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,15… 

The remainder of the article (full-text free): 

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:  

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:

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):  

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


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:  

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):  

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:  

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):  

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 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:  

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 

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.

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.