Monday, September 12, 2011

Lit Bits: Sept 12, 2011

From the recent medical literature...

1. Prospective (in)validation of the ABCD2 score for patients in the ED with TIA

Perry JJ, Stiell IG, et al. CMAJ. 2011 Jul 12;183(10):1137-45.

BACKGROUND: The ABCD2 score (Age, Blood pressure, Clinical features, Duration of symptoms and Diabetes) is used to identify patients having a transient ischemic attack who are at high risk for imminent stroke. However, despite its widespread implementation, the ABCD2 score has not yet been prospectively validated. We assessed the accuracy of the ABCD2 score for predicting stroke at 7 (primary outcome) and 90 days.

METHODS: This prospective cohort study enrolled adults from eight Canadian emergency departments who had received a diagnosis of transient ischemic attack. Physicians completed data forms with the ABCD2 score before disposition. The outcome criterion, stroke, was established by a treating neurologist or by an Adjudication Committee. We calculated the sensitivity and specificity for predicting stroke 7 and 90 days after visiting the emergency department using the original "high-risk" cutpoint of an ABCD2 score of more than 5, and the American Heart Association recommendation of a score of more than 2.

RESULTS: We enrolled 2056 patients (mean age 68.0 yr, 1046 (50.9%) women) who had a rate of stroke of 1.8% at 7 days and 3.2% at 90 days. An ABCD2 score of more than 5 had a sensitivity of 31.6% (95% confidence interval [CI] 19.1-47.5) for stroke at 7 days and 29.2% (95% CI 19.6-41.2) for stroke at 90 days. An ABCD2 score of more than 2 resulted in sensitivity of 94.7% (95% CI 82.7-98.5) for stroke at 7 days with a specificity of 12.5% (95% CI 11.2-14.1). The accuracy of the ABCD2 score as calculated by either the enrolling physician (area under the curve 0.56; 95% CI 0.47-0.65) or the coordinating centre (area under the curve 0.65; 95% CI 0.57-0.73) was poor.

INTERPRETATION: This multicentre prospective study involving patients in emergency departments with transient ischemic attack found the ABCD2 score to be inaccurate, at any cut-point, as a predictor of imminent stroke. Furthermore, the ABCD2 score of more than 2 that is recommended by the American Heart Association is nonspecific.

2. Development of a Clinical Prediction Rule for 30-Day Cardiac Events in ED Patients with Chest Pain and Possible ACS

Hess EP, et al. Ann Emerg Med. 2011 Aug 31. [Epub ahead of print]

STUDY OBJECTIVE: Evaluation of emergency department (ED) patients with chest pain who are at low risk for acute coronary syndrome is resource intensive and may lead to false-positive test results and unnecessary downstream procedures. We seek to identify patients at low short-term risk for a cardiac event for whom additional ED investigations might be unnecessary.

METHODS: We prospectively enrolled patients older than 24 years and with a primary complaint of chest pain from 3 academic EDs. Physicians completed standardized data collection forms before diagnostic testing. The primary adjudicated outcome was acute myocardial infarction, revascularization, or death of cardiac or unknown cause within 30 days. We used recursive partitioning to derive the rule and validated the model with 5,000 bootstrap replications.

RESULTS: Of 2,718 patients enrolled, 336 (12%) experienced a cardiac event within 30 days (6% acute myocardial infarction, 10% revascularization, 0.2% death). We developed a rule consisting of the absence of 5 predictors: ischemic ECG changes not known to be old, history of coronary artery disease, pain typical for acute coronary syndrome, initial or 6-hour troponin level greater than the 99th percentile, and age greater than 50 years. Patients aged 40 years or younger required only a single troponin evaluation. The rule was 100% sensitive (95% confidence interval 97.2% to 100.0%) and 20.9% specific (95% confidence interval 16.9% to 24.9%) for a cardiac event within 30 days.

CONCLUSION: This clinical prediction rule identifies ED chest pain patients at very low risk for a cardiac event who may be suitable for discharge. A prospective multicenter study is needed to validate the rule and determine its effect on practice.

3. How Much CPR Before Defibrillation Shock?

Administering more cardiopulmonary resuscitation before defibrillation and rhythm analysis does not improve outcomes.

To examine the theory that a more perfused heart will respond better to defibrillation shock, researchers conducted a cluster-randomized study in 9933 patients with nontraumatic out-of-hospital cardiac arrest at 10 Resuscitation Outcomes Consortium sites in the U.S. and Canada. Patients were divided into two groups and received cardiopulmonary resuscitation (CPR) by emergency medical services (EMS) providers for either 30 to 60 seconds (until pads were applied) or 180 seconds before defibrillation and initial electrocardiograph rhythm analysis. EMS providers received study-specific training every 6 months that emphasized uninterrupted compressions and ventilations in a 30:2 ratio.

The primary outcome — survival to hospital discharge with satisfactory neurological function as measured by the modified Rankin score — was 5.9% in both groups. The authors concluded that delaying analysis of cardiac rhythm during EMS-administered CPR provided no advantage. Of note, despite aggressive training of already "high-functioning" EMS providers, the duration of CPR before the first rhythm analysis did not fall within the assigned target for 36% of patients.

Comment: Even the best CPR delivers only a small fraction of normal cardiac output, which, as this study shows, is insufficient to "prime" the heart for defibrillation shock. Achieving a normal effective rhythm as soon as possible remains the single most important goal of resuscitation. The 64% adherence to the assigned duration of CPR by EMS providers shows how messy things are in real-life delivery of care for out-of-hospital cardiac arrest. This study does not alter the mantra for bystander-delivered CPR: "Always push early and often."

— J. Stephen Bohan, MD, MS, FACP, FACEP

Published in Journal Watch Emergency Medicine September 9, 2011. Citation: Stiell IG et al. Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. N Engl J Med 2011 Sep 1; 365:787.


4. Sudden Death Etiologies Vary by Age Group

By Will Boggs MD. NEW YORK (Reuters Health) Sep 07 - The primary cause of sudden cardiac death in young adults differs before and after age 35, new data show.

"Screening programs focus disproportionate attention on the identification of hypertrophic cardiomyopathy," Dr. Robert E. Eckart from Brooke Army Medical Center, San Antonio, Texas told Reuters Health by email.

"While exclusion of this potentially deadly disease is critical, we should be focusing attention toward the leading cause of sudden death in the young, sudden arrhythmic death syndrome," he said.

As reported in the September 13th Journal of the American College of Cardiology, Dr. Eckart and colleagues used the Department of Defense Cardiovascular Death Registry to identify the cause of all nontraumatic sudden deaths over a 10-year period in military personnel 18 years of age and over.

Ultimately they reviewed 902 records with autopsy data for deaths of presumed cardiac etiology.

The mortality rate for sudden cardiac death per 100,000 person-years was 6.68 for males and 1.40 for females. Rates per 100,000 person-years rose from 3.25 for individuals under 20 years of age to 105.57 for those over 50.

Before age 35, the leading cause of sudden cardiac death -- accounting for 41% of cases -- was "sudden death without an identifiable cardiac structural abnormality, presumably arrhythmic," whereas for older individuals it was atherosclerotic coronary artery disease, which accounted for 73% of cases.

Only 57 deaths (6.3%) were attributed to hypertrophic cardiomyopathy and only 26 (2.9%) to hypertensive cardiomyopathy.

"Interestingly, cholesterol and BMI, conventional indicators, were not associated with risk of sudden death from atherosclerotic coronary disease, but the doubling of relative risk beyond age 35 years suggests we lower the standard ages at which we suspect disease, particularly in those with family history," Dr. Eckart said.

"As we look at newer modalities for detection of disease, not risk for disease, but actual disease states, like CT angiography, we need to consider adjusting risk models based on known incidence of fatal disease," he said.

"When a young adult dies, particularly in the public forum, whether that be a high school athletic field or on a military base, there is significant early media attention," Dr. Eckart continued. "When a cause is identified, the findings spread rapidly; but if a cause is not clearly identified, community interest wanes, as the outcome was felt to be a mystery, or simply inevitable."

"Of more importance is the significance of a family history of sudden death at a young age, particularly in someone who passes out," Dr. Eckart said. "If someone under age 35 loses consciousness or passes out without a clearly identifiable explanation, and they have a family history of sudden death, it is critical that they be evaluated by a cardiologist or a cardiac electrophysiologist without delay."

Eckart RE, et al. J Am Coll Cardiol. 2011 Sep 13;58(12):1254-61.


5. Medicare Prepares Rule to Penalize Hospitals with High Readmission Rates

By Jordan Rau. Kaiser Health News. August 29, 2011

When hospitals discharge patients, they typically see their job as done. But soon, they could be on the hook for what happens after Medicare patients leave the premises, and particularly if they are readmitted within a month.

In an effort to save money and improve care, Medicare, the federal program for the elderly and disabled, is about to release a final rule aimed at getting hospitals to pay more attention to patients after discharge.

A key component of the new approach is to cut back payments to hospitals where high numbers of patients are readmitted, prodding hospitals to make sure patients see their doctors and fill their prescriptions.

Medicare also wants to pay less to hospitals with higher-than-average costs for patient care. It has proposed calculating the costs by combining a patient's hospital expenses with fees incurred up to 90 days after discharge.

The efforts, called for in last year's health care law, are part of a push to make hospitals the hub for coordinating care. Hospital care is the largest chunk of Medicare spending; Medicare says readmissions alone cost $26 billion in a decade. Plus, many experts argue hospitals are the most organized actors in a splintered and often dysfunctional health system, and thus best able to take the lead in overseeing patient care.

But hospital groups complain that Medicare's plans could punish them for things they can't control, such as unavoidable readmissions and patients who can't afford the costs of prescriptions.

"A lot of this is very unfair," says Blair Childs, a vice president at Premier, an alliance of more than 200 hospitals. He says hospitals that don't have a lot of money to invest in improving their oversight of former patients could end up losing more money under Medicare's proposals, putting them in an even bigger financial hole. In particular, he says, the changes may hurt inner city hospitals.

"These are often very stressed hospitals, and they're the ones that are going to be penalized the most," Childs says.

Some academics who have studied hospitals also think Medicare may be being too harsh. "The truth is the 30-day readmission is a relatively lousy quality measure for a hospital, because a lot is happening outside a hospital's control," says Dr. Ashish Jha, a professor at Harvard's School of Public Health.

Medicare's penalties could be significant-and widespread. Almost 7 percent of acute-care hospitals -- 307 out of 4,498 -- had higher-than-expected readmissions rates for heart failure, heart attack or pneumonia, according to Medicare data. Under Medicare's draft proposal, which it put out in May, penalties would start in October 2012; hospitals with the worst readmissions rates eventually could lose up to 3 percent of their regular Medicare payments.

Hospitals with patients who cost Medicare lots of money during and after their hospital stays also could be hurt. Beginning in October 2013, these spending levels would count for a fifth of Medicare's "value-based purchasing program," which alters hospital payments based on long list of quality measures.

"The incentives we're putting into place have created a whole new way to think about hospital care," says Jonathan Blum, deputy administrator of the federal Centers for Medicare & Medicaid Services, or CMS.

These initiatives come on top of other Medicare experiments that will make not just hospitals but also surgeons responsible for costs run up from complications that occur beyond the operating room. One approach is "bundled payments," where Medicare pays a set fee for the entire cost of a patient's treatment, including expenses after discharge. And Medicare's high-profile venture to create "accountable care organizations," where teams of doctors and hospitals share the financial risks and rewards for caring for patients, would also hold hospitals partially to account for the costs of treatments that patients get elsewhere.

Hospitals "can no longer see our job as just being within the four walls we've built," says Leah Binder, chief executive of the Leapfrog Group, a nonprofit that evaluates hospital quality.

CMS has limited leeway to tinker with the readmissions rule, because much of it was spelled out in the health care law. CMS has more freedom to change its plan to measure per-patient spending, as the law didn't detail how it should work.

Regardless of what CMS ultimately decides, many hospitals are already scrambling to change how they supervise former patients, says Chas Roades, chief research officer at The Advisory Board Company, a health care consultancy. "One of the big themes I'm hearing now across the hospital industry is, 'We can no longer think of ourselves as just hospital companies, we have to be full-service health care managers,'" he says.

Consider Trinity Health, which owns 50 hospitals around the country, including Holy Cross in Silver Spring, Md. Before patients leave the hospital, Trinity's nurses now set up appointments for them with their regular doctors. They also make sure patients can get to the appointment, either by helping them figure out whether Medicare or Medicaid pays for transportation, or by paying for the trips directly.

"We're trying to do a better job of sending them home better-prepared, rather than just saying good luck," says Dr. Terry O'Rourke, Trinity's chief clinical officer. But he says there are limits to what they can do: "The majority of physicians are not employed by the hospital, and we don't have control over their practices."

Dr. Kavita Patel, a Brookings Institution fellow and former Obama administration official, says changes occurring in both the private sector and Medicare will speed up the trend of hospitals' overseeing the care of former patients.

For example, she says, many hospitals are buying the practices of primary care doctors, making it easier for them to arrange and oversee the care of patients after discharge. "The more hospitals realize they're going to be held accountable, that's where they are going to get creative," Patel says.

6. Chocolate consumption and cardiometabolic disorders

Buitrago-Lopez A, et al. Chocolate consumption and cardiometabolic disorders: systematic review and meta-analysis. BMJ 2011; 343:d4488

High levels of chocolate consumption might be associated with a one third reduction in the risk of developing heart disease, according to this systematic review and meta-analysis. The findings confirm results of existing studies that generally agree on a potential beneficial link between chocolate consumption and heart health. However, the authors stress that further studies are needed to test whether chocolate actually causes this reduction or if it can be explained by some other unmeasured (confounding) factor.

Full-text (free):

7. Immediate Complications of IV Contrast for CT Imaging in the Outpatient Setting Are Rare

Mitchell AM, et al. Acad Emerg Med. 2011;18:1005-1009.

Objectives:  Despite increasing attention to the long-term risks of radiation exposure and contrast-induced nephropathy (CIN), institutional guidelines and patient consent procedures for contrast-enhanced computed tomography (CECT) imaging in the emergency department (ED) setting have focused primarily on more immediate complications, directly attributable to the administration of intravenous (IV) iodinated contrast administration. Thus, this study sought to define the risk of these immediate complications with the overall aim of improving institutional guidelines and patient consent procedures.

Methods:  This was a prospective, consecutive cohort study of patients undergoing CECT of any body region in the ED, for complications occurring within 1 week of contrast administration, using predefined implicit definitions. Severe complications were defined as any of the following requiring medical or surgical intervention: bronchospasm with acute respiratory failure, airway obstruction, anaphylactoid shock, or acute pulmonary edema. The development of compartment syndrome, lactic acidosis, or pulmonary edema within 1 week of contrast administration was also considered a severe complication.

Results:  Of 633 patients, only five (0.8%, 95% confidence interval [CI] = 0.3% to 1.8%) reported any immediate complications, all of which were classified as minor. No patient developed a reaction meeting the study definition of a severe complication.

Conclusions:  The frequency of severe, immediate complications from CECT imaging that includes IV contrast is less than 1%, and the frequency of mild complications is less than 2%. The authors conclude that CECT is associated with a very low rate of severe immediate complications.

8. Decision Rule Falls Short in Identifying Children at Low Risk for Pneumonia

Even the lowest-risk group had a 7.6% pneumonia rate.

In a prospective cohort study of 2574 patients (age, below 21 years; median age, 2.3 years) who presented to a tertiary pediatric emergency department and who underwent chest radiography for suspected pneumonia, investigators sought to develop a clinical decision rule for chest radiography.

Overall, 422 patients (16%) had radiographic pneumonia (radiograph suggestive of pneumonia); a subset of 199 patients (8% of the total) had definite pneumonia (radiograph diagnostic for pneumonia). In multivariate analysis, significant predictors of both radiographic pneumonia and definite pneumonia (with odds ratios ranging from 1.37–3.69) were oxygen saturation (O2 sat) 92% at triage, chest pain, focal rales, and O2 sat between 93% and 96% at triage. Wheezing on exam was a significant negative predictor in the entire cohort but not in patients younger than 5 years.

Recursive partitioning stratified patients into risk groups as follows: 20 patients with O2 sat 92%, no wheeze, and focal rales had the highest risk for radiographic pneumonia (pneumonia rate, 70.0%); 38 patients with O2 sat above 92%, no history of fever, no focal decreased breath sounds, and no focal rales were at lowest risk (pneumonia rate, 7.6%). Among patients younger than 5 years, O2 sat 92% at triage was the best predictor of radiographic pneumonia (pneumonia rate 39% vs. 15% for those with O2 sat above 92%); investigators were unable to characterize low-risk characteristics in patients younger than 5.

Comment: Radiation exposure from a single chest x-ray is negligible (0.05–0.10 millisieverts), and missing 7.6% of pediatric pneumonia cases is unacceptable. Unfortunately, this rule misses too many positive cases, and further refinement will be needed before it is a useful clinical tool.

— Katherine Bakes, MD. Published in Journal Watch Emergency Medicine August 26, 2011.
Citation: Neuman MI et al. Prediction of pneumonia in a pediatric emergency department. Pediatrics 2011 Aug; 128:246.

OBJECTIVE: To study the association between historical and physical examination findings and radiographic pneumonia in children who present with suspicion for pneumonia in the emergency department, and to develop a clinical decision rule for the use of chest radiography.

METHODS: We conducted a prospective cohort study in an urban pediatric emergency department of patients younger than 21 who had a chest radiograph performed for suspicion of pneumonia (n = 2574). Pneumonia was categorized into 2 groups on the basis of an attending radiologist interpretation of the chest radiograph: radiographic pneumonia (includes definite and equivocal cases of pneumonia) and definite pneumonia. We estimated a multivariate logistic regression model with pneumonia status as the dependent variable and the historical and physical examination findings as the independent variables. We also performed a recursive partitioning analysis.

RESULTS: Sixteen percent of patients had radiographic pneumonia. History of chest pain, focal rales, duration of fever, and oximetry levels at triage were significant predictors of pneumonia. The presence of tachypnea, retractions, and grunting were not associated with pneumonia. Hypoxia (oxygen saturation ≤92%) was the strongest predictor of pneumonia (odds ratio: 3.6 [95% confidence interval (CI): 2.0-6.8]). Recursive partitioning analysis revealed that among subjects with O(2) saturation above 92%, no history of fever, no focal decreased breath sounds, and no focal rales, the rate of radiographic pneumonia was 7.6% (95% CI: 5.3-10.0) and definite pneumonia was 2.9% (95% CI: 1.4-4.4).

CONCLUSION: Historical and physical examination findings can be used to risk stratify children for risk of radiographic pneumonia.

9. Comparison of Serial Qualitative and Quantitative Assessments of Caval Index and Left Ventricular Systolic Function During Early Fluid Resuscitation of Hypotensive ED Patients

Weekes AJ, et al. Acad Emerg Med. 2011;18:912-921.

Objectives:  The objective was to determine whether serial bedside visual estimates of left ventricular systolic function (LVF) and respiratory variation of the inferior vena cava (IVC) diameter would agree with quantitative measurements of LVF and caval index in hypotensive emergency department (ED) patients during fluid challenges. The authors hypothesized that there would be moderate inter-rater agreement on the visual estimates.

Methods:  This prospective observational study was performed at an urban, regional ED. Patients were eligible for enrollment if they were hypotensive in the ED as defined by a systolic blood pressure (sBP) below 100 mm Hg or mean arterial pressure of ≤65 mm Hg, exhibited signs or symptoms of shock, and the treating physician intended to administer intravenous (IV) fluid boluses for resuscitation. Sonologists performed a sequence of echocardiographic assessments at the beginning, during, and toward the end of fluid challenge. Both caval index and LVF were determined by the sonologist in qualitative then quantitative manners. Deidentified digital video clips of two-dimensional IVC and LVF assessments were later presented, in random order, to an ultrasound (US) fellowship–trained emergency physician using a standardized rating system for review. Statistical analysis included both descriptive statistics and correlation analysis.

Results:  Twenty-four patients were enrolled and yielded 72 caval index and LVF videos that were scored at the bedside prior to any measurements and then reviewed later. Visual estimates of caval index compared to measured caval index yielded a correlation of 0.81 (p below 0.0001). Visual estimates of LVF compared to fractional shortening yielded a correlation of 0.84 (p below 0.0001). Inter-rater agreement of respiratory variation of IVC diameter and LVF scores had simple kappa values of 0.70 (95% confidence interval [CI] = 0.56 to 0.85) and 0.46 (95% CI = 0.29 to 0.63), respectively. Significant differences in mean values between time 0 and time 2 were found for caval index measurements, the visual scores of IVC diameter variation, and both maximum and minimum IVC diameters.

Conclusions:  This study showed that serial visual estimations of the respiratory variation of IVC diameter and LVF agreed with bedside measurements of caval index and LVF during early fluid challenges to symptomatic hypotensive ED patients. There was moderate inter-rater agreement in both visual estimates. In addition, acute volume loading was associated with detectable acute changes in IVC measurements.

10. Another Trial of “Open-Label Placebo”

Placebo Effects and the Common Cold: A Randomized Controlled Trial

Barrett B, et al. Ann Fam Med 2011;9:312-322.

PURPOSE We wanted to determine whether the severity and duration of illness caused by the common cold are influenced by randomized assignment to open-label pills, compared with conventional double-blind allocation to active and placebo pills, compared with no pills at all.

METHODS We undertook a randomized controlled trial among a population with new-onset common cold. Study participants were allocated to 4 parallel groups: (1) those receiving no pills, (2) those blinded to placebo, (3) those blinded to echinacea, and (4) those given open-label echinacea. Primary outcomes were illness duration and area-under-the-curve global severity. Secondary outcomes included neutrophil count and interleukin 8 levels from nasal wash at intake and 2 days later.

RESULTS Of 719 randomized study participants, 2 were lost and 4 exited early. Participants were 64% female, 88% white, and aged 12 to 80 years. Mean illness duration for each group was 7.03 days for those in the no-pill group, 6.87 days for those blinded to placebo, 6.34 days for those blinded to echinacea, and 6.76 days for those in the open-label echinacea group. Mean global severity scores for the 4 groups were no pills, 286; blinded to placebo, 264; blinded to echinacea, 236; and open-label echinacea, 258. Between-group differences were not statistically significant. Comparing the no-pill with blinded to placebo groups, differences (95% confidence interval [CI]) were –0.16 days (95% CI, –0.90 to 0.58 days) for illness duration and –22 severity points (95% CI, –70 to 26 points) for global severity. Comparing the group blinded to echinacea with the open-label echinacea group, differences were 0.42 days (95% CI, –0.28 to 1.12 days) and 22 severity points (95% CI, –19 to 63 points). Median change in interleukin 8 concentration and neutrophil cell count, respectively by group, were 30 pg/mL and 1 cell for the no-pill group, 39 pg/mL and 1 cell for the group binded to placebo, 58 pg/mL and 2 cells for the group blinded to echinacea, and 70 pg/mL and 1 cell for the group with open-label echinacea, also not statistically significant. Among the 120 participants who at intake rated echinacea’s effectiveness as greater than 50 on a 100-point scale for which 100 is extremely effective, illness duration was 2.58 days shorter (95% CI, –4.47 to –0.68 days) in those blinded to placebo rather than no pill, and mean global severity score was 26% lower but not significantly different (–97.0, 95% CI, –249.8 to 55.8 points). In this subgroup, neither duration nor severity differed significantly between the group blinded to echinacea and the open-label echinacea group.

CONCLUSIONS Participants randomized to the no-pill group tended to have longer and more severe illnesses than those who received pills. For the subgroup who believed in echinacea and received pills, illnesses were substantively shorter and less severe, regardless of whether the pills contained echinacea. These findings support the general idea that beliefs and feelings about treatments may be important and perhaps should be taken into consideration when making medical decisions.

11. Unexplained chest pain in the ED: could it be panic?

Foldes-Busque G, et al. Amer J Emerg Med. 2011;29:743-751.

Purpose: This study aimed at (1) establishing the prevalence of paniclike anxiety in emergency department (ED) patients with unexplained chest pain (UCP); (2) describing and comparing the sociodemographic, medical, and psychiatric characteristics of UCP patients with and without paniclike anxiety; and (3) measuring the rate of identification of panic in this population.

Basic Procedure: A structured interview, the Anxiety Disorders Interview Schedule for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, was administered to identify paniclike anxiety and evaluate patients' psychiatric status. Anxious and depressive symptoms were evaluated with self-report questionnaires. Medical information was extracted from patients' medical records.

Main Findings: The prevalence of paniclike anxiety was 44% (95% CI, 40%-48%) in the sample (n = 771). Psychiatric disorders were more common in panic patients (63.4% vs 20.1%), as were suicidal thoughts (21.3% vs 11.3%). Emergency physician diagnosed only 7.4% of panic cases.

Principal Conclusions: Paniclike anxiety is common in ED patients with UCP, and this condition is rarely diagnosed in this population.

12. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: results from the international registry of acute aortic dissection

Rogers AM, et al. Circulation. 2011;123(20):2213-8.

BACKGROUND: In 2010, the American Heart Association and American College of Cardiology released guidelines for the diagnosis and management of patients with thoracic aortic disease, which identified high-risk clinical features to assist in the early detection of acute aortic dissection. The sensitivity of these risk markers has not been validated.

METHODS AND RESULTS: We examined patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2009. The number of patients with confirmed acute aortic dissection who presented with 1 or more of 12 proposed clinical risk markers was determined. An aortic dissection detection (ADD) risk score of 0 to 3 was calculated on the basis of the number of risk categories (high-risk predisposing conditions, high-risk pain features, high-risk examination features) in which patients met criteria. The ADD risk score was tested for sensitivity. Of 2538 patients with acute aortic dissection, 2430 (95.7%) were identified by 1 or more of 12 proposed clinical risk markers. With the use of the ADD risk score, 108 patients (4.3%) were identified as low risk (ADD score 0), 927 patients (36.5%) were intermediate risk (ADD score 1), and 1503 patients (59.2%) were high risk (ADD score 2 or 3). Among 108 patients with no clinical risk markers present (ADD score 0), 72 had chest x-rays recorded, of which 35 (48.6%) demonstrated a widened mediastinum.

CONCLUSIONS: The clinical risk markers proposed in the 2010 thoracic aortic disease guidelines and their application as part of the ADD risk score comprise a highly sensitive clinical tool for the detection of acute aortic dissection.

13. When Doctors Become Patients

By ERIC D. MANHEIMER. New York Times. September 2, 2011

FRANK SINATRA’S greatest hits album, filtered through the jet engine noise of the Varian linear accelerator, was not what I felt like hearing at 9 a.m. I made a mental note to bring a Steely Dan CD for my next appointment.

I was strapped to a hard metal sheet, and the technician had just bolted my head down using a black mask that had been heat-molded to the contours of my face. The sheet and I would slide first up and then back in an overhead arc that would send high-energy electrons into my head and neck from computerized data sets outlining my throat cancer and its spread into adjacent lymph nodes.

I wasn’t a doctor anymore. I was a patient.

That was almost three years ago. This spring, the Archives of Internal Medicine published a much-discussed study that showed that doctors might recommend different treatments for their patients than they would for themselves. They were far more likely to prescribe for patients a potentially life-saving treatment with severe side effects than they were to pick that treatment for themselves.

Understandably, people are worried that this means doctors know something they’re not telling their patients. But my own experience with illness taught me a simpler truth: when it comes to their own health, doctors are as irrational as everyone else.

The remainder of the essay:

14. A Prospective Comparison of Procedural Sedation and Ultrasound-guided Interscalene Nerve Block for Shoulder Reduction in the ED

Blaivas M, et al. Acad Emerg Med. 2011;18:922-927.

Objectives:  Emergency physicians (EPs) are beginning to use ultrasound (US) guidance to perform regional nerve blocks. The primary objective of this study was to compare length of stay (LOS) in patients randomized to US-guided interscalene block or procedural sedation to facilitate reduction of shoulder dislocation in the emergency department (ED). The secondary objectives were to compare one-on-one health care provider time, pain experienced by the patient during reduction, and patient satisfaction between the two groups.

Methods:  This was a prospective, randomized study of patients presenting to the ED with shoulder dislocation. The study was conducted at an academic Level I trauma center ED with an annual census of approximately 80,000. Patients were eligible for the study if they were at least 18 years of age and required reduction of a shoulder dislocation. A convenience sample of patients was randomized to either traditional procedural sedation or US-guided interscalene nerve block. Procedural sedation was performed with etomidate as the sole agent. Interscalene blocks were performed by hospital-credentialed EPs using sterile technique and a SonoSite MicroMaxx US machine with a high-frequency linear array transducer. Categorical variables were evaluated using Fisher’s exact test, and continuous variables were analyzed using the Wilcoxon rank sum test.

Results:  Forty-two patients were enrolled, with 21 patients randomized to each group. The groups were not significantly different with respect to sex or age. The mean (±SD) LOS in the ED was significantly higher in the procedural sedation group (177.3 ± 37.9 min) than in the US-guided interscalene block group (100.3 ± 28.2 minutes; p below 0.0001). The mean (±SD) one-on-one health care provider time was 47.1 (±9.8) minutes for the sedation group and 5 (±0.7) minutes for the US-guided interscalene block group (p below 0.0001). There was no statistically significant difference between the two groups in patient satisfaction or pain experienced during the procedure. There were no significant differences between groups with respect to complications such as hypoxia or hypotension (p = 0.49).

Conclusions:  In this study, patients undergoing shoulder dislocation reduction using US-guided interscalene block spent less time in the ED and required less one-on-one health care provider time compared to those receiving procedural sedation. There was no difference in pain level or satisfaction when compared to procedural sedation patients.

15. Hypothermia Aids Survival After Cardiac Arrest With Non-Shockable Initial Rhythms

By Will Boggs MD. NEW YORK (Reuters Health) Sep 05 - Therapeutic hypothermia (TH) was tied to lower in-hospital mortality in a new meta-analysis of cardiac arrest patients with non-shockable initial rhythms, researchers have found.

"The available evidence indicates that TH is probably beneficial, and certainly not harmful, for promoting survival and neurological recovery of patients with non-ventricular fibrillation (non-VF) rhythms," said senior author Dr. Clifton W. Callaway.

"Given the absence of any other therapies, physicians should use TH in this population," Dr. Callaway, of the University of Pittsburgh, told Reuters Health by email.

The new meta-analysis and systematic review, published online August 9 in Resuscitation, included two randomized trials with 44 patients and 12 nonrandomized trials with 1,292 patients. All patients had return of spontaneous circulation after cardiac arrest with non-shockable initial rhythm.

The two randomized trials showed a 15% improvement in six-month mortality with TH, although the effect was not statistically significant. The one randomized trial that reported neurological outcome showed a nonsignificant improvement of 12% in the TH group.

In 10 nonrandomized trials reporting survival at hospital discharge, TH was associated with a significant 16% reduction in mortality, but the difference in neurological outcome between TH and normothermia did not reach significance.

In subgroup analyses, TH was linked to improved survival after out-of-hospital cardiac arrest, in single center studies, and in prospective studies. The procedure also significantly cut the risk of poor neurological outcome in prospective studies, but not in any of the other subgroups.

Overall, however, the quality of the evidence was very low in both the randomized and nonrandomized trials, Dr. Callaway and his colleagues report.

"TH is a component of a comprehensive package of care for patients after cardiac arrest," he said. "Particularly in observational studies, it is impossible to separate whether any observed benefit resulted from the temperature control or from the associated aspects of care that go along with TH (sedation, monitoring, altered timing for neurological prognostication, blood pressure goals, etc.). While many of us are enthusiastic about TH, researchers in this field recognize the low quality of available data, and are actively trying to create higher levels of evidence."

The authors note that mild TH for 12 to 24 hours after cardiac arrest is now strongly recommended for comatose adult patients with return of spontaneous circulation after out-of-hospital cardiac arrest with ventricular fibrillation.

Nevertheless, there is conflicting evidence even for these patients, with one recent study showing a doubling of survival with TH and another failing to find such an effect (see Reuters Health reports of September 29, 2010, and June 24, 2011.)

"The ideal trial would include a normothermia control group (36-37C) and a hypothermia intervention group (32-34C), and would enroll patients resuscitated from non-VF as well as VF cardiac arrest," Dr. Callaway said. "However, clinicians in North America have reservations about potentially withholding the only promising therapy from patients who would be randomized to a normothermia control group."

Dr. Callaway added, "I am aware that researchers in Sweden do have an ongoing randomized clinical trial that will compare normothermia (36C) to hypothermia (33C) for 24 hours in a cohort of patients. There may be data from that trial in a couple of years."

Kim YM, et al. Resuscitation. 2011 Aug 9. [Epub ahead of print]


16. ED Utilization: Impact of Foreclosure Rates and Health Care Reform

A. Foreclosure Rates Correlated With ED Visits, Hospitalizations

Janet Currie, Erdal Tekin. NBER Working Paper No. 17310. Issued in August 2011

We investigate the relationship between foreclosure activity and the health of residents using zip code level longitudinal data. We focus on Arizona, California, Florida, and New Jersey, four states that have been among the hardest hit by the foreclosure crisis. We combine foreclosure data for 2005 to 2009 from RealtyTrac with data on emergency room visits and hospital discharges. Our zip code level quarterly data allow us to control for many potential confounding factors through the inclusion of fixed effects for each zip code as well as for each combination of county, quarter, and year.

We find that an increase in the number of foreclosures is associated with increases in medical visits for mental health (anxiety and suicide attempts), for preventable conditions (such as hypertension), and for a broad array of physical complaints that are plausibly stress-related. They are not related to visits for cancer morbidity, which arguably should not respond as rapidly to stress. Foreclosures also have a zero or negative effect on elective procedures, as one might expect. Age specific results suggest that the foreclosure crisis is having its most harmful effects on individuals 20 to 49. We also find that larger effects for African-Americans and Hispanics than for whites, consistent with the perception that minorities have been particularly hard hit.

B. Massachusetts' Health Care Reform and ED Utilization

Chen C, et al. N Engl J Med. September 7, 2011

Does an expansion of health insurance increase or decrease use of the emergency department (ED)? Both predictions can be justified logically. On the one hand, research on patient cost sharing predicts that by reducing the out-of-pocket costs of an ED visit, expanded insurance coverage, especially in the face of physician shortages, could result in increased ED utilization.1 This view has been echoed by elected leaders: Senator Jon Kyl (R-AZ), citing the Massachusetts experience with health care reform, claimed that if anything, universal coverage brought even higher rates of emergency room visits due to increased difficulty in getting appointments for outpatient physician visits.2 Others have predicted that expanded coverage would actually reduce ED use, since previously uninsured patients would now have access to preventive care. The relative importance of these countervailing forces is a question that clearly weighs on physicians: in a survey of emergency physicians conducted in April 2010, about 71% said they expected emergency visits to increase after the passage of the Affordable Care Act (ACA).3

To explore the importance of these effects, we examined the Massachusetts experience. The state's 2006 health care reform was a model for the ACA and reduced the proportion of Massachusetts adults under the age of 65 who were uninsured by 7.7 percentage points between the fall of 2006 and the fall of 2009.4 To determine whether any changes in ED utilization in Massachusetts reflected the effect of Massachusetts' reform or were merely representative of broader regional trends in ED utilization, we used New Hampshire and Vermont as control states.

The remainder of the article:

17. Comparison of bedside ultrasound and panorex radiography in the diagnosis of a dental abscess in the ED

Adhikari S, et al. Amer J Emerg Med. 2011;29:790-795.

Objective: The purpose of the study was to compare bedside ultrasound (US) and panorex radiography in the diagnosis of a dental abscess in emergency department (ED).

Methods: A retrospective review of ED records of adult patients with atraumatic facial pain, swelling, and toothache who received a panorex x-ray and bedside US was performed. Medical records were reviewed for ED evaluation and disposition. Sensitivity and specificity of US and panorex x-ray were calculated to determine the clinical utility of the 2 tests.

Results: A total of 19 patients were identified. No periapical abscess was reported on panorex x-rays in 7 (37%) of 19 patients. Ultrasound agreed with panorex x-rays in 6 (86%) of 7 cases. One case where US disagreed with x-rays was evaluated by dentistry consultants; and incision and drainage were performed, confirming the presence of an abscess. An x-ray diagnosis of periapical abscess was made in 12 (63%) of 19 patients. Ultrasound agreed with panorex x-ray in 10 (83%) of 12 cases. In 1 of the 2 cases where US disagreed with panorex x-rays, x-ray abnormalities were reported on the nonsymptomatic side. The other patient was given antibiotics and recommended outpatient follow-up. Follow-up information was not available to further confirm the presence of an abscess. Assuming that the patient who was lost to follow-up had dental abscess, the sensitivity and specificity of US in diagnosing a dental abscess were 92% and 100%, respectively.

Conclusions: Bedside US is nonionizing, is readily available, and can provide an alternative to panorex x-rays in the evaluation of a dental abscess in ED.

18. Aging Gracefully? Patient Safety Advocates Call for Ongoing Skills Assessments for Older Physicians

McKenna M. Ann Emerg Med. 2011;58:A15-A17.

In an era focused on quality measures, it has become common to compare medicine with aviation. The air industry's practices, from checklists during procedures to training exercises for entire teams, seem to offer lessons for medical institutions still struggling with errors and health care–associated infections.

Some patient advocates are asking whether medicine—and especially emergency medicine, a specialty that, like flying, runs on adrenaline and relies on quick decisionmaking—should adopt another aviation practice: a mandatory retirement age.

Advocates are pressing at least for medicine to adopt some standardized means of assessing any age-related decay in physicians' practice skills. The crucial lack, say advocates, is that periodic recertification—which older physicians in some specialties can escape through grandfathering—addresses only didactic knowledge and does not measure clinical expertise.

“The overarching problem in our system is that we don't regularly test the competency of doctors throughout their careers,” said Lisa McGiffert, BA, director of the Safe Patient Project at Consumers' Union. “There has to be some real experience testing—not just pencil and paper knowledge tests, but ability to examine a patient and diagnose a patient.”

“Some people are as good at 80 as they were at 60, no question,” said Diane Pinakiewicz, MBA, executive director of the National Patient Safety Foundation. “But the fact that there is no process to evaluate that, and that it is left to the discretion of the individual to perceive—you don't find that in other industries. We have come a long way in patient-safety work by looking at other industries and learning from them, and we should do that with respect to this issue as well.”

Pilot Performance

In aviation, she offered, pilots undergo ongoing simulator training, as well as periodic observation by another pilot while they are flying an aircraft. Even with those benchmarks, commercial airline pilots must retire from active service by age 65 years.
“I personally feel that [a mandatory retirement age] is something we should be looking at,” Pinakiewicz said. At least, she added, there should be some assessment of a physician's skill by someone other than the physician himself.

“You hear stories of physicians who are well thought of for their clinical skill, who begin a decline due to inevitable aging, and there is no structured way for anyone to deal with that, so that it falls to a brave colleague to try to convince them,” she said. “It is inconceivable to me that in an industry like ours, where the stakes are everything, we do not have any check and balance on this issue.”

A small but consistent body of literature confirms the intuitive assumption that physicians' skills decay as they age.

As far back as 1972, researchers from Johns Hopkins School of Medicine found that primary care physicians with decades in private practice were less likely to prescribe drugs appropriately than physicians who had left training recently.1 In 2000, health care quality analysts at Cornell University found that the risk of death after carotid endarterectomy increased with the surgeon's age.2 In 2002, faculty from McMaster University in Ontario reported that older general-practice physicians scored lower than younger ones on performance assessments that included mock encounters with standardized patients.3 In 2005, Harvard surgeon and author Atul Gawande, MD, MPH, and his collaborators analyzed the results of a multicenter Veterans Administration trial of open versus laparoscopic herniorrhaphies and found that the risk of recurrence was 1.72 times higher for surgeons older than 45 years.4

And a 2005 meta-analysis of 62 studies of physician performance and age or time since licensure found that more than half confirmed the inverse relationship. The longer a physician had been in practice, the worse his or her outcomes were likely to be, and participation in continuing medical education and recertification made no difference to the result.5

An accompanying editorial, written by staff from the American Board of Internal Medicine, called for dramatic changes in professional development requirements. “The profession cannot ignore this striking finding and its implications: Practice does not make perfect, but it must be accompanied by ongoing active effort to maintain competence and quality of care,” they said. “The message is clear for certifying boards (which have the responsibility to ensure the public of the ongoing competence of physicians in their specialty) and medical specialty societies (which have the responsibility to provide relevant and effective continuing education and tools that enable physicians to maintain competence).”6

To be fair, none of the studies that examined the relationship between physician competence and aging looked specifically at emergency physicians. But there seems little reason to believe emergency physicians would be exempt from the effects of aging that have been observed in practitioners from other specialties.

Survey Said

In fact, one survey of emergency physicians, conducted in 2006 to 2007 on behalf of the American College of Emergency Physicians (ACEP) (publisher of Annals of Emergency Medicine) suggests how universal the effects of aging may be. The college sent surveys to a random sample of 1,000 ACEP members who were older than 55 years and received 802 usable replies. Although the respondents saw themselves as competent clinicians experiencing little decline in their procedural skills, the survey also showed that

1. 74% had difficulty recovering from nightshifts;

2. 44% experienced emotional exhaustion at the end of a shift;

3. 40% felt less ability to manage heavy patient volume;

4. 36% reported they were less able to manage the overall stress of emergency medicine;

5. 28% believed their memory was somewhat or considerably worse;

6. 25% believed they were less able to incorporate new diagnosis and treatment modalities into their practice.7

Those percentages were robust enough to provoke action, and the college began drafting guidelines to help older members think about the demands of their practice, as well as to offer resources for questions about finances in relation to approaching retirement.

In a policy statement, posted online in June 2009, the college observed that 30% of its membership was aged 50 years or older and urged “workload modifications” as appropriate. Changes included minimizing rotating shifts, moving older physicians off nightshifts, scheduling additional recovery time after nightshifts, shortening shifts to 8 to 10 hours or less, and encouraging physicians to transition from clinical to administrative work.8

The remainder of the essay (with reference) full-text free:

19. Ultrasound Does Not Detect Early Blood Loss in Healthy Volunteers Donating Blood

Resnick J, et al. J Emerg Med. 2011;41:270-275.

Background: Ultrasound has been suggested as a useful non-invasive tool for the detection of early blood loss. Two possible sonographic markers for hypovolemia are the diameter of the inferior vena cava (IVC) and the thickness of the left ventricle (LV).

Study Objectives: The goal of the study was to evaluate the utility of ultrasound to detect signs of early hemorrhagic shock in healthy volunteers, compared with changes in vital signs.

Methods: In the current study, healthy volunteers from blood donation drives were used as models for early hemorrhage. Changes in vital signs, IVC diameter, and LV wall thickness were recorded after approximately 500 cc of blood loss.

Results: Thirty-eight subjects were enrolled and completed the study. After blood donation, there was a 7-mm Hg (8%) decrease in mean arterial pressure without a significant change in heart rate. There was a decrease in maximum IVC diameter (IVCmax) (12% decrease [95% confidence interval (CI) −6 to −19] in short axis and 20% decrease [95% CI −12 to −27] in long axis), but no change was seen in the respiratory caval index ((IVCmax − IVCmin)/IVCmax) × 100). There was no change in LV wall thickness.

Conclusion: In this study, serial changes in vital signs, IVC diameter, and LV wall thickness were clinically insignificant after approximately 500 cc of blood loss in healthy volunteers.

20. Guess the Uncommon Cause of This Rhythm

Kyuhyun Wang, MD. MedScape Emergency Medicine. 09/08/2011

21. For Physicians: The Perils and Pitfalls of Social Networks

Désirée Lie, MD, MSEd. MD Consult. Posted: 08/26/2011

A Primer for Responsible Social Networking

Consider the following situations:

A. You maintain a personal Facebook account that identifies you by photograph, name, age, and practice status. You use the highest privacy setting. A patient who lives in your neighborhood and whose children go to the same school as yours makes an online request to "friend" you. You Google the patient and find her social contacts and information about her employment and political opinions. How would you respond to her request?

B. You are in private practice and maintain contact with colleagues through online social networks. You notice a recent tweet from a colleague employed by a prominent local hospital asking for advice from psychiatrists about management of an acutely suicidal patient without explicit patient permission. What, if anything, should you do?

These situations raise some key questions. Can physicians, nurses, pharmacists, and other healthcare professionals separate their personal and professional identities online? What are the duties of healthcare providers to maintain the integrity and status of their respective professions when it comes to other clinicians' use of social media?

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