law, for example, sets a pay-for-performance course and charges the US Department of Health and Human Services with developing new and improved quality metrics, such as patient experience and satisfaction.

The BMJ study involved 4573 patients seen by 150 physicians in 27 practices. Lead author Chris Salisbury, MD, a professor of primary care at the University of Bristol in the United Kingdom, and colleagues set out to examine how factors at the practice, physician, and patient level affected what patients had to say about healthcare services.

The researchers asked patients to answer the question, "All things considered, how satisfied are you with the practice?" on a 7-point scale. They found that 93.9% of the variance in the satisfaction scores stemmed from patient characteristics plus random error on an unadjusted basis. In contrast, just 4.6% and 1.5% of the variance occurred at the practice level and physician level, respectively. When the analysis was adjusted for physician-, practice-, and patient-related variables, the medical practices accounted for only 3.4% of the variance in scores. In the case of patients, the variables were age, male sex, white ethnicity, housing status, and being employed.

The statistical picture cleared up somewhat when researchers asked patients how quickly they were usually seen, a question that focused on practice as opposed to physician performance because patient scheduling is more of an organizational responsibility. The practices in the study accounted for 20.2% of the variance — the variance that mattered — in scores on an unadjusted basis and 7.3% on an adjusted basis.

The study produced similar results when patients were asked 6 questions — converted into a scale — about access to their practice in terms of making an appointment or speaking to someone. Almost 15% of the variance occurred on the practice level on an unadjusted basis (9.7% adjusted).

Another set of questions centered on the quality of care provided by physicians — specifically, how well they communicated. Here, only 1.2% of the variance (unadjusted) stemmed from the practices themselves. Instead, physicians themselves accounted for 6.3% of the variance (unadjusted) — the variance that the questions were designed to spotlight. Patients and random error supplied the rest.

Science of Patient Surveys "Has a Long Way to Go"

Although questions about a patient's experience more sharply discriminate between physicians and practices than those about satisfaction, patient characteristics and random error still play more of a wild-card role than researchers would like to see.

"For the communication scale in our study," the BMJ authors write, "so little variation exists at the level of the doctor that the reliability of using this type of measure to assess an individual doctor's performance is questionable." They note, however, that the scores can prove helpful in identifying physicians at the extremes.

Charles Vega, MD, an associate professor in the Department of Family Medicine at the University of California–Irvine School of Medicine, told Medscape Medical News that he agrees somewhat with these conclusions. High-end scores for physicians are less telling because they tend to reflect grade inflation, said Dr. Vega, but scores at the bottom can identify "problematic doctors and practices."

The BMJ study suggests that patient surveys are too imprecise to discriminate between physicians on a percentile basis, he added.

"We have a long way to go," Dr. Vega said about designing these instruments.

The need for further research also is apparent to Lee Hargraves, PhD, a research associate professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School in Worcester.

Dr. Hargraves noted that when the BMJ authors adjusted the variance results to reflect their 5 patient variables, not very much changed. If the authors had included other important patient variables such as health status in their adjustments, score variance might have shifted more to the physician and practice level, Dr. Hargraves said.

The authors of the study have disclosed no relevant financial relationships. Dr. Vega is a member of the editorial advisory board for Medscape Family Medicine. He and Dr. Hargraves have disclosed no relevant financial relationships.

BMJ. Published online October 12, 2010. Full-text: http://www.bmj.com/content/341/bmj.c5004.full

6. American Academy of Neurology Recommends DWI MRI in Acute CVA within 12 Hours

Stroke is the third leading cause of death and the leading cause of permanent disability and disability-adjusted loss of independent life-years in Western countries. Presently, the only specific, approved therapy for acute ischemic stroke is IV tissue plasminogen activator (tPA) given within 4.5 hours. tPA use has been limited due to the short treatment window, concerns about the limitations of CT-based diagnosis, and fear of hemorrhagic risks.

Noncontrast CT is the current diagnostic standard for acute stroke due to its wide availability and presumed near-perfect sensitivity for acute intracerebral hemorrhage (ICH), the most important differential diagnosis to ischemic stroke. For ischemic infarction, a number of early signs have been described and formalized CT scores have been developed. The sensitivity of CT in acute ischemic stroke varies, depending on the imaging features of infarction, examination time from clinical onset, study population, and other variables. Sensitivity estimates range from 12% to 92%, with an overall estimate of 40%–60% for the 6-hour time window. A post hoc analysis of the CT data from the National Institute of Neurological Disorders and Stroke tPA study yielded a 31% sensitivity for early infarct signs. Despite the fact that CT accuracy in acute stroke has never been established by formal assessment of the evidence relative to an independent standard, CT has become the de facto diagnostic standard.

As noncontrast CT has limited sensitivity for the diagnosis of ischemic stroke in the initial hours, improved accuracy of stroke diagnosis is necessary for the development and application of optimal thrombolytic and other stroke therapy. New MRI techniques such as diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) add another dimension to diagnostic imaging and have the potential to improve the diagnostic yield while being practical and feasible.

Full-text: http://www.neurology.org/cgi/content/full/75/2/177

Discussion in ACEP News Oct (page 11): http://www.nxtbook.com/nxtbooks/elsevier/acep1010/#/10

7. Empiric Outpatient Therapy with Trimethoprim-Sulfamethoxazole, Cephalexin, or Clindamycin for Cellulitis

Khawcharoenporn T, et al. Amer J Med. 2010;123:942-950.

Background
Limited data exist on optimal empiric oral antibiotic treatment for outpatients with cellulitis in areas with a high prevalence of community-associated methicillin-resistant Staphylococcus aureus (MRSA) infections.

Methods
We conducted a 3-year retrospective cohort study of outpatients with cellulitis empirically treated at a teaching clinic of a tertiary-care medical center in Hawaii. Patients who received more than 1 oral antibiotic, were hospitalized, or had no follow-up information were excluded. Treatment success rates for empiric therapy were compared among commonly prescribed antibiotics in our clinic: cephalexin, trimethoprim-sulfamethoxazole, and clindamycin. Risk factors for treatment failure were evaluated using multivariate logistic regression analysis.

Results
Of 544 patients with cellulitis, 405 met the inclusion criteria. The overall treatment success rate of trimethoprim-sulfamethoxazole was significantly higher than the rate of cephalexin (91% vs 74%; P less than .001), whereas clindamycin success rates were higher than those of cephalexin in patients who had subsequently culture-confirmed MRSA infections (P=.01), had moderately severe cellulitis (P=.03), and were obese (P=.04). Methicillin-resistant S. aureus was recovered in 72 of 117 positive culture specimens (62%). Compliance and adverse drug reaction rates were not significantly different among patients who received these 3 antibiotics. Factors associated with treatment failure included therapy with an antibiotic that was not active against community-associated MRSA (adjusted odds ratio 4.22; 95% confidence interval, 2.25-7.92; P less than .001) and severity of cellulitis (adjusted odds ratio 3.74; 95% confidence interval, 2.06-6.79; P less than .001).

Conclusion
Antibiotics with activity against community-associated MRSA, such as trimethoprim-sulfamethoxazole and clindamycin, are preferred empiric therapy for outpatients with cellulitis in the community-associated MRSA-prevalent setting.

8. Images in EM

Man with Knee Pain
http://www.annemergmed.com/article/S0196-0644(09)01705-3/fulltext

9. CT Scans for Trauma Evaluation Calculated to Raise Lifetime Cancer Risk

Daniel M. Keller, PhD. October 14, 2010 (Washington, DC) — Low-dose radiation used to evaluate trauma patients can increase lifetime risk for cancer, with greater risk for younger patients and for girls. These findings, presented at the American College of Surgeons 96th Annual Clinical Congress, argue for the judicious use of computed tomography (CT) scanning and a risk/benefit analysis to limit radiation exposure.

Senior author Margaret Griffen, MD, trauma surgeon at Inova Fairfax Hospital and Regional Trauma Center in Falls Church, Virginia, said medical radiation accounts for about 11% of all radiation exposure in the American population, and includes medical x-rays, nuclear medicine scans, and CT scans. In 2005, 62 million CT scans were performed, 4 million of which were on children.

Dr. Griffen and coworkers undertook a prospective study to examine the actual radiation dosage to a trauma patient during routine evaluation and treatment. Comparing these figures with data on cancer risk, they were able to determine the possible cancer risk and cancer mortality at the organ level.

The study comprised all trauma-team-activated patients being evaluated with CT scans at a level 1 trauma center between September 2009 and January 2010. Four dosimeters were placed along a Plexiglas strip at 4 surrogate reference points, corresponding to the level of head, neck, chest, and gonads. Strips were placed behind a patient at the midclavicle and midinguinal ligament line. Each strip had a patient identifier on it and was used each time a patient received a scan. The strips were collected at discharge.

All the strips were read by a single observer, who calculated a whole body dose. To get organ-specific doses, the researchers constructed 3 phantom models — an infant, a child, and an adult size. Dosimetry strips were placed behind the phantoms and within the bodies at specific organ locations. "From this, we could then create a cross-reference coefficient that we could use to multiply by the dosimeter readings for our specific patients and come up with organ-specific radiation dosing in milligrays," Dr. Griffen said.

The study involved 462 patients, the majority of them male (63%) and adults (most younger than 50 years), and almost all with blunt trauma (92%). They received an average of 3.5 CT scans. The average Injury Severity Score was 7.9, and the majority (46%) of patients were discharged home.

Dr. Griffen reported that total body radiation exposure increased with increasing patient age. "The average exposure total for males was about 61 mGy. The average exposure for females was about 58 or 59 mGy," she said. The average exposure for patients who went home from the emergency department was 58 mGy for males and 42 mGy for females. Organ-specific doses were higher for the head and thyroid and lower for the chest and gonads for both males and females, with the females getting somewhat less radiation.

Using the 2006 Biological Effects of Ionizing Radiation model (BEIR VII, phase 2), put out by the National Academies, which assumes a linear no-threshold relationship in which every dose counts and in which dose is proportional to risk, the researchers estimated organ-specific risks using their own data and the BEIR tables.

For thyroid cancer, males had much lower risk, about 10 to 12 per 100,000, when exposed at a very young age, whereas females had a potential lifetime risk for thyroid cancer of about 120 per 100,000. Risk for thyroid cancer diminished sharply if exposure occurred in the second decade of life for females, and reached an age-equivalent level in males only with exposures in the fifth decade.

Similarly, for female breast cancer, exposure at a very young age (first decade) greatly increased the lifetime risk, at about 100 per 100,000. For breast cancer mortality, "at a very young age, exposing these patients to radiation increases their likelihood of cancer mortality," Dr. Griffen said. Uterine and ovarian cancer rates were low and fairly constant, regardless of age at exposures.

She concluded that low-dose ionizing radiation for the evaluation of trauma patients potentially puts them at greater risk for cancer and cancer mortality. "The judicious use of [the] CT scan has to be part of our practice," she advised. "Age at exposure and gender do play a role in their future risk." She said future plans include looking at the 46% of patients who are sent home from the emergency department to see if the researchers can make an impact there.

Session comoderator Thomas Scalea, MD, professor of surgery and director of the program in trauma at the University of Maryland School of Medicine in Baltimore, said that the use of CT scanning helped Dr. Griffen's trauma unit send almost half the patients home rather than hospitalizing and observing them. "The alternative would be to go on to a clinical exam, which we know means you will miss some injuries. So how many injuries are you willing to miss in order to avoid irradiating these people?" he asked.

Dr. Griffen agreed that that was the critical question, giving as an example the potentially catastrophic nature of missing even 1 cervical spine injury. She suggested that there might be ways to observe some patients without admitting them to the hospital to adequately evaluate them without doing a CT scan.

Comoderator Ronald Maier, MD, professor and vice chair of surgery at the University of Washington and director of the Northwest Regional Trauma Center in Seattle, asked if the results of the prediction model (which he noted is not experimental proof) are sufficiently worrisome that magnetic resonance imaging (MRI) rather than CT scanning should be used. Dr. Griffen replied that MRI would probably not be feasible because it is too slow and not useful enough to replace CT scanning in the trauma setting.

Dr. Griffen and Dr. Maier have disclosed no relevant financial relationships.

American College of Surgeons (ACS) 96th Annual Clinical Congress: Session SP05. Presented October 4, 2010.

10. Compression-Only CPR Program Improves Survival

Reed Miller. October 6, 2010 (Phoenix, Arizona) — A large prospective cohort study provides more support for compression-only bystander cardiopulmonary resuscitation (CPR) as the preferred technique to teach the public.

Recently, two prospective randomized trials with over 2200 patients showed that performing CPR with just chest compressions is at least as effective as conventional CPR with both compressions and mouth-to-mouth ventilations.

Dr Bentley Bobrow (Arizona Department of Health Services, Phoenix) and colleagues tested the same hypothesis in a five-year prospective observational cohort study following a statewide public-education campaign to teach compression-only CPR. Results of the study are published in the October 6, 2010 issue of the Journal of the American Medical Association. This is the first report of a relationship between a public-education program and an increase in the rate of bystander CPR for a whole state, according to the authors.

The program includes in-person training in a variety of community settings (usually sponsored by fire departments), training kits sent to schools, public-service announcements featuring the governor and famous athletes, and other kinds of advertising and publicity.

The study included 5272 adults with out-of-hospital cardiac arrest not observed by responding emergency medical personnel. Of these, 779 were excluded because bystander CPR was provided by a healthcare professional or the arrest occurred in a medical facility, so a total of 4415 met all inclusion criteria for analysis, including 2900 who received no bystander CPR, 666 who received conventional CPR, and 849 who received compression-only CPR.

The study found that following the launch of the public-education campaign, from 2005 to 2009, the percentage of out-of-hospital cardiac-arrest patients that received "lay rescuer" CPR increased from 28.2% to 39.9% (p less than 0.001). The proportion of CPR that was compression-only increased from 19.6% to 75.9%, (p less than 0.001), and overall survival increased from 3.7% to 9.8% (p less than 0.001).

Only 5.2% of the patients who did not receive any bystander CPR survived to hospital discharge, compared with 7.8% of the conventional-CPR group and 13.3% for compression-only CPR. The adjusted odds ratio for survival following compression-only CPR vs conventional CPR is 1.60. The adjusted odds ratio for survival with conventional CPR vs no CPR at all is 0.99. The adjusted odds ratio for survival with compression-only CPR vs no CPR is 1.59.

"The nature of this study precludes determining the relative contributions of the various components of this statewide initiative," the authors note. However, "encouraging a technique that is easier to perform and more acceptable to the public may have helped increase the CPR rate independent of the public-education efforts. Ultimately, we suspect that only the combination of a local, state, and national public-education campaign and the endorsement of compression-only CPR made this effort successful." They predict that the American Heart Association ongoing Hands-Only CPR campaign could have similar success across the country.

JAMA abstract: http://www.ncbi.nlm.nih.gov/pubmed/20924010

11. The Association between Money and Opinion in Academic Emergency Medicine

Birkhahn RH, et al. Western J Emerg Med. 2010;11(2):126-131.

Introduction
With healthcare spending now 15% of the United States (US) economy, it is no surprise that pharmaceutical companies are spending in excess of seven billion dollars annually to market their products to physicians. The topic of physicianindustry relations has been debated in depth over the years in countless articles and, although still a controversial issue, academic medical societies have published guidelines with regard to the activities of their members.

This trend has been amplified by recent media coverage of unprincipled activities involving some of the most prestigious medical societies in the US. The American Heart Association and the American College of Cardiology, for example, recently were criticized for their revisions of guidelines outlining increased use of statins. It was discovered that seven of the nine members who drafted the guidelines had personal financial arrangements with drug manufacturers. These financial relationships result in an appearance of impropriety that undermines the public's trust in medicine as an institution.

Although the effects of industry-physician relations on professional behavior and prescribing patterns have been addressed by both opinion surveys and commentary, the impact of money has not been objectively studied.

The reporting of financial conflicts of interest has become commonplace in all areas of academic medicine, although the exact meaning of those conflicts remains to be understood. This study utilizes the results from a recent survey of the Society of Academic Emergency Medicine (SAEM) membership to determine if an association between money and personal opinion exists.

Objectives: Financial conflicts of interest have come under increasing scrutiny in medicine, but their impact has not been quantified. Our objective was to use the results of a national survey of academic emergency medicine (EM) faculty to determine if an association between money and personal opinion exists.

Methods: We conducted a web-based survey of EM faculty. Opinion questions were analyzed with regard to whether the respondent had either 1) received research grant money or 2) received money from industry as a speaker, consultant, or advisor. Responses were unweighted, and tests of differences in proportions were made using Chi-squared tests, with p less than 0.05 set for significance.

Results: We received responses from 430 members; 98 (23%) received research grants from industry, while 145 (34%) reported fee-for-service money. Respondents with research money were more likely to be comfortable accepting gifts (40% vs. 29%) and acting as paid consultants (50% vs. 37%). They had a more favorable attitude with regard to societal interactions with industry and felt that industry-sponsored lectures could be fair and unbiased (52% vs. 29%). Faculty with fee-for-service money mirrored those with research money. They were also more likely to believe that industry-sponsored research produces fair and unbiased results (61% vs. 45%) and less likely to believe that honoraria biased speakers (49% vs. 69%).

Conclusion: Accepting money for either service or research identified a distinct population defined by their opinions. Faculty engaged in industry-sponsored research benefitted socially (collaborations), academically (publications), and financially from the relationship.

Full-text (free): http://www.escholarship.org/uc/item/5qx5z0q2

12. Can Emergency Physicians Safely Rule out Ectopic Pregnancy?

By Will Boggs, MD. NEW YORK (Reuters Health) Oct 08 - A meta-analysis from the University of California, San Francisco, says yes, properly trained emergency physicians can safely rule out ectopic pregnancy using bedside ultrasonography.

"For all emergency physicians, I would hope they could consider whether such technology may help improve patient care and patient flow in their emergency departments," lead author Dr. John C. Stein told Reuters Health by email.

"But in particular, for those emergency physicians practicing in locations where access to ultrasonography is difficult, initiating training in this modality may be a tremendous advance for both patients and providers," he said.

Dr. Stein and colleagues conducted a systematic review and meta-analysis of 10 studies involving 2057 women (152 with ectopic pregnancy) to evaluate the appropriateness of bedside ultrasonography performed by emergency physicians as a screening examination for ectopic pregnancy.

In a paper published online September 15th in Annals of Emergency Medicine, they say seven of the 10 studies reported sensitivities and negative predictive values of 100%. The pooled estimate of this analysis reached 99.3% for sensitivity and 99.96% for negative predictive value. There was excellent homogeneity among the studies.

Specificity and positive predictive value showed significant heterogeneity among the studies, reaching 94.9% and 63.6%, respectively.

Overall, investigators say, emergency physicians ruled out ectopic pregnancy in between 38% and 74% of cases that were screened.

"Currently, the American College of Emergency Physicians (ACEP) Ultrasound Guidelines recommend an initial combined didactic and hands-on training course followed by at least 25 to 50 training pelvic ultrasound examinations before clinicians become credentialed," Dr. Stein said. "Although the training regimens in the studies reported in this review do not all meet these criteria, there is nothing to suggest that the ACEP guidelines are insufficient."

"Our research group is currently funded through a K-08 from the Agency for Healthcare Research and Quality to create a long-term cohort of patients evaluated by emergency physician pelvic ultrasonography," Dr. Stein added. "At this point our study is largely observational, but we would like to perform future intervention trials based on our findings, which measure patient and emergency department outcomes."

Ann Emerg Med. Posted online September 15, 2010. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20828874

13. Bacteria and viruses equally associated with wheezy episodes in young children

Bisgaard H, et al. BMJ 2010; 341:c4978

Introduction
Recurrent wheezy episodes in young children are the major reason for use of paediatric healthcare resources1 and represent an important unmet need for improved treatment strategies. Virus infections have been repeatedly and consistently associated with wheezy episodes, leading to the common use of the term viral wheeze.

A recent survey of preschool children in Europe and the United States found that antibiotics were among the most commonly prescribed drugs for wheezy episodes in this population.10 Yet no studies have suggested that bacterial infections are associated with wheezy episodes in young children and no randomised controlled trials have reported the clinical efficacy of antibiotics for such episodes. Current guidelines for the treatment of wheezy episodes in preschool children recommend that antibiotics should not be given routinely.

In this study we determined if common pathogenic bacteria were associated with acute wheezy episodes in children and whether any association was independent of virus infection. The children were prospectively examined for common airway pathogenic bacteria and viruses from age 4 weeks to 3 years during wheezy episodes and outside of such episodes as a part of the Copenhagen Prospective Study on Asthma in Childhood. To validate the pathogens detected, we also investigated the association of infections with clinical pneumonia.

Abstract
Objective: To study the association between wheezy symptoms in young children and the presence of bacteria in the airways.

Design: Birth cohort study.

Setting: Clinical research unit in Copenhagen.

Participants: Children of asthmatic mothers, from age 4 weeks to 3 years, with planned visits and acute admissions to the research clinic.

Main outcome measure: Frequency of bacteria and virus carriage in airway aspirates during wheezy episodes and at planned visits without respiratory symptoms.

Results: 984 samples (361 children) were analysed for bacteria, 844 (299 children) for viruses, and 696 (277 children) for both viruses and bacteria. Wheezy episodes were associated with both bacterial infection (odds ratio 2.9, 95% confidence interval 1.9 to 4.3; P less than 0.001) and virus infection (2.8, 1.7 to 4.4; P less than 0.001). The associations of bacteria and viruses were independent of each other.

Conclusion: Acute wheezy episodes in young children were significantly associated with bacterial infections similar to but independent of the association with virus infections.

Full-text (free): http://www.bmj.com/content/341/bmj.c4978.full

14. Dexamethasone Effective in Bacterial Meningitis

Allison Gandey. September 30, 2010 — A large prospective study shows dexamethasone improves outcomes in patients with bacterial meningitis. Investigators report a 10% reduction in mortality. The results appear in the September 29 online issue of Neurology.

The idea of using corticosteroids with antibiotics for bacterial meningitis came under fire after other large studies suggested they were ineffective. But despite the findings, recent guidelines recommend routine use of dexamethasone in adults with pneumococcal meningitis. These latest numbers support what guideline authors are proposing.

"This shows that adults with suspected bacterial meningitis should indeed be treated with adjunctive dexamethasone," lead investigator Diederik van de Beek, MD, from the University of Amsterdam in the Netherlands, told Medscape Medical News.

Most patients in the recent cohort started taking dexamethasone. Few patients in earlier years received treatment (84% vs 3%).

Herbert Schaumburg, MD, from the neurotoxicology unit at the Albert Einstein College of Medicine in the Bronx, New York, applauds this new study for having "considerable epidemiological power." This work, he says, "strongly confirms many widely held notions that corticosteroid cotreatment with antibiotics can reduce morbidity in bacterial meningitis."

Dutch investigators conducted a nationwide study evaluating the use of adjunctive dexamethasone therapy in adults with pneumococcal meningitis. Dexamethasone has been implemented on a large scale in the Netherlands. Most physicians now adhere to current guidelines recommending a standard regimen of 10 mg of intravenous dexamethasone given every 6 hours for 4 days started before or with the first dose of antibiotics.

"We were surprised by the strong implementation of this new therapy," Dr. van de Beek said. Almost 80% of patients were treated with dexamethasone according to the guidelines.

Supported by Guidelines

"Another surprise," Dr. van de Beek noted, "was the large effect of this implementation on outcome."

His team compared 357 recent meningitis cases to 352 cases from a period before the guidelines recommended dexamethasone. The researchers used a Glasgow Outcome Scale and defined an unfavorable outcome as a score of 1 to 4 points at discharge.

They found the outcome of adults with community-acquired pneumococcal meningitis on a national level has significantly improved during the last few years. Rates of hearing loss have also improved (12% vs 22%, P = .001). Differences in outcome remained after adjusting for differences in case mix between cohorts.

The power of this study, Dr. Schaumburg pointed out to Medscape Medical News, comes from the large populations involved and the use of a previously untreated control group.

Adults with suspected bacterial meningitis should indeed be treated with adjunctive dexamethasone.

The investigators found that dexamethasone appears to be more effective in patients older than 55 years. This is consistent with findings of a recent meta-analysis that included more than 2000 patients from 5 randomized controlled trials (Lancet Neurol. 2010;9:254-263). In the analysis, treatment was not associated with a reduction in death for all patients but was effective in those older than 55 years (odds ratio, 0.41; 95% confidence interval, 0.20 – 0.84; P = .01).

Meta-analysis authors attributed the apparent benefit in adults older than 55 years as having occurred by chance because there was no clear evidence of heterogeneity between the different age groups.

An age-related beneficial effect of dexamethasone could be an explanation for the apparent conflicting results of recent randomized controlled trials, the researchers suggest.

"If all patients with pneumococcal meningitis were treated with adjunctive dexamethasone," Dr. van de Beek said, "we would save 1 life every day in a country as large as the United States."

This study was funded by the Netherlands Organization for Health Research and Development and the Academic Medical Center. Dr. van de Beek has received research support from the study sponsors. He also contributed to the Cochran review below.

Neurology. Published online September 29, 2010.

See recent Cochran review: Brouwer MC, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2010 Sep 8;9:CD004405. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20824838

AUTHORS' CONCLUSIONS: Corticosteroids significantly reduced hearing loss and neurological sequelae, but did not reduce overall mortality. Data support the use of corticosteroids in patients with bacterial meningitis in high-income countries. We found no beneficial effect in low-income countries.

15. Myocarditis Masquerading as a ST Elevation Myocardial Infarction (STEMI)

Shah A. South Med J. 2010;103(9):936-939.

Myocarditis is an inflammatory disease of the myocardium with a wide range of clinical presentations, from vague flu-like symptoms to rapidly progressive heart failure. The diagnosis is made histopathologically, with the help of immunohistochemical stains. Myocarditis is classified by specific criteria, and the myocardial biopsy reveals an inflammatory infiltrate with necrosis and/or degeneration of adjacent myocytes. The case of a young woman who presented with a ST elevation myocardial infarction (STEMI) is presented. The current literature is reviewed to discuss the approach to evaluation and treatment of suspected myocarditis.

Full-text (free): http://www.medscape.com/viewarticle/728287

16. Feasibility and Reliability of the SHOT: A Short Scale for Measuring Pretreatment Severity of Alcohol Withdrawal in the ED

Gray S, et al. Acad Emerg Med. 2010;17:1048–1054.

Background:  Use of a symptom-triggered scale to measure the severity of alcohol withdrawal could reduce the rate of seizures and other complications. The current standard scale, the Clinical Institute of Withdrawal Assessment (CIWA), takes a mean (±SD) of 5 minutes to complete, requiring 30 minutes of nursing time per patient when multiple measures are required.

Objectives:  The objective was to assess the feasibility and reliability of a brief scale of alcohol withdrawal severity.

Methods:  The SHOT is a brief scale designed to assess alcohol withdrawal in the emergency department (ED). It includes four items: sweating, hallucinations, orientation, and tremor (SHOT). It was developed based on a literature review and a consensus process by emergency and addiction physicians. The SHOT was first piloted in one ED, and then a prospective observational study was conducted at a different ED to measure its feasibility and reliability. Subjects included patients who were in alcohol withdrawal. One nurse administered the SHOT and CIWA, and the physician repeated the SHOT independently. The SHOT was done only at baseline, before treatment was administered.

Results:  In the pilot study (12 patients), the SHOT took 1 minute to complete on average, and the CIWA took 5 minutes. Sixty-one patients participated in the prospective study. For the SHOT and the CIWA done by the same nurse, the kappa was 0.88 (95% confidence interval [CI] = 0.52 to 1.0; p less than 0.0001), and the Pearson’s r was 0.71 (p less than 0.001). The kappa for the nurse’s CIWA score and the physician’s SHOT score was 0.61 (95% CI = 0.25 to 0.97; p less than 0.0006), and the Pearson’s r was 0.48 (p = 0.002). The SHOTs performed by the nurse and physician agreed on the need for benzodiazepine treatment in 30 of 37 cases (82% agreement, kappa = 0.35, 95% CI = 0.03 to 0.67; p less than 0.02). The mean (±SD) time taken by nurses and physicians to complete the SHOT was 1 (± 0.52) minute (median = 0.6 minutes). Seventeen percent of patients scored positive on the SHOT for hallucinations or disorientation.

Conclusions:  The SHOT has potential as a feasible and acceptable tool for measuring pretreatment alcohol withdrawal severity in the ED. Further research is needed to validate the SHOT, to assess the utility of serial measurements of the SHOT, and to demonstrate that its use reduces length of stay and improves clinical outcomes.

17. Emergency department visits among recipients of chronic opioid therapy.

Braden JB, et al. Arch Intern Med. 2010;170:1425-32.

BACKGROUND: There has been an increase in overdose deaths and emergency department visits (EDVs) involving use of prescription opioids, but the association between opioid prescribing and adverse outcomes is unclear.

METHODS: Data were obtained from administrative claim records from Arkansas Medicaid and HealthCore commercially insured enrollees, 18 years and older, who used prescription opioids for at least 90 continuous days within a 6-month period between 2000 and 2005 and had no cancer diagnoses. Regression analysis was used to examine risk factors for EDVs and alcohol- or drug-related encounters (ADEs) in the 12 months following 90 days or more of prescribed opioids.

RESULTS: Headache, back pain, and preexisting substance use disorders were significantly associated with EDVs and ADEs. Mental health disorders were associated with EDVs in HealthCore enrollees and with ADEs in both samples. Opioid dose per day was not consistently associated with EDVs but doubled the risk of ADEs at morphine-equivalent doses over 120 mg/d. Use of short-acting Drug Enforcement Agency Schedule II opioids was associated with EDVs compared with use of non-Schedule II opioids alone (relative risk range, 1.09-1.74). Use of Schedule II long-acting opioids was strongly associated with ADEs (relative risk range, 1.64-4.00).

CONCLUSIONS: Use of Schedule II opioids, headache, back pain, and substance use disorders are associated with EDVs and ADEs among adults prescribed opioids for 90 days or more. It may be possible to increase the safety of chronic opioid therapy by minimizing the prescription of Schedule II opioids in these higher-risk recipients.

18. Droperidol Bests Midazolam in ED Sedation

By David Douglas. NEW YORK (Reuters Health) Oct 25 - Intramuscular droperidol has advantages over midazolam when patients in the emergency department (ED) are violent or acutely disturbed, Australian researchers report in the October issue of Annals of Emergency Medicine.

The study "challenges the concept that droperidol is unsafe," Dr. Geoffrey K. Isbister told Reuters Health by email. "It shows that droperidol is as effective at sedating aggressive patients as midazolam and that there were more safety issues with midazolam."

At Dr. Isbister's hospital, his colleagues are convinced of the superiority of droperidol. Since the study, "we only use droperidol and avoid benzodiazepines such as midazolam," he said, "and we have maintained the findings in the study in an open-label continuation."

Dr. Isbister of Calvary Mater Newcastle and colleagues conducted a blinded randomized trial in 91 ED patients who required physical restraint and parenteral sedation. Patients received either droperidol 10 mg, midazolam 10 mg, or midazolam 5 mg plus droperidol 5 mg.

The median duration of disturbances (20 minutes) did not differ across groups. However, only 33% in the droperidol group needed additional sedation, compared to 62% of the midazolam group and 41% of the combination group. Droperidol, say the investigators, produced more consistent moderate sedation and less highly variable and unpredictable sedation.

With droperidol as the referent, the hazard ratio for needing additional sedation was 2.31 with midazolam and 1.18 with the combination.

Patient and staff injuries and number of further episodes of violent and acute behavioral disturbance did not differ between the groups.

Adverse events were seen in 6% of the droperidol group, 28% of midazolam patients and 7% of the combination group. The authors point out that "midazolam is associated with more respiratory depression in a patient group in which alcohol intoxication is common."

Six percent of droperidol patients, 7% of midazolam patients and 14% of the combination group had an abnormal QT interval.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)00563-9/fulltext

19. Fresh Frozen Plasma Transfusion Increases Organ Failure in Trauma Patients

NEW YORK (Reuters Health) Oct 21 - Transfusion of fresh frozen plasma in critically injured patients is associated with an increased risk for multiple organ failure, according to results of a new study, highlighting the need for improved transfusion protocols.

"Changes in cell-mediated and humoral immunity are well established after transfusion and likely contribute to the increased risk of infection and multiple organ failure (MOF)," the researchers write in the October issue of Archives of Surgery.

"The scientific rationale for early FFP (fresh frozen plasma) administration remains a matter of debate; neither the efficacy nor the safety of this approach is well described," say first author Dr. Jeffrey Johnson and colleagues at the University of Colorado at Denver. "In fact, the clinical efficacy of FFP transfusion remains largely unproven, and most evidence for FFP administration is from observational data alone."

Based on accumulating evidence of the dangers of blood product transfusions, the investigators hypothesized that transfusing FFP and platelets would lead to MOF.

Their prospective cohort study included 1,440 critically injured patients admitted to a surgical intensive care unit between 1992 and 2004. MOF developed in 346 patients (24.0%), and 118 (8.2%) died; 660 patients (45.8%) received packed red blood cells, 410 (28.5%) received FFP and 147 (10.2%) received platelets.

FFP transfusion was associated with the development of MOF regardless of the units of packed red blood cells transfused. The negative effects of FFP, though, were seen more strongly among patients who received less than 6 U per 12 hours of packed red blood cell transfusion.

The study adds to a body of work suggesting that early aggressive FFP transfusion can incur risk for MOF, and the authors write that further work is needed to develop clotting assays that differentiate between types of coagulopathy.

Until such work is done, it will remain difficult to firmly establish transfusion protocols for FFP and platelets in critically injured patients. "In the interim... it would seem wise to proceed with caution," Dr. Johnson and associates say.

Arch Surg. Posted October 2010. http://archsurg.ama-assn.org/cgi/content/abstract/145/10/973

20. Natural History of Acute Colonic Diverticular Bleeding: A Prospective Study in 133 Consecutive Patients

Poncet G, et al. Alimentary Pharmacology & Therapeutics. 2010;32(3):466-471.

Introduction

Colonic diverticular disease is common in Western countries, with a prevalence increasing from less than 10% in adults under 40 to about 60% in those over 80.[1] The disease remains asymptomatic in 80% of affected individuals, while the rest develop complications. The most frequent complication is diverticulitis with the risks of abscess formation, fistulation, perforation and obstruction. The second complication is acute diverticular bleeding, affecting 3–15% of individuals with diverticular disease. Diverticular haemorrhage usually stops spontaneously in 70–90% of cases. The rate of rebleeding after one episode is between 20% and 38%, hence aggressive search for bleeding site and elective colectomy are sometimes proposed. This study was performed to provide the latest and most accurate answers to the following questions: (i) what proportion of bleeding in patients with colonic diverticular stop spontaneously, (ii) what is the 30-day mortality rate after the first episode of bleeding and (iii) what proportion of patients bleed again and what is the outcome?

Background: Bleeding recurrence rate after spontaneous haemostasis of colonic diverticular haemorrhage varies in the literature, and a small minority of patients will require endoscopic, radiological or surgical intervention.

Aim: To study the natural history of colonic diverticular bleeding in consecutive patients.

Methods: We studied prospectively consecutive patients admitted for colonic diverticular bleeding from 1997 to 2005. Data on age, gender, 30-day mortality, therapeutic modality for bleeding management and subsequent rebleeding were collected.

Results: One hundred and thirty-three patients (mean age 75.7 years) were recruited. Bleeding stopped spontaneously in 123 patients (92.4%). A more interventional approach was necessary in 10 patients. Thirty-day mortality rate for first bleeding was 2.25%. Out of the 123 patients managed conservatively and submitted to an average follow-up of 47.5 months, 17 (13.8%) presented at least one recurrent diverticular bleeding. Spontaneous haemostasis was obtained in all recurrent cases except one, who died. The estimated bleeding recurrence rate was 3.8% at 1 year, 6.9% at 5 years and 9.8% at 10 years.

Conclusions: The low estimated rebleeding rate and the fact that rebleeding can be treated conservatively in most cases suggest that an aggressive approach with intervention is not justified.

Full-text (free): http://www.medscape.com/viewarticle/729796

21. Use of Bedside Ultrasound to Assess Degree of Dehydration in Children with Gastroenteritis

Chen L, et al. Acad Emerg Med 2010; 17:1042–1047

Objectives:  Prospectively identifying children with significant dehydration from gastroenteritis is difficult in acute care settings. Previous work by our group has shown that bedside ultrasound (US) measurement of the inferior vena cava (IVC) and the aorta (Ao) diameter ratio is correlated with intravascular volume. This study was designed to validate the use of this method in the prospective identification of children with dehydration by investigating whether the IVC/Ao ratio correlated with dehydration in children with acute gastroenteritis. Another objective was to investigate the interrater reliability of the IVC/Ao measurements.

Methods:  A prospective observational study was carried out in a pediatric emergency department (PED) between November 2007 and June 2009. Children with acute gastroenteritis were enrolled as subjects. A pair of investigators obtained transverse images of the IVC and Ao using bedside US. The ratio of IVC and Ao diameters (IVC/Ao) was calculated. Subjects were asked to return after resolution of symptoms. The difference between the convalescent weight and ill weight was used to calculate the degree of dehydration. Greater than or equal to 5% difference was judged to be significant. Linear regression was performed with dehydration as the dependent variable and the IVC/Ao as the independent variable. Pearson’s correlation coefficient was calculated to assess the degree of agreement between observers.

Results:  A total of 112 subjects were enrolled. Seventy-one subjects (63%) completed follow-up. Twenty-eight subjects (39%) had significant dehydration. The linear regression model resulted in an R2 value of 0.21 (p less than 0.001) and a slope (B) of 0.11 (95% confidence interval [CI] = 0.08 to 0.14). An IVC/Ao cutoff of 0.8 produced a sensitivity of 86% and a specificity of 56% for the diagnosis of significant dehydration. Forty-eight paired measurements of IVC/Ao ratios were made. The Pearson correlation coefficient was 0.76.

Conclusions:  In this pilot study the ratio of IVC to Ao diameters, as measured by bedside US, was a marginally accurate measurement of acute weight loss in children with dehydration from gastroenteritis. The technique demonstrated good interrater reliability.

Lit Bits: Oct 2, 2010

From the recent medical literature (and conferences)...

2010 ACEP Scientific Assembly Highlights

Day 1: http://www.acep.org/WorkArea/DownloadAsset.aspx?id=49754&libID=49783
Day 2: http://www.acep.org/WorkArea/DownloadAsset.aspx?id=49783&libID=49812
Day 3: http://www.acep.org/WorkArea/DownloadAsset.aspx?id=49802&libID=49831

1. Clinically Suspected Coagulopathy in Blunt Head Trauma? Get the CT

Medzon R, et al. J Emerg Med. 2010;39:399-405.

Patients with moderate to severe head injury and abnormal coagulation studies have a significantly higher risk of brain injury. The objective of this study was to determine the association of clinical suspicion of coagulopathy and intracranial injury (ICI) among patients sustaining blunt head trauma, including minor injuries.

As part of the NEXUS II blunt head injury study, enrolled patients were prospectively evaluated for ICI and suspicion of coagulopathy. We examined the relationship between suspicion of coagulopathy and the presence of any clinically significant or “therapeutically inconsequential” ICI based on head computed tomography (CT) scan results.

The NEXUS II study enrolled 13,728 patients, including 493 with suspicion of coagulopathy. Significant ICI was present in 46 (9.3%; 95% confidence interval [CI] 6.9–12.2) patients with suspected coagulopathy, and in 460 of 9863 (4.7%; 95% CI 4.3–5.1) patients without such suspicion. “Therapeutically inconsequential” findings were found on head CT scan in 74 patients, and 7 of these had suspected coagulopathy. Interventions including intubation, intracranial pressure monitoring, or craniotomy were performed in 5 of these 7 (71%; 95% CI 29–96) individuals, compared with only 3 of 67 (4%; 95% CI 1–12) patients without suspicion of coagulopathy.

Initial clinical suspicion of coagulopathy, independent of laboratory confirmation, is associated with a greater prevalence of significant ICI injury after blunt head trauma; it also substantially increases the risk of morbidity despite the presence of an apparent “therapeutically inconsequential” injury. CT scanning of the head should be performed initially based on clinical suspicion of coagulopathy.

2. Using Etomidate in Patients with Suspected Sepsis Does Not Increase LOS

Megan Brooks. September 24, 2010 — In a prospective, randomized study, patients with suspected sepsis who received a bolus of etomidate before rapid sequence intubation spent no more time in the hospital than similar patients who received a bolus of midazolam.

Etomidate, the researchers note, is ideal for rapid intubation in septic patients because of its "predictability in dosing, reliable hypnotic effect, rapid onset, and short duration of effects and because it has no effect on histamine release, which contributes to its hemodynamic stability." However, previous studies have found adverse outcomes from a single bolus dose of etomidate in septic patients.

But in this study, along with similar hospital stays, the two groups also spent similar amounts of time in intensive care and on a ventilator, according to a September 10th online paper in Annals of Emergency Medicine.

But the trial was underpowered to detect any differences in mortality, "which is the more meaningful clinical outcome," first author Dr. Karis L. Tekwani, from Advocate Christ Medical Center in Oak Lawn, Illinois, noted in an e-mail to Reuters Health.

"Our study found a non-significant 7% increase in mortality in patients given single bolus doses of etomidate," she said. "Another randomized controlled study comparing etomidate to ketamine for rapid sequence intubation by Jabre et al also found a similar non-significant 8% increase in mortality in patients with sepsis given single bolus doses of etomidate."

Therefore, Dr. Tekwani said, it is still possible that a larger study would detect a significant difference, "and hence we would urge clinicians to at least consider using alternative induction agents in the critically ill population at risk of adrenal suppression."

Dr. Tekwani and her colleagues had randomly assigned 122 critically ill patients with presumed sepsis to etomidate (0.3 mg/kg IV) or midazolam (0.1 mg/kg IV) before emergency department intubation at their hospital. The investigators were blinded to treatment assignment. Demographics and baseline characteristics were fairly similar between the two groups. The median patient age was 70 in the etomidate group, 73 in the midazolam group.

Two patients in the etomidate arm were lost to follow-up. In intention-to-treat analysis, the median number of days in the hospital (the primary outcome) was 7.3 in the etomidate group and 9.5 in the midazolam group.

There was also no significant difference in intent-to-treat analysis in the secondary outcome of ICU stay: 3.1 days in the etomidate arm vs 4.2 days in the midazolam arm. The same was true for number of ventilator days (median 2.1 with etomidate and 2.8 days with midazolam).

The in-hospital mortality rate was 43% (26 of 61) with etomidate and 36% (21 of 59) with midazolam. "Kaplan-Meier survival analysis likewise showed no statistically significant differences between groups (p = 0.22)," the authors note.

The decision to use steroids was left to the treating physician; 20 patients in the etomidate arm (33%) got steroids in the ED versus 28 (47%) in the midazolam arm. Overall, there were no significant effects from the use of steroids, "although trends toward increased mortality were evident with supplemental steroid use, irrespective of induction agent," they report.

Etomidate has been shown to cause "measurable adrenal suppression after a single bolus dose," the authors point out, although the clinical significance of this in patients with sepsis "remains controversial." The current study, however, was not designed to obtain quantitative measures of adrenal function.

Pulse oximetry results and systolic blood pressures were similar in the two groups, both before and after intubation; 25% of patients in each group had a systolic blood pressure below 90 mm Hg after intubation.

A per-protocol analysis of 45 etomidate- and 51 midazolam-treated subjects with confirmed sepsis yielded largely findings similar to the intention-to-treat analysis.

In their report, Dr. Tekwani and colleagues try to reconcile their findings with prior studies that hinted at increased harm with etomidate in patients with sepsis. They say, for instance, that to their knowledge theirs is the only randomized, double-blind comparison of etomidate to an alternative agent for intubation in patients with presumed sepsis.

And they cite several methodological problems with past studies. The current study, they say, "overcomes many of the limitations of previous observational studies and raises the possibility that previous findings were influenced by confounding variables."
Nevertheless, they admit, this study was relatively small. This, combined with the non-significant increase in mortality in the etomidate group, raises the possibility that there may be a clinically important difference in mortality after all.

Clearly, more study is needed, they conclude.

Ann Emerg Med. Published online September 10, 2010.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20828877

3. Risk Stratification for Hospitalization in Acute Asthma: the CHOP classification tree

Tsai C, et al. Amer J Emerg Med. 2010;28:803-808.

Objective
Simple risk stratification rules are limited in acute asthma. We developed and externally validated a classification tree for asthma hospitalization.

Methods
Data were obtained from 2 large, multicenter studies on acute asthma, the National Emergency Department Safety Study and the Multicenter Airway Research Collaboration cohorts. Both studies involved emergency department (ED) patients aged 18 to 54 years presenting to the ED with acute asthma. Clinical information was obtained from medical record review. The Classification and Regression Tree method was used to generate a simple decision tree. The tree was derived in the National Emergency Department Safety Study cohort and then was validated in the Multicenter Airway Research Collaboration cohort.

Results
There were 1825 patients in the derivation cohort and 1335 in the validation cohort. Admission rates were 18% and 21% in the derivation and validation cohorts, respectively.

The Classification and Regression Tree method identified 4 important variables (CHOP): change [C] in peak expiratory flow severity category, ever hospitalization [H] for asthma, oxygen [O] saturation on room air, and initial peak expiratory flow [P]. In a simple 3-step process, the decision rule risk-stratified patients into 7 groups, with a risk of admission ranging from 9% to 48%. The classification tree performed satisfactorily on discrimination in both the derivation and validation cohorts, with an area under the receiver operating characteristic curve of 0.72 and 0.65, respectively.

Conclusions
We developed and externally validated a novel classification tree for hospitalization among ED patients with acute asthma. Use of this explicit risk stratification rule may aid decision making in the emergency care of acute asthma.






Fig. 1



Fuzzily shown here is Figure 1 which depicts the final tree generated by the CART analysis along with the admission rate for each terminal node of this tree. Overall, the CART method used 4 variables to stratify patients into 7 terminal nodes. “Ever hospitalization for asthma” was the best single discriminator, followed by room-air oxygen saturation (95% or greater vs less than 95%) and PEF severity category (severe/very severe vs mild/moderate) as the second-level discriminators. For the node of lower oxygen saturation, changes in PEF (improved vs unchanged/worsened) provided additional prognostic value. Overall, the tree resulted in 3 groups with an admission rate that was below the average (light gray boxes) and 4 groups with an admission rate that was above the average (dark gray boxes).

4. This Just In: You'll get Sued Eventually

AMA Study: EPs Rank 5th in Liability Claims Frequency

by Louise B. Andrew, MD, JD. Published in Emergency Physicians Monthly, Sept 2010

A just-released AMA study has revealed that more than 42% of physicians across all specialties has at some time been sued for malpractice, and more than 20% have been sued two or more times. Based on a 2007-2008 survey of a statistically valid sample (5285 physicians from 42 specialties randomly selected from the AMA physician masterfile) the survey asked whether the physician had ever been sued, and whether they had been named in a suit in the past year. The survey was jointly sponsored by the AMA, CMS, and 40 specialty societies, including ACEP.

Overall, 95 claims were reported ever filed for each 100 physicians, with approximately five physicians out of every 100 reporting claims in the preceding year. There was remarkable variability in the suit frequency between specialties, as well as age and gender disparities.

Surgeons and ObGyns experienced twice the overall average claims rate, followed closely by surgical subspecialists. Emergency physicians ranked fifth in claims frequency, just below radiologists, at 109 claims per 100 physicians. The lowest claims rates were experienced by psychiatrists and pediatricians.

Emergency physicians experienced an 8.7% claims rate in the year covered by the study. If this year was representative, this could approximate our annual claims rate.

Remainder of the essay: http://www.epmonthly.com/features/current-features/ama-study-eps-rank-5th-in-liability-claims-frequency/

AMA Study: http://www.ama-assn.org/ama1/pub/upload/mm/363/prp-201001-claim-freq.pdf

5. Bedside Ocular US for the Detection of Retinal Detachment in the ED

Yoonessi R, et al. Acad Emerg Med. 2010;17:913-917.

Objectives:  Acute retinal detachments (RD) can be difficult to diagnose and may require emergent intervention. This study was designed to assess the performance of emergency department ocular ultrasound (EOUS) for the diagnosis of RD.

Methods:  This was a prospective, observational study using a convenience sample of emergency department (ED) patients. Physicians performed EOUS for the diagnosis of RD prior to evaluation by an ophthalmologist. The criterion standard was the diagnosis of a RD by the ophthalmologist who was blinded to the results of EOUS.

Results:  Fifteen physicians evaluated 48 patients with acute visual changes. Eighteen patients (38%) had RDs and all were correctly identified (true positives). Of the 30 patients (62%) without RD, 25 patients were correctly identified (true negatives), and five patients with vitreous hemorrhages were misidentified as having RDs (false positives). Therefore, the sensitivity and specificity of EOUS for RD were 100% (95% confidence interval [CI] = 78% to 100%) and 83% (95% CI = 65% to 94%), respectively.

Conclusions:  Emergency department ocular ultrasound is sensitive for the diagnosis of RD and may have a role in excluding RD in patients presenting to the ED.

6. Rapid Diagnostic Testing for Seasonal Influenza: An Evidence-Based Review and Comparison with Unaided Clinical Diagnosis

Petrozzino JJ, et al. J Emerg Med. 2010;39:476-490.e1

Background: Worldwide, seasonal influenza imposes a considerable health and economic burden. Clinical diagnosis of influenza-like illness (ILI) is complicated by non-specific symptomatology. Rapid flu tests (RFTs) impact treatment decisions and may improve patient care; yet, recommendations for RFT use are broad, and the performance of unaided clinical diagnosis relative to RFTs is unclear.

Objectives: To determine age-stratified, overall sensitivities and specificities of the widely studied RFT, QuickVue® (Quidel Corporation, San Diego, CA), and clinical diagnosis of ILI by meta-analysis and to seek factors associated with poorer clinical diagnostic discrimination.

Methods: A systematic literature review was conducted using article selection criteria identifying studies indexed in PubMed/MEDLINE, the Cochrane Library, and other pertinent sources of studies reporting sensitivity, specificity, and effects of RFTs and clinical diagnosis on decision-making for patients with ILI.

Results: QuickVue's® diagnostic specificity exceeds that of unaided clinical diagnosis by 29–31%. False-positive results occur approximately 8.2 times more frequently by unaided clinical diagnosis than by the RFT alone. These findings were unaffected by seasonal variations in disease prevalence. RFTs reduce diagnostic testing, antibiotic use, and emergency department utilization while increasing antiviral prescription rates. No systematic relationship between the broadness of clinical diagnostic criteria for influenza and diagnostic performance was observed across studies included in this review.

Conclusions: Use of RFTs improves seasonal influenza diagnostic specificity above that based on unaided clinical diagnosis irrespective of the broadness of clinical diagnostic criteria, and affects clinical decision-making. These results provide an improved framework upon which to diagnose influenza, design future RFT studies, and modify existing recommendations for improved ILI patient management.

7. Prophylactic Intravenous Magnesium Sulfate for treatment of Aneurysmal Subarachnoid Hemorrhage: a Randomized, Placebo-controlled, Clinical Study

Westermaier T, et al. Crit Care Med. 2010;38:1284-90.

OBJECTIVE: To examine whether the maintenance of elevated magnesium serum concentrations by intravenous administration of magnesium sulfate can reduce the occurrence of cerebral ischemic events after aneurysmal subarachnoid hemorrhage.

DESIGN: Prospective, randomized, placebo-controlled study.

SETTING: Neurosurgical intensive care unit of a University hospital.

INTERVENTIONS: One hundred ten patients were randomized to receive intravenous magnesium sulfate or to serve as controls. Magnesium treatment was started with a bolus of 16 mmol, followed by continuous infusion of 8 mmol/hr. Serum concentrations were measured every 8 hrs, and infusion rates were adjusted to maintain target levels of 2.0-2.5 mmol/L. Intravenous administration was continued for 10 days or until signs of vasospasm had resolved. Thereafter, magnesium was administered orally and tapered over 12 days.

MEASUREMENTS AND MAIN RESULTS: Delayed ischemic infarction (primary end point) was assessed by analyzing serial computed tomography scans. Transcranial Doppler sonography and digital subtraction angiography were used to detect vasospasm. Delayed ischemic neurologic deficit was determined by continuous detailed neurologic examinations; clinical outcome after 6 months was assessed using the Glasgow outcome scale. Good outcome was defined as Glasgow outcome scale score 4 and 5.The incidence of delayed ischemic infarction was significantly lower in magnesium-treated patients (22% vs. 51%; p = .002); 34 of 54 magnesium patients and 27 of 53 control patients reached good outcome (p = .209). Delayed ischemic neurologic deficit was nonsignificantly reduced (9 of 54 vs. 15 of 53 patients; p = .149) and transcranial Doppler-detected/angiographic vasospasm was significantly reduced in the magnesium group (36 of 54 vs. 45 of 53 patients; p = .028). Fewer patients with signs of vasospasm had delayed cerebral infarction.

CONCLUSION: These data indicate that high-dose intravenous magnesium can reduce cerebral ischemic events after aneurysmal subarachnoid hemorrhage by attenuating vasospasm and increasing the ischemic tolerance during critical hypoperfusion.

8. What to Do When the Nurses Can’t Get a Line

When the RNs can’t plant an IV, you might be more successful securing an US-guided peripheral line that going for the EJ.

Ultrasound-Guided Peripheral Venous Access vs. the External Jugular Vein as the Initial Approach to the Patient with Difficult Vascular Access

Costantino TG, et al. J Emerg Med. 2010;39:462-467.

Background: Traditionally, Emergency Physicians (EPs) have used the external jugular (EJ) vein to gain vascular access in patients who have failed nursing attempts at peripheral access. Recently, some EPs have used ultrasound (USIV) to gain peripheral access.

Study Objective: This study seeks to determine which initial approach by EPs would lead to greater success. Methods: This was a prospective, randomized study of all adult patients who presented to the Emergency Department (ED) between June and December 2007. Inclusion criteria were failed nursing attempts at peripheral access (at least three). EPs were 2nd- or 3rd-year residents who had previously performed more than five each of EJs and USIVs. Patients were randomized into either an initial EJ or USIV approach.

Results: Sixty patients were enrolled, 32 in the ultrasound group, 28 in the EJ group. Fifteen different EPs performed access. Initial Success: USIV 84% (95% confidence interval [CI] 68–93%) vs. EJ 50% (95% CI 33–67%), p = 0.006. Success if EJ visible: USIV 84% vs. EJ 66% (p = 0.18). Overall success, including data from the crossover pathway: a total of 41 lines were successfully placed by ultrasound out of 46 attempts (89%) vs. 18 out of 33 for EJ (55%), p = 0.001. In total, 59/60 patients (98%) had a peripheral i.v. successfully placed. The percentage of functioning lines when the patient left the ED was: USIV 89% (95% CI 72–96%) vs. EJ 93% (95% CI 68–98%), p = 0.88.

Conclusion: As an initial approach to all patients with difficult venous access, ultrasound-guided peripheral lines are superior to the EJ approach. However if the EJ was visible, there was no difference in success among the initial approaches. Both techniques, when used together, could achieve peripheral vascular access in 98% of difficult access patients.

9. Clinical Updates from EM:RAP

A New Look at Thyroid Emergencies by Stuart P. Swadron, MD

Part I: Myxedema Coma

On the EM:RAP program, Mel Herbert and I recently did a two-part series on two rare and exotic emergencies – myxedema coma and thyroid storm. Our expert for this segment was Dr. Jonathan LoPresti, a senior endocrinologist and thyroid researcher at LA County/USC Medical Center. I interviewed him on two occasions and, quite frankly, what he had to say was fascinating. In the first part of this series, we will discuss myxedema coma. Next month we will cover thyroid storm.

Myxedema coma is one of a long list of “misnomer” diagnoses in medicine; patients with the condition are rarely edematous or comatose. Dr. LoPresti prefers to use the term “decompensated hypothyroidism”. And it is decompensated hypothyroidism that we as ER Docs need to identify and treat in the emergency department.

Dr. LoPresti has a remarkably simple and useful way of explaining what decompensated hypothyroidism is all about. Basically, patients who are hypothyroid, and thus have a decreased metabolic rate, conserve heat by being in a constant state of vasoconstriction. That is why they feel cool to the touch. They also are in a relative state of volume depletion, and although their blood pressure may be mildly elevated, they have a reduced cardiac output.

Decompensation typically occurs with infection and sepsis. These patients, who are dependent on chronic vasoconstriction to get by, suddenly have the bottom pulled out from beneath them. They are now vasodilated, volume depleted, and unable to produce enough cardiac output to cope with it. Simply stated, decompensated hypothyroidism is cardiovascular collapse in a hypothyroid patient with sepsis.

So what do these patients look like? They are cold, their skin is dry, the recovery phase of their deep tendon reflexes are delayed, their sodium and white blood cell counts are low, and there is some precipitating event going on – usually an infection. Although the formal definition of myxedema coma involves some alteration of mental status, this can be subtle: Dr. LoPresti gave the example of a patient who lost their ability to speak in a second language.

The bottom line is that it doesn’t matter to us if they meet the formal definition. If in doubt, TREAT! Despite what a lot of us have been led to believe, we have far less to worry about if we don’t treat than if we do. The only issue is the way that you treat them…

The remainder of the essay: http://www.epmonthly.com/clinical-skills/emrap/a-new-look-at-thyroid-emergencies/

Part II: Handling Thyroid Storm

…Patients with hyperthyroidism walk around every day in a state of vasodilatation. They are dependent on vasodilatation to get rid of the excess heat that they generate in their hypermetabolic state. Patients with thyroid storm are decompensated – no longer able to vasodilate sufficiently, their core temperature begins to rise. This occurs in response to any number of stressors that result in a release of catecholamines, to which the hyperthyroid patients are uniquely sensitive.

The diagnosis of thyroid storm is made on the basis of the following: characteristic clinical features, such as sweating, tremor, hyperreflexia and supraventricular tachycardias, elevated temperature, and some precipitating event, such as infection, surgery or trauma. Lastly, in order to make the formal diagnosis of storm, the patient must also have some degree of altered mental status, but this may be rather subtle and subjective.

The diagnosis is even more difficult in the elderly because they have a less dramatic response to the hyperthyroid state. Interestingly, even though the diagnosis is easier to make in younger people, thyroid storm is more dangerous for them because of their greater capacity to respond to the inappropriately high thyroid activity. This is something that seems quite counterintuitive to most EPs, but it makes sense when you think about it.

Because infection is such a common trigger of a decompensated hyperthyroid state, you should draw blood and urine cultures and initiate empiric antibiotic treatment when the diagnosis of storm is being entertained. To help confirm the diagnosis, a TSH and T4 should be sufficient. Other laboratory abnormalities that are typical include a mild normocytic anemia, low platelets, and hypocalcemia. White blood cell counts are typically, and misleadingly, low.

The thing that scares most EPs is pulling the trigger on thyroid-specific treatment, especially before results of thyroid laboratory studies are available. These patients are critically ill and we worry that treatment of the hyperthyroid state might blunt their ability to compensate for shock. Just like in decompensated hypothyroidism, the critical message here is that when in doubt, the EP should treat. If left untreated, thyroid storm is fatal. If you are wrong, a few doses of anti-thyroid medication is unlikely to harm the euthyroid patient…

The remainder of the essay: http://www.epmonthly.com/clinical-skills/emrap/a-new-look-at-thyroid-emergencies-part-ii-handling-thyroid-storm/

10. Low-dose Ketamine for Analgesia in the ED: a retrospective case series

Lester L, et al. Amer J Emerg Med. 2010;28:820-827.

Objectives
The aim of this study was to describe the use and effect of low-dose ketamine (LDK) for analgesia in the emergency department (ED).

Methods
A chart review was performed to identify all adult patients who received LDK for analgesia in our ED. Cases were identified by pharmacy record of ketamine administration. Low-dose ketamine was defined as the administration of 0.1 to 0.6 mg/kg of ketamine for pain control. Use of ketamine during procedural sedation was excluded. Data were analyzed descriptively.

Results
Thirty-five cases in which patients received LDK in the ED for a 2-year period were identified. Doses ranged from 5 to 35 mg. Administration was intravenous in 30 (86%) of 35 cases and intramuscular in 5 (14%) of 35 cases. Opioids were administered before or coadministered with LDK in 32 (91%) of 35 cases, and in the remaining 3 cases, opioids were used before the patient came to the ED. Improvement in pain was observed in 19 (54%) of 35 cases in which patients received LDK. Pain scores did not improve in 8 (23%) of 35 cases. Insufficient data were available to determine LDK effect for 8 (23%) of 35 cases. No significant adverse events were identified in any of the 35 cases.

Conclusions
The administration of LDK in the ED may be a safe and effective adjunct for analgesia in some patients. However, prospective randomized controlled trials are needed before widespread use of LDK for analgesia in the ED can be recommended.

11. Delaying Appendectomy May Not Be Harmful for Adults with Acute Appendicitis

Laurie Barclay, MD. September 24, 2010 — Delaying appendectomy for 12 hours or more may not be harmful for adults with acute appendicitis, according to the results of a retrospective cohort study reported in the September issue of the Archives of Surgery.

"Appendectomy is the most common emergent surgical procedure performed worldwide, with appendicitis accounting for approximately 1 million hospital days annually," write Angela M. Ingraham, MD, MS, from the American College of Surgeons in Chicago, Illinois, and colleagues. "Increased time from onset of symptoms to operative intervention is associated with more advanced disease. Recent developments in imaging and antibiosis have afforded improved preoperative assessment and treatment, allowing for non-operative management of abscesses and phlegmons and potentially limiting the need for immediate operative intervention to halt disease progression."

The goal of the study was to determine the impact of delay from surgical admission for acute appendicitis to induction of anesthesia on outcomes after appendectomy in adults, using data from 32,782 patients submitted to the American College of Surgeons National Surgical Quality Improvement Program database from January 1, 2005, through December 31, 2008. The principal exposure was time to operation, and primary study endpoints were 30-day overall morbidity and serious morbidity or mortality. Probabilities of outcomes were adjusted for patient and surgical risk factors with use of regression models.

Appendectomy was performed within 6 hours of surgical admission in 24,647 patients (75.2%), from more than 6 through 12 hours in 4934 patients (15.1%), and more than 12 hours after surgical admission in 3201 patients (9.8%). Although there were statistically significant differences in operative duration (51, 50, and 55 minutes, respectively; P below .001), these were not clinically meaningful. Similarly, the difference in length of postoperative stay (2.2 days for the greater than 12-hour group vs 1.8 days for the remaining groups; P less than .001) was not clinically meaningful.

In regression models, duration from surgical admission to induction of anesthesia did not predict overall morbidity or serious morbidity or mortality. There were no significant differences in adjusted overall morbidity (5.5%, 5.4%, and 6.1%, respectively; P = .33) or serious morbidity or mortality (3.0%, 3.6%, and 3.0%, respectively; P = .17).

"In this retrospective study, delay of appendectomy for acute appendicitis in adults does not appear to adversely affect 30-day outcomes," the study authors write. "This information can guide the use of potentially limited operative and professional resources allocated for emergency care."

Limitations of this study include retrospective design, lack of randomization, possible differences in patient or organizational factors, and use of operative and diagnostic codes to identify appendicitis.

"Because of the growing issues surrounding access to emergency care and specialist coverage, care for emergency general surgery patients is increasingly the responsibility of acute care surgeons and specialized services, which cover the specialties of trauma, emergency general surgery and critical care," the study authors conclude. "...As the elderly population continues to increase, the medical needs of patients presenting for emergency general surgical care will become increasingly complex and will demand additional resources and attention. Because of potentially limited physical and professional staffing resources, an acute care surgeon may need to delay the operation of less critically ill patients to appropriately care for those requiring immediate attention."

Critique: Findings a "Win-Win-Win Situation"

In an accompanying invited critique, John G. Hunter, MD, from Oregon Health & Science University in Portland, notes that these findings validate the practice of treating acute appendicitis urgently rather than emergently.

"Financial savings without any evidence of adversity to the patient and the promise of a well-rested surgeon in the morning provide benefit sufficiently ample for me to embrace these recommendations," Dr. Hunter writes. "At the end of the day, it is clearly a win-win-win situation when the interests of the patient, the surgeon, and the hospital are in complete alignment around such a shift in surgical practice."

The study authors and Dr. Hunter have disclosed no relevant financial relationships.

Arch Surg. 2010;145:886-892. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20855760

12. Bolus Dose of Ketamine Offers Fast-Acting Alleviation of Acute Depression in ED Setting

Nancy A. Melville. September 29, 2010 (Las Vegas, Nevada) — A single subanesthetic dose of intravenous ketamine administered to acutely depressed and suicidal patients presenting to the emergency department (ED) can rapidly alleviate depression and can alleviate suicidal thoughts for up to 10 days, according to a study presented here at the American College of Emergency Physicians 2010 Scientific Assembly.

The study involved 15 patients who presented to the ED with a primary complaint of depression and/or suicidal ideation. Results showed that all patients who were administered a single subanesthetic intravenous bolus of ketamine (0.20 mg/kg over 1 to 2 minutes) had decreased suicidal ideation at 40, 80, 120, and 240 minutes postinfusion. Suicidal ideation was completely resolved in 14 of the 15 subjects within 40 minutes, and was sustained at 10-day follow-up in 13 of the 14 patients.

Previous studies have looked at ketamine as a treatment for depression. Researchers from the Yale University School of Medicine's Department of Emergency Medicine, in New Haven, Connecticut, decided to evaluate the drug's fast-acting potential.

"Currently there is no good pharmacotherapy for the treatment of acute depression or suicide ideation. However, several studies have shown that ketamine may exert effects on patients who present with depression," said coauthor Robert Turelli, MD.

The study's findings, although preliminary, are promising, Dr. Turelli said. "Our study is the first to show that a reduction in depressive systems can be achieved with a rapid bolus, which is a more feasible application in a busy ED setting," he said.

"There was no sign of remission of any of the suicidal thoughts among patients who underwent the study in the 10 days of follow-up." Dr. Turelli added.

Patients' moods were evaluated at baseline on the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Beck Scale for Suicidal Ideation (SSI)

Scores were 42 (range, 38 to 47) for MADRS and 19 (range, 12 to 28) for Beck's SSI. Mean MADRS scores at baseline, and at 40, 80, 120, and 240 minutes postinfusion were 41.5,14.9, 13.6, 12.2, and 12.0, respectively (repeated-measures analysis of variance; P below .0001).

Mild positive psychotic-like symptoms or adverse effects were experienced, but all resolved within 40 minutes. Two patients experienced significant unpleasant dissociative symptoms, but those resolved within 30 minutes.

The patients did not have a significantly longer ED stay than 15 age- and diagnosis-matched control subjects who did not receive the drug.

The patients all endorsed the statement that "the benefits of receiving this medication outweigh any inconvenience, discomfort, or side effects."

The study's limitations include the small number of patients and the lack of a placebo group, but Dr. Turelli said the findings suggest a potentially important new use for the drug.

"Despite the small numbers, these results are dramatic and very impressive, suggesting that ketamine is feasible and possibly beneficial for the emergency setting."

According to Michael P. Wilson, MD, PhD, from the Department of Emergency Medicine at University of California at San Diego, the findings are significant in suggesting a potentially valuable, fast-acting use for the drug in depressed patients.

"The study is unique in showing that the drug can be given safely in the emergency department for depressed patients. The study authors also gave the drug rapidly, instead of at a low dose over a long period of time," Dr. Wilson said.

"You would expect that such a low dose wouldn't work for most patients, but the drug made people feel better — 100% of them — so it's really an interesting study and it seems that it might be a very exciting tool."

The study was supported by funding from the Connecticut College of Emergency Physicians. Dr. Turelli and Dr. Wilson have disclosed no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2010 Scientific Assembly: Abstract 157. Presented September 28, 2010.

13. At-Risk Populations and the Critically Ill Rely Disproportionately on Ambulance Transport to Emergency Departments

Squire BT. Ann Emerg Med. 2010;56:341-347.

Study objective
Emergency department (ED) crowding increases ambulance diversion. Ambulance diversion disproportionately affects individuals who rely on ambulance transport. The purpose of this study is to determine which populations rely most on ambulance transport.

Methods
We queried the National Hospital Ambulatory Medical Care Survey database for 1997 to 2000 and 2003 to 2005 for patients who arrived by ambulance or personal transport. We performed bivariate analysis to assess the extent to which all patients and a subset of critically ill patients use ambulance transport relative to self-transport.

Results
In our sample, 30,455 (15%; 95% confidence interval [CI] 15% to 16%) patients arrived by ambulance and 162,091 (85%; 95% CI 84% to 85%) arrived by walk-in/self-transport. Overall, patients with Medicare insurance were more likely to rely on ambulance transport, at 34% (95% CI 33% to 35%), than the privately insured, at 11% (95% CI 10% to 11%). Among the critically ill, privately insured patients were less likely to rely on ambulance transport, at 47% (95% CI 42% to 52%), than those with Medicare insurance (61%; 95% CI 58% to 65%), the publicly insured (60%; 95% CI 52% to 67%), or the uninsured (57%; 95% CI 49% to 64%). Among the critically ill, patients aged 15 to 24 years and those older than 74 years were most likely to rely on ambulance transport, at 63% (95% CI 53% to 72%) and 67% (95% CI 62% to 71%), respectively. Fifty-seven percent (95% CI 54% to 59%) of the critically ill used ambulance versus 15% (95% CI 14% to 15%) of noncritical patients.

Conclusion
Patients with Medicare insurance or public insurance, the uninsured, the elderly, and the critically ill disproportionately rely on ambulance transport to the ED. Ambulance diversion may disproportionately affect these populations.

14. Decreasing Unplanned Return Visits in Children with Fever in the Emergency Department

Dunn AL, et al. Abstract Presented at the annual meeting of the Eastern Society for Pediatric Research 2010

BACKGROUND: Overcrowding in the emergency department (ED) is one of the most pressing issues in the national health care debate today. One of the many causes of ED overcrowding is unplanned return visits. Young febrile children frequently make unplanned return visits to the emergency department (ED). Specific discharge instructions were developed to address parental fears and provide proper antipyretic dosing to decrease unneccessary return visits to the ED for fever.

OBJECTIVE: To evaluate the association between receiving specific fever instructions and the rate of return to the ED within the subsequent 48 hours.

DESIGN/METHODS: This study is a retrospective case-control study of a sample of children aged 8 weeks to 5 years who presented to the ED with fever over a one-year time period. Demographic characteristics were compared along with receipt of specific fever instructions and the completeness of the instructions. Inclusion criteria were fever over 100.4 degrees F and age 8 weeks to 5 years. Exclusion criteria included: admission to the hospital, chronic medical conditions, returned to the ED for an unrelated complaint and patients that left without being seen.

RESULTS: 202 medical charts were audited. 120 (59.4%) did not return to the ED and 82 (40.6%) did return within 48 hours of index ED visit. 74.2% of children who did not return to the ED received specific instructions compared with 53.7% of patients that did return (p=0.003). Demographic characteristics of children who did and did not return within 48 hours were similar including age, gender, insurance, race, average temperature, and receipt of antipyretics in the ED. More patients in the 48-hour return group received instructions missing antipyretic dosing than children in the group that did not return (53.7% vs 40.8%).

CONCLUSIONS: Among children with fever seen in the ED, those who did not return within 48 hours were more likely to have received specifically designed instructions for fever. Specifically designed discharge instructions, may be helpful in decreasing unplanned return visits to the ED for common illnesses.

Associated essay in ACEP News: http://www.acep.org/acepnews.aspx?id=48685

Below are some highlights from their discharge instructions (courtesy of the PI):

-- Fever is not a disease. It is a normal way for your body to fight a possible infection.

-- Fever may be caused by an infection. But, sometimes other things like exercise, too much clothing, or hot weather may cause your child’s temperature to rise.

-- Many infections are caused by a virus. Antibiotics will not help when infections are caused by a virus. Your doctor will prescribe an antibiotic only if your child has an infection caused by bacteria.

-- Fever will often return as the medicine (that is, the antipyretic) wears off until the infection begins to get better.

--Call your doctor if your child has fever that is not gone away in 5-7 days.

15. K2/Spice: Much More than “Fake Marijuana”

by Evan Schwarz, MD. Published in Emergency Physicians Monthly, Sept 2010

Over the last six months, the drug K2 – or “spice” – has gained national attention both from the media and the medical community. This synthetic cannabinoid, which is completely legal in most states, is sending users to the ED with symptoms from hallucinations to seizures.
K2 is a tetrahydrocannabinol (THC) analogue, which is the psychoactive component of marijuana. Synthetic cannabinoids have been around since the 1980s, when scientists discovered receptors that bind cannabinoids and cause their effects. In fact, in search of a new analgesic, Pfizer developed their own line of synthetic cannabinoids known as the CP series. In 1994, Clemson professor John W. Huffman developed a series of synthetic cannabinoids. One of them, JWH-018, is thought to be the active ingredient in K2.

While many of us in the United States may be unfamiliar with K2, mention of the synthetic marijuana can be found on the internet dating back to 2006. The drug has gained notoriety in both Asia and Europe leading to Germany banning it in early 2009. However four weeks after it was outlawed in Germany, second-generation products were reported. In most places in the United States, K2 can be purchased over the internet or at any local head shop for about $30. A head shop is any local retail outlet that sells items such as pipes, rolling papers, or other products that can be used as drug paraphernalia. K2 is sold under many names including Spice, Spice Gold, and Spice Diamond. It is marketed as an incense or herbal preparation. In most cases the packaging states that the product is not for human use. Spice is a combination of different herbs that have been sprayed with a synthetic marijuana such as JWH-018. The user can then make it into a cigarette or place it into a bong to smoke just as they would with regular marijuana.

The average marijuana user can be envisioned as the college stoner sitting on his couch while eating junk food and laughing at children’s cartoons. Anyone that has ever treated a patient presenting after using Spice knows that they do not act like this. While undoubtedly some users have a similar experience when they use Spice as they have after smoking marijuana, an increasing amount of patients are not. While I can’t remember the last time a patient, assuming they weren’t being detained by the police or involved in a car accident, was brought to the ED because of marijuana intoxication, local poison center data do show a consistent climb in the number of calls originating from EDs regarding patients using K2. They can present drowsy and with hallucinations. However a number of them present with agitation, bad GI upset, tachycardia, hypertension, and even seizures. Marijuana used in large amounts or very high concentrations can cause some of these symptoms; but once again, when was the last time you saw multiple agitated patients after only using marijuana. Whether these symptoms are due to an inherent characteristic of K2 or just due to the concentration that is sprayed on the herbal product is unknown. Care generally involves symptomatic treatment with hydration and benzodiazepines for agitation. The standard urine drug test, while it can detect marijuana, will not detect K2. While there are some research laboratories that have equipment sensitive enough to detect K2, this technology is not available in a clinically useful manner. Little research has been conducted on possible long-term sequelae after using these drugs.

The drug has also gained the attention of law enforcement. In addition to not showing up on drug tests, part of the popularity of K2 is likely related to it being easily accessible. Its availability is a consequence of it being completely legal in most states. Kansas was the first state to outlaw K2. Missouri and Arkansas have since followed with similar legislation reported in Illinois, Louisiana, Michigan, New Jersey, New York and Texas.

16. Clinical Predictors for Testicular Torsion as Seen in the Pediatric ED

This Small Series Confirms What We Already Know

Beni-Israel T, et al. Amer J Emerg Med. 2010;28:786-789.

Objective
The aim of the study was to identify clinical findings associated with increased likelihood of testicular torsion (TT) in children.

Design
This study used a retrospective case series of children with acute scrotum presenting to a pediatric emergency department (ED).

Results
Five hundred twenty-three ED visits were analyzed. Mean patient age was 10 years 9 months. Seventeen (3.25%) patients had TT. Pain duration of less than 24 hours (odds ratio [OR], 6.66; 95% confidence interval [CI], 1.54-33.33), nausea and/or vomiting (OR, 8.87; 95% CI, 2.6-30.1), abnormal cremasteric reflex (OR, 27.77; 95% CI, 7.5-100), abdominal pain (OR, 3.19; 95% CI, 1.15-8.89), and high position of the testis (OR, 58.8; 95% CI, 19.2-166.6) were associated with increased likelihood of torsion.

Conclusions
Testicular torsion is uncommon among pediatric patients presenting to the ED with acute scrotum. Pain duration of less than 24 hours, nausea or vomiting, high position of the testicle, and abnormal cremasteric reflex are associated with higher likelihood of torsion.

17. Suggested Work-up of Pts with Postcholecystectomy Syndrome

Schofer JM, et al. J Emerg Med. 2010;39:406-410.

Background: The postcholecystectomy syndrome refers to the persistence of gastrointestinal symptoms after cholecystectomy; patients with this syndrome commonly seek treatment in the Emergency Department (ED). There are a multitude of biliary and non-biliary causes of postcholecystectomy syndrome.

Objectives: To review the biliary causes of postcholecystectomy syndrome and present a suggested diagnostic workup.

Discussion: A number of biliary causes are discussed, including choledocholithiasis, bile duct injury and biliary leaks, cystic duct and gallbladder remnants, sphincter of Oddi dysfunction, and biliary ascariasis. The ED workup should focus on differentiating biliary from non-biliary causes of the patient's symptoms.

Conclusion: A right upper quadrant abdominal ultrasound, liver transaminases, alkaline phosphatase, and serum bilirubin are the tests most useful in the ED for making this distinction and determining the most appropriate treatment and disposition of the patient. Computed tomography may be of use in the initial post-operative period.

18. A Discussion of Antiemetic Therapy for Nausea and Vomiting in the ED

Patanwala AE, et al. J Emerg Med. 2010;39:330-336.

Background: Antiemetic agents are among the most frequently prescribed medications in the emergency department (ED). Nevertheless, there are no widely accepted evidence-based guidelines to optimize the use of these medications for nausea or vomiting in this setting.

Objective: The objective of this article is to briefly review the evidence supporting the use of antiemetic agents for the treatment of nausea or vomiting for adults in the ED, and to provide recommendations to help guide therapy.

Discussion: The antiemetic agents studied include droperidol, promethazine, prochlorperazine, metoclopramide, and ondansetron. Droperidol was commonly used in the past, and is more effective than prochlorperazine or metoclopramide, but due to the US Food and Drug Administration black box warning regarding the potential for QT prolongation with this drug, its use is limited to refractory cases. Promethazine is more sedating than other comparative agents, and also has the potential for vascular damage upon intravenous administration. It may be a suitable option when sedation is desirable. Patients given prochlorperazine or metoclopramide must be monitored for akathisia that can develop at any time over 48 h post administration. Decreasing the infusion rate can reduce the incidence of this adverse effect, and the effect can be treated with intravenous diphenhydramine. Ondansetron is as effective as promethazine, and is not associated with sedation or akathisia.

Conclusion: Based on the safety and efficacy of ondansetron, it may be used as a first-line agent for relief of nausea or vomiting for most patient populations in the ED.

19. What Is the Appropriate Antibiotic Course for the Treatment of UTIs in Children?

Seupaul RA. Ann Emerg Med. 2010;56:300-301.

Data Sources

The authors searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE from 1966 to 2005, and EMBASE from 1988 to 2005, without language restriction.

Study Selection

Randomized and quasirandomized controlled trials comparing short-term (2 to 4 days) with standard (7 to 14 days) oral antibiotic therapy in children aged 3 months to 18 years, with culture-proven urinary tract infections.

Data Extraction and Synthesis

Two authors independently assessed study quality and extracted data from included trials. A random-effects model was used to analyze data. Only randomized controlled trials were included; only 2 clearly described allocation concealment, whereas none of the trials defined appropriate blinding or used an intention-to-treat analysis.

Take-Home Message

Short-course antibiotic therapy (2 to 4 days) is probably as effective as a standard duration of therapy (7 to 14 days) in treating children with their first lower urinary tract infection.

Commentary

Lower urinary tract infection is a common occurrence in children, but unlike the generally benign course in adults, urinary tract infection in the pediatric population is well recognized as a cause of hypertension and renal insufficiency in adulthood.[1] Although antibiotics provide effective therapy, it is unclear what the appropriate duration of therapy should be. Shorter courses of antibiotics (less than 7 to 14 days) have the potential to reduce the rate of adverse events, decrease cost, and improve compliance but may place the patient at risk for relapse and long-term sequelae. The authors of this review pooled data to determine whether a short course of antibiotics is safe and as effective as a standard duration of therapy. The results indicate that there is no difference in the frequency of failed treatment or recurrence; however, there were insufficient data to estimate the effects on symptom resolution, development of bacterial resistance, adverse events, compliance, or cost savings.

Additionally, the authors analyzed the risk of relapse between children with recurrent urinary tract infection (a higher-risk group) and those with their first infection. Although there was not a large enough sample to reach a definitive conclusion, the data suggest that for this high-risk group, short-course antibiotic therapy is probably not appropriate. Current guidelines support the findings of this systematic review. They specify a 3-day course for uncomplicated urinary tract infection in children and a longer course with appropriate subspecialty evaluation for all others.

20. The Future of Emergency Medicine

Schneider SM, et al. Acad Emerg Med. 2010 Sep;17(9):998-1003.

Physician shortages are being projected for most medical specialties. The specialty of emergency medicine continues to experience a significant workforce shortage in the face of increasing demand for emergency care. The limited supply of emergency physicians, emergency nurses, and other resources is creating an urgent, untenable patient care problem.

In July 2009, representatives of the leading emergency medicine organizations met in Dallas for the Future of Emergency Medicine Summit. The organizations represented met specifically to address the issues facing the emergency care workforce. This consensus document, agreed to and co-written by all participating organizations, describes the substantive issues discussed and provides a foundation for the future of the specialty. There are other, non workforce issues that were not addressed that will also inevitably influence the future of emergency medicine.

Attendees at the Future of Emergency Medicine Summit agreed that:

1. Emergency medical care is an essential community service that should be available to all. Public expectations as well as federal law require the ready availability of emergency care. Resources, including funding, should be made available to meet this well-intended goal.

2. An insufficient emergency physician workforce also represents a potential threat to patient safety.

3. Accreditation Council for Graduate Medical Education/American Osteopathic Association (AOA)-accredited emergency medicine residency training and American Board of Medical Specialties/AOA emergency medicine board certification is the recognized standard for physician providers currently entering a career in emergency care. Physicians who enter the practice of emergency medicine in the 21st century without this training represent a potential threat to patient safety.

4. Physician supply shortages in all fields contribute to—and will continue to contribute to—a situation where providers with other levels of training may be a necessary part of the workforce for the foreseeable future. These providers include nurse practitioners, physician assistants, and physicians trained in fields other than emergency medicine.

5. A maldistribution of emergency medicine residency–trained physicians persists, with few pursuing practice in small or rural settings.

6. Assuring that the public receives high-quality emergency care while continuing to produce highly skilled emergency medicine specialists through emergency medicine training programs is the challenge for emergency medicine’s future.

7. It is important that all providers of emergency care receive continuing postgraduate education.

21. The Effect of Physician Risk Tolerance and the Presence of an Observation Unit on Decision Making for ED Patients with Chest Pain

Pines JM, et al. Amer J Emerg Med 2010;28:771-779.

Objectives
We sought to determine whether risk tolerance as measured by scales (malpractice fear scale [MFS], risk-taking scale [RTS], and stress from uncertainty scale [SUS]) is associated with decisions to admit or use computed tomography (CT) coronary angiogram and decisions to order cardiac markers in emergency department (ED) patients with chest pain. We also studied if the opening of an ED-based observation unit affected the relationship between risk scales and admission decisions.

Methods
Data from a prospective study of ED patients 30 years or older with chest pain were used. Risk scales were administered to ED attending physicians who initially evaluated them. Physicians were divided into quartiles for each separate risk scale. Fisher's exact test and logistic regression were used for statistical analysis.

Results
A total of 2872 patients were evaluated by 31 physicians. The most risk-averse quartile of RTS was associated with higher admission rates (78% vs 68%) and greater use of cardiac markers (83% vs 78%) vs the least risk-averse quartile. This was not true for MFS or SUS. Similar associations were observed in low-risk patients (Thrombolysis in Myocardial Infarction risk score of 0 or 1). The observation unit was not associated with a higher admission rate and did not modify the relationship between risk scales and admission rates.

Conclusion
The RTS was associated with the decision to admit or use computed tomography coronary angiogram, as well as the use of cardiac markers, whereas the MFS and SUS were not. The observation unit did not affect admission rates and nor did it affect how physician's risk tolerance affects admission decisions.

Wanna See How You Rank?

In each instrument, physicians were asked to respond to the questions using a 5- to 6-point Likert scale from “strongly disagree” to “strongly agree.”

Risk-taking scale (The RTS is a 6-item scale that is derived from the risk-taking subscale of the Jackson Personality Index.)

1. I enjoy taking risks.

2. I try to avoid situations that have uncertain outcomes.

3. Taking risks does not bother me if the gains involved are high.

4. I consider security and important element in every aspect of my life.

5. People have told me that I seem to enjoy taking chances.

6. I rarely, if ever, take risks when there is another alternative.

Stress from uncertainty scale (cf. http://www.ncbi.nlm.nih.gov/pubmed/2385142)

1. The uncertainty of patient care often troubles me.

2. Not being sure of what is best for a patient is one of the most stressful parts of being a physician.

3. I am tolerant of the uncertainties present in patient care.

4. I find the uncertainty involved in patient care disconcerting.

5. I usually feel anxious when I am not sure of a diagnosis.

6. When I am uncertain of a diagnosis, I imagine all sorts of bad scenarios—patient dies, patient sues, etc.

7. I am frustrated when I do not know a patient's diagnosis.

8. I fear being held accountable for the limits of my knowledge.

9. Uncertainty in patient care makes me uneasy.

10. I worry about malpractice when I do not know a patient's diagnosis.

11. The vastness of the information that physicians are expected to know overwhelms me.

12. I frequently wish I had gone into a specialty or subspecialty that would minimize the uncertainties of patient care.

13. I am quite comfortable with the uncertainty in patient care.

Fear of malpractice scale (cf. http://www.ncbi.nlm.nih.gov/pubmed/10718896)

1. I have had to make significant changes in my practice pattern because of recent legal developments concerning medical delivery.

2. I am concerned that I will be involved in a malpractice case sometime in the next 10 years.

3. I feel pressured in my day-to-day practice by the threat of malpractice litigation.

4. I order some tests or consultations simply to avoid the appearance of malpractice.

5. Sometimes, I ask for consultant opinions primarily to reduce my risk of being sued.

6. Relying on clinical judgment rather than on technology to make a diagnosis is becoming riskier from a medicolegal perspective.