Saturday, February 26, 2011

Lit Bits: Feb 26, 2011

From the recent medical literature...

1. Treatment of Acute Otitis Media in Infants and Young Children

Do these two studies end the debate?

Currently, no consensus exists about whether young children with acute otitis media (AOM) should be treated with antibiotics. Two new double-blind, placebo-controlled, randomized trials might end the debate. In both studies, AOM was defined by acute onset and presence of middle-ear effusion, bulging tympanic membrane, and otalgia or erythema of the tympanic membrane.

Researchers in Finland randomized 319 children (age range, 6–35 months) with AOM to receive amoxicillin-clavulanate or placebo for 7 days. Treatment failure (no overall improvement by day 3, worsening condition, no improvement in otoscopic signs, perforation, severe infection requiring antimicrobial treatment, or stopping the study drug for any reason) was significantly less common in the antibiotic group than in the placebo group (18.6% vs. 44.9%; number needed to treat, 3.8). Children who received antibiotics were significantly more likely to develop diarrhea (47.8% vs. 26.6%).

Researchers in Pittsburgh randomized 291 children (age range, 6–23 months) with AOM to receive amoxicillin-clavulanate or placebo for 10 days. Children who received amoxicillin-clavulanate achieved symptom resolution more quickly than children in the placebo group (35% vs. 28% on day 2; 61% vs. 54% on day 4; 74% vs. 54% on day 7). Results were similar for sustained resolution of symptoms. Children who received antibiotics were significantly more likely to develop diarrhea (24% vs. 1%) and diaper-area dermatitis (47% vs. 4%).

A General Pediatrician's Perspective
Both studies overcome the flaws of previous studies and provide the best data to date. Jerry Klein, a leading AOM expert, believes that these studies end the debate about treatment of AOM in young children. He states, "More young children with a certain diagnosis of acute otitis media recover more quickly when they are treated with an appropriate antimicrobial agent." Because most cases of AOM are caused by bacteria sensitive to amoxicillin-clavulanate, it's my belief that the issue isn't whether young children with AOM benefit from antibiotics, but whether the diagnosis of AOM is accurate. Both trials highlight the well-known adverse effects associated with use of antibiotics but do not address serious complications such as mastoiditis. Together, they do suggest that young children with AOM get better faster if they are treated with antibiotics, but treatment decisions must be balanced against the risk for adverse effects, particularly diarrhea.
— Howard Bauchner, MD

A Pediatric Infectious Disease Specialist's Perspective

I doubt that our readers were surprised to see additional documentation that antibiotics work for AOM. To me, the question that remains is "When do we need to treat and when can we watch and wait?" Placebo was a successful option for more than half the children in both studies. For children who look well, are old enough to easily evaluate, and can be comforted with supportive care (e.g., Tylenol and TLC), watchful waiting remains in my armamentarium. Parental wishes, history of prior infections, concerns about excess antibiotic use, and adverse effects still factor into my decision. Finally, although amoxicillin-clavulanate was used in these two studies, amoxicillin alone is still first-line therapy for many children.
— Peggy Sue Weintrub, MD

Published in Journal Watch Pediatrics and Adolescent Medicine February 2, 2011. Citation(s):
Tähtinen PA et al. A placebo-controlled trial of antimicrobial treatment for acute otitis media. N Engl J Med 2011 Jan 13; 364:116. Hoberman A et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med 2011 Jan 13; 364:105. Klein JO. Is acute otitis media a treatable disease? N Engl J Med 2011 Jan 13; 364:168.

See also recent JAMA review:

2. A randomized, placebo-controlled trial of ondansetron, metoclopramide, and promethazine in adults

Barrett TW, et al. Amer J Emerg Med. 2011;29:247-255.

The objective of the study was to assess whether ondansetron has superior nausea reduction compared with metoclopramide, promethazine, or saline placebo in emergency department (ED) adults.

This randomized, placebo-controlled, double-blinded superiority trial was intended to enroll a convenience sample of 600 patients. Nausea was evaluated on a 100-mm visual analog scale (VAS) at baseline and 30 minutes after treatment. Patients with a minimum preenrollment VAS of 40 mm were randomized to intravenous ondansetron 4 mg, metoclopramide 10 mg, promethazine 12.5 mg, or saline placebo. A 12-mm VAS improvement in nausea severity was deemed clinically important. We measured potential drug adverse effects at baseline and 30 minutes. Patients received approximately 500 mL of saline hydration during the initial 30 minutes.

Of 180 subjects who consented, 163 completed the study. The median age was 32 years (interquartile range, 23-47), and 68% were female. The median 30-minute VAS reductions (95% confidence intervals) and saline volume given for ondansetron, metoclopramide, promethazine, and saline were −22 (−32 to −15), −30 (−38 to −25.5), −29 (−40 to −21), and −16 (−25 to −3), and 500, 500, 500, and 450, respectively. The median 30-minute VAS differences (95% confidence intervals) between ondansetron and metoclopramide, promethazine, and saline were −8 (−18.5 to 3), −7 (−21 to −5.5), and 6 (−7 to 20), respectively. We compared the antiemetic efficacy across all treatments with the Kruskal-Wallis test (P = .16).

Our study shows no evidence that ondansetron is superior to metoclopramide and promethazine in reducing nausea in ED adults. Early study termination may have limited detection of ondansetron's superior nausea reduction over saline.

3. Two Days of Dexamethasone Versus 5 Days of Prednisone in the Treatment of Acute Asthma: A Randomized Controlled Trial

Kravitz J, et al. Ann Emerg Med. 2011; in press

Study objective
Dexamethasone has a longer half-life than prednisone and is well tolerated orally. We compare the time needed to return to normal activity and the frequency of relapse after acute exacerbation in adults receiving either 5 days of prednisone or 2 days of dexamethasone.

We randomized adult emergency department patients (aged 18 to 45 years) with acute exacerbations of asthma (peak expiratory flow rate less than 80% of ideal) to receive either 50 mg of daily oral prednisone for 5 days or 16 mg of daily oral dexamethasone for 2 days. Outcomes were assessed by telephone follow-up.

Ninety-six prednisone and 104 dexamethasone subjects completed the study regimen and follow-up. More patients in the dexamethasone group reported a return to normal activities within 3 days compared with the prednisone group (90% versus 80%; difference 10%; 95% confidence interval 0% to 20%; P=.049). Relapse was similar between groups (13% versus 11%; difference 2%; 95% confidence interval –7% to 11%, P=.67).

In acute exacerbations of asthma in adults, 2 days of oral dexamethasone is at least as effective as 5 days of oral prednisone in returning patients to their normal level of activity and preventing relapse.

4. New Consensus Statement on Cardiac Ultrasound Released

ACEP News. January 2011

By Jeffrey S. Eisenberg. Elsevier Global Medical News

ST. LOUIS - Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient's bedside - allowing for earlier, possibly lifesaving interventions - and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the consensus statement (see full-text link below). FOCUS also can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The consensus statement also outlines the following specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient's bedside.

Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure. FOCUS can also determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. In addition, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

Dyspnea/shortness of breath. In cases of dyspnea, FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease, according to the statement.

Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (A diameter greater than 4 cm is suspicious for type A dissection.) However, the authors caution, a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

FOCUS training should include positive and negative cases of various cardiac pathologies, and any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses, the statement said.

Labovitz et al. J. Am. Soc. Echocardiogr. 2010;23:1225-30.
Full-text (free):

5. Effect of Routine Sterile Gloving on Contamination Rates in Blood Culture: A Cluster Randomized Trial

Nak-Hyun Kim N, et al. Ann Intern Med 2011;154:145-151

Background: Blood culture contamination leads to inappropriate or unnecessary antibiotic use. However, practical guidelines are inconsistent about the routine use of sterile gloving in collection of blood for culture.

Objective: To determine whether the routine use of sterile gloving before venipuncture reduces blood culture contamination rates.

Design: Cluster randomized, assessor-blinded, crossover trial ( registration number: NCT00973063).

Setting: Single-center trial involving medical wards and the intensive care unit.

Participants: 64 interns in charge of collection of blood for culture were randomly assigned to routine-to-optional or optional-to-routine sterile gloving groups for 1854 adult patients who needed blood cultures.

Intervention: During routine sterile gloving, the interns wore sterile gloves every time before venipuncture, but during optional sterile gloving, sterile gloves were worn only if needed.

Measurements: Isolates from single positive blood cultures were classified as likely contaminant, possible contaminant, or true pathogen. Contamination rates were compared by using generalized mixed models.

Results: A total of 10 520 blood cultures were analyzed: 5265 from the routine sterile gloving period and 5255 from the optional sterile gloving period. When possible contaminants were included, the contamination rate was 0.6% in routine sterile gloving and 1.1% in optional sterile gloving (adjusted odds ratio, 0.57 [95% CI, 0.37 to 0.87]; P = 0.009). When only likely contaminants were included, the contamination rate was 0.5% in routine sterile gloving and 0.9% in optional sterile gloving (adjusted odds ratio, 0.51 [CI, 0.31 to 0.83]; P = 0.007).

Limitation: Blood cultures from the emergency department, surgical wards, and pediatric wards were not assessed.

Conclusion: Routine sterile gloving before venipuncture may reduce blood culture contamination.

Full-text (free):

6. Outcomes associated with small changes in normal-range cardiac markers

McMullin N, et al. Amer J Emerg Med. 2011;29:162-167.

Troponin concentrations rising above an institutional cutpoint are used to define acute myocardial necrosis, yet it is uncertain what outcomes are associated with fluctuations in troponin that do not exceed this level. We evaluate the association between troponin fluctuations below an institutional upper limit of normal and acute coronary syndrome (ACS).

Materials and methods
This was a post hoc analysis of the Internet tracking registry of ACS (i*trACS), which describes patients presenting to emergency departments (EDs) with suspected ACS across the spectrum of risk. Patients were included in this registry if they were at least 18 years old and had suspected ACS at the time of their ED visit. Inclusions in this analysis required that patients had at least 1 cardiac marker (creatine kinase-MB [CK-MB], troponin T, or troponin I) drawn twice within 6 hours of presentation, with both measures being below the institution's upper limit of normal. A marker change was defined as either an increase or decrease that exceeded 15% of the institutional upper limit of normal. Acute coronary syndrome was defined as a positive stress test, documented myocardial infarction, coronary revascularization, or death within 30 days of their ED admission.

Of 17 713 patient visits, 2162 met inclusion and exclusion criteria. There were 1872 patient visits with 2 troponin results and 1312 with 2 CK-MB results. Patient visits with increasing troponin had increased odds of ACS compared with those with stable troponin levels (odds ratio, 3.6; 95% confidence interval, 1.4-9.2). Changing CK-MB and decreasing troponin were not associated with increased odds of ACS.

Small increases in troponin concentration below the upper limit of normal are associated with increased odds of ACS.

7. Clinical Outcomes in Obese and Normal-weight Children Undergoing Ultrasound for Suspected Appendicitis

Sulowski C, et al. Acad Emerg Med 2011;18:167–173.

Background:  Obesity constitutes an independent predictor for a nondiagnostic screening ultrasound (US) in suspected appendicitis. Furthermore, the imaging route consisting of the screening US with a second US if necessary has a significantly lower diagnostic accuracy in the obese children (83%) than their lean counterparts (93%). However, the effect of this association on clinical outcomes in the obese population is unknown.

Objectives:  In children presenting to the emergency department (ED) undergoing US for suspected appendicitis, the objective was to examine if there is a significant difference in the proportions of those with a “desirable outcome” in the obese group versus their normal-weight counterparts.

Methods:  This was a reanalysis of a recent prospective cohort study conducted at a tertiary care pediatric ED. A consecutive sample of 263 previously healthy children 4–17 years of age undergoing screening US for suspected appendicitis was enrolled. Study patients were divided into obese (body mass index-for-age percentiles [BMI-FAP] ≥ 85%) and normal-weight groups. The main outcome was the proportion of children with the desirable outcome in the obese and normal-weight groups. Desirable outcomes for patients with a nondiagnostic screening US were defined as either 1) nonperforated appendicitis or alternate surgical diagnosis undergoing appropriate surgical procedure within 24 hours of assessment without a computed tomography (CT) scan or 2) no appendicitis, discharged from the ED within 24 hours without a CT scan. Secondary outcomes included hospitalization, CT imaging for any reason within 30 days of initial presentation, length of hospital stay, return visits, time to and length of surgery, and complications.

Results:  Of the 263 patients, 76 (28.9%) were obese, and 187 had a normal weight. Ninety-nine children (37.6%) had appendicitis (obese = 24, normal-weight = 75). The desirable outcome was achieved in 46 (64.5%) of the obese patients versus 137 (73.3%) of the normal-weight children (95% confidence interval [CI] for the difference = −0.21 to 0.04). Compared to the normal-weight children, the obese children had similar hospitalization rates (44.7% vs. 45.5%), median length of hospital stay (20.5 hours vs. 23.0 hours), and return ED visit rates (11.8% vs. 9.1%). The median time to surgery (obese = 10.5 hours, normal-weight = 9.0 hours), complications (obese = 25%, normal-weight = 21.3%), perforations (obese = 33%, normal-weight = 31%), and length of surgery (obese 80 [±37] minutes, normal-weight 67 [±25] minutes) were also similar. The rate of CT within 30 days of initial presentation was higher in the obese compared to the normal-weight group (13/76 or 17.1% vs. 13/187 or 6.9%, 95% CI = 0.02 to 0.23).

Conclusions:  Previously healthy obese children undergoing screening US for suspected appendicitis experienced comparable clinical outcomes to their normal-weight counterparts. However, they were three times more likely to receive a CT scan during their investigation. These results argue for continuing current practice of using the screening US in this population, followed by a CT if clinically warranted upon reexamination.

8. Etiology and Diagnosis of Systolic Murmurs in Adults

McGee S, Amer J Med. 2011;123:913-921.e1


In his Treatise on the Diseases of the Heart and Great Vessels,1 published in 1832, just 11 years after Laennec's invention of the stethoscope, the British physician James Hope fully described the characteristics of systolic murmurs, attributing them to either abnormal forward flow over semilunar valves (eg, aortic or pulmonic valve) or regurgitation of blood from high pressure chambers into low pressure ones (eg, mitral or tricuspid regurgitation). His observations—along with those of Austin Flint (1812-1886), Graham Steell (1851-1942), and others using phonocardiography during the 1950s and 1960s—form virtually our entire knowledge base about systolic murmurs, including the classic teaching that pathologic systolic murmurs are identifiable by their location on the chest wall and by additional abnormalities of the neck veins, precordial pulsations, arteries, and heart tones.

During recent decades the diagnosis and treatment of heart disease have changed significantly, and it is unknown whether these classic tenets remain true. For example, original observations were mostly of young patients with rheumatic and congenital heart disease and normal ejection fractions; modern patients, in contrast, are frequently elderly and more often have ischemic, calcific, or degenerative heart disease with reduced ventricular function.

Echocardiography has been widely applied to modern cardiovascular diagnosis, yet few if any studies providing additional insights into systolic murmurs have appeared. The purpose of this study is to carefully examine a series of hospitalized patients and compare their physical findings to transthoracic echocardiography, thereby investigating both the etiology of systolic murmurs and the modern diagnostic value of the bedside examination.

Full-text (free):

9. Erythromycin Infusion or Gastric Lavage for Upper Gastrointestinal Bleeding: A Multicenter Randomized Controlled Trial

Pateron D, et al. Ann Emerg Med. 2011; in press

Study objective
The quality of endoscopy depends on the quality of upper gastrointestinal tract preparation. We determine whether in acute upper gastrointestinal bleeding the frequency of satisfactory stomach visualization was different after intravenous erythromycin, a nasogastric tube with gastric lavage, or both.

We performed a prospective, randomized, multicenter (6 emergency departments) study in patients with acute upper gastrointestinal bleeding presenting with hematemesis or melena. The patients were randomized into 3 groups: (1) intravenous erythromycin infusion without nasogastric tube placement (erythromycin group), (2) nasogastric tube placement without erythromycin (nasogastric group), and (3) intravenous erythromycin infusion combined with nasogastric tube placement (nasogastric-erythromycin group). The main outcome measure was the proportion of satisfactory stomach visualization.

Two hundred fifty-three patients (181 men, mean age 61 years [SD 15 years], 84 with cirrhosis) were randomized: 84 (erythromycin group), 85 (nasogastric group), and 84 (nasogastric-erythromycin group). Overall, there was 85% satisfactory stomach visualization; between-group differences were not significant: −4% (95% confidence interval [CI] −15% to 6%) for the erythromycin group and nasogastric-erythromycin group, 2% (95% CI −14% to 9%) for the erythromycin group and nasogastric group, and −6.5% (95% CI −17% to 4%) for the nasogastric group and nasogastric-erythromycin group. The duration of the endoscopic procedure, rebleeding frequency, the need for a second endoscopy, the number of transfused blood units, and mortality at days 2, 7, and 30 did not differ significantly between groups.

In acute upper gastrointestinal bleeding, administration of intravenous erythromycin provides satisfactory endoscopic conditions, without the need for a nasogastric tube and gastric lavage.

10. New Guidelines Released for Cerebral Venous Thrombosis

Allison Gandey. February 4, 2011 — The American Heart Association/American Stroke Association has unveiled its first scientific statement on cerebral venous thrombosis. The recommendations will help clinicians identify this uncommon cause of stroke that mostly affects young people.

"The diagnosis and management of cerebral venous thrombosis requires a high level of suspicion," committee chair Gustavo Saposnik, MD, from the University of Toronto in Ontario, Canada, told Medscape Medical News. "The guidelines are intended to improve awareness and recognition."

The committee includes a multidisciplinary group of experts from the United States, Canada, Mexico, Portugal, and Argentina. The guidelines were published online February 3 in the journal Stroke.
Cerebral venous thrombosis is caused by clots in the dural venous sinuses and accounts for 0.5% to 1% of all strokes. It disproportionally affects women who are pregnant or taking oral contraceptives and people 45 years and younger.

The incidence of cerebral venous thrombosis during pregnancy and post partum ranges from 1 in 2500 deliveries to 1 in 10,000 deliveries in Western countries, according to the guidelines. The greatest risk periods are during the third trimester and in the first 4 postpartum weeks. Up to 73% of cerebral venous thrombosis in women occurs during the time immediately after childbirth. However, the risk for complications during future pregnancies is low, report the guideline authors.

They recommend patients with suspected cerebral venous thrombosis undergo blood studies to see whether they have a prothrombotic factor, such as protein C or S, antithrombin deficiency, antiphospholipid syndrome, prothrombin G20210A mutation, and factor V Leiden.

"A predisposing condition to form clots or a direct cause is identified in about two-thirds of patients with cerebral venous thrombosis,” Dr. Saposnik said.

An estimated 30% to 40% of patients with cerebral venous thrombosis may develop an intracranial hemorrhage. "It’s important to distinguish a hemorrhage caused by rupture of a brain artery from those associated with cerebral venous thrombosis," he said. "The mechanisms — and treatment — of the bleeding are quite different."

The guidelines suggest that patients having a brain hemorrhage with an unclear cause undergo imaging of their cerebral veins.

Headache Most Common Symptom

According to the International Study on Cerebral Venous and Dural Sinuses Thrombosis, headache is the most common symptom and was recorded in about 90% of patients (Stroke. 2005;36:1720–1725).

"The usual appropriate acute treatment includes prevention of complications and anticoagulation therapy," Dr. Saposnik said. The guidelines emphasize that magnetic resonance imaging and magnetic resonance venography are the most sensitive and therefore recommended tests.

In the emergency department, computed tomography may be useful when magnetic resonance imaging is not readily available, Dr. Saposnik added.

For patients who develop a stroke, he emphasized the importance of care in an appropriate setting, such as a stroke unit, for the prevention and management of complications.

"Testing for prothrombotic conditions in the acute phase has limited value," he noted. "Thorough blood work should be completed later. And the duration of anticoagulation therapy should ultimately depend on the underlying etiology."

Dr. Saposnik pointed out to Medscape Medical News there is limited evidence regarding endovascular treatment or thrombolysis in patients with cerebral venous thrombosis. "Based on that, the current guidelines recommend this approach only in patients with progressive neurological deterioration despite the best medical treatment."

"As with any guideline," Dr. Saposnik said, "the current one provides a general approach analyzing the available evidence. It doesn't address individual situations."

Committee chair Dr. Saposnik has disclosed no relevant financial relationships.

Stroke. Published online February 3, 2011.

Full-text (free pdf):

11. Patient history and physician suspicion accurately exclude pregnancy

Minnerop MH, et al. Amer J Emerg Med. 2011;29:212-215.

Reliance upon patient assessment in excluding pregnancy is questionable. Physicians are encouraged to obtain pregnancy tests in all women of childbearing age. We affirmed the accuracy of women and their physicians in predicting pregnancy.

This was a prospective, observational study performed in a suburban academic emergency department on adult women with an ordered pregnancy test. A standardized gynecologic history was obtained by trained research assistants. Subjects estimated their likelihood of pregnancy as impossible, possible, or definite. Emergency department physicians estimated the likelihood of pregnancy as high, moderate, or low. All women had either a serum or urine β-human chorionic antigen. The diagnostic characteristics of patient and physician predictions of pregnancy were calculated with 95% confidence intervals (CIs).

We enrolled 377 subjects. Median age was 29 (interquartile range, 22-37) years. Twelve percent of the women were pregnant. Women's estimates of pregnancy were as follows: impossible, 64.7%; possible, 22.5%; and definite, 12.7%. The pregnancy rates among women with estimates of impossible, possible, and definite were 0% (95% CI, 0%-1.5%), 4.7% (95% CI, 1.9%-11.5%), and 89.6% (95% CI, 77.8%-95.5%) (P < .001). Physicians' suspicions of pregnancy were high (13.7%), moderate (11.3%), and low (75.1%). The rate of pregnancy among low, moderate, and high physician suspicion groups were 0% (95% CI, 0%-1.4%), 9.5% (95% CI, 3.8%-22%), and 84.3% (95% CI, 72%-92%) (P < .001). Conclusions There were no pregnancies among women who estimated pregnancy as impossible or whose physicians thought that the likelihood of pregnancy was low. Routine pregnancy testing before radiological imaging and medication administration may not be required in adult women of childbearing age.

12. Images in Emergency Medicine

Decreased Skin Turgor

Pseudomembranous Colitis

Secondary Syphilis

Diphenhydramine Poisoning


Cutaneous cryptococcal infection as a manifestation of disseminated disease

Woman With Right-Sided Flank Pain

13. Clinical Review: Approach to the Anticoagulated Patient with Spontaneous ICH

Roberts, JR. EM News. 2011;33:13-16.

Individuals with spontaneous intracranial hemorrhage (ICH) are common denizens of every ED. The public is relatively clueless about the nefarious and debilitating effects of brain hemorrhage, and often think patients who have had a hemorrhagic stroke can get back to normal through the prowess of highly skilled physicians, especially if everything is done correctly. While this might be somewhat true for a modicum of fortunate survivors, bleeding brains usually continue to bleed, and dead brain usually stays dead. Fortunately, rehabilitation of other areas of the brain and the body's remarkable reparative processes offer some respite from certain paralysis or a long-term vegetative existence. But exactly what doctors can do to help the acutely bleeding brain or enhance potential recovery is still quite a mystery.

… I will now embark on a review of the recent 2010 guidelines from the American Heart Association (AHA) and American Stroke Association (ASA) for treating ICH in patients with warfarin-induced coagulopathy, thrombocytopenia, and dysfunctional platelets.

The remainder of the essay:

The Guidelines (full-text free):

14. Prehospital Active Compression-Decompression CPR

ACD cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure during decompression was associated with a higher rate of neurologically functional survival than was standard CPR.

Active compression-decompression cardiopulmonary resuscitation (ACD-CPR) achieves greater negative intrathoracic pressure during the decompression phase than standard CPR. In a prospective industry-sponsored study that involved 46 U.S. emergency medical services (EMS) systems, 1653 adults with nontraumatic cardiac arrest were randomized to receive either standard CPR or ACD-CPR with augmentation of negative intrathoracic pressure during decompression via an impedance-threshold device attached to the face mask. ACD-CPR was performed with a hand-held suction cup device containing a metronome and force gauge to guide depth and timing of compressions.

The rate of survival to hospital discharge with modified Rankin scale score 3 (the primary outcome) was significantly higher in the ACD-CPR group than the standard-CPR group (9% vs. 6%). This difference persisted at 1 year. Disability rating scale scores and rates of major adverse events were similar between groups; however, pulmonary edema was more common in the ACD-CPR group (11% vs. 8%). Mean time from emergency call to start of professional rescuer CPR did not differ between groups (approximately 6.7 minutes); no patient met the primary endpoint when professional CPR was started more than 10 minutes after the call.

Comment: Active compression-decompression CPR augmented with a negative-pressure impedance device leads to a better rate of neurologically functional survival after out-of-hospital cardiac arrest and should be adopted by EMS systems. Whether this technique would also benefit victims of arrest in the hospital — where professional CPR likely would be started much sooner — is unclear.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine February 11, 2011. Citation: Aufderheide TP et al. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: A randomised trial. Lancet 2011 Jan 22; 377:301.

15. CSF Reference Values for Febrile Infants without Infection

Normal ranges for cerebrospinal fluid profiles in febrile infants should be revised.

Previous reference ranges for normal cerebrospinal fluid (CSF) values in infants are based on findings from small studies that did not exclude infants with viral disease. To better characterize normal values, investigators retrospectively evaluated CSF profiles of infants (age range, 1–90 days) at a pediatric medical center in Utah from 1996 to 2002 who met the following criteria: rectal temperature 38°C, negative bacterial cultures, negative enteroviral polymerase chain reaction testing, term birth (37 weeks' gestation), no antibiotics within 48 hours, and no herpes simplex virus infection.

Of 823 infants, 743 had atraumatic lumbar punctures (red blood cell count 1000/mm3). CSF white blood cell (WBC) counts above 14.5/ mm3 were considered statistical outliers (presumed due to unidentified viral infections) and were excluded. In the remaining 677 patients with atraumatic lumbar punctures, mean and median CSF WBC counts were 4.3/mm3 and 3.0/mm3, respectively (range, 0–12/mm3). Infants in the first month of life, compared to those in the second and third months of life, had significantly higher mean CSF WBC counts (6.1/mm3 vs. 3.1/mm3 and 3.0/mm3) and mean CSF protein concentrations (75.4 mg/dL vs. 58.9 and 39.2 mg/dL); mean CSF glucose concentrations were similar in the first and second months and significantly lower than in the third month (45.3 mg/dL, 48.0 mg/dL, and 57.7 mg/dL). Traumatic lumbar puncture did not significantly affect WBC count norms, with mean and median counts of 6.5/mm3 and 5.0/mm3, respectively (range, 0–16/mm3).

Comment: The authors appropriately call into question previously established normal values of infant cerebrospinal fluid. Moreover, they define new values that physicians should use when evaluating febrile infants for meningitis.

— Katherine Bakes, MD. Published in Journal Watch Emergency Medicine February 25, 2011.
Citation: Byington CL et al. Normative cerebrospinal fluid profiles in febrile infants. J Pediatr 2011 Jan; 158:130.

16. The Effect of Triage Diagnostic Standing Orders on Emergency Department Treatment Time

Retezar R, et al. Ann Emerg Med. 2011;89-99.e2

Study objective
Triage standing orders are used in emergency departments (EDs) to initiate evaluation when there is no bed available. This study evaluates the effect of diagnostic triage standing orders on ED treatment time of adult patients who presented with a chief complaint for which triage standing orders had been developed.

We conducted a retrospective nested cohort study of patients treated in one academic ED between January 2007 and August 2009. In this ED, triage nurses can initiate full or partial triage standing orders for patients with chest pain, shortness of breath, abdominal pain, or genitourinary complaints. We matched patients who received triage standing orders to those who received room orders with respect to clinical and temporal factors, using a propensity score. We compared the median treatment time of patients with triage standing orders (partial or full) to those with room orders, using multivariate linear regression.

Of the 15,188 eligible patients, 25% received full triage standing orders, 56% partial triage standing orders, and 19% room orders. The unadjusted median ED treatment time for patients who did not receive triage standing orders was 282 minutes versus 230 minutes for those who received a partial triage standing order or full triage standing orders (18% decrease). Controlling for other factors, triage standing orders were associated with a 16% reduction (95% confidence interval −18% to −13%) in the median treatment time, regardless of chief complaint.

Diagnostic testing at triage was associated with a substantial reduction in ED treatment time for 4 common chief complaints. This intervention warrants further evaluation in other EDs and with different clinical conditions and tests.

Full-text (free):

17. Ultrasound-Guided Needle Aspiration "Insufficient" for Skin Abscesses

By Megan Brooks. NEW YORK (Reuters Health) Jan 28 - For treatment of uncomplicated skin abscesses, ultrasound-guided needle aspiration is not on par with incision and drainage. It doesn't even come close, a new study shows.

In a nonblinded randomized trial of about 100 patients, the overall treatment failure rate was 74% with needle aspiration compared with 20% for incision and drainage.

Treatment failure after ultrasound-guided needle aspiration is "unacceptably high," Dr. Romolo Gaspari from University of Massachusetts Memorial Medical Center in Worcester, Massachusetts and colleagues report in the January 18 online issue of Annals of Emergency Medicine. They say their data don't support use of this drainage technique for skin and soft tissue infections.

"Needle aspiration of an abscess cavity, even with ultrasound guidance, is insufficient and should be abandoned," Dr. Gaspari told Reuters Health. "This is true for all patients but especially true for patients with methicillin-resistant Staphylococcus aureus (MRSA)."

It's also important to note, Dr. Gaspari said, that patients with MRSA "did worse regardless of the drainage procedure and independent of antibiotics, which is scary as a clinician."

Needle aspiration with ultrasound guidance has been advocated for superficial abscesses as a less invasive alternative to incision and drainage, which is considered the primary intervention.

Dr. Gaspari and colleagues randomly assigned 54 patients with uncomplicated superficial abscesses to incision and drainage with packing and 47 similar patients to ultrasound-guided needle aspiration. They defined successful treatment as a combination of sonographic resolution and clinical resolution of the signs and symptoms of ongoing infection at day 7.

According to the investigators, the overall success rate was 26% with needle aspiration compared with 80% for incision and drainage, a difference of 54%.

"I was very surprised by the results as I initially designed this trial thinking that ultrasound-guided needle aspiration would be equivalent to incision and drainage," Dr. Gaspari said. "We had seen some failures from needle aspiration but I assumed that this was because of a lack of ultrasound guidance."

Staphylococcus aureus was isolated in 64 of 101 patients (63%); 33 of the isolates (52%) were community-acquired MRSA. There was no difference in the percentage of MRSA in either group.

Overall success rates of both drainage methods were lower in patients with than without MRSA - 8% versus 55% for needle aspiration and 61% versus 89% for incision and drainage.

In a multivariate analysis comparing outcomes of MRSA and non-MRSA, failure of therapy was independent of drainage procedure, making MRSA an independent risk factor for failure of therapy.

Needle aspiration may continue to have limited clinical indications for abscesses for which immediate incision and drainage is less desirable, such as abscesses on the face, according to the researchers. They advise, based on their experience, that any needle aspiration be accompanied by ultrasound guidance.

Ann Emerg Med. Posted January 18, 2011.

18. Clinical Decision Rule for Intussusception in Children

A clinical decision rule identified low-risk patients who might not require further imaging beyond plain radiography.

Weihmiller SN, et al. Pediatrics 2011;127:e296.

CONTEXT: Intussusception is the most common cause of intestinal obstruction in young children, and delayed diagnosis may lead to bowel perforation.

OBJECTIVE: To determine predictive clinical criteria and develop a decision tree to risk-stratify children with possible intussusception.

DESIGN/METHODS: This is a prospective observational cohort study of children aged 1 month to 6 years who presented with possible intussusception. A data-collection form was completed before knowledge of any advanced imaging. Univariate analysis was performed, and decision trees were developed using recursive partitioning.

RESULTS: In the study, 310 patients were enrolled, including 38 (12.3%) with intussusception. The median age was 21.1 months and 61% were male. Univariate predictors of intussusception included age older than 6 months (P = 0.04), male gender (P = .007), history of lethargy (P = .001), and abnormal plain x-ray (P = .0001). Multivariate analysis through recursive partitioning identified decision trees (with and without the result of a plain abdominal x-ray) and allowed identification of patients at low risk. The decision tree based on the results of an abdominal x-ray (negative or positive), age (≤5 or >5 months), diarrhea (present or absent), and bilious emesis (present or absent) had the best test performance (sensitivity: 97% [95% confidence interval (CI): 86-100]; negative predictive value: 99% [95% CI: 93-100]; negative likelihood ratio: 0.08 [95% CI: 0.01-0.6]).

CONCLUSIONS: Among children who were being evaluated for intussusception, we prospectively determined clinical criteria and developed a decision tree to risk-stratify children with possible intussusception.

19. Ketamine with and without Midazolam for Emergency Department Sedation in Adults: A Randomized Controlled Trial

Senar S, et al. Ann Emerg Med. 2011;57:109-114.e2

Study objective
We assess whether midazolam reduces recovery agitation after ketamine administration in adult emergency department (ED) patients and also compared the incidence of adverse events (recovery agitation, respiratory, and nausea/vomiting) by the intravenous (IV) versus intramuscular (IM) route.

This prospective, double-blind, placebo−controlled, 2×2 factorial trial randomized consecutive ED patients aged 18 to 50 years to 4 groups: receiving either 0.03 mg/kg IV midazolam or placebo, and with ketamine administered either 1.5 mg/kg IV or 4 mg/kg IM. Adverse events and sedation characteristics were recorded.

Of the 182 subjects, recovery agitation was less common in the midazolam cohorts (8% versus 25%; difference 17%; 95% confidence interval [CI] 6% to 28%; number needed to treat 6). When IV versus IM routes were compared, the incidences of adverse events were similar (recovery agitation 13% versus 17%, difference 4%, 95% CI –8% to 16%; respiratory events 0% versus 0%, difference 0%, 95% CI –2% to 2%; nausea/vomiting 28% versus 34%, difference 6%, 95% CI –8% to 20%).

Coadministered midazolam significantly reduces the incidence of recovery agitation after ketamine procedural sedation and analgesia in ED adults (number needed to treat 6). Adverse events occur at similar frequency by the IV or IM routes.

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20. Emergency, Primary Care Physicians Need More Teamwork

Robert Lowes. February 25, 2011 — Emergency department (ED) physicians and their primary care counterparts all too often work poorly together, and that spells trouble for patient care, say researchers at the Center for Studying Health System Change (HSC) in a new study.

In one common example of clinical uncoordination, a primary care physician (PCP) refers a patient to a hospital ED but fails to send along pertinent chart information. Or the material gets lost in transit. As a result, the patient arrives in the ED as a medical blank slate and announces to a physician, "My doctor told me to come over here," according to the study, conducted for the nonprofit National Institute for Health Care Reform.

Operating in the dark, an ED physician may duplicate tests and procedures already performed by a PCP.

But when PCPs brief ED physicians about why they are referring a patient, patient care can become more streamlined. "It probably gets you to manage the patient a little quicker," one ED physician told researchers.

The researchers write that better communication and coordination among PCPs and ED physicians are more important than ever since the nation’s new healthcare reform law will extend insurance coverage to more than 30 million additional Americans, who will be more likely to visit EDs as a result.

Barriers Are Personal, Technological, Financial

The HSC team last year interviewed 21 pairs of ED physicians and PCPs who practiced at the same hospital in 12 communities across the country. They uncovered numerous hindrances to teamwork, some of them reflective of structural changes in medicine.

With more hospitalists on the job, fewer and fewer PCPs round at the hospital; consequently, PCPs miss the opportunity to develop close working ties with ED physicians. At the same time, the shift to group practice means that ED physicians who seek information about a patient from his or her regular doctor may end up talking to a less knowledgeable cross-covering physician instead.

Other barriers to teamwork are technological in nature. Telephones trigger time-consuming phone-tag. Faxing records does not permit real-time dialogue, nor is it readily apparent that faxes arrive at their destination or get read. That uncertainty also characterizes email, although this medium at least enables an online conversation. ED physicians and PCPs may use electronic health record (EHR) systems that cannot talk to each other.

Then there is money. Discussions about follow-up care for a patient leaving the ED go unreimbursed and distract both ED physicians and PCPs from the crunch of patients and billable services in their respective workplaces, the HSC researchers write.

The authors recommend wide-ranging solutions to the problem of poor coordination of ED patients. Communitywide networks of interoperable EHRs among providers would allow an ED physician to easily view medical records maintained by a PCP. Federal incentives for meaningful use of EHRs could be revised to reward that kind of data sharing. And rewarding conglomerations of physicians and hospitals for controlling the utilization of services — and therefore costs — will motivate ED physicians and PCPs to work in tandem.

More cooperation also depends on medical liability reform. Right now, ED physicians tend to be the only ones sued for malpractice when they decide not to conduct a certain test or admit a patient because a PCP told them it was unnecessary — and then something goes wrong. This unequal risk discourages ED physicians from soliciting advice from PCPs in the first place. The HSC researchers recommend that states revise their medical liability laws to give EDs a "safe harbor" from malpractice claims if they coordinate patient care with their PCP colleagues.

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21. Trial: Nesiritide Safe for Acute Heart Failure but of Limited Value

November 14, 2010 Steve Stiles. Chicago, IL - Designed to settle a debate that loomed over cardiology about five years ago, a randomized trial with >7000 patients has concluded that the IV vasodilator nesiritide (Natrecor, Scios/Johnson & Johnson) doesn't compromise renal function or increase mortality within a month of its use in acute decompensated heart failure (ADHF) [1].

Nor, of note, does it seem to have much more of an effect against acute dyspnea than can be currently achieved in ADHF with conventional diuretics and vasodilators, both of which are less expensive than nesiritide, a mass-production version of a native natriuretic peptide.

In the Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF), there was "no evidence for a major benefit" from nesiritide vs placebo on top of standard care, said Dr Robert Califf (Duke Clinical Research Institute, Durham, NC) at a presentation of the trial for the media.

Califf chairs the ASCEND-HF executive committee, which he said collectively concluded that physicians, based on the data, "can make their [own] decisions about the value of the effect of this drug on dyspnea."

He addressed the past controversy about whether nesiritide—once widely popular for what seemed to be a consistent, rapid benefit against dyspnea in ADHF—might worsen renal function and actually increase 30-day mortality, as suggested by two meta-analyses [2,3]. "We constantly put drugs on the market without doing the right outcome trials. If this outcome trial had been done earlier, clinicians and patients would have had a much better idea of the potentially very limited role of this treatment, but they also would have known that it was not harmful."

Nesiritide rode to widespread use on the basis of studies with designs that made them inconclusive, Califf observed for heartwire. "The effect of nesiritide on dyspnea was overestimated, partly because the original trial withheld other therapies for the first three hours," he said.

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