Wednesday, August 03, 2011

Lit Bits: Aug 3, 2011

From the recent medical literature...

1. Sensitivity of CT performed within six hours of onset of headache for diagnosis of SAH: prospective cohort study

Perry JJ, Stiell IG, et al. BMJ 2011; 343:d4277

Objective: To measure the sensitivity of modern third generation computed tomography in emergency patients being evaluated for possible subarachnoid haemorrhage, especially when carried out within six hours of headache onset.

Design: Prospective cohort study.

Setting: 11 tertiary care emergency departments across Canada, 2000-9.

Participants: Neurologically intact adults with a new acute headache peaking in intensity within one hour of onset in whom a computed tomography was ordered by the treating physician to rule out subarachnoid haemorrhage.

Main outcome measures: Subarachnoid haemorrhage was defined by any of subarachnoid blood on computed tomography, xanthochromia in cerebrospinal fluid, or any red blood cells in final tube of cerebrospinal fluid collected with positive results on cerebral angiography.

Results: Of the 3132 patients enrolled (mean age 45.1, 2571 (82.1%) with worst headache ever), 240 had subarachnoid haemorrhage (7.7%). The sensitivity of computed tomography overall for subarachnoid haemorrhage was 92.9% (95% confidence interval 89.0% to 95.5%), the specificity was 100% (99.9% to 100%), the negative predictive value was 99.4% (99.1% to 99.6%), and the positive predictive value was 100% (98.3% to 100%). For the 953 patients scanned within six hours of headache onset, all 121 patients with subarachnoid haemorrhage were identified by computed tomography, yielding a sensitivity of 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%).

Conclusion: Modern third generation computed tomography is extremely sensitive in identifying subarachnoid haemorrhage when it is carried out within six hours of headache onset and interpreted by a qualified radiologist.

2. WHO Says Hospital Admission Far Riskier than Flying

By Stephanie Nebehay, Reuters Health Information. GENEVA, Jul 21 - Millions of people die each year from medical errors and infections linked to health care and going into hospital is far riskier than flying, the World Health Organization said on Thursday.

"If you were admitted to hospital tomorrow in any country... your chances of being subjected to an error in your care would be something like 1 in 10. Your chances of dying due to an error in health care would be 1 in 300," Dr. Liam Donaldson, the WHO's newly appointed envoy for patient safety, told a news briefing.

This compared with a risk of dying in an air crash of about 1 in 10 million passengers, according to Dr. Donaldson, formerly England's chief medical officer.

"It shows that health care generally worldwide still has a long way to go," he said.

Hundreds of millions of people suffer infections linked to health care each year. Patients should ask questions and be part of decision-making in hospitals, which must use basic hygiene standards and WHO's checklist to ensure safe surgical procedures were followed.

More than 50 percent of acquired infections can be prevented if health care workers clean their hands with soap and water or an alcohol-based handrub before treating patients.

Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection, according to the United Nations agency.

"The longer patients stay in an ICU (intensive care unit), the more at risk they become of acquiring an infection," it said. Medical devices such as urinary catheters and ventilators are associated with high infection rates.


Each year in the United States, 1.7 million infections are acquired in hospital, leading to 100,000 deaths, a far higher rate than in Europe where 4.5 million infections cause 37,000 deaths, according to WHO.

"Health care is a high-risk business, inevitably, because people are sick and modern health care is delivered in a fast-moving, high-pressured environment involving a lot of complex technology and a lot of people," Dr. Donaldson said.

A heart operation can involve a team of up to 60 people, about the same number needed to run a jumbo jet, he said.

"Infection is a big problem, injuries after falls in hospitals is a big problem and then there are problems that are on a smaller scale but result in preventable deaths. Medication errors are common," he said.

Risk is even higher in developing countries, with about 15% of patients acquiring infections, said Dr. Benedetta Allegranzi of the WHO's "Clean Care is Safer Care" program.

"The risk is really higher in high-risk areas of the hospitals, in particular ICUs or neonatal units in developing countries."

About 100,000 hospitals worldwide now use the WHO's surgical safety checklist, which the agency said has been shown to reduce surgery complications by 33% and deaths by 50%.

If the checklist is effectively used worldwide, an estimated 500,000 deaths could be prevented each year, it says.

"Frankly, if I was having an operation tomorrow I wouldn't go into a hospital that wasn't using the checklist because I wouldn't regard it as safe," said Dr. Donaldson.

3. CLUE: a randomized Comparative effectiveness trial of IV nicardipine versus Labetalol Use in the ED

Peacock WF, et al. Crit Care. 2011 Jun 27;15(3):R157.

INTRODUCTION: Our purpose was to compare the safety and efficacy of food and drug administration (FDA) recommended dosing of IV nicardipine versus IV labetalol for the management of acute hypertension.

METHODS: Multicenter randomized clinical trial. Eligible patients had 2 systolic blood pressure (SBP) measures [greater than or equal to]180 mmHg and no contraindications to nicardipine or labetalol. Before randomization, the physician specified a target SBP +/- 20 mmHg (the target range: TR). The primary endpoint was the percent of subjects meeting TR during the initial 30 minutes of treatment.

RESULTS: Of 226 randomized patients, 110 received nicardipine and 116 labetalol. End organ damage preceded treatment in 143 (63.3%); 71 nicardipine and 72 labetalol patients. Median initial SBP was 212.5 (IQR 197, 230) and 212 mmHg (IQR 200,225) for nicardipine and labetalol patients (P=0.68), respectively. Within 30 minutes, nicardipine patients more often reached TR than labetalol (91.7 vs. 82.5%, P=0.039). Of 6 BP measures (taken every 5 minutes) during the study period, nicardipine patients had higher rates of five and six instances within TR than labetalol (47.3% vs. 32.8%, P=0.026). Rescue medication need did not differ between nicardipine and labetalol (15.5 vs. 22.4%, P=0.183). Labetalol patients had slower heart rates at all time points (P less than 0.01). Multivariable modeling showed nicardipine patients were more likely in TR than labetalol patients at 30 minutes (OR 2.73, P=0.028; C stat for model = 0.72)

CONCLUSION: Patients treated with nicardipine are more likely to reach the physician-specified SBP target range within 30 minutes than those treated with labetalol.

Full-text (free):

4. EM Myths Exploded: ED Care Less Than 2% of Health Care Spending

Berger E. Ann Emerg Med. 2011;58:A18-A20.

Coffee sobers you up.

Going out in cold weather makes you sick.

Too much sugar makes your kids hyperactive.

Chewing gum, once swallowed, takes 7 years to digest.

To be safe, wait 30 minutes after eating before swimming.

Taking vitamin C, echinacea, or zinc prevents colds.

These are half a dozen medical myths that much of the American population, and even more than a handful of physicians, believes. Here's one more: Emergency medical care is expensive and inefficient.

Readers of this article probably won't be taken in by that myth, but in this respect, readers of this journal are out of step with the general public and, perhaps still more important, policymakers. Consider a Senate bill (SB 1781) introduced in October 2009, called the Reducing Emergency Department Utilization Through Coordination and Empowerment (REDUCE) Act. According to its language, the bill sought to address emergency department (ED) overuse, improve quality of care, and save taxpayers' money by establishing pilot programs to better coordinate care for frequent ED users.

“Far too many people rely on emergency room services for routine or primary care,” said US Senator Sherrod Brown (D-OH), one of the bill's authors. ”By strategically expanding outreach services to frequent ER visitors and better coordinating their care, we can cut the associated costs to taxpayers. This initiative takes an important step toward fixing our broken health care system and improving the quality of care for communities in Ohio and across the country.”

Brown is not alone in holding such beliefs. In March 2011, Health and Human Services Secretary Kathleen Sebelius joined the public radio talk program The Diane Rehm Show and responded to a small business owner in Nantucket, MA, who was concerned about paying $1,600 per month for health insurance coverage for her family of 3 under the state's universal health insurance plan, with a $5,000 deductible because of her son's preexisting condition.

“Right now, as a taxpayer, the family from Nantucket is also paying for everyone who doesn't have insurance who is coming through emergency room doors accessing the health care system, often in a very expensive way,” Sebelius said.

In recognition of this pervasive myth about emergency care, as well as others, the American College of Emergency Physicians (ACEP) launched the “Just 2% Campaign” in April 2011. The national public education campaign seeks to promote the value of emergency medicine and to educate the public and policymakers that emergency care is less than 2% of the nation's health care dollar.

During a talk at ACEP's Health Writer's Conference in New York City on April 19, President Sandra Schneider, MD, a professor and chair emeritus in the Department of Emergency Medicine, University of Rochester, Rochester, NY, laid out the campaign for members of the media.

“Health care spending is a huge issue in the United States, representing more than 16% of our gross domestic product. Yet, as became clear during the health care reform debate last year, there are misconceptions about the costs and efficiencies of emergency rooms,” she said. “The bottom line is this: Policymakers seeking to trim fat from the nation's rising health care bills are looking in the wrong place if they take aim at emergency departments.”

ACEP launched the campaign amid a widespread rhetoric from policymakers, public policy wonks, and some sectors of the health care industry on the need to reduce visits to the ED as a way to control increasing health care costs. This article, then, seeks to amplify this educational effort by dispelling the “too costly” myth, as well as others being bandied about by politicians and the press.

Myth No. 1: Emergency Care is Too Expensive…

Myth No. 2: EDs are Crowded by Patients with Nonurgent Medical Issues…

Myth No. 3: Undocumented Immigrants Cause ED crowding…

Myth No. 4: Health Care Reform Will Lead to a Substantial Reduction in Costly ED Visits…

The remainder of the essay can be found here (full-text free):

5. Stable Patients with Pulmonary Embolism Can Be Treated as Outpatients

In a randomized trial of outpatient versus inpatient care, outcomes did not differ between groups.

Typically, diagnosis of pulmonary embolism (PE) means certain admission. Researchers performed an open-label, randomized, noninferiority study to compare outcomes of outpatient and inpatient treatment in consecutive adult patients who presented to 19 emergency departments in Europe and the U.S. with symptomatic PE and risk for death less than 4% (based on the PE Severity Index; see table). Patients were excluded if they had oxygen saturation below 90% on room air, systolic blood pressure below 100 mm Hg, chest pain requiring opioids, active bleeding, or were at high risk for hemorrhage (recent stroke or gastrointestinal bleeding or platelet count above 75,000/mm3). All patients initially received subcutaneous enoxaparin (1 mg/kg twice daily) followed by anticoagulation with vitamin K antagonists for at least 90 days.

Overall, the study included 171 outpatients (mean age, 47) and 168 inpatients (mean age, 49). Cancer prevalence was 1% and 2%, respectively. Within 90 days, one patient in each group died, neither from PE. Recurrent venous thromboembolism occurred in only one patient (outpatient group). Major bleeding occurred within 90 days in three outpatients (intramuscular hematoma on day 3 and day 13 and menometrorrhagia on day 50) and no inpatients. At 14 days, more than 90% of patients in both groups were satisfied or very satisfied with treatment.

Comment: These data suggest that stable low-risk patients with PE can be safely and effectively treated as outpatients with low-molecular-weight heparin. The results might not be applicable to older patients than those in this study or to patients with cancer.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine July 22, 2011. Citation: Aujesky D et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: An international, open-label, randomised, non-inferiority trial. Lancet 2011 Jul 2; 378:41.


6. MRSA Superbug: Can Coffee And Tea Protect You?

Meghan Neal, The Huffington Post. Posted: 7/15/11.

More good news for coffee drinkers? Possibly.

A government study looked at 5,500 Americans and found those that drank tea or coffee had half the chance of carrying the MRSA superbug in their nasal carriage. Scientists have long been aware of tea and coffee's antimicrobial properties.

"Our findings raise the possibility of a promising new method to decrease MRSA nasal carriage that is safe, inexpensive, and easily accessible," wrote the study authors in the Annals Of Family Medicine.

Still, more research is needed. Lead researcher Eric Matheson, of the University of South Carolina, told Reuters: “The study shows an association between the two, but you never can conclude causation from an association. I can't tell you that this finding isn't just a coincidence.”

Since its discovery in the early 1960s, the antibiotic-resistant "superbug" MRSA, short for Methicillin-resistant Staphylococcus Aureus, has been quickly spreading across the U.S. and oversees -- suggesting epidemic levels.

In June a new strain of MRSA was discovered in cow's milk. While alarming, researchers said it was unlikely the bacteria would seep into the food chain.

Matheson EM, et al. Ann Family Med 2011;9:299-304. Abstract:

7. Do Children With Blunt Head Trauma and Normal Cranial CT Scan Results Require Hospitalization for Neurologic Observation?

Holmes JF, et al with PECARN Network. Ann Emerg Med. Article in press.

Study objective: Children evaluated in the emergency department (ED) with minor blunt head trauma, defined by initial Glasgow Coma Scale (GCS) scores of 14 or 15, are frequently hospitalized despite normal cranial computed tomography (CT) scan results. We seek to identify the frequency of neurologic complications in children with minor blunt head trauma and normal ED CT scan results.

Methods: We conducted a prospective, multicenter observational cohort study of children younger than 18 years with blunt head trauma (including isolated head or multisystem trauma) at 25 centers between 2004 and 2006. In this substudy, we analyzed individuals with initial GCS scores of 14 or 15 who had normal cranial CT scan results during ED evaluation. An abnormal imaging study result was defined by any intracranial hemorrhage, cerebral edema, pneumocephalus, or any skull fracture. Patients with normal CT scan results who were hospitalized were followed to determine neurologic outcomes; those discharged to home from the ED received telephone/mail follow-up to assess for subsequent neuroimaging, neurologic complications, or neurosurgical intervention.

Results: Children (13,543) with GCS scores of 14 or 15 and normal ED CT scan results were enrolled, including 12,584 (93%) with GCS scores of 15 and 959 (7%) with GCS scores of 14. Of 13,543 patients, 2,485 (18%) were hospitalized, including 2,107 of 12,584 (17%) with GCS scores of 15 and 378 of 959 (39%) with GCS scores of 14. Of the 11,058 patients discharged home from the ED, successful telephone/mail follow-up was completed for 8,756 (79%), and medical record, continuous quality improvement, and morgue review was performed for the remaining patients. One hundred ninety-seven (2%) children received subsequent CT or magnetic resonance imaging (MRI); 5 (0.05%) had abnormal CT/MRI scan results and none (0%; 95% confidence interval [CI] 0% to 0.03%) received a neurosurgical intervention. Of the 2,485 hospitalized patients, 137 (6%) received subsequent CT or MRI; 16 (0.6%) had abnormal CT/MRI scan results and none (0%; 95% CI 0% to 0.2%) received a neurosurgical intervention. The negative predictive value for neurosurgical intervention for a child with an initial GCS score of 14 or 15 and a normal CT scan result was 100% (95% CI 99.97% to 100%).

Conclusion: Children with blunt head trauma and initial ED GCS scores of 14 or 15 and normal cranial CT scan results are at very low risk for subsequent traumatic findings on neuroimaging and extremely low risk of needing neurosurgical intervention. Hospitalization of children with minor head trauma after normal CT scan results for neurologic observation is generally unnecessary.

8. Discontinuation of low dose aspirin and risk of MI

Individuals with a history of cardiovascular events who stop taking low dose aspirin are at increased risk of non-fatal myocardial infarction compared with those who continue treatment, say the authors of this case-control study in UK primary care. Editorialists Giuseppe Biondi-Zoccai and Giovanni Landoni say that these findings are important and support previous studies showing an increase in adverse events after aspirin withdrawal. They suggest that patients should be advised never to stop aspirin unless explicitly told to do so, and doctors should maintain their patients on low dose aspirin for as long as they can.

García Rodríguez LA, et al. BMJ 2011; 343:d4094

Objective:s To evaluate the risk of myocardial infarction and death from coronary heart disease after discontinuation of low dose aspirin in primary care patients with a history of cardiovascular events.

Design: Nested case-control study.

Setting: The Health Improvement Network (THIN) database in the United Kingdom.

Participants: Individuals aged 50-84 with a first prescription for aspirin (75-300 mg/day) for secondary prevention of cardiovascular outcomes in 2000-7 (n=39 513).

Main outcome measures: Individuals were followed up for a mean of 3.2 years to identify cases of non-fatal myocardial infarction or death from coronary heart disease. A nested case-control analysis assessed the risk of these events in those who had stopped taking low dose aspirin compared with those who had continued treatment.

Results: There were 876 non-fatal myocardial infarctions and 346 deaths from coronary heart disease. Compared with current users, people who had recently stopped taking aspirin had a significantly increased risk of non-fatal myocardial infarction or death from coronary heart disease combined (rate ratio 1.43, 95% confidence interval 1.12 to 1.84) and non-fatal myocardial infarction alone (1.63, 1.23 to 2.14). There was no significant association between recently stopping low dose aspirin and the risk of death from coronary heart disease (1.07, 0.67 to 1.69). For every 1000 patients, over a period of one year there were about four more cases of non-fatal myocardial infarction among patients who discontinued treatment with low dose aspirin (recent discontinuers) compared with patients who continued treatment.

Conclusions: Individuals with a history of cardiovascular events who stop taking low dose aspirin are at increased risk of non-fatal myocardial infarction compared with those who continue treatment.

Full-text (free):

9. Current methods of diagnosis and treatment of scaphoid fractures

Rhemrev SJ, et al. International J Emerg Med. 2011;4:4

Fractures of the scaphoid bone mainly occur in young adults and constitute 2-7% of all fractures. The specific blood supply in combination with the demanding functional requirements can easily lead to disturbed fracture healing. Displaced scaphoid fractures are seen on radiographs. The diagnostic strategy of suspected scaphoid fractures, however, is surrounded by controversy. Bone scintigraphy, magnetic resonance imaging and computed tomography have their shortcomings. Early treatment leads to a better outcome. Scaphoid fractures can be treated conservatively and operatively. Proximal scaphoid fractures and displaced scaphoid fractures have a worse outcome and might be better off with an open or closed reduction and internal fixation. The incidence of scaphoid non-unions has been reported to be between 5 and 15%. Non-unions are mostly treated operatively by restoring the anatomy to avoid degenerative wrist arthritis.

Full-text (free):

10. Rocuronium Versus Succinylcholine: Cochrane Synopsis Reconsidered

Strayer RJ, et al. Ann Emerg Med. 2011;58:217-218.

To the Editor:

I read with interest the summary by Seupaul and Jones1 of the 2008 Cochrane systematic review comparing intubating conditions produced by rocuronium and succinylcholine during rapid sequence intubation. The summary reports the study's conclusion, which is that succinylcholine produces excellent intubating conditions more frequently than rocuronium, with a relative risk of 0.86. This result is taken from 37 studies, of which 24 used rocuronium at a dose of 0.6 mg/kg, 5 used a dose of 0.9 mg/kg or greater, and 8 used a combination of doses.

The speed with which rocuronium causes paralysis is dose dependent. At the classically recommended dose of 0.6 mg/kg, excellent intubating conditions are significantly delayed. At 1.0 mg/kg, excellent intubating conditions are produced at 60 seconds, about 15 seconds later than with succinylcholine. At 1.2 mg/kg, the currently recommended dose, rocuronium produces excellent intubating conditions at 40 seconds and cannot be distinguished from succinylcholine.2 In fact, the authors of the Cochrane review state, “We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2 mg/kg rocuronium.” A recent emergency department (ED)–based head-to-head comparison supports this conclusion.3

The Cochrane authors follow this evidence-based result with the following assertion: “…[H]owever, succinylcholine was clinically superior as it has a shorter duration of action.” Mallon et al4 used a similar argument in their cited critical appraisal.

The longer duration of action of rocuronium is an advantage, not a disadvantage. Emergency clinicians who believe they are protected against a can't-intubate, can't-ventilate scenario by the short duration of succinylcholine are usually wrong5 and make dangerous decisions as a result. When early attempts at laryngoscopy fail, further attempts are hindered by the return of the patient's airway reflexes; this already precarious situation is worsened if the patient puts his now-functioning muscles to use by vomiting.

These problems are eliminated by the longer duration of rocuronium. Furthermore, rocuronium is not burdened by a list of rare but lethal contraindications, most of which are not routinely screened for by emergency physicians. Succinylcholine also occasionally causes masseter spasm, rendering laryngoscopy impossible until a nondepolarizing paralytic is located and administered.

In conclusion, succinylcholine is more likely to produce excellent intubating conditions than rocuronium only if the incorrect dose of rocuronium is used. At 1.2 mg/kg, rocuronium is as effective as succinylcholine at facilitating laryngoscopy and offers a host of other advantages. Although both drugs are safe and effective for rapid sequence intubation in the ED, rocuronium should be the preferred agent in most circumstances.


11. Ultrasound-Guided Central Line Placement: No X-Ray Needed?

No pneumothoraces were detected on chest x-ray in 1202 asymptomatic patients after ultrasound-guided central venous line placement.

With ultrasound-guided central line placement, is a postinsertion chest x-ray still necessary to assess for pneumothorax? Researchers reviewed records for 1258 real-time, ultrasound-guided, internal jugular vein central line placements and 4 external jugular vein placements performed in 1066 patients during 4 years in the vascular and interventional radiology suite at a single U.S. hospital.

Postprocedure upright chest x-rays were obtained in 1202 patients (after an average of 65 minutes); supine chest x-rays were performed as part of routine care in 66 hospitalized and bedridden patients. No patient had symptoms or radiographic evidence of pneumothorax. The authors conclude that eliminating routine postprocedure x-rays would save time and costs and reduce radiation exposure.

Comment: This study was performed in a more controlled environment than an emergency department. Chest x-ray is not necessary after ultrasound-guided internal jugular vein cannulation when assessment of catheter positioning is not needed. When pneumothorax is suspected, bedside ultrasound for lung sliding likely is a better test than a chest x-ray (JW Emerg Med Nov 6 2009).

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine July 29, 2011. Citation: Oner B et al. Pneumothorax following ultrasound-guided jugular vein puncture for central venous access in interventional radiology: 4 years of experience. J Intensive Care Med 2011 Jul 14; [e-pub ahead of print].

12. Children Presenting With Acute Pericarditis to the ED

Ratnapalan S, et al, Pediatr Emerg Care. 2011;27(7):581-585.

Objective: The objective of the study was to evaluate the clinical features and the outcome of children who presented to the emergency department and were ultimately diagnosed with pericarditis.

Methods: A retrospective chart review of all children diagnosed with acute pericarditis from January 2000 through March 2007 was conducted.

Results: There were 94 children with pericarditis as the sole or one of the discharge diagnoses: 34 with postsurgical pericarditis and 38 with pericarditis as a component of a generalized illness were not examined further. Of the 22 children included in the study, the mean age was 12.3 (SD, 2.7) years, and 80% were males. Chest pain was present in 96%, and fever was present in 56%. All children had electrocardiographic changes comprising ST and T-wave abnormalities. Initial chest radiographs were reported as normal in 40%; although 82% (n = 18) had a pericardial effusion on echocardiography, 7 (32%) required pericardiocentesis. The etiology was considered idiopathic in 68% (n = 15). All children improved on treatment with nonsteroidal anti-inflammatory drugs. Eight children (36%) had recurrent pericarditis, of whom 2 had multiple recurrences.

Conclusions: Children presenting with chest pain require further investigation if electrocardiographs show any abnormalities. Children presenting with pericarditis require follow-up and caution about recurrence.

13. Association of Hospitalist Care with Medical Utilization After Discharge: Evidence of Cost Shift From a Cohort Study

Kuo YF, et al. Ann Intern Med 2011;155:152-159.

Most studies of hospitalist care have focused on the inpatient stay. This study compared hospitalized patients who were cared for by primary care physicians with those cared for by hospitalists. Hospitalists' patients had shorter and less expensive hospitalizations. During the 30 days after discharge, however, hospitalists' patients had more visits to the emergency department, more readmissions to the hospital, and higher total expenses. Savings during hospitalization that are associated with hospitalist care may be offset by higher expenses after discharge.


14. Accuracy of Stated Energy Contents of Restaurant Foods

Urban LE, et al. JAMA. 2011 Jul 20;306(3):287-93.

Context: National recommendations for the prevention and treatment of obesity emphasize reducing energy intake. Foods purchased in restaurants provide approximately 35% of the daily energy intake in US individuals but the accuracy of the energy contents listed for these foods is unknown.

Objective: To examine the accuracy of stated energy contents of foods purchased in restaurants.

Design and Setting: A validated bomb calorimetry technique was used to measure dietary energy in food from 42 restaurants, comprising 269 total food items and 242 unique foods. The restaurants and foods were randomly selected from quick-serve and sit-down restaurants in Massachusetts, Arkansas, and Indiana between January and June 2010.

Main Outcome Measure: The difference between restaurant-stated and laboratory-measured energy contents, which were corrected for standard metabolizable energy conversion factors.

Results: The absolute stated energy contents were not significantly different from the absolute measured energy contents overall (difference of 10 kcal/portion; 95% confidence interval [CI], −15 to 34 kcal/portion; P = .52); however, the stated energy contents of individual foods were variable relative to the measured energy contents. Of the 269 food items, 50 (19%) contained measured energy contents of at least 100 kcal/portion more than the stated energy contents. Of the 10% of foods with the highest excess energy in the initial sampling, 13 of 17 were available for a second sampling. In the first analysis, these foods contained average measured energy contents of 289 kcal/portion (95% CI, 186 to 392 kcal/portion) more than the stated energy contents; in the second analysis, these foods contained average measured energy contents of 258 kcal/portion (95% CI, 154 to 361 kcal/portion) more than the stated energy contents (P less than.001 for each vs 0 kcal/portion difference). In addition, foods with lower stated energy contents contained higher measured energy contents than stated, while foods with higher stated energy contents contained lower measured energy contents (P less than.001).

Conclusions: Stated energy contents of restaurant foods were accurate overall. However, there was substantial inaccuracy for some individual foods, with understated energy contents for those with lower energy contents.

15. Images in Emergency Medicine

Elderly Female with Syncope

Man with Generalized Weakness

Infant With Facial Lesions

Woman With Hypertension and Seizure

Small-Intestinal Volvulus

Evolution of a Jellyfish Sting


Thrombosis of the Inferior Vena Cava and Dilated Veins of the Trunk

Dependent Rubor

16. IV Volume Expansion Helpful in Hemolytic Uremic Syndrome

Laurie Barclay, MD. Medscape News. July 25, 2011 — In children who have diarrhea and are at risk for hemolytic uremic syndrome (HUS), intravenous volume expansion may help protect against oligoanuric renal failure, according to the results of a prospective, observational cohort study reported online July 22 in the Archives of Pediatrics and Adolescent Medicine. Since an Escherichia coli outbreak was first reported in Germany in May 2011, there have been more than 900 cases of HUS reported in 16 countries in Europe and North America.

"[T]he pathophysiologic cascade leading to renal failure might provide an opportunity to mitigate renal damage," write Christina A. Hickey, MD, from Washington University School of Medicine and St. Louis Children's Hospital, Missouri, and colleagues. "If patients at risk for HUS are recognized early in illness, then the brief interval between first presentation with diarrhea and HUS onset could be exploited to maintain or improve renal perfusion, possibly averting renal shutdown."

The study goal was to assess the effect of interventions during the pre-HUS diarrhea phase on maintenance of urine output during HUS. At 11 pediatric hospitals in the United States and Scotland, children younger than 18 years with diarrhea-associated HUS received intravenous fluid within the first 4 days of diarrhea onset. Inclusion criteria were hematocrit level lower than 30% with smear evidence of intravascular erythrocyte destruction, thrombocytopenia with platelet count lower than 150 × 103/mm3, and impaired renal function, defined as serum creatinine concentration higher than the upper limit of reference range for age. The main study endpoint was presence or absence of oligoanuria, defined as a urine output of 0.5 mL/kg/hour or less for more than 1 day.

Among the 50 participants, the overall oligoanuric rate was 68%, but those who received no intravenous fluids in the first 4 days of illness had an oligoanuric rate of 84%. When fluids were not given during this time, the relative risk for oligoanuria was 1.6 (95% confidence interval, 1.1 - 2.4; P = .02).

Compared with children without oligoanuria, those with oligoanuric HUS received less total intravenous fluid (r = −0.32; P = .02) and sodium (r = −0.27; P = .05) during the first 4 days of illness. The most significant covariate in multivariable analysis was volume infused, but volume and sodium strongly covaried.

"Intravenous volume expansion is an underused intervention that could decrease the frequency of oligoanuric renal failure in patients at risk of HUS," the study authors write.

Limitations of this study include the lack of randomization and the inability to address the optimal sodium content of the fluid given or the value or safety of isotonic intravenous volume expansion in children whose serum creatinine concentrations are rising, but who are still urinating.

"Because presence and/or duration of oligoanuria are so repeatedly associated with long-term sequelae in children with HUS, it seems appropriate to prioritize maintenance of urine output during HUS, even though our data do not permit us to state that pre-HUS intravenous volume expansion prevents long-term renal sequelae," the study authors conclude. "Intravenous volume expansion appears to be a logical strategy that can be used now to achieve this goal, because we cannot hasten renal recovery once oligoanuria is established. We reiterate that volume expansion in these situations must be accompanied by assiduous monitoring for cardiopulmonary overload and hypertension."

The Doris Duke Clinical Research Fellowship supported this study. The study authors have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2011 Jul 22. PubMed Abstract:

17. A Task Analysis of Emergency Physician Activities in Academic and Community Settings

Chisholm CD, et al. Ann Emerg Med. 2011;58:117-122.

Study objective: We characterize and compare the work activities, including peak patient loads, associated with the workplace in the academic and community emergency department (ED) settings. This allows assessment of the effect of future ED system operational changes and identifies potential sources contributing to medical error.

Methods: This was an observational, time-motion study. Trained observers shadowed physicians, recording activities. Data included total interactions, distances walked, time sitting, patients concurrently treated, interruptions, break in tasks, physical contact with patients, hand washing, diagnostic tests ordered, and therapies rendered. Activities were classified as direct patient care, indirect patient care, or personal time with a priori definitions.

Results: There were 203 2-hour observation periods of 85 physicians at 2 academic EDs with 100,000 visits per year at each (N=160) and 2 community EDs with annual visits of 19,000 and 21,000 (N=43). Reported data present the median and minimum-maximum values per 2-hour period. Emergency physicians spent the majority of time on indirect care activities (academic 64 minutes, 29 to 91 minutes; community 55 min, 25 to 95 minutes), followed by direct care activities (academic 36 minutes, 6 to 79 minutes; community 41 minutes, 5 to 60 minutes). Personal time differed by location type (academic 6 minutes, 0 to 66 minutes; community 13 minutes, 0 to 69 minutes). All physicians simultaneously cared for multiple patients, with a median number of patients greater than 5 (academic 7 patients, 2 to 16 patients; community 6 patients, 2 to 12 patients).

Conclusion: Emergency physicians spend the majority of their time involved in indirect patient care activities. They are frequently interrupted and interact with a large number of individuals. They care for a wide range of patients simultaneously, with surges in multiple patient care responsibilities. Physicians working in academic settings are interrupted at twice the rate of their community counterparts.

18. Examination of staphylococcal stethoscope contamination in the ED

Tang PHP, et al. CJEM 2011;13(4):239-244

Introduction: The objective of this study was to determine the prevalence of Staphylococcus-contaminated stethoscopes belonging to emergency department (ED) staff and to identify the proportion of these that were Staphylococcus aureus or methicillin-resistant Staphylococcus aureus (MRSA).

Methods: We conducted a prospective observational cohort study of bacterial cultures from 100 ED staff members' stethoscopes at three EDs. Study participants were asked to complete a questionnaire.

Results: Fifty-four specimens grew coagulase-negative staphylococci and one grew methicillin-susceptible S. aureus. No MRSA was cultured. Only 8% of participants, all of whom were nurses, reported cleaning their stethoscope before or after each patient assessment. Alcohol-based wipes were most commonly used to clean stethoscopes. A lack of time, being too busy, and forgetfulness were the most frequently reported reasons for not cleaning the stethoscope in the ED.

Conclusions: This study indicates that although stethoscope contamination rates in these EDs are high, the prevalence of S. aureus or MRSA on stethoscopes is low.

19. Interexaminer Agreement in Physical Examination for Children with Suspected Soft Tissue Abscesses

Giovanni JE. Pediatr Emerg Care. 2011;27(6):475-478.

Objective: This study aimed to measure interexaminer agreement for physical examination (PE) findings in children with a suspected soft tissue abscess.

Methods: A prospective study was conducted from March 1 to July 31, 2007, at an urban, tertiary care children's hospital emergency department. Children presenting to the emergency department with a suspected local skin abscess were independently examined by 2 physicians. Interrater agreement of 7 PE findings for children with a suspected soft tissue abscess was assessed. Interrater agreement was calculated for the diagnosis of the lesion and decision to incise and drain.

Results: A total of 105 paired observations were completed by a total of 27 physicians. The patients examined were aged 2 weeks to 18 years, with a mean age of 80 months. Lesions were most frequently encountered on the buttocks (38%). Incision and drainage was attempted in 75% of cases, with purulent material obtained in 92% of all attempts. Interrater agreement was substantial for erythema (κ = 0.66) and size of the lesion (intraclass correlation coefficient = 0.78), moderate for drainage (κ = 0.57) and tenderness (κ = 0.40), fair for fluctuance (κ = 0.35), and poor for warmth (κ = 0.15) and showed no agreement for induration (κ = −0.08). There was moderate agreement on diagnosing the lesion as an abscess (κ = 0.48) and determination if the lesion required incision and drainage (κ = 0.44).

Conclusions: Interexaminer agreement of examination findings and diagnosis of an abscess was fair to moderate, implying a lack of precision of PE as the primary means for diagnosis. Future studies of diagnostic adjuncts, such as bedside ultrasonography, may lead to improved management of soft tissue infections in children.

20. ED Management of Patients on Warfarin Therapy

Meeker E, et al. Ann Emerg Med. 2011;58:192-199.

Study objective: To characterize warfarin management in the emergency department (ED).

Methods: This was a retrospective, cross-sectional, observational study of patients who were receiving warfarin and were discharged from a tertiary care, academic urban ED between June and August 2007. We abstracted patient demographics, presenting complaint, international normalized ratio (INR) if tested, indication for warfarin if documented, new medications administered or prescribed in the ED, and discharge instructions. Presenting complaints were categorized according to whether they were warfarin-related and concerning for thrombosis or bleeding. The primary outcome measure was the prevalence of warfarin therapy. The secondary outcome measures were frequency with which ED providers obtained an INR result, response to nontherapeutic results, administration or prescription of interacting medications, and percentage of patients receiving recommendations for anticoagulation follow-up.

Results: Two percent (111/7,195) of all patients presenting to and discharged from the ED during the study period were found to be receiving warfarin. Seventy-one percent (79/111) had an INR checked. Nontherapeutic INRs were recorded for 49% (39/79) of patients; ED providers intervened to address these results in 21% (8/39) of cases. Seventy-one percent (5/7) of patients with a supratherapeutic INR received an intervention compared with 9% (3/32) of patients with a subtherapeutic INR. Seventeen percent (19/111) and 13% (14/111) of patients received or were prescribed potentially interacting medications, respectively. Recommendations for specific anticoagulation follow-up were documented for 19% (21/111) of all patients.

Conclusion: Patients receiving warfarin frequently present to the ED and often have nontherapeutic INRs. Potential areas for improvement in ED management include greater attention to subtherapeutic INRs, interacting medications, and discharge planning.

21. Performance of stroke risk scores in older people with atrial fibrillation not taking warfarin: comparative cohort study from BAFTA trial

Hobbs FDR, et al. BMJ 2011; 342:d3653

Objective: To compare the predictive power of the main existing and recently proposed schemes for stratification of risk of stroke in older patients with atrial fibrillation.

Design: Comparative cohort study of eight risk stratification scores.

Setting: Trial of thromboprophylaxis in stroke, the Birmingham Atrial Fibrillation in the Aged (BAFTA) trial.

Participants: 665 patients aged 75 or over with atrial fibrillation based in the community who were randomised to the BAFTA trial and were not taking warfarin throughout or for part of the study period.

Main outcome measures: Events rates of stroke and thromboembolism.

Results: 54 (8%) patients had an ischaemic stroke, four (0.6%) had a systemic embolism, and 13 (2%) had a transient ischaemic attack. The distribution of patients classified into the three risk categories (low, moderate, high) was similar across three of the risk stratification scores (revised CHADS2, NICE, ACC/AHA/ESC), with most patients categorised as high risk (65-69%, n=460-457) and the remaining classified as moderate risk. The original CHADS2 (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes, previous Stroke) score identified the lowest number as high risk (27%, n=180). The incremental risk scores of CHADS2, Rietbrock modified CHADS2, and CHA2DS2-VASc (CHA2DS2-Vascular disease, Age 65-74 years, Sex) failed to show an increase in risk at the upper range of scores. The predictive accuracy was similar across the tested schemes with C statistic ranging from 0.55 (original CHADS2) to 0.62 (Rietbrock modified CHADS2), with all except the original CHADS2 predicting better than chance. Bootstrapped paired comparisons provided no evidence of significant differences between the discriminatory ability of the schemes.

Conclusions: Based on this single trial population, current risk stratification schemes in older people with atrial fibrillation have only limited ability to predict the risk of stroke. Given the systematic undertreatment of older people with anticoagulation, and the relative safety of warfarin versus aspirin in those aged over 70, there could be a pragmatic rationale for classifying all patients over 75 as “high risk” until better tools are available.

Full-text (free):