Friday, October 07, 2011

Lit Bits: Oct 7, 2011

From the recent medical literature...

1. Outcomes of patients undergoing early sepsis resuscitation for cryptic shock compared with overt shock.

Puskarich MA, et al. Resuscitation. 2011 Jun 23. [Epub ahead of print]

INTRODUCTION: We sought to compare the outcomes of patients with cryptic versus overt shock treated with an emergency department (ED) based early sepsis resuscitation protocol.

METHODS: Pre-planned secondary analysis of a large, multicenter ED-based randomized controlled trial of early sepsis resuscitation. All subjects were treated with a quantitative resuscitation protocol in the ED targeting 3 physiological variables: central venous pressure, mean arterial pressure and either central venous oxygen saturation or lactate clearance. The study protocol was continued until all endpoints were achieved or a maximum of 6h. Outcomes data of patients who were enrolled with a lactate ≥4mmol/L and normotension (cryptic shock) were compared to those enrolled with sustained hypotension after fluid challenge (overt shock). The primary outcome was in-hospital mortality.

RESULTS: A total of 300 subjects were enrolled, 53 in the cryptic shock group and 247 in the overt shock group. The demographics and baseline characteristics were similar between the groups. The primary endpoint of in-hospital mortality was observed in 11/53 (20%, 95% CI 11-34) in the cryptic shock group and 48/247 (19%, 95% CI 15-25) in the overt shock group, difference of 1% (95% CI -10 to 14; log rank test p=0.81).

CONCLUSION: Severe sepsis with cryptic shock carries a mortality rate not significantly different from that of overt septic shock. These data suggest the need for early aggressive screening for and treatment of patients with an elevated serum lactate in the absence of hypotension.

2. Mandatory Triage Delays Care for High-Acuity Patients

Triage was not completed within the recommended 10 minutes in more than half of high-acuity patients at a single emergency department.

Emergency physicians and nurses rely on triage to sort patients who can wait for care from those who cannot, yet mandatory triage consumes valuable nursing resources and might impede rapid access to care. In a retrospective chart review of all ambulatory patients who presented to a single U.S. academic emergency department (ED) during 2008, researchers assessed compliance with the 5-level Emergency Severity Index (ESI) triage system recommendation that all high-acuity patients (ESI 1 or 2) be treated by a physician within 10 minutes of presentation.

Among 3932 high-acuity ambulatory ED patients (63 ESI 1 and 3869 ESI 2), median time from arrival to completion of triage was 12.3 minutes (range, 0–128 minutes). Triage was completed within 10 minutes in 41% of patients, took more than 20 minutes in 25%, and took more than 30 minutes in 10%. For ESI 2 patients, triage times were significantly longer when presentation was during peak arrival time (10:00 AM to 10:00 PM).

Comment: Although practice should not change on the basis of this small, single-site study, elimination of triage should be strongly considered as part of efforts to decrease unnecessary wait times and to streamline emergency care.

— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine September 16, 2011. Citation: Weber EJ et al. Mandatory triage does not identify high-acuity patients within recommended time frames. Ann Emerg Med 2011 Aug; 58:137.


3. Validation of the Simplified Motor Score in the Out-of-Hospital Setting for the Prediction of Outcomes after Traumatic Brain Injury

Thompson DO, et al. Ann Emerg Med. 2011; in press.

Study objective: The Glasgow Coma Scale (GCS) score is widely used to assess patients with head injury but has been criticized for its complexity and poor interrater reliability. A 3-point Simplified Motor Score (SMS) (defined as obeys commands=2, localizes pain=1, and withdraws to pain or worse=0) was created to address these limitations. Our goal is to validate the SMS in the out-of-hospital setting, with the hypothesis that it is equivalent to the GCS score for discriminating brain injury outcomes.

Methods: This was a secondary analysis of an urban Level I trauma registry. Four outcomes and their composite were studied: emergency tracheal intubation, clinically meaningful brain injury, need for neurosurgical intervention, and mortality. The out-of-hospital GCS score and SMS were evaluated by comparing areas under the receiver operating characteristic curve with a paired nonparametric approach. Multiple imputation was used for missing data. A clinically significant difference in areas under the receiver operating characteristic curve was defined as greater than or equal to 0.05, according to previous literature.

Results: We included 19,408 patients, of whom 18% were tracheally intubated, 18% had brain injuries, 8% required neurosurgical intervention, and 6% died. The difference between the area under the receiver operating characteristic curve for the out-of-hospital GCS score and SMS was 0.05 (95% confidence interval [CI] −0.01 to 0.11) for emergency tracheal intubation, 0.05 (95% CI 0 to 0.09) for brain injury, 0.04 (95% CI −0.01 to 0.09) for neurosurgical intervention, 0.08 (95% CI 0.02 to 0.15) for mortality, and 0.05 (95% CI 0 to 0.10) for the composite outcome.

Conclusion: In this external validation, SMS was similar to the GCS score for predicting outcomes in traumatic brain injury in the out-of-hospital setting.

Accompanying Editorial

Steve Green. Cheerio, Laddie! Bidding Farewell to the Glasgow Coma Scale. Ann Emerg Med. 2011; in press

It is time to abandon the Glasgow Coma Scale (GCS). As discussed below, this ubiquitous neurologic scoring system is confusing, unreliable, and unnecessarily complex, and its manner of common clinical use is statistically unsound.

Teasdale and Jennett devised the GCS in 1974 not for acute care, but rather for the “repeated bedside assessment” in a neurosurgical unit to detect “changing states” of consciousness and to measure the “duration of coma.”1 They never intended for its elements to be assigned numeric scores or for its 3 subscales to be merged or totaled. Yet, despite their objections2 both such dubious modifications subsequently proved irresistible to the medical community.

The quantitative GCS subsequently has become the undisputed universal criterion standard for mental status assessment and is thus a fundamental part of the culture of emergency medicine, out-of-hospital care, trauma surgery, and neurosurgery.3-7 This scale is a core component of prominent trauma and life support courses,4-7 and in most of the developed world out-of-hospital care providers routinely assess the GCS for each patient with trauma or altered mental status.3-5 The original GCS article has been cited almost 6,000 times.

This editorial outlines the potent limitations of the GCS and why it should now be considered obsolete within acute care medicine. This scale might be useful, however, for detecting subtle neurologic changes over time in an ICU (as originally envisaged). Curiously, though, it has never been validated for this separate role.

The advantages of the GCS are that it has face validity, wide acceptance, and established statistical associations with adverse neurologic outcomes, including brain injury, neurosurgical intervention, and mortality.3,8,9 However, these are offset by several important limitations.

The GCS isn’t reliable. To be accurate and useful, a clinical scale must be reproducible. Unfortunately, the GCS contains multiple subjective elements (Figure) and has repeatedly demonstrated surprisingly low interrater reliability in a variety of settings.3,10-18

The remainder of the essay (subscription required):

4. Reperfusion Paradox in STEMI

Armstrong PW, et al. Ann Intern Med. 2011;155:389-391.

The current treatment paradigm for STEMI asserts superior reperfusion with primary percutaneous coronary intervention (PPCI) over fibrinolysis. However, most patients present to non-PPCI hospitals, and many end up not receiving the benefit of pharmacologic reperfusion. This article describes the treatment paradox in which efforts to promote PPCI for acute STEMI often lead to unnecessary avoidance and delay in the use of fibrinolysis. The authors believe that clinicians should embrace an integrated dual reperfusion strategy.


5. A Randomized Clinical Trial Comparing Oral, Aerosolized Intranasal, and Aerosolized Buccal Midazolam

Klein EJ, et al. Ann Emerg Med. 2011;58:323-329.

Study objective: We determine whether aerosolized intranasal or buccal midazolam reduces the distress of pediatric laceration repair compared with oral midazolam.

Methods: Children aged 0.5 to 7 years and needing nonparenteral sedation for laceration repair were randomized to receive oral, aerosolized intranasal, or aerosolized buccal midazolam. Patient distress was rated by blinded review of videotapes, using the Children's Hospital of Eastern Ontario Pain Score. Secondary outcomes included activity scores, sedation adequacy, sedation onset, satisfaction, and adverse events.

Results: For the 169 subjects (median age 3.1 years) evaluated for the primary outcome, we found significantly less distress in the buccal midazolam group compared with the oral route group (P=.04; difference −2; 95% confidence interval −4 to 0) and a corresponding nonsignificant trend for the intranasal route (P=.08; difference −1; 95% confidence interval −3 to 1). Secondary outcomes (177 subjects) favored the intranasal group, including a greater proportion of patients with an optimal activity score (74%), a greater proportion of parents wanting this sedation in the future, and faster sedation onset. Intranasal was the route least tolerated at administration. Adverse events were similar between groups.

Conclusion: When comparing the administration of midazolam by 3 routes to facilitate pediatric laceration repair, we observed slightly less distress in the aerosolized buccal group. The intranasal route demonstrated a greater proportion of patients with optimal activity scores, greater proportions of parents wanting similar sedation in the future, and faster onset but was also the most poorly tolerated at administration. Aerosolized buccal or intranasal midazolam represents an effective and useful alternative to oral midazolam for sedation for laceration repair.

6. Zofran Can Cause Dysrythmias? Darn!

From EP Monthly White Coat Blog September 2011.

FDA: Zofran May Be DEADLY. Get ready for a “black box” warning on Zofran.

The FDA has just issued a “safety alert” stating that Zofran may now be potentially deadly.


The FDA is now recommending ECG monitoring in patients who receive Zofran who have potential “electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia), congestive heart failure, bradyarrhythmias, or in patients taking other medications that can lead to QT prolongation.”

After all, Zofran has now gone generic like previous anti-nausea medications that have also received black box warnings. The FDA approved Zofran for use in 1991, meaning that Zofran has been on the market for twenty years.

Now, through diligent research, the FDA has decided that that Zofran may cause QT prolongation — just like most of the other anti-nausea medications. Cf.

As a result, GlaxoSmithKline has been ordered to perform studies to determine whether Zofran could prolong QT intervals, and, if so, to what extent.

Since the FDA states that it has been performing “ongoing safety studies” … for the past twenty years … why doesn’t the FDA actually publish the results of those safety studies that led to the posting of its alarming “safety notice”?

Now we have one less medication in our armamentarium to treat nausea and vomiting. I suppose we can always give ginger root until that gets a black box warning, too. It’s only been around for a few centuries.

Whoa. I think that my heart just skipped a beat. Reading FDA safety notices may have caused me to have QT prolongation. I think that we need to put black box warnings on FDA safety notices and no one should read them without proper EKG monitoring.

[Speaking of nausea, have you heard of the Barf Scale? Some call it the eighth vital sign…]

7. Development and validation of a pictorial nausea rating scale for children.

Baxter AL, et al. Pediatrics. 2011;127(6):e1542-9.

Laurie Barclay, MD. Medscape News. June 1, 2011 — A pictorial scale to measure the severity of pediatric nausea can detect change after treatment, according to the results of a study reported in the June issue of Pediatrics.

"A simple, reliable, validated pictorial scale for measuring nausea in children may help in its management," write Amy L. Baxter, MD, from Medical College of Georgia and Pediatric Emergency Medicine Associates in Atlanta, and colleagues. "Current pictorial scales for nausea have limited construct and convergent validity and may lack specificity in the presence of pain.... The goal of this study was to create and validate a pictorial scale with regular incremental levels between scores depicting increasing nausea intensity."

A total of 30 oncology patients and 15 nurses developed the Baxter Retching Faces (BARF) scale, a pictorial nausea scale with 6 faces scored from 0 to 10. The BARF scale was validated in 52 emergency department patients with vomiting and in 75 healthy patients undergoing day surgery procedures (age range, 7 - 18 years). Patients were presented with visual analog scales (VAS) for nausea and pain, the pictorial Faces Pain Scale–Revised (FPS-R), and the BARF scale. Patients receiving opioid analgesics or antiemetic medications were evaluated for pain and nausea before treatment and 30 minutes after treatment. Spearman ρ correlation coefficients were calculated, and a Wilcoxon matched-pair rank test was used to compare pain and nausea scores before and after antiemetic medications were received.

The Spearman ρ correlation coefficient was 0.93 for the first paired BARF and VAS for nausea scores. Patients requiring antiemetic medications had significantly higher VAS scores for nausea and BARF scores (P = .20), and these scores decreased significantly after treatment. In contrast, posttreatment pain scores (P = .47) did not decrease in patients receiving only antiemetic medications.

"We describe the development of a pictorial scale with beginning evidence of construct validity for a self-report assessment of the severity of pediatric nausea," the study authors write. "The scale had convergent and discriminant validity, along with an ability to detect change after treatment.... Its use in the clinical and research setting may assist in nausea management in children."

Limitations of this study include those involving use of the VAS as a comparator for pediatric nausea. In addition, the study was limited to a 2-center, single-country, English-speaking population.

"Future studies need to be performed to determine if there are age, gender, culture, ethnic, or language variations in the validation of the BARF scale," the study authors conclude. "Patient preferences of the BARF scale compared with the VAS or a global rating of change need to be determined, along with the minimum clinically important difference in BARF scores."


8. Mandatory HPV Vaccination and Political Debate

Lawrence O. Gostin, JD. JAMA. Published online October 6, 2011.

Vaccinations are among the most cost-effective and widely used public health interventions but have provoked popular resistance, with compulsory vaccination framed as an unwarranted state interference. When the US Food and Drug Administration (FDA) approved a human papillomavirus (HPV) vaccine in 2006, conservative religious groups strongly opposed a mandate, arguing it would condone premarital sex and undermine parental rights. Yet Governor Rick Perry signed an executive order in 2007 making Texas the first state to enact a mandate—later revoked by the state legislature.

Mandatory HPV vaccination received additional attention during a recent debate among Republican presidential candidates. Michele Bachmann, US representative from Minnesota, Rick Santorum, former US senator from Pennsylvania, and Governor Perry had spirited exchanges about the executive order that Perry issued in 2007. Bachmann called the vaccine “a dangerous drug” and Santorum added, “There is no government purpose served for having little girls inoculated at the force and compulsion of the government.” Perry almost immediately disavowed his action, saying first that the vehicle of an executive order was wrong and then that vaccination should be “opt-in.”1

Comments such as these could cause parents to decide not to have their children vaccinated, thereby potentially leading to preventable illness and perhaps even death. The scientific evidence demonstrates that population-based HPV vaccination is safe and effective, justifying widespread adoption of the vaccine. The question is whether a state mandate would increase vaccination rates or result in a backlash not only against HPV vaccination but also wider childhood vaccinations. Given the political divisiveness, states should launch health education campaigns before resorting to compulsion.

HPV Vaccine Effectiveness and Safety

Human papillomavirus infection and HPV-associated cancers pose a major public health threat. Human papillomavirus is the most common sexually transmitted infection in the United States, with an estimated 20 million individuals currently infected and 6.2 million newly infected annually.2 The HPV prevalence among girls and women is 26.8% overall, with increasing prevalence each year from ages 14 to 24 years (44.8% for ages 20-24 years), followed by a gradual decline through age 59 years; high-risk HPV types are detected in only 3.4% of women tested.2

Nononcogenic HPV types 6 and 11 are associated with genital warts and recurrent respiratory papillomatosis. High-risk HPV types are detected in virtually all cervical, vaginal, and vulvar cancers in women, and HPV types 16 and 18 are associated with 70% of cervical cancers. Each year, more than 12 000 new cervical cancer cases are diagnosed in the United States, with more than 4000 deaths from cervical cancer occurring annually.3 Human papillomavirus also is associated with cancer of the penis, as well as cancers of the oropharynx and anus in both women and men. Persons with lower education and higher poverty experience disproportionate burdens of HPV-associated cancers.

In June 2006, the FDA licensed a prophylactic quadrivalent HPV vaccine against HPV types 6, 11, 16, and 18 for use among girls and women aged 9 to 26 years.4 In October 2009, the FDA approved a bivalent vaccine against HPV types 16 and 18.5 The Advisory Committee on Immunization Practices (ACIP) recommends routine quadrivalent or bivalent vaccination of girls aged 11 or 12 years with 3 doses that can start at age 9 years. The ACIP recommends “catch-up” vaccination for girls and women aged 13 to 26 years who have not been previously vaccinated. Quadrivalent HPV vaccine may be given to boys and men aged 9 to 26 years.6 Ideally, vaccination should begin before sexual activity.

Numerous public health organizations including the Centers for Disease Control and Prevention, the American Academy of Pediatrics, and the American Academy of Family Physicians endorse HPV vaccination for young women…

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

9. Apixaban versus Warfarin in Patients with Atrial Fibrillation

Granger CB, et al. N Engl J Med 2011; 365:981-992

Background: Vitamin K antagonists are highly effective in preventing stroke in patients with atrial fibrillation but have several limitations. Apixaban is a novel oral direct factor Xa inhibitor that has been shown to reduce the risk of stroke in a similar population in comparison with aspirin.

Methods: In this randomized, double-blind trial, we compared apixaban (at a dose of 5 mg twice daily) with warfarin (target international normalized ratio, 2.0 to 3.0) in 18,201 patients with atrial fibrillation and at least one additional risk factor for stroke. The primary outcome was ischemic or hemorrhagic stroke or systemic embolism. The trial was designed to test for noninferiority, with key secondary objectives of testing for superiority with respect to the primary outcome and to the rates of major bleeding and death from any cause.

Results: The median duration of follow-up was 1.8 years. The rate of the primary outcome was 1.27% per year in the apixaban group, as compared with 1.60% per year in the warfarin group (hazard ratio with apixaban, 0.79; 95% confidence interval [CI], 0.66 to 0.95; P less than 0.001 for noninferiority; P=0.01 for superiority). The rate of major bleeding was 2.13% per year in the apixaban group, as compared with 3.09% per year in the warfarin group (hazard ratio, 0.69; 95% CI, 0.60 to 0.80; P less than 0.001), and the rates of death from any cause were 3.52% and 3.94%, respectively (hazard ratio, 0.89; 95% CI, 0.80 to 0.99; P=0.047). The rate of hemorrhagic stroke was 0.24% per year in the apixaban group, as compared with 0.47% per year in the warfarin group (hazard ratio, 0.51; 95% CI, 0.35 to 0.75; P less than 0.001), and the rate of ischemic or uncertain type of stroke was 0.97% per year in the apixaban group and 1.05% per year in the warfarin group (hazard ratio, 0.92; 95% CI, 0.74 to 1.13; P=0.42).

Conclusions: In patients with atrial fibrillation, apixaban was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding, and resulted in lower mortality

10. Rapid Rehydration in the ED Effective for Children

Tinker Ready and Jacqueline A. Hart, MD. September 26, 2011 — A 4-hour rehydration technique for children with gastroenteritis worked just as well as a 24-hour inpatient approach, according to a study published online September 26 in Pediatrics.

Researchers at the Royal Children's Hospital in Melbourne, Australia, led by Colin V.E. Powell, MD, FRACP, FRCPCH, screened more than 9000 children with acute gastroenteritis who arrived at 2 metropolitan teaching pediatric hospital emergency departments (EDs). Of the children screened, who ranged in age from 6 months to 6 years, 254 were randomly assigned to receive either standard nasogastric rehydration over the course of 24 hours in the hospital (n = 122) or treatment with rapid nasogastric rehydration (RNR) over the course of 4 hours in the ED (n = 132).

The researchers defined viral gastroenteritis as the sudden onset of nonbloody diarrhea with 2 loose stools in a 24-hour period, with or without vomiting, and lasting for a full week. Only children with moderate dehydration were included in the study.

Primary failure rates, defined as more than 2% weight loss during the rehydration period, were similar for RNR (11.8%; 95% confidence interval [CI], 6.0% - 17.6%) and standard nasogastric rehydration (9.2%; 95% CI, 3.7% - 14.7%; P = .52). Secondary treatment failure, defined as the inability to tolerate a nasogastric tube, frequent or persistent vomiting, need for intravenous rehydration, 3 clinical signs of continued moderate dehydration, a need for nasogastric fluids beyond 24 hours in the standard group, or impending circulatory collapse, was more common in the standard treatment group (44%; 95% CI, 34.6% - 53.4%) than in the RNR group (30.3%; 95% CI, 22.5% - 38.8%; P = .03).

Despite RNR, 22.7% of those treated in the ED were admitted to the hospital, and 7.6% were readmitted to the hospital within 24 hours.

"Primary treatment failure and clinical outcomes were similar for RNR and [standard nasogastric rehydration]," the authors concluded. "Although RNR generally reduced the need for hospitalization, discharge home from the ED failed for approximately one-fourth of the patients."

All of the children recovered without complications. The researchers note that although the sample size was too small for a noninferiority analysis, the findings did suggest that RNR in the ED offers "a useful alternative to 24-hour nasogastric rehydration in the inpatient setting."

The study has several additional limitations, including lack of blinding and that only the rehydration schedule was controlled; the remainder of the clinical decisions were left to the treating medical team.

Compared with intravenous rehydration, oral rehydration therapy is less likely to result in complications such as electrolyte imbalances, cerebral edema, or phlebitis, the researchers write. "Therefore, [oral rehydration therapy] is recommended as the treatment of choice for children with acute gastroenteritis and moderate dehydration."

They researchers point out that "[s]ince the introduction of a rotavirus vaccine, rates of hospitalization for treatment of acute gastroenteritis have decreased in many developed countries." However, in the developing world, "dehydration secondary to viral gastroenteritis remains a major cause of morbidity and death."

The study was supported by a clinical research grant from the Department of Human Services, Government of Victoria, Australia. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online September 26, 2011. Abstract:

11. Mortality Does Not Increase with Time from Shock Diagnosis to Antibiotic Administration

But, patients who received antibiotics before shock criteria developed fared better than those who received them after.

Puskarich MA, et al. Crit Care Med. 2011 Sep;39(9):2066-2071.

OBJECTIVE: We sought to determine the association between time to initial antibiotics and mortality of patients with septic shock treated with an emergency department-based early resuscitation protocol.

DESIGN: Preplanned analysis of a multicenter randomized controlled trial of early sepsis resuscitation.

SETTING: Three urban U.S. emergency departments.

PATIENTS: Adult patients with septic shock.

INTERVENTIONS: A quantitative resuscitation protocol in the emergency department targeting three physiological variables: central venous pressure, mean arterial pressure, and either central venous oxygen saturation or lactate clearance. The study protocol was continued until all end points were achieved or a maximum of 6 hrs.

MEASUREMENTS AND MAIN RESULTS: Data on patients who received an initial dose of antibiotics after presentation to the emergency department were categorized based on both time from triage and time from shock recognition to initiation of antibiotics. The primary outcome was inhospital mortality. Of 291 included patients, mortality did not change with hourly delays in antibiotic administration up to 6 hrs after triage: 1 hr (odds ratio [OR], 1.2; 0.6-2.5), 2 hrs (OR, 0.71; 0.4-1.3), 3 hrs (OR, 0.59; 0.3-1.3). Mortality was significantly increased in patients who received initial antibiotics after shock recognition (n = 172 [59%]) compared with before shock recognition (OR, 2.4; 1.1-4.5); however, among patients who received antibiotics after shock recognition, mortality did not change with hourly delays in antibiotic administration.

CONCLUSION: In this large, prospective study of emergency department patients with septic shock, we found no increase in mortality with each hour delay to administration of antibiotics after triage. However, delay in antibiotics until after shock recognition was associated with increased mortality.

12. Do Mechanism-of-Injury Triage Criteria Predict Need for Trauma Center?

Some currently used criteria, including vehicle rollover and motor vehicle crash speed over 40 mph, are poor predictors.

Only anatomical and physiological criteria are validated indications for transport to a trauma center, but many systems also use mechanism of injury (MOI) criteria, which are largely based on expert consensus opinion. In a prospective observational 2-year study, investigators assessed the predictive value of MOI criteria in a convenience sample of 9483 adults who presented to three level I regional trauma centers directly from the scene of injury and who did not meet physiological or anatomical criteria. The trauma centers were primary receiving centers for patients with traumatic injuries, regardless of whether they met criteria for trauma-center transport.

Of 2363 patients who were transported to a trauma center on the basis of MOI criteria, 204 (9%) were considered in retrospect to need a trauma center (defined as nonorthopedic surgery within 24 hours, intensive care unit admission, or in-hospital death). Of the 7120 patients who did not meet MOI criteria, 310 (4%) were considered to need a trauma center. Death of another vehicle occupant, fall greater than 20 feet, and motor vehicle crash (MVC) extrication time above 20 minutes were good predictors of need for trauma center (positive likelihood ratio over 5); intrusion beyond 12 inches, ejection from a vehicle, and vehicle deformity more than 20 inches were moderate predictors (LRs 2–5); and MVC at greater than 40 mph, motorcycle crash at greater than 20 mph, vehicle rollover, rider separated from motorcycle, and pedestrian or bicyclist thrown, run over, or struck at speed above 5 mph were poor predictors of need for trauma center (LR 2).

Comment: Use of mechanism-of-injury criteria alone results in dramatic overtriage to trauma centers. Systems should rely on validated physiological and anatomical criteria to determine transport destination for trauma patients. For patients who do not meet physiological or anatomical criteria, death of another vehicle occupant, fall more than 20 feet, and extrication time greater than 20 minutes might predict need for trauma center.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine September 23, 2011. Citation: Lerner EB et al. Does mechanism of injury predict trauma center need? Prehosp Emerg Care 2011 Oct/Dec; 15:518.


13. Synopsis of the NIH and Clinical Excellence Guideline for Management of Transient Loss of Consciousness

Cooper PN, et al. Ann Intern Med. 2011; published online September 19, 2011

Description: Transient loss of consciousness (TLoC) is common and often leads to incorrect diagnosis, unnecessary investigation, or inappropriate choice of specialist referral. In August 2010, the National Institute for Health and Clinical Excellence published a guideline that addressed the initial assessment of and most appropriate specialist referral for persons who have experienced TLoC. The guideline focused on correct diagnosis and relevant specialist referral and did not make treatment recommendations. This synopsis describes the principal recommendations concerning assessment and referral of a patient with TLoC.

Methods: The National Clinical Guideline Centre developed the guidelines by using the standard methodology of the National Institute for Health and Clinical Excellence. A multidisciplinary guideline panel generated review questions, discussed evidence, and formulated recommendations. The panel included a technical team from the National Clinical Guideline Centre, who reviewed and graded all relevant evidence identified from literature searches published in English up to November 2009 and performed health-economic modeling. Both guideline development and final modifications were informed by comments from stakeholders and the public.

Recommendations: The panel made clear recommendations regarding the assessment of a person after TLoC, which emphasized the importance of clinical reasoning in diagnosis. Persons with uncomplicated faint, situational syncope, or orthostatic hypotension should receive electrocardiography but do not otherwise require immediate further investigation or specialist referral. Persons with features that suggest epilepsy should be referred for specialist neurologic assessment; brief seizure activity was recognized as a common occurrence during syncope that should not be regarded as indicating epilepsy. Persons with a suspected cardiac cause for TLoC or in whom TLoC is unexplained after initial assessment should receive specialist cardiovascular assessment. Guidance was provided on the appropriate choices of cardiovascular investigation, according to the presenting clinical circumstances.

Full-text (free):

The full version of the guideline is available on the NICE Web site at

14. Clinical Decision Rules for Excluding PE: A Meta-analysis

Lucassen W, et al. Ann Intern Med. 2011;155:448-460.

Background: Clinical probability assessment is combined with d-dimer testing to exclude pulmonary embolism (PE).

Purpose: To compare the test characteristics of gestalt (a physician's unstructured estimate) and clinical decision rules for evaluating adults with suspected PE and assess the failure rate of gestalt and rules when used in combination with d-dimer testing.

Data Sources: Articles in MEDLINE and EMBASE in English, French, German, Italian, Spanish, or Dutch that were published between 1966 and June 2011.

Study Selection: 3 reviewers, working in pairs, selected prospective studies in consecutive patients suspected of having PE. Studies had to estimate the probability of PE by using gestalt or a decision rule and verify the diagnosis by using an appropriate reference standard.

Data Extraction: Data on study characteristics, test performance, and prevalence were extracted. Reviewers constructed 2 × 2 tables and assessed the methodological quality of the studies.

Data Synthesis: 52 studies, comprising 55 268 patients, were selected. Meta-analysis was performed on studies that used gestalt (15 studies; sensitivity, 0.85; specificity, 0.51), the Wells rule with a cutoff value less than 2 (19 studies; sensitivity, 0.84; specificity, 0.58) or 4 or less (11 studies; sensitivity, 0.60; specificity, 0.80), the Geneva rule (5 studies; sensitivity, 0.84; specificity, 0.50), and the revised Geneva rule (4 studies; sensitivity, 0.91; specificity, 0.37). An increased prevalence of PE was associated with higher sensitivity and lower specificity. Combining a decision rule or gestalt with d-dimer testing seemed safe for all strategies, except when the less-sensitive Wells rule (cutoff value ≤4) was combined with less-sensitive qualitative d-dimer testing.

Limitations: Studies had substantial heterogeneity due to prevalence of PE and differences in threshold. Many studies (63%) had potential bias due to differential disease verification.

Conclusion: Clinical decision rules and gestalt can safely exclude PE when combined with sensitive d-dimer testing. The authors recommend standardized rules because gestalt has lower specificity, but the choice of a particular rule and d-dimer test depend on both prevalence and setting.

15. The Sonographic Ottawa Foot and Ankle Rules Study (the SOFAR Study)

Canagasabey MD, et al. Emerg Med J 2011;28:838-840.

Introduction: Foot and ankle injuries are common in the Emergency Department (ED). Of those requiring radiographs in accordance with the Ottawa Foot and Ankle Rules, approximately 22% have a fracture. Ultrasound is developing as a tool for emergency musculoskeletal assessment—it is inexpensive and rapid, and visualises soft tissue and bony structures.

Methods: This diagnostic cohort study examined if ultrasound could detect acute bony foot and ankle injuries. Ottawa Rules-positive patients over 16 years were eligible. An ultrasound scan (USS) was performed blind to radiograph findings by an ED member. Patient management was according to radiograph. Significant fractures were defined as per the Ottawa Foot and Ankle Rules study group. All radiographic reporting was conducted blind to USS findings. All USS operators received specific 2-day training in musculoskeletal ultrasound.

Results: 110 subjects were recruited. 11 had significant radiological fractures, and 10 were seen on ultrasound. The single missed fracture arose due to the operator not scanning proximally enough on the fibula. On rescanning following radiograph review, the fracture was clearly seen. The sensitivity of USS is 90.9% (95% CI 65.7 to 98.3), and the specificity is 90.9% (95% CI 88.1 to 91.7). The positive predictive value is 0.526 (95% CI 0.380 to 0.569). The negative predictive value is 0.989 (95% CI 0.959 to 0.998). The positive likelihood ratio is 10.00 (95% CI 5.526 to 11.901), and the negative likelihood ratio is 0.100 (95% CI 0.018 to 0.389).

Conclusion: This pilot study demonstrates that ultrasound shows great promise for the sensitive detection of foot and ankle fractures, thus identifying patients who require radiographic evaluation more efficiently.

16. Images in Medicine

Abdominal Lump in an Old Woman

Young Man With Skin Discoloration

Elderly Male With Mesogastric Pain

Ectopic Tooth in the Maxillary Sinus

Orbital and Cerebral Arteriovenous Malformations

Porphyria Cutanea Tarda

Patent Urachus

17. Lit Reviews in EM, Courtesy of Ann Emerg Med

A. Are Tissue Adhesives an Acceptable Alternative for Simple Lacerations?

Emergency physicians should incorporate the use of tissue adhesives for simple laceration repairs. Compared with standard wound closure, they result in equivalent cosmesis, less pain, and more rapid wound closure.

Full-text (free):

B. Can a Negative D-dimer Result Rule Out Acute Aortic Dissection?


Full-text (free):

18. Contagion, the Movie: An Expert Medical Review

Paul A. Offit, MD. Medscape Infectious Disease. 09/13/2011

Medscape Editor's Note:
We thought that Medscape readers would be interested in hearing from one of our infectious disease experts about the medical aspects of the movie Contagion. So often, science is trumped by drama in popular movies -- but not this time, says Paul A. Offit, MD, a vaccine coinventor in real life. The movie was filmed in part at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, so we also provide links to stories about the work being done at CDC every day.

Hi. My name is Paul Offit, and I'm talking to you today from the Vaccine Education Center at the Children's Hospital of Philadelphia. I thought it might be fun to talk about a movie that I saw this weekend, Steven Soderbergh's Contagion. This movie deals with a pandemic-like influenza virus to which no one in the population has been previously exposed and which has the potential to do a tremendous amount of harm. It was an interesting movie. Typically when movies take on science, they tend to sacrifice the science in favor of drama. That wasn't true here.

The moviemakers did a very good job of illustrating how Southeast Asia can essentially serve as a "genetic reassortment laboratory" with influenza strains being created as a combination event among strains from pigs and chickens (and in this case, bats) to create a strain that the population has never seen before. They do a very good job of explaining that possibility and in showing how easy the virus can spread from one person to another. In fact, in bringing up the concept of contagiousness as "R0," they compare the R0 of influenza, polio, and smallpox. It's very interesting that they were willing to spend time explaining what contagiousness means.

They also do an excellent job of describing the phenomenon of fomites -- that one can, in fact, transmit microorganisms very easily by shaking a hand or touching a martini glass or a door handle. The camera lingered on these different items to the point that it essentially becomes a commercial for hand sanitizer (which they actually show at one point during the movie).

They discuss how difficult it is to try and stop this virus. The heroes of the story are vaccines. In discussing how they would go about making a vaccine, they make a distinction between a whole kill virus and a live attenuated vaccine. They show how the CDC, through active case hunting, can actually figure out exactly how this virus was generated and collaborate with academia -- in this case, a virologist in California named Sussman, played by Elliott Gould. You have to be able to imagine Elliott Gould as a virologist, but if you can, it really is a nice touch, showing how he is the first to be able to grow the virus in cell culture, allowing a vaccine to be made.

The movie then explores the difficulties in trying to decide who can get vaccine, given that the supply is limited. These are all the issues that we faced when we talked about the possibility of how devastating the most recent swine flu pandemic could be. The movie is quite accurate as it portrays how society breaks down in the face of potentially millions of deaths caused by limited vaccine and limited food supplies. It's really well done.

The movie also shows the antiscience forces. In this case, it's in the person of the appropriately named Alan Krumwiede, who is played by Jude Law. Krumwiede is a paranoid conspiracy theorist who believes that this is all just a government plot, and he is very antiscience. He has created a treatment (that he has taken himself), called Forsythia, a homeopathic remedy, which obviously is of no value because it is simply something diluted to the point that it's not there anymore. He claims that he has been treated by this product, even though he was actually never sickened by the virus. The movie demonstrates the impact of the Internet. In this case, Krumwiede has a blog called "Truth Serum Now" that creates -- or feeds into -- a lot of mistrust in the general population.

In Contagion, Dr. Sanjay Gupta interviews a CDC official played by Laurence Fishburne, and he gives Krumwiede equal time. It's interesting that what the conspiracy theorist talks about is people. Krumwiede confronts Fishburne with questions such as "What did you know?" and "When did you know it?" when, in fact, the issues are "How can we identify this virus?," "How can we make a vaccine against it?," and "How can we prevent its spread?" It's an issue of science, not an issue of people. But in this movie, Sanjay Gupta, playing himself, makes it an issue about people -- another example of art imitating life, because Gupta has been perfectly willing to allow antivaccine celebrities to be on his show. In another interesting example of art imitating life, Jude Law [reportedly] actually believes in homeopathy.

In summary, Contagion is an excellent movie in that it is willing to allow science to prevail over drama. It is quite well done, so I recommend it. Thank you.

See also: CDC: Contagion Movie: Fact and Fiction in Film

19. Comparison of Aerobic Versus Resistance Exercise Training Effects on Metabolic Syndrome

Bateman LA, et al. Amer J Cardiol 2011;108:838-844.

Aerobic training (AT) improves the metabolic syndrome (MS) and its component risk factors; however, to our knowledge, no randomized clinical studies have addressed whether resistance training (RT) improves the MS when performed alone or combined with AT. Sedentary, overweight dyslipidemic men and women, aged 18 to 70 years completed a 4-month inactive run-in period and were randomized to 1 of 3 eight-month exercise programs (n = 196). The exercise programs were (1) RT (3 days/week, 3 sets/day of 8 to 12 repetitions of 8 different exercises targeting all major muscle groups); (2) AT (∼120 minutes/week at 75% of the maximum oxygen uptake), and (3) AT and RT combined (AT/RT) (exact combination of AT and RT).

Of the 196 randomized patients, 144 completed 1 of the 3 exercise programs. The 86 participants with complete data for all 5 MS criteria were used in the present analysis, and a continuous MS z score was calculated. Eight months of RT did not change the MS score. AT improved the MS score (p less than 0.07) and showed a trend toward significance compared to RT (p less than 0.10). AT/RT significantly decreased the MS score and was significantly different from RT alone. In conclusion, RT was not effective at improving the MS score; however, AT was effective. Combined AT and RT was similarly effective but not different from AT alone. When weighing the time commitment versus health benefit, the data suggest that AT alone was the most efficient mode of exercise for improving cardiometabolic health.

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20. New AAP Guidelines for Diagnosis and Management of Febrile UTI in Infants and Young Children

These recommendations outline a systematic approach to diagnosis and management that minimizes harm, maximizes benefit, and optimizes use of labs and procedures.

Diagnosis and management of urinary tract infection (UTI) in febrile infants are challenging for several reasons: Obtaining a sterile urine sample requires either inserting a urethral catheter or performing a suprapubic aspirate, both the route and duration of antibiotics are not standardized, and follow-up evaluation often includes voiding cystourethrography (VCUG) that involves irradiation of the pelvis. The American Academy of Pediatrics Subcommittee on UTI extensively reviewed studies published during the past 10 years on UTI in young children and developed sensible, updated evidence-based guidelines to direct practitioners in the diagnosis and management of febrile UTI in children aged 2 to 24 months. The seven key action statements are as follows:


1. If a febrile patient with no known source of fever is deemed ill enough to require immediate antibiotic therapy, obtain urine culture by either catheterization or suprapubic aspiration before initiating treatment.

2. Assess the likelihood of UTI. Risk factors for UTI are female sex, not being circumcised, no other source of fever, and fever 39°C. Additional risk factors in girls are white race, age below 12 months, and fever for beyond 2 days. Additional risk factors in boys are nonblack race and fever for 24 hours.
• Low-risk patients can be followed clinically without urine evaluation.
• In patients who are not low risk, obtain a urine culture by either catheterization or suprapubic aspiration for urinalysis and culture, or obtain a urine specimen for urinalysis followed by culture if positive.

3. Establish UTI diagnosis. Diagnosis requires both abnormal urinalysis (pyuria, bacteriuria, or both) and urine culture with more than 50,000 CFU/mL of a urinary pathogen.


4. Oral therapy and parenteral therapy are both efficacious, and decisions should be based on practical considerations (e.g., the patient's ability to take oral medication). Adjust antibiotics according to sensitivity patterns. Minimal duration of therapy is 7 days. No differences in efficacy have been documented among 7-, 10-, and 14-day regimens.

5. Evaluation after a first febrile UTI should include renal and bladder ultrasound. Increasing evidence indicates that antibiotic prophylaxis for low-grade reflux does not improve outcomes. Therefore, routine VCUG is not recommended after a first UTI.

6. VCUG should be performed in patients with a first UTI only if ultrasound suggests high-grade vesicoureteral reflux. VCUG is indicated for recurrent febrile UTI.

7. Following a confirmation of UTI, physicians should instruct parents to seek prompt care for future unexplained febrile illness.

Comment: In the era of conjugated vaccines for Haemophilus influenzae and Streptococcus pneumoniae, bacteria that cause UTI have become one of the most common causes of serious bacterial infection in infants aged 2 to 24 months. This extremely clear document outlines a systematic approach to diagnosis and management that minimizes harm, maximizes benefit, and optimizes the use of lab tests and procedures in patients who are most likely to receive benefit.

— Peggy Sue Weintrub, MD. Published in Journal Watch Pediatrics and Adolescent Medicine September 21, 2011

Citation: Subcommittee on Urinary Tract Infection. Urinary tract infection: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011 Sep; 128:595.

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21. Too Many Tasks

Dustin Ballard, MD, MBE. Chair, KP CREST Network. Monday, September 19, 2011.

I’m sitting down to write on an important topic. “I should check my email. Right, where was I?” An important topic for students, parents, professionals, and, well, just about everyone. “Who’s texting me? Oh shoot; I need to finish that Amazon order. I forgot to call the plumber. And the dog needs to go out. Did I feed my daughter’s Brazilian water frog? I should check my email.” Wait, focus. Important topic. Interesting topic. And it’s critical that everyone understand the limitations and risks associated with it. “I really should check my email.” Multi... "must check email!” …Tasking.

Like many people in our digitalized and sensory-loaded world, I’m a fervent multi-tasker. Email, bills, scheduling, patient-care, child-care, pet-care, Twitter-care, fantasy sports; I can do it all. And I can do it all at the same time! At least so I thought. “Just checked my email for the fourth time this paragraph. My wife wants to know if we can go to a school fundraiser tonight. My boss is trying to schedule a tennis match. I wonder which QBs are available on the cbsportsline waiver wire? Expedia has a new fare alert for me. $299 bucks to fly to Omaha! Sweet.” Contrary to the ethos I’ve prided myself on, in a world of information overload, constant data processing can actually ‘smog,’ ‘asphyxiate,’ and starve away productive time. In fact, multi-tasking may threaten efficiency more than aid it.

Skeptical? Well, stay with me here (your stock portfolio and Facebook newsfeed can wait), and consider evidence from cognitive testing. Researchers looking at individuals performing two or more tasks at once have found that, quite consistently, people complete tasks faster if they do them serially (one, then the other) rather than in parallel (start one, start the other, back to the first, and so on). In fact, loss of efficiency has been estimated to be around half-a-second per task switch and up to twice the sum of the time needed to complete two tasks in order. So, for example, if it takes me two minutes to check and respond to my email and three minutes to order a new mattress online, it would take me up to ten minutes to do the two tasks ‘at the same time’ (switching back and forth between tasks with a delay with each switch). But if I did the tasks serially (i.e. focusing on one task and completing it before moving on to the next), the two tasks should take me only five minutes.

Now, as we all know, multi-tasking is more or less a fact of life. Most of us are forced to multi-task some or all of the time, both at work and at home. A busy shift in the Emergency Department (ED) is an excellent example of this, and one that I’m quite familiar with. I spend my days talking with patients, performing physical exams, entering orders, documenting, calling consultants, communicating with nursing and other personnel, performing procedures, making referrals, all while trying not to neglect an important task like prescribing the correct medication. Studies of ED physicians demonstrate that their tasks will be interrupted four to fourteen times per hour, or every four minutes or so. An observational study of nurses reported that ED nurses (at work) multitask 34% of the time. Each and every single one of the interruptions that ED providers experience could have disastrous consequences. (This is why we have developed safety mechanisms like timeouts and checklists.)

But of course, some multi-tasking is unavoidable. Our patients surely appreciate that we break away from a routine task, like charting, to tackle another more critical task, such as providing acute resuscitation. And, keep in mind that some ‘multitasking’ is not harmful. For some people, listening to music while driving or studying is not really multi-tasking at all but rather a multi-sensory approach to a task. This habit may or may not affect efficiency and performance. People are (according to cognitive studies) able to train themselves to block out distractions when performing an assignment. Note that I say ‘distractions’ and not tasks. Tasks, especially ones that require working memory - very short term memory designed to aid in completion of short term tasks - will be more efficiently completed in order and cannot be blocked out as part of a multisensory approach. Working memory is ephemeral and highly sensitive to interruptions. We all experience this as those ‘I lost my train of thought’ moments.

Can you minimize brain stalls and achieve a healthy level of multi-tasking? Maybe, but first you have to set aside dedicated time to think, focus, and plan. Creativity benefits from focus and people who have planned or rehearsed tasks beforehand are less likely to suffer delays. Here’s another tip: try to resist over-dosing on jolts of satisfaction (‘dopamine squirts’) associated with compulsive behavior – like checking email every 2.4 minutes. And when possible, finish what you started - NOW – rather than deferring it to the ‘later’ bucket. Working memory is temporary and what may seem unforgettable right now is actually quite forgettable in 15 minutes. Finally, experiment with focus adjuncts – meditation or paying attention to your breathing may help, as might noise-erasing headphones (which, my wife lovingly has dubbed ‘wife- and kid-erasers’). Of course, a lot of the modern world cannot be easily ‘noise-erased,’ but if you make an effort to slow down, especially with important endeavors, your reward, ultimately, will be higher efficiency and fewer mistakes.

Well, phew, I’ve made it through this task. Hope you did too. “How many unread emails do I have? That frog must be absolutely starving.” Now, if you’ll excuse me, I’ve got a few other things to do…

From his blog: