Wednesday, June 20, 2012

Lit Bits: June 20, 2012

From the recent medical literature...

1. Evaluation of PE in the ED and Consistency with a National Quality Measure: Quantifying the Opportunity for Improvement  

A prospective, observational ED study found that imaging tests for possible PE may have been avoidable in nearly one-third of cases because of failure to employ appropriately a D-dimer. 

Venkatesh AK, et al. Arch Intern Med. 2012;():1-5. doi:10.1001/archinternmed.2012.1804 

Published online June 2012 

Background  The National Quality Forum (NQF) has endorsed a performance measure designed to increase imaging efficiency for the evaluation of pulmonary embolism (PE) in the emergency department (ED). To our knowledge, no published data have examined the effect of patient-level predictors on performance. 

Methods  To quantify the prevalence of avoidable imaging in ED patients with suspected PE, we performed a prospective, multicenter observational study of ED patients evaluated for PE from 2004 through 2007 at 11 US EDs. Adult patients tested for PE were enrolled, with data collected in a standardized instrument. The primary outcome was the proportion of imaging that was potentially avoidable according to the NQF measure. Avoidable imaging was defined as imaging in a patient with low pretest probability for PE, who either did not have a D-dimer test ordered or who had a negative D-dimer test result. We performed subanalyses testing alternative pretest probability cutoffs and imaging definitions on measure performance as well as a secondary analysis to identify factors associated with inappropriate imaging. χ2 Test was used for bivariate analysis of categorical variables and multivariable logistic regression for the secondary analysis. 

Results  We enrolled 5940 patients, of whom 4113 (69%) had low pretest probability of PE. Imaging was performed in 2238 low-risk patients (38%), of whom 811 had no D-dimer testing, and 394 had negative D-dimer test results. Imaging was avoidable, according to the NQF measure, in 1205 patients (32%; 95% CI, 31%-34%). Avoidable imaging owing to not ordering a D-dimer test was associated with age (odds ratio [OR], 1.15 per decade; 95% CI, 1.10-1.21). Avoidable imaging owing to imaging after a negative D-dimer test result was associated with inactive malignant disease (OR, 1.66; 95% CI, 1.11-2.49). 

Conclusions  One-third of imaging performed for suspected PE may be categorized as avoidable. Improving adherence to established diagnostic protocols is likely to result in significantly fewer patients receiving unnecessary irradiation and substantial savings. 


2. Drowning: NEJM Current Concepts 2012 

Szpilman D, et al. N Engl J Med 2012; 366:2102-2110.  

According to the World Health Organization (WHO), 0.7% of all deaths worldwide — or more than 500,000 deaths each year1 — are due to unintentional drowning.2 Since some cases of fatal drowning are not classified as such according to the codes of the International Classification of Disease, this number underestimates the real figures, even for high-income countries,3 and does not include drownings that occur as a result of floods, tsunamis, and boating accidents. 

Drowning is a leading cause of death worldwide among boys 5 to 14 years of age.2 In the United States, drowning is the second leading cause of injury-related death among children 1 to 4 years of age, with a death rate of 3 per 100,000,4 and in some countries, such as Thailand, the death rate among 2-year-old children is 107 per 100,000.5 In many countries in Africa and in Central America, the incidence of drowning is 10 to 20 times as high as the incidence in the United States. Key risk factors for drowning are male sex,4 age of less than 14 years,6 alcohol use,7 low income,1 poor education,5 rural residency,5 aquatic exposure,6,7, risky behavior,6,7, and lack of supervision.6 For people with epilepsy, the risk of drowning is 15 to 19 times as high as the risk for those who do not have epilepsy. 8 Exposure-adjusted, person-time estimates for drowning are 200 times as high as such estimates for deaths from traffic accidents.9 Coastal drownings are estimated to cost more than $273 million per year in the United States10 and more than $228 million per year (in U.S. dollars) in Brazil.11 For every person who dies from drowning, another four persons receive care in the emergency department for nonfatal drowning.12  

Definition and Terminology 

According to the new definition adopted by the WHO in 2002, “Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid.”13 The drowning process begins with respiratory impairment as the person's airway goes below the surface of the liquid (submersion) or water splashes over the face (immersion). If the person is rescued at any time, the process of drowning is interrupted, which is termed a nonfatal drowning. If the person dies at any time as a result of drowning, this is termed a fatal drowning. Any submersion or immersion incident without evidence of respiratory impairment should be considered a water rescue and not a drowning. Terms such as “near drowning,” “dry or wet drowning,” “secondary drowning,” “active and passive drowning,” and “delayed onset of respiratory distress” should be avoided.13 A uniform way to report data after a drowning event in order to allow comparison among different medical centers is to adopt the Utstein template for categorization of drowning (for details, see the Supplementary Appendix, available with the full text of this article at NEJM.org).14,15… 

The remainder of the article (full-text free): http://www.nejm.org/doi/full/10.1056/NEJMra1013317 

3. Prediction of Heart Failure Mortality in Emergent Care: A Cohort Study 

A risk score, called the Emergency Heart Failure Mortality Risk Grade, derived from variables that are routinely gathered in the emergency department may help guide the decision to admit or discharge patients presenting with acute heart failure. 

Note that there were 10 variables significantly associated with a greater likelihood of dying in the first week that were included in the risk score, including transportation by emergency medical services, elevated serum troponin, use of metolazone at home, and active cancer. 

Lee DS, et al. Ann Intern Med. 2012 Jun 5;156(11):767-75. 

Background: Heart failure contributes to millions of emergency department (ED) visits, but hospitalization-versus-discharge decisions are often not accompanied by prognostic risk quantification.  

Objective: To derive and validate a model for acute heart failure mortality applicable in the ED.  

Design: Clinical data abstraction with development of a broadly applicable multivariate risk index for 7-day death using initial vital signs, clinical and presentation features, and readily available laboratory tests.  

Setting: Multicenter study of 86 hospitals in Ontario, Canada.  

Patients: Population-based random sample of 12 591 patients presenting to the ED from 2004 to 2007.  

Measurements: Death within 7 days of presentation.  

Results: In the derivation cohort (n = 7433; mean age, 75.4 years [SD, 11.4]; 51.5% men), mortality risk increased with higher triage heart rate (adjusted odds ratio [OR], 1.15 [95% CI, 1.03 to 1.30] per 10 beats/min) and creatinine concentration (OR, 1.35 [CI, 1.14 to 1.60] per 1 mg/dL [88.4 µmol/L]), and lower triage systolic blood pressure (OR, 1.52 [CI, 1.31 to 1.77] per 20 mm Hg) and initial oxygen saturation (OR, 1.16 [CI, 1.01 to 1.33] per 5%). Nonnormal serum troponin levels (OR, 2.75 [CI, 1.86 to 4.07]) were associated with increased mortality risk. Areas under the receiver-operating characteristic curves of the multivariate model were 0.805 for the derivation data set (bootstrap-corrected, 0.811) and 0.826 for validation data set (n = 5158; mean age, 75.7 years [SD, 11.4]; 51.6% men). In the derivation cohort, a multivariate index score stratified 7-day mortality with rates of 0.3%, 0.3%, 0.7%, and 1.9% in quintiles 1 to 4, respectively. Mortality rates in the 2 highest risk groups were 3.5% and 8.2% in deciles 9 and 10, respectively.  

Limitation: Left ventricular ejection fraction was not included in the model.  

Conclusion: A multivariate index comprising routinely collected variables stratified mortality risk with high discrimination in a broad group of patients with acute heart failure presenting to the ED. 


4. A New Prediction Model for the Presence of CAD in Low-Prevalence Populations: The CAD consortium 

Genders TS, et al. Prediction model to estimate presence of coronary artery disease: retrospective pooled analysis of existing cohorts. BMJ 2012;344:e3485.

Objectives To develop prediction models that better estimate the pretest probability of coronary artery disease in low prevalence populations. 

Design Retrospective pooled analysis of individual patient data. 

Setting 18 hospitals in Europe and the United States. 

Participants Patients with stable chest pain without evidence for previous coronary artery disease, if they were referred for computed tomography (CT) based coronary angiography or catheter based coronary angiography (indicated as low and high prevalence settings, respectively). 

Main outcome measures Obstructive coronary artery disease (≥50% diameter stenosis in at least one vessel found on catheter based coronary angiography). Multiple imputation accounted for missing predictors and outcomes, exploiting strong correlation between the two angiography procedures. Predictive models included a basic model (age, sex, symptoms, and setting), clinical model (basic model factors and diabetes, hypertension, dyslipidaemia, and smoking), and extended model (clinical model factors and use of the CT based coronary calcium score). We assessed discrimination (c statistic), calibration, and continuous net reclassification improvement by cross validation for the four largest low prevalence datasets separately and the smaller remaining low prevalence datasets combined. 

Results We included 5677 patients (3283 men, 2394 women), of whom 1634 had obstructive coronary artery disease found on catheter based coronary angiography. All potential predictors were significantly associated with the presence of disease in univariable and multivariable analyses. The clinical model improved the prediction, compared with the basic model (cross validated c statistic improvement from 0.77 to 0.79, net reclassification improvement 35%); the coronary calcium score in the extended model was a major predictor (0.79 to 0.88, 102%). Calibration for low prevalence datasets was satisfactory. 

Conclusions Updated prediction models including age, sex, symptoms, and cardiovascular risk factors allow for accurate estimation of the pretest probability of coronary artery disease in low prevalence populations. Addition of coronary calcium scores to the prediction models improves the estimates. 

What’s your risk? Online calculator: http://rcc.simpal.com/NpfpV5  

5. CT Angiography Is More Likely to Be Negative for PE When Ordered for Defensive Reasons 

Fear of missing pulmonary embolism was cited as a reason for ordering computed tomography pulmonary angiography in 55% of cases in this single-center Swiss study. 

Rohacek M, et al. Intensive Care Med. 2012 May 15. [Epub ahead of print] 

PURPOSE: To identify reasons for ordering computed tomography pulmonary angiography (CTPA), to identify the frequency of reasons for CTPA reflecting defensive behavior and evidence-based behavior, and to identify the impact of defensive medicine and of training about diagnosing pulmonary embolism (PE) on positive results of CTPA. 

METHODS: Physicians in the emergency department of a tertiary care hospital completed a questionnaire before CTPA after being trained about diagnosing PE and completing questionnaires. 

RESULTS: Nine hundred patients received a CTPA during 3 years. For 328 CTPAs performed during the 1-year study period, 140 (43 %) questionnaires were completed. The most frequent reasons for ordering a CTPA were to confirm/rule out PE (93 %), elevated D-dimers (66 %), fear of missing PE (55 %), and Wells/simplified revised Geneva score (53 %). A positive answer for "fear of missing PE" was inversely associated with positive CTPA (OR 0.36, 95 % CI 0.14-0.92, p = 0.033), and "Wells/simplified revised Geneva score" was associated with positive CTPA (OR 3.28, 95 % CI 1.24-8.68, p = 0.017). The proportion of positive CTPA was higher if a questionnaire was completed, compared to the 2-year comparison period (26.4 vs. 14.5 %, OR 2.12, 95 % CI 1.36-3.29, p < 0.001). The proportion of positive CTPA was non-significantly higher during the study period than during the comparison period (19.2 vs. 14.5 %, OR 1.40, 95 % CI 0.98-2.0, p = 0.067). 

CONCLUSION: Reasons for CTPA reflecting defensive behavior-such as "fear of missing PE"-were frequent, and were associated with a decreased odds of positive CTPA. Defensive behavior might be modifiable by training in using guidelines. 

See similar article (same lead author) on head CT: Rohacek M, et al. Reasons for ordering computed tomography scans of the head in patients with minor brain injury. Injury. 2012 Jan 23. [Epub ahead of print] Abstract here: http://www.ncbi.nlm.nih.gov/pubmed/22277106

6. Effect of Bedside Ultrasonography on the Certainty of Physician Clinical Decision-making for Septic Patients in the ED 

Haydar SA, et al. Ann Emerg Med. 2012; in press 

Study objective: Sepsis protocols promote aggressive patient management, including invasive procedures. After the provision of point-of-care ultrasonographic markers of volume status and cardiac function, we seek to evaluate changes in emergency physician clinical decisionmaking and physician assessments about the clinical utility of the point-of-care ultrasonographic data when caring for adult sepsis patients. 

Methods: For this prospective before-and-after study, patients with suspected sepsis received point-of-care ultrasonography to determine cardiac contractility, inferior vena cava diameter, and inferior vena cava collapsibility. Physician reports of treatment plans, presumed causes of observed vital sign abnormalities, and degree of certainty were compared before and after knowledge of point-of-care ultrasonographic findings. The clinical utility of point-of-care ultrasonographic data was also evaluated. 

Results: Seventy-four adult sepsis patients were enrolled: 27 (37%) sepsis, 30 (40%) severe sepsis, 16 (22%) septic shock, and 1 (1%) systemic inflammatory response syndrome. After receipt of point-of-care ultrasonographic data, physicians altered the presumed primary cause of vital sign abnormalities in 12 cases (17% [95% confidence interval {CI} 8% to 25%]) and procedural intervention plans in 20 cases (27% [95% CI 17% to 37%]). Overall treatment plans were changed in 39 cases (53% [95% CI 41% to 64%]). Certainty increased in 47 (71%) cases and decreased in 19 (29%). Measured on a 100-mm visual analog scale, the mean clinical utility score was 65 mm (SD 29; 95% CI 58 to 72), with usefulness reported in all cases. 

Conclusion: Emergency physicians found point-of-care ultrasonographic data about cardiac contractility, inferior vena cava diameter, and inferior vena cava collapsibility to be clinically useful in treating adult patients with sepsis. Increased certainty followed acquisition of point-of-care ultrasonographic data in most instances. Point-of-care ultrasonography appears to be a useful modality in evaluating and treating adult sepsis patients. 

See also Lyon ML, et al.  Ultrasound Guided Volume Assessment Using Inferior Vena Cava Diameter. Open Emerg Med J 2010;3:22-24. Full-text (free): http://www.benthamscience.com/open/toemj/articles/V003/SI0021TOEMJ/22TOEMJ.pdf  


7. CT scans and cancer risk in children 

Pearce MS, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet, Early Online Publication, 7 June 2012. doi:10.1016/S0140-6736(12)60815-0  

New research highlights the risk of ionising radiation from computed tomography (CT) scans given to children. Radiation exposure from 2 to 3 CT scans of the head in childhood (aged under 15 years)—giving a cumulative dose of around 60 mGy—could increase the risk of developing brain cancer; around 5 to 10 scans (cumulative dose around 50 mGy) could increase the risk of leukaemia. While the absolute risk of these cancers occurring after CT scanning is small, radiation doses from CT scans should be kept as low as possible and alternative procedures, that do not use ionising radiation, should be considered. 



8. Early Administration of Systemic Corticosteroids Reduces Hospital Admission Rates for Children with Moderate and Severe Asthma Exacerbation

Bhogal SK, et al. Ann Emerg Med. 2012;60:84-91.e3 

Study objective: The variable effectiveness of clinical asthma pathways to reduce hospital admissions may be explained in part by the timing of systemic corticosteroid administration. We examine the effect of early (within 60 minutes [SD 15 minutes] of triage) versus delayed (>75 minutes) administration of systemic corticosteroids on health outcomes. 

Methods: We conducted a prospective observational cohort of children aged 2 to 17 years presenting to the emergency department with moderate or severe asthma, defined as a Pediatric Respiratory Assessment Measure (PRAM) score of 5 to 12. The outcomes were hospital admission, relapse, and length of active treatment; they were analyzed with multivariate logistic and linear regressions adjusted for covariates and potential confounders. 

Results: Among the 406 eligible children, 88% had moderate asthma; 22%, severe asthma. The median age was 4 years (interquartile range 3 to 8 years); 64% were male patients. Fifty percent of patients received systemic corticosteroids early; in 33%, it was delayed; 17% of children failed to receive any. Overall, 36% of patients were admitted to the hospital. Compared with delayed administration, early administration reduced the odds of admission by 0.4 (95% confidence interval 0.2 to 0.7) and the length of active treatment by 0.7 hours (95% confidence interval −1.3 to −0.8 hours), with no significant effect on relapse. Delayed administration was positively associated with triage priority and negatively with PRAM score. 

Conclusion: In this study of children with moderate or severe asthma, administration of systemic corticosteroids within 75 minutes of triage decreased hospital admission rate and length of active treatment, suggesting that early administration of systemic corticosteroids may allow for optimal effectiveness. 

9. Emergency Physicians Monthly Reports their Top 10 SAEM Abstracts 

The Society for Academic Emergency Medicine’s Annual Meeting was held May 9-12, 2012 in Chicago, Illinois. The Research Forum featured 746 Abstracts, and 37 Innovations in Emergency Medicine education presentations.  We selected the 10 we thought had the most potential to impact the practice of emergency physicians. 

Titles only:

Policy-driven Improvements in Crowding: System-level Changes Introduced by a Provincial Health Authority and Its Impact on Emergency Department Operations in 15 Centers 

The Usefulness of the 3-Minute Walk Test in Predicting Adverse Outcomes in ED Patients with Heart Failure and COPD 

A Comparison of Cosmetic Outcomes of Lacerations of the Trunk and Extremity Repaired Using Absorbable Versus Nonabsorbable Sutures 

Safety of Droperidol for Sedation of Acute Behavioural Disturbance 

Meta-analysis of Magnetic Resonance Imaging for the Diagnosis of Appendicitis 

Use of Single Dose of Intramuscular Methadone for Acute Opioid Withdrawal 

Direct Bedding, Bedside Registration, and Patient Pooling to Improve Pediatric Emergency Department Length of Stay

Impact of Health Care Reform in Massachusetts on Emergency Department and Hospital Utilization 

Derivation of a Simplified Pulmonary Embolism Triage Score (PETS) to Predict the Mortality in Patients with Confirmed Pulmonary Embolism from the Emergency Medicine Pulmonary Embolism in the Real World Registry (EMPEROR) 

Cannabinoid Hyperemesis: Relevance to Emergency Medicine 

10. Ultrafast 3-T MRI in the evaluation of children with acute lower abdominal pain for the detection of appendicitis. 

Johnson AK, et al. AJR Am J Roentgenol. 2012 Jun;198(6):1424-30. 

OBJECTIVE: The purpose of this study is to evaluate the feasibility of ultrafast 3-T MRI in the evaluation of children with acute lower abdominal pain for the detection of appendicitis. 

SUBJECTS AND METHODS: Forty-two pediatric patients (30 girls and 12 boys; mean age, 11.5 years; age range, 4-17 years) with acute abdominal pain were prospectively studied. Ultrafast 3-T MRI was performed with a three-plane single-shot turbo spin-echo sequence and an axial T2-weighted turbo spin-echo sequence with fat suppression. All scans were performed without sedation or oral or IV contrast agent. Scan times were less than 8 minutes 45 seconds (median, 5 minutes 40 seconds). Patients underwent CT or ultrasound or both as a comparison study to the MRI examination. The MRI, CT, and ultrasound examinations were interpreted independently by four board-certified radiologists who were blinded to patient information, study interpretations, surgical pathologic findings, and final diagnosis. 

RESULTS: Twelve of 42 cases of acute appendicitis were detected with 100% sensitivity, 99% specificity, 100% negative predictive value, and 98% positive predictive value, all of which were statistically significant (p < 0.01). The pooled and individual receiver operating characteristic curves for radiologists' interpretation of the diagnosis of acute appendicitis were greater than 0.95 in all cases (p < 0.01).

CONCLUSION: Ultrafast 3-T MRI is a feasible alternative imaging modality for the diagnosis of acute appendicitis in children, particularly in cases where ultrasound is equivocal or nondiagnostic, as an alternative to CT. Ultrafast MRI requires no sedation and no oral or IV contrast agent and has no associated radiation exposure risks. 

11. Painfree AMI Presentations are Common and Fare Poorly 

Canto AJ, et al. Differences in symptom presentation and hospital mortality according to type of acute myocardial infarction. Amer Heart J. 2012;163:572-9. 

Background: Chest pain/discomfort (CP) is the hallmark symptom of acute myocardial infarction (MI), but some patients with MI present without CP. We hypothesized that MI type (ST-segment elevation MI [STEMI] or non-STEMI [NSTEMI]) may be associated with the presence or absence of CP. 

Methods: We investigated the association between CP at presentation and MI type, hospital care, and mortality among 1,143,513 patients with MI in the National Registry of Myocardial Infarction (NRMI) from 1994 to 2006. 

Results: Overall, 43.6% of patients with NSTEMI and 27.1% of patients with STEMI presented without CP. For both MI type, patients without CP were older, were more frequently female, had more diabetes or history of heart failure, were more likely to delay hospital arrival, and were less likely to receive evidence-based medical therapies and invasive cardiac procedures. Multivariable analysis indicated that NSTEMI (vs STEMI) was the strongest predictor of atypical symptoms (adjusted odds ratio [95% CI], 1.93 [1.91-1.95]). Within the 4 CP/MI type categories, hospital mortality was highest for no CP/STEMI (27.8%), followed by no CP/NSTEMI (15.3%) and CP/STEMI (9.6%), and was lowest for CP/NSTEMI (5.4%). The adjusted odds ratio of mortality was 1.38 (1.35-1.41) for no CP (vs CP) in the STEMI group and 1.31 (1.28-1.34) in the NSTEMI group. 

Conclusions: Hospitalized patients with NSTEMI were nearly 2-fold more likely to present without CP than patients with STEMI. Patients with MI without CP were less quickly diagnosed and treated and had higher adjusted odds of hospital mortality, regardless of whether they had ST-segment elevation. 

12. Pain Pills Add Cost and Delays to Job Injuries

By Barry Meier. New York Times. June 2, 2012 

Workplace insurers are accustomed to making billions of dollars in payments each year, with the biggest sums going to employees hurt in major accidents, like those mangled by machines or crushed in building collapses.  

Now they are dealing with another big and fast-growing cost — payouts to workers with routine injuries who have been treated with strong painkillers, including many who do not return to work for months, if ever. 

Workplace insurers spend an estimated $1.4 billion annually on narcotic painkillers, or opioids. But they are also finding that the medications, if used too early in treatment, too frequently or for too long, can drive up associated disability payouts and medical expenses by delaying an employee’s return to work.  

Workers who received high doses of opioid painkillers to treat injuries like back strain stayed out of work three times longer than those with similar injuries who took lower doses, a 2008 study of claims by the California Workers Compensation Institute found. When medical care and disability payments are combined, the cost of a workplace injury is nine times higher when a strong narcotic like OxyContin is used than when a narcotic is not used, according to a 2010 analysis by Accident Fund Holdings, an insurer that operates in 18 states.  

“What we see is an association between the greater use of opioids and delayed recovery from workplace injuries,” said Alex Swedlow, the head of research at the California Workers Compensation Institute.  

The use of narcotics to treat occupational injuries is part of a broader problem involving what many experts say is the excessive use of drugs like OxyContin, Percocet and Duragesic. But workplace injuries are drawing particular interest because the drugs are widely prescribed to treat common problems like back pain, even though there is little evidence that they provide long-term benefits. 

Along with causing drowsiness and lethargy, high doses of opioids can lead to addiction, and they can have other serious side effects, including fatal overdoses.  

Between 2001 and 2008, narcotics prescriptions as a share of all drugs used to treat workplace injuries jumped 63 percent, according to insurance industry data. Costs have also soared.  

In California, for example, workplace insurers spent $252 million on opioids in 2010, a figure that represented about 30 percent of all prescription costs; in 2002, opioids accounted for 15 percent of drug expenditures.  

As a result, states are struggling to find ways to reverse the trend, and some of them have issued new pain treatment guidelines, or are expected to do so soon. These states include New York, Colorado, Texas and Washington. Insurers are also trying to influence how physicians prescribe the drugs.  

Doctors in four states — Louisiana, Massachusetts, New York and Pennsylvania — appear to be the biggest prescribers of the drugs for workers’ injuries, according to a review of data from 17 states by the Workers Compensation Research Institute, a group in Cambridge, Mass.  

Painkiller-related costs are also hitting taxpayers, who underwrite coverage for public employees like police officers and firefighters, experts say. In February, one major underwriter, the American International Group, said that it would no longer sell backup coverage to workplace insurers, citing rising pain treatment expenses as one reason.  

There is little question that strong pain medications can help some patients return to work and remain productive. But injured workers who are put on high doses of the drugs can develop chronic pain and face years of difficult treatments. It is not clear how, or if, the drugs are involved in the process, but when pain becomes chronic, the cost of a commonplace injury can equal a crippling one, experts said.

“Some of these claims look like someone who fell down an elevator shaft and had multiple injuries,” said Dr. Edward J. Bernacki, the director of the division of occupational and environmental medicine at Johns Hopkins University in Baltimore.  

For decades, workers’ compensation plans, which vary by state, have been plagued by problems like lengthy legal battles over an injury’s financial value. But it is in recent years that opioid painkillers have emerged as a major driver of costs, experts said.  

Accident Fund Holdings examined its claims and found that the cost of a typical workplace injury — the sum of an employee’s medical expenses and lost wage payments — was about $13,000. But when a worker was prescribed a short-acting painkiller like Percocet, that cost tripled to $39,000 and tripled again to $117,000 when a stronger longer-acting opioid like OxyContin was prescribed, said Jeffrey Austin White, an executive with the insurer, which is based in Lansing, Mich.  

In a sense, insurers are experiencing the consequences of their own policies. During the last decade, they readily reimbursed doctors for prescribing painkillers while eliminating payments for treatments that did not rely on drugs, like therapy.  

Those policies may “have created a monster,” said Dr. Bernyce M. Peplowski, the medical director of the State Compensation Insurance Fund of California, a quasi-public agency.  

For patients, such policies had consequences… 


13. Images in Clinical Medicine 

Bladder Stones

Scrofuladerma

Obstructive Parotitis

Flashing, Pulsating Angioma

Postherpetic Pseudohernia

Elderly Female with Abdominal Pain

Rapidly Progressing Flank Mass

14. Emergency Departments, Medicaid Costs, and Access to Primary Care — Understanding the Link 

Arthur L. Kellermann, et al. N Engl J Med 2012; 366:2141-2143.  

In December, 2011, Washington State's Health Care Authority announced its intention to stop paying for emergency department (ED) visits by Medicaid beneficiaries “when those visits are not necessary for that place of service.”1 To identify unnecessary visits, the state proposed a list of approximately 500 diagnosis codes (see examples in the tableSelected Diagnoses (with ICD-9 Codes) from the Washington State Health Authority's List of “Nonemergency” Conditions.). The proposed rule would apply to all Medicaid beneficiaries, irrespective of age, disability, or place of residence (such as a nursing home) — even if the patient, the child's parent, or the nursing home staff believed that ED care was needed. 

Previously, the Authority had sought to impose an annual three-visit limit on nonemergency ED use but was rebuffed by a state court ruling. Although the new policy is arguably harsher than the first, officials expressed confidence that it could withstand legal challenge. In its press release, the Authority stated that the Centers for Medicare and Medicaid Services had advised it that the new policy would not require a State Plan Amendment.1  

On April 1, 2012, the day the new policy was supposed to take effect, Washington Governor Chris Gregoire suspended implementation in order to try a less drastic alternative worked out with the state's hospitals and emergency physicians. The compromise plan calls for the rapid development and statewide adoption of an unspecified set of “best practices” to “reduce medical assistance expenditures through the reduction of unnecessary emergency department visits.” By July 1, hospitals accounting for at least 75% of ED utilization by Medicaid fee-for-service clients must submit legal attestations that they are complying with the plan. If they fail to do so, the Authority may proceed with implementing its policy of nonpayment for ED visits it determines to be nonemergency visits. 

The motive for Washington State's actions is clear enough. Since 2008, a total of 9.8 million Americans have lost employer-sponsored health insurance. As a result, Medicaid rolls have swelled by 7.5 million. Squeezed between rising expenditures and falling tax revenues, state governments are desperately searching for new ways to cut Medicaid spending. Given this fiscal challenge, the notion that many Medicaid beneficiaries overuse EDs was too tempting to ignore. 

The genesis for the idea of denying payment for nonemergency ED visits is frequently traced to the research of John Billings, a professor of health policy at New York University. In the early 2000s, he developed an algorithm that used discharge diagnoses to identify ED visits that are “ambulatory care sensitive.” In his view, ambulatory care–sensitive visits fall into one of two groups: those that are “primary care treatable,” meaning that the problem could safely be managed in a doctor's office, and those that are “primary care preventable,” meaning that the visit might have been averted if care had been provided sooner. An uncomplicated lower urinary tract infection would be considered “primary care treatable.” An asthma flare-up would be categorized as “primary care preventable.”2  

Unfortunately, policymakers have generally misinterpreted Billings's findings. The fact that many ED visits could be managed in primary care settings does not mean that such care is available. In fact, Billings himself asserted that high rates of ED use for ambulatory care–sensitive conditions are a strong indicator of poor access to care — not poor judgment on the part of patients. 

Two decades of research support this view. In 1994, research assistants posing as Medicaid patients telephoned a random sample of primary care doctors and clinics in 10 cities to determine whether Medicaid patients could get treatment for minor problems without visiting an ED. The callers were successful only 26% of the time. When office staff members were asked to suggest an alternative, the most common advice was no advice. The next most common recommendation was “Go to an ED.”3 

In 1996, researchers who were posted in 56 EDs nationwide interviewed 6187 walk-in patients over a single 24-hour period. When asked why they chose an ED for care, the vast majority of walk-in patients cited clinical reasons or preferences. Forty-five percent thought they had a medical emergency or were too sick to go elsewhere; 19% said they were sent to the ED by a health care professional.4  

Getting follow-up care after an ED visit can be challenging as well. In 2005, research assistants posing as patients telephoned 499 randomly selected primary care practices and clinics in nine U.S. cities. Claiming that they had been seen in an ED the night before and had received a diagnosis of one of three serious problems (pneumonia, hypertension, or possible ectopic pregnancy), callers requested follow-up care. When they said they were covered by Medicaid, only one third could secure a timely appointment.5  

Billings hoped that his algorithm would be used to evaluate the performance of primary care systems and assess promising interventions to improve access to care. He never intended it to be used to judge individual decisions to seek care. Ironically, the population-based tool he designed to improve access to care is instead being used to restrict it. 

Perhaps the Authority's actions will encourage Medicaid beneficiaries to forgo nonemergency ED visits and instead forge enduring relationships with primary care providers. If that happens, it will be a good thing. Unfortunately, acutely ill patients aren't particularly adept at determining the level of care they need. Even experienced triage nurses get it wrong: 3 to 5% of patients whose condition is classified as “nonurgent” at the ED triage desk require immediate hospitalization.5 If the Authority's efforts inadvertently cause more Medicaid beneficiaries to delay or forgo needed care, they could worsen outcomes and increase costs. 

Perhaps the Authority assumes that the state's hospitals will keep treating Medicaid beneficiaries anyway, since the federal Emergency Medical Treatment and Active Labor Act requires EDs to evaluate and stabilize all in need, without regard for the patient's ability to pay. Then, if the ED workup reveals that the patient's cough and fever were due to acute bronchitis instead of pneumonia, or that a painfully swollen ankle was severely sprained rather than fractured, payment can be denied. “Retrospective denials” of this sort are so unfair that Congress included “prudent layperson” language in the Affordable Care Act (ACA). As a result, health plans, including Medicaid managed-care organizations, can no longer deny payment of a claim if the patient or the parent of a pediatric patient reasonably believed that the problem required treatment in an emergency department. Although it is questionable whether the prudent-layperson provision in the ACA extends to enrollees in fee-for-service Medicaid, one thing is clear: for millions of low-income Americans, not only is the ED a reasonable choice — often, it is the only choice. 

If the compromise measure falters and Washington State's Health Authority goes forward with its nonpayment policy, other states could quickly follow suit. If that happens, the resulting spike in uncompensated care costs will probably accelerate an already alarming national trend in ED closures. Everyone's access to emergency care could be affected. 

Clearly, something must be done to stop the hemorrhaging of state budgets. But ill-considered actions could make things worse. Medicaid was created to ensure that the poorest of the poor have access to care. Rather than confronting the challenge of inadequate access to primary care, Washington State's Health Care Authority is attempting to restrict access to ED care. Instead of blocking the doors to the ED, policymakers in Washington State and elsewhere should draw the proper lessons from Billings's research and unlock the doors to primary care. 

Interview with Dr. Arthur Kellermann on the increasing use of ED and access to primary care. (13:59) here: http://www.nejm.org/doi/full/10.1056/NEJMp1203247  

15. What Oxygen Saturation is Best for ED Patients with COPD? 

You’d think “100%” but that may not be the case. Thanks to EM-RAP for bringing this 2010 article to our attention. 

Austin MA, et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ. 2010 Oct 18;341:c5462. doi: 10.1136/bmj.c5462. 

OBJECTIVES: To compare standard high flow oxygen treatment with titrated oxygen treatment for patients with an acute exacerbation of chronic obstructive pulmonary disease in the prehospital setting. 

DESIGN: Cluster randomised controlled parallel group trial. 

SETTING: Ambulance service in Hobart, Tasmania, Australia. 

PARTICIPANTS: 405 patients with a presumed acute exacerbation of chronic obstructive pulmonary disease who were treated by paramedics, transported, and admitted to the Royal Hobart Hospital during the trial period; 214 had a diagnosis of chronic obstructive pulmonary disease confirmed by lung function tests in the previous five years. 

INTERVENTIONS: High flow oxygen treatment compared with titrated oxygen treatment in the prehospital (ambulance/paramedic) setting. 

MAIN OUTCOME MEASURE: Prehospital or in-hospital mortality. 

RESULTS: In an intention to treat analysis, the risk of death was significantly lower in the titrated oxygen arm compared with the high flow oxygen arm for all patients (high flow oxygen n=226; titrated oxygen n=179) and for the subgroup of patients with confirmed chronic obstructive pulmonary disease (high flow n=117; titrated n=97). Overall mortality was 9% (21 deaths) in the high flow oxygen arm compared with 4% (7 deaths) in the titrated oxygen arm; mortality in the subgroup with confirmed chronic obstructive pulmonary disease was 9% (11 deaths) in the high flow arm compared with 2% (2 deaths) in the titrated oxygen arm. Titrated oxygen treatment reduced mortality compared with high flow oxygen by 58% for all patients (relative risk 0.42, 95% confidence interval 0.20 to 0.89; P=0.02) and by 78% for the patients with confirmed chronic obstructive pulmonary disease (0.22, 0.05 to 0.91; P=0.04). Patients with chronic obstructive pulmonary disease who received titrated oxygen according to the protocol were significantly less likely to have respiratory acidosis (mean difference in pH 0.12 (SE 0.05); P=0.01; n=28) or hypercapnia (mean difference in arterial carbon dioxide pressure -33.6 (16.3) mm Hg; P=0.02; n=29) than were patients who received high flow oxygen. 

CONCLUSIONS: Titrated oxygen treatment significantly reduced mortality, hypercapnia, and respiratory acidosis compared with high flow oxygen in acute exacerbations of chronic obstructive pulmonary disease. These results provide strong evidence to recommend the routine use of titrated oxygen treatment in patients with breathlessness and a history or clinical likelihood of chronic obstructive pulmonary disease in the prehospital setting. 


16. MS Diagnosis Stumps Emergency Docs (no surprise) 

By John Gever, Senior Editor, MedPage Today. June 02, 2012. SAN DIEGO -- Many patients with early signs of multiple sclerosis go to an emergency room for care, but, at one big-city hospital, the diagnosis was initially missed in 40% of cases, a researcher said here. 

Review of patient records at Mount Sinai Medical Center in New York City indicated that, among patients treated at the emergency room who were later diagnosed with MS at the institution, only 61% received the diagnosis at that visit, said Stephen Krieger, MD. 

"That's good," he told attendees at the joint meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis. 

But it also means that the diagnosis was delayed in 39%, said Krieger, a neurologist at Mount Sinai. In fact, multiple sclerosis was not diagnosed in 16% of the patients until at least 1 year later. 

Because early treatment for MS is associated with reduced disease activity and delayed onset of disability, the findings suggest that the emergency department could represent an opportunity to improve MS patient care, Krieger said. 

The study covered all patients seen in Mount Sinai's emergency department from 2005 to 2009, focusing on those patients whose records indicated a subsequent diagnosis of MS. 

For purposes of this analysis, Krieger said, "diagnosis" was defined broadly as the first mention of MS in the record, which could be in the clinical notes or a radiologist's report as well as a formal diagnostic code.

The search turned up 49 patients who had a total of 98 emergency room visits before receiving an MS diagnosis. 

Their mean age was 33. Otherwise their demographic profile was typical for MS patients in the upper Manhattan community served by the hospital -- about 70% female, with some 40% Hispanic, 30% African American, and 18% white. Roughly 70% had private insurance. 

Exactly half the visits involved neurological symptoms. The investigators' review of the patients' charts indicated that 44% of the 98 visits were for symptoms that were most likely the initial manifestation of MS. 

The most common were sensory loss (seen in 24% of visits), paresthesia (17%), vision loss (14%), and limb weakness (13%). 

In addition to the approximately 61% of patients who were diagnosed in the emergency department or after being admitted directly from it, another 10% were diagnosed within a week of the visit. The remainder had a significant delay in receiving a diagnosis, Krieger indicated. 

The only factor examined by the researchers that was significantly (P<0.05) associated with an immediate MS diagnosis was admission from the emergency department. 

Krieger said that was natural -- patients admitted would have had relatively severe symptoms and a thorough workup that would raise the odds of reaching an MS diagnosis. 

There were also trends toward greater likelihood of immediate diagnosis with race, gender, and other factors, but the small number of patients in the study were a handicap, Krieger said. He said a larger, multicenter study that included rural and suburban hospitals as well as urban academic centers could provide a clearer view of the barriers to faster diagnosis. 

But although the current study involved only a single center, he suggested that it represents "sort of a best-case scenario." 

He noted that Mount Sinai has a neurology residency program and an MS clinic, which would presumably increase the chances that MS symptoms would be spotted for what they were. 

Session moderator Lael Stone, MD, of the Cleveland Clinic, told MedPage Today that it was important to be looking at the reasons for delayed diagnoses. 

She said the study, though small, showed that "we have a way to go, even in a relatively sophisticated emergency room, in actually picking up MS [there], which we should be able to do." 

Stone pointed out, though, that some patients present with relatively nonspecific symptoms that, in practice, usually won't be linked to MS by emergency room personnel. 

For example, she said, an early symptom of the MS-related condition neuromyelitis optica is intractable vomiting. Even a very sophisticated emergency department is unlikely to connect that with a demyelinating disorder, she suggested. 

"The intractable vomiting goes to a GI doctor," she said. "I've been doing this forever -- I don't always ask about intractable vomiting when I take a history." 

Primary source: Consortium of Multiple Sclerosis Centers-Americas Committee for Treatment and Research in Multiple Sclerosis. Source reference: Farber R, et al "Emergency department visits before the diagnosis of multiple sclerosis (data from RESUMS-D: Resource Utilization in MS Diagnosis)" CMSC-ACTRIMS 2012; Abstract DX90. 

17. The Safety of Cardioversion of Recent-Onset Atrial Fibrillation in Emergency Department Patients 

Vinson DR. Ann Emerg Med. 2012;60:134-135.  

In response to Von Besser and Mills: Ann Emerg Med. 2011;58:517-520.   

Von Besser and Mills1 are to be commended for compiling a concise overview of 5 studies making a collective case that active cardioversion is both effective and safe in stable emergency department (ED) patients with recent-onset atrial fibrillation. More recent research brings into sharper focus issues of safety, both in the ED and postdischarge. 

Immediate complications from attempted ED cardioversion in the reviewed studies were uncommon, were nearly always readily resolved, and rarely resulted in a change in disposition.1 Yet the strength of these conclusions is tempered by methodological constraints. Four of the studies were retrospective record reviews, with an inherent underdocumentation bias. And the only prospective study contained just 30 cases. 

This safety record, however, is substantively confirmed by 2 large prospective studies. Bellone et al2 randomized 247 ED patients with recent-onset atrial fibrillation to either electricity or intravenous propafenone. Overall, cardioversion was achieved in 81.4% (201/247). Only 7 (2.8%) patients experienced an adverse event in the ED, 6 of which were minor and limited. The seventh patient experienced cardiac ischemia. Vinson et al3 conducted a multicenter observational study of practice patterns in the management of 206 patients with recent-onset atrial fibrillation and flutter, 115 of whom underwent attempted cardioversion. Cardioversion was achieved in 110 patients (95.6%). Among the 115 cardioversion attempts, there were 6 (5.3%) intervention-requiring adverse events in the ED, all of which resolved without sequelae. Two of these resulted in a change in disposition. 

And after discharge? Von Besser and Mills1 reported a return visit rate for relapsed atrial fibrillation of 3% to 17%. In a recent study that followed discharged patients after ED cardioversion with 24-hour Holter monitoring, Fundarò et al4 found that only 79% (46/58) remained in stable sinus rhythm at 7 days. 

A thromboembolic event is rightly described by Von Besser and Mills1 as the most feared complication of ED cardioversion of noncoagulated patients. In their 5 studies, none was reported.1 But methodological shortcomings moderate this result as well. Three of the retrospective studies limited their follow-up to a chart review of only site-specific visits within 7 days. Another retrospective study expanded follow-up to 30 days and included return visits at other regional hospitals. The most thorough follow-up was undertaken by the small prospective study, which contacted all of its 24 patients approximately 3 weeks postdischarge. 

Prospective data solidify this post discharge safety profile. Review of electronic records was complemented by telephone contact in 99% (204/206) of the cohort studied by Vinson et al.3 Thirty-day thromboembolism occurred in 1 (0.9%) of 110 cardioverted patients. She was receiving aspirin and had a CHADS2 score of 1. Interestingly, another patient (CHADS2 score 2) of the larger cohort also developed a stroke, but without having undergone ED cardioversion.3 Weigner et al,5 in a similar prospective observational study of patients with recent-onset atrial fibrillation, reported 3 (0.8%) strokes within 30 days among 357 patients, 107 of whom were actively cardioverted and 250 spontaneously cardioverted. All 3 stroke patients had spontaneously cardioverted. Perhaps active cardioversion incurs no greater risk of thromboembolism than spontaneous cardioversion. 


The reply from Von Besser and Mills (full-text free): http://www.annemergmed.com/article/S0196-0644(12)00041-8/fulltext  

18. Lack of Sleep Ups Stroke Risk in Low-Risk Adults 

Sleeping less than 6 hours a night was associated with a 4-fold increased risk for stroke symptoms in a cohort of middle-aged, normal-weight adults relatively free of major stroke risk factors. 

Essay at Medscape News: http://www.medscape.com/viewarticle/765593  

19. Dabigatran--Uncharted Waters and Potential Harms 

Radecki RP. Ann Intern Med published 28 May 2012.

This past November, an eye-opening headline was printed in the German newspaper Der Speigel (1): “Boehringer besta¨tigt Todesfa¨lle durch Schlaganfal-Mittel” (“Boehringer Confirms Deaths Due to Stroke Drug”). Mainstream awareness of complications associated with dabigatran, the oral direct thrombin inhibitor from Boehringer Ingelheim, comes in tandem with alarms raised in the medical community about serious adverse events. After an Institute for Safe Medication Practices publication about an influx of dabigatran-related adverse event reports (2), the U.S. Food and Drug Administration recently noted the need for ongoing surveillance for potential serious bleeding events related to dabigatran (3). 

Approved for prevention of thromboembolic stroke in the setting of atrial fibrillation in the United States and for prevention and treatment of venous thromboembolism in Europe, dabigatran is the first in a wave of potential replacements for warfarin. Its recently approved competitors, rivaroxaban and apixaban, have also been evaluated in large, phase 3 trials that suggested their efficacy and safety were similar or superior to warfarin for specified indications (4, 5). Dabigatran, however, received the advantages and scrutiny associated with first-mover status in the lucrative warfarin-replacement market. The applied clinical effectiveness of a drug often does not match the efficacy and safety demonstrated in industry-sponsored trials; such is the case with dabigatran. 

The large trial that evaluated the drug was conducted by the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) study group. It was a phase 3 prospective, nonblinded, randomized, multicenter, noninferiority clinical trial of warfarin versus dabigatran in nonvalvular atrial fibrillation (6). For the primary outcome of preventing stroke or systemic embolism, annual incidence was 1.69% in the warfarin group, 1.53% in the 110-mg dabigatran group, and 1.11% in the 150-mg dabigatran, group. The 110-mg dose was noninferior to warfarin, whereas the 150-mg dose was noninferior and statistically superior to warfarin. For the primary safety end point of major bleeding, annual incidence was 3.36% in the warfarin group, 2.71% in the 110-mg dabigatran group, and 3.11% in the 150-mg dabigatran group. Given the minimal baseline differences between groups, similar or superior efficacy, and an apparently favorable safety profile, dabigatran was approved in the United States and overseas as an alternative to warfarin. 

Within 12 weeks of initial marketing approval for the United States in October 2010, the Institute for Safe Medication Practices reported that dabigatran was responsible for more serious adverse events than 98.7% of all medications (2). The 307 reported adverse events—compared with 202 with warfarin—mostly involved serious bleeding or venous thromboembolism in elderly patients. As prescriptions for dabigatran increased in the first quarter of 2011, dabigatran was responsible for 505 adverse event reports due to hemorrhage (including 65 deaths), compared with only 176 reports for warfarin (7). The observed harms may have exceeded expectations because of the confounding dosing options for dabigatran… 

The rest of the article (for subscribers only; sorry): http://www.annals.org/content/early/2012/05/23/0003-4819-157-1-201207030-00467.extract  

20. Drotrecogin Alfa (Activated) without Benefit in Adults with Septic Shock 

Ranieri VM, et al. for the PROWESS-SHOCK Study Group. N Engl J Med 2012; 366:2055-2064. 

Background: There have been conflicting reports on the efficacy of recombinant human activated protein C, or drotrecogin alfa (activated) (DrotAA), for the treatment of patients with septic shock. 

Methods: In this randomized, double-blind, placebo-controlled, multicenter trial, we assigned 1697 patients with infection, systemic inflammation, and shock who were receiving fluids and vasopressors above a threshold dose for 4 hours to receive either DrotAA (at a dose of 24 μg per kilogram of body weight per hour) or placebo for 96 hours. The primary outcome was death from any cause 28 days after randomization. 

Results: At 28 days, 223 of 846 patients (26.4%) in the DrotAA group and 202 of 834 (24.2%) in the placebo group had died (relative risk in the DrotAA group, 1.09; 95% confidence interval [CI], 0.92 to 1.28; P=0.31). At 90 days, 287 of 842 patients (34.1%) in the DrotAA group and 269 of 822 (32.7%) in the placebo group had died (relative risk, 1.04; 95% CI, 0.90 to 1.19; P=0.56). Among patients with severe protein C deficiency at baseline, 98 of 342 (28.7%) in the DrotAA group had died at 28 days, as compared with 102 of 331 (30.8%) in the placebo group (risk ratio, 0.93; 95% CI, 0.74 to 1.17; P=0.54). Similarly, rates of death at 28 and 90 days were not significantly different in other predefined subgroups, including patients at increased risk for death. Serious bleeding during the treatment period occurred in 10 patients in the DrotAA group and 8 in the placebo group (P=0.81). 

Conclusions: DrotAA did not significantly reduce mortality at 28 or 90 days, as compared with placebo, in patients with septic shock. (Funded by Eli Lilly; PROWESS-SHOCK ClinicalTrials.gov number, NCT00604214.) 

21. Therapy and outcomes in massive PE from the Emergency Medicine Pulmonary Embolism in the Real World Registry. 

Lin BW, et al. Am J Emerg Med. 2012 May 23. [Epub ahead of print] 

STUDY AIM: Clinical guidelines recommend fibrinolysis or embolectomy for acute massive pulmonary embolism (PE) (MPE). However, actual therapy and outcomes of emergency department (ED) patients with MPE have not previously been reported. We characterize the current management of ED patients with MPE in a US registry. 

METHODS: A prospective, observational, multicenter registry of ED patients with confirmed PE was conducted from 2006 to 2008. Massive PE was defined as PE with an initial systolic blood pressure less than 90 mm Hg. We compared inpatient and 30-day mortality, bleeding complications, and recurrent venous thromboembolism. 

RESULTS: Of 1875 patients enrolled, 58 (3.1%) had MPE. There was no difference in frequency of parenteral anticoagulation (98.3% [95% confidence interval {CI}, 90.5-101.6] vs 98.5% [95% CI, 97.9-99.1], P = .902) between patients with and without MPE. Fibrinolytic therapy and embolectomy were infrequently used but were used more in patients with MPE than in patients without MPE (12.1% [95% CI, 3.7-20.5] vs 2.4% [95% CI, 1.7-3.1], P < .001, and 3.4% [95% CI, 0.0-8.1] vs 0.7% [95% CI, 0.3-1.1], P = .022, respectively). Comparison of outcomes revealed higher all-cause inpatient mortality (13.8% [95% CI, 4.9-22.7] vs 3.0% [95% CI, 2.2-3.8], P < .001), higher risk of inpatient bleeding complications (10.3% [95% CI, 2.5-18.1] vs 3.5% [95% CI, 2.7-4.3], P = .007), and a higher 30-day mortality (14.0% [95% CI, 4.4-23.6] vs 1.8% [95% CI, 1.2-2.4], P < .001) for patients with MPE. 

CONCLUSIONS: In a contemporary registry of ED patients, MPE mortality was 4-fold higher than patients without MPE, yet only 12% of the MPE cohort received fibrinolytic therapy. Variability exists between the treatment of MPE and current recommendations. 

22. Social Ties Move Kids to Exercise  

Gesell SB, et al. The distribution of physical activity in an after-school friendship network. Pediatrics 2012;129:1064–1071. 

By Crystal Phend, Senior Staff Writer, MedPage Today. May 28, 2012 

Kids tend to imitate their friends, even when it comes to exercise, according to findings of a social network study that may have implications for fighting childhood obesity. 

The biggest influence on how much moderate-to-vigorous activity 5- to 12-year-olds got in an after-school program was how much activity their immediate friends got, Sabina B. Gesell, PhD, of Vanderbilt University in Nashville, Tenn., and colleagues found. 

Kids consistently altered their activity level by 10% or more to match their friends, with an odds ratio of 6.89 for that magnitude of change (P<0.01), the group reported in the June issue of Pediatrics. 

And that was common, because the kids didn't appear to make friends or break them based on similar level of activity. 

That being the case, "we could develop novel intervention strategies that leverage the social influences of social networks to make a real impact on childhood obesity," the researchers suggested. 

They proposed a system of rolling enrollment in after-school programs, starting with a group of very active children and slowly adding in others to keep assimilation biased toward more activity. 

The study included 81 public-school students, ages 5 to 12 (average age 8), participating in two after-school care programs from 3 p.m. to 6 p.m., Monday to Friday. 

The cohort was fairly diverse, with 40% being African American, 39% white, and 19% Latino. Among them, 23% were overweight and 21% obese. 

Three times over the 4-month semester, the kids completed surveys about whom they spent the most time with in the after-school program. They also wore accelerometers to monitor activity. 

Those of different initial activity levels weren't any less likely to choose each other as friends, nor was obesity a significant factor in making or breaking friendships. 

Friendship was significant more likely for the following (all P<0.01):  

Being of similar age, which boosted the odds 2.40-fold. Attending the same school, with an odds ratio of 1.78. Being of the same gender, which made friendship 56% more likely (OR 1.56) Being of the same race, with an odds ratio of 1.28 

Overall activity level of the whole cohort didn't change, but that of individuals did. 

In the fully-adjusted model, how many new friends children made or how many they dropped didn't impact activity level either. 

But how active their circle of friends, typically four to six in number, appeared to be the biggest factor in changes in their own activity from one assessment to the next. 

The measure of average similarity in activity level across a network of friends retained its sign, magnitude, and statistical significance in the fully-adjusted model (P<0.01), "indicating that children were very likely to adjust their activity level to become more similar to the levels of their immediate group of friends." 

Age and obesity tended to moderate those adjustments to friends' activity level (P<0.10) but with relatively small effects. 

The researchers cautioned that kids' after-school network of friends may differ their other networks of friends, such as at school. 

Also, some potentially important factors were not considered in the study, including children's preferences and intentions regarding activity, whether the parents were overweight, and diet quality. 

Nevertheless, the effects found in the study "are of real world importance, because many after-school programs are trying to increase physical activity to meet state-level guidelines," the researchers noted. 

23. Jellyfish First Aid 

By Crystal Phend, MedPage Today. June 11, 2012 

Sun, sand, waves … jellyfish.  

Not sure you want to pee on the swath of pain left behind by the jelly’s tentacles? Good thinking, because it probably doesn’t work anyway, according to emergency physicians.  

Warm urine isn’t the only folk remedy for a run-in with jellyfish venom. Vinegar, baking soda, and meat tenderizer have been recommended as well.  

“Some of the remedies promoted by word-of-mouth and online, such as vinegar, actually make the pain worse with certain species of jellyfish,” Nicholas T. Ward, MD, of the University of California San Diego’s emergency medicine department, warned in a press release. 

His group reviewed the evidence from 19 studies to see what really does help, and published the results in the Annals of Emergency Medicine.  

For the type of jellyfish commonly encountered on North American shores and out into the Pacific in Hawaii, the best and most consistent evidence says to carefully remove the tentacles and wash the area off with water. 

The best bet is a wash with hot water and slathering on some kind of diluted local anesthetic, such as topical benzocaine or lidocaine from the drugstore, the researchers concluded.  

A hot shower may not be easy to find at the beach, so seawater is a good substitute, they suggested. 

Some first aid manuals say to use pressure bandages, but there’s not enough evidence one way or the other, according to the review.  

The American Red Cross recommends vinegar or a slurry of baking soda followed by heat (or an ice pack if not available) for all jellyfish stings in North America and Hawaii, it pointed out. 

Vinegar may actually be helpful against the Portugueseman-of-war (Bluebottle jellyfish) but exacerbates pain or venom release with most other species. 

Ward NT, et al. Evidence-Based Treatment of Jellyfish Stings in North America and Hawaii. Ann Emerg Med. 2012; in press. Abstract: http://www.annemergmed.com/article/S0196-0644(12)00393-9/abstract  

24. Diagnostic Pitfalls at Admission in Patients with Acute Superior Mesenteric Artery Occlusion. 

Acosta S, et al. J Emerg Med. 2011 Nov 30. [Epub ahead of print] 

BACKGROUND: Acute superior mesenteric artery (SMA) occlusion leads to acute intestinal ischemia and is associated with high mortality. Early diagnosis is often missed, and confounding factors leading to diagnostic delays need to be highlighted. 

OBJECTIVES: To identify potential diagnostic laboratory pitfalls at admission in patients with acute SMA occlusion. 

METHODS: Fifty-five patients with acute SMA occlusion were identified from the in-hospital register during a 4-year period, 2005-2009. 

RESULTS: The median age was 76 years; 78% were women. The occlusion was embolic in 53% and thrombotic in 47% of patients. At admission, troponin I was above the clinical decision level (> 0.06 μg/L) for acute ischemic myocardial injury in 9/19 (47%) patients with embolic occlusion. Elevated pancreas amylase and normal plasma lactate were found in 12/45 and 13/27, respectively. A troponin I (TnI) above the clinical decision level was associated with a high frequency of referrals from the general surgeon to a specialist in internal medicine (p = 0.011) or a cardiologist (p = 0.024). The diagnosis was established after computed tomography angiography in 98% of the patients. The overall in-hospital mortality rate was 33%. Attempting intestinal revascularization (n = 43; p < 0.001), with a 95% frequency rate of completion control of the vascular procedure, was associated with a higher survival rate, whereas referral to the cardiologist was associated with a higher mortality rate (p = 0.018). 

CONCLUSION: Elevated TnI was common in acute SMA occlusion, and referral to the cardiologist was found to be associated with adverse outcome. Elevated pancreas amylase and normal plasma lactate values are also potential pitfalls at admission in patients with acute SMA occlusion. 

25. Why Physicians Work When Sick  

Jena AB, et al. Arch Intern Med. 2012; June [epub ahead of print] doi:10.1001/archinternmed.2012.1998 

Introduction
Despite ongoing attention to rising rates of hospital-acquired infections and efforts to stem this growth,1 limited focus has been given to whether physicians and other health care personnel contribute to workplace transmission of illness by choosing to work when ill.2 - 4 Presenteeism —the act of working while ill—has important implications for health care personnel, whose repeated interactions with patients make productivity declines from illness more dangerous and disease transmission more likely. While the pressure to work while ill is common across all health care workers, the demand among resident physicians may be particularly great due to pressure from peers and lack of an adequate system of coverage.5 - 6 Most residents report coming to work when sick at least once annually, with rates varying little according to sex, specialty, or hospital. These results suggest that presenteeism is ubiquitous and not confined to specific specialties or hospital cultures.5 - 6 Despite evidence that most residents work when ill, little is known about the reasons they choose to do so.


Comment
Although drawn from a nonrepresentative sample of residents, our findings are consistent with national estimates of the prevalence of presenteeism among residents.5 - 6 Our results provide the first-ever information to our knowledge on the reasons that residents in the United States choose to work when sick. Residents appear driven mainly by a sense of obligation to patients and colleagues, exemplified by higher rates of presenteeism among more senior residents, who traditionally shoulder more responsibility for unifying care for a team's patients and therefore may feel more pressured to provide care when sick. 

The practice of presenteeism by resident physicians raises important questions about the development of professionalism in young physicians. Deciding among conflicting values and resolving ethical and moral decisions is basic to this process. On the one hand, sick residents may be motivated to work when sick because of their duty to care for their patients, dedication to work, loyalty to colleagues, and possible fear of institutional reprisal. On the other hand, residents may be conflicted by the ethical injunction against harming patients; their own scientific knowledge and awareness of the risks of exposing patients, colleagues, and staff to potential illness; and their professional obligation to perform at their best when caring for patients. High rates of presenteeism highlight that the current balance of these values is in favor of coming to work sick..

Resident presenteeism should be better identified and addressed by medical educators and residency leaders. In addition to adequate systems of coverage and occupational health guidelines regarding working when ill, faculty should ensure that residents are taught that refraining from work while ill is the best and most professional way to ensure responsible and safe care for patients. 

26. Quick Take-Homes from Ann Emerg Med 

A. Can Emergency Physicians Safely Increase the Proportion of Patients With Community-Acquired Pneumonia Who Are Treated in the Outpatient Setting? 

Huner B, et al. Ann Emerg Med. 2012;60:106-107.  

Can Emergency Physicians Safely Increase the Proportion of Patients With Community-Acquired Pneumonia Who Are Treated in the Outpatient Setting? 

Take-Home Message: Physicians using the Pneumonia Severity Index are more likely to treat low-risk patients with community-acquired pneumonia as outpatients without compromising patient safety. 


B. Is There a Blood Test That Can Rule Out Serious Bacterial Infection in Children? 

Hom J. Ann Emerg Med. 2012;60:92-93.  

Take-Home Message: A normal C-reactive protein or procalcitonin result decreases the likelihood of serious bacterial infections in children but cannot be used as a rule-out test. 

Friday, June 01, 2012

Lit Bits: June 1, 2012

From the recent medical literature... 

1. Prevalence and Factors Associated With False-Positive STEMI Diagnoses at Primary PCI-Capable Centers: A Report From the Activate-SF Registry. 

McCabe JM, et al. Arch Intern Med. 2012 May 7. [Epub ahead of print] 

BACKGROUND: Rapid activation of the cardiac catheterization laboratory for primary percutaneous coronary intervention (PCI) improves outcomes for ST-segment elevation myocardial infarction (STEMI), but selected emphasis on minimizing time to reperfusion may lead to a greater frequency of false-positive activations. 

METHODS: We analyzed consecutive patients referred for primary PCI for a possible STEMI at 2 centers from October 2008 to April 2011. "False-positive STEMI activation" was defined as lack of a culprit lesion by angiography or by assessment of clinical, electrocardiographic, and biomarker data in the absence of angiography. Clinical and electrocardiographic factors associated with false-positive activations were evaluated in a backward stepwise selection bootstrapped logistic regression model. 

RESULTS: Of 411 STEMI activations by emergency physicians, 146 (36%) were deemed to be false-positive activations. Structural heart disease and heart failure were the most common diagnoses among false-positive activations. Electrocardiographic left ventricular hypertrophy (adjusted odds ratio [AOR], 3.15; 95% CI, 1.55-6.40; P = .001), a history of coronary disease (AOR, 1.93; 95% CI, 1.04-3.59; P = .04), or prior illicit drug abuse (AOR, 2.67; 95% CI, 1.13-6.26; P = .02) independently increased the odds of false-positive STEMI activations. Increasing body mass index decreased the odds of a false-positive activation (AOR, 0.91; 95% CI, 0.86-0.97; P = .004), as did angina at presentation (AOR, 0.28; 95% CI, 0.14-0.57; P < .001). 

CONCLUSIONS: More than a third of patients referred for primary PCI from the emergency department did not have a STEMI. Multiple patient-level characteristics were significantly associated with an increased odds of false-positive STEMI activation. 


2. The Use of Cephalosporins in PCN-allergic Patients: A Literature Review Confirms Safety 

Campagna JD, et al. J Emerg Med. 2012;42:612-20. 

Background: The practice of avoiding cephalosporin administration to penicillin-allergic patients persists despite the low rate of cross reactions between both groups of antibiotics. 

Objective: The purpose of this literature review is to evaluate the published evidence regarding the commonly held belief that patients with a history of an allergic reaction to penicillin have a significantly increased risk of an allergic reaction to cephalosporins. 

Materials and Methods: Articles were identified through a computerized search of MEDLINE from 1950 to the present using the search terms “penicillin$,” “cephalosporin$,” “allerg$,” “hypersensitivity,” and “cross-react$.” All articles were reviewed, and additional sources cited in them were added to the literature review. 

Results: Penicillins have a cross allergy with first-generation cephalosporins (odds ratio 4.8; confidence interval 3.7–6.2) and a negligible cross allergy with second-generation cephalosporins (odds ratio 1.1; confidence interval 0.6–2.1). Laboratory and cohort studies confirm that the R1 side chain is responsible for this cross reactivity. Overall cross reactivity between penicillins and cephalosporins is lower than previously reported, though there is a strong association between amoxicillin and ampicillin with first- and second-generation cephalosporins that share a similar R1 side chain. 

Conclusions: Although a myth persists that approximately 10% of patients with a history of penicillin allergy will have an allergic reaction if given a cephalosporin, the overall cross-reactivity rate is approximately 1% when using first-generation cephalosporins or cephalosporins with similar R1 side chains. However, a single study reported the prevalence of cross reactivity with cefadroxil as high as 27%. For penicillin-allergic patients, the use of third- or fourth-generation cephalosporins or cephalosporins with dissimilar side chains than the offending penicillin carries a negligible risk of cross allergy. 

3. Magnesium No Help for Subarachnoid Bleed 

By Todd Neale, Senior Staff Writer, MedPage Today. May 25, 2012 

An infusion of magnesium does not improve outcomes for patients with an aneurysmal subarachnoid hemorrhage, a randomized trial showed. 

The rate of poor functional outcome or death within 3 months of the hemorrhage was 26.2% in the magnesium group and 25.3% in the placebo group (RR 1.03, 95% CI 0.85 to 1.25), according to Sanne Dorhout Mees, MD, of the University Medical Center Utrecht in the Netherlands, and colleagues. 

None of the patient subgroups showed a benefit from the infusion, the researchers reported online in The Lancet. The findings, they wrote, have clinical implications because many centers routinely administer magnesium in this patient population. 

Taking into consideration the results of the current and other trials, "we do not recommend routine use of intravenous magnesium 64 mmol/day for the improvement of outcome after aneurysmal subarachnoid hemorrhage," they wrote. 

Magnesium sulfate is a neuroprotective agent, and smaller trials have evaluated IV magnesium to improve outcomes following aneurysmal subarachnoid hemorrhage, with the thought that the treatment would reduce delayed cerebral ischemia. 

A phase II trial by Dorhout Mees and colleagues showed a 23% relative reduction in the risk of poor outcome with magnesium versus placebo. 

Based on those results, the researchers initiated MASH 2, a phase III trial conducted at six centers in the Netherlands and one each in Scotland and Chile. 

The study included 1,203 adult patients (mean age 57) with an aneurysmal pattern of subarachnoid hemorrhage on brain imaging. All were admitted to the hospital within 4 days of hemorrhage. 

The patients were randomized to IV magnesium sulfate (64 mmol/day) or placebo. Treatment lasted for 20 days after hemorrhage onset or until hospital discharge or death. Patients also were treated according to local protocols, which included oral nimodipine (360 mg/day), bed rest until aneurysm occlusion, and early aneurysm occlusion. 

The primary outcome was a composite of poor functional outcome -- defined as a score of 4 or 5 on the modified Rankin Scale -- or death within 3 months. Magnesium did not reduce that outcome. 

The researchers updated a previous meta-analysis of trials of magnesium treatment for aneurysmal subarachnoid hemorrhage with the results of MASH 2 and found that it, too, showed a lack of benefit (RR 0.96, 95% CI 0.86 to 1.08). 

There were four unexpected serious adverse events during the trial, all in the magnesium group. They included one case of asymptomatic hypocalcemia, two cases of asymptomatic hypermagnesemia, and one case of suspected hypermagnesemia. 

The researchers acknowledged that the study was limited by the lack of quality-of-life assessments and of information on medication adherence. 

In an accompanying editorial, Jose Suarez, MD, and Chethan Venkatasubba Rao, MD, of Baylor College of Medicine in Houston, noted that the trial was the largest to study the use of magnesium sulfate for aneurysmal subarachnoid hemorrhage but did have additional shortcomings. 

The trial lacked an assessment of radiological severity, measurement of underlying systemic severity, information on the rate of delayed cerebral ischemia, and on-site monitoring of the immediate physiological effects of the magnesium infusion, they wrote. 

"Despite these limitations, the results, although disappointing, are nonetheless very pertinent to the management of patients with aneurysmal subarachnoid hemorrhage," the editorialists wrote. "We agree with the researchers, and previous findings, that routine intravenous magnesium sulfate infusion cannot be recommended for patients with aneurysmal subarachnoid hemorrhage." 

4. A Game to Help Doctors Ask Tough Questions on Drug-seeking Behavior 

By Dirk Johnson. New York Times. May 25, 2012 

CHICAGO — As Dr. Danielle McCarthy listens to a man beg for a prescription for painkillers, she weighs her possible responses.  

A 31-year-old emergency room physician, she listens patiently as the man tells her that “every morning I wake up in pain,” describing the agony he continues to endure, three years after being injured in a car wreck.  

He has tried physical therapy, acupuncture and chiropractic treatment, he says. Nothing works except pills, he insists, as his voice grows louder and more demanding.  

Their exchange is similar to conversations that take place on almost every shift at Northwestern Memorial Hospital here, Dr. McCarthy said. But it is fiction — part of an interactive video game designed to train doctors to identify deceptive behavior by people likely to abuse prescription painkillers. The patient is an actor whose statements and responses are generated by the program.


The video game was designed based on research by Dr. Michael F. Fleming at the Northwestern University Feinberg School of Medicine and draws on technology used by the F.B.I. to train agents in interrogation tactics. It teaches doctors to look for warning signs of drug abuse, like a history of family problems, and to observe nonverbal signs of nervousness, like breaking eye contact, fidgeting and finger-tapping.  

The game, which is in its final phase of testing, is aimed at primary care and family doctors, who often feel uncomfortable and unqualified assessing their patients in this regard.  

“This isn’t something medical students have traditionally been trained for,” Dr. Fleming said. “These are hard conversations to have.”  

It can be a thorny matter, Dr. McCarthy said, because physicians are trained to help patients, but they do not want to enable drug abuse. “You don’t want people to be in pain,” she said. “And you’re put on the spot. I’ve had patients yell at me. I’ve never been hit, but once or twice I’ve felt physically threatened.”  

In 2009, for the first time, the number of deaths from drug overdoses surpassed those from highway traffic accidents, according to Gail Hayes, a spokeswoman for the Centers for Disease Control and Prevention. She said misuse of prescription medication has been largely the cause. About 75 percent of overdoses involved prescription drugs, she added.  

So health care professionals are searching for better ways to distinguish patients who can be trusted to use prescription pain medications properly from those out to abuse them. According to the C.D.C., prescription drug abuse is the fastest growing drug problem in the United States, fueled by the use of highly addictive opioid analgesics like OxyContin.  

The Web-based interactive video game, which will soon be available online for a fee to medical schools and health care providers, includes about 2,000 statements by the patient, ranging in tone from charming to irate. A doctor can choose from 1,500 questions and responses, selecting one from five to seven options that appear on the screen when it is time to speak to the patient.  

The dialogue is drawn from research by Dr. Fleming, based on interviews with more than 1,000 patients who were receiving opioids for pain. “We have 95 percent of what a patient and doctor would say or do,” he said.

Sharp skills are needed to assess a patient’s motives, he said, because an objective measurement, like from a blood test or an X-ray, is not available to gauge pain, and the opioids can be highly addictive. 

The game’s software was developed by Dale E. Olsen, a former professor of engineering at Johns Hopkins University. He is the founder and president of Simmersion, a company that has created simulation training programs for the F.B.I. The game’s development was financed by a $1 million grant from the Small Business Administration and the National Institute on Drug Abuse. Dr. Olsen, who has a Ph.D. in statistics, said the game would cost users about $50 an hour. It is designed to be used for 10 sessions of 15 to 20 minutes each. He said customers would most likely include medical schools, as well as private and government health care providers.  

The game encourages doctors to adopt a more collaborative and less accusatory approach with patients, Dr. Olsen said. “The goal is to build rapport,” he said.  

Dr. McCarthy, wearing headphones and blue scrubs, faces the computer screen, where the patient, named Tom, a trim man with a neatly cropped beard, is asking for pain medication.  

The physician asks Tom to describe his pain. Tom points vaguely to his lower back. She asks about whether he has ever had any problems with pills. He acknowledges that he once accidentally took too many pills, but that it was “no big deal.”  

When she asks him to submit to a drug screening, he is testy, but agrees to do so if she insists — “and then I want my pills.”  

At the end of the interactive portion, the game awarded Dr. McCarthy high marks for communication skills, for asking for a drug test and for declining the request for a prescription. She lost points for not asking enough questions.  

Dr. McCarthy nodded at the screen in acknowledgment of her score. She explained that there are time constraints in her work.  

“We move pretty quickly in the emergency room,” she said. “We’re not usually going to have time for 60 questions.”  

She sometimes has had a hunch that a patient was exaggerating or fabricating pain, she said. She found the training useful, she said, because it offered new suggestions of responses to patients. 

5. Applications of minimally invasive cardiac output monitors. 

Porhomayon J, et al. Int J Emerg Med. 2012 Apr 24;5:18. 

Because of the increasing age of the population, critical care and emergency medicine physicians have seen an increased number of critically ill patients over the last decade. Moreover, the trend of hospital closures in the United States t imposes a burden of increased efficiency. Hence, the identification of devices that facilitate accurate but rapid assessments of hemodynamic parameters without the added burden of invasiveness becomes tantamount. The purpose of this review is to understand the applications and limitations of these new technologies. 

The ultimate goal of any hemodynamic monitoring system is to provide the clinicians with additional information on the underlying pathological condition and to guide fluid or vasopressor therapy. Cardiac output measurement and its response to therapeutic interventions are frequently used in critically ill patients. As the use of CO monitoring devices increases today, it is necessary to understand the application of such devices in different clinical settings… 


6. Cricothyroid Membrane Identification by Palpation Is Difficult in Females 

Identification is most difficult in obese female patients.  

Researchers determined the accuracy of identification of the cricothyroid membrane by palpation in females. Each of 24 physicians (17 anesthesiologists and 7 OB/GYN residents) identified the membrane and marked its location and midline in 56 female patients (15 with body-mass index >30 kg/m2) who were in the supine position with their heads in both neutral and extended positions. The actual location was then confirmed by ultrasound. The physician's estimated location was considered correct if it was between the membrane's upper and lower limits and within 5 mm of its midline. 

Physicians correctly identified the location in 0 of 15 obese patients and 10 of 41 nonobese patients in the neutral head position and in 1 obese and 12 nonobese patients in the extended head position. Estimates of the location were as much as 3 cm too high, 4 cm too low, and 1.6 cm off from midline. Physicians considered identification to be more difficult in obese than in nonobese patients (scores of 5.3 vs. 3.3 on a 10-point visual analogue scale). 

Comment: Identification of the cricothyroid membrane is difficult in females, whose laryngeal prominence is less obvious than men's, and is even more difficult in obese patients. The results are not surprising, particularly because the physicians received no additional training in locating the membrane before the study. Although ultrasonography could help to identify the membrane more accurately, prior practice with ultrasonographic landmark identification would be necessary, and time constraints often would prohibit its use. Physicians expected to perform emergency cricothyroidotomy should be trained in the technique and in landmark identification. Use of a vertical midline incision helps correct for imprecise localization of the membrane. 

— Cheryl Lynn Horton, MD. Published in Journal Watch Emergency Medicine May 25, 2012.

Citation: Aslani A et al. Accuracy of identification of the cricothyroid membrane in female subjects using palpation: An observational study. Anesth Analg 2012 May; 114:987. 


7. ED patients with vertigo: can we identify clinical factors associated with acute stroke? 

Chase M, et al. Am J Emerg Med. 2012;30(4):587-91. 

BACKGROUND: Vertigo is a common emergency department (ED) complaint with benign and serious etiologies with overlapping features. Misdiagnosis of acute stroke may result in significant morbidity and mortality. Magnetic resonance imaging (MRI) is superior to computer tomography (CT) for diagnosis of acute stroke but is costly with limited availability. 

OBJECTIVE: The aim of this study was to identify clinical characteristics associated with a cerebrovascular cause for vertigo. 

METHODS: We performed a retrospective chart review on patients with an MRI for vertigo, with or without additional historical or physical examination findings, over 18 months. Study patients were seen in the ED for vertigo within 2 weeks of MRI. Data collected included medical history, physical findings, and imaging results. Fisher's exact test was used to identify factors associated with the primary outcome, an acute stroke. 

RESULTS: There were 325 eligible patients; 131 were ED patients. Patients were 57 (±18) years, and 53% were women. There were 12 ED patients with a new stroke (9.2%). Two variables were associated with acute stroke: a presenting complaint of gait instability (odds ratio, 9.3; 95% confidence interval, 2.6-33.9) or a subtle neurologic finding (odds ratio, 8.7; 95% confidence interval, 2.3-33.1). One patient with a new stroke had a prior stroke, 3 were age >65 years, and none had coronary artery disease or dysrhythmia. Among patients with acute stroke, 5 also had head CT, and none detected the stroke. 

CONCLUSIONS: This study identified 2 variables associated with acute stroke that should be considered in the evaluation of ED patients with vertigo. Head CT was inadequate for diagnosing acute stroke in this patient population. 

8. Reminder: CT is Insensitive for Posterior Circulation Infarcts 

Hwang DY, et al. Comparative Sensitivity of Computed Tomography vs. Magnetic Resonance Imaging for Detecting Acute Posterior Fossa Infarct. J Emerg Med. 2012;42:559-565. 

Background: Posterior fossa strokes, particularly those related to basilar occlusion, pose a high risk for progression and poor neurological outcomes. The clinical history and examination are often not adequately sensitive or specific for detection. 

Study Objectives: Because this population stands to benefit from acute interventions such as intravenous and intra-arterial tissue plasminogen activator, mechanical thrombectomy, and intensive monitoring for neurologic deterioration, this study examined the sensitivity of non-contrast head computed tomography (NCCT) for diagnosing posterior fossa strokes in the emergency department. 

Methods: This study analyzed a prospectively collected database of acute ischemic stroke patients who underwent head NCCT within 30h of symptom onset and who were subsequently found to have a posterior fossa infarct on brain magnetic resonance imaging (MRI) performed within 6h of the NCCT. 

Results: There were 67 patients identified who had restricted diffusion on MRI in the posterior fossa. The National Institutes of Health Stroke Scale (NIHSS) scores ranged from 0 to 36, median 3. Only 28 patients had evidence of infarction on the initial NCCT scan. The timing of NCCT scans ranged from 1.2 to 28.9h after symptom onset. The sensitivity of NCCT was 41.8% (95% confidence interval 30.1–54.4). The longest period of time between symptom onset and a negative NCCT with a subsequent positive diffusion-weighted imaging MRI was 26.7h. 

Conclusions: Head NCCT imaging is frequently insensitive for detecting posterior fossa infarction. Temporal evolution of strokes in this distribution, coupled with beam-hardening artifact, may contribute to this limitation. When a posterior fossa stroke is suspected and the NCCT is non-diagnostic, MRI is the preferred imaging modality to exclude posterior fossa infarction.

9. Concurrent use of warfarin and antibiotics and the risk of bleeding in older adults. 

Baillargeon J, et al. Am J Med. 2012;125(2):183-9. 

BACKGROUND: Antibiotic medications are associated with an increased risk of bleeding among patients receiving warfarin. The recent availability of data from the Medicare Part D prescription drug program provides an opportunity to assess the association of antibiotic medications and the risk of bleeding in a national population of older adults receiving warfarin. 

METHODS: We conducted a case-control study nested within a cohort of 38,762 patients aged 65 years and older who were continuous warfarin users, using enrollment and claims data for a 5% national sample of Medicare beneficiaries with Part D benefits. Cases were defined as patients hospitalized for a primary diagnosis of bleeding and were matched with 3 control subjects on age, race, sex, and indication for warfarin. Logistic regression analysis was used to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the risk of bleeding associated with prior exposure to antibiotic medications. 

RESULTS: Exposure to any antibiotic agent within the 15 days of the event/index date was associated with an increased risk of bleeding (aOR 2.01; 95% CI, 1.62-2.50). All 6 specific antibiotic drug classes examined (azole antifungals [aOR, 4.57; 95% CI, 1.90-11.03], macrolides [aOR, 1.86; 95% CI, 1.08-3.21], quinolones [aOR, 1.69; 95% CI, 1.09-2.62], cotrimoxazole [aOR, 2.70; 95% CI, 1.46-5.05], penicillins [aOR, 1.92; 95% CI, 1.21-2.07], and cephalosporins [aOR, 2.45; 95% CI, 1.52-3.95]) were associated with an increased risk of bleeding. 

CONCLUSION: Among older continuous warfarin users, exposure to antibiotic agents-particularly azole antifungals-was associated with an increased risk of bleeding. 

10. Is Urine Odor Associated with UTI in Kids? Sometimes… 

Parental report of malodorous urine was significantly associated with urinary tract infection in young febrile children. 

Gauthier M, et al. Pediatrics. 2012 May;129(5):885-90.  

OBJECTIVE: To determine whether parental reporting of malodorous urine is associated with urinary tract infection (UTI) in children. 

METHODS: We conducted a prospective consecutive cohort study in the emergency department of a pediatric hospital from July 31, 2009 to April 30, 2011. All children aged between 1 and 36 months for whom a urine culture was prescribed for suspected UTI (ie, unexplained fever, irritability, or vomiting) were assessed for eligibility. A standardized questionnaire was administered to the parents by a research assistant. The primary outcome measure was a UTI. 

RESULTS: Three hundred ninety-six children were initially enrolled, but 65 were excluded a posteriori either because a urine culture, although prescribed, was not done (11), was collected by bag (39), and/or showed gross contamination (25). Therefore, 331 children were included in the final analysis. Their median age was 12 months (range, 1-36). Criteria for UTI were fulfilled in 51 (15%). A malodorous urine was reported by parents in 57% of children with UTI and in 32% of children without UTI. On logistic regression, malodorous urine was associated with UTI (odds ratio 2.83, 95% confidence interval: 1.54-5.20). This association remained statistically significant when adjusted for gender and the presence of vesicoureteral reflux (odds ratio 2.73, 95% confidence interval: 1.46-5.08). 

CONCLUSIONS: Parental reporting of malodorous urine increases the probability of UTI among young children being evaluated for suspected UTI. However, this association is not strong enough to definitely rule in or out a diagnosis of UTI. 

11. Stroke Thrombolysis Safe in Eligible Warfarin Users w/ INR ≤ 1.7 

Megan Brooks. May 24, 2012 — Patients with acute ischemic stroke who are receiving warfarin can safely receive intravenous (IV) tissue plasminogen activator (tPA) if their international normalized ratio (INR) is 1.7 or lower, a new study shows. 

With an INR of 1.7 less, "there appears to be no difference in risk of intracranial hemorrhage (ICH) comparing those taking warfarin to those not taking warfarin," lead author Ying Xian, MD, PhD, from the Duke Clinical Research Institute in Durham, North Carolina, told Medscape Medical News. 

He presented the data at the American Heart Association (AHA)/American Stroke Association (ASA) Quality of Care & Outcomes Research 2012 Scientific Sessions in Atlanta, Georgia. 

Support for Guidelines 

This study "provides support for the current INR guideline cut point of 1.7 or less for those on warfarin," Philip B. Gorelick, MD, MPH, medical director of the Hauenstein Neuroscience Center, St. Mary's Health Care in Grand Rapids, Michigan, who was not involved in the study, told Medscape Medical News. 

"Patients undergoing consideration for IV tPA therapy in acute ischemic stroke within a 4.5-hour time window may have taken warfarin at some time proximal to the onset of ischemic stroke," Dr. Gorelick explained. Current guidance suggests that if the INR is 1.7 or lower, IV tPA may be given. 

This INR cut point has been the focus of several case series publications, some of which suggest that this threshold may be safe, "whereas in some patients it has been reported that there may be elevation in the risk of brain hemorrhage with administration of intravenous tPA given this circumstance," Dr. Gorelick noted. 

Dr. Xian's team analyzed data on 23,437 patients with ischemic stroke treated with IV tPA in more than 1200 Get With the Guidelines-Stroke hospitals between April 2009 and June 2011. They performed multivariable logistic regression analysis to evaluate the association of preadmission warfarin use on ICH risk while adjusting for potential confounders. 

At the time of admission and IV tPA administration, 1802 (7.7%) patients were taking warfarin (INR ≤ 1.7). These patients were older (median age, 77 vs 71 years; P < .001) and had more comorbid illness and greater stroke severity (median National Institutes of Health Stroke Scale score, 14 vs 11; P < .001). 

The researchers say crude rates of ICH were higher in warfarin-treated patients (5.7% vs 4.7%); however, after adjustment for numerous potentially confounding factors, ICH risks were similar and these findings were consistent across several sensitivity analyses. 

Among those receiving warfarin, a trend toward higher crude ICH rates was observed among those with higher baseline INR levels (Cochran-Mantel-Haenszel trend test, P = .03). However, after adjustment for risk factors, higher INR levels had only a marginally significant association with ICH risk (adjusted odds ratio, 1.10; 95% confidence interval, 1.00 - 1.20; P = .06 for each 0.1-unit increase in INR). 

This analysis, Dr. Xian and colleagues say, "represents the largest clinical experience" of the safety of thrombolysis in warfarin-treated patients who meet clinical guideline eligibility criteria. 

Dr. Gorelick said, "Although the group data from this study provides some assurance of safety of IV tPA administration in patients who have received warfarin if the INR is ≤1.7, practicing clinicians should note that there still could be some patients with INR ≤1.7 who are at risk of major bleeding." 

"This potential risk should be discussed with the patient and family members though the weight of the GWTGS data suggests that administration of IV tPA under these circumstances may be safe," he added. 

The authors and Dr. Gorelick have disclosed no relevant financial relationships. AHA/ASA Quality of Care & Outcomes Research 2012 Scientific Sessions. Oral Abstract 10. Presented Thursday, May 10, 2012. 

12. Is magnetic resonance safe in implanted cardiac devices patients? 

Cernuschi G, et al. Intern Emerg Med. 2012 Apr 11. [Epub ahead of print] 

Magnetic resonance imaging (MRI) is often avoided in patients with implanted cardiac devices such as pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs) because of safety concerns [1]. The overwhelming majority of implanted devices are considered a contraindication to MRI by the U.S. Food and Drug Administration and by devices manufacturers [2]. Exposure to electromagnetic fields could cause variations in sensing, lead impedance and capture threshold. Moreover, it can revert the device to a back-up programming mode known as “power on reset”, during which the device is susceptible to inhibition of pacing output and activation of antitachycardia therapies.  

These alterations together with interference with the ICDs functions may cause adverse clinical events, such as induction of dysrhythmias.  

It is estimated that during their lives, up to 75 % of patients with cardiac devices need an MRI examination… 

Clinical bottom line: With appropriate safety measures and a proper protocol, MRI examinations can be performed safely in patients with selected cardiac devices. Since changes in device variables and programming may occur, electrophysiologic monitoring and strict follow-up are essential. Extrathoracic MRIs seem to be less dangerous than examination involving the body region near the heart. 


13. Intra-abdominal injury rare after a normal abdominal CT scan in adults with blunt trauma 

Holmes JF, et al. Amer J Emerg Med. 2012;30:574-9.  

Objective: The objective of this study is to determine the rate of intra-abdominal injury (IAI) in adults with blunt abdominal trauma after a normal abdominal computed tomographic (CT) scan. We hypothesize that the risk of subsequent IAI is so low that hospital admission and observation for possible IAI are unnecessary. 

Methods: We conducted a prospective, observational cohort study of adults (>18 years) with blunt trauma who underwent abdominal CT scanning in the emergency department. Computed tomographic scans were obtained with intravenous contrast but no oral contrast. Abnormalities on abdominal CT included all visualized IAIs or any finding suggestive of possible IAI. Patients were followed up to determine the presence or absence of IAI and the need for therapeutic intervention if IAI was identified. 

Results: Of the 3103 patients undergoing abdominal CT, 2734 (88%) had normal CT scans. The median age was 39 years (interquartile range, 26-51 years); and 2141 (78%) were admitted to the hospital. Eight (0.3%; 95% confidence interval, 0.1%-0.6%) were identified with IAIs after normal abdominal CT scans including the following injuries: pancreas (5), liver (4), gastrointestinal (2), and spleen (2). Five underwent therapy at laparotomy. Abdominal CT had a likelihood ratio (+) of 20.9 (95% confidence interval, 17.7-24.8) and likelihood ratio (−) of 0.034 (0.017-0.068). 

Conclusion: Adult patients with blunt torso trauma and normal abdominal CT scans are at low risk for subsequently identified IAI. Thus, hospitalization for evaluation of possible IAI after a normal abdominal CT scan is unnecessary in most cases. 

14. Effect of Empirical Treatment with Moxifloxacin and Meropenem vs Meropenem on Sepsis-Related Organ Dysfunction in Patients with Severe Sepsis: A Randomized Trial  

Brunkhorst FM, et al. JAMA 2012. Published online 

Context:  Early appropriate antimicrobial therapy leads to lower mortality rates associated with severe sepsis. The role of empirical combination therapy comprising at least 2 antibiotics of different mechanisms remains controversial. 

Objective:  To compare the effect of moxifloxacin and meropenem with the effect of meropenem alone on sepsis-related organ dysfunction. 

Design, Setting, and Patients:  A randomized, open-label, parallel-group trial of 600 patients who fulfilled criteria for severe sepsis or septic shock (n = 298 for monotherapy and n = 302 for combination therapy). The trial was performed at 44 intensive care units in Germany from October 16, 2007, to March 23, 2010. The number of evaluable patients was 273 in the monotherapy group and 278 in the combination therapy group. 

Interventions:  Intravenous meropenem (1 g every 8 hours) and moxifloxacin (400 mg every 24 hours) or meropenem alone. The intervention was recommended for 7 days and up to a maximum of 14 days after randomization or until discharge from the intensive care unit or death, whichever occurred first. 

Main Outcome Measure:  Degree of organ failure (mean of daily total Sequential Organ Failure Assessment [SOFA] scores over 14 days; score range: 0-24 points with higher scores indicating worse organ failure); secondary outcome: 28-day and 90-day all-cause mortality. Survivors were followed up for 90 days. 

Results:  Among 551 evaluable patients, there was no statistically significant difference in mean SOFA score between the meropenem and moxifloxacin group (8.3 points; 95% CI, 7.8-8.8 points) and the meropenem alone group (7.9 points; 95% CI, 7.5-8.4 points) (P = .36). The rates for 28-day and 90-day mortality also were not statistically significantly different. By day 28, there were 66 deaths (23.9%; 95% CI, 19.0%-29.4%) in the combination therapy group compared with 59 deaths (21.9%; 95% CI, 17.1%-27.4%) in the monotherapy group (P = .58). By day 90, there were 96 deaths (35.3%; 95% CI, 29.6%-41.3%) in the combination therapy group compared with 84 deaths (32.1%; 95% CI, 26.5%-38.1%) in the monotherapy group (P = .43). 

Conclusion:  Among adult patients with severe sepsis, treatment with combined meropenem and moxifloxacin compared with meropenem alone did not result in less organ failure. 

15. When patients do not hurt: silent acute abdomen in a patient with schizophrenia. 

Retamero C, et al. Gen Hosp Psychiatry. 2012 Mar-Apr;34(2):210.e9-11 

Introduction: The phenomenon of pain insensitivity, or hypoalgesia, in schizophrenia and psychotic disorders has been described since the early 20th century [1], [2]. Surgical emergencies such as acute appendicitis are frequently diagnosed late in patients with schizophrenia, and therefore, these individuals suffer from higher rates of surgical complications and death [3].

We present the case of a middle-aged man with schizophrenia who, despite experiencing perforated pyloric ulcers and active gastroduodenal artery bleeding, presented without pain, abdominal rigidity or anorexia… 

[Case not included here.] 

Discussion: Mr. T presented with a painless acute abdomen. The classic, earliest symptom of acute abdomen is pain [4]. In one study of 100 patients with perforated peptic ulcer, 100% presented with complaints of abdominal pain; more than half complained of anorexia, indigestion and/or nausea and approximately 40% had vomiting. Over 75% of patients had a rigid abdomen [5]. In contrast, in a study of 79 psychotic patients, 21.4% of those with acute perforated ulcers and 36.8% of those with acute appendicitis presented without any complaint of pain [6]. Cases of patients with schizophrenia with perforated bowel or acute appendicitis who presented without complaint of pain [7], [8], with pain that appeared late in the course of their illness [9] or with mild, intermittent pain and no abdominal rigidity have also been described [10]. Indeed, the only presenting symptom may be worsening of the patient's psychotic symptoms [9]. This atypical presentation has been shown to result in late diagnosis of the patient's condition and, therefore, in higher rates of morbidity (56% in patients with schizophrenia vs. 16% in the population as a whole) and mortality (4% in patients with schizophrenia vs. 1.8% in the general population) [3]. Moreover, patients with schizophrenia have been found to have increased delirium and confusion in the postoperative period [11]. 

The phenomenon of hypoalgesia in psychotic disorders has long been described but remains poorly understood and has not been verified unequivocally under experimental conditions [12]. In 1911, Bleuler [1] attributed acts of self-mutilation to a “complete analgesia” associated with schizophrenia. Eight years later, Kraepelin [2] noted that patients with schizophrenia were “less sensitive to bodily discomfort.” In 1930, Bender and Schilder [13] observed that patients with schizophrenia exhibit abnormal responses to painful stimuli, such as failure to withdraw or dissociation. Marchand [14], in 1955, evaluating a group of psychotic patients who had suffered acute myocardial infarction found that 85% did not present with pain. In 1958, Goldfarb [15] observed that among a group of children with a diagnosis of schizophrenia, 80% exhibited decreased or no reaction to trauma that ought to have produced tears. Recent experimental studies have demonstrated that pain thresholds are significantly higher in patients with schizophrenia than in healthy controls [16], [17]. 

There are a number of hypotheses that seek to explain pain insensitivity in schizophrenia. Malmo et al. [18] suggested that patients with schizophrenia suffer from a motor deficit that hinders their response to painful stimuli. It has been posited that the use of neuroleptics in psychotic patients might mask pain and contribute to the difficulty of diagnosing medical conditions in this population [7], [8]. A meta-analysis by Potvin and Marchand [19], however, suggests that this phenomenon cannot solely be attributed to the effects of antipsychotic medication. It has been proposed that increased levels of endorphins may account for decreased sensitivity to pain and other symptoms of schizophrenia [20], [21]; however, no correlation between hypoalgesia and levels of endogenous opioids has been found [22]. Recently, Bonnot et al. [23] suggested that the apparent pain insensitivity in schizophrenia is related more to a different mode of pain expression than to a real endogenous analgesia. 

General medical and surgical communities need to be familiarized with the phenomenon of hypoalgesia in psychotic disorders. Physicians should maintain a high index of suspicion for acute abdomen in seriously mentally ill patients who may exhibit diminished or absent perception of pain and may present with unusual signs and symptoms. 


16. Inter-rater Reliability of Sonographic Measurements of the Inferior Vena Cava 

Saul T, et al. J Emerg Med. 2012;42:600-5. 

Background: Bedside ultrasound is emerging as a useful tool in the assessment of intravascular volume status by examining measurements of the inferior vena cava (IVC). Many previous studies do not fully describe their scanning protocol. 

Objectives: The objective of this study was to evaluate which of three commonly reported IVC scanning methods demonstrates the best inter-rater reliability. 

Methods: Three physicians visualized the IVC in three common views and utilized M-mode to measure the maximal and minimal diameter during quiet respiration. Pairwise correlation coefficients were determined using Pearson product-moment correlation. 

Results: The most reliable pair of measurements (inspiratory and expiratory) was found to be using the anterior midaxillary line longitudinal view with a Kappa value for both at 0.692. 

Conclusion: Imaging with the anterior midaxillary longitudinal approach using the liver as an acoustic window provides the best inter-rater reliability when measuring the IVC. Our findings demonstrate that IVC measurements differ based on anatomic location. 

17. ECG Differentiation of Early Repolarization from Subtle Anterior ST-Segment Elevation Myocardial Infarction 

Smith SW, et al. Ann Emerg Med 2012 Apr 18. [Epub ahead of print] 

Study objective: Anterior ST-segment elevation myocardial infarction (STEMI) can be difficult to differentiate from early repolarization on the ECG. We hypothesize that, in addition to ST-segment elevation, T-wave amplitude to R-wave amplitude ratio (T-wave amplitudeavg/R-wave amplitudeavg), and R-wave amplitude in leads V2 to V4, computerized corrected QT interval (QTc) and upward concavity would help to differentiate the 2. We seek to determine which ECG measurements best distinguish STEMI versus early repolarization. 

Methods: This was a retrospective study of patients with anterior STEMI (2003 to 2009) and early repolarization (2003 to 2005) at 2 urban hospitals, one of which (Minneapolis Heart Institute) receives 500 STEMI patients per year. We compared the ECGs of nonobvious (“subtle”) anterior STEMI with emergency department noncardiac chest pain patients with early repolarization. ST-segment elevation at the J point and 60 ms after the J point, T-wave amplitude, R-wave amplitude, QTc, upward concavity, J-wave notching, and T waves in V1 and V6 were measured. Multivariate logistic regression modeling was used to identify ECG measurements independently predictive of STEMI versus early repolarization in a derivation group and was subsequently validated in a separate group. 

Results: Of 355 anterior STEMIs identified, 143 were nonobvious, or subtle, compared with 171 early repolarization ECGs. ST-segment elevation was greater, R-wave amplitude lower, and T-wave amplitudeavg/R-wave amplitudeavg higher in leads V2 to V4 with STEMI versus early repolarization. Computerized QTc was also significantly longer with STEMI versus early repolarization. T-wave amplitude did not differ significantly between the groups, such that the T-wave amplitudeavg/R-wave amplitudeavg difference was entirely due to the difference in R-wave amplitude. An ECG criterion based on 3 measurements (R-wave amplitude in lead V4, ST-segment elevation 60 ms after J-point in lead V3, and QTc) was derived and validated for differentiating STEMI versus early repolarization, such that if the value of the equation ([1.196 x ST-segment elevation 60 ms after the J point in lead V3 in mm]+[0.059 x QTc in ms]–[0.326 x R-wave amplitude in lead V4 in mm]) is greater than 23.4 predicted STEMI and if less than or equal to 23.4, it predicted early repolarization in both groups, with overall sensitivity, specificity, and accuracy of 86% (95% confidence interval [CI] 79, 91), 91% (95% CI 85, 95), and 88% (95% CI 84, 92), respectively, with positive likelihood ratio 9.2 (95% CI 8.5 to 10) and negative likelihood ratio 0.1 (95% CI 0.08 to 0.3). Upward concavity, upright T wave in V1 or T wave, in V1 greater than T wave in V6, and J-wave notching did not provide important information. 

Conclusion: R-wave amplitude is lower, ST-segment elevation greater, and QTc longer for subtle anterior STEMI versus early repolarization. In combination with other clinical data, this derived and validated ECG equation could be an important adjunct in the diagnosis of anterior STEMI. 

18. Red Flags in Electrocardiogram for Emergency Physicians: Remembering Wellens’ Syndrome and Upright T wave in V1 (worth a second posting)

Ünlüer EE, et al. West J Emerg Med. 2012;13:160-162. 

As the electrocardiography (ECG) is a simple, noninvasive tool in the diagnosis and management of coronary artery disease (CAD), emergency physicians (EP) must be proficient in the interpretation of ECGs during evaluation of patients in the emergency department (ED). Sometimes specific T-wave changes for coronary artery disease in precordial ECG derivations may be interpreted as nonspecific T-wave changes by EPs. Failure to diagnose these conditions with subsequent inappropriate management may have fatal consequences. 

CASE REPORT

A 67-year-old man presented to the ED with anterior chest pain that did not radiate to the neck and left arm. The pain was localized, tight in nature, and had no association with exertion. The patient came from home where the chest pain initiated and was pain free on admission to the ED. His positive cardiac risk factors were smoking and hypertension. The examination was unremarkable. A 12-lead ECG was performed when the patient was free of discomfort and showed normal sinus rhythm with positive T wave in V1, which was greater than T waves in V6 (Figure 1, upper trace). Serum troponin I concentration was 0.03 ng/ml (normal values ,0.04 ng/ml). The patient was admitted to the cardiology service for ECG and cardiac marker follow up. Approximately 4 h later, repeated ECG (Figure 1, lower trace) showed obvious positive T waves in V1 and biphasic T waves in leads V2–3 and negative T waves in V4–5 without chest pain. There were also inverted T waves in lateral leads. Repeated serum troponin I concentration was within the normal range. The electrocardiograph pattern raised the possibility of left anterior descending (LAD) coronary T-wave syndrome. The patient was transferred to another center for cardiac catheterization, which revealed a 95% proximal LAD artery occlusion (Figure 2). The patient underwent emergent percutaneous coronary intervention following coronary angiography with successful outcome. 

DISCUSSION (and IMAGES)


19. Use of a limited lights and siren protocol in the prehospital setting vs standard usage 

Merlin MA, et al. Amer J Emerg Med 2012;30:519-525. 

Objective: Our objective was to determine if implementing a standard lights and sirens (L&S) protocol would reduce their use and if this had any effect on patient disposition. 

Methods: In a prospective cohort study, we trained emergency medical services (EMS) personnel from 4 towns in an L&S protocol and enrolled control personnel from 4 addition towns that were not using the protocol. We compare the use of L&S between them over a 6-month period. Our protocol restricted the usage of L&S to patients who had maladies requiring expedited transport. Emergency medical services personnel from the control towns had no such restrictions and were not aware that we were tracking their usage of L&S. We also considered if patient disposition was affected by the judicious usage of L&S. 

Results: Prehospital EMS personnel who were trained in an L&S protocol were 5.6 times less likely to use L&S when compared with those not trained. Of the 808 patients transported by both types of workers, no difference in patient disposition was observed. 

Conclusions: Our protocol significantly reduced the use of L&S. Judicious use of L&S has significant implications for transport safety. By allowing for selective transport with L&S usage, we observed no impact in patient disposition. 

20. t-PA OK for Octogenarians 

By Chris Kaiser, Cardiology Editor, MedPage Today. May 25, 2012 

Recombinant tissue plasminogen activator (rt-PA) works just as well in those older than 80 as it does in younger patients, two studies have found. 

In the randomized Third International Stroke (IST-3) trial, a subgroup analysis of 1,617 patients older than 80 suggested "greater benefit" from thrombolysis in these patients, "contrary to expectations," according to Peter Sandercock, DM, from the University of Edinburgh in Scotland, and colleagues. 

The second study, a meta-analysis that included IST-3, found no difference in the number of events between those older and younger than 80, whether treated with thrombolysis or placebo, reported Joanna M. Wardlaw, MD, also from the University of Edinburgh, and colleagues. 

Both studies were published May 23 online in The Lancet. 

"IST-3 and the updated meta-analysis are an important achievement in stroke research," claimed Didier Leys, MD, and Charlotte Cordonnier, MD, from Roger Salengro Hospital in Lille, France, in an accompanying editorial. 

"Their main strength is the large sample size, allowing subgroup analyses in categories usually excluded from trials, especially elderly patients," they wrote. 

They added, "[T]he role of stroke and emergency physicians is now not to identify patients who will be given rt-PA, but to identify the few who will not." 

Rt-PA is approved in the European Union to treat strokes in patients younger than 80 years, but is not licensed for use in patients over 80. It has been approved in the U.S. since 1996 with no age restrictions. 

The FDA approved rt-PA (alteplase) with the stipulation it be delivered within 3 hours of stroke onset. Guidelines from the American Heart Association/American Stroke Association were updated in 2009 to reflect emerging evidence that rt-PA can be given within 4.5 hours of stroke onset. However, the FDA has not approved this timeline. 

The AHA/ASA guidelines also recommend not giving intravenous rt-PA to patients older than 80. 

"The key message of IST-3 and the updated meta-analysis is that many eligible patients from subgroups excluded by the European licence should now be given rt-PA," Didier and Cordonnier wrote in their editorial. 

IST-3 enrolled 3,035 patients in 156 centers in 12 countries from 2000 to 2011. They were randomized to rt-PA or placebo. 

An early hazard of intracranial hemorrhage and death in the rt-PA group at 7 days evened out at 6 months, where there was no significant difference between the two arms regarding the number of patients who were alive and independent, the primary outcome. 

However, researchers performed an ordinal analysis and found that the rt-PA group had significantly better handicap scores at 6 months (P=0.001). 

Sandercock and colleagues said the 7% fatal or nonfatal symptomatic intracranial hemorrhage rate within 7 days in the rt-PA group was not unexpected, since they "sought to recruit older patients and patients who did not strictly meet prevailing licence criteria for thrombolytic therapy with rt­-PA." 

IST-3 showed that the benefit of thrombolysis was greatest within 3 hours. However, the trial did not have enough power to show any benefit beyond 3 hours. Results also indicated that rt-PA should not be restricted because of the severity of stroke or the presence of early ischemic change on the baseline brain scan, researchers said. 

The meta-analysis by Wardlaw and colleagues of 12 trials (7,012 patients) that compared rt-PA to placebo also revealed that treatment works best within the 3-hour window. However, they suggested that some patients might benefit up to 6 hours after stroke. 

In fact, for every 1,000 patients given thrombolytic therapy up to 6 hours after stroke onset, 42 more patients were alive and independent, and 55 more were alive with a favorable outcome at the end of follow-up. 

Wardlaw and colleagues said that the survival benefit occurred despite the early hazard from intracranial hemorrhage. 

As with IST-3, the meta-analysis showed a benefit from rt-PA despite the severity of stroke and a benefit for those older than 80. 

The investigators suggested that the "small gains in functional ability by 3 to 6 months" could reduce healthcare costs in the long term due to "survival free of disability." 

21. Half of EDs overcrowded, leaders report 

FierceHealthcare May 10, 2012 | By Karen M. Cheung 

Almost half (46 percent) of healthcare leaders say their emergency department (ED) is overcrowded--and 51 percent of those worry it will jeopardize patient safety, according to a HealthLeaders Media report released yesterday. 

In a survey of nearly 300 respondents in operations, clinical work, finance and information, 43 percent of health leaders reported that ED patient flow was their biggest strategic challenge, followed by physician alignment and adherence to quality goals and reimbursement challenges, each at 13 percent. An overwhelming 95 percent said they are working on efforts to improve throughput, including a fast-tracking area for less acute illnesses or injuries (65 percent), a triage medical evaluation process (56 percent), coordination with inpatient floor nurses (55 percent) and a streamlined registration process (54 percent). Only a quarter saw enlarging the ED as a solution to addressing efficiency. 

"We need to examine how we look at the ED and try to find ways to relieve pressure from it that cascades through the hospital systems," Philip A. Newbold, President and CEO of Memorial Hospital & Health System and Elkhart General Healthcare System in South Bend, Ind., said in the report. Newbold said that solutions include express care or around-the-clock urgent care services.  

The report confirms conventional wisdom that the industry is biting its nails over ED overcrowing. As one healthcare leader noted in the report, some patients see the ED as their only care option--whether hospitals like it or not. The report also offers some solutions, such as tending to the most urgent cases first, creating separate areas or freestanding buildings for less acute cases and improving coordination among providers--all with the patient (and experience) in mind.