Lit Bits: March 28, 2012

From the recent medical literature...

1. Effect of computerized clinical decision support on the use and yield of CT pulmonary angiography in the ED.

Raja AS, et al. Radiology. 2012 Feb;262(2):468-74.

INTRO: As part of the Health Information Technology for Economic and Clinical Health Act (1), the Department of Health and Human Services meaningful use criteria for the use of electronic health records require the implementation of at least one clinical decision support (CDS) tool (2). CDS has been shown to decrease the volume of imaging orders in certain clinical contexts (3). In addition, it has been proposed that implementation of CDS can increase the appropriateness of imaging (4).

Given that the use of emergency department (ED) computed tomographic (CT) pulmonary angiography for the diagnosis of pulmonary embolism (PE) is increasing (a recent study [5] found that the number of ED CT pulmonary angiograms of the chest at one large academic institution increased fivefold from 2001 to 2007) and that evidence-based guidelines for imaging patients suspected of having PE exist (6), it may be an excellent target for evaluating the impact of CDS. If suboptimal use of CT pulmonary angiography for the evaluation of PE in the ED exists, then integrating CDS for CT pulmonary angiography into a computerized physician order entry system has the potential to increase quality and appropriateness of ED imaging while decreasing potentially unnecessary examinations.

CDS: The CDS consisted of three rules. The first rule required that ordering clinicians choose both a d-dimer level (elevated, normal, or not evaluated) and the clinical suspicion of PE (high, intermediate, or low). The second rule displayed advice in patients with an intermediate or low level of suspicion in whom a d-dimer assay was not performed (“measuring a d-dimer value in patients with a low and/or intermediate clinical suspicion of PE is an appropriate first step in the work-up of acute PE and will exclude the need for CT pulmonary angiography in some patients”). The third rule displayed a second piece of advice in patients with a normal d-dimer level and intermediate or low suspicion for PE (“based on current evidence as well as our experience at Brigham and Women’s Hospital, diagnosing an acute PE with CT pulmonary angiography in low- or intermediate-risk patients with a normal d-dimer level is extremely unlikely”) (Fig 1). At each stage, clinicians could either cancel the imaging order or ignore the advice (Fig 2).

PURPOSE: To determine the effect of evidence-based clinical decision support (CDS) on the use and yield of computed tomographic (CT) pulmonary angiography for acute pulmonary embolism (PE) in the emergency department (ED).

MATERIALS AND METHODS: Institutional review board approval was obtained for this HIPAA-compliant study, which was performed between October 1, 2003, and September 30, 2009, at a 793-bed quaternary care institution with 60,000 annual ED visits. Use (number of examinations per 1000 ED visits) and yield (percentage of examinations positive for acute PE) of CT pulmonary angiography were compared before and after CDS implementation in August 2007. The authors included all adult patients presenting to the ED and developed and validated a natural language processing tool to identify acute PE diagnoses. Linear trend analysis was used to assess for variation in CT pulmonary angiography use. Logistic regression was used to determine variation in yield after controlling for patient demographic and clinical characteristics.

RESULTS: Of 338,230 patients presenting to the ED, 6838 (2.0%) underwent CT pulmonary angiography. Quarterly CT pulmonary angiography use increased 82.1% before CDS implementation, from 14.5 to 26.4 examinations per 1000 patients (P less than .0001) between October 10, 2003, and July 31, 2007. After CDS implementation, quarterly use decreased 20.1%, from 26.4 to 21.1 examinations per 1000 patients between August 1, 2007, and September 30, 2009 (P=.0379). Overall, 686 (10.0%) of the CT pulmonary angiographic examinations performed during the 6-year period were positive for PE; subsequent to CDS implementation, yield by quarter increased 69.0%, from 5.8% to 9.8% (P=.0323).

CONCLUSION: Implementation of evidence-based CDS in the ED was associated with a significant decrease in use, and increase in yield, of CT pulmonary angiography for the evaluation of acute PE.

2. Lung-Protective Ventilation Linked to Improved Survival

Steven Fox. Medscape Medical News. March 27, 2012 — Reducing breath size and pressure settings for mechanical ventilators used in intensive care units can substantially improve long-term survival in patients with acute lung injury (ACI), according to results from the most comprehensive study to date evaluating the long-term effects of mechanical ventilation on patients with ACI.

The prospective cohort study was conducted by Dale Needham, MD, associate professor, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues. The study was published online March 27 in the British Medical Journal.

"Average tidal volume showed a linear relation with two year survival, such that even a relatively small decrease in average tidal volume over stay in the intensive care unit was independently associated with an important decrease in risk of mortality," the authors write. "Greater use of lung protective ventilation in routine clinical practice could reduce long-term mortality in patients with acute lung injury."

Previous studies have shown that using volume-limited and pressure-limited mechanical ventilation (so-called lung-protective ventilation) in patients with acute lung injury can significantly reduce short-term mortality. One earlier randomized trial found that using such an approach resulted in an absolute 8.8% reduction in short-term mortality. http://www.nejm.org/doi/full/10.1056/NEJM200005043421801

Recommended settings for lung-protective ventilation can be found on the National Heart, Lung, and Blood Institute's Acute Respiratory Distress Syndrome Network (ARDS) Web site. http://www.ardsnet.org/system/files/6mlcardsmall_2008update_final_JULY2008.pdf

In the current study, Dr. Needham and colleagues wanted to find out whether similarly favorable results could be obtained during the longer term.

They studied 2-year survival rates in 485 consecutive mechanically ventilated patients with acute lung injury who were treated in the intensive care units of 4 hospitals in Baltimore. Data on the 485 patients included 6240 ventilator settings, as measured twice each day, for a median of 8 ventilator settings per patient.

A ventilator setting was considered adherent to lung-protective ventilation if it satisfied 2 criteria:
• It had a tidal volume equal to or less than 6.5 mL/kg of predicted body weight, which is the threshold used in a seminal study of reduced tidal volumes that was conducted by ARDS to designate study sites' adherence to the goal tidal volume of 6.0 mL/kg predicted body weight.
• The setting had a plateau pressure equal to or less than 30 cm of water, which was based on documentation of respiratory therapy. When pressure-regulated modes of ventilation were used, in which plateau pressure is not measured, the researchers used peak pressure or the sum of positive end expiratory pressure and the prescribed increment in inspiratory pressure.

Dr. Needham and colleagues report that only 41% of the more than 6200 total ventilator settings adhered to recommended settings for lung-protective ventilation. About 37% of patients never received lung-protective ventilation, the researchers say.

Of the 485 patients included in the study, 311 (64%) died within 2 years, the authors say. For each 1 mL/kg predicted body weight increase in average tidal volume, there was an associated 18% increase in risk for death during the subsequent 2 years.

Further, after adjusting for the total length of time patients were on ventilation, along with other relevant factors, each additional ventilator setting that was adherent to lung-protective ventilation was associated with a 3% decrease in the risk for mortality over 2 years (hazard ratio, 0.97; 95% confidence interval [CI], 0.95 - 0.99; P = .002), the authors note.

When those figures were compared with no adherence, the authors add, estimated absolute risk reduction in mortality for a typical patient with 50% adherence to lung-protective ventilation was 4.0% (95% CI, 0.8% - 7.2%; P = .012). With full, 100% adherence, risks were reduced even further, by 7.8% (95% CI, 1.6% - 14.0%; P = .011).

The authors stress that settings for ventilators should be based on patients' height, sex, and predicted weight, rather than their actual weight, because lung size remains essentially the same, regardless of how much a patient weighs, the researchers say.

Limitations include that the study is observational and lacked, at times, measurement or recording of plateau pressures.

"Given the study's findings that patients with acute lung injury often did not receive lung protective ventilation, greater efforts to implement lung protective ventilation in routine clinical practice should be undertaken to reduce patients' long term mortality," the authors conclude.

The study was supported by the National Institutes of Health, and 1 author received a clinician-scientist award from the Canadian Institutes of Health Research. The authors have disclosed no relevant financial relationships.

BMJ. Published online March 27, 2012

3. TNKase Tops Activase for Ischemic Stroke for Select Patients

By Michael Smith, MedPage Today. Published: March 21, 2012

A genetically engineered clot-buster improved clinical outcomes compared with standard thrombolytic therapy in a selected population of people with ischemic strokes, researchers reported.

In an open-label phase IIb randomized trial, tenecteplase (TNKase) also did better than alteplase (Activase) in re-establishing blood flow to the affected brain regions, according to Mark Parsons, MD, of John Hunter Hospital in Newcastle, Australia, and colleagues.

Both drugs were equally safe, Parsons and colleagues reported in the March 22 issue of the New England Journal of Medicine.

Alteplase, a recombinant tissue plasminogen activator, is the only thrombolytic drug approved for stroke, the researchers noted, but it is known for "incomplete and often delayed" reperfusion.

Tenecteplase, a genetically engineered mutant tissue plasminogen activator, is approved to treat heart attack but not stroke, but Parsons and colleagues argued it might have some pharmacokinetic advantages over the older drug that could translate into better outcomes, including better reperfusion.

To test the hypothesis, they conducted a trial in a group of stroke patients who were selected by CT imaging as being likely to benefit from early reperfusion -- those with large-vessel occlusion and a large perfusion lesion but not a large infarct core.

All told, 75 patients were randomized between 2008 and 2011 to standard treatment with alteplase or to one of two doses of tenecteplase, 0.1 or 0.25 mg/kg to a maximum dose of 10 or 25 mg, respectively.

The standard dose of alteplase is 0.9 mg/kg, with the first 10% in an initial bolus and the rest given over a one-hour period, to a maximum of 90 mg. Tenecteplase, in contrast, is given as a single bolus.

The primary outcomes were the proportion of the perfusion lesion that had blood flow re-established after 24 hours, as seen by magnetic resonance imaging, and the extent of clinical improvement at 24 hours, assessed on the National Institutes of Health Stroke Scale.

Among other things, the researchers also looked for major neurologic improvement at 24 hours, defined as a reduction from baseline of 8 or more points on the 42-point stroke scale, and excellent or good recovery at 90 days, defined as a modified Rankin score of 0, 1, or 2.

Parsons and colleagues found that the average baseline stroke scale score was 14.4 and the average time to treatment was 2.9 hours.

When researchers combined both tenecteplase groups, they found that these patients had significantly greater reperfusion (P=0.004) than those getting alteplase. The average proportion of the lesion that was reperfused with tenecteplase was 79.3%, compared with 55.4% for alteplase.

The tenecteplase patients also had significantly greater clinical improvement at 24 hours, with an average improvement on the stroke scale of 8 points compared with 3 for the alteplase patients.

At 90 days, 11 alteplase patients and 36 tenecteplase patients had an excellent or good recovery (P=0.02).

The investigators reported that the higher dose of tenecteplase was superior to the lower dose and to alteplase for all efficacy outcomes. In addition, they observed no significant between-group differences in intracranial bleeding or other serious adverse events.

The researchers cautioned that the results can't be applied directly to the usual group of stroke patients eligible for thrombolysis, since patients in this trial were selected as being most likely to benefit from thrombolytic therapy.

Nonetheless, they concluded, the results support a broader phase III trial, using the higher dose of tenecteplase.

The study was supported by the Australian National Health and Medical Research Council. Parsons reported financial links with Bayer Australia.

Parsons M, et al. N Engl J Med 2012; 366: 1099-1107. Abstract: http://www.nejm.org/doi/full/10.1056/NEJMoa1109842

4. Prehospital Epinephrine for Cardiac Arrest Reduces Survival and Worsens Neurological Outcomes at 1 Month

A large observational study places added scrutiny on the use of epinephrine for out-of-hospital cardiac arrest.

A recent prospective, randomized, placebo-controlled trial of epinephrine for out-of-hospital cardiac arrest demonstrated that epinephrine increased the rate of return of spontaneous circulation but had no effect on survival to hospital discharge (http://emergency-medicine.jwatch.org/cgi/content/full/2011/1014/1). However, that study was underpowered.

Researchers in Japan conducted a prospective observational propensity analysis of data for 417,188 out-of-hospital cardiac arrests in patients aged 18 years (mean age, 72) who were treated by emergency medical services and transported to a hospital from 2005 through 2008.

The odds of return of spontaneous circulation prior to hospital arrival were significantly higher in patients who received epinephrine in the field than in those who did not (adjusted odds ratio, 2.36). However, at 1 month, patients who received epinephrine had significantly lower odds of survival (AOR, 0.46); good or moderate cerebral performance (AOR, 0.31); and no, mild, or moderate neurological disability (AOR, 0.32).

Comment: Epinephrine is thought to increase aortic and coronary artery perfusion pressure, but this might occur at the expense of other organs and systems, including the heart and cerebral microcirculation. This large study, one of few to look at long-term outcomes, demonstrates that epinephrine might provide a short-term advantage for return of spontaneous circulation but a negative effect on 1-month survival and neurological outcomes. Unfortunately, care subsequent to the prehospital phase was neither standardized nor studied. An editorialist calls for a randomized, controlled, adequately powered study to determine whether and under what circumstances epinephrine should be administered to patients with out-of-hospital cardiac arrest.
— John A. Marx, MD, FAAEM

Published in Journal Watch Emergency Medicine March 23, 2012.

Citation: Hagihara A et al. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA 2012 Mar 21; 307:1161.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22436956

Associated Medscape essay: http://www.medscape.com/viewarticle/760612

5. Prospective study of the frequency and outcomes of patients with suspected PE administered heparin prior to confirmatory imaging.

Kline JA, et al. Thromb Res. 2012 Apr;129(4):e25-8.

OBJECTIVES: The administration of empiric systemic anticoagulation (ESA) before confirmatory radiographic testing in patients with suspected pulmonary embolism (PE) may improve outcomes, but no data have been published regarding current practice. We describe the use of ESA in a large prospective cohort of emergency department (ED) patients and report the outcomes of those treated with ESA compared with patients not receiving ESA.

METHODS: 12-center, noninterventional study of ED patients who presented with symptoms concerning for PE. Clinical data including pretest probability and decision to start ESA were recorded at point of care by attending physicians. Patients were followed for adverse in-hospital outcomes and recurrence of venous thromboembolism.

RESULTS: ESA was initiated 342/7932 (4.3%) of enrolled patients, including 142/618 (23%) patients with high pretest probability. Patients receiving ESA had more abnormal vital signs and were more likely to have a history of venous thromboembolism than those who did not receive ESA. Overall, 481/7,932 (6.1%) had PE diagnosed, 72/481 (15.0%) with PE had ESA, and 72/342 (21%) of ESA patients had PE. Three patients (0.9%, 95%CI: 0.2-2.5%) who received ESA suffered hemorrhagic complications compared with 38 patients (0.5%, 95%CI: 0.4-0.7%) who did not receive ESA.

CONCLUSIONS: In this multicenter sample, ED physicians administered ESA to a small, generally more acutely ill subset of patients with high pretest probability of PE, and very few had hemorrhagic complications. ESA was not associated with any clear difference in outcomes. More study is needed to clarify the risk versus benefit of ESA.

6. Asthma Improves When Triage Nurses Give Corticosteroids

Joe Barber Jr, PhD. From Medscape Medical News. March 19, 2012 — Corticosteroid initiation before physician assessment is associated with improved quality and efficiency of care in the emergency department (ED) for children with asthma, according to the findings of a time-series controlled trial.

Roger Zemek, MD, from the Children's Hospital of Eastern Ontario in Ottawa, Canada, and colleagues published their findings in the April issue of Pediatrics.

Although the benefits of early corticosteroid administration have been demonstrated, the authors note that their administration is less than optimal. "Improving efficiency in asthma management is an essential element of relieving ED overcrowding, attributable in part to suboptimal flow, because asthma is the most prevalent childhood chronic disease requiring ED visits," the authors write. "Despite evidence supporting their need, physicians underprescribe corticosteroids for children, and delays to administration remain long."

Among the 644 eligible participants (nurse-initiated phase, 336 children; physician-initiated phase, 308 children) with moderate to severe asthma, children in the nurse-initiated phase exhibited clinical improvement (defined as a reduction in the Preschool Respiratory Assessment Measure (PRAM) score ≥ 3) a median of 24 minutes (95% confidence interval [CI], 1 - 50 minutes; P = .04) earlier than those in the physician-initiated phase (158 minutes [interquartile range, 139 - 177 minutes] vs 182 minutes [interquartile range, 168 - 202 minutes]; P = .04).

The authors included children aged 2 to 17 years who had moderate to severe asthma exacerbation (defined as a PRAM score ≥ 4). The participants were divided into 2 groups: nurse-initiated and physician-initiated phases. The 2 groups were sampled consecutively for 4 months, with a 1-month training period separating the 2 phases.

The primary outcome measure was time to clinical improvement, and the secondary outcome measures were total time in the ED, time to mild status, and return ED visit within the next 7 days. Children with PRAM scores of 4 to 7 received 3 salbutamol treatments via metered-dose inhalation, whereas those with PRAM scores of 8 or higher received 3 salbutamol plus ipratropium bromide nebulizations for the first hour, followed by hourly salbutamol treatment as needed.

Nurse-initiated corticosteroid administration was also associated with decreases in the admission rate (adjusted odds ratio, 0.54; 95% CI, 0.34 - 0.86; P = .01), time to corticosteroid receipt (adjusted hazard ratio [HR], 2.40; 95% CI, 2.03 - 2.83; P less than .001), time to mild status (adjusted HR, 1.24; 95% CI, 1.03 - 1.48; P = .02), and time to discharge (adjusted HR, 1.22; 95% CI, 1.03 - 1.45; P = .02). No significant differences were found in the characteristics of the 2 groups in terms of age, sex, vital signs, or medical history, although children in the physician-initiated phase were more likely to have a documented upper respiratory tract infection preceding this hospital visit.

The exclusion criteria included the presence of chronic lung disease; chronic cardiac, metabolic, or neurological disorders; and contraindication or hypersensitivity to any of the study medications. Limitations of the study included a lack of randomization, the sampling period, and other confounders related to the seasonal variability between the phases.

The authors suggest that their findings, if implemented, could improve the treatment of asthma in the ED. "Widely adopted, this strategy could optimize the function of multidisciplinary teams and have a significant impact on the burden of asthma in EDs," the authors write.

Martin Pusic, MD, from the Columbia University Medical Center in New York City, agrees that earlier treatment would be beneficial for patients. "We know that steroids work, and that it takes 4 hours for them to [be absorbed]," Dr. Pusic told Medscape Medical News. "Earlier administration leads to earlier effectiveness."

One coauthor received honoraria and/or educational grants from AstraZeneca Canada, Merck Frosst Canada, and Nycomed Canada. The other authors and the commentator have disclosed no relevant financial relationships.

Pediatrics. 2012;129:671-680. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22430452

7. Rocuronium and Succinylcholine Are Equally Effective at Doses of 1 mg/kg or greater

No significant differences in intubation time, conditions, or success rates were noted.

This author conducted a structured literature review of studies that compared succinylcholine and rocuronium at doses 1 mg/kg to determine whether the two agents are similarly effective in providing optimal conditions for emergency intubation. Of seven papers that were considered relevant, three were conducted in the emergency department (ED) setting, and one was a Cochrane review.

A prospective cohort analysis of 578 ED patients showed that succinylcholine provided paralysis 5 seconds earlier than rocuronium (the difference was not considered clinically relevant), and the two agents produced similar intubating conditions. A retrospective study of 327 ED patients showed no significant difference in first-attempt intubation success between the two agents (JW Emerg Med Feb 18 2011). The Cochrane review found no difference between the two agents in producing excellent or acceptable intubating conditions. The remaining four studies, which were conducted in the surgery setting, had similar findings.

Comment: Succinylcholine and rocuronium at ED-appropriate doses (above 1 mg/kg) produce virtually identical intubating conditions. At these doses, however, rocuronium paralysis lasts up to 45 minutes, versus 6 to 10 minutes for succinylcholine. Assessing a patient for a possible difficult airway and preparing a backup airway are essential in all intubations.

— Diane M. Birnbaumer, MD, FACEP. Published in Journal Watch Emergency Medicine March 16, 2012

Citation: Herbstritt A. BET 3: Is rocuronium as effective as succinylcholine at facilitating laryngoscopy during rapid sequence intubation? Emerg Med J 2012 Mar; 29:256.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22337834

8. ROMICAT II: CT-First ACS Strategy Matches Current Practice

Reed Miller. Heartwire. March 27, 2012 (Chicago, Illinois) — The coronary computed-tomography angiography (CCTA)-based strategy for screening chest-pain patients in the emergency department is safe and reduces overall patient time in the hospital but costs about the same overall as the current standard approach, the Rule Out Myocardial Infarction Using Computer Assisted Tomography II (ROMICAT II) results show.

Dr Udo Hoffman (Massachusetts General Hospital, Boston) presented results of the randomized ROMICAT II trial today at the American College of Cardiology (ACC) 2012 Scientific Sessions. The study randomized 1000 chest-pain patients with suspected acute coronary syndrome on a 1:1 ratio to either a CCTA screening approach or standard care left to the discretion of the physician.

The average time to diagnosis was 10.4 hours in the CCTA group and 18.7 hours in the control group (p=0.001). By reducing the time to diagnosis in the patients who were not suffering ACS, the CCTA-first approach reduced chest-pain patients' average hospital stay from about 31 hours to 23 hours (p=0.0002) compared with the standard approach. About half the chest-pain patients scanned with CCTA to rule out possible noncardiac causes of their chest pain were safely discharged from the hospital within nine hours of arriving at the emergency department. Only 15% of patients receiving standard care were in and out that fast. The hospital stay for patients with ACS was about 3.5 days in both groups.

Patients in the CCTA group were much more likely to be discharged directly from the emergency department (46.7% vs 12.4%), but only slightly less likely to be admitted to the hospital (25.4% vs 31.7%). About half the patients in the control group were moved to an observation unit, compared with about a quarter of the CCTA patients.

The safety of the CCTA-based approach was comparable to that of the standard approach. There were no missed ACS cases in either group, and major adverse events within 30 days were statistically similar in both the CCTA and standard-care groups (0.4 and 1.0, p=0.37). Results of the ACRIN-PA study, presented earlier at the ACC meeting, also affirmed the safety and low-miss rate of the CCTA-first approach.

ROMICAT II also shows that the CCTA-first strategy cost about the same overall as the standard approach. The CCTA-first approach cost about 19% less per patient than the standard approach, but hospital costs were about 50% more with the CCTA approach, apparently because CCTA patients underwent more angiography (12% vs 8%, p=0.04) and a statistically insignificant greater number of coronary interventions--either percutaneous intervention or bypass surgery (6.4% vs. 4.2%, p=0.16).

If it doesn't reduce cost, how is it better?

Dr Ray Gibbons (Mayo Clinic, Rochester, MN) argues that, viewed in the context of the current healthcare-cost crisis in the US, the data do not show that the CCTA-first approach is better than the standard approach to screening potential ACS patients who come to the emergency room.

The difference in total hospital admissions--about 25% vs 32%--is probably not significant. The ROMICAT-II investigators "chose to analyze it in terms of direct discharge, but I think that's more of a matter of semantics," Gibbons told heartwire in an interview. "Will a patient really see it as different having a CCTA and being discharged vs going down the hall [to the chest-pain unit] for a few hours? Is that a big difference? I don't think so. . . . As for time in the emergency department? I'd view that as secondary.

"If the patients went home directly from the emergency department more often, which is what they should do, why aren't the costs different?" he asked. In the ROMICAT II data, the answer appears to be that the minor differences in percutaneous-intervention and bypass-surgery rates between the two groups drive more costs, he said. And, he added, the revascularization rates shown in ROMICAT-II are relatively low. Gibbons believes that if the CCTA-first strategy were tried across the country, it would be associated with much greater costs than the standard-screening approach in many areas where hospitals revascularize a much higher portion of the chest-pain patients that present to the emergency department than the centers in ROMICAT-II.

"If the outcomes are equivalent, you should try to reduce total costs, and that should be the primary goal," Gibbons said. "I know that in some areas of the country that emergency-department overcrowding is an issue, but that pales in comparison to what is happening to Medicare and the total healthcare costs in this country."

Gibbons said that Medicare data show that increased utilization of CCTA screening leads to higher revascularization rates, and "I'm very worried about the impact of CCTA on revascularization rates, because these are [often] revascularizations of low value."

Getting patients out of the emergency room faster will not save nearly as much money as keeping the very low-risk patients from ever coming to the emergency department, Gibbons said. So a next step in the effort to cut costs in ACS treatment should be to develop tools to better screen the calls of worried patients who believe they might be suffering an ACS and encourage the very low-risk patients to see their cardiologist or general practitioner rather than come to the emergency department.

9. Safety and Efficiency of a CP Diagnostic Algorithm with Selective Outpatient Stress Testing for ED Patients with Potential Ischemic CP

Scheuermeyer FX, et al. Ann Emerg Med 2012;59:256-264.e3.

Study objective: Chest pain units have been used to monitor and investigate emergency department (ED) patients with potential ischemic chest pain to reduce the possibility of missed acute coronary syndrome. We seek to optimize the use of hospital resources by implementing a chest pain diagnostic algorithm.

Methods: This was a prospective cohort study of ED patients with potential ischemic chest pain. High-risk patients were referred to cardiology, and patients without ECG or biomarker evidence of ischemia were discharged home after 2 to 6 hours of observation. Emergency physicians scheduled discharged patients for outpatient stress ECGs or radionuclide scans at the hospital within 48 hours. Patients with positive provocative test results were immediately referred back to the ED. The primary outcome was the rate of missed diagnosis of acute coronary syndrome at 30 days.

Results: We prospectively followed 1,116 consecutive patients who went through the chest pain diagnostic algorithm, of whom 197 (17.7%) were admitted at the index visit and 254 (22.8%) received outpatient testing on discharge. The 30-day acute coronary syndrome event rate was 10.8%, and the 30-day missed acute coronary syndrome rate was 0% (95% confidence interval 0% to 2.4%). Of the 120 acute coronary syndrome cases, 99 (82.5%) were diagnosed at the index ED visit, and 21 patients (17.5%) received the diagnosis during outpatient stress testing.

Conclusion: In ED patients with chest pain, a structured diagnostic approach with time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appears both safe and diagnostically efficient, even though some patients with acute coronary syndrome may be discharged for outpatient stress testing on the index ED visit.

10. Look for Warning Signs of Sudden Death in Kids

By Nancy Walsh, Staff Writer, MedPage Today. Published: March 26, 2012

Awareness of warning signs and family history are crucial for the prevention of sudden cardiac arrest in young people, according to a new policy statement from the American Academy of Pediatrics.

Pediatric sudden cardiac arrest can be lethal within minutes if unrecognized and untreated, and some 2,000 related deaths are thought to occur in the U.S. each year, according to the statement, which was published online ahead of print in the April issue of Pediatrics.

"Although [sudden cardiac arrest] may be the sentinel event, symptoms in patients with structural-functional or primary electrical disorders may, in fact, be relatively common," the statement reads.

Symptoms can include chest pain, dizziness, exercise-induced syncope, and dyspnea, which may have been disregarded by the patient and family; a detailed history also may reveal the sudden, unexplained death of a young relative.

In fact, estimates suggest these warning signs may be present in up to half of cases of sudden cardiac arrest in children.

The most common underlying causes of sudden cardiac arrest in this age group are structural or functional disorders such as hypertrophic cardiomyopathy and coronary artery anomalies, and primary cardiac electrical disorders such as familial long QT syndrome and Wolff-Parkinson-White syndrome.

The most frequent immediate event is a ventricular tachyarrhythmia, the statement authors noted.

Some types of arrhythmias, such as torsades de pointes, can be transient and may appear similar to seizures, which highlights the importance of accurate diagnosis.

The statement recommends that clinicians recognize the warning signs and symptoms of sudden cardiac arrest, including those that may incorrectly be attributed to noncardiac diseases and, thus, delay correct diagnosis.

For example, if the patient is thought to be experiencing a seizure, the likely referral may be to a neurologist, which could delay the diagnosis -- with potentially disastrous results.

Similarly, if dyspnea is the presenting symptom, the workup may focus on a respiratory etiology, so a lack of response to initial treatment should trigger a reconsideration of potential cardiac causes, they suggested.

The statement also addressed the issue of screening young athletes before permitting sports participation.

A variety of risk-assessment tools have been used, and although these have not been validated or assessed for sensitivity or specificity, expert opinion currently emphasizes the importance of these "ominous" findings on a preparticipation screen:
• A history of fainting or having a seizure, especially during exercise
• Past episodes of chest pain or shortness of breath with exercise
• A family member with unexpected sudden death or a condition such as hypertrophic cardiomyopathy or Brugada syndrome

The academy also considered the role of ECG screening for young athletes and referred to earlier American Heart Association guidelines that did not endorse widespread use of this test, citing the possibilities of false-positive and false-negative results, cost, and medicolegal problems.

"Wide-scale ECG screening would require a major infrastructure enhancement not currently available in the U.S.," the statement pointed out, and called for additional data and debate on the subject.

Another recommendation was regarding the "molecular autopsy," which would include a postmortem genetic analysis aimed at detecting cardiac channel abnormalities in any child with sudden cardiac death. This currently is primarily a research tool, but could provide valuable information to survivors.

As to secondary prevention of sudden death following an episode of cardiac arrest, the authors of the statement acknowledged that identification, treatment, and appropriate activity restriction can't be successful in every case.

They therefore recommended extensive placement of automated external defibrillators in schools, along with cardiopulmonary resuscitation training of staff and others.

The statement also argued in favor of the establishment of a central registry for pediatric sudden cardiac arrest.

Other groups that have endorsed the statement include the American Heart Association, the American College of Cardiology, and the Heart Rhythm Society.

American Academy of Pediatrics "Pediatric sudden cardiac arrest" Pediatrics 2012; DOI: 10.1542/peds.2012-0144.

Full-text (free) as pdf: http://pediatrics.aappublications.org/content/early/2012/03/21/peds.2012-0144.full.pdf+html

11. Images in Clinical Medicine

Barium Aspiration (I hope you haven’t seen this!)
http://www.nejm.org/doi/full/10.1056/NEJMicm1108468

Westermark Sign in Pulmonary Embolism
http://www.nejm.org/doi/full/10.1056/NEJMicm1107936

Hemotympanum
http://www.nejm.org/doi/full/10.1056/NEJMicm1110484

Eruptive Xanthoma
http://www.nejm.org/doi/full/10.1056/NEJMicm1105301

Spider Angioma
http://www.nejm.org/doi/full/10.1056/NEJMicm1109272

Sigmoid Perforation in Association with Colonoscopy
http://www.nejm.org/doi/full/10.1056/NEJMicm1106348

Kerion Celsi
http://www.nejm.org/doi/full/10.1056/NEJMicm1104889

Kayser–Fleischer Rings in Wilson's Disease
http://www.nejm.org/doi/full/10.1056/NEJMicm1101534

Drowsy Man with Breathlessness and Blurred Vision
http://www.annemergmed.com/article/S0196-0644(11)01411-9/fulltext

Man with Confusion and Resolved Paralysis
http://www.annemergmed.com/article/S0196-0644(11)01410-7/fulltext

Acute Vision Loss
http://www.annemergmed.com/article/S0196-0644(11)01543-5/fulltext

12. Oral Rivaroxaban for the Treatment of Symptomatic Pulmonary Embolism

The EINSTEIN–PE Investigators. N Engl J Med. 2012; published online March 26

Introduction: Pulmonary embolism is a common disease, with an estimated annual incidence of 70 cases per 100,000 population.1,2 The condition usually leads to hospitalization and may recur; it can be fatal.3

For half a century, the standard therapy for most patients with pulmonary embolism has been the administration of heparin, overlapped and followed by a vitamin K antagonist.4,5 This regimen is effective but complex.5-9 Recently developed oral anticoagulants that are directed against factor Xa or thrombin overcome some limitations of standard therapy, including the need for injection and for regular dose adjustments on the basis of laboratory monitoring.5,10,11

Current data suggest that rivaroxaban, an oral direct inhibitor of factor Xa, is effective and safe for the prevention of venous thromboembolism after major orthopedic surgery, for the prevention of stroke in patients with atrial fibrillation, and in the treatment of acute coronary syndromes.12-14 The EINSTEIN program evaluated the concept of using rivaroxaban alone for anticoagulant therapy for acute deep-vein thrombosis and pulmonary embolism, replacing both heparin and vitamin K antagonists.15,16 This single-drug approach, starting with an increased dose for 3 weeks, appeared to be successful in treating deep-vein thrombosis. Here we report the findings for this regimen in patients with pulmonary embolism.

Background: A fixed-dose regimen of rivaroxaban, an oral factor Xa inhibitor, has been shown to be as effective as standard anticoagulant therapy for the treatment of deep-vein thrombosis, without the need for laboratory monitoring. This approach may also simplify the treatment of pulmonary embolism.

Methods: In a randomized, open-label, event-driven, noninferiority trial involving 4832 patients who had acute symptomatic pulmonary embolism with or without deep-vein thrombosis, we compared rivaroxaban (15 mg twice daily for 3 weeks, followed by 20 mg once daily) with standard therapy with enoxaparin followed by an adjusted-dose vitamin K antagonist for 3, 6, or 12 months. The primary efficacy outcome was symptomatic recurrent venous thromboembolism. The principal safety outcome was major or clinically relevant nonmajor bleeding.

Results: Rivaroxaban was noninferior to standard therapy (noninferiority margin, 2.0; P=0.003) for the primary efficacy outcome, with 50 events in the rivaroxaban group (2.1%) versus 44 events in the standard-therapy group (1.8%) (hazard ratio, 1.12; 95% confidence interval [CI], 0.75 to 1.68). The principal safety outcome occurred in 10.3% of patients in the rivaroxaban group and 11.4% of those in the standard-therapy group (hazard ratio, 0.90; 95% CI, 0.76 to 1.07; P=0.23). Major bleeding was observed in 26 patients (1.1%) in the rivaroxaban group and 52 patients (2.2%) in the standard-therapy group (hazard ratio, 0.49; 95% CI, 0.31 to 0.79; P=0.003). Rates of other adverse events were similar in the two groups.

Conclusions: A fixed-dose regimen of rivaroxaban alone was noninferior to standard therapy for the initial and long-term treatment of pulmonary embolism and had a potentially improved benefit–risk profile. (Funded by Bayer HealthCare and Janssen Pharmaceuticals; EINSTEIN-PE ClinicalTrials.gov number, NCT00439777.)

Full-text (free at this reading): http://www.nejm.org/doi/pdf/10.1056/NEJMoa1113572

13. Impaired Driving: What is Your Responsibility as an Emergency Physician?

Schroeder E. Ann Emerg Med. 2012;59:324-326.

You are driving home from a busy shift when you glance over at the driver next to you as she swerves out of her lane. Your heart sinks when you recognize her as the woman you just discharged. She came in toward the end of your shift with her “typical migraine” and told you that the last time she was in the emergency department (ED), she was administered a combination of medications that helped. You gave her a “migraine cocktail” of Compazine, Benadryl, and Toradol, and she was feeling better when you checked on her; thus, you told her she could go home. You assumed that she had a ride home; apparently, that was a poor assumption.

The rest of the essay (full-text free) is here: http://www.annemergmed.com/article/S0196-0644(12)00154-0/fulltext

14. Ibuprofen May KO Altitude Sickness

By Michael Smith, MedPage Today. Published: March 21, 2012

If you long for a "Rocky Mountain high" but not the headache, fatigue, dizziness, nausea, and vomiting that sometimes accompany a climb, fear not.

A randomized placebo-controlled trial found that ibuprofen reduces the incidence of mountain sickness, according to Grant Lipman, MD, of Stanford University School of Medicine in Stanford, Calif., and colleagues.

The nonsteroidal anti-inflammatory also appeared to reduce the severity of illness, Lipman and colleagues reported online in Annals of Emergency Medicine.

The issue is important for tourists, recreational mountaineers, military operations, and search and rescue missions, where participants often don't have time to prepare for the climb.

A slow ascent, allowing the body to acclimate, can reduce the chances of the condition, which Lipman said in a statement is like "a really nasty hangover." As well, prescription medications are available but they have significant risks and have to be taken well before the climb starts.

In contrast, ibuprofen is well tolerated, widely available, and can be taken the same day as the climb, the researchers reported.

"If you are heading to the mountains," Lipman said, "take some ibuprofen the day you go."

The exact causes of mountain sickness are not known, but there is some evidence it is a result of an inflammatory process, Lipman and colleagues noted. So, it made sense to test ibuprofen in a group of 86 healthy adult volunteers who live at low altitude.

During July and August 2010, in the White Mountains of California, the volunteers were randomly assigned to take 600 milligrams of ibuprofen or an identical-appearing placebo three times a day.

The study began at an altitude of 1,240 meters (4,100 feet) at 8 a.m., after the volunteers completed questionnaires covering acute mountain sickness symptoms and demographics, had their oxygen saturation measured and received the first dose of medication.

Volunteers were then driven to a staging area at 3,545 meters (11,700 feet) and received the second medication dose at 2 p.m. Then they hiked about 4.3 kilometers (2.7 miles) to 3,810 meters (12,570 feet), where they took the third dose at 8 p.m. They spent the night and received a final dose the following morning.

The primary outcome measures were incidence and severity of mountain sickness, as calculated on the Lake Louise Questionnaire, Lipman and colleagues reported.

They found that 19 volunteers in the ibuprofen group (43%) developed acute mountain sickness compared with 29 in the placebo group (69%), for an odds ratio of 0.3 (95% CI from 0.1 to 0.8).

The number needed to treat to prevent one case of acute mountain sickness was 3.9 (95% CI 2 to 33).

Mountain sickness severity was higher in those who became ill in the placebo group than in those who became sick while taking ibuprofen -- 4.4 versus 3.2 on the questionnaire, on average -- but the difference was not statistically significant (mean difference 0.9%, 95% CI 0.3% to 3%).

The findings could prove especially useful for vacationers who are planning high-altitude trips. "You don't want to feel horrible for 15% to 20% of your vacation," Lipman said. "Ibuprofen could be a way to prevent [mountain sickness] in a significant number of the tens of millions of people who travel to high altitudes each year."

The researchers cautioned that they could not control for such things as temperature, wind speed, rate of ascent, or the underlying physiologic condition of participants.

As well, they noted, participants were self-selected and might not be similar to other hiking and climbing groups.

While other drugs are available to prevent mountain sickness, such as acetazolamide (Diamox) and dexamethasone, they have drawbacks that ibuprofen doesn't have, the researchers noted.

"The safety profile of ibuprofen makes it more attractive then dexamethasone, which has been associated with hyperglycemia, adrenal suppression, delirium, depression, insomnia, and mania," Lipman and colleagues argued. As well, acetazolamide has adverse effects -- nausea, dizziness, and fatigue -- that are usually well tolerated but "can be as debilitating as acute mountain sickness," they noted

"Availability alone makes ibuprofen an appealing drug for individuals who travel to high altitudes," they concluded.

The study was supported by the Stanford University School of Medicine and the American Alpine Club. The journal said the authors had reported no commercial, financial, and other relationships relevant to the article.

Lipman GS, et al. Ibuprofen prevents altitude illness: a randomized controlled trial for prevention of altitude illness with nonsteroidal anti-inflammatories. Ann Emerg Med 2012; DOI: 10.1016/j.annemergmed.2012.01.019.

For a little review of prophylactic agents for AMS, see http://www.annemergmed.com/article/S0196-0644(11)01700-8/abstract

15. CT Angiography for Safe Discharge of Patients with Possible ACS

Litt HI, et al. N Engl J Med. Online March 26, 2012 (10.1056/NEJMoa1201163)

Introduction: Patients who present to the emergency department with signs and symptoms consistent with a possible acute coronary syndrome pose a diagnostic dilemma.1-6 Despite the introduction of clinical decision rules6-15 and the improved sensitivity of cardiac markers,15-17 most patients are admitted to the hospital so that an acute coronary syndrome can be ruled out, even though for most of these patients, the symptoms are ultimately found not to have a cardiac cause.

The absence of evidence of coronary disease on invasive coronary angiography is associated with a low risk of future cardiac events.18,19 Coronary computed tomographic angiography (CCTA) is a noninvasive test with a negative predictive value of nearly 100% for the detection of coronary artery disease.20

Prior studies21-30 have shown that the rate of cardiac events among patients with minimal or no coronary artery disease is very low. However, these studies were not large enough to clarify whether a CCTA-based strategy, as compared with traditional approaches, allows the safe discharge of patients after a negative test. We conducted a trial to determine the safety and efficiency of a CCTA-based strategy.

Background: Admission rates among patients presenting to emergency departments with possible acute coronary syndromes are high, although for most of these patients, the symptoms are ultimately found not to have a cardiac cause. Coronary computed tomographic angiography (CCTA) has a very high negative predictive value for the detection of coronary disease, but its usefulness in determining whether discharge of patients from the emergency department is safe is not well established.

Methods: We randomly assigned low-to-intermediate-risk patients presenting with possible acute coronary syndromes, in a 2:1 ratio, to undergo CCTA or to receive traditional care. Patients were enrolled at five centers in the United States. Patients older than 30 years of age with a Thrombolysis in Myocardial Infarction risk score of 0 to 2 and signs or symptoms warranting admission or testing were eligible. The primary outcome was safety, assessed in the subgroup of patients with a negative CCTA examination, with safety defined as the absence of myocardial infarction and cardiac death during the first 30 days after presentation.

Results: We enrolled 1370 subjects: 908 in the CCTA group and 462 in the group receiving traditional care. The baseline characteristics were similar in the two groups. Of 640 patients with a negative CCTA examination, none died or had a myocardial infarction within 30 days (0%; 95% confidence interval [CI], 0 to 0.57). As compared with patients receiving traditional care, patients in the CCTA group had a higher rate of discharge from the emergency department (49.6% vs. 22.7%; difference, 26.8 percentage points; 95% CI, 21.4 to 32.2), a shorter length of stay (median, 18.0 hours vs. 24.8 hours; P less than 0.001), and a higher rate of detection of coronary disease (9.0% vs. 3.5%; difference, 5.6 percentage points; 95% CI, 0 to 11.2). There was one serious adverse event in each group.

Conclusions: A CCTA-based strategy for low-to-intermediate-risk patients presenting with a possible acute coronary syndrome appears to allow the safe, expedited discharge from the emergency department of many patients who would otherwise be admitted. (Funded by the Commonwealth of Pennsylvania Department of Health and the American College of Radiology Imaging Network Foundation

Full-text (Currently free): http://www.nejm.org/doi/full/10.1056/NEJMoa1201163#t=article

16. Variation in Use of Head CT by Emergency Physicians.

Prevedello LM, Am J Med. 2012 Feb 10. [Epub ahead of print]

OBJECTIVE: Variation in emergency department head computed tomography (CT) use in patients with atraumatic headaches between hospitals is being measured nationwide. However, the magnitude of interphysician variation within a hospital is currently unknown. We hypothesized that there was significant variation in the rates of physician head CT use, both overall and for patients diagnosed with atraumatic headaches.

METHODS: This cross-sectional study was conducted in the emergency department of a large urban academic hospital, and institutional review board approval was obtained. All emergency department visits from 2009 were analyzed, and the primary outcome measure was whether or not head CT was performed. Logistic regression was used to control for patient, physician, and visit characteristics potentially associated with head CT ordering. The degree of interphysician variability was tested, both before and after controlling for these variables.

RESULTS: Of 55,286 emergency department patient encounters, 4919 (8.9%) involved head CT examinations. Unadjusted head CT ordering rates per physician ranged from 4.4% to 16.9% overall and from 15.2% to 61.7% in patients diagnosed with atraumatic headaches, with both rates varying significantly between physicians. Two-fold variation in head CT ordering overall (6.5%-13.5%) and approximately 3-fold variation in head CT ordering for atraumatic headaches (21.2%-60.1%) persisted even after controlling for pertinent variables.

CONCLUSION: Emergency physicians vary significantly in their use of head CT both overall and in patients with atraumatic headaches. Further studies are needed to identify strategies to reduce interphysician variation in head CT use.

17. Clinical presentation of acute PE: survey of 800 cases.

Miniati M, et al. PLoS One. 2012;7(2):e30891.

BACKGROUND: Pulmonary embolism (PE) is a common and potentially fatal disease that is still underdiagnosed. The objective of our study was to reappraise the clinical presentation of PE with emphasis on the identification of the symptoms and signs that prompt the patients to seek medical attention.

METHODOLOGY/PRINCIPAL FINDINGS: We studied 800 patients with PE from two different clinical settings: 440 were recruited in Pisa (Italy) as part of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISAPED); 360 were diagnosed with and treated for PE in seven hospitals of central Tuscany, and evaluated at the Atherothrombotic Disorders Unit, Firenze (Italy), shortly after hospital discharge. We interviewed the patients directly using a standardized, self-administered questionnaire originally utilized in the PISAPED. The two samples differed significantly as regards age, proportion of outpatients, prevalence of unprovoked PE, and of active cancer. Sudden onset dyspnea was the most frequent symptom in both samples (81 and 78%), followed by chest pain (56 and 39%), fainting or syncope (26 and 22%), and hemoptysis (7 and 5%). At least one of the above symptoms was reported by 756 (94%) of 800 patients. Isolated symptoms and signs of deep vein thrombosis occurred in 3% of the cases. Only 7 (1%) of 800 patients had no symptoms before PE was diagnosed.

CONCLUSIONS/SIGNIFICANCE: Most patients with PE feature at least one of four symptoms which, in decreasing order of frequency, are sudden onset dyspnea, chest pain, fainting (or syncope), and hemoptysis. The occurrence of such symptoms, if not explained otherwise, should alert the clinicians to consider PE in differential diagnosis, and order the appropriate objective test.

Full-text (free): http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0030891

18. Health Insurance Status Change and ED Use Among US Adults

Ginde AA, et al. Arch Intern Med. Published online March 26, 2012. doi:10.1001/archinternmed.2012.34

Background Recent events have increased the instability of health insurance coverage. We compared emergency department (ED) use by newly insured vs continuously insured adults and by newly uninsured vs continuously uninsured adults.

Methods We analyzed 159 934 adult respondents to the 2004 through 2009 National Health Interview Survey. Health insurance status was categorized as newly insured (currently insured but lacked health insurance at some point during the prior 12 months) vs continuously insured and as newly uninsured (currently uninsured but had health insurance at some point during the prior 12 months) vs continuously uninsured. We analyzed the number of ED visits during the prior 12 months using multivariable Poisson regression.

Results Overall, 20.7% of insured adults and 20.0% of uninsured adults had at least 1 ED visit. However, 29.5% of newly insured adults compared with 20.2% of continuously insured adults had at least 1 ED visit. Similarly, 25.7% of newly uninsured adults compared with 18.6% of continuously uninsured adults had at least 1 ED visit. After adjusting for demographics, socioeconomic status, and health status, recent health insurance status change was independently associated with greater ED use for newly insured adults (incidence rate ratio [IRR], 1.32; 95% CI, 1.22-1.42 vs continuously insured adults) and for newly uninsured adults (IRR, 1.39; 95% CI, 1.26-1.54 vs continuously uninsured adults). Among newly insured adults, this association was strongest for Medicaid beneficiaries (IRR, 1.45) but was attenuated for those with private insurance (IRR, 1.24) (P less than .001 for interaction).

Conclusions Recent changes in health insurance status for newly insured adults and for newly uninsured adults were associated with greater ED use. As policy and economic forces create disruptions in health insurance status, new surges in ED use should be anticipated.

19. Hold Off on Antibiotics for Sinus Infection, New Guidelines Urge

By Michael Smith, MedPage Today. Published: March 21, 2012

Action Points

A. New guidelines for acute sinusitis address issues that include the inability of existing clinical criteria to accurately differentiate bacterial from viral acute rhinosinusitis and excessive and inappropriate antimicrobial therapy.

B. Point out that the guidelines recommend empiric antimicrobial therapy with amoxicillin-clavulanate rather than amoxicillin alone when the clinical diagnosis of acute bacterial rhinosinusitis is established.

______________

Between 90% and 98% of sinus infections won't respond to antibiotics, so doctors should hesitate before reaching for the prescription pad, according to new guidelines for the treatment of rhinosinusitis from the Infectious Diseases Society of America.

"There is no simple test that will easily and quickly determine whether a sinus infection is viral or bacterial, so many physicians prescribe antibiotics 'just in case,'" commented Anthony Chow, MD, of the University of British Columbia in Vancouver, who chaired the panel that developed the guidelines.

But, he added in a statement, "if the infection turns out to be viral -- as most are -- the antibiotics won't help and in fact can cause harm by increasing antibiotic resistance, exposing patients to drug side effects unnecessarily and adding cost."

The guidelines, published online in Clinical Infectious Diseases, offer primary care physicians 18 recommendations to help ensure appropriate treatment, ranging from how to tell bacterial from viral infections to when to call in a specialist.

Although most cases are viral, the guidelines suggest suspecting a bacterial cause when:
Symptoms or signs are persistent, lasting at least 10 days without any evidence of clinical improvement.

The disease onset is characterized by severe symptoms or signs of high fever (of at least 39° C or 102° F) and purulent nasal discharge or facial pain lasting for at least three or four days.
The disease gets worse with a new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection that lasted five or six days and had appeared to be improving.

Where a bacterial cause is likely, the guidelines suggest prompt treatment with an antibiotic.

Many previous guidelines had suggested empiric therapy with the beta-lactam antibiotic amoxicillin, but an increasing proportion of respiratory pathogens now produce beta-lactamase, which breaks down the drug.

So, the new guidelines say, initial therapy should add clavulanate, a beta-lactamase inhibitor, to the amoxicillin.

The recommendation applies to both adults and children.

Because of increasing rates of drug resistance, the guidelines also recommend not using other common antibiotics, including azithromycin (Zithromax), clarithromycin (Biaxin), and trimethoprim-sulfamethoxazole (Septra).

The new guidelines also say that a shorter treatment time for adults -- five to seven days, rather than 10 to 14 -- is long enough to treat a bacterial infection without encouraging resistance.

Children should still be treated for 10 days to two weeks, the guidelines say.

Regardless of the cause of the infection, the guidelines discourage decongestants and antihistamines, which don't help and in some cases can make symptoms worse.

On the other hand, nasal steroids can help ease symptoms in people who have sinus infections and a history of allergies.

Saline nasal irrigation might help relieve some symptoms, the guidelines say, although it might not be as helpful in children because of the discomfort of the therapy.

The work was supported by the Infectious Diseases Society of America.

Chow reported financial links with Inimex, Migenix, Bayer, Merck, Wyeth, MEDACorp Clinical Advisors, Pfizer, Merck-Frosst Canada, and Core Health.

Chow AW, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012; DOI: 10.1093/cid/cir1043

Full-text (free): http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full

20. When to Transfuse? A Review

Here’s a rule of thumb with which we’d all agree: “While definitive data are lacking at this time, the likelihood of a transfusion being of benefit is high when the patient's hemoglobin is less than 6 g/dL (60 g/L) and is low when it is greater than 10 g/dL (100 g/L).” Up-To-Date. “Indications for red cell transfusion in the adult” Feb 2012

In our Sept 13, 2010 issue of Lit Bits we brought you highlights from this helpful review: Walsh TS, et al. Managing anaemia in non-bleeding critically ill adults: state of the evidence. BMJ 2010; 341:c4408. http://drvinsonlitbits.blogspot.com/2010/09/lit-bits-sept-13-2010.html Scroll down to #16.

For the most recent guidelines, see Napolitano LM, et al. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. Crit Care Med. 2009;37(12):3124. http://www.ncbi.nlm.nih.gov/pubmed/19773646

Below I append a few paragraphs from a nice (free online) review: Collins TA. Packed red blood cell transfusions in critically ill patients. Crit Care Nurse. 2011;31(1):25-33; quiz 34.

Transfusion Trigger

The hemoglobin value that should trigger a transfusion of RBCs is currently under debate. The Surviving Sepsis Campaign Guidelines recommend giving patients a transfusion when the hemoglobin level is less than 7 g/dL with a goal of maintaining a hemoglobin level of 7 to 9 g/dL; however, this does not include patients with active hemorrhage, myocardial ischemia, or lactic acidosis.23 On the other hand, the American Society of Anesthesiologists Task Force does not recommend giving a patient a transfusion on the basis of the patient’s hemoglobin value, but rather recommends that the decision be based on the clinical situation.31,32 Because of the continuing debate over transfusion, health care providers should continue to monitor each patient’s clinical picture. The health care team should watch for blood loss, monitor for signs of inadequate perfusion and ischemia in the form of vital signs and urine output, and track the patients’ hemoglobin values.31

Number of Units Transfused

The number of units of RBCs appears to correlate with increased mortality, so the number of units transfused should be as few as possible.2,26,27,29,30 When a provider decides to give a patient a transusion of RBCs, 2 units are often transfused. It is, however, not always necessary to transfuse 2 units of blood. The expected response in hemoglobin level should be an increase of 1 g/dL per unit of blood transfused. If a stable patient with no known history of heart disease or active hemorrhage has a hemoglobin level of 7 g/dL and is given a transfusion of 1 unit of blood, the hemoglobin level should increase to 8 g/dL. One unit of blood should be transfused, and then the hemoglobin level should be measured. If an appropriate response in the level is noted, it may not be necessary to transfuse more blood products. However, if an appropriate response is not noted, then more blood should be transfused. This advice may not apply in emergency situations, in patients with active hemorrhage, or in patients showing signs of ischemia. Transfusing only 1 unit of blood decreases the risk of mortality and also decreases the risk of transfusion-transmitted infections.

Age of Stored Blood and Leukoreduction

Taylor et al25 reported that 65.3% of patients received blood products close to or over their expiration date, which highlights the importance of noting the expiration date before administration. As previously discussed, health care providers should know whether their institution uses leukoreduced or nonleukoreduced blood products. Leukoreduced blood is given universally in some countries and institutions; however, leukoreduction is associated with a significant cost. The cost for each unit of blood that undergoes leukoreduction ranges approximately from $30 to $100.33,34

References and full-text here: http://ccn.aacnjournals.org/content/31/1/25.long

21. Calorie Intake Rises as Sleep Time Drops

Does this mean night shifts contribute to obesity? Now we have an excuse!

By Crystal Phend, Senior Staff Writer, MedPage Today. March 15, 2012

Not getting enough sleep may lead to weight gain, according to a laboratory sleep restriction study finding a big boost in calorie intake.

Healthy individuals ate almost 550 extra calories when they missed out on an average 1 hour 20 minutes of sleep, Andrew D. Calvin, MD, MPH, of the Mayo Clinic in Rochester, Minn., and colleagues found.

But activity didn't increase to compensate during the extra time awake, the group reported at the American Heart Association's Epidemiology and Prevention/Nutrition, Physical Activity and Metabolism (EPI/NPAM) meeting in San Diego.

Those unburned calories likely "would accumulate and eventually translate into extra fat," Calvin explained in an interview with MedPage Today. "Lack of sleep probably does contribute to weight gain and obesity."

There's no magic number for sleep duration that would keep one thin, though, he cautioned.

Sleep needs vary by individual, so people should aim for what feels like enough, Calvin suggested.

"At this point our best recommendation for individuals is if they are looking to maintain a healthy weight or to lose weight, they should make sure they get enough sleep," he said.

Clinicians too need to consider sleep -- not just related to weight, but for any number of health problems, Calvin suggested.

"It is always worthwhile to ask about sleep," he told MedPage Today. "It's a simple first step."

His group's study included 17 healthy adults ages 18 to 40 who spent eight days and nights in a lab where they were free to eat whatever food they wanted, but were randomized to have their normal sleep time cut by a third, or to sleep normally.

For the sleep-deprived individuals, continuous brain wave monitoring showed that they spent only 5.2 hours asleep compared with 6.5 hours at baseline, a modest difference similar to what often happens in everyday life, the researchers noted.

The extra time awake didn't raise active energy expenditure as measured by inclinometers and accelerometers; neither group saw a significant change.

However, sleep restriction raised average calorie intake by 549 kcal per day compared with baseline; the controls actually cut their calorie intake by 143 kcal per day in the lab (P less than 0.01 for difference).

It's possible that people got hungry to counteract tiredness or that they simply had more opportunities to eat given the longer time spent awake, Calvin noted. But adjusting for the extra time awake with an analysis of calories-per-hours-of-wakefulness still showed a surplus in the sleep restriction group.

That suggests "there are real biologic changes that are happening because of a lack of sleep that make people eat more," Calvin pointed out.

But exactly what those impacts are remains unclear.

The researchers suspected they would see a change in hormones that regulate appetite and did find trends for increased leptin with sleep deprivation (+8.4% versus -9.8% among controls, P=0.12) and decreased ghrelin (-4.9% versus +4.6%, P=0.38). However, those shifts were the opposite of what was expected and "more consistent with a consequence of a positive energy balance than a cause," the researchers explained.

From the American Heart Association:

Calvin AD, et al “Insufficient sleep increases caloric intake but not energy expenditure" EPI/NPAM 2012; Abstract MP030.

22. HLA Class II Locus and Susceptibility to Podoconiosis

Whoops, sorry. Not really ED-related…

Lit Bits: March 10, 2012

From the recent medical literature...

1. Association of Age and Sex with CP-free AMI and In-Hospital Mortality

Canto JG, et al. JAMA 2012;307(8):813-822.

Context Women are generally older than men at hospitalization for myocardial infarction (MI) and also present less frequently with chest pain/discomfort. However, few studies have taken age into account when examining sex differences in clinical presentation and mortality.

Objective To examine the relationship between sex and symptom presentation and between sex, symptom presentation, and hospital mortality, before and after accounting for age in patients hospitalized with MI.

Design, Setting, and Patients Observational study from the National Registry of Myocardial Infarction, 1994-2006, of 1 143 513 registry patients (481 581 women and 661 932 men).

Main Outcome Measures We examined predictors of MI presentation without chest pain and the relationship between age, sex, and hospital mortality.

Results The proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0% [95% CI, 41.8%-42.1%] vs 30.7% [95% CI, 30.6%-30.8%]; P less than .001). There was a significant interaction between age and sex with chest pain at presentation, with a larger sex difference in younger than older patients, which became attenuated with advancing age. Multivariable adjusted age-specific odds ratios (ORs) for lack of chest pain for women (referent, men) were younger than 45 years, 1.30 (95% CI, 1.23-1.36); 45 to 54 years, 1.26 (95% CI, 1.22-1.30); 55 to 64 years, 1.24 (95% CI, 1.21-1.27); 65 to 74 years, 1.13 (95% CI, 1.11-1.15); and 75 years or older, 1.03 (95% CI, 1.02-1.04). Two-way interaction (sex and age) on MI presentation without chest pain was significant (P less than .001). The in-hospital mortality rate was 14.6% for women and 10.3% for men. Younger women presenting without chest pain had greater hospital mortality than younger men without chest pain, and these sex differences decreased or even reversed with advancing age, with adjusted OR for age younger than 45 years, 1.18 (95% CI, 1.00-1.39); 45 to 54 years, 1.13 (95% CI, 1.02-1.26); 55 to 64 years, 1.02 (95% CI, 0.96-1.09); 65 to 74 years, 0.91 (95% CI, 0.88-0.95); and 75 years or older, 0.81 (95% CI, 0.79-0.83). The 3-way interaction (sex, age, and chest pain) on mortality was significant (P less than .001).

Conclusion In this registry of patients hospitalized with MI, women were more likely than men to present without chest pain and had higher mortality than men within the same age group, but sex differences in clinical presentation without chest pain and in mortality were attenuated with increasing age.

2. Septic Shock? Reach for Norepinephrine After Fluid Resuscitation

A meta-analysis shows that dopamine is associated with increased risk for death and arrhythmic events compared with norepinephrine.

Although current guidelines recommend either dopamine or norepinephrine as the vasopressors of choice for septic shock, a recent meta-analysis of six interventional studies suggested that norepinephrine is the superior agent (JW Emerg Med Apr 22 2011). Investigators conducted a meta-analysis of the same six interventional studies — excluding patients with nonseptic shock — and five observational studies; the analysis involved a total of 2768 adult patients.

Observational studies showed significant heterogeneity in results overall and no difference in mortality between patients treated with dopamine and those treated with norepinephrine. After exclusion of one trial that accounted for the heterogeneity, dopamine was associated with an increased risk for death at 28 days over norepinephrine (relative risk, 1.23). Interventional trials were homogeneous and likewise showed a significantly increased risk for death with dopamine use (RR, 1.12). Two interventional studies that reported arrhythmic events showed a significant increase in these events in the dopamine groups (RR, 2.34).

An editorialist suggests that dopamine, a more powerful β-agonist than norepinephrine, could still be considered in patients with septic shock, hypotension (systolic blood pressure below 90 mm Hg), and either a low cardiac index (below 2.5 L/minute/m2) or low heart rate (below 90 beats per minute).

Comment: This study supports norepinephrine as the vasopressor of choice for adult patients with septic shock. Dopamine is relegated to a secondary role, perhaps to be used when cardiac output is insufficient despite optimal use of norepinephrine.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine March 2, 2012. Citation: De Backer D et al. Dopamine versus norepinephrine in the treatment of septic shock: A meta-analysis. Crit Care Med 2012 Mar; 40:725.

3. Patients Often Use ED Even When Primary Care Is Available

Lasker KE. Emergency department use by primary care patients at a safety-net hospital. Arch Int Med. 2012;172:278-280.

Larry Hand. Medscape Medical News. February 14, 2012 — As national healthcare reform proceeds, hospitals that have benefited financially from high use of emergency departments (EDs) by routine primary care patients will be challenged to retool primary care delivery and payment methods, according to a research letter published in the February 13 issue of the Archives of Internal Medicine.

Karen E. Lasker, MD, MPH, from the Section of General Internal Medicine, Department of Medicine, Boston Medical Center (BMC) and Boston University School of Medicine, and the Department of Community Health Sciences, Boston University School of Public Health, in Massachusetts, and colleagues analyzed the use of ED services by established primary care patients at BMC, a safety-net hospital, between July 1, 2009, and July 1, 2010. They found that about half of all ED primary care visits took place during weekdays when primary care practices were open and seeing patients.

BMC has 8 primary care practices employing 105 primary care physicians (PCPs). During the study period, a total of 39,603 patients had 1 or more primary care visits to BMC. Of those, 65.4% did not visit the ED during the study period; however, 29.8% visited the ED 1 to 3 times and 4.9% visited the ED 4 or more times. Overall the 11,787 patients in the intermediate-use group made 17,759 visits and the 1928 patients in the frequent-use group made 12,289 visits.

The researchers estimate that most ED visits were for low-severity services, based on an analysis of International Classification of Diseases, Ninth Revision, Clinical Modification, codes.

Dr. Lasker and colleagues cited the lack of available PCP appointments as a possible reason for the ED visits during weekdays. At the same time, the practices experienced almost a 25% rate of missed appointments, which often correlates with long wait times for schedule appointments.

"It is possible that patients called the practices with an urgent problem, did not have their telephone call answered promptly, and decided to seek care in the ED instead," the authors write. Patients abandoned about 13% of their calls to the PCP offices during the study period.

Another possible factor in the use of ED services for low-severity needs is that about a fifth of the primary care services are provided by residents who have limited availability because of hospital requirements.

"Massachusetts has been a bellwether for the implementation of health reform and will be a bellwether for the transformation of primary care, with the move away from fee-for-service payments and the introduction of global payments for health care," the authors write. In that regard, they note, as Massachusetts health reform has led to more newly insured patients getting primary care services in large numbers, "it is possible that access to primary care has worsened for other patients."

Whether changes in practice and payment will reduce high ED usage in this way is unclear, they conclude.

The study was supported by the Department of Medicine at Boston Medical Center/Boston University School of Medicine. Dr. Lasker has disclosed that she was a consultant to Rise Health in 2011.

4. Prediction of haematoma growth and outcome in patients with ICH using the CT-angiography spot sign (PREDICT): a prospective observational study

Demchuk AM, et al. The Lancet Neurology, Early Online Publication, 8 March 2012

Background: In patients with intracerebral haemorrhage (ICH), early haemorrhage expansion affects clinical outcome. Haemostatic treatment reduces haematoma expansion, but fails to improve clinical outcomes in many patients. Proper selection of patients at high risk for haematoma expansion seems crucial to improve outcomes. In this study, we aimed to prospectively validate the CT-angiography (CTA) spot sign for prediction of haematoma expansion.

Methods: PREDICT (predicting haematoma growth and outcome in intracerebral haemorrhage using contrast bolus CT) was a multicentre prospective observational cohort study. We recruited patients aged 18 years or older, with ICH smaller than 100 mL, and presenting at less than 6 h from symptom onset. Using two independent core laboratories, one neuroradiologist determined CTA spot-sign status, whereas another neurologist masked for clinical outcomes and imaging measured haematoma volumes by computerised planimetry. The primary outcome was haematoma expansion defined as absolute growth greater than 6 mL or a relative growth of more than 33% from initial CT to follow-up CT. We reported data using standard descriptive statistics stratified by the CTA spot sign. Mortality was assessed with Kaplan-Meier survival analysis.

Findings: We enrolled 268 patients. Median time from symptom onset to baseline CT was 135 min (range 22—470), and time from onset to CTA was 159 min (32—475). 81 (30%) patients were spot-sign positive. The primary analysis included 228 patients, who had a follow-up CT before surgery or death. Median baseline ICH volume was 19•9 mL (1•5—80•9) in spot-sign-positive patients versus 10•0 mL (0•1—102•7) in spot-sign negative patients (p less than 0•001). Median ICH expansion was 8•6 mL (−9•3 to 121•7) for spot-sign positive patients and 0•4 mL (−11•7 to 98•3) for spot-negative patients (p less than 0•001). In those with haematoma expansion, the positive predictive value for the spot sign was 73%; the negative predictive value was 84%, sensitivity was 63%, and specificity was 90%. Median 3-month modified Rankin Scale (mRS) was 5 in CTA spot-sign-positive patients, and 3 in spot-sign-negative patients (p less than 0•001). Mortality at 3 months was 43•4% (23 of 53) in CTA spot-sign positive versus 19•6% (31 of 158) in CTA spot-sign-negative patients (HR 2•4, 95% CI 1•4—4•0, p=0•002).

Interpretation: These findings confirm previous single-centre studies showing that the CTA spot sign is a predictor of haematoma expansion. The spot sign is recommended as an entry criterion for future trials of haemostatic therapy in patients with acute ICH.

5. Pilot Study Suggests that Tenecteplase Might Edge t-PA in Acute Stroke

By: Mitchell Zoler, Elsevier Global Medical News. 03/08/12

NEW ORLEANS – The potential advantages of tenecteplase, a modified form of tissue plasminogen activator engineered to outperform the native molecule, finally shone through for treating patients with acute, ischemic stroke.

A head-to-head comparison of tenecteplase against recombinant tissue plasminogen activator (t-PA; alteplase) showed that the modified molecule produced better reperfusion and better clinical recovery 24 hours after treatment in a randomized trial of 75 Australian patients whose treatment was guided by CT brain imaging, Dr. Bill O’Brien reported at the International Stroke Conference.

Although Dr. O’Brien cautioned that this pilot study did not produce definitive results, the superiority of tenecteplase eclipsed its failure to surpass t-PA in a randomized comparison of 112 patients reported in 2010.

The results "support using advanced imaging to identify the patients who are most likely to benefit" from tenecteplase, he said. The use of systematic CT brain imaging to select patients appeared to be the main factor that distinguished this study from the previous trial where tenecteplase failed to show an advantage, said Dr. O’Brien, a stroke physician at John Hunter Hospital in Newcastle, Australia.

Targeted patient selection may also explain why the tenecteplase treatment was so safe, resulting in a trend toward a reduced rate of type 2 parenchymal hemorrhages, compared with t-PA, despite the superior thrombolytic activity shown by tenecteplase, he said.

Although the current trial had "compelling results," another study will follow to compare the two drugs by several 3-month outcomes, Dr. O’Brien said in an interview. The successful dosages of tenecteplase tested also have the advantage of being cheaper than the standard t-PA dosage, he added.

Developed in the 1990s, tenecteplase resulted from three targeted amino acid substitutions in conventional t-PA. This produced a molecule with increased fibrin specificity, and longer plasma half-life due to increased resistance to enzymatic degradation, which meant that it could be administered by an intravenous bolus instead of requiring continuous infusion like t-PA. When used to treat myocardial infarctions, tenecteplase has also resulted in fewer bleeding complications than t-PA.

The study enrolled 75 patients within 6 hours of onset of an ischemic stroke at any of three Australian hospitals, following selection by CT imaging to identify patients with a small infarct core and a large penumbra of salvageable brain. Researchers randomized patients to receive 0.1 mg/kg tenecteplase or 0.25 mg/kg tenecteplase by an intravenous bolus injection, or standard infusion with 0.9 mg/kg t-PA. The patients averaged 70 years old, their average NIHSS (National Institutes of Health Stroke Scale) score at entry was about 14, and patients received treatment an average of about 3 hours after symptom onset.

The reperfusion rate after 24 hours was 78% among all 50 patients treated with tenecteplase, and 55% among the t-PA treated patients, a statistically significant difference for one of the study’s two primary end points, Dr. O’Brien said. The second primary end point, change in NIHSS score after 24 hours, improved by an average of 8 points in all 50 tenecteplase patients, and by an average of 3 points in the t-PA patients, also a significant difference.

The results appeared to show a dose-response relationship for tenecteplase, with the 25 patients who received the 0.25-mg/kg dosage having better reperfusion rates and reductions in their NIHSS scores than the 25 patients who received a 0.1-mg/kg dosage as well as the patients treated with t-PA, but Dr. O’Brien did not report specific numbers from this analysis.

Of the 50 tenecteplase patients, 2 (4%) developed a type 2 parenchymal hemorrhage within 24 hours, compared with 4 (16%) of the 25 t-PA-treated patients, a difference that trended toward significance. The rates of symptomatic intracerebral hemorrhages and death at 24 hours were similar with both drugs. But at 90 days after treatment, the combined rate of death or severe disability was 10% in the 50 tenecteplase patients and 25% in the t-PA patients, a difference that also trended toward significance.

These findings contrast with a 2010 report from a randomized trial that compared three different tenecteplase dosages with t-PA in a multicenter U.S. study of 112 patients (Stroke 2010;41:707-11). The results showed no significant differences between any of the tenecteplase dosages and t-PA for any of the outcomes measured out to 90 days after treatment.

The major difference between the U.S. study and the new Australian study was in patient selection, Dr. O’Brien said. "We used imaging to balance the groups," and to select patients who stood to benefit most from effective reperfusion, he said.

Dr. O’Brien said that he and his associates had no disclosures.

6. Proxies Put Rosy Tint on Grim Prognoses

By Crystal Phend, Senior Staff Writer, MedPage Today. March 08, 2012

Surrogate decision makers readily accepted good news about critically-ill patients, but showed an optimistic bias when it came to a poor prognosis, researchers found.

Surrogates' interpretation of a 90% chance of surviving was accurate without much variation, according to an ICU-based study by Douglas B. White, MD, of the University of Pittsburgh Medical Center, and colleagues.

But when the surrogates heard "5% chance of survival," the interpretation was a median 15% chance of survival and above 40% in a quarter of cases (P less than 0.001 for difference), the group reported in the March 6 issue of the Annals of Internal Medicine.

The presumption is often that discordance on prognosis is because physicians aren't being clear or surrogates simply misunderstand, they noted.

However, interviews with the surrogates pointed to two main reasons for the inaccurate interpretations:
Need for hope in the face of a poor prognosis
Belief that the patient has attributes unknown to the physician

Clinicians need to be aware of these biases, which likely impact decisions on life support, the researchers noted.

"Interventions to improve this element of decision making will probably require attention not only to the clarity with which risk information is conveyed but also to the emotional and psychological factors that affect how individuals process such information," White's group recommended.

They conducted an experiment with 80 surrogates of critically-ill patients at three ICUs at San Francisco hospitals, asking them to interpret various prognostic statements hypothetically rather than as part of clinical conversations with the patient's physician.

The questionnaire asked randomly ordered questions, such as "If a doctor says 'He will definitely survive,' what does that mean to you?" Participants could answer in five-percentage point increments on a probability scale from "Will not survive (0% chance of survival)" to "Will survive (100% chance of survival)."

When asked to interpret a 90% chance of survival, 60% put down down the correct answer (median 90%, P=0.11).

The opposite was true when interpreting a 5% chance of survival, with 65% rating the chances of survival as higher than 5% (median 15%, P less than 0.001).

Interpretations of a 50% chance of survival fell in the middle, with 40% answering more optimistically than warranted by the statement.

Interviews with fifteen of the surrogates whose answers were overly optimistic suggested that they often weren't aware of their bias (seven of 15).

Explanations given by the surrogates for their optimistic reinterpretation of the prognostic statements included:

"I always hope for the best outcome for my husband. Even with [a] five percent chance of survival there is still hope."

"I do think that a person's will to live and their ability to survive very stressful situations can have an impact on whether they are going to survive or not."

"I don't give a lot of weight to the individual number. I tend not to trust the individual number as much as the overall feeling that [the physician] is conveying. When [the physician] says 90%, I'm not thinking 9 out [of] 10, I'm thinking that [the physician] is very confident but not entirely sure."

Skepticism in the accuracy of predictions of death isn't necessarily irrational, White's group noted.

But optimism isn't always ethically benign, they added.

"For example, if self-protection makes a surrogate emotionally unable to acknowledge when a patient has a very poor prognosis," the investigators wrote, "the surrogate may request ongoing use of life support when the patient's values suggest that a transition to comfort measures only is more appropriate."

The group cautioned that their hypothetical results "may not fully replicate the circumstances and emotional responses that arise in actual clinician–family encounters."

Zier LS, et al "Surrogate decision makers' interpretation of prognostic information: a mixed-methods study" Ann Intern Med 2012; 156: 360-366.

http://www.annals.org/content/156/5/360.abstract

7. CPR: Pump Hard, Fast, and Deep

Most patients in this large study received chest compressions at depths less than the recommended amount.

Recent emphasis on the quality of cardiopulmonary resuscitation (CPR) and concern about chest compressions being too slow and too shallow have prompted real-time measurement. Researchers analyzed electronic CPR compression depth data from the Resuscitation Outcomes Consortium for a convenience sample of 1029 adult patients treated by 58 emergency medical services (EMS) agencies in seven U.S. and Canadian cities from 2006 to 2009. Patients with EMS-witnessed arrest and those who received bystander defibrillation were excluded.

Overall, median compression rate was 106 per minute, and median compression depth was 37.3 mm. About half of patients (53%) had a recorded compression depth less than 38 mm, and nearly all (92%) had depths less than 50 mm. Faster compression rates correlated with smaller compression depths. In a univariate comparison of characteristics of the 50 patients who survived to hospital discharge with those of patients who did not survive, outcomes were better when compression depth was greater than 38 mm.

Comment: The recommended depth for CPR is at least 50 mm (and was 38–50 mm at the time of the study). The results of this study are dismal, showing that depth of compression was inadequate for most patients. We need to ensure proper feedback-facilitated training along with performance measurement for quality improvement. If we do not train adequately and measure performance, we cannot improve clinical outcomes.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine March 9, 2012. Citation: Stiell IG et al. What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation? Crit Care Med 2012 Jan 5; [e-pub ahead of print].

8. Do Physicians Understand Cancer Screening Statistics? A National Survey of Primary Care Physicians in the United States

Wegwarth O, et al. Ann Intern Med. 2012;156:340-349 .

Background: Unlike reduced mortality rates, improved survival rates and increased early detection do not prove that cancer screening tests save lives. Nevertheless, these 2 statistics are often used to promote screening.

Objective: To learn whether primary care physicians understand which statistics provide evidence about whether screening saves lives.

Design: Parallel-group, randomized trial (randomization controlled for order effect only), conducted by Internet survey. (ClinicalTrials.gov registration number: NCT00981019)

Setting: National sample of U.S. primary care physicians from a research panel maintained by Harris Interactive (79% cooperation rate).

Participants: 297 physicians who practiced both inpatient and outpatient medicine were surveyed in 2010, and 115 physicians who practiced exclusively outpatient medicine were surveyed in 2011.

Intervention: Physicians received scenarios about the effect of 2 hypothetical screening tests: The effect was described as improved 5-year survival and increased early detection in one scenario and as decreased cancer mortality and increased incidence in the other.

Measurements: Physicians' recommendation of screening and perception of its benefit in the scenarios and general knowledge of screening statistics.

Results: Primary care physicians were more enthusiastic about the screening test supported by irrelevant evidence (5-year survival increased from 68% to 99%) than about the test supported by relevant evidence (cancer mortality reduced from 2 to 1.6 in 1000 persons). When presented with irrelevant evidence, 69% of physicians recommended the test, compared with 23% when presented with relevant evidence (P less than 0.001). When asked general knowledge questions about screening statistics, many physicians did not distinguish between irrelevant and relevant screening evidence; 76% versus 81%, respectively, stated that each of these statistics proves that screening saves lives (P = 0.39). About one half (47%) of the physicians incorrectly said that finding more cases of cancer in screened as opposed to unscreened populations “proves that screening saves lives.”

Limitation: Physicians' recommendations for screening were based on hypothetical scenarios, not actual practice.

Conclusion: Most primary care physicians mistakenly interpreted improved survival and increased detection with screening as evidence that screening saves lives. Few correctly recognized that only reduced mortality in a randomized trial constitutes evidence of the benefit of screening.

9. Efficacy of immunoglobulin plus prednisolone for prevention of coronary artery abnormalities in severe Kawasaki disease (RAISE study): a randomised, open-label, blinded-endpoints trial

Kobayashi T, et al. The Lancet, Early Online Publication, 8 March 2012

Background: Evidence indicates that corticosteroid therapy might be beneficial for the primary treatment of severe Kawasaki disease. We assessed whether addition of prednisolone to intravenous immunoglobulin with aspirin would reduce the incidence of coronary artery abnormalities in patients with severe Kawasaki disease.

Methods: We did a multicentre, prospective, randomised, open-label, blinded-endpoints trial at 74 hospitals in Japan between Sept 29, 2008, and Dec 2, 2010. Patients with severe Kawasaki disease were randomly assigned by a minimisation method to receive either intravenous immunoglobulin (2 g/kg for 24 h and aspirin 30 mg/kg per day) or intravenous immunoglobulin plus prednisolone (the same intravenous immunoglobulin regimen as the intravenous immunoglobulin group plus prednisolone 2 mg/kg per day given over 15 days after concentrations of C-reactive protein normalised). Patients and treating physicians were unmasked to group allocation. The primary endpoint was incidence of coronary artery abnormalities during the study period. Analysis was by intention to treat. This trial is registered with the University Hospital Medical Information Network clinical trials registry, number UMIN000000940.

Findings: We randomly assigned 125 patients to the intravenous immunoglobulin plus prednisolone group and 123 to the intravenous immunoglobulin group. Incidence of coronary artery abnormalities was significantly lower in the intravenous immunoglobulin plus prednisolone group than in the intravenous immunoglobulin group during the study period (four patients [3%] vs 28 patients [23%]; risk difference 0•20, 95% CI 0•12—0•28, p less than 0•0001). Serious adverse events were similar between both groups: two patients had high total cholesterol and one neutropenia in the intravenous immunoglobulin plus prednisolone group, and one had high total cholesterol and another non-occlusive thrombus in the intravenous immunoglobulin group.

Interpretation: Addition of prednisolone to the standard regimen of intravenous immunoglobulin improves coronary artery outcomes in patients with severe Kawasaki disease in Japan. Further study of intensified primary treatment for this disease in a mixed ethnic population is warranted.

10. Greet and Street: Streamlining the ED or Taking Risks?

Shaw, Gina. Emergency Medicine News: March 2012 - Volume 34 - Issue 3 - pp 1,22

Sometimes a headache is just a headache. But sometimes it's a subarachnoid hemorrhage.

The triage process in the emergency department is meant to distinguish between such cases and prioritize the most critical patients. At Halifax Health System in Daytona Beach, FL, a new cost-saving policy aimed at reducing unnecessary ED use has recently raised the stakes for accurate triage.

Beginning in mid-May, all patients 18 to 64 deemed not to be emergencies are directed to an on-site health clinic charging $48 per visit or are given a list of community resources. If they really want to be seen in the emergency department, they can pay their insurance co-pay or $350 in cash up front.

Director of Emergency Services Peter Springer, MD, explained that likely nonemergent cases are identified by chief complaint, for which they did a literature review to establish categories, such as chronic tooth and ear pain, sore throats and minor cold and flu symptoms, suture removals, hemorrhoids and constipation, and nonacute psychiatric presentations. Patients are given a quick, focused physical by a physician or physician assistant. “If it really is a nonemergent case, we give them some choices,” he said.

Halifax is not alone in this policy, which some have dubbed “greet and street.” Those who swear by it say it's EMTALA-compliant: as long as every patient seeking emergency care is given a screening exam, EMTALA doesn't mandate that the hospital has any further obligations if that exam does not reveal an emergent medical condition. Indeed, Central Florida Regional Hospital in nearby Sanford implemented a similar rule to little fanfare a couple of years ago. Like many hospitals, Halifax is facing budget constraints, and notes that about a third of its bad debt is generated by its emergency departments.

“We're trying to appropriately utilize our resources so we have the capacity to effectively treat the true emergencies,” Dr. Springer said.

But what are the risks of such a strict triage policy? And will it really cut costs?

Timothy Platts-Mills, MD, an assistant professor of emergency medicine at the University of North Carolina School of Medicine, has written about ED crowding and the accuracy of triage. He noted that Halifax's exclusion of very young and elderly patients from the new approach mitigates some of the hazards. “In a study we conducted of older adult triage, we found that for roughly a quarter of patients who required an immediate intervention, the need for an immediate intervention was not identified at the time of triage,” he said. “Older adults are more likely to have life-threatening illness or injury, and identifying emergencies in older adults is probably more difficult. To the extent that these providers feel the need to have a policy of diverting nonurgent patients, I think these age limit exclusions make sense.”

The question remains if the rest of patients presenting to the ED — the 18- to 64-year-olds — can be triaged safely to an outpatient setting. “The answer depends on a number of things, including the characteristics of the triage process and the capacity of the outpatient clinic to provide care and recognize when a mis-triage has occurred,” Dr. Platts-Mills said. “If practitioners have limited time to complete triage assessments or if they face external pressure to triage patients into a nonurgent category, I think there is risk to patients. No one is perfect. A triage system that uses a chief complaint alone to identify nonurgent patients would almost certainly be unsafe because for almost any complaint [including common, seemingly mundane complaints such as back pain or dental pain], there will be some patients with that complaint who have a life-threatening condition.”

The essay continues here: http://journals.lww.com/em-news/Fulltext/2012/03000/Breaking_News__Greet_and_Street__Streamlining_the.3.aspx

11. Cardioversion of acute AF in the ED: a prospective randomised trial.

Shocking more effective than propafenone (89% vs 74%) and required a much shorter LOS

Bellone A, et al. Emerg Med J. 2012;29:188-191

Background: Strategies to restore sinus rhythm in patients with atrial fibrillation (AF) lasting less than 48h with haemodynamic stability remain controversial. The aim of this study was to test the hypothesis that electrical cardioversion (EC) would be more effective and safer in converting acute AF to sinus rhythm, compared with intravenous propafenone treatment.

Methods: In the emergency department (ED) of Valduce Hospital, a single-centre randomised trial was conducted to compare EC with pharmacological cardioversion (PC) to restore the sinus rhythm in selected patients with acute AF. A total of 247 patients was enrolled (121 in the EC group and 126 in the PC group). Results EC was more successful than PC in restoring sinus rhythm. Successful cardioversion was achieved in 108 out of 121 patients in the EC group (89.3%) and 93 out of 126 patients in the PC group (73.8%) (HR in the EC group, 0.34; 95% CI 0.17 to 0.68; p=0.02). The time patients spent in the ED undergoing treatment was significantly lower in the EC group compared with the PC group (median (range), 180 (120-900) vs 420 (120-1400) min; p less than 0.001).

Conclusions: EC was more effective in patients with acute AF and resulted in a shorter length of stay in the ED than PC. Adverse events were small in number and transient in both groups of patients.

12. Assessment of Medicare's (Unreliable) Imaging Efficiency Measure for Emergency Department Patients with Atraumatic Headache

Schuur JD, et al. Ann Emerg Med 2012; in press

Study objective: Computed tomography (CT) use has increased rapidly, raising concerns about radiation exposure and cost. The Centers for Medicare & Medicaid Services (CMS) developed an imaging efficiency measure (Outpatient Measure 15 [OP-15]) to evaluate the use of brain CT in the emergency department (ED) for atraumatic headache. We aim to determine the reliability, validity, and accuracy of OP-15.

Methods: This was a retrospective record review at 21 US EDs. We identified 769 patient visits that CMS labeled as including an inappropriate brain CT to identify clinical indications for CT and reviewed the 748 visits with available records. The primary outcome was the reliability of OP-15 as determined by CMS from administrative data compared with medical record review. Secondary outcomes were the measure's validity and accuracy. Outcome measures were defined according to the testing protocol of the American Medical Association's Physician Consortium for Performance Improvement.

Results: On record review, 489 of 748 ED brain CTs identified as inappropriate by CMS had a measure exclusion documented that was not identified by administrative data; the measure was 34.6% reliable (95% confidence interval [CI] 31.2% to 38.0%). Among the 259 patient visits without measure exclusions documented in the record, the measure's validity was 47.5% (95% CI 41.4% to 53.6%), according to a consensus list of indications for brain CT. Overall, 623 of the 748 ED visits had either a measure exclusion or a consensus indication for CT; the measure's accuracy was 16.7% (95% CI 14% to 19.4%). Hospital performance as reported by CMS did not correlate with the proportion of CTs with a documented clinical indication (r=–0.11; P=.63).

Conclusion: The CMS imaging efficiency measure for brain CTs (OP-15) is not reliable, valid, or accurate and may produce misleading information about hospital ED performance.

13. Premature Documentation of Poor Prognosis in Postarrest Therapeutic Hypothermia

In a small study, 21% of patients with factors indicating poor prognosis during postarrest therapeutic hypothermia made full neurological recovery.

Perman SM et al. Crit Care Med 2012 Mar; 40:719
.
OBJECTIVE: Early assessment of neurologic recovery is often challenging in survivors of cardiac arrest. Further, little is known about when to assess neurologic status in comatose, postarrest patients receiving therapeutic hypothermia. We sought to evaluate timing of prognostication in cardiac arrest survivors who received therapeutic hypothermia.

DESIGN: A retrospective chart review of consecutive postarrest patients receiving therapeutic hypothermia (protocol: 24-hr maintenance at target temperature followed by rewarming over 8 hrs). Data were abstracted from the medical chart, including documentation during the first 96 hrs post arrest of "poor" prognosis, diagnostic tests for neuroprognostication, consultations used for determination of prognosis, and outcome at discharge.

SETTING: Two academic urban emergency departments.

PATIENTS: A total of 55 consecutive patients who underwent therapeutic hypothermia were reviewed between September 2005 and April 2009.

INTERVENTION: None.

RESULTS: Of our cohort of comatose postarrest patients, 59% (29 of 49) were male, and the mean age was 56 ± 16 yrs. Chart documentation of "poor" or "grave" prognosis occurred "early": during induction, maintenance of cooling, rewarming, or within 15 hrs after normothermia in 57% (28 of 49) of cases. Of patients with early documentation of poor prognosis, 25% (seven of 28) had care withdrawn within 72 hrs post arrest, and 21% (six of 28) survived to discharge with favorable neurologic recovery. In the first 96 hrs post arrest: 88% (43 of 49) of patients received a head computed tomography, 90% (44 of 49) received electroencephalography, 2% (one of 49) received somatosensory evoked potential testing, and 71% (35 of 49) received neurology consultation.

CONCLUSIONS: Documentation of "poor prognosis" occurred during therapeutic hypothermia in more than half of patients in our cohort. Premature documentation of poor prognosis may contribute to early decisions to withdraw care. Future guidelines should address when to best prognosticate in postarrest patients receiving therapeutic hypothermia.

14. Outcomes of Pregnancies with ED-documented IUPs

A. Fetal loss in symptomatic first-trimester pregnancy with documented yolk sac intrauterine pregnancy

Hessert MJ, et al. Amer J Emerg Med. 2012;30:399-404.

Background: The possibility of spontaneous miscarriage is a common concern among pregnant women in the emergency department (ED).

Objective: This study sought to determine fetal outcomes for women following ED evaluation for first-trimester abdominopelvic pain or vaginal bleeding who had an intrauterine pregnancy (IUP) on ultrasound before a visible fetal pole (“yolk sac IUP”).

Methods: A retrospective chart review of consecutive ED charts from December 2005 to September 2006 identified patients with a yolk sac IUP. Demographic data, obstetric/gynecologic history, and presenting symptoms were obtained. Outcomes were determined via computerized records. Fetal loss was diagnosed by falling β-human chorionic gonadotropin or pathology specimen. Live birth was diagnosed by viable fetus at 20-week ultrasound or delivery.

Results: A total of 131 patients were enrolled in this study. Of these, 14 were lost to follow-up (12%), leaving 117 patient encounters. Of the 117 women, 82 carried their pregnancies to at least 20-week gestation. Thirty-five patients miscarried. Fetal loss rate by chief complaint were as follows: 8 of 46 patients presenting with pain only, 14 of 34 presenting with vaginal bleeding only, and 13 of 37 with both vaginal bleeding and pain.

Conclusion: Seventy percent of women diagnosed with a yolk sac IUP in the ED carried their pregnancy to at least 20 weeks. The remaining women (30%) experienced fetal loss. Vaginal bleeding (with or without pain) increased the rate of fetal loss compared with women with pain only. These data will assist the emergency physician in counseling women with symptomatic first-trimester pregnancies.

B. Prospective outcomes of pregnant ED patients with documented fetal cardiac activity on ultrasound

Mallin M, et al. Amer J Emerg Med. 2012;30:472-475.

Background: Evaluation of rates of spontaneous abortion (SAB) may aid in counseling pregnant patients seen in the emergency department (ED). A recent chart review reported an SAB rate of 10% among ED patients with a documented intrauterine pregnancy (IUP) and cardiac activity on ultrasound. We sought to prospectively evaluate outcomes among pregnant ED patients with documented cardiac activity on ultrasound.

Methods: We prospectively enrolled a convenience sample of pregnant patients presenting to the University of Utah ED between January 1, 2008, and April 30, 2009. Ultrasound was performed during the ED visit. Patient outcomes were followed up 30 days after the ED visit. Patients were contacted by telephone or the medical record was reviewed for documentation of pregnancy status.

Results: Seventy-one patients with an IUP and documented fetal cardiac activity were enrolled. We were able to obtain 30-day follow-up information on 61 patients (85.9%). Average patient age was 26.7 years (range, 17-42 years), average reported gravida was 3.3 (range, 1-8), and average gestational age was 10 weeks. Nine patients (14.8%; 95% confidence interval, 8.7%-23.9%) either reported or had a documented SAB during the 30 days after the ED visit.

Conclusion: In this study, which represents the first prospective evaluation of ED patients with documented IUP with fetal heart tones, the rate of SAB was consistent with that reported previously for this population. These results confirm that ED patients represent a high-risk group, and additional research is needed to better characterize risk factors for SAB.

15. Early vs. Late Treatment of Acute Migraine Attacks

An open-label study in daily neurological practice confirms that migraine attacks should be treated early.

Lantéri-Minet M, et al. Cephalalgia. 2012 Feb;32(3):226-35.

Aim: To compare the effectiveness of early or late triptan intake in the treatment of acute migraine attacks.

Methods: The TEMPO study was a French prospective, multicentre, two-phase study conducted in neurological practice. Two-hundred-and-ten migraine patients who were regular triptan users were enrolled. In the first phase, patients treated three attacks as they usually did. In the second phase, those who initially practiced late dosing ( ≥ 1 hour after headache onset) were instructed to change to early dosing (within 1 hour).

Results: A total of 144 patients completed the first phase. Seventy-nine patients constituted the 'early dosers' group and 65 patients the 'late dosers' group. In this phase, early dosing produced higher rates (n = 38; 52.8%) of freedom from pain at 2 hours in at least two of three attacks compared with late dosing (n = 19; 30.2%; p  less than  0.01). In the second phase, switching from late to early dosing following the physician's instruction (n = 42 patients) also improved the rates of freedom from pain at 2 hours (from 38.1% (n = 16) to 53.7% (n = 22); p  less than  0.05).

Conclusion: This suggests that advising patients on the importance of early triptan intake after headache onset may help improve the efficacy of acute migraine treatments..

16. The Problem with Pradaxa

by Kevin Klauer, DO, EJD. Emergency Physicians Monthly, March 6, 2012.

The FDA-approved drug dabigatran is being marketed as a safe alternative to Coumadin. But without a proven reversal agent available, it has the potential to create a new set of complications, and send unsuspecting patients right back to the ED.

A 77-year-old patient presented to the ED a few months ago after gently falling over onto a carpeted floor while using his walker. The patient appeared well with the exception of dry mucous membranes. He complained of his typical back pain (upper, mid-thoracic) and he reported decreased P.O. intake. His initial blood pressure was 76/48. With no other physical findings, serial fluid boluses were ordered to address the potential of dehydration as the cause of his hypotension and subsequent fall. A further diagnostic evaluation was taken while the fluids were being administered. Sure enough, his urinalysis showed positive nitrate with greater than 100 WBCs. In addition, his BUN and creatinine were 56 and 3.1, respectively. These changes were new. His WBC count was 10.2, Hgb was 11.0, and he was afebrile. Before you ask, his ECG showed an AV-sequential pacemaker without any changes from previous.

So, we had a clinically dehydrated 77-year-old patient with new onset renal failure, most likely secondary to his dehydration associated with his UTI and poor P.O. intake. With a negative review of systems and relatively negative exam, his hypotension fit the picture. However, after two 500cc fluid boluses, his blood pressure hadn’t changed. In a non-septic patient with dehydration, an improvement was expected. However, when the square peg didn’t fit the round hole, it was time to broaden the differential diagnosis. Again, he was asked about his history: “Any new medications? Are you sure this is the same pain you always have? Are you on any blood thinners?” He replied, “Nope. Exactly the same, I used to be on Coumadin but my doctor took me off of that a month ago.” Although this patient’s pain was typical for him, a CT of the chest was ordered.

The CT revealed a pericardial effusion that was further confirmed as cardiac tamponade by bedside 2-D echo, following a call from Radiology reporting a pericardial effusion. The Echo confirmed early tamponade. Now there seemed to be an explanation.

Superimposing tamponade on dehydration likely limited the physical findings of tamponade to refractory hypotension. But what was the cause of the tamponade? On further more insistence history, it turned out the patient was on Pradaxa and Plavix. But now we had a relatively bare cabinet of antidotes. As a result, he received FFP and vitamin K and an emergent pericardial window evacuation of 1000 cc of blood from his acute hemopericardium.

With its narrow therapeutic window, ugly side-effect profile and need for drug monitoring, Coumadin leaves much to be desired, and many physicians have looked forward to a “white knight” drug to take its place. But be careful what you wish for. If you are too needy and too desperate, as we all have been to avoid the use of Coumadin, we may be enticed into early adoption of an alternative that may actually be worse. (I may have been an early adopter of parachute pants in the 80s, but I learned my lesson.) The combination of Coumadin’s drawbacks and the ramped up marketing efforts for Pradaxa has resulted in skyrocketing use of the new drug.

As bad as Coumadin can be, it is inexpensive – less than $0.50 a pill – and its shortcomings are very well known. On the other hand, a daily course of Pradaxa (150 mg BID) will cost over $8. But I certainly wouldn’t advocate the continued use of Coumadin from a cost perspective. If we have something safer, the higher cost is money well spent. The point, however, is that dabigatran’s safety is truly debatable, despite the fact that it was approved by the FDA. (There have been a laundry list of bad actors pulled from the market for safety reasons, despite the FDA’s willingness to approve them.)

At an EM conference in February attended by many international physicians, I asked the participants, “Has anyone seen any complications from Pradaxa yet?” I expected just a few, but I was amazed to see almost half of the audience raise their hands. Despite the fact that no case reports have yet been published, it appears, anecdotally, that real safety issues do exist.

The rest of the essay can be found here: http://www.epmonthly.com/features/current-features/the-problem-with-pradaxa/

17. Incidence of Immediate Hypersensitivity Reaction and Serum Sickness Following Administration of Crotalidae Polyvalent Immune Fab Antivenom: A Meta-analysis

Schaeffer TH, et al. Acad Emerg Med 2012;19:121-131.

Objectives:  Crotalidae polyvalent immune Fab (ovine) (FabAV) is commonly used in the treatment of symptomatic North American crotaline snake envenomation. When approved by the U.S. Food and Drug Administration in 2000, the incidences of immediate hypersensitivity reactions and serum sickness were reported as 0.14 and 0.18, respectively. The objective of this meta-analysis was to evaluate the incidence of immediate hypersensitivity reactions and serum sickness reported in studies of patients treated with FabAV therapy after North American crotaline envenomation.

Methods:  The authors searched PubMed, Ovid MEDLINE, and EMBASE from January 1, 1997, to September 20, 2010, for English-language medical literature and cross-referenced bibliographies of reviewed articles. The published abstracts of the major toxicology conferences were also searched. All prospective and retrospective cohort studies with patients receiving FabAV therapy for North American crotaline envenomations were eligible for data abstraction. Two content experts reviewed full-text articles and extracted relevant study design and outcome data. Proportions of immediate hypersensitivity and serum sickness for each study were analyzed in a random-effects model to produce an overall estimate of immediate hypersensitivity and serum sickness incidence associated with FabAV administration.

Results:  The literature search revealed 11 unique studies of patients who received FabAV that contained information on immediate hypersensitivity reactions and serum sickness. The meta-analysis produced a combined estimate of the incidence of immediate hypersensitivity of 0.08 (95% confidence interval [CI] = 0.05 to 0.11) and a combined estimate of the incidence of serum sickness of 0.13 (95% CI = 0.07 to 0.21).

Conclusions:  In this systematic literature review and meta-analysis, the combined estimates of the incidence of immediate hypersensitivity reactions and serum sickness from FabAV in the treatment of symptomatic North American crotaline envenomations appear to be lower than previously reported, at 0.08 and 0.13, respectively.

18. Predicting outcome of IV thrombolysis-treated ischemic stroke patients: The DRAGON score.

Strbian D, et al. Neurology. 2012 Feb 7;78(6):427-32.

OBJECTIVE: To develop a functional outcome prediction score, based on immediate pretreatment parameters, in ischemic stroke patients receiving IV alteplase.

METHODS: The derivation cohort consists of 1,319 ischemic stroke patients treated with IV alteplase at the Helsinki University Central Hospital, Helsinki, Finland. We evaluated the predictive value of parameters associated with the 3-month outcome and developed the score according to the magnitude of logistic regression coefficients. We assessed accuracy of the model with bootstrapping. External validation was performed in a cohort of 330 patients treated at the University Hospital Basel, Basel, Switzerland. We assessed the score performance with area under the receiver operating characteristic curve (AUC-ROC).

RESULTS: The DRAGON score (0-10 points) consists of (hyper)Dense cerebral artery sign/early infarct signs on admission CT scan (both = 2, either = 1, none = 0), prestroke modified Rankin Scale (mRS) score above 1 (yes = 1), Age (80 years or older = 2, 65-79 years = 1, less than 65 years = 0), Glucose level at baseline (greater than 8 mmol/L [144 mg/dL] = 1), Onset-to-treatment time (over 90 minutes = 1), and baseline National Institutes of Health Stroke Scale score (above 15 = 3, 10-15 = 2, 5-9 = 1, 0-4 = 0). AUC-ROC was 0.84 (0.80-0.87) in the derivation cohort and 0.80 (0.74-0.86) in the validation cohort. Proportions of patients with good outcome (mRS score 0-2) were 96%, 88%, 74%, and 0% for 0-1, 2, 3, and 8-10 points, respectively. Proportions of patients with miserable outcome (mRS score 5-6) were 0%, 2%, 5%, 70%, and 100% for 0-1, 2, 3, 8, and 9-10 points, respectively. External validation showed similar results.

CONCLUSIONS: The DRAGON score is valid at our site and was reliable externally. It can support clinical decision-making, especially when invasive add-on strategies are considered. The score was not studied in patients with basilar artery occlusion. Further external validation is warranted.

19. Pediatric Pain from Fractures Is Undertreated in the ED

Only 70% of children with isolated long bone fractures received pain medication during their emergency department stays.

Dong L, et al. Pediatr Emerg Care 2012 Feb;28(2):109-14.

OBJECTIVES: The objective of the study was to describe analgesia utilization before and during the emergency department (ED) visit and assess factors associated with analgesia use in pediatric patients with isolated long-bone fractures.

METHODS: This retrospective cohort study of patients aged 0 to 15 years with a diagnosis of an isolated long-bone fracture was conducted at a single, level I pediatric trauma center. Patients included were treated in the ED within 12 hours of injury and subsequently admitted to the hospital from January 2005 through August 2007. Pain medication received within the first hour after ED arrival was categorized based on prespecified standard doses as follows: adequate, inadequate, and no pain medication received. Cumulative logistic regression analysis assessed factors associated with analgesia use.

RESULTS: There were 773 patients with isolated long-bone fracture included in the analysis. Overall, 10% of patients received adequate pain medicine; 31% received inadequate medicine; and 59% received no pain medicine within 1 hour of ED arrival. In multivariable analysis, children with younger age, longer time from injury to ED arrival, closed fractures, and upper-extremity fractures were less likely to receive adequate pain medicine during the ED visit. Of those transported by emergency medical services directly from the scene to the ED, 9 (10%) of 88 were given pain medication during transport.

CONCLUSIONS: Pain management in pediatric patients following a traumatic injury has been recognized as an important component of care. This study suggests that alleviation of pain after traumatic injury requires further attention in both the prehospital and ED settings, especially among the youngest children.
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20. The Emergency Airway: The Best Airway Articles of 2011

Braude, Darren MD, EMT-P. Emergency Medicine News: March 2012 - Volume 34 - Issue 3 - p 10

It is time again to review the most interesting airway literature from this past year, one that gave us some impressive research that every emergency physician should read.

Full-text here: http://journals.lww.com/em-news/Fulltext/2012/03000/The_Emergency_Airway__The_Best_Airway_Articles_of.7.aspx

21. Beam me up Scotty! Impact of personal wireless communication devices in the ED

Richards JD, Harris T. Emerg Med J. 2011 Jan;28(1):29-32.

OBJECTIVE: A qualitative study performed with a cross-sectional survey to report staff perceptions on emergency department (ED) communication while trialling a personal hands-free wireless communication device (WCD) between August and October 2008 in a busy inner city ED.

METHOD: A survey of all Royal London Hospital ED staff was conducted pre and post-implementation of a personal WCD. The survey included responses to occupation, experience, communication modes, communication wait times, perceived interruptions at the bedside and general perceptions of communication efficiency.

RESULTS: No appreciable change in communication modes or perceived waiting times was reported No increase in bedside interruptions were reported. An overwhelming number of respondents considered the system had contributed significantly to improving the quality of the work environment, patient safety and care.

CONCLUSION: This study correlated with others showing a very strong perception of improved communication and working environment: less noise, better handovers and improved staff resource use. The study adds to the limited number of published trials examining WCD in health care. Observational reports post-implementation were overwhelmingly positive. Quantitative studies measuring the impact on patient flow, safety and cost benefits should be considered.