Monday, May 07, 2012

Lit Bits: May 7, 2012

From the recent medical literature...

1. Thrombolytic Therapy in Unstable Patients with Acute PE: Saves Lives but Underused

Stein PD, et al. Amer J Med 2012;125:465-470.  

Introduction: Since the first clinical report of the use of a thrombolytic agent (streptokinase) in patients with pulmonary embolism by Browse and James in 1964, several randomized controlled trials, beginning with the Urokinase Pulmonary Embolism Trial, showed more rapid lysis of pulmonary thromboemboli with thrombolytic agents than with anticoagulants alone. Among symptomatic patients with pulmonary embolism who were not in shock, randomized controlled trials showed that case fatality rate was comparable in those treated with thrombolytic agents and those treated with anticoagulants alone. A meta-analysis of patients not in shock showed no benefit of thrombolytic agents compared with anticoagulants in terms of recurrent pulmonary embolism or death.

Clinical Significance: Thrombolytic therapy would seem appropriate in patients in shock; however, data are sparse and inconsistent. Among patients in shock in the Urokinase Pulmonary Embolism Trial, 2-week case fatality rate among those treated with urokinase was 2 of 2 (100%) versus 1 of 1 (100%) in those treated with anticoagulants. In a trial of patients with massive pulmonary embolism in shock, case fatality rate was 0 of 4 (0%) in patients randomized to streptokinase and 4 of 4 (100%) among patients randomized to heparin alone (P=.02).13 Among hypotensive patients with pulmonary embolism in the International Cooperative Pulmonary Embolism Registry (ICOPER), 90-day case fatality rate was similar in 33 patients who received thrombolytic therapy and in 73 patients who did not (46% vs 55%). Meta-analysis of 5 trials that included patients with unstable pulmonary embolism and patients who were not unstable showed a lower end point of death or recurrent pulmonary embolism in patients treated with thrombolytic agents (9.4% vs 19.0%).

There are no definitive trials that prove the value of thrombolytic therapy in unstable patients with pulmonary embolism. It is extremely remote that a randomized controlled trial will be performed in the future. We therefore analyzed the database of the Nationwide Inpatient Sample to test the hypothesis that thrombolytic therapy reduces case fatality rate in unstable patients with acute pulmonary embolism.


Background: Data are sparse and inconsistent regarding whether thrombolytic therapy reduces case fatality rate in unstable patients with acute pulmonary embolism. We tested the hypothesis that thrombolytic therapy reduces case fatality rate in such patients. 

Methods: In-hospital all-cause case fatality rate according to treatment was determined in unstable patients with pulmonary embolism who were discharged from short-stay hospitals throughout the United States from 1999 to 2008 by using data from the Nationwide Inpatient Sample. Unstable patients were in shock or ventilator dependent. 

Results: Among unstable patients with pulmonary embolism, 21,390 of 72,230 (30%) received thrombolytic therapy. In-hospital all-cause case fatality rate in unstable patients with thrombolytic therapy was 3105 of 21,390 (15%) versus 23,820 of 50,840 (47%) without thrombolytic therapy (P less than .0001). All-cause case fatality rate in unstable patients with thrombolytic therapy plus a vena cava filter was 505 of 6630 (7.6%) versus 4260 of 12,850 (33%) with a filter alone (P less than .0001). Case fatality rate attributable to pulmonary embolism in unstable patients was 820 of 9810 (8.4%) with thrombolytic therapy versus 1080 of 2600 (42%) with no thrombolytic therapy (P less than .0001). Case fatality rate attributable to pulmonary embolism in unstable patients with thrombolytic therapy plus vena cava filter was 70 of 2590 (2.7%) versus 160 of 600 (27%) with a filter alone (P less than .0001). 

Conclusion: In-hospital all-cause case fatality rate and case fatality rate attributable to pulmonary embolism in unstable patients was lower in those who received thrombolytic therapy. Thrombolytic therapy resulted in a lower case fatality rate than using vena cava filters alone, and the combination resulted in an even lower case fatality rate. Thrombolytic therapy in combination with a vena cava filter in unstable patients with acute pulmonary embolism seems indicated. 

See also: Stein PD, et al. Case Fatality Rate with Pulmonary Embolectomy for Acute Pulmonary Embolism. Amer J Med. 2012;125:471-477. 

Stein PD, et al. Impact of Vena Cava Filters on In-hospital Case Fatality Rate from Pulmonary Embolism. Amer J Med. 2012;125:478-484. 

Dalen JE. Thrombolytics and Vena Cava Filters Decrease Mortality in Patients with Unstable Pulmonary Embolism. Amer J Med. 2012;125:429-430. 

2. Hospital Strategies for Reducing Risk-Standardized Mortality Rates in AMI 

Bradley EH, et al. Ann Intern Med. 2012;156:618-626. 

Mortality after acute myocardial infarction (AMI) varies greatly between U.S. hospitals, even accounting for patient factors. This cross-sectional survey of 537 U.S. hospitals identified several hospital strategies associated with lower mortality after AMI: a culture that encouraged physicians to solve problems creatively, physicians and nurses acting as quality-of-care champions, hospital and emergency department clinicians meeting at least monthly to review care, cardiologists always being present in the hospital, and not cross-training nurses to work in both intensive care and cardiac catheterization settings. However, less than 10% of hospitals reported using at least 4 of the 5 strategies. 

3.  Variation in Head CT Use for ED Trauma Patients and Physician Risk Tolerance 

Andruchow JE, at al. Arch Intern Med. 2012;172(8):660-661. 

Introduction: Physician risk intolerance and malpractice fear have been implicated as leading to defensive behaviors and increased use of health care resources. In the emergency department (ED), physician risk aversion has been associated with higher rates of testing and hospitalization for low-risk patients with chest pain, greater use of diagnostic imaging for patients with abdominal pain,4 and an increased likelihood of performing head computed tomography (CT) in scenarios involving pediatric patients with minor head injury. 

In this study, we explore predictors of head CT use for ED trauma patients, including assessing the impact of physician risk intolerance and malpractice fear. Patients with trauma were chosen because (1) the most common indication for head CT in the ED is trauma, (2) head CT can definitively exclude life-threatening injuries, and (3) missed diagnoses can have dire consequences for both patients and physicians. Furthermore, because emergency physicians overestimate the likelihood of clinically significant findings on head CT and the medicolegal risk of not obtaining diagnostic imaging, head CT use may be associated with defensive practice. We hypothesized that variation exists in head CT use and is predicted by physician risk intolerance and malpractice fear… 

Excerpts from the rest of the article 

Head CT use was associated with increasing patient age (P less than .001), male sex (P = .001), higher triage acuity (P less than .001), and time of presentation (overnight greater than evening or day) (P less than .008) (Table). Physician demographic characteristics and risk taking (P = .32), stress from uncertainty (P = .30), and malpractice fear (P = .26) were not predictive of head CT use. Even after controlling for the patient factors, physician identity was still strongly associated with head CT use (P less than .001), suggesting that significant variation in head CT use exists among physicians. 

We found significant variation in head CT use for ED trauma patients that was not explained by patient factors and was not associated with physician risk tolerance or malpractice fear. Variation in head CT use by ED physicians has been demonstrated previously, but not specifically for ED trauma patients. Because well-validated decision rules are available to guide imaging for patients with mild traumatic brain injury, this suggests that an opportunity for quality improvement exists. 

The lack of association between physician risk tolerance and head CT use contrasts with prior findings of physician risk aversion being associated with increased use of diagnostic imaging and health care resources. One reason for this discrepancy may be the shared decision making involved in the care of ED patients at our academic center, which, at a minimum, includes either a resident physician or physician assistant in addition to the attending physician. For patients with trauma team activation, the surgical trauma service and possibly other consulting services may be involved. Because this study measured only the risk tolerance of ED attending physicians, its impact on use may have been diluted by the influence of other decision makers. Initiatives to reduce variation and inappropriate imaging for ED trauma patients should consider all decision makers involved in patient care and might ultimately require institution-level support for clinical decision rules or appropriateness measures. 

4. Low-Dose Abdominal CT as Good of High-Dose for Evaluating Suspected Appendicitis 

Kim K, et al. N Engl J Med 2012; 366:1596-1605.  

Background: Computed tomography (CT) has become the predominant test for diagnosing acute appendicitis in adults. In children and young adults, exposure to CT radiation is of particular concern. We evaluated the rate of negative (unnecessary) appendectomy after low-dose versus standard-dose abdominal CT in young adults with suspected appendicitis. 

Methods: In this single-institution, single-blind, noninferiority trial, we randomly assigned 891 patients with suspected appendicitis to either low-dose CT (444 patients) or standard-dose CT (447 patients). The median radiation dose in terms of dose–length product was 116 mGy·cm in the low-dose group and 521 mGy·cm in the standard-dose group. The primary end point was the percentage of negative appendectomies among all nonincidental appendectomies, with a noninferiority margin of 5.5 percentage points. Secondary end points included the appendiceal perforation rate and the proportion of patients with suspected appendicitis who required additional imaging. 

Results: The negative appendectomy rate was 3.5% (6 of 172 patients) in the low-dose CT group and 3.2% (6 of 186 patients) in the standard-dose CT group (difference, 0.3 percentage points; 95% confidence interval, −3.8 to 4.6). The two groups did not differ significantly in terms of the appendiceal perforation rate (26.5% with low-dose CT and 23.3% with standard-dose CT, P=0.46) or the proportion of patients who needed additional imaging tests (3.2% and 1.6%, respectively; P=0.09). 

Conclusions: Low-dose CT was noninferior to standard-dose CT with respect to negative appendectomy rates in young adults with suspected appendicitis. (Funded by GE Healthcare Medical Diagnostics and others; number, NCT00913380.) 

5. Eradication of Community-Associated Staphylococcus aureus Is Effective in Only Half of Cases 

But a larger reduction in subsequent skin and soft-tissue infections was seen when the entire household was treated. 

Fritz SA, et al. Household versus individual approaches to eradication of community-associated Staphylococcus aureus in children: a randomized trial. Clin Infect Dis. 2012 Mar;54(6):743-51.  

BACKGROUND: Community-associated Staphylococcus aureus infections often affect multiple members of a household. We compared 2 approaches to S. aureus eradication: decolonizing the entire household versus decolonizing the index case alone. 

METHODS: An open-label, randomized trial enrolled 183 pediatric patients (cases) with community-onset S. aureus skin abscesses and colonization of anterior nares, axillae, or inguinal folds from 2008 to 2009 at primary and tertiary centers. Participants were randomized to decolonization of the case alone (index group) or of all household members (household group). The 5-day regimen included hygiene education, twice-daily intranasal mupirocin, and daily chlorhexidine body washes. Colonization of cases and subsequent skin and soft tissue infection (SSTI) in cases and household contacts were ascertained at 1, 3, 6, and 12 months. 

RESULTS: Among 147 cases with 1-month colonization data, modified intention-to-treat analysis revealed S. aureus eradication in 50% of cases in the index group and 51% in the household group (P = 1.00). Among 126 cases completing 12-month follow-up, S. aureus was eradicated from 54% of the index group versus 66% of the household group (P = .28). Over 12 months, recurrent SSTI was reported in 72% of cases in the index group and 52% in the household group (P = .02). SSTI incidence in household contacts was significantly lower in the household versus index group during the first 6 months; this trend continued at 12 months. 

CONCLUSIONS: Household decolonization was not more effective than individual decolonization in eradicating community-associated S. aureus carriage from cases. However, household decolonization reduced the incidence of subsequent SSTI in cases and their household contacts. 

6. Health Insurance Status Change and ED Use among US Adults

Ginde AA, et al. Arch Intern Med. 2012;172(8):642-647.  

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

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

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

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

7. Patients with Rib Fractures Do Not Develop Delayed Pneumonia: A Prospective, Multicenter Cohort Study of Minor Thoracic Injury 

Chauny JM, et al. Ann Emerg Med. 2012 Apr 26. [Epub ahead of print] 

Study objective: Patients admitted to emergency departments (EDs) for minor thoracic injuries are possibly at risk of delayed pneumonia. We aimed to evaluate the incidence of delayed pneumonia post–minor thoracic injury and the associated risk factors. 

Methods: A prospective, multicenter cohort study was conducted in 4 Canadian EDs, from November 2006 to November 2010. All consecutive patients aged 16 years and older with minor thoracic injury who were discharged from the ED were screened for eligibility. Uniform clinical and radiologic evaluations were performed on the initial ED visit and were repeated at weeks 1 and 2. Relative risk analyses quantified incidence with comparison by age, sex, smoking status, alcohol intoxication, pulmonary comorbidity, ability to cough atelectasis, pain level, and number of rib fractures. 

Results: Of the 1,057 participants recruited, 347 (32.8%) had at least 1 rib fracture, 87 (8.2%) had asthma, and 36 (3.4%) had chronic obstructive pulmonary disease. Only 6 patients (0.6%; 95% confidence interval 0.24% to 1.17%) developed pneumonia during the follow-up period. The relative risk for patients with preexistent pulmonary disease and radiologically proven rib fractures was 8.6 (P=.045; 95% confidence interval 1.05 to 70.9). Sex, smoking habit, initial atelectasis, ability to cough, and alcohol intoxication were not significantly associated with delayed pneumonia. 

Conclusion: This prospective cohort study of nonhospitalized patients with minor thoracic injuries revealed a low incidence of delayed pneumonia. Nonetheless, our results support tailored follow-up for asthmatic or chronic obstructive pulmonary disease patients with rib fracture. 

8. Clostridium difficile Infection Incidence, Costs Reach Historic Highs  

Community-onset Cases More Likely to Require Colectomy, Study Finds  

AAFP. 04/30/2012  --  Clostridium difficile infection (CDI) took center stage in a report recently published in Morbidity and Mortality Weekly Report (MMWR) that stated "the incidence, deaths, and excess health care costs resulting from CDIs in hospitalized patients are all at historic highs."  

According to the March 9 MMWR Vital Signs report, which analyzed population-based surveillance data from the CDC's Emerging Infections Program and other sources, hospital stays directly tied to CDIs tripled in the past decade and the number of hospitalized patients with any CDI discharge diagnosis more than doubled -- from about 139,000 to 336,600. 

9. Diagnostic value of single complete compression US in pregnant and postpartum women with suspected DVT: prospective study 

Le Gal G, et al. BMJ 2012;344:e2635 

Introduction: Because pregnancy is known to be a risk factor for venous thromboembolism and pregnant women often experience symptoms compatible with deep vein thrombosis (pain, tenderness, and swelling of the legs), the threshold for clinical suspicion and the accuracy of clinical examination are reduced. Misdiagnoses during pregnancy, however, should be avoided as much as possible—for example, false positive test results lead to inappropriate anticoagulant treatment, which increases the risk of bleeding and requires daily heparin injections during the pregnancy. In contrast, false negative test results may lead to a life threatening thromboembolic event. Thus the accuracy of diagnostic methods used in pregnant women is crucial. Phlebography remains the reference method for the diagnosis of deep vein thrombosis, but it is invasive and costly and exposes the fetus to radiation. Serial impedance plethysmography is the only non-invasive test that has been formally proved, in a prospective study, to be safe during pregnancy. This test is no longer in use, however, mainly because it has been shown to be less accurate than compression ultrasonography in non-pregnant patients.4 In such patients, assessment of clinical probability combined with D-dimer measurement is a well validated step for ruling out deep venous thrombosis. D-dimer levels, however, tend to increase steadily with pregnancy stage and to decrease slowly during the first weeks after delivery. As a result, the clinical usefulness—that is, the proportion of women with D-dimer levels below the diagnostic cut-off—is reduced. Moreover, the safety of ruling out deep vein thrombosis on the basis of D-dimer levels and clinical probability has never been prospectively validated in an outcome study of management during pregnancy. 

In recent years, real time compression ultrasonography has become the main diagnostic test for suspected deep vein thrombosis. In non-pregnant patients with suspected deep vein thrombosis, a negative single complete compression ultrasonography result allows the diagnosis to be safely ruled out. Indeed, the rate of thromboembolic events in the three months after a negative single complete compression ultrasonography result has been shown to be about 1%, a figure comparable to the 1.3% (95% confidence interval 0.3% to 4.4%) thromboembolic rate observed after a negative phlebography test result. 

Although compression ultrasonography is widely used, it has not been prospectively evaluated in pregnancy and post-partum. Its accuracy may be lower for several reasons. Firstly, pregnant women often present with conditions that make visualisation of the veins difficult, such as leg oedema or a gravid uterus, and that interfere with the visualisation of the proximal veins. Secondly, isolated iliac venous thromboses, which may be encountered more often in pregnancy, are more difficult to be diagnosed by compression ultrasonography, as the usual accepted criterion for deep vein thrombosis—lack of compressibility of the veins—may be difficult to evaluate at the iliac level in pregnant women. Thirdly, pregnancy is associated with changes in the anatomy and physiology of veins—namely, an increased vessel diameter and reduced flow velocity. These physiological changes are associated with technical difficulties for the ultrasound examination, and they persist for days or weeks after delivery. 

Nevertheless, a retrospective study suggested that single complete compression ultrasonography may safely exclude deep vein thrombosis during pregnancy and post partum. We assessed the safety of ruling out the diagnosis of deep vein thrombosis in pregnant or early postpartum women using single compression ultrasonography. 


Objective: To assess the safety of using single complete compression ultrasonography in pregnant and postpartum women to rule out deep vein thrombosis. 

Design: Prospective outcome study. 

Setting: Two tertiary care centres and 18 private practices specialising in vascular medicine in France and Switzerland. 

Participants: 226 pregnant and postpartum women referred for suspected deep vein thrombosis. 

Methods: A single proximal and distal compression ultrasonography was performed. All women with a negative complete compression ultrasonography result did not receive anticoagulant therapy and were followed up for a three month period. 

Main outcome measures: Symptoms of venous thromboembolism, second compression ultrasonography or chest imaging, a thromboembolic event, and anticoagulant treatment. 

Results: 16 women were excluded, mainly because of associated suspected pulmonary embolism. Deep vein thrombosis was diagnosed in 22 out of the 210 included women (10.5%). 10 patients received full dose anticoagulation despite a negative test result during follow-up. Of the 177 patients without deep vein thrombosis and who did not receive full dose anticoagulant therapy, two (1.1%, 95% confidence interval 0.3% to 4.0%) had an objectively confirmed deep vein thrombosis during follow-up. 

Conclusions: The rate of venous thromboembolic events after single complete compression ultrasonography in pregnant and postpartum women seems to be within the range of that observed in studies in the non-pregnant population. These data suggest that a negative single complete compression ultrasonography result may safely exclude the diagnosis of deep vein thrombosis in this setting. 

10. Images in Clinical Medicine 

Torsion of Undescended Testis


Man with Oropharyngeal Trauma

Infant with Head Injury

A Woman with Painless Swelling in the Right Lower Abdominal Quadrant

11. Ultrasound-Guided Peripheral IV Training Reduces Central Line Placement 

Nancy A. Melville. Medscape Medical News. April 27, 2012 (Phoenix, Arizona) — The rate of inappropriately placed central venous catheters (CVCs) substantially declines when residents and emergency department (ED) technicians are trained to perform ultrasound-guided peripheral intravenous access (USPIV), according to a study presented here at the American Institute of Ultrasound in Medicine (AIUM) 2012 Annual Convention. 

A research team led by Hamid Shokoohi, MD, from The George Washington University (GWU) Medical Center in Washington, DC, evaluated the monthly rate of CVC placement in high- and low-acuity patients from 2006 to 2010. 

In 2008, administrators at the GWU Medical Center implemented a program to train residents and ED technicians to use USPIV. 

Whereas the ED saw an increase in patients over the study period, from 60,239 in 2006 to 71,431 in 2010, the number of CVCs placed was reduced by nearly 65%, from 426 in 2006 to 152 in 2010. 

"In 2006, nearly 13% of patients who received CVC had the line removed and it turned out the patient could be sent home," Dr. Shokoohi reported. "This number dropped to just 1% in 2010." 

In addition, most patients who did receive a CVC were admitted to the intensive care unit (ICU). 

"This is very important because we assume the people who go to the ICU are the most severe patients who need the CVC for reasons other than simply poor peripheral IV access," said Dr. Shokoohi. "In 2006, only about a third [33.2%] of patients who got CVC were admitted to the ICU; by 2010, this number went up to 82%." 

The findings underscore the association between USPIV and CVC reduction in low-acuity patients who need IV access but not central line access, Dr. Shokoohi noted. 

"The study demonstrates that the best outcome can be achieved using ultrasound first and replacing an unnecessary invasive CVC procedure with a safe and successful method of obtaining IV access in low-acuity patients with difficult IV access." 

Michael Blaivas, MD, FACEP, professor of emergency medicine in the Department of Emergency Medicine at Northside Hospital Forsyth, in Cumming, Georgia, said the findings support the sentiment of many physicians that CVC, and its potential for complications, can be avoided more often than many realize. 

"This is a really important study," said Dr. Blaivas, who moderated the session and is chair of the AIUM Emergency and Critical Care Ultrasound Section. 

"It's amazing how many of us, over the years, have had the gestalt that the central line is often unnecessary, and documenting that is critical." 

USPIV is "simple and extremely effective because it can help you avoid the central line completely. Obviously, many central lines do need to be placed, but as the study indicated, you can avoid it in as many as a third of cases." 

Although there is a bit of a learning curve for USPIV, Dr. Blaivas said the training isn't too difficult. "In general, we've found that training can be accomplished with a 2-hour course, lectures, some demonstrations, practice on a phantom, and then trying it out on about 5 patients in a proper setting with the oversight of an expert." 

USPIV is used at nearly all academic medical centers in the United States, but its use in other settings needs to be increased, he said. 

"The community healthcare providers tend to pick this up less, so they are the next big battleground," Dr. Blaivas said. "The Emergency Nurses Association has put out a statement endorsing this, and I think you will start seeing more and more implementation." 

12. Association between Repeated Intubation Attempts and Adverse Events in EDs: An Analysis of a Multicenter Prospective Observational Study 

Hasegawa K, et al. Ann Emerg Med. 2012 Apr 27 [Epub ahead of print] 

Study objective: Although repeated intubation attempts are believed to contribute to patient morbidity, only limited data characterize the association between the number of emergency department (ED) laryngoscopic attempts and adverse events. We seek to determine whether multiple ED intubation attempts are associated with an increased risk of adverse events. 

Methods: We conducted an analysis of a multicenter prospective registry of 11 Japanese EDs between April 2010 and September 2011. All patients undergoing emergency intubation with direct laryngoscopy as the initial device were included. The primary exposure was multiple intubation attempts, defined as intubation efforts requiring greater than or equal to 3 laryngoscopies. The primary outcome measure was the occurrence of intubation-related adverse events in the ED, including cardiac arrest, dysrhythmia, hypotension, hypoxemia, unrecognized esophageal intubation, regurgitation, airway trauma, dental or lip trauma, and mainstem bronchus intubation. 

Results: Of 2,616 patients, 280 (11%) required greater than or equal to 3 intubation attempts. Compared with patients requiring 2 or fewer intubation attempts, patients undergoing multiple attempts exhibited a higher adverse event rate (35% versus 9%). After adjusting for age, sex, principal indication, method, medication, and operator characteristics, intubations requiring multiple attempts were associated with an increased odds of adverse events (odds ratio 4.5; 95% confidence interval 3.4 to 6.1). 

Conclusion: In this large Japanese multicenter study of ED patients undergoing intubation, we found that multiple intubation attempts were independently associated with increased adverse events. 

13. Mild Therapeutic Hypothermia May Benefit Patients with Post-arrest Cardiogenic Shock 

Mild hypothermia reduced need for vasopressors and inotropes in patients with cardiogenic shock after out-of-hospital cardiac arrest. 

Zobel C, et al. Crit Care Med. 2012 Apr 6. [Epub ahead of print] 

OBJECTIVE: Mortality in patients with cardiogenic shock after out-of-hospital cardiac arrest remains high despite advances in resuscitation and early revascularization strategies. Recent studies suggest a reduced mortality in survivors of cardiac arrest subjected to mild therapeutic hypothermia, but the underlying mechanisms are not yet clear. Because positive hemodynamic effects of mild therapeutic hypothermia have been suggested, we aimed at testing the hypothesis that patients in cardiogenic shock might benefit from mild therapeutic hypothermia. 

METHODS: Hemodynamic effects of mild therapeutic hypothermia in 20 consecutive patients admitted in cardiogenic shock after successful resuscitation from out-of-hospital cardiac arrest were investigated. A historic normothermic control group was matched (one-to-one) by means of a propensity score. Patients were cooled to 33°C for 24 hrs using an endovascular cooling device and hemodynamic variables were continuously recorded by means of pulse contour analysis. Cardiac performance was determined by echocardiography. 

RESULTS: Mild therapeutic hypothermia induced a significant decrease in heart rate from 74 to 64 beats per minute. Despite the reduction in heart rate, cardiac index remained unchanged under mild therapeutic hypothermia likely due to an increase in ejection fraction from 43 ± 4% to 55 ± 4%. Mean arterial pressure increased rapidly from 75 ± 2 mm Hg to 84 ± 3 mm Hg (p = .001) upon induction of hypothermia paralleled by an initial increase in systemic vascular resistance. Accordingly, patients with mild therapeutic hypothermia required lower cumulative doses of vasopressors and inotropes. 

CONCLUSIONS: We conclude that in cardiogenic shock mild therapeutic hypothermia provides circulatory support and an increase in systemic vascular resistance that leads to reduced vasopressor use and may result in lower oxygen consumption. These findings suggest that mild therapeutic hypothermia could be a therapeutic option in hemodynamically unstable patients independent of cardiac arrest and further randomized clinical studies are needed. 

14. Red Flags in Electrocardiogram for Emergency Physicians: Remembering Wellens’ Syndrome and Upright T wave in V1 

Ünlüer EE, et al. West J Emerg Med. 2012;13(2):160–162. 

We present a case of Wellens’ syndrome together with upright T wave in lead V1 in a man presenting with atypical chest pain, and we discuss the significance of its prompt recognition by the emergency physicians who are involved in the evaluation of patients with coronary artery disease in emergency departments.  

15. Taser Voltage Enough to Kill 

A shock to the chest from a stun gun can cause sudden cardiac arrest and death. How so? The threshold for automated external defibrillators is the output of the TASER X26. 

By Chris Kaiser, Cardiology Editor, MedPage Today. May 02, 2012.  

A shock to the chest from a stun gun can cause sudden cardiac arrest and death, a small study suggested. 

In eight cases of stun-gun induced loss of consciousness, the first recorded rhythms were ventricular tachycardia/fibrillation in six and asystole (after about 30 minutes of nonresponsiveness) in one, according to the first clinical study of taser effects published in a peer reviewed journal. 

An external defibrillator reported a shockable rhythm in one case, but no recording was made, Douglas P. Zipes, MD, from Indiana University School of Medicine in Indianapolis, reported online in Circulation: Journal of the American Heart Association. 

Given the animal and clinical data, Zipes concluded that shocks from stun guns can cause ventricular fibrillation, which can lead to death.  

Stun guns, also known as tasers, are classified as nonlethal weapons. They are not considered firearms and, therefore, are not regulated by the Bureau of Alcohol, Tobacco, Firearms, and Explosives, Zipes noted. 

However, they are capable of delivering an initial shock of 50,000 volts, followed by shorter 1,200-volt shocks that the user can stop, repeat, or sustain longer. 

The safety of stun guns has been questioned, particularly by Amnesty International, which reported more than 500 deaths in the U.S. following shocks from stun guns since 2001. 

Of the cases studied, about 60 deaths have been directly linked to the stun gun, either as a cause or contributing factor, according to Amnesty International. 

Zipes traced the first documented case of stun-gun death in the literature to 2005. Animal studies, as well as a few human studies, have shown that shocking the chest with the TASER X26 (the model preferred by law enforcement) or a new prototype causes cardiac electrical capture, which is the ability of the electrical impulse to initiate a cardiac response. Some animal studies have shown that the shock could provoke rapid ventricular fibrillation. 

In fact, the "concept of cardiac capture by transthoracic electrical impulses in humans ... is now a standard part of resuscitative equipment," Zipes wrote. He added that the threshold for automated external defibrillators is the output of the TASER X26. 

With this as background, Zipes said he wanted to determine whether tasers can cause an electrical response and whether that could lead to an arrhythmia and subsequent death. 

He analyzed eight cases that were part of litigation associated with taser shock (one from 2006, four from 2008, and three from 2009). In each case, the device used was the TASER X26. All but one individual died. 

When such information was available, Zipes used records from police, hospitals, and emergency response teams; as well as data from stun guns, automated external defibrillators, ECG strips, depositions, and autopsy results. 

All eight men had previously been clinically healthy, he noted. All received shocks in the anterior chest near or over the heart. And all lost consciousness during or immediately after the shock. 

One of the potential mechanisms of ventricular fibrillation from a taser shock could come from a sudden loss of blood pressure from an initial shock-induced increase in heart rate, which is exacerbated by repeated shocks, potentially causing ischemia and provoking ventricular fibrillation, Zipes wrote.

He admitted that not all deaths following taser shocks can be linked to the shock itself. However, when loss of consciousness happens during or immediately after the shock "and the subsequent rhythm is VT/VF ... it becomes difficult to exonerate the effects of the shock," he wrote. 

Zipes stressed that the report is not intended to condemn the use of stun guns by trained ofessionals. 

In that vein, he offered several suggestions:
      ·         Avoid chest shocks if possible
·         Monitor the person following a shock
·         Suspect the possibility of an arrhythmia in those who lose consciousness
·         Be prepared to resuscitate, including the use of an automated external defibrillator 

The study is limited by not having an ECG recording during the application of the shock, Zipes said. 

16. IMS 3 Trial of Mechanical Embolectomy in Stroke Stopped 

Pauline Anderson. From Medscape Medical News. April 27, 2012 (New Orleans, Louisiana) — The Interventional Management of Stroke 3 (IMS 3) trial, which was comparing intravenous (IV) tissue plasminogen activator (tPA) alone with combination tPA and intra-arterial (IA) therapy using intra-arterial tPA or mechanical thrombectomy in stroke patients, has suspended enrollment after crossing a prespecified interim analysis threshold. 

That means that even if the study continued, it would not produce the expected result — that combination therapy is superior to tPA alone, said principal investigator Joseph P. Broderick, MD, professor and chairman, neurology, University of Cincinnati, Ohio. "This is not what we had hoped," he told Medscape Medical News. 

However, he said, "we remain optimistic about mechanical embolectomy technology; we just need to do a better job" of proving that these devices improve patient outcome. 

The IMS 3 is a phase 3, randomized, open-label trial that was to enroll 900 patients with a National Institutes of Health Stroke Scale score of 8 or greater treated within 3 hours. The aim of the study was to examine whether a combined IV and IA approach to recanalization is superior to standard IV recombinant (rt)-PA alone. 

The primary outcome is a favorable outcome in terms of functional independence as measured by a Modified Rankin Scale score of 0 to 2 at 3 months. The trial was designed to test whether there is an overall absolute difference of at least 10% in the proportion of a favorable outcome for patients treated with the combined IV/IA approach as compared to those treated with the IV rt-PA only approach. 

It's important to note that the study was not put on hold because of safety concerns, said Dr. Broderick. He also emphasized that he and the other investigators remain blinded to the study results and that patient follow-up will continue. 

American Academy of Neurology (AAN) 64th Annual Meeting 

17. Ultrasound Imaging Reveals Cervical Vascular Injury Signature 

Nancy A. Melville. Medscape Medical News. April 24, 2012 (Phoenix, Arizona) — Transcranial Doppler ultrasound imaging is a potentially useful tool to detect blood flow disruptions related to blunt cervical vascular injury (BCVI) that might otherwise go undetected by computed tomography angiography (CTA), according to research presented here at the American Institute of Ultrasound in Medicine 2012 Annual Convention. 

CTA, currently the gold standard in imaging for BCVI, has disadvantages, including radiation exposure, contrast risk, false-positive results as high as 35% to 40%, and the need for patients who have undergone multiple traumas to move. 

In addition, CTA can miss vascular injuries, explained lead author Dianna Purvis, PhD, from the Department of Neuroscience, Electrical, and Computer Engineering at George Mason University in Centreville, Virginia. 

"When arteries supplying blood to the brain are injured in some sort of blunt trauma, often a thrombus forms and can cause a subsequent stroke; however, there is usually a silent period in which it is very hard to detect," Dr. Purvis explained. 

She noted that at her center, a 26-year-old female presented who had been sent home twice from another emergency department with a clear head computed tomography scan. 

"She then presented at our trauma center with a cerebellar stroke," she said. "This was a woman who had just graduated from college and relatively was young." 

The case underscores the need for bedside screening, Dr. Purvis said. "Serial dynamics have not been well studied in response to this cervical disruption of blood flow." 

In an effort to better understand the dynamics and the value of transcranial Doppler ultrasound in detecting or monitoring a cervical disruption of blood flow, Dr. Purvis and her colleagues have been conducting an ongoing prospective pilot study in which trauma patients with BCVI are screened with CTA as well as transcranial Doppler ultrasound. 

The aim of the study is to look for Doppler signatures that are reliably characteristic of BCVIs. 

"We are extracting Doppler indices from the Doppler wave form to characterize alterations in flow, both in the local cervical region and global cerebral region," she explained. 

Specifically, these include mean flow velocity, pulsatility indices, and side-to-side asymmetries, she said. 

The researchers are also looking at patterns in the inverse damping factor. "This is simply the ratio of the pulsatility distal to a thrombus, or the proximal pulsatility," Dr. Purvis explained. 

Preliminary findings include evaluations of 35 trauma patients, 12 with BCVI. Among the BCVI patients, 4 had internal carotid artery injuries; 4 had vertebral artery injuries, 2 had bilateral vertebral artery injuries, and 2 had concurrent internal carotid artery and vertebral artery injuries. 

Evaluations of the patients showed that internal carotid artery BCVI is characterized by more middle cerebral artery mean flow velocity asymmetry of 25% or higher than patients without BCVI (75% vs 0%; P = .009). Internal carotid artery BCVI also shows a lower mean middle cerebral artery ipsilateral pulsatility index (0.57 vs 1.20; P = .007). 

Patients with vertebral artery BCVI had more middle cerebral artery mean flow velocity asymmetry of 25% or greater than patients with no BCVI (100% vs 0%; P less than .001). 

In patients with internal carotid artery BCVI, mean internal carotid artery flow was significantly dampened, compared with patients with no BCVI (0.44 vs 0.95; P less than .001). It was also dampened in those with concurrent internal carotid artery and vertebral artery BCVI (0.58 vs 0.95; P = .002). 

Dr. Purvis noted that the small sample size is a limitation; however, the research team has received funding to continue to enroll up to 100 patients. 

"Even though the sample size is small, the findings lead us to believe we might be seeing some converging patterns with different types of vascular injuries in the cervical region," she concluded. 

"This may in fact be a viable method to not only screen these injuries, but to follow their progress and assess hemodynamics throughout the injury progression," she noted. 

Other limitations include the fact that the there is no assurance that all of the hemodynamic alterations observed were related to BCVI; many of the patients had multiple injuries. Age and sex might also play a role in different cerebral velocities, Dr. Purvis added. 

Daniel B. Hoch, PhD, MD, assistant professor of neurology at Harvard Medical School and neurologist in the Department of Neurology at Massachusetts General Hospital in Boston, agreed that CTA, despite its value in such cases, has its drawbacks. 

"It takes time to get one, requires some transport of the patient to the scanner, and the patient gets an intravenous contrast dose that has to be cleared by the kidneys," said Dr. Hoch. 

"If a highly sensitive test that is portable, fast, and cheap can be provided to screen these patients, then our colleagues in trauma management would be enthused." 

He agrees, however, that larger studies are needed to better evaluate the role of transcranial Doppler ultrasound in the trauma department. 

"The study is encouraging. It's a very small number of patients, though, and it's going to take a many more patients who get both CTA and transcranial Doppler ultrasound before we know how sensitive this approach really is," Dr. Hoch said. 

"It's really important not to miss anyone, so the false-negative rate has to be really low for this to be a helpful test." 

Dr. Purvis and Dr. Hoch have disclosed no relevant financial relationships. 

American Institute of Ultrasound in Medicine (AIUM) 2012 Annual Convention. Abstract 1241283. Presented March  31, 2012. 

18. Warfarin or Aspirin in Patients with Heart Failure and Sinus Rhythm 

Homma S, et al. N Engl J Med. 2012; May 2, 2012 (10.1056/NEJMoa1202299)  

Background: It is unknown whether warfarin or aspirin therapy is superior for patients with heart failure who are in sinus rhythm. 

Methods: We designed this trial to determine whether warfarin (with a target international normalized ratio of 2.0 to 3.5) or aspirin (at a dose of 325 mg per day) is a better treatment for patients in sinus rhythm who have a reduced left ventricular ejection fraction (LVEF). We followed 2305 patients for up to 6 years (mean [±SD], 3.5±1.8). The primary outcome was the time to the first event in a composite end point of ischemic stroke, intracerebral hemorrhage, or death from any cause. 

Results: The rates of the primary outcome were 7.47 events per 100 patient-years in the warfarin group and 7.93 in the aspirin group (hazard ratio with warfarin, 0.93; 95% confidence interval [CI], 0.79 to 1.10; P=0.40). Thus, there was no significant overall difference between the two treatments. In a time-varying analysis, the hazard ratio changed over time, slightly favoring warfarin over aspirin by the fourth year of follow-up, but this finding was only marginally significant (P=0.046). Warfarin, as compared with aspirin, was associated with a significant reduction in the rate of ischemic stroke throughout the follow-up period (0.72 events per 100 patient-years vs. 1.36 per 100 patient-years; hazard ratio, 0.52; 95% CI, 0.33 to 0.82; P=0.005). The rate of major hemorrhage was 1.78 events per 100 patient-years in the warfarin group as compared with 0.87 in the aspirin group (P less than 0.001). The rates of intracerebral and intracranial hemorrhage did not differ significantly between the two treatment groups (0.27 events per 100 patient-years with warfarin and 0.22 with aspirin, P=0.82). 

Conclusions: Among patients with reduced LVEF who were in sinus rhythm, there was no significant overall difference in the primary outcome between treatment with warfarin and treatment with aspirin. A reduced risk of ischemic stroke with warfarin was offset by an increased risk of major hemorrhage. The choice between warfarin and aspirin should be individualized. 

19. Mental Health Issues Not a Priority in ED 

By Charles Bankhead, Staff Writer, MedPage Today. May 05, 2012 

Weiss AP, et al. Patient and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med 2012 May 1. [Epub ahead of print]  

Seeking psychiatric care in an emergency department led to a wait of more than 11 hours, and the wait was even longer for older, intoxicated, and uninsured patients, a study of five urban hospitals showed. The median wait lasted 8.2 hours. Patients discharged to home had a wait on par with the median, but a transfer outside a system of care almost doubled the wait time for patients with psychiatric emergencies. 

"The results of this study are important because they highlight the interrelatedness of the various components of the mental health system and provide objectively identified targets for quality improvement," Anthony P. Weiss, MD, of Harvard and Massachusetts General Hospital in Boston, and co-authors wrote in an article published online in Annals of Emergency Medicine. 

"Emergency departments (EDs) that are embedded within a larger system of care and have ready access to various levels of after care options ... are likely to be better positioned to more rapidly transition patients through the ED," they added. 

Several recent studies have shown that patients who go to emergency departments for psychiatric care have substantially longer waits compared with patients seeking other types of care. Data from the National Center for Health Statistics showed that the average wait for mental health services in an emergency department was 42% greater than the wait for nonmental health issues (Psychiatr Ser 2010; 61: 678-684). 

In a survey by the American College of Emergency Physicians, 40% of emergency department medical directors said psychiatric patients waited more than 8 hours from disposition decision to discharge from the ED. In contrast, 7% of the directors said medical patients had to wait that long.

Factors that contribute to the long wait times for mental health services have received little attention in the literature. In an effort to identify patient-related and clinical management factors associated with longer ED waits, Weiss and colleagues conducted a prospective study involving five Boston-area hospitals (two academic, three community). 

Each hospital collected data on approximately 200 consecutive patients seeking psychiatric consultation in the hospital emergency department. Relevant information was obtained from the emergency department, mental health clinical staff, and patients' individual electronic medical records. 

The final analysis involved 1,092 patients. The median age was 39 and there was even distribution between the sexes. The authors found that non-Hispanic whites constituted 71% of the study sample; that two-thirds of the patients had public insurance; and that 13% of the patients were homeless. 

The most common (37%) presenting complaint was subjective mental distress (depressed or anxious), followed by suicidal ideation or nonlethal self-harm (33%). In about 90% of cases, patients provided serum or urine for a toxicology screen, which was uninformative 61% of the time. The substance identified most often was alcohol (33% of total sample), with or without other drugs. 

The most common discharge diagnoses were mood disorder (69%) and substance use disorder (41%). Subsequently, 299 patients were discharged to home and 679 patients were admitted to the hospital or transferred to a psychiatric unit. The remaining 114 patients had a heterogeneous make-up. 

In summarizing the key findings, the authors reported the following average wait times and average added times:
·         Transfer outside the care system, 15 hours
·         Transfer within the system, 12.9 hours
·         Transfer to psychiatric unit in hospital, 11 hours
·         Older age: 12.6 hours for ages 60 and older, 11.9 hours for ages 41 to 59, 10.7 hours for ages 18 to 40
·         Positive screen for alcohol, +6.2 hours (14-hour average)
·         Diagnostic imaging, +3.2 hours
·         Use of a restraint, +4.2 hours
·         Uninsured, +4 hours 

The extended time associated with admission or transfer resulted from an additional 3.3 to 7.4 hours added to the time from decision disposition to the end of the emergency department visit. 

"The need for inpatient admission was the factor associated with the greatest influence on length of stay, an effect that was due to long wait times after the decision to pursue admission had been made," the authors wrote. 

"Approximately two-thirds of all patients receiving emergency mental healthcare in this sample were either admitted or transferred to a psychiatric unit," they added. "Although these hospitalized patients tended to be seen and assessed more quickly than patients discharged home, they had significantly longer overall length of stay because of the extended wait time between the decision to admit and the ED discharge." 

The study had some limitations including the reliance on chart review, rather than direct observation, so there may have been incomplete documentation of some patient-related factors. Also, the results may not apply on a general level because the study was done at a single system of care within on U.S. region. 

However, the authors pointed out that the findings were consisted across the five different hospitals, which ranged from a 150-bed community hospital to a 900-bed academic tertiary care hospital. 

20. The Long-Term Effect of Premier Pay for Performance on Patient Outcomes 

Jha AK, et al. N Engl J Med 2012; 366:1606-1615.  

Background: Pay for performance has become a central strategy in the drive to improve health care. We assessed the long-term effect of the Medicare Premier Hospital Quality Incentive Demonstration (HQID) on patient outcomes. 

Methods: We used Medicare data to compare outcomes between the 252 hospitals participating in the Premier HQID and 3363 control hospitals participating in public reporting alone. We examined 30-day mortality among more than 6 million patients who had acute myocardial infarction, congestive heart failure, or pneumonia or who underwent coronary-artery bypass grafting (CABG) between 2003 and 2009. 

Results: At baseline, the composite 30-day mortality was similar for Premier and non-Premier hospitals (12.33% and 12.40%, respectively; difference, −0.07 percentage points; 95% confidence interval [CI], −0.40 to 0.26). The rates of decline in mortality per quarter at the two types of hospitals were also similar (0.04% and 0.04%, respectively; difference, −0.01 percentage points; 95% CI, −0.02 to 0.01), and mortality remained similar after 6 years under the pay-for-performance system (11.82% for Premier hospitals and 11.74% for non-Premier hospitals; difference, 0.08 percentage points; 95% CI, −0.30 to 0.46). We found that the effects of pay for performance on mortality did not differ significantly among conditions for which outcomes were explicitly linked to incentives (acute myocardial infarction and CABG) and among conditions not linked to incentives (congestive heart failure and pneumonia) (P=0.36 for interaction). Among hospitals that were poor performers at baseline, mortality was similar in the two groups of hospitals at the start of the study (15.12% and 14.73%; difference, 0.39 percentage points; 95% CI, −0.36 to 1.15), with similar rates of improvement per quarter (0.10% and 0.07%; difference, −0.03 percentage points; 95% CI, −0.08 to 0.02) and similar mortality rates at the end of the study (13.37% and 13.21%; difference, 0.15 percentage points; 95% CI, −0.70 to 1.01). 

Conclusions: We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest. 

21. Radiological and biomechanical analysis of humeral fractures occurring during arm wrestling 

Arm wrestling? Seriously? What, against Schwarzenegger?  

Kruczyński J, et al. Med Sci Monit. 2012 Apr 23;18(5):CR303-307. 

22. Accounting for the Polarization of Politics: Recent Research in the Behavioral Sciences

Jonathan Haidt, social psychologist at the University of Virginia, provides a fascinating sketch of human nature in The Righteous Mind: Why Good People Are Divided by Politics and Religion (New York: Pantheon Books: 2012).

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