1. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and pre-injury warfarin or clopidogrel use.
Nishijima DK, and the KP CREST Network. Ann Emerg Med.
2012;59(6):460-468.e7
Study objective: Patients receiving warfarin or clopidogrel
are considered at increased risk for traumatic intracranial hemorrhage after
blunt head trauma. The prevalence of immediate traumatic intracranial
hemorrhage and the cumulative incidence of delayed traumatic intracranial
hemorrhage in these patients, however, are unknown. The objective of this study
is to address these gaps in knowledge.
Methods: A prospective, observational study at 2 trauma
centers and 4 community hospitals enrolled emergency department (ED) patients
with blunt head trauma and preinjury warfarin or clopidogrel use from April
2009 through January 2011. Patients were followed for 2 weeks. The prevalence
of immediate traumatic intracranial hemorrhage and the cumulative incidence of
delayed traumatic intracranial hemorrhage were calculated from patients who
received initial cranial computed tomography (CT) in the ED. Delayed traumatic
intracranial hemorrhage was defined as traumatic intracranial hemorrhage within
2 weeks after an initially normal CT scan result and in the absence of repeated
head trauma.
Results: A total of 1,064 patients were enrolled (768
warfarin patients [72.2%] and 296 clopidogrel patients [27.8%]). There were 364
patients (34.2%) from Level I or II trauma centers and 700 patients (65.8%)
from community hospitals. One thousand patients received a cranial CT scan in
the ED. Both warfarin and clopidogrel groups had similar demographic and
clinical characteristics, although concomitant aspirin use was more prevalent
among patients receiving clopidogrel. The prevalence of immediate traumatic
intracranial hemorrhage was higher in patients receiving clopidogrel (33/276,
12.0%; 95% confidence interval [CI] 8.4% to 16.4%) than patients receiving
warfarin (37/724, 5.1%; 95% CI 3.6% to 7.0%), relative risk 2.31 (95% CI 1.48
to 3.63). Delayed traumatic intracranial hemorrhage was identified in 4 of 687
(0.6%; 95% CI 0.2% to 1.5%) patients receiving warfarin and 0 of 243 (0%; 95%
CI 0% to 1.5%) patients receiving clopidogrel.
Conclusion: Although there may be unmeasured confounders
that limit intergroup comparison, patients receiving clopidogrel have a
significantly higher prevalence of immediate traumatic intracranial hemorrhage
compared with patients receiving warfarin. Delayed traumatic intracranial
hemorrhage is rare and occurred only in patients receiving warfarin.
Discharging patients receiving anticoagulant or antiplatelet medications from
the ED after a normal cranial CT scan result is reasonable, but appropriate
instructions are required because delayed traumatic intracranial hemorrhage may
occur.
The accompanying editorial (Li J. Ann Emerg Med.
2012;59(6):469-470) summarizes the operational impact of this clinical
research. To quote:
- Scan anyone with head trauma who is receiving warfarin or clopidogrel.
- For patients with normal initial CT scan results, ensure follow-up with at least a telephone call and rescan those with symptoms of delayed intracranial hemorrhage because such hemorrhage is rare but real.
- Finally, at least in the United States, the practice of routine hospitalization for anticoagulated patients with normal initial CT scan results is too costly to be worthwhile.
Fine AM, et al. Arch Intern Med. Published online May 7,
2012.
Introduction
Group A streptococcal (GAS) pharyngitis is the most common
cause of bacterial pharyngitis affecting over half a billion people annually
worldwide. GAS pharyngitis is both the antecedent for invasive streptococcal
infections such as necrotizing fasciitis and the postinfectious immunologic
complication of rheumatic fever and/or rheumatic heart disease, a leading cause
of cardiovascular morbidity and mortality in many developing parts of the
world. Physical examination of the posterior oropharynx is an inaccurate method
to distinguish GAS from other causes of acute pharyngitis, so Snow and others,
most importantly the Centers for Disease Control and Prevention (CDC) and the
American College of Physicians–American Society of Internal Medicine
(ACP-ASIM), endorse applying the 4-point Centor clinical scoring scale to
classify the risk of GAS and guide management of acute pharyngitis in adults
(Table 1). Developed 3 decades ago and based on the evaluation of 286 adults at
a single emergency department, the Centor score helps clinicians to distinguish
GAS from viral pharyngitis and thereby to appropriately prescribe antibiotics
to alleviate symptoms and decrease the rates of acute rheumatic fever,
suppurative complications, missed school and work days, and disease
transmission.
The McIsaac score, derived from 521 patients from a
university-affiliated family practice in Toronto, Ontario, Canada, and
validated on 621 patients from 49 Ontario communities, adjusts the Centor score
for the patient's age. Since younger patients are more likely to have GAS than
older patients, the McIsaac score is calculated by adding 1 point to the Centor
score for patients aged 3 to 14 years and subtracting 1 point for those 45
years or older. Because clinical prediction models may perform poorly when
applied to new settings, it is important to validate them on different
populations and over time. Furthermore, despite endorsement from CDC and
ACP-ASIM, the clinical scores have gained poor traction in clinical practice,
perhaps in part owing to the perception that the scores were derived from a
relatively small sample. Herein, we analyze a geographically diverse population
of patients who presented with sore throat to MinuteClinic, a large retail health
chain, to perform the largest validation studies of the Centor and McIsaac
scores.
Background: The
Centor and McIsaac scores guide testing and treatment for group A streptococcal
(GAS) pharyngitis in patients presenting with a sore throat, but they were
derived on relatively small samples. We perform a national-scale validation of
the prediction models on a large, geographically diverse population.
Methods: We analyzed
data collected from 206 870 patients 3 years or older who presented with a painful
throat to a United States national retail health chain from September 1, 2006,
to December 1, 2008. Main outcome measures were the proportions of patients
testing positive for GAS pharyngitis according to the Centor and McIsaac scores
(both scales, 0-4).
Results: For patients
15 years or older, 23% (95% CI, 22%-23%) tested positive for GAS, including 7%
(95% CI, 7%-8%) of those with a Centor score of 0; 12% (95% CI, 11%-12%) of
those with a Centor score of 1; 21% (95% CI, 21%-22%) of those with a Centor
score of 2; 38% (95% CI, 38%-39%) of those with a Centor score of 3; and 57%
(95% CI, 56%-58%) of those with a Centor score of 4. For patients 3 years or
older, 27% (95% CI, 27%-27%) tested positive for GAS, including 8% (95% CI,
8%-9%) of those testing positive with a McIsaac score of 0; 14% (95% CI,
13%-14%) of those with a McIsaac score of 1; 23% (95% CI, 23%-23%) of those
with a McIsaac score of 2; 37% (95% CI, 37%-37%) of those with a McIsaac score
of 3; and 55% (95% CI, 55%-56%) of those with a McIsaac score of 4. The 95% CIs
overlapped between our retail health chain–derived probabilities and the prior
reports.
Conclusion: Our study
validates the Centor and McIsaac scores and more precisely classifies risk of
GAS infection among patients presenting with a painful throat to a retail
health chain.
Full-text (free): http://archinte.ama-assn.org/cgi/content/full/archinternmed.2012.950
3. New AHA/ASA Guideline on Aneurysmal Subarachnoid
Hemorrhage
Megan Brooks. Medscape Medical News. May 3, 2012 — Patients
diagnosed with aneurysmal subarachnoid hemorrhage (aSAH) in hospitals that
manage fewer than 10 cases per year should be considered for immediate transfer
to a hospital that treats at least 35 cases a year, according to updated
guidelines on management of aSAH from the American Heart Association/American
Stroke Association (AHA/ASA).
Research has shown that 30-day death rates are significantly
higher in low-volume facilities (39% in hospitals treating fewer than 10
patients compared with 27% in hospitals treating more than 35 patients each
year), the AHA/ASA notes in a statement.
The new guideline, published online May 3 in Stroke, updates
guidelines issued in 2009 and reported by Medscape Medical News at that time.
Rapidly Developing Field
"These guidelines are released every 2 to 3 years;
nothing prompted them, they were a planned update," E. Sander Connolly Jr,
MD, chair of the statement writing group, noted in an email to Medscape Medical
News.
"The biggest take home message is that the field is
changing fast. There are lots of new guidelines; staying on top of these is critical
to patient care," added Dr. Connolly, vice-chairman of neurological
surgery at Columbia University in New York City and the co-director of the
neurosciences intensive care unit at New York-Presbyterian Hospital.
The writing group notes that the new update, "which is
based on a mere 42 months of publications," contains 21 new
recommendations (outlined in Table 4 in the paper), 5 of which are Class I
recommendations. There are also 9 changes in prior recommendations. In total,
there are now 22 Class I recommendations (outlined in Table 3).
Although it's not completely clear why outcomes are better
at high-volume centers, "patients admitted to high-volume facilities have
increased access to experienced cerebrovascular surgeons and endovascular
specialists, as well as multidisciplinary neuro-intensive care services, such
as EEG [electroencephalography] monitoring to rule out non-convulsive status
seizures," Dr. Connolly noted in a statement.
Larry B. Goldstein, MD, professor of medicine (neurology) and
director of the Duke Stroke Center in Durham, North Carolina, told Medscape
Medical News that transfer to high-volume centers when possible "makes
sense [as] there is an association between center volume and outcomes, and has
been seen for some other conditions."
He noted, however, that "decisions regarding transfer
of unstable patients with recent SAH is a bit more complicated, and would
likely need to be determined regionally and depending on individual patient
issues."
In these patients, "a multidisciplinary approach
afforded in larger centers might also contribute to better outcomes. Studies
have shown better outcomes for patients with hemorrhagic strokes cared for in
Primary Stroke Centers, even though the focus of these centers is on non-hemorrhagic
strokes. This may reflect institutional commitment to stroke care in general,
and better care organization."
aSAH is responsible for about 5% of all strokes and affects
more than 30,000 Americans each year, most of them aged 40 to 60 years.
Prevention recommendations still center on controlling hypertension and
avoiding cigarette smoking and excessive alcohol use.
Some of the new class I (level B) recommendations are as follows:
• Digital subtraction angiography with 3-dimensional
rotational angiography is indicated for detection of aneurysm in patients with
aSAH (except when the aneurysm was previously diagnosed by noninvasive
angiography) and for planning treatment (to determine whether an aneurysm is
amenable to coiling or to expedite microsurgery).
• Between the time of aSAH symptom onset and aneurysm
obliteration, blood pressure should be controlled with a titratable agent to
balance the risk for stroke, hypertension-related rebleeding, and maintenance
of cerebral perfusion pressure.
Some of the revised recommendations are as follows:
• For patients with
an unfavorable delay in obliteration of aneurysm, a significant risk for
rebleeding, and no compelling medical contraindications, short-term (< 72
hours) therapy with tranexamic acid or aminocaproic acid is reasonable to
reduce the risk for early aneurysm rebleeding. (Class IIa, Level B)
• Low-volume hospitals should consider early transfer of
patients with aSAH to high-volume centers. (Class I, Level B)
• Maintaining euvolemia and normal circulating blood volume
is recommended to prevent delayed cerebral ischemia (DCI). (Revised, Class I,
Level B)
In this "fast-developing field," frequent revision
of these guidelines is "clearly needed [and] the data presented here only
begin to scratch the surface of the burgeoning knowledge," the writing
group concludes. "Those faced with managing these patients will thus do
well to use these guidelines as merely a starting point for doing everything
possible to improve the outcomes of patients with aSAH."
Executive summary: http://stroke.ahajournals.org/content/suppl/2012/05/02/STR.0b013e3182587839.DC1/Executive_Summary.pdf
4. Outcomes of Patients Admitted for Observation of Chest
Pain
Penumetsa SC, et al. Arch Intern Med. Published online May
7, 2012.
Background: Low-risk
chest pain is a common cause of hospital admission; however, to our knowledge,
there are no guidelines regarding the appropriate use of stress testing in such
cases.
Methods: We performed
a retrospective cohort study of patients 21 years and older who were admitted
to our tertiary care center with chest pain in 2007 and 2008. Using electronic
records and chart review, we sought (1) to identify differences in the use of
stress testing based on patient demographics and comorbidities, pretest
probability of coronary artery disease, and house staff coverage and (2) to
describe the results of stress testing and patient outcomes, including
revascularization procedures and 30-day readmissions for myocardial infarction.
Results: Of 2107
patients, 1474 (69.9%) underwent stress tests, and the results were abnormal in
184 patients (12.5%). Within 30 days, 22 patients (11.6%) with abnormal test
results underwent cardiac catheterization, 9 (4.7%) underwent
revascularization, and 2 (1.1%) were readmitted for myocardial infarction. In a
multivariable model, stress test ordering was positively associated with age
younger than 70 years (RR [relative risk], 1.12; 95% CI, 1.02-1.23), private
insurance (vs Medicare/Medicaid: RR, 1.19; 95% CI, 1.11-1.27), and no house
staff coverage (RR, 1.39; 95% CI, 1.28-1.50). Of patients with low (<10%)
pretest probability, 68.0% underwent stress testing, but only 4.5% of these had
abnormal test results.
Conclusions: Most
patients who are admitted with low-risk chest pain undergo stress testing,
regardless of pretest probability, but abnormal test results are uncommon and
rarely acted on. Ordering stress tests based on pretest probability could
improve efficiency without endangering patients.
5. Guidelines Out for Diagnostic Cath Use
By Chris Kaiser, Cardiology Editor, MedPage Today. May 09,
2012
The explosion of advanced cardiovascular diagnostic
technology has prompted the publication of the first-ever appropriate use
criteria for diagnostic catheterization. Out of a possible 166 clinical
scenarios for the use of diagnostic cath, a panel of experts identified nearly
half as appropriate, 30% as uncertain, and 25% as inappropriate, according to
Manesh Patel, MD, from Duke University, and colleagues.
The appropriate use criteria (AUC) document covers coronary
artery disease situations, but also includes valvular disease,
cardiomyopathies, and transplantation, and whether it's appropriate to use
adjunctive invasive techniques such as fractional flow reserve and
intravascular ultrasound.
The document will be published in the May 29 issue of the
Journal of the American College of Cardiology and also will be co-published in
Catheterization and Cardiovascular Interventions and the Journal of Thoracic
and Cardiovascular Surgery.
The writers emphasized that a designation of
"uncertain" does not mean the procedure is never done nor does it
constitute grounds for nonreimbursement. The term indicates that the test may
be generally acceptable, but may need more patient information for a specific
indication. "The ultimate objective of the AUC is to improve patient care
and health outcomes in a cost-effective manner while recognizing that some
ambiguity and nuance is intrinsic to clinical decision making," the
experts wrote.
A test is deemed appropriate if the "expected
incremental information combined with clinical judgment exceeds the negative
consequences by a sufficiently wide margin."
A few examples where the technical panel determined that
diagnostic cardiac catheterization was appropriate include patients:
·
Without prior stress testing but who report symptoms
and have a high pretest probability, or high likelihood of disease in the
physician's judgment
·
With definite or suspected acute coronary
syndrome
·
With typical symptoms and intermediate- or
high-risk findings on prior diagnostic testing
·
With suspected pulmonary hypertension with
equivocal or borderline elevated estimated right ventricular systolic pressure
on resting echo
For the full-text article itself (free): http://content.onlinejacc.org/cgi/content/full/j.jacc.2012.03.003
6. Outcomes of PCI at Hospitals with or without On-Site
Cardiac Surgery
Aversano T, et al. N Engl J Med 2012; 366:1792-1802.
Background: Performance of percutaneous coronary
intervention (PCI) is usually restricted to hospitals with cardiac surgery on
site. We conducted a noninferiority trial to compare the outcomes of PCI
performed at hospitals without and those with on-site cardiac surgery.
Methods: We randomly assigned participants to undergo PCI at
a hospital with or without on-site cardiac surgery. Patients requiring primary
PCI were excluded. The trial had two primary end points: 6-week mortality and
9-month incidence of major adverse cardiac events (the composite of death,
Q-wave myocardial infarction, or target-vessel revascularization).
Noninferiority margins for the risk difference were 0.4 percentage points for
mortality at 6 weeks and 1.8 percentage points for major adverse cardiac events
at 9 months.
Results: A total of 18,867 patients were randomly assigned
in a 3:1 ratio to undergo PCI at a hospital without on-site cardiac surgery
(14,149 patients) or with on-site cardiac surgery (4718 patients). The 6-week
mortality rate was 0.9% at hospitals without on-site surgery versus 1.0% at
those with on-site surgery (difference, −0.04 percentage points; 95% confidence
interval [CI], −0.31 to 0.23; P=0.004 for noninferiority). The 9-month rates of
major adverse cardiac events were 12.1% and 11.2% at hospitals without and
those with on-site surgery, respectively (difference, 0.92 percentage points;
95% CI, 0.04 to 1.80; P=0.05 for noninferiority). The rate of target-vessel
revascularization was higher in hospitals without on-site surgery (6.5% vs.
5.4%, P=0.01).
Conclusions: We found that PCI performed at hospitals
without on-site cardiac surgery was noninferior to PCI performed at hospitals
with on-site cardiac surgery with respect to mortality at 6 weeks and major
adverse cardiac events at 9 months. (Funded by the Cardiovascular Patient
Outcomes Research Team [C-PORT] participating sites; ClinicalTrials.gov number,
NCT00549796.)
See also this review: Shahian DM, et al. Percutaneous
Coronary Interventions without On-Site Cardiac Surgical Backup. N Engl J Med 2012;
366:1814-1823.
7. Does Everyone With Chest Pain Need a Stress Test?
Penumetsa SC, et al. Outcomes of Patients Admitted for
Observation of Chest Pain. Arch Intern Med. 2012 May 7. [Epub ahead of print]
By Kerry Grens. From Reuters Health Information. NEW YORK
(Reuters Health) May 09 - People who come to the emergency department
complaining of chest pain often get stress tests that aren't helping them very
much, according to a new study. The results "showed something that we have
thought, that we probably do stress testing too often," said Dr. Troy
Madsen, a professor at the University of Utah School of Medicine, who was not
involved in the research.
Dr. Srikanth Penumetsa and colleagues of Baystate Medical
Center in Springfield, Massachusetts, who published their findings online May
7th in the Archives of Internal Medicine, sought to find out whether giving
stress tests to people admitted to the hospital with chest pain was helping to
identify those who would end up having a heart attack within the month
following the hospital visit.
They looked back on the medical records of about 2,100
patients who had been admitted over a two-year period to their hospital. Seven
out of every 10 patients received a stress test, with abnormal results in 12%.
Of the 184 patients who had abnormal results, 23 (12.5%) underwent a follow-up
test (usually angiography) and 10 had bypass surgery or stenting.
Dr. Madsen said he was surprised that more people didn't get
a follow up test - but Dr. Penumetsa said not all patients require an angiogram
after an abnormal test, and "therefore I do not think this number should
have been higher." Within a month after discharge, seven patients suffered
a heart attack, including three who had undergone stress testing.
Dr. Penumetsa said the results show that stress testing does
not lower the chances of having a heart attack within the next 30 days. "Since
stress testing has not been shown to decrease the risk of having a heart
attack, there is no absolute need to routinely perform this test prior to
discharge," Dr. Penumetsa wrote in an email to Reuters Health.
Dr. Anthony Napoli, an emergency physician at Rhode Island
Hospital, said a good starting place to reduce unnecessary stress tests would
be with patients at low risk of having heart disease. "They might be the
one group that you could target as having a planned protocol that would say,
those who are low risk don't get a stress test and just get a certain follow
up," Dr. Napoli said. "That would reduce stress test utilization, but
also maintain the same safety and efficacy."
Dr. Penumetsa suggested that after a brief observation in
the hospital, and after a heart attack is ruled out, patients could be sent
home and followed up a few days later in a doctor's office, instead of given a
stress test.
Dr. Napoli, who was not involved with the new research, said
the idea of limiting stress tests to those at a higher risk of having a heart
attack would need to be studied before it could be widely recommended.
Dr. Penumetsa also that doctors' concerns over lawsuits
might also be affecting their care. "If they've ordered a stress test,
then they can say that 'they've done everything possible' before sending the
patient home, even if 'everything possible' doesn't actually change the outcome
at all," said Dr. Penumetsa.
8. One Troponin Test to Identify Low-Risk Patients Fast
Sue Hughes. From Heartwire. May 18, 2012 (Updated May 21,
2012) (Christchurch, New Zealand) — A simple strategy of measuring just
contemporary central-laboratory troponin I within two hours of presentation as
the sole biomarker in conjunction with ECG and the TIMI risk score can identify
a large group of chest-pain patients who are at low risk of cardiac events and
are suitable for safe early discharge from the ER, a new study suggests [1].
"As the components required for this strategy are
already widely available, rapid uptake of this accelerated diagnostic protocol
is possible by most hospitals with the potential for immediate health service
benefit," the authors conclude.
The study was published online May 9, 2012 in the Journal of
the American College of Cardiology, by a group led by Dr Martin Than
(Christchurch Hospital, New Zealand).
They tested this protocol on a group of 1975 patients
presenting to the ER with chest pain. The accelerated protocol classified 392
patients (20%) as low risk, only one of whom (0.25%) had a cardiac event within
the next 30 days. This translates into a sensitivity of 99.7% and a negative
predictive value of 99.7%.
Than commented to heartwire: "There haven't been many
papers on combining clinical risk stratification with a troponin test. There is
a lot of interest in the high-sensitivity troponin test for identifying a
low-risk population, but this is not available in many places yet. While we are
waiting for this test to come through, we have come up with an approach than
can be used here and now."
He noted that at present guidelines recommend two troponin
tests for chest-pain patients in the ER, six to 12 hours apart. "So
patients are normally admitted overnight. Our approach allows 20% of patients
to leave fairly quickly. They will still need outpatient follow-up within the
next few days, but we can be pretty sure they are not having an MI and don't
need immediate hospitalization."
The authors note that patients with chest pain account for
approximately 10% of ER presentations and 25% of hospital admissions, yet up to
85% do not have a final diagnosis of ACS. "Prolonged assessment
contributes to duplication of work, high costs, and emergency-department
overcrowding," they write.
"This study also demonstrates that central-laboratory
troponin assays currently in use have sufficient sensitivity at an early time
point to negate the need for additional biomarkers (such as myoglobin and
creatine kinase-MB)," they add.
Than said that his team is now investigating variations on
this accelerated protocol that would include a different clinical risk score or
the high-sensitivity troponin test that may identify more people (maybe up to
50%) who can be sent home early.
9. Does this adult patient have a blunt intra-abdominal
injury?
Nishijima DK, et al. JAMA. 2012 Apr 11;307(14):1517-27.
CONTEXT: Blunt abdominal trauma often presents a substantial
diagnostic challenge. Well-informed clinical examination can identify patients
who require further diagnostic evaluation for intra-abdominal injuries after
blunt abdominal trauma.
OBJECTIVE: To systematically assess the precision and
accuracy of symptoms, signs, laboratory tests, and bedside imaging studies to
identify intra-abdominal injuries in patients with blunt abdominal trauma.
DATA SOURCES: We conducted a structured search of MEDLINE
(1950-January 2012) and EMBASE (1980-January 2012) to identify English-language
studies examining the identification of intra-abdominal injuries. A separate,
structured search was conducted for studies evaluating bedside ultrasonography.
STUDY SELECTION: We included studies of diagnostic accuracy
for intra-abdominal injury that compared at least 1 finding with a reference
standard of abdominal computed tomography, diagnostic peritoneal lavage,
laparotomy, autopsy, and/or clinical course for intra-abdominal injury. Twelve
studies on clinical findings and 22 studies on bedside ultrasonography met
inclusion criteria for data extraction.
DATA EXTRACTION: Critical appraisal and data extraction were
independently performed by 2 authors.
DATA SYNTHESIS: The prevalence of intra-abdominal injury in
adult emergency department patients with blunt abdominal trauma among all
evidence level 1 and 2 studies was 13% (95% CI, 10%-17%), with 4.7% (95% CI,
2.5%-8.6%) requiring therapeutic surgery or angiographic embolization of
injuries. The presence of a seat belt sign (likelihood ratio [LR] range,
5.6-9.9), rebound tenderness (LR, 6.5; 95% CI, 1.8-24), hypotension (LR, 5.2;
95% CI, 3.5-7.5), abdominal distention (LR, 3.8; 95% CI, 1.9-7.6), or guarding
(LR, 3.7; 95% CI, 2.3-5.9) suggest an intra-abdominal injury. The absence of
abdominal tenderness to palpation does not rule out an intra-abdominal injury
(summary LR, 0.61; 95% CI, 0.46-0.80). The presence of intraperitoneal fluid or
organ injury on bedside ultrasound assessment is more accurate than any history
and physical examination findings (adjusted summary LR, 30; 95% CI, 20-46);
conversely, a normal ultrasound result decreases the chance of injury detection
(adjusted summary LR, 0.26; 95% CI, 0.19-0.34). Test results increasing the
likelihood of intra-abdominal injury include a base deficit less than -6 mEq/L
(LR, 18; 95% CI, 11-30), elevated liver transaminases (LR range, 2.5-5.2),
hematuria (LR range, 3.7-4.1), anemia (LR range, 2.2-3.3), and abnormal chest
radiograph (LR range, 2.5-3.8). Symptoms and signs may be most useful in
combination, particularly in identification of patients who do not need further
diagnostic workup.
CONCLUSIONS: Bedside ultrasonography has the highest
accuracy of all individual findings, but a normal result does not rule out an
intra-abdominal injury. Combinations of clinical findings may be most useful to
determine which patients do not require further evaluation, but the ideal
combination of variables for identifying patients without intra-abdominal
injury requires further study.
10. Normal White Blood Cell Count Does Not Rule Out
Bacteremia
Of 289 patients with bacteremia, 52% had normal WBC count
and 17% had neither WBC elevation nor fever.
Despite multiple studies showing that a normal white blood
cell (WBC) count does not exclude serious disease, physicians in all
specialties continue to behave as if it did. To assess whether a normal WBC
count or absence of fever reliably excludes bacteremia in patients with
suspected infection, investigators conducted a secondary analysis of data from
a prospective study of 3563 adults who had blood cultures at a single emergency
department.
Among 289 patients (8%) with positive blood cultures, 77%
had fever and 48% had elevated WBC count on initial measurement. Neither fever
nor an elevated WBC count was noted in 17% of bacteremic patients.
Comment: The fact that leukocytosis is associated with
infection does not mean that the white blood cell count is a good test for infection,
because many patients with infection have no leukocytosis, and many patients
with leukocytosis have no infection. Temperature is also not foolproof, but
this investigation was limited by its reliance on initial temperature only, and
some patients may have been found to be febrile later in the visit. The WBC
count is the right test for neutropenia and malignancies of the white blood
cell, but it is not a discriminatory test for infection. When evaluating a
patient for possible infection, WBC counts should be used only as part of
validated multivariable decision rules that have adequate predictive value for
medical decision making, such as the Bacterial Meningitis Score (JW Pediatr
Adolesc Med Jan 31 2007).
— Daniel J. Pallin, MD, MPH. Published in Journal Watch
Emergency Medicine May 11, 2012.
Citation: Seigel TA et al. Inadequacy of temperature and
white blood cell count in predicting bacteremia in patients with suspected
infection. J Emerg Med 2012 Mar; 42:254. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20674238
11. Hypertonic Saline Improves Acute Wheezing Outcomes
Lara C. Pullen, PhD. From Medscape Medical News. May 21,
2012 — Inhalation of a solution of 5% hypertonic saline (HS) significantly
shortens hospital length of stay and lowers admission rates in children
presenting to the emergency department with an acute wheezing episode. HS is a
pro–airway surface liquid hydration therapy.
Dorit Ater, MD, from Tel Aviv University in Israel, and
colleagues published the results of their randomized controlled, double-blind
study online May 21 in Pediatrics. This was the first study to examine HS
treatment in preschool children (32 ± 17 months of age) with a wheezing
episode.
The study included 41 children (age range, 1 - 6 years) who
presented to the emergency department between January 2009 and January 2011.
The authors excluded viral bronchiolitis cases, and only 1 patient was
diagnosed with respiratory syncytial virus by polymerase chain reaction.
The children were given 1 albuterol treatment and then
randomly assigned to receive either 4 mL of 5% HS (n = 16) or 4 mL of normal
saline (NS; n = 25). Both groups were given 0.5 mL albuterol twice every 20
minutes in the emergency department and 4 times a day thereafter if
hospitalized.
The primary outcome was length of stay, and the secondary
outcomes were admission rate and clinical severity score.
The addition of HS inhalations to common practice treatment
shortened length of stay by 33% (P = .027). The length of stay was 1 day
shorter in the HS group (median, 2 days; range, 0 - 6 days) than the NS group
(median, 3 days; range, 0 - 5 days).
The absolute risk for hospitalization was decreased by 30%
(62.2% in the NS group and 92% in the HS group). Although the clinical severity
score improved significantly in both groups, the difference between the 2
groups did not reach statistical significance (P = .1).
The authors note that the majority of the control group
(92%) required hospitalization. This rate is higher than the rates previously
reported by the hospital in 1997 and 1998. They also explain that children
older than 4 or 5 years were underrepresented in the study.
HS acts on the airways by inducing an osmotic flow of water
into the mucous layer. This rehydrates secretions and improves mucous rheology. The authors have disclosed no relevant financial
relationships.
12. ED Care: When Needed—Not When Better Choices Are
Unavailable
Katz MH, et al. Arch Intern Med. 2012;172(8):609-610.
The increasing use of emergency departments (EDs) is a perplexing
problem across the United States. Between 1997 and 2007, a national study1
showed that ED visits increased almost twice as much as what would have been
expected from the size of the population growth. When EDs are crowded, patients
who have serious problems are at risk for delayed treatment. In addition, ED
care is expensive, is unlikely to provide needed preventive care, and does not
facilitate continuity in physician-patient relationships, a key component of
quality care.
With EDs already overcrowded, it is of great concern what
will happen when insurance coverage is expanded under the provisions of the
Patient Protection and Affordable Care Act.2 It is estimated that under the Act
16 million uninsured persons will gain Medicaid coverage and an additional 16
million uninsured persons will gain coverage through a subsidized insurance
exchange. Will these newly insured persons be more or less likely to use the
ED? Certainly, the promise of affordable care should result in some patients
seeking care in primary care settings rather than in the ED. Indeed, one reason
why the uninsured now use the ED is that under the federal Emergency Medical
Treatment and Labor Act3 patients who go to a hospital ED cannot be denied care
because of inability to pay. No such obligation exists in physician offices or
other outpatient settings, in which patients who cannot pay are routinely
turned away.
Although increased coverage will undoubtedly result in some
uninsured patients seeking care through primary care physicians instead of EDs,
there is reason to worry that increases in coverage could result in even higher
ED volume. First, patients who newly gain insurance will have a way to pay for
emergency care that they did not previously have. (The Emergency Medical Treatment
and Labor Act guarantees the right to care without payment. It does not prevent
a hospital from sending a bill that will drive a patient into bankruptcy.)
Second, newly insured patients may have difficulty establishing primary care or
obtaining needed specialty care in an outpatient setting. In particular,
patients with Medicaid coverage may find few physicians willing to see them.4
This may explain why Medicaid enrollees accounted for most of the increase in
ED visits between 1997 and 2007 in the previously cited study.1 Third, even
when patients have a primary care physician, they may encounter barriers to
obtaining timely appointments. Appointments may be unavailable as quickly as
needed or at hours that would allow a working person to obtain care. As would
be expected, barriers to timely primary care have been shown to be associated
with greater use of the ED.5 Fourth, health care seeking is a complex behavior,
and not all patients will instantly change their patterns of ED use simply
because they have an insurance card in their wallet. If people are used to
going to the ED when they are sick, especially on a night or weekend, they may
still go without thinking of calling their medical care practice to see if
there are extended hours or an on-call physician.
The complexity of factors leading to ED use is well
illustrated by Ginde et al6 in this issue of the Archives. Using data from the
National Health Interview Survey, the authors found that those patients who
gained insurance in the prior year were more likely than patients who were
continuously insured to have at least 1 ED visit in the prior 12 months. Their
findings raise concern that the expansion of insurance coverage under health
reform will only worsen existing ED overcrowding. Indeed, ED use in
Massachusetts, which has enacted a health insurance expansion, has increased,
although not to a greater extent than in nearby states that did not enact
similar reforms.7 - 8
In the study by Ginde et al,6 it is telling that not only
were the newly insured more likely to use the ED than the continuously insured,
but also the newly uninsured were more likely to use the ED than the
continuously uninsured. It would seem that disruptions of insurance coverage in
either direction result in increased ED use. The newly uninsured likely went to
the ED for continuation of whatever treatment they had been receiving. Also,
some of the newly uninsured may have lost their insurance because of a new
illness, and this group may have used the ED more than the continuously
uninsured because they were more ill.
The point of EDs is to rapidly triage and diagnose those
with serious illnesses. However, it is clear that EDs in the United States
function more as safety valves than as triage centers. They care for patients
with no other place to go, no other place they can afford to go, no other place
open when they are off from work, or no right place to go. They care for those
who cannot find a physician to see them in an ambulatory setting, who cannot
afford to pay for care at the time they need it, who have no sick leave and
cannot obtain care during regular working hours, or who have a social problem
(eg, inebriation or a caregiver unwilling to continue caring for them) for
which the ED is the only place that cannot say no.
If the United States is ever to have a system that provides
high-quality care at an affordable price, we must direct patients to the right
place at the right time to see the right person. The ED should not be the
default option because other places are not open or are open only to those with
the right billfold. Before the insurance expansion occurs, we need to expand
the capacity and capability of primary care, including extended hours and
same-day appointments, so that EDs can do their job of triaging and caring for
the acutely ill or injured.
See also Ginde AA, et al. Health Insurance Status Change and
Emergency Department Use Among US Adults. Arch Intern Med. 2012 Apr
23;172(8):642-7. Full-text (free): http://archinte.jamanetwork.com/article.aspx?doi=10.1001/archinternmed.2012.34
13. Steroids for 10 days Good for Bell's Palsy and Antivirals
Ineffective finds Randomized Trial
Berg T, el al. The effect of prednisolone on sequelae in
bell's palsy. Arch Otolaryngol Head Neck Surg 2012;138(5):445-449.
By Rita Baron-Faust, Contributing Writer, MedPage Today.
Published: May 23, 2012. Early treatment with the corticosteroid prednisolone
appeared to significantly reduce mild to moderate sequelae in Bell's palsy as
judged by two scoring systems, according to results from a large Scandinavian
trial.
As measured by the Sunnybrook scoring system, among more
than 800 patients randomized to 1 of 4 treatment groups, those who received
prednisolone had a significant reduction in mild to moderate impaired facial
function at 12 months (P<0.001) compared with those who did not receive the
steroid, Thomas Berg, MD, PhD, of Oslo University Hospital Rikshospitalet in
Norway, and colleagues reported.
The difference between patients who received prednisolone
and those did not in two House-Brackmann gradings levels was also significant
(P<0.001 and P=0.01, respectively), Berg and co-authors wrote in the May
issue of the Archives of Otolaryngology – Head & Neck Surgery.
Two of the treatment groups also received the antiviral
valacyclovir (Valtrex), but no significant differences were found in those
groups, they added.
The cause of Bell's palsy, which damages the facial cranial
nerve and affects up to 40,000 Americans, is unknown. One theory is that
reactivation of a latent herpes simplex virus may cause inflammation and injury
to the facial nerve, Berg and his co-authors noted, adding that treatment has
been based on this theory.
About 70% of Bell's palsy patients recover completely within
6 months without any treatment, the authors noted. The remaining 30% have
varying degrees of sequelae with functional, psychosocial, and aesthetic
disturbances. And despite some data that prednisolone improved complete
recovery rates, large controlled studies on the effect of corticosteroids (and
any additive effect of antivirals) were lacking.
To help correct this information deficit, the researchers
recruited 829 patients (341 women and 488 men) over a 5-year period. They
ranged in age from 18 to 75 and were enrolled at 17 public referral centers
involved in the Swedish and Finnish Scandinavian Bell's Palsy Study, a
prospective, randomized, double-blind, placebo-controlled, multicenter trial. The
patients were randomized within 72 hours in a factorial fashion to placebo plus
placebo (n=206); prednisolone, 60 mg/d for 5 days, with the dosage then tapered
for 5 days, plus placebo (n=210); valacyclovir hydrochloride, 1,000 mg 3 times
daily for 7 days, plus placebo (n=207); or prednisolone plus valacyclovir
(n=206).
The researchers then evaluated facial functioning at 12
months, using two separate grading systems -- Sunnybrook and House-Brackmann.
The Sunnybrook system, considered the more sensitive of the
two, evaluates resting symmetry, degree of voluntary movement, and synkinesis
to form a composite score, for which 0 indicates complete paralysis and 100,
normal function.
The House-Brackmann system consists of a 6-grade scale (I to
VI), in which I indicates normal function and VI, complete paralysis.
Follow-up visits were between days 11 to 17 and at 1, 2, 3,
6, and 12 months after randomization. If the recovery was complete (defined as
a Sunnybrook score of 100) at 2 or 3 months, the next follow-up was at 12
months. Patients were grouped according to severity of sequelae by both scoring
systems at 12 months.
In 184 of the 829 patients, the Sunnybrook score was less
than 90 at 12 months; 71 had been treated with prednisolone and 113 had not
(P<0.001). In 98 patients, the Sunnybrook score was less than 70; 33 had
received prednisolone and 65 had not (P<0.001), Berg and colleagues wrote.
The difference between patients who received prednisolone
and who did not in House-Brackmann gradings higher than I and higher than II
was also significant (P<0.001 and P=0.01, respectively). No significant
difference was found between patients who received prednisolone and those who
did not in Sunnybrook scores less than 50 (P=0.10) or House-Brackmann grades
higher than III (P=0.80).
Synkinesis was assessed with the Sunnybrook score in 743
patients. Among those, 96 patients had a synkinesis score more than 2, of whom
33 had received prednisolone and 63 had not (P=0.001). There were 60 patients
who had a synkinesis score more than 4, of whom 22 had received prednisolone
and 38 had not (P=.005).
The authors cited several limitations to their study. "Subgroup
analyses led to a reduction of patients in the analysis groups, which makes
statistical comparisons more hazardous" they wrote. Nor did they
"make the distinction between incomplete and complete palsy at
baseline," but analyzed the median baseline scoring levels, which were
found to be similar in the different treatment groups.
The investigators concluded that while "treatment with
prednisolone significantly reduced mild and moderate sequelae in Bell's palsy
at 12 months, prednisolone did not reduce the number of patients with severe
sequelae," and valacyclovir had no effect.
Full-text (free): http://archotol.jamanetwork.com/article.aspx?articleid=1157682
14. Aspirin Prevents Recurrent Unprovoked Venous
Thromboembolism
Aspirin is probably less effective –– but safer –– than
warfarin.
Patients with unprovoked venous thromboembolism (VTE) face a
dilemma: Recurrent VTE is common after warfarin anticoagulation is stopped, but
the cumulative incidence of serious bleeding is high when patients continue
warfarin therapy indefinitely. This difficult tradeoff provides an impetus to
see whether aspirin is a suitable alternative for such patients.
Italian researchers identified 403 patients with a first
symptomatic VTE event that was unprovoked (i.e., not associated with standard
VTE risk factors); 63% had proximal deep venous thrombosis, and 37% had
pulmonary embolism. After 6 to 18 months of treatment with a vitamin K
antagonist, patients were randomized to either aspirin (100 mg daily) or
placebo for 2 years.
The incidence of recurrent VTE was significantly lower in
the aspirin group than in the placebo group (6.6% vs. 11.2% annually; P=0.02).
The frequency of bleeding events was identical in the two groups (1 major bleed
and 3 nonmajor bleeds). Aspirin afforded protection both to patients whose
index event was deep venous thrombosis and to those whose index event was
pulmonary embolism.
Comment: For patients with unprovoked VTE, this trial
provides persuasive evidence that aspirin reduces the incidence of recurrent
events after conventional warfarin therapy. Aspirin is less effective than
warfarin, but bleeding risks are lower with aspirin. Newer oral anticoagulants
(e.g., dabigatran and rivaroxaban) have also been studied as extended
maintenance therapies for patients with VTE, but are not yet FDA-approved for
this purpose.
— Allan S. Brett, MD. Published in Journal Watch General
Medicine May 24, 2012. Citation: Becattini C et al. Aspirin for preventing the recurrence of
venous thromboembolism. N Engl J Med 2012 May 24; 366:1959.
(http://www.nejm.org/doi/full/10.1056/NEJMoa1114238)
15. Images in Clinical Medicine
An Electrocardiographic Sine Wave in Hyperkalemia
Vertebra Plana with Spontaneous Healing
“Half-Half” Blisters
Eye Pain after Blunt Ocular Trauma
Progressive Foot Swelling and Pain
Male with Left Lower Quadrant Abdominal Pain
16. Driver electronic device use--put down that cell
telephone!
Chakravarthy B, et al. Ann Emerg Med. 2012;59(6):495-496.
You are driving home from work. You're at a stoplight and
suddenly you hear that “bing” your mobile telephone makes when you've received
a text message or an e-mail. The temptation wells up inside of you to take a
glance at your mobile device to see if that message is important. Your internal
logic appears to be sound: “I am at a stoplight. I'm not moving. I'll take a
quick peek before the traffic starts to move.”
Unfortunately, this dangerous scenario occurs daily on our
roadways, and more often than not what is actually occurring is that drivers
don't listen to the warning in their head and are using their mobile devices
when actually moving. Obviously this can lead to crashes, property damage,
injuries, and death. This form of driver distraction may not seem that foreign
to us as emergency physicians because we ourselves are repeatedly tempted to
answer that “bing.” What we should remember is all the times we had to break
bad news to some loving parents about their son's or daughter's death in a
motor vehicle crash. The news media have made this clear to far too many
communities across the nation, with frequent reports of deaths directly
attributable to texting while driving.1
The recent NHTSA report on driver electronic device use is
frustrating in that the visible manipulation of these devices is on the
increase, from 0.6% in 2009 to 0.9% in 2010.2 Since 2003, data collected by the
NOPUS has shown a 350% increase during the past 6 years. What is even more
worrisome is that these data are difficult to record—for example, drivers using
built-in vehicular technology to manipulate their telephones would not be
recorded—and it is certain that the numbers described in this study are but the
tip of the iceberg and point toward a much larger problem.
NOPUS, although a useful tool, has a few key limitations.
The study relies on trained observers watching stopped vehicles at about 1,400
intersections across the country, determined by probabilistic sampling. Data
collection occurs only between 7 am and 6 pm for about 3 weeks every June.
Although the observers are good at what they do, there is an inherent
limitation in relying on a person's ability to quickly ascertain whether the
driver, front passenger, and up to 2 more passengers are texting, speaking on a
headset, holding a telephone to their ear, or just chatting with one another in
the amount of time an average driver spends stopped at an intersection.
Furthermore, because of the nature of the data collection, it is not possible
to observe evening or night behaviors, which could be different, particularly for
younger drivers driving long after the school day has ended. Finally, the time
of year may also affect behaviors. Accordingly, it is quite possible that the
data reported here do not fully describe the scope of driver electronic device
use.
As scientists, we want to be able to quantify how risky a
particular behavior might be. Handheld device manipulation while driving is a
difficult risk to quantify, but let's put it in perspective. Driving simulation
studies have shown that handheld device manipulation slows a subject's response
time to braking, impairs forward and lateral control of the vehicle, and
correlates to more crashes than are experienced by controls who are not
driving.3 Another simulator-based study quantified the risk of using handheld devices
when driving to be greater than using alcohol to the legal limit or smoking
marijuana.4 Even more persuasive is a study that showed a 4-fold increase
associated with crashes when using a mobile telephone.5 Clearly, our culture
frowns on alcohol and illicit drug use while driving. What we haven't quite
grasped is that the level of distractibility of cell telephone manipulation
while driving poses a similar risk.
Another striking fact from this NHTSA report is that 32
states, along with the District of Columbia, have made text messaging while
driving illegal, yet there has still been an astronomical increase in the
number of individuals using electronic devices when driving; at any given
daylight moment, about 118,800 drivers in the United States are visibly
manipulating their handheld devices. This rate of increase is beyond just that
in the number of vehicles on the road, which has increased only slightly during
the past years.6 What it likely signifies is that mobile telephone use, and in
particular Smartphone use, is increasing and that drivers are relying on them
more and more. In the current information era, text messages and e-mails are
sent at lightning speeds and our culture pressures us to respond to these calls
immediately. Our lack of awareness about the downstream effects of driving when
using mobile devices can be catastrophic.
Age is a significant variable in the issue of using mobile
devices while driving. In fact, this report showed that since 2007, 16- to
24-year-olds have had the most significant level of driver manipulation of
handheld devices and are partially responsible for the sharp increase in these
numbers in 2010. Youths are already engaging in risky driving behavior such as
speeding and alcohol use, with those risks magnified by inexperience.7 We know
that young driver mortality increases with the number of passengers in their
vehicle.8 The use of mobile devices further compounds that risk and makes our
roadways less safe to travel. Imagine your teenage son or daughter driving his
or her friends home from school, all the while distracted in the vehicle by the
passengers and also receiving a text message from another friend. The driver
responds to that “bing” and picks up the telephone, with distractions all
around. The driver then decides to reply to the text with another text, and
bing! it's sent out. Little did the driver realize that the roadway was curving
and traffic is coming to an abrupt halt. Bang! Crash, injuries, and possible
disability and death are the result of this preventable distraction.
So how do we prevent such occurrences? There is a growing
wave of “countertechnology” to help curtail these issues and reduce the amount
of risk involved with driving when using mobile devices. Applications on
Smartphones have appeared on the market. One such application recognizes
through the global positioning system that the cell telephone is traveling more
than 10 miles per hour and locks the telephone, thereby making it unusable
while driving. That means no cell usage whatsoever while driving. This might be
enticing to parents who must rely on their children to drive and still want
them to have access to a mobile telephone during emergencies. Still other
applications will record and transmit e-mail “citations” to a parent of the
driver about mobile telephone usage while driving. Whether the technology is
prevention or policing it still is a distant second to cultural change.
Culture is not easily altered. But what we must do is to
model behavior. As emergency physicians, we see the result of many risky
behaviors. Drunk driving, speeding, unsafe sex, alcohol abuse, and violence are
but a few familiar scenarios we routinely face in the emergency department.
When we see the casualties of these events, we shake our heads, exhale deeply,
and mutter to ourselves about how much of a waste this event was and how
preventable it all could have been. This is where the rubber meets the road.
Setting the proper precedent is paramount and we should take personal
responsibility in this effort. We need to put our mobile devices away while
driving and lock them up in our glove compartment to eliminate all temptation.
We need to encourage this behavior with our family and friends. We need to
continue to support public health measures, policymakers, and enforcement when
it comes to this important preventable, modifiable risk for injury.
So make a mental note the next time you're on a shift and a
victim of a motor vehicle crash arrives and needs a chest tube for a
pneumothorax, a pelvic binder for a pelvic fracture, or tracheal intubation for
an intracerebral hemorrhage. Perhaps this will trigger that “bing” in the
recesses of your memory, and the next time you hear that same “bing” when
you're driving you will have the willpower to not reach for your mobile device.
See also Phoning
and Texting while Driving—Way Too Common.
National Highway Traffic Safety Administration. Ann Emerg Med 2012;59(6):494-495.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)00249-1/fulltext
Copies of the 8-page report Driver Electronic Device Use in
2010 can be downloaded from the NHTSA Web site at http://www.distraction.gov/download/research-pdf/8052_TSF_RN_DriverElectronicDeviceUse_1206111_v4_tag.pdf
17. The benefits and harms of intravenous thrombolysis
with recombinant tissue plasminogen activator within 6 h of acute ischaemic
stroke (the third international stroke trial [IST-3]): a randomised controlled
trial
The Lancet, Early Online Publication, 23 May 2012
Background: Thrombolysis is of net benefit in patients with
acute ischaemic stroke, who are younger than 80 years of age and are treated
within 4·5 h of onset. The third International Stroke Trial (IST-3) sought to
determine whether a wider range of patients might benefit up to 6 h from stroke
onset.
Methods: In this international, multicentre, randomised,
open-treatment trial, patients were allocated to 0·9 mg/kg intravenous
recombinant tissue plasminogen activator (rt-PA) or to control. The primary
analysis was of the proportion of patients alive and independent, as defined by
an Oxford Handicap Score (OHS) of 0—2 at 6 months. The study is registered,
ISRCTN25765518.
Findings: 3035 patients were enrolled by 156 hospitals in 12
countries. All of these patients were included in the analyses (1515 in the
rt-PA group vs 1520 in the control group), of whom 1617 (53%) were older than
80 years of age. At 6 months, 554 (37%) patients in the rt-PA group versus 534
(35%) in the control group were alive and independent (OHS 0—2; adjusted odds
ratio [OR] 1·13, 95% CI 0·95—1·35, p=0·181; a non-significant absolute increase
of 14/1000, 95% CI −20 to 48). An ordinal analysis showed a significant shift
in OHS scores; common OR 1·27 (95% CI 1·10—1·47, p=0·001). Fatal or non-fatal
symptomatic intracranial haemorrhage within 7 days occurred in 104 (7%)
patients in the rt-PA group versus 16 (1%) in the control group (adjusted OR
6·94, 95% CI 4·07—11·8; absolute excess 58/1000, 95% CI 44—72). More deaths
occurred within 7 days in the rt-PA group (163 [11%]) than in the control group
(107 [7%], adjusted OR 1·60, 95% CI 1·22—2·08, p=0·001; absolute increase
37/1000, 95% CI 17—57), but between 7 days and 6 months there were fewer deaths
in the rt-PA group than in the control group, so that by 6 months, similar
numbers, in total, had died (408 [27%] in the rt-PA group vs 407 [27%] in the
control group).
Interpretation: For the types of patient recruited in IST-3,
despite the early hazards, thrombolysis within 6 h improved functional outcome.
Benefit did not seem to be diminished in elderly patients.
Full-text (free p registration): http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60768-5/fulltext
18. Birth Control That Really Works
In the Contraceptive CHOICE project, IUDs and implants were
20 times more effective than pills, patches, or rings.
Despite their proven safety, intrauterine devices (IUDs) and
implants are used by only a small fraction of U.S. women and even fewer
adolescents. To compare the effectiveness of IUDs, implants, and depot
medroxyprogesterone acetate (DMPA) with other commonly prescribed
contraceptives, prospectively collected data were analyzed from 7486
participants in the Contraceptive CHOICE project, in which they received free
contraceptives of their choosing.
Cumulative contraceptive failure rates among participants who
used combined hormonal contraception (CHC; pills, patches, or rings) were 4.8%,
7.8%, and 9.4% during years 1, 2, and 3, respectively. Among women using IUDs
or implants, these rates were 0.3%, 0.6%, and 0.9% (P<0.001); rates were
similarly low among women who returned to receive all DMPA injections (but only
43% of women who started DMPA were using it 1 year later [JW Womens Health May
12 2011]). The adjusted hazard ratio for unintended pregnancy in CHC users
compared with IUD or implant users was 21.8. Unintended pregnancy rates in
women younger than 21 were similar to those for older participants when IUDs or
implants were used, but were twice those for older participants when CHC was
used.
Comment: These findings highlight the need to ensure that
young women are informed about and have access to intrauterine devices and
contraceptive implants. Women are more likely to be very satisfied with these
methods, and therefore are more apt to continue using them.
— Eleanor Bimla Schwarz, MD, MS. Published in Journal Watch
Women's Health May 24, 2012.
Citation: Winner B et al. Effectiveness of long-acting
reversible contraception. N Engl J Med 2012 May 24; 366:1998. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22621627
19. Patterns and Preexisting Risk Factors of 30-Day
Mortality after a Primary Discharge Diagnosis of Syncope or Near Syncope
Derose SF, et al. Acad Emerg Med. 2012;19:488-496.
Objectives: The risk of short-term mortality after an
emergency department (ED) visit for syncope is poorly understood, resulting in
prognostic uncertainty and frequent hospital admission. The authors determined
patterns and risk factors for short-term mortality after a diagnosis of syncope
or near syncope to aid in medical decision-making.
Methods: A retrospective cohort study was performed of
adult members of Kaiser Permanente Southern California seen at 11 EDs from 2002
to 2006 with a primary discharge diagnosis of syncope or near syncope
(International Classification of Diseases, Ninth Revision [ICD-9] 780.2). The
outcome was 30-day mortality. Proportional hazards time-to-event regression
models were used to identify risk factors.
Results: There were 22,189 participants with 23,951 ED
visits, resulting in 307 deaths by 30 days. A relatively lower risk of death
was reached within 2 weeks for ages 18 to 59 years, but not until 3 months or
more for ages 60 and older. Preexisting comorbidities associated with increased
mortality included heart failure (hazard ratio [HR] = 14.3 in ages 18 to 59
years, HR = 3.09 in ages 60 to 79 years, HR = 2.34 in ages 80 years plus; all p
< 0.001), diabetes (HR = 1.49, p = 0.002), seizure (HR = 1.65, p = 0.016),
and dementia (HR = 1.41, p = 0.034). If the index visit followed one or more
visits for syncope in the previous 30 days, it was associated with increased
mortality (HR = 1.86, p = 0.024). Absolute risk of death at 30 days was under
0.2% in those under 60 years without heart failure and more than 2.5% across
all ages in those with heart failure.
Conclusions: The low risk of death after an ED visit for
syncope or near syncope in patients younger than 60 years old without heart
failure may be helpful when deciding who to admit for inpatient evaluation. The
presence of one or more comorbidities that predict death and a prior visit for
syncope should be considered in clinical decisions and risk stratification
tools for patients with syncope. Close clinical follow-up seems advisable in
patients 60 years and older due to a prolonged risk of death.
20. Voluminous Coffee-drinkers Live Longer
Freedman ND, et al. Association of Coffee Drinking with
Total and Cause-Specific Mortality. N Engl J Med 2012; 366:1891-1904.
Background: Coffee is one of the most widely consumed
beverages, but the association between coffee consumption and the risk of death
remains unclear.
Methods: We examined the association of coffee drinking with
subsequent total and cause-specific mortality among 229,119 men and 173,141 women
in the National Institutes of Health–AARP Diet and Health Study who were 50 to
71 years of age at baseline. Participants with cancer, heart disease, and
stroke were excluded. Coffee consumption was assessed once at baseline.
Results: During 5,148,760 person-years of follow-up between
1995 and 2008, a total of 33,731 men and 18,784 women died. In age-adjusted
models, the risk of death was increased among coffee drinkers. However, coffee
drinkers were also more likely to smoke, and, after adjustment for
tobacco-smoking status and other potential confounders, there was a significant
inverse association between coffee consumption and mortality. Adjusted hazard
ratios for death among men who drank coffee as compared with those who did not
were as follows: 0.99 (95% confidence interval [CI], 0.95 to 1.04) for drinking
less than 1 cup per day, 0.94 (95% CI, 0.90 to 0.99) for 1 cup, 0.90 (95% CI,
0.86 to 0.93) for 2 or 3 cups, 0.88 (95% CI, 0.84 to 0.93) for 4 or 5 cups, and
0.90 (95% CI, 0.85 to 0.96) for 6 or more cups of coffee per day (P<0.001
for trend); the respective hazard ratios among women were 1.01 (95% CI, 0.96 to
1.07), 0.95 (95% CI, 0.90 to 1.01), 0.87 (95% CI, 0.83 to 0.92), 0.84 (95% CI,
0.79 to 0.90), and 0.85 (95% CI, 0.78 to 0.93) (P<0.001 for trend). Inverse
associations were observed for deaths due to heart disease, respiratory
disease, stroke, injuries and accidents, diabetes, and infections, but not for
deaths due to cancer. Results were similar in subgroups, including persons who
had never smoked and persons who reported very good to excellent health at
baseline.
Conclusions: In this large prospective study, coffee
consumption was inversely associated with total and cause-specific mortality.
Whether this was a causal or associational finding cannot be determined from
our data. (Funded by the Intramural Research Program of the National Institutes
of Health, National Cancer Institute, Division of Cancer Epidemiology and
Genetics.)
21. Placing Art in the Waiting Room Mellows Patients and
Visitors
A simple study shows that installing images of nature in the
waiting room can reduce restless behavior.
Nanda U, et al. J Emerg Med. 2012 Feb 8. [Epub ahead of
print]
BACKGROUND: Wait times have been reported to be one of the
most important concerns for people visiting emergency departments (EDs).
Affective states significantly impact perception of wait time. There is
substantial evidence that art depicting nature reduces stress levels and
anxiety, thus potentially impacting the waiting experience.
STUDY OBJECTIVES: To analyze the effect of visual art
depicting nature (still and video) on patients' and visitors' behavior in the
ED.
METHODS: A pre-post research design was implemented using
systematic behavioral observation of patients and visitors in the ED waiting
rooms of two hospitals over a period of 4 months. Thirty hours of data were
collected before and after new still and video art was installed at each site.
RESULTS: Significant reduction in restlessness, noise level,
and people staring at other people in the room was found at both sites. A
significant decrease in the number of queries made at the front desk and a
significant increase in social interaction were found at one of the sites.
CONCLUSIONS: Visual art has positive effects on the ED
waiting experience.
