Saturday, March 10, 2012

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.

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. ( 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:

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.


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:

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.
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:

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.