A collection of assorted summaries, highlights, and abstracts from the recent medical literature.
Friday, July 13, 2012
Lit Bits: July 13, 2012
From the recent medical literature...
Drive Post-MI Readmissions
Dunlay SM, et al. Thirty-day rehospitalizations after acute
myocardial infarction: A cohort study. Ann Intern Med 2012;157: 11-18.
By Crystal Phend, Senior Staff Writer, MedPage Today.
Published: July 05, 2012
A return to the hospital soon after an admission for
myocardial infarction (MI) often relates more to complications and
comorbidities than to the heart attack itself, researchers found.
Over 30% of rehospitalizations within 30 days of an MI were
deemed unrelated to the incident event, according to an observational study by
Véronique L. Roger, MD, MPH, of the Mayo Clinic in Rochester, Minn., and
Comorbidities and complications of treatment weighed heavily
among the risk factors for readmission, the group reported in the July 3 issue
of the Annals of Internal Medicine.
The rate of repeat admission reached 35.3% among patients
with an angiography complication during their initial stay and 31.6% among
those with a reperfusion or revascularization complication.
That was nearly double the 16.8% rate of 30-day readmission
among patients who were reperfused or revascularized without complications.
"Prevention of complications and close follow-up for
patients who have had a complication may be of particular importance for
preventing rehospitalizations," Roger's group noted.
Another implication is for coordination of care, as
comorbidities are so common in MI patients.
With an aging population and 30-day rehospitalization now
used as a quality of care marker, "these data underscore the importance of
implementing a comprehensive management strategy in patients after incident MI
to help prevent rehospitalizations," the researchers wrote.
Their study included 3,010 incident MIs from 1987 to 2010
within the population-based registry of Olmsted County, Minn., where the Mayo
Clinic is located.
Retrospective analysis showed 643 rehospitalizations within
30 days in 561 patients (18.6%).
Among these cases, 42.6% were rehospitalized related to the
incident MI or its treatment, for reasons such as sternal wound infection,
heart failure, acute renal failure, or pleural effusion.
The 30.2% deemed unrelated to the initial MI were for
reasons such as cancer, fracture, aspiration pneumonia, and end-stage renal
disease in patients on dialysis prior to MI.
The remaining 27.2% of rehospitalizations didn't clearly fit
into either category and were most commonly for atypical chest pain.
Significant, independent risk factors for readmission within
30 days of the initial MI were:
·A complication of angiography during the index
hospitalization (hazard ratio 2.40)
·A complication of reperfusion or
revascularization during the index hospitalization (HR 2.12)
·Diabetes mellitus (HR 1.34)
·Chronic obstructive pulmonary disease (HR 1.43)
·Anemia (HR 1.25)
·Worse heart failure as marked by a higher Killip
class at presentation (HR 1.22 for class 2 to 4)
·A longer initial hospitalization (HR 1.34 for 4
to 7 days and 1.65 for more than 7 days compared with 3 or less)
Acute kidney injury after percutaneous coronary intervention
during the index MI hospitalization, which occurred in 5% of patients, boosted
risk of readmission 92% after adjustment for baseline kidney problems. But it
wasn't often a primary reason for rehospitalization.
Rehospitalization after MI showed no trends over time during
the 24-year study period.
"Despite advances in therapies and improved inhospital
outcomes after MI, rehospitalizations remain a serious problem and have shown
no signs of abating," Roger's group concluded.
Limitations of the study included that missed MIs that did
not result in hospitalizations, and hospitalizations that occurred outside of
the county studied as well.
The largely white population of the county might have
limited generalizability too.
The study was funded by grants from the National Institutes
of Health and the Rochester Epidemiology Project.
Roger reported grant funds to her institution from the
National Heart, Lung and Blood Institute.
3. Unsustainable ED
crowding grows twice as fast as visits
FierceHealthcare. By Karen M. Cheung
Emergency department crowding is growing twice as fast as
visits and will rise to unsustainable proportions, according to Jesse Pines,
director of the Center for Healthcare Quality at George Washington University
and associate professor of emergency medicine and health policy in Washington,
ED visits increased 60 percent faster than population growth
over an eight-year period. Crowding, or occupancy, as it's called, grew even
faster, according to an Annals of Emergency Medicine study published online
Tuesday. While ED visits increased by 1.9 percent annually from 2001 to 2008,
crowding grew by 3.1 percent.
"Visit volume is going up, which is outpacing
population group, and patients are staying longer and longer within the ED
getting more intense work-ups and treatments," Pines said in a statement
to FierceHealthcare. "Together, the 'occupancy,' which is the number of
patients in our nation's emergency care system at one time, is rising at a very
rapid, unsustainable rate."
Although advanced imaging often receives much of the blame
for delays in the ED, researchers found that it had more to do with practice
intensity, that is, blood work and x-rays at triage, that's really bogging down
Patients are getting more tests, fluids and procedures for a
number of reasons, Pines explained. Some providers are practicing defensive
medicine, but patients and providers also expect high-technology care, such as
requiring CT scans or other advanced test before admitting the patient to the
"As technology outside the ED improves, such as organ
transplantation and cancer care, when patients have complications--and they
do--they end up coming in and are sicker and need more ED resources to take
care of them," Pines said about the older, sicker population.
Even more, EDs have become rapid diagnostic centers. For
example, patients who need X-rays will go to the ED because it's the fastest
place to do it, especially when their physicians refer them there, Pines said.
"Lengthy work-ups in the emergency department are not
always a bad thing if they prevent a costly hospitalization. The problem is
that more and more demands are being placed on emergency departments and the
mood in the health policy community is to shrink emergency departments, not
grow them," Pines said in a research announcement.
Providers can help patients early in the care process,
trimming off wasted time in the waiting room. For instance, hospitals can place
a physician at triage or eliminate triage altogether when there are empty
In addition, facilities can use space better to meet patient
demands. When the ED is full, patients can wait in the ED, as opposed to
outside of it in the waiting room, for tests to be completed.
And lastly, much of the way that ED crowding should be
avoided is pinching it off at the source and preventing ED visits altogether
with public health measures so patients don't get sick or allowing patients to
get "sick visits" at their doctor's office, Pines noted.
A. Excerpt from
“Right-sizing testing for PE: recognizing the risks of detecting any clot.”
Green SM, Yealy DM. Ann Emerg Med. 2012 Jun;59(6):524-6.
Seven-Step Program for Reducing Testing for Pulmonary
Step 1: Accept That You Cannot Identify All Pulmonary Emboli
As amply displayed by the case report in this issue,
emergency physicians must abandon any pretense that they can identify all
pulmonary emboli on a first visit. Each of us will miss pulmonary emboli, and
on rare occasions the outcome will be poor despite the well appearance. Resign
yourself to a more pragmatic and utilitarian approach.
Step 2: Recognize That Any Strategy That Seeks to Detect All
Pulmonary Emboli Does More Harm Than Good
As discussed, aggressive testing is not beneficial overall
but simply shifts the net risks from the few patients with disease to the many
without.  , 
Step 3: Risk-Stratify and Reduce Your Testing
Identify low-risk patients and don't initiate a diagnostic
evaluation for pulmonary embolism. PERC is a well-validated tool for this
purpose. PERC-negative patients aren't just low risk but also ultralow risk.
Identifying true zero risk is not achievable, even with testing.
Don't like the validated decision aids? No problem. Because
PERC simply mimics unstructured clinical judgment, there is every reason to
believe that the gestalt of a skilled emergency physician will similarly
identify patients whose lower risk of pulmonary embolism does not warrant the
risks of a diagnostic evaluation.  , 
Step 4: Try “Watchful Waiting”
In the ED, our mindset is to make correct diagnoses on the
spot, whereas most other physicians assess the likelihood of disease longitudinally.
Emergency physicians need to gain more comfort delaying evaluations for
pulmonary embolism and other diagnoses, a strategy sometimes nicknamed
“watchful waiting” or “masterful inactivity.”
To avoid unnecessary risks of testing, a feasible
alternative for “on-the-fence” patients might simply be a 24-hour recheck
either in the ED or with their regular physician. By then, the lack of disease
may have become obvious, and if the patient is unimproved you can always test
at this second visit. Patient satisfaction with watchful waiting can be just as
high as with immediate testing. We currently do this safely in low-risk
venous thrombosis, the common pulmonary embolism companion.
Step 5: Document Your Medical Decisionmaking
The no-testing strategy can be readily documented on the
medical record: “Given the known potential harms of a diagnostic evaluation for
pulmonary embolism, my clinical judgment for this patient is that those risks
currently outweigh the likely benefits.” If using watchful waiting, then add:
“Instead, I have asked the patient to be rechecked in 24 hours (or earlier if
worse) to reassess this risk, either in the ED or with his or her regular
Step 6: Be Less Afraid of Litigation
Adverse malpractice verdicts occur commonly when physicians
fail to meet a reasonably well-defined standard of care and when more than a
single opportunity is lost. Our recommendations resolve both of these directly.
When that standard is murky, when the diagnosis is inapparent, and when the
risks of testing are very real (as with pulmonary embolism), those judging our
care will likely understand and support the physician who is attempting to act
in the patient's best interests. Moreover, our patients will know we cared for
them, especially if we share our knowledge and concern for their immediate and
long-term safety and well-being.
Step 7: Spread the Word
Educate your trainees, partners, and colleagues about
tailored decisionmaking and the pitfalls of testing “at any cost.” Track such
testing in your continuous quality improvement programs. Ensure that your local
ED logistics effectively facilitate return visits for watchful waiting.
So that's the news, both bad and good. That we cannot
consistently diagnose this protean disease safely is bad news. However, it is
good news that the current scientific evidence supports a strategy of using
clinical judgment to substantially reduce testing for pulmonary embolism. We
will not always be right with individual patients, but aggressive testing for
all only shifts who receives what bad event; it does not decrease harm
5. Risks of
Intracranial Hemorrhage among Patients with Acute Ischemic Stroke Receiving
Warfarin and Treated With Intravenous Tissue Plasminogen Activator
Xian Y, et al. JAMA. 2012;307(24):2600-2608.
In an earlier Lit Bits prelim results from a conference
presentation were posted. The full article now is available in press and online.
tissue plasminogen activator (tPA) is known to improve outcomes in ischemic
stroke; however, patients receiving long-term chronic warfarin therapy may face
an increased risk for intracranial hemorrhage when treated with tPA. Although
current guidelines endorse administering intravenous tPA to warfarin-treated
patients if their international normalized ratio (INR) is 1.7 or lower, there
are few data on safety of intravenous tPA in warfarin-treated patients in
the risk of symptomatic intracranial hemorrhage (sICH) among patients with
ischemic stroke treated with intravenous tPA who were receiving warfarin vs
those who were not and to determine this risk as a function of INR.
Design, Setting, and Patients Observational study, using data from the
American Heart Association Get With The Guidelines–Stroke Registry, of 23 437
patients with ischemic stroke and with INR of 1.7 or lower, treated with
intravenous tPA in 1203 registry hospitals from April 2009 through June 2011.
Main Outcome MeasureSymptomatic intracranial hemorrhage. Secondary end points include
life-threatening/serious systemic hemorrhage, any tPA complications, and
(7.7%) patients with stroke treated with tPA were receiving warfarin (median
INR, 1.20; interquartile range [IQR], 1.07-1.40). Warfarin-treated patients
were older, had more comorbid conditions, and had more severe strokes. The
unadjusted sICH rate in warfarin-treated patients was higher than in
non–warfarin-treated patients (5.7% vs 4.6%, P < .001), but these
differences were not significantly different after adjustment for baseline
clinical factors (adjusted odds ratio [OR], 1.01 [95% CI, 0.82-1.25]).
Similarly, there were no significant differences between warfarin-treated and
non–warfarin-treated patients for serious systemic hemorrhage (0.9% vs 0.9%;
adjusted OR, 0.78 [95% CI, 0.49-1.24]), any tPA complications (10.6% vs 8.4%;
adjusted OR, 1.09 [95% CI, 0.93-1.29]), or in-hospital mortality (11.4% vs
7.9%; adjusted OR, 0.94 [95% CI, 0.79-1.13]). Among warfarin-treated patients
with INRs of 1.7 or lower, the degree of anticoagulation was not statistically
significantly associated with sICH risk (adjusted OR, 1.10 per 0.1-unit
increase in INR [95% CI, 1.00-1.20]; P = .06).
patients with ischemic stroke, the use of intravenous tPA among
warfarin-treated patients (INR ≤1.7) was not associated with increased sICH
risk compared with non–warfarin-treated patients.
6. Age Is an Inverse
Predictor of Propofol Dose for Procedural Sedation in Children
But age accounted for only 7% of variability in induction
To determine if age predicts dosing of propofol in children,
investigators retrospectively reviewed records of 88 patients aged <18 years
(mean age, 11 years) who received only propofol for procedural sedation at a
single emergency department between 2005 and 2009.
Indications for sedation included fracture manipulation
(60%), dislocation manipulation (17%), imaging (7%), and lumbar puncture (5%).
The mean cumulative propofol dose was 2.1 mg/kg administered in a median of 3
boluses, with mean consecutive doses of 0.94, 0.49, and 0.40 mg/kg. Mean time
to adequate sedation was 3.9 minutes. In linear regression analyses, age was
inversely predictive of propofol dose; procedure type, opioid administration,
and preprocedural pain scores were not predictors. Respiratory depression
(oxygen saturation <90%, end tidal carbon dioxide >50 mm Hg or increase
of >10 mm Hg from baseline, or apnea) occurred in 12 patients (14%); only 1
patient required temporary bag-mask ventilation. Transient hypotension occurred
in 7 patients (8%) and required no intervention. Of note, although age was
significantly inversely related to propofol dose, age accounted for only 7% of
variability in doses.
Comment: The aim in propofol dosing is to select an initial
dose that achieves prompt and adequate sedation while minimizing adverse
events. Younger patients are more likely to require higher doses of propofol,
but the initial dose requirement for any one patient cannot be perfectly
— Katherine Bakes, MD. Published in Journal Watch Emergency
Medicine June 15, 2012. Citation: Jasiak KD et al. Induction dose of propofol
for pediatric patients undergoing procedural sedation in the emergency
department. Pediatr Emerg Care 2012 May; 28:440.
7. The Debate
Surrounding the EGDT Bundle (courtesy of EP Monthly)
A. Sepsis: Unbundling
the Bundle by Kevin Klauer, DO, EJD on May 24, 2012.
Years after its debut, studies continue to question the
efficacy of EGDT
Two years ago I called into question the use of the sepsis
bundle of therapies defined by the “Surviving Sepsis” campaign (EPM, March
2010) Although aggressively managing sepsis is a good thing, and the mere focus
on the rapid identification and application of appropriate management
strategies for sepsis is essential to good patient outcomes, it appears that
EGDT and the research it was based on may have promised more than it could
As it is with many modalities that are rapidly and widely
accepted based on a few sentinel studies, years later we often find that our early
adoption was premature and ill advised. With all due respect to the authors of
the study, I respectfully submit that the sepsis bundle described in EGDT fits
squarely into that category…
B. Sepsis: EGDT
Continues to Deliver by Emanuel Rivers, MD, MPH on July 10, 2012.
The concept and components of early goal directed therapy
(EGDT) for sepsis management has been part of the emergency medicine (EM)
literature for over 40 years.1-3 Eleven years after the original publication of
EGDT, the literature reflects the opposite position to that of Dr. Klauer, as
put forth in last month’s Op/Ed. EGDT has been validated and proven effective
in over 54 publications comprising over 23,000 patients (shown in the table at
right).4 Because of these robust finding, the emergency department (ED) has had
the most influential impact on sepsis outcomes in the last decade.5 EGDT
remains one of the most important components of the Surviving Sepsis Campaign
(SSC) recommendations.6 EGDT has not “failed to deliver,” as Dr. Klauer
By Chris Kaiser, Cardiology Editor, MedPage Today.
Published: July 02, 2012.
NATIONAL HARBOR, Md. -- It may be possible for internists
and emergency room physicians to diagnose cardiogenic shock using a model of
clinical and echocardiographic variables, researchers suggested.
A retrospective derivation cohort of 122 acute myocardial
infarction (MI) patients used to test the noninvasive model had an overall
accuracy of 83%, with good sensitivity (83%) and specificity (82%), according
to Amir H. Najafi, MD, a cardiology fellow at Washington Hospital Center in
Washington, D.C., and colleagues.
When the model was validated in an all-comers cohort of 90
consecutive patients undergoing pulmonary artery catheterization, the overall
accuracy was 81%, while the sensitivity dropped to 71%, which Najafi deemed
"still respectable," during his report at American Society of
Echocardiography annual meeting. In addition, the specificity came in at 86%.
Patients identified as having cardiogenic shock using the
echocardiography-based criteria had the same inhospital mortality rate as those
identified using the invasive criteria (both 29%).
The current protocol for diagnosing cardiogenic shock
requires the insertion of a catheter into the pulmonary artery. However, some
expert cardiologists often make the assessment without pulmonary artery
"We hypothesized that learning the thought process of
these experts who utilize clinical and echocardiographic data to make their
diagnosis might help us develop a model for other noncardiologists to
use," Najafi told MedPage Today.
There were three sets of clinical criteria and one set of
echocardiographic variables that Najafi and colleagues determined patients
should have as part of the noninvasive model.
The first set consists of any of these predisposing
·Anterior STEMI (ST-segment elevation myocardial
infarction) or any acute MI with an ejection fraction less than 40%
·Right ventricular MI
·Severe mitral or aortic regurgitation or
·Ventricular septal rupture or free wall rupture
·Severe left ventricular dysfunction
Next is evidence of hypotension:
·Systolic blood pressure less than 90 mmHg for 30
minutes or longer
·Need for supportive measures such as
intra-aortic balloon pump, vasopressor, or inotrope to maintain systolic blood
pressure greater than 90 mmHg
Then evidence of hypoperfusion:
·Urine output of 25 mL/hour
·CO2 less than 18 mmol/L
·Lactate greater than 2 mmol/L
Finally, echocardiographic evidence of elevated filling
pressures such as:
·Mitral pulse Doppler E/A wave ratio greater than
0.9 (or if this is not measurable due to E/A fusion or the absence of A)
·Minimum inferior vena cava diameter during full
respiratory cycle greater than 15 mm
"A patient may fulfill all three clinical criteria, but
we still need evidence of elevated filling pressures for a definitive diagnosis
of cardiogenic shock," Najafi said. "There are different types of
shock and we want to be sure these patients are triaged properly and
In the E/A ratio, E is the early diastolic filling of the
left ventricle, which should be greater than A, the late atrial systolic push
into the left ventricle. "An E/A ratio greater than 1 is suggestive of
elevated filling pressures," Najafi said. "We believe 0.9 is the best
cutoff value for this."
In cases of tachycardia, the E/A can become fused, or
difficult to separate, and in cases of atrial fibrillation, the A will
sometimes be absent. That is why Najafi and colleagues allow for a second
echocardiographic measurement of the inferior vena cava diameter.
They also are testing other echocardiographic parameters,
particularly tissue Doppler, in an ongoing prospective evaluation. For this
ongoing study, nurses in the critical care unit at Washington Hospital Center
have been asked to record the pulmonary artery catheterization data
simultaneously with the echo parameters.
They have more than 100 patients in the prospective study
and intend to enroll several hundred. The interim analysis shows the trend is
heading in the right direction, Najafi told MedPage Today.
The researchers reported no conflicts of interest.
Najafi A, et al "Accurate, noninvasive diagnosis of
cardiogenic shock based on echocardiography rather than invasive hemodynamic
assessment" American Society of Echocardiography 2012; Abstract P1-13.
10. Rapid Rule-Out
Protocol for Patients with Suspected Cardiac Chest Pain
The combination of TIMI score of zero at presentation, no
new ischemic changes on initial electrocardiogram, and negative troponin
results at zero and 2 hours had a sensitivity of 99.7%.
In a prospective observational study of 1975 patients who
presented to two hospitals in Australia and New Zealand with chest pain
suggestive of acute coronary syndrome, researchers assessed whether or not an
accelerated diagnostic protocol could identify patients at low risk for major
adverse cardiac events within 30 days. Patients with ST segment elevation on initial
electrocardiogram (ECG) were excluded. Patients received usual care, including
serial troponin testing, in accordance with international guidelines; each
hospital used its standard troponin test.
The protocol consisted of a Thrombolysis in Myocardial
Infarction (TIMI) score at presentation, initial ECG results, and troponin I
concentrations at zero and 2 hours; patients with a TIMI score of zero, no new
ischemic changes on initial ECG, and negative troponin results at zero and 2
hours were deemed low risk.
Major adverse cardiac events (acute myocardial infarction,
death, cardiac arrest, cardiogenic shock, emergency revascularization, and
ventricular dysrhythmia requiring intervention) occurred in 302 patients (15%),
usually within 10 days. The protocol identified 392 patients (20%) as being low
risk; one of these patients (0.25%) had a major cardiac event (myocardial
infarction diagnosed on the basis of an elevated troponin result at 12 hours).
The sensitivity and negative predictive value of the protocol for identifying
patients with major adverse cardiac events were both 99.7%, and the specificity
Comment: This study begs for a randomized trial in which
low-risk patients are actually sent home, but such a study is unlikely to ever
be conducted. The study's strength is its use of current (i.e., not highly
sensitive) troponin assays from two different manufacturers. These findings
support institutions developing internal protocols to efficiently evaluate
patients with low-risk chest pain. Developers of such protocols should
recognize that most patients will require further testing, such as exercise
tolerance testing, to exclude ischemia.
— J. Stephen Bohan, MD, MS, FACP, FACEP. Published in
Journal Watch Emergency Medicine June 29, 2012
Citation(s): Than M et al. 2-hour accelerated diagnostic
protocol to assess patients with chest pain symptoms using contemporary
troponins as the only biomarker: The ADAPT trial. J Am Coll Cardiol 2012 Jun 5;
59:2091. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22578923
11. Heart Size Skews
By Charles Bankhead, Staff Writer, MedPage Today. Published:
June 29, 2012.
Levels of troponin I significantly overestimated infarct
size after ST-elevation myocardial infarction (STEMI) in patients with left
ventricular hypertrophy (LVH), a retrospective review of 500 cases showed.
Patients with mild LVH had a mean troponin I level that was
13.7% higher than patients with no hypertrophy. The difference increased to
17.8% for patients with moderate to severe LVH.
In contrast, creatinine kinase (CK) levels remained stable
across the range from no hypertrophy to moderate/severe LVH, as reported online
in the Journal of the American College of Cardiology.
"After our findings, it may be speculated that LVH can
act as a confounding factor when troponins are used as infarct size
estimators," Borja Ibañez, MD, PhD, of the Carlos III National Center for
Cardiovascular Studies in Madrid, and co-authors wrote. "Here we show that
STEMI patients with LVH had significantly greater troponin I release than
patients with normal left ventricle thickness at a given CK value.
"According to the incidence of LVH in our nonselected
STEMI patient population and others, myocardial infarction size calculated
according to peak troponin release can be overestimated in 30% of patients,
something that should be taken into consideration in studies evaluating the
effect of therapies in infarct size."
Studies have shown that peak and area under the curve of
circulating CK and troponins correlate with infarct size after STEMI. Moreover,
measurement of troponin concentration at a single point in time has good
correlation with infarct size. As a result, measurement of circulating biomarkers
has become widespread in clinical practice and trials.
Hypertrophied myocardium has elevated troponin
concentrations as opposed to normal myocardial tissue, but CK levels are
similar. Ibañez and co-authors hypothesized that troponin release following
STEMI will be increased relative to CK in patients with LVH. Consequently,
prediction of infarct size by troponin levels might be confounded by the
presence of LVH.
Investigators studied 504 patients treated for STEMI during
2004 to 2009. The group consisted of 331 patients with no LVH, 107 patients
with mild LVH, and 66 patients with moderate to severe LVH. Biomarker release
was compared in patients with and without LVH.
Peak CK values did not differ significantly across
categories of LVH. However, compared with patients with no LVH, patients who
had mild or moderate to severe LVH had 13.7% (95% CI 2.5% to 26.1%, P<0.02)
and 17.8% higher troponin levels (95% CI 3.3% to 34%, P<0.02), respectively.
"In the presence of LVH, the discrepancy between total
CK and troponin I can be as much as 34%," the authors wrote. "Such a
variation in infarct size is of great biological impact in clinical trials
testing the effect of cardioprotective interventions, and therefore the current
results have a significant impact."
The study is limited by its retrospective nature and
researchers said that more studies need to be performed to confirm their
By Peggy Peck, Executive Editor, MedPage Today. May 31, 2012
WASHINGTON -- Rubbing topical anesthetics such as Anbesol or
Orajel on the throbbing gums of a teething baby can lead to methemoglobinemia,
a serious condition that leads to oxygen deprivation and -- in extreme cases --
death, the FDA warned today.
Products sold over-the-counter for teething and toothache
pain contain benzocaine, and that is the source of the FDA's concern, said FDA
pharmacist Mary Ghods, RPH, in a statement.
The risk is greatest among children younger than 2, the age
range at which most children experience teething pain.
The FDA first warned about the products -- a list that
includes Hurricaine, Baby Orajel and Orabase, as well as Orajel and Anbesol --
in 2006, and since then the agency has received "29 reports of benzocaine
gel-related cases of methemoglobinemia. Nineteen of those cases occurred in
children, and 15 of the 19 cases occurred in children under 2 years of
age," FDA pharmacist Kellie Taylor, PharmD, MPH, said in a statement.
The FDA issued a second warning a year ago, but, Taylor
said, the agency remains concerned about "the difficulty parents may have
recognizing the signs and symptoms of methemoglobinemia when using these
products at home."
Moreover, the symptoms can occur within minutes of use or
may not manifest until hours after the drug is applied, and a child can become
symptomatic with first use or only after several uses.
Symptoms of methemoglobinemia include:
·Pale, gray, or blue-colored skin, lips and nail
·Shortness of breath
·Rapid heart rate
As an alternative to using numbing drugs on gums, the American
Academy of Pediatrics recommends giving the baby a chilled teething ring or
gently massaging the baby's gums with a finger.
If those remedies fail, the AAP recommends contacting a
health professional for advice.
The FDA noted that in addition to OTC sales of benzocaine
products, physicians and dentists use benzocaine sprays to numb areas of the
mouth and throat for procedures such as transesophageal echocardiograms,
endoscopy, and feeding tube placements.
Adults -- especially those with heart disease, asthma,
bronchitis, or emphysema, as well as smokers -- are also at risk from
benzocaine products, and Taylor recommended that adults with those conditions
have a preprocedure consult to discuss the risks.
13. Answering the
myth: use of emergency services on Friday the 13th
Lo BM, et al. Amer J Emerg Med. 2012;30:886-889.
Objective: The aim of the study was to evaluate the risk of
Friday the 13th on hospital admission rates and emergency department (ED)
Methods: This was a retrospective chart review of all ED
visits on Friday the 13th from November 13, 2002, to December 13, 2009, from 6
hospital-based EDs. Thirteen unlikely conditions were evaluated as well as
total ED volumes. As a control, the Friday before and after and the month
before and after were used. χ2 Analysis and Wilcoxon rank sum tests were used
for each variable, as appropriate.
Results: A total of 49 094 patient encounters were
evaluated. Average ED visits for Friday the 13th were not increased compared
with the Friday before and after and the month before. However, compared with
the month after, there were fewer ED visits on Friday the 13th (150.1 vs 134.7,
P = .011). Of the 13 categories evaluated, only penetrating trauma was noted to
have an increase risk associated with Friday the 13th (odds ratio, 1.65; 95%
confidence interval, 1.04-2.61). No other category was noted to have an increase
risk on Friday the 13th compared with the control dates.
Conclusions: Although the fear of Friday the 13th may exist,
there is no worry that an increase in volume occurs on Friday the 13th compared
with the other days studies. Of 13 different conditions evaluated, only
penetrating traumas were seen more often on Friday the 13th. For those
providers who work in the ED, working on Friday the 13th should not be any
different than any other day.
14. If pre-procedure
hydration is standard protocol in high-risk patients with stage 3 or 4 chronic
kidney disease, what is the incidence of contrast-induced nephropathy (CIN)?
Synopsis: Adult patients in the Netherlands who were to
undergo a procedure requiring IV contrast were divided into two cohorts based
on high or low risk for CIN, and all had a creatinine measured 3-5 days after
the procedure.Those in the high risk
group (eGFR <60mL/min + DM, eGFR 45-60 mL/min and at least 2 risk factors,
or eGFR <45 mL/min) were hydrated with 250mL/hr of NS for four hours before
and after the procedure (over 10 hours pre and post if eGFR <30mL/min, CHF,
or on diuretics).Low risk patients did
not receive hydration.The rate of CIN
was about 2.4% in each cohort and 2.4% overall.CHF, low BMI, and prior contrast within the past year were all
independent risk factors for CIN.
Upshot: If your patient is at high risk for CIN, give 1L of
NS before and after the administration of IV contrast if at all possible.Interesting how much lower the incidence of
CIN was in this study than in the study Madji reviewed this week regarding CIN
in patients getting CT pulmonary angiography.It looks like hydration may have made a big difference.
15. High Rate of
Positive CT Scans in Older Patients with Minor Head Trauma
Head computed tomography was positive in two thirds of
patients aged >65 with Glasgow Coma Scale scores of 15 and no loss of
Moore MM, et al. Impact of age and anticoagulation: Need for
neurosurgical intervention in trauma patients with mild traumatic brain injury.
J Trauma Acute Care Surg. 2012 May 2. [Epub ahead of print]
BACKGROUND: Of the 500,000 brain injuries in the United
States annually, 80% are considered mild (mild traumatic brain injury).
Unfortunately, 2% to 3% of them will subsequently deteriorate and result in
severe neurologic dysfunction. Intracerebral changes in the elderly, chronic
oral anticoagulation, and platelet inhibition may contribute to the development
of intracranial bleeding after minor head injury. We sought to investigate the
association of age and the use of anticoagulation and antiplatelet therapy with
neurologic deterioration and the need for neurosurgical intervention in
patients presenting with mild traumatic brain injury.
METHODS: A retrospective review of all adult (>14 years)
patients admitted to our Level I trauma service with a Glasgow Coma Scale (GCS)
score of 14 to 15 who underwent neurosurgical intervention during their
hospital stay was performed. Patients were stratified into two groups, age
<65 years and age ≥65 years. Each group was then further stratified by the
use of anticoagulants: warfarin, aspirin, clopidogrel, or a combination.
Mechanism of injury, prehospital complaints, admission GCS, type of
neurosurgical intervention, intensive care unit length of stay, hospital length
of stay, and discharge disposition were evaluated. Z test and logistic
regression were used to compare proportions or percentages from different
RESULTS: Of the 7,678 patients evaluated during the study
period, 101 (1.3%) required neurosurgical intervention. The ≥65 years population
underwent significantly more interventions as did those patients on
CONCLUSION: All patients aged 65 years or older who present
with a GCS score of >13 after head trauma should undergo a screening
computed tomography of the head regardless of prehospital use of
anticoagulation. Patients younger than 65 years can be selectively screened
based on presenting complaints and mechanism of injury provided they are not on
16. Good News About
Antibiotic Use in Children, but Judicious Use Is Still Needed
From 2000–2005, the decline in antibiotic dispensing rates
for children in Massachusetts was largely attributable to lower rates of otitis
media diagnoses, but the decline has stalled.
Researchers obtained antibiotic dispensing and diagnosis
data for children from two health insurers in 16 Massachusetts communities from
2000 to 2009 and analyzed the data according to three age groups: 3 to 24
months, 24 to 48 months, and 48 to 72 months.
Annual population-based antibiotic dispensing rates (number
of antibiotic dispensings divided by number of person-years) declined in all
three age groups. The decline was greatest (24%) in the 3- to 24-month-old
group (from 2.3 to 1.8 antibiotic dispensings per person-year). The downward
trend leveled off after 2005 in the two youngest groups and after 2001 in the
older group, with no further significant change through 2009. The decline was
primarily attributable to a lower rate of otitis media diagnoses. Lower rates
of antibiotic dispensing unrelated to office visits in each age group also
contributed to the decline. The authors were unable to determine if use of the
pneumococcal vaccine, changes in the threshold for diagnosis of otitis media,
or both contributed to the downward trend. Although overall use of
second-generation macrolides was relatively low, use increased among children
aged 48 to 72 months during the study period.
Comment: The downward trend in the use of antibiotics in
children during the last decade is a positive development. The message
concerning the need for judicious use of antibiotics is being heard. However,
the decline has stalled. We now need to reduce improper use of antibiotics —
such as second-generation macrolides (e.g., azithromycin) — instead of less expensive
and more effective first-line treatment with penicillin (e.g., amoxicillin).
— Louis M. Bell, MD. Published in Journal Watch Pediatrics
and Adolescent Medicine July 11, 2012. Citation: Greene SK et al. Trends in
antibiotic use in Massachusetts children, 2000–2009. Pediatrics 2012 Jul;
17. Dehydration in
children with diabetic ketoacidosis: a prospective study.
Sottosanti M, et al. Arch Dis Child. 2012 Feb;97(2):96-100.
OBJECTIVES: To investigate the association between the
degree of patient dehydration on presentation with diabetic ketoacidosis (DKA)
and clinical and laboratory parameters obtained on admission.
DESIGN: Prospective descriptive study.
SETTING: A tertiary care children's hospital.
PATIENTS: Thirty-nine paediatric patients (1 month-16 years)
presenting with 42 episodes of DKA.
INTERVENTION: Clinical and biochemical variables were
collected on admission. Dehydration was calculated by measuring acute changes
in body weight during the period of illness. All patients were treated
according to a previously established protocol.
MAIN OUTCOME MEASURES: Magnitude of dehydration, defined as
% loss of body weight (LBW), was determined by the difference in body weight
obtained at presentation and at discharge. The relationship between the
magnitude of dehydration and the clinical assessment and biochemical parameters
RESULTS: The median (25th-75th centiles) magnitude of
dehydration at presentation was 5.7% (3.8-8.3%) (mean ± SD 6.8 ± 5%). Neither
the initial clinical assessment nor the comprehensive biochemical profile at
admission correlated with the magnitude of dehydration. Despite considerable
variation in the degree of dehydration and biochemical disequilibrium, all
patients recovered from DKA within 24 h with a standardised therapeutic
approach. Furthermore, the rapidity of patient recovery did not correlate with
the magnitude of dehydration on presentation or the amount of fluid
administered (median (25th-75th centiles) 48.8 ml/kg (38.5-60.3)) in the first
CONCLUSION: The magnitude of dehydration in DKA is not
reflected by either clinical or biochemical parameters. These findings need
confirmation in larger studies.
pain management protocol reduces children's memory of pain at discharge from the
Crocker PJ, et al. Amer J Emerg Med. 30:861-871.
Background: Historically, pain has been poorly managed in
the pediatric emergency department (ED) (PED), resulting in measurable
psychosocial issues both acute and delayed.
Objective: The aim of the study was to measure the impact of
protocolized pain management on patients with painful conditions or undergoing
painful procedures in the PED.
Methods: We performed an analysis before and after the
implementation of the protocol, dubbed the “Comfort Zone.” Validated,
age-appropriate pain scales were performed. Validation (using Cronbach α,
confirmatory factor analysis) was followed by comparison of responses between
the pre- and posttests collected (χ2 and Wilcoxon rank sum tests). Pain scores
were collected at triage and at discharge. At triage, patients were asked to
report pain levels. At discharge, they were asked to report their current pain
and recall the level of pain during their stay. At triage, parents were asked
to report about their perception of the child's pain. At discharge, they were
asked to report about their perception of the child's current pain and recall
the level of pain during the stay and during procedures, if done.
Results: Five hundred thirty-one patients were enrolled in
the preprotocol group; 47% were women with a median age of 5 years (range, 30
days-18 years). Two hundred sixty-three patients were enrolled in the protocol
group; 39% were women with a median age of 6 years (range, 30 days-18 years).
Patient-recalled pain scores of the ED visit in the protocol group were
significantly lower than those of the preprotocol group (Wong-Baker Faces Pain
Scale, 5.07-4.01; P < .001); yet parent estimates of pain did not show a
significant change at any point. Patient assessment of pain at ED discharge did
not show a significant change either (Wong-Baker Faces Pain Scale, 1.99-1.56; P
= .09). The Faces scale is not well validated for patients younger than 4, so
that group had only parental assessment of pain and, consistent with the larger
data set, showed no significant pain scale reduction at any point.
Conclusion: Protocolized pain management reduces patients'
memory of pain during PED visits but may not affect parental memory of
perceived pain or parent- and patient-reported pain at discharge.
19. A Simple Score
Predicts Aortic Injury in Patients with Blunt Chest Trauma
A score based on seven physical exam and chest x-ray
findings had high sensitivity for aortic injury.
Mosquera VX, et al. Traumatic aortic injury score (TRAINS):
an easy and simple score for early detection of traumatic aortic injuries in
major trauma patients with associated blunt chest trauma.
Intensive Care Med. 2012 May 23. [Epub ahead of print].
PURPOSE: To develop a risk score based on physical examination
and chest X-ray findings to rapidly identify major trauma patients at risk of
acute traumatic aortic injury (ATAI).
METHODS: A multicenter retrospective study was conducted
with 640 major trauma patients with associated blunt chest trauma classified
into ATAI (aortic injury) and NATAI (no aortic injury) groups. The score data
set included 76 consecutive ATAI and 304 NATAI patients from a single center,
whereas the validation data set included 52 consecutive ATAI and 208 NATAI
patients from three independent institutions. Bivariate analysis identified
variables potentially influencing the presentation of aortic injury. Confirmed
variables by logistic regression were assigned a score according to their
corresponding beta coefficient which was rounded to the closest integer value
RESULTS: Predictors of aortic injury included widened
mediastinum, hypotension less than 90 mmHg, long bone fracture, pulmonary
contusion, left scapula fracture, hemothorax, and pelvic fracture. Area under
receiver operating characteristic curve was 0.96. In the score data set,
sensitivity was 93.42 %, specificity 85.85 %, Youden's index 0.79, positive
likelihood ratio 6.60, and negative likelihood ratio 0.08. In the validation
data set, sensitivity was 92.31 % and specificity 85.1 %.
CONCLUSIONS: Given the relative infrequency of traumatic
aortic injury, which often leads to missed or delayed diagnosis, application of
our score has the potential to draw necessary clinical attention to the
possibility of aortic injury, thus providing the chance of a prompt specific
diagnostic and therapeutic management.
20. CT without Oral
Contrast Saves Time, Maintains Quality
James Brice, Medscape Medical News. July 6, 2012 — An
emergency department (ED) strategy that eliminates the routine use of oral
contrast for abdominal-pelvic (AP) computed tomography (CT) for
undifferentiated abdominal pain can reduce ED length of stay (LOS) without
compromising diagnostic accuracy.
Robin B. Levenson, MD, and colleagues from the Emergency
Radiology Division of Beth Israel Deaconess Medical Center, Boston,
Massachusetts, found the rescan rate with oral contrast was modest after the
staff stopped routinely administering oral contrast for these procedures. Their
findings were drawn from the clinical experience with a cohort of 1014
consecutive ED patients who underwent AP CT with oral contrast compared with
that of a subsequent group of 987 patients who had AP CT without oral contrast.
The study found additional CT scans with oral contrast
rarely affected the results of the initial reading in any case. In patients
admitted to the hospital, additional abdominal pelvic imaging during their stay
did not alter their diagnosis.
Dr. Levenson and colleagues found no statistically
significant difference in the rate of return to the ED in the 72 hours after
discharge for patients who underwent CT without oral contrast compared with
those who had conventional AP CT with contrast.
Oral CT contrast administration adds time to ED visits,
noted Dr. Levenson and colleagues in the study, published online June 29 in
Emergency Radiology. Multidetector CT is delayed 60 to 90 minutes to allow oral
contrast to opacify the bowel.
Several studies have demonstrated that AP CT without oral
contrast leads to accurate evaluations of abdominal pain, especially for
suspected acute appendicitis. The Beth Israel Deaconess group sought to assess
the effect of AP CT without oral contrast on ED LOS.
The current researchers showed, as hypothesized, that the
routine use of oral contrast for AP CT was not necessary for patients with
nontraumatic, undifferentiated abdominal pain.
Oral contrast was still ordered, however, for patients with
a known history of inflammatory bowel disease, gastrointestinal tract–altering
surgery, or extremely lean body habitus, Dr. Levenson and colleagues write.
The study did not consider patients with symptoms that have
not traditionally led to oral contrast before AP CT. Indications excluding
patients from the study were trauma, a suspected genitourinary stone,
hemodynamic instability, suspected mesenteric ischemia, retroperitoneal
hematoma, aortic rupture/dissection, and suspected pulmonary embolism.
Before the protocol change, 95% of patients eligible for
oral contrast received it before AP CT. Afterward, the proportion dropped to a
statistically significant 42% (P < .001). ED LOS was cut by a mean of 97.7
minutes (P < .001), and the time between an order for CT and the actual
procedure fell by 66.2 minutes (P < .001).
"As our study demonstrates, elimination of routine oral
contrast used in the ED for patients eligible for oral contrast may lead to
decrease in patient time from CT ordered to CT performed and in mean ED
LOS," the authors write.
In terms of diagnostic quality, no patient had repeat CT
with oral contrast during the initial ED episode or a 72-hour return visit to
the ED that resulted in a change in CT diagnosis.
Study limitations include the retrospective design, lack of
follow-up to verify accuracy of diagnoses, inability to assess whether
discharged patients presented to a different hospital, and radiologic
assessment by only 1 attending radiologist.
The authors note that Beth Israel Deaconess continues to
administer oral contrast before AP CT for patients who have a history of
gastrointestinal tract–altering surgery or inflammatory bowel disease or who
are subjectively thin. More study and analysis are needed before CT without
oral contrast can be justified for these patients, the authors write.
The published study did not include a statement that would
have identified any potential conflicts of interests among the investigators.
21. The Growing Role
of EDs in Hospital Admissions
Schuur JD, et al. New Engl J Med. July 11, 2012
Growing use of U.S. emergency departments (EDs), cited as a
key contributor to rising health care costs, has become a leading target of
health care reform. ED visit rates increased by more than a third between 1997
and 2007, and EDs are increasingly the safety net for underserved patients,
particularly adult Medicaid beneficiaries.1 Although much attention has been
paid to increasing ED use, the ED's changing role in our health care system has
been less thoroughly examined. EDs serve as a hub for prehospital emergency
medical systems, an acute diagnostic and treatment center, a primary safety
net, and a 24/7 portal for rapid inpatient admission. Approximately a quarter
of all acute care outpatient visits in the United States occur in EDs, a
proportion that has been growing since 2001.2 We examined the proportion of
hospital admissions that come through the ED, hypothesizing that use of the ED
as the admission portal had increased across conditions.
We analyzed data from the Nationwide Inpatient Sample (NIS),
the largest all-payer database of U.S. inpatient care, from 1993 to 2006 (the
most recent year for which the ED admission data are available on HCUPnet, an
interactive Web-based tool that uses data from the Healthcare Cost and
Utilization Project of the Agency for Healthcare Research and Quality). The NIS
contains data from approximately 8 million hospital stays each year and is
weighted to produce national estimates. We used HCUPnet to query the NIS
regarding trends in the 20 clinical conditions for which patients were most
frequently admitted to the hospital in 2006. Clinical Classifications Software
was used to group the conditions into clinically meaningful categories. We
excluded two conditions for which patients are rarely admitted through the ED
(osteoarthritis and back problems), one psychiatric condition that was not
consistently coded in claims data (affective disorder), and four obstetrical
diagnoses that are generally evaluated in other care settings, such as
labor-and-delivery triage areas (liveborn infant, maternal birth trauma, other
complications of birth, other complications of pregnancy).
The number of hospital admissions increased by 15.0%, from
34.3 million in 1993 to 39.5 million in 2006; admissions from the ED increased
by 50.4%, from 11.5 million to 17.3 million. The proportion of all inpatient
stays involving admission from the ED increased from 33.5 to 43.8%
(P<0.001). In 12 of the 13 conditions for which patients were most
frequently admitted and that met our inclusion criteria, an increased
proportion of admitted patients came through the ED (P<0.001), regardless of
the trend in overall admissions; the exception was coronary atherosclerosis,
for which rapid “rule-out” protocols and ED-based chest-pain observation units
have reduced the need for inpatient admission. (For details on the 12
conditions, see the Supplementary Appendix, available with the full text of
this article at NEJM.org.) The graphProportion of U.S. Hospitalizations in
Which Patient Was Admitted through the Emergency Department, 1993–2006. shows
the trend in admissions from the ED for conditions that the Centers for
Medicare and Medicaid Services includes in assessments of 30-day readmission
and mortality rates.
Historically, clinically stable patients with acute problems
who required hospital care for conditions such as community-acquired pneumonia
would see an outpatient provider and be directly admitted from the physician's
office. Our findings show that since 1993, EDs have played an increasing role
in admissions for almost all conditions.
There are several possible explanations of this growing
role. One frequently cited hypothesis is that overuse of the ED for conditions
that would more appropriately be treated in primary care providers' offices
could lead to increased admission rates — either because reduced access to
primary care leads to worsening of patients' conditions and greater need for
emergency hospitalization or because emergency physicians are more likely than
primary care providers to admit patients to the hospital. The latter theory is
based in part on assumptions that emergency physicians are trained to assume
the worst and are more likely to admit patients with uncertain diagnoses and
with whom they don't have an ongoing relationship, and that they are unwilling
to discharge patients when they cannot guarantee outpatient follow-up.3
Alternatively, the trend could be driven by changes in the
organization of medical services that favor the rapid diagnostic technologies
and early treatment available in the ED. As diagnostic services have improved
(with the introduction of such tools as computed tomographic scanning and
troponin testing) and expectations of rapid and accurate diagnosis and
treatment have become standard (e.g., percutaneous coronary intervention for
ST-segment–elevation myocardial infarction), the evaluation of common symptoms
such as chest pain, abdominal pain, and shortness of breath has become de facto
reasons for ED referral. Public education campaigns emphasizing the importance
of early emergency care for symptoms suggestive of heart attack or stroke have
encouraged this approach.
In addition, primary care providers are less likely than EDs
to provide regular access for unscheduled acute care — and therefore less
likely to admit patients to the hospital. A large national survey and observational
studies have found that it is difficult for patients to arrange a sick visit
with a primary care provider in a timely fashion, because schedules are often
full, after-hours service is unavailable, and many acute problems are not well
suited to office practices lacking basic laboratory and imaging capabilities.4
As hospitals strive for administrative efficiency by maximizing occupancy
rates, it becomes more difficult for outpatient providers to admit patients
directly to the hospital. Yet since such hospitals' practices have largely been
reactive, it is unclear whether this trend reflects high-value use of limited
emergency care resources and whether it has resulted in more or less
appropriate use of scarce inpatient beds.
This increasing use of EDs for inpatient admissions has
important implications for the redesign of delivery systems. The need for more
efficient use of inpatient resources is a clear focus of the Affordable Care
Act (ACA), and the increased role of EDs in inpatient admissions will affect
the implementation of central ACA principles, such as quality measurement, care
coordination, and payment reform. Yet policymakers seem to view EDs as little
more than a locus of inefficient or unnecessary care — the place where patients
without access or insurance seek care at great expense to taxpayers. This
popular view fails to address the ED's increasingly important role in hospital
admissions, and it is not supported by the data.5
EDs' growing role in hospital admissions is a clue to their
critical role in the health care system. Rigorous research to identify drivers
of this trend and determine the value or cost of emergency care is needed to
inform health policy. For example, comparative effectiveness studies on
admission from the ED versus direct admission can evaluate whether early access
to diagnostic and therapeutic services improves outcomes while shortening
lengths of stay. Similarly, studies of conditions that are ideally evaluated in
the ED, such as chest pain, must demonstrate the ability of evidence-based
rapid diagnostic pathways to safely stratify patients according to risk level
and reduce admissions rates.
Should we return to having primary care providers initiate
and direct hospital admissions? Because of the increasingly specialized nature
of patient care, our systems have evolved into separate arenas of
hospital-based and ambulatory care provided by clinicians with different types
of training. As reimbursement models shift from providing incentives for
admissions as a hospital's revenue source to providing incentives for reducing
admissions, EDs will probably reduce their use of hospital admission. Yet the
ACA's expansion of insurance coverage, the reality of an aging population with
complex conditions, and the expectation of timely, specialized, and coordinated
care mean that the trend toward increasing percentages of ED admissions is
unlikely to be reversed. New models of acute care delivery aiming to improve
the use of scarce intensive, hospital-based services should take into account
this change in patient and provider expectations.