Friday, May 25, 2012

Lit Bits: May 25, 2012

From the recent medical literature...

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.
2. Large-Scale Validation of the Centor and McIsaac Scores to Predict Group A Streptococcal Pharyngitis

Fine AM, et al. Arch Intern Med. Published online May 7, 2012.


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. 

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." 

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 

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; 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:  

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):  

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. 

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. ( 

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):  

Copies of the 8-page report Driver Electronic Device Use in 2010 can be downloaded from the NHTSA Web site at  

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. 

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:  

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.