Friday, July 27, 2012

Lit Bits: July 27, 2012

From the recent medical literature...

1. Evolving Considerations in the Management of Patients with Left BBB and Suspected MI 

Neeland IJ, et al. J Amer Coll Cardiol 2012 Jul 10;60(2):96-105. 

Patients with a suspected acute coronary syndrome and left bundle branch block (LBBB) present a unique diagnostic and therapeutic challenge to the clinician. Although current guidelines recommend that patients with new or presumed new LBBB undergo early reperfusion therapy, data suggest that only a minority of patients with LBBB are ultimately diagnosed with acute myocardial infarction, regardless of LBBB chronicity, and that a significant proportion of patients will not have an occluded culprit artery at cardiac catheterization.  

The current treatment approach exposes a significant proportion of patients to the risks of fibrinolytic therapy without the likelihood of significant benefit and leads to increased rates of false-positive cardiac catheterization laboratory activation, unnecessary risks, and costs. Therefore, alternative strategies to those for patients with ST-segment elevation myocardial infarction are needed to guide selection of appropriate patients with a suspected acute coronary syndrome and LBBB for urgent reperfusion therapy. In this article, we describe the evolving epidemiology of LBBB in acute coronary syndromes and discuss controversies related to current clinical practice. We propose a more judicious diagnostic approach among clinically stable patients with LBBB who do not have electrocardiographic findings highly specific for ST-segment elevation myocardial infarction. 

2. Poor Prognosis in Warfarin-Associated Intracranial Hemorrhage despite Anticoagulation Reversal 

Dowlatshahi D, et al. Stroke 2012;43:1812-1817. 

Background and Purpose Anticoagulant-associated intracranial hemorrhage (aaICH) presents with larger hematoma volumes, higher risk of hematoma expansion, and worse outcome than spontaneous intracranial hemorrhage. Prothrombin complex concentrates (PCCs) are indicated for urgent reversal of anticoagulation after aaICH. Given the lack of randomized controlled trial evidence of efficacy, and the potential for thrombotic complications, we aimed to determine outcomes in patients with aaICH treated with PCC.  

Methods We conducted a prospective multicenter registry of patients treated with PCC for aaICH in Canada. Patients were identified by local blood banks after the release of PCC. A chart review abstracted clinical, imaging, and laboratory data, including thrombotic events after therapy. Hematoma volumes were measured on brain CT scans and primary outcomes were modified Rankin Scale at discharge and in-hospital mortality.  

Results Between 2008 and 2010, 141 patients received PCC for aaICH (71 intraparenchymal hemorrhages). The median age was 78 years (interquartile range, 14), 59.6% were male, and median Glasgow Coma Scale was 14. Median international normalized ratio was 2.6 (interquartile range, 2.0) and median parenchymal hematoma volume was 15.8 mL (interquartile range, 31.8). Median post-PCC therapy international normalized ratio was 1.4: 79.5% of patients had international normalized ratio correction (<1.5) within 1 hour of PCC therapy. Patients with intraparenchymal hemorrhage had an in-hospital mortality rate of 42.3% with median modified Rankin Scale of 5. Significant hematoma expansion occurred in 45.5%. There were 3 confirmed thrombotic complications within 7 days of PCC therapy.  

Conclusions PCC therapy rapidly corrected international normalized ratio in the majority of patients, yet mortality and morbidity rates remained high. Rapid international normalized ratio correction alone may not be sufficient to alter prognosis after aaICH. 

3. Adapted PECARN Head Injury Rule Is Safe and Effective 

A modified PECARN head injury rule had good staff adherence and identified all patients with clinically important brain injuries. 

Bressan S, et al. Acad Emerg Med 2012;19:801-807. 

Objectives:  Of the currently published clinical decision rules for the management of minor head injury (MHI) in children, the Pediatric Emergency Care Applied Research Network (PECARN) rule, derived and validated in a large multicenter prospective study cohort, with high methodologic standards, appears to be the best clinical decision rule to accurately identify children at very low risk of clinically important traumatic brain injuries (ciTBI) in the pediatric emergency department (PED). This study describes the implementation of an adapted version of the PECARN rule in a tertiary care academic PED in Italy and evaluates implementation success, in terms of medical staff adherence and satisfaction, as well as its effects on clinical practice. 

Methods:  The adapted PECARN decision rule algorithms for children (one for those younger than 2 years and one for those older than 2 years) were actively implemented in the PED of Padova, Italy, for a 6-month testing period. Adherence and satisfaction of medical staff to the new rule were calculated. Data from 356 visits for MHI during PECARN rule implementation and those of 288 patients attending the PED for MHI in the previous 6 months were compared for changes in computed tomography (CT) scan rate, ciTBI rate (defined as death, neurosurgery, intubation for longer than 24 hours, or hospital admission at least for two nights associated with TBI) and return visits for symptoms or signs potentially related to MHI. The safety and efficacy of the adapted PECARN rule in clinical practice were also calculated. 

Results:  Adherence to the adapted PECARN rule was 93.5%. The percentage of medical staff satisfied with the new rule, in terms of usefulness and ease of use for rapid decision-making, was significantly higher (96% vs. 51%, p < 0.0001) compared to the previous, more complex, internal guideline. CT scan was performed in 30 patients (8.4%, 95% confidence interval [CI] = 6% to 11.8%) in the implementation period versus 21 patients (7.3%, 95% CI = 4.8% to 10.9%) before implementation. A ciTBI occurred in three children (0.8%, 95% CI = 0.3 to 2.5) during the implementation period and in two children (0.7%, 95% CI = 0.2 to 2.5) in the prior 6 months. There were five return visits (1.4%) postimplementation and seven (2.4%) before implementation (p = 0.506). The safety of use of the adapted PECARN rule in clinical practice was 100% (95% CI = 36.8 to 100; three of three patients with ciTBI who received CT scan at first evaluation), while efficacy was 92.3% (95% CI = 89 to 95; 326 of 353 patients without ciTBI who did not receive a CT scan). 

Conclusions:  The adapted PECARN rule was successfully implemented in an Italian tertiary care academic PED, achieving high adherence and satisfaction of medical staff. Its use determined a low CT scan rate that was unchanged compared to previous clinical practice and showed an optimal safety and high efficacy profile. Strict monitoring is mandatory to evaluate the long-lasting benefit in patient care and/or resource utilization. 

4. Coronary CT Speeds Triage of Chest Pain, Yet… 

By Crystal Phend, Senior Staff Writer, MedPage Today. Published: July 25, 2012 

Action Points 

·         A coronary CT angiography scan early in the course of chest pain evaluation safely speeds emergency department discharge for low-to-intermediate-risk patients.

·         Note that although early coronary CT angiography didn't alter mean cost of care, it did increase further diagnostic testing and radiation exposure. 

A coronary CT angiography scan early in the course of chest pain evaluation safely speeds emergency department discharge for low-to-intermediate-risk patients, a randomized trial showed. 

The strategy cut hospital length of stay by a mean 7.6 hours compared with standard evaluation (23 versus 31 hours, P<0.001), and didn't result in any missed acute coronary syndromes, Udo Hoffmann, MD, MPH, of Massachusetts General Hospital in Boston, and colleagues found. 

Although early coronary CT angiography didn't alter mean cost of care, at $4,289 versus $4,060 (P=0.65), it did increase further diagnostic testing and radiation exposure, they reported in the July 26 issue of the New England Journal of Medicine. 

These ROMICAT-II trial findings matched those reported in March at the American College of Cardiology meeting. 

Two other studies reported over the past year have also supported coronary CT for lower-risk patients in the emergency department:
·         ACRIN PA showing earlier discharge and no events compared with usual evaluation
·         CT STAT showing faster discharge with no increase in major adverse cardiac events compared with SPECT myocardial perfusion imaging  

These results are important given the pressures on emergency departments, J. Jeffrey Marshall, MD, of the Northeast Georgia Heart Center in Atlanta and president of the Society for Cardiovascular Angiography and Interventions, commented in an interview with MedPage Today. 

"The doctors on the front lines have very little time to sift through a thousand patients to find the eight that have heart disease that could kill them," he said. "Our emergency rooms are flooded, overrunning with people. In the real world, you're going to have to do tests on these patients." 

However, an editorial accompanying the NEJM paper challenged that perspective. "In short, the question is not which test leads to faster discharge of patients from the emergency department, but whether a test is needed at all," Rita F. Redberg, MD, of the University of California San Francisco, wrote. 

There is no evidence that CT angiography or any other test improves outcomes for low-to-intermediate-risk patients, she argued, citing the Choosing Wisely campaign against unnecessary testing. 

In ROMICAT-II, the rate of acute coronary syndromes was 8% among the 1,000 patients presenting to the emergency department with a possible ACS but no ischemic signs on electrocardiography and an initial negative troponin test. 

Randomization to early coronary CT imaging didn't significantly impact major adverse cardiac event rates over 28-day follow-up compared with standard evaluation (exercise, echocardiography, or SPECT at physician's discretion) in the emergency department. 

Four myocardial infarctions and two cases of unstable angina pectoris requiring stenting occurred in the standard evaluation group compared with one MI and one case of unstable angina requiring stenting (P=0.18). 

Those low rates made it impossible to tell whether the CT angiography group got any benefit from the early imaging in terms of preventing events by treating disease found on the imaging, Redberg noted. 

Marshall agreed that the study was probably too small to have found a significant difference in rates in the safety analysis but called the threefold difference meaningful on a population scale. 

While the benefits were arguable, the risks were clear. 

Cumulative radiation exposure was nearly tripled in the early CT angiography group, at a mean of 14 mSv versus 5 mSv in the standard group (P<0.001). Redberg noted that 10 mSv of radiation would kill one patient from cancer in every 2,000 exposed. 

Another downside was more downstream diagnostic and functional testing in the early coronary CT imaging group (both P<0.001). 

While Marshall noted that more tests are not always a bad thing, Redberg cited risk of serious complications and added the risk of nephrotoxicity and adverse reactions from the CT contrast dye to the list. 

"The decision regarding the need for diagnostic testing in these patients usually can be safely deferred to outpatient follow-up within a few weeks after the visit to the emergency department," she concluded. "I believe judicious clinical follow-up is safer and in the best interests of the majority of these patients." 

Regardless, the trial is unlikely to substantially boost early CT use in emergency departments around the country, Marshall predicted. 

"I don't actually think many places will take all comers and put them in CT scanners," he told MedPage Today, suggesting that use would be limited to the population with some risk factors and histories that are difficult to untangle. 

The study was supported by grants from the National Heart, Lung, and Blood Institute and the National Institutes of Health. Hoffmann reported receiving grant support from the American College of Radiology Imaging Network, Bracco Diagnostics, Genentech, and Siemens Healthcare on behalf of his institution. Redberg reported being a member of the coronary angiography assessment forum as a part of the FDA cardiovascular expert device panel. Marshall reported having no conflicts of interest to disclose. 

Hoffmann U, et al. N Engl J Med 2012; 367:299-308. Study abstract:  

Redberg RF. N Engl J Med 2012;367:375-376. Editorial (subscription only):  

From the American Heart Association: 2010 Expert Consensus Document on Coronary CT Angiography. Full-text (free):  

5. A Novel Approach to Identifying Targets for Cost Reduction in the Emergency Department. 

Smulowitz PB, et al. Ann Emerg Med. 2012 Jul 12. [Epub ahead of print] 

This article introduces a novel framework that classifies emergency department (ED) visits according to broad categories of severity, identifying those categories of visits that present the most potential for reducing costs associated with the ED. Although cost savings directly attributable to the ED are apt to be an important emphasis of organizations operating under reformed payment systems, our framework suggests that a focus on diverting low-acuity visits away from the ED would result in far less savings compared with strategies aimed at reducing admissions and to a lesser extent improving the efficiency of ED care for intermediate or complex conditions. We conclude that targeting these categories, rather than minor injuries/illnesses, should be the primary focus of cost-reduction strategies from the ED. Given this understanding, we then discuss the implications of these findings on the financing of an emergency care system that needs to account for the required fixed costs of "stand-by capacity" of the ED and explore ways in which the ED can be better integrated into a patient-centered health care system. 

Associated Medscape Essay:  

6. Challenges in Clinical Electrocardiography 

ECG Findings in a Young Man With Tachycardia and Hypotension  

Parikh VN, et al. Arch Intern Med. 2012;():1-1. doi:10.1001/archinternmed.2012.2727

A 25-year-old man presented to the emergency department complaining of shortness of breath, cough, and malaise, which had progressed over the preceding several weeks. He had a 7-year history of daily methamphetamine use. He had presented to the emergency department 3 times in the previous month complaining of similar symptoms and had been discharged with treatment for an upper respiratory infection; there was no evidence of hemodynamic instability. At this presentation, however, his blood pressure was 95/60 mm Hg, his heart rate was 114 beats/min, and his oxygen saturation was 98% on room air..

Physical examination revealed a jugular venous pressure of 15 cm H2O, bilateral pulmonary rales, an inferolaterally displaced point of maximal impulse, and an S3 gallop, all of which were new findings compared with those of previous examinations. A chest x-ray film revealed bibasilar pulmonary infiltrates, consistent with pulmonary edema, and an enlarged cardiac silhouette. An electrocardiogram (ECG) was obtained (Figure 1). 

Questions: What are the critical findings on this ECG and what is the cause? 

For the rest of the article, including ECG tracings, link here: For the answer, link here:   

7. A Clinical Decision Rule to Identify Infants with Apparent Life-Threatening Event Who Can Be Safely Discharged From the ED 

Mittal M, et al. Pediatr Emerg Care 2012;28:599-605.  

Objective: This study aimed to formulate a clinical decision rule (CDR) to identify infants with apparent-life threatening event (ALTE) who are at low risk of adverse outcome and can be discharged home safely from the emergency department (ED). 

Methods: This is a prospective cohort study of infants with an ED diagnosis of ALTE at an urban children’s hospital. Admission was considered warranted if the infant required significant intervention during the hospital stay. Logistic regression and recursive partitioning were used to develop a CDR identifying patients at low risk of significant intervention and thus suitable for discharge from the ED. 

Results: A total of 300 infants were enrolled; 228 (76%) were admitted; 37 (12%) required significant intervention. None died during hospital stay or within 72 hours of discharge or were diagnosed with serious bacterial infection. Logistic regression identified prematurity, abnormal result in the physical examination, color change to cyanosis, absence of symptoms of upper respiratory tract infection, and absence of choking as predictors for significant intervention. These variables were used to create a CDR, based on which, 184 infants (64%) could be discharged home safely from the ED, reducing the hospitalization rate to 102 (36%). The model has a negative predictive value of 96.2% (92%–98.3%). 

Conclusions: Only 12% of infants presenting to the ED with ALTE had a significant intervention warranting hospital admission. We created a CDR that would have decreased the admission rate safely by 40%. 

8. Therapy and outcomes in massive pulmonary embolism 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. 

9. Smartphones May Aid Eye Diagnoses in the ED 

Lamirel C, et al. Arch Ophthalmol. 2012;130(7):939-940. 

If smartphones can be used to transit successfully fundoscopic images (what emergency physicians are able to take those images??), imagine what other images could be routed to specialists. 

By Genevra Pittman. NEW YORK (Reuters Health) Jul 11 - Sending patient images to ophthalmologists via smartphone may be an option for emergency [physicians] looking to make a quick eye-related diagnosis, a new study suggests. 

Two ophthalmologists gave higher quality ratings to inner-eye photos when they looked at the images on an iPhone as compared to a desktop computer, according to results published online Monday in the Archives of Ophthalmology. 

That may mean the phones can be used to diagnose and plan treatment for more obvious eye conditions -- even when an ophthalmologist isn't available at the hospital, researchers noted. 

"Not every hospital in the country in the ER has access to an eye doctor always," said Dr. Rohit Krishna, an ophthalmologist from the University of Missouri-Kansas City School of Medicine, who wasn't involved in the new study. 

Non-eye doctors, Dr. Krishna added, "don't always feel really comfortable with eye care. So having tools in your pocket that enable you to do ophthalmologic examination elements are a great asset." 

He said smartphones could be used to take and send pictures of damage to the eyelid or the front of the eye. When it comes to complicated, inner-eye photos, using a more advanced camera to take a photo -- and then sending it to an ophthalmologist via smartphone for diagnosis -- is also a good option, he told Reuters Health. 

For the new study, Dr. Valerie Biousse from Emory University in Atlanta and her colleagues collected information on 350 patients with a headache, changes in eyesight and other signs of vision problems who came to the ER for treatment. Emergency staff took photos of the interior of their eyes, including the retina, using an ocular camera. 

Two ophthalmologists looked at those photos and rated their quality on a typical desktop computer, and later assessed 100 of the images on an iPhone. 

Both reviewers consistently rated the phone images as the same or higher quality on a one-to-five scale than the same photos viewed on the computer. 

One ophthalmologist said 53 of the photos were the same quality, 46 were better on an iPhone and one was better on the desktop. The other ophthalmologist rated the photos equally 56 times, the iPhone images better 42 times and chose the desktop photos twice. 

Consulting electronically with an ophthalmologist can give ER staff a better idea of what a patient's prognosis will be, Dr. Krishna said, as well as the severity of the eye injury. 

"Using (an) iPhone to transmit images to colleagues as a help with patient triage in the ER is a new concept," Dr. Biousse told Reuters Health in an email. 

"ER departments are working at improving acute patient care by developing ways to access specialty consultations such as ophthalmology." 

The next step, Dr. Biousse said, is to show whether or not "the triage and acute patient care are expedited and ophthalmologic consultations can be obtained faster and more accurately" when photos are sent from the ER to an ophthalmologist's smartphone. 

Dr. Charles Wykoff, an ophthalmologist from Retina Consultants of Houston, said his one worry would be doctors using smartphone pictures to rule out all eye problems and then having a patient sent home. 

"The concern for me is possibly false reassurance when there's a normal picture," he told Reuters Health. "I don't think it replaces the need for a complete eye exam." 

But if using a smartphone does help ER patients get faster and accurate diagnoses, Dr. Wykoff, who wasn't involved in the new study, said he'd be all for it. 

10. Adult Intussusception: Presentation, Management, and Outcomes of 148 Patients 

Lindor RA, et al. J Emerg Med 2012;43:1-6.  

Background: Intussusception is a predominantly pediatric diagnosis that is not well characterized among adults. Undiagnosed cases can result in significant morbidity, making early recognition important for clinicians. 

Study Objectives: We describe the presentation, clinical management, disposition, and outcome of adult patients diagnosed with intussusception during a 13-year period. 

Methods: A retrospective study of consecutive adult patients diagnosed with intussusception at a tertiary academic center was carried out from 1996 to 2008. Cases were identified using International Classification of Diseases, 9th Revision codes and a document search engine. Data were abstracted in duplicate by two independent authors. 

Results: Among 148 patients included in the study, the most common symptoms at presentation were abdominal pain (72%), nausea (49%), and vomiting (36%). Twenty percent were asymptomatic. Sixty percent of cases had an identifiable lead point. Patients presenting to the emergency department (ED) (31%) had higher rates of abdominal pain (relative risk [RR] 5.7) and vomiting (RR 3.4), and were more likely to undergo surgical intervention (RR 1.8) than patients diagnosed elsewhere. There were 77 patients who underwent surgery within 1 month; patients presenting with abdominal pain (RR 2.2), nausea (RR 1.7), vomiting (RR 1.4), and bloody stool (RR 1.9) were more likely to undergo surgery. 

Conclusions: Adult intussusception commonly presents with abdominal pain, nausea, and vomiting; however, approximately 20% of cases are asymptomatic and seem to be diagnosed by incidental radiologic findings. Patients presenting to an ED with intussusception due to a mass as a lead point or in an ileocolonic location are likely to undergo surgical intervention. 

11. Images in Clinical Medicine

A Scalp Nevus


Traumatic Abducens Nerve Palsy

Denervation Atrophy of the Tongue after Hypoglossal-Nerve Injury

Man with Nausea and Vomiting

Young Man with Left Thoracic Pain

12. Does This Fracture Need to Be Reduced? ED management of distal radial fractures in children

by Karen Serrano, MD on July 20, 2012. Emergency Physicians Monthly 

Distal radial fractures are among the most common fractures in childhood, and are a frequent presenting complaint in the emergency department. Traditionally, ED management of displaced distal radial fractures in children has included closed reduction and splinting of displaced fractures, usually under sedation. While generally safe when proper monitoring is used, procedural sedation nonetheless carries risks of respiratory depression, hypoxia, hypotension, vomiting, and emergence reactions.1 In addition, procedural sedation is time- and labor-intensive, resulting in longer lengths of stay for patients and sequestering physicians and nursing staff away from seeing other patients, which can backlog even the most efficiently run ED. Therefore if a fracture can be managed effectively without procedural sedation, it would be welcome news both for patients and busy emergency departments everywhere. 

Data suggests that many displaced and angulated distal radial fractures in children do not require anatomic reduction to achieve good outcomes. Children have tremendous remodeling potential in their bones, with younger age and proximity to growth plates corresponding to greater degree of remodeling. Because growth plates begin to close at puberty, young children with more years of bone growth ahead of them exhibit greater remodeling potential than do older children. In addition, the distal forearm is a particularly “forgiving” area for fractures, and greater degrees of displacement and angulation can be tolerated. This is due to its proximity to the highly biologically active growth plates of the distal radius and ulna, which are responsible for 75% and 81% of the longitudinal growth of each bone, respectively.2… 

For the remainder of the essay, along with images and references, link here:  

13. Do Low-dose Corticosteroids Improve Mortality or Shock Reversal in Patients with Septic Shock? A Systematic Review and Position Statement Prepared for the AAEM 

Sherwin RL, et al. J Emerg Med 2012;43:7-12. 

Background: The management of septic shock has undergone a significant evolution in the past decade. A number of trials have been published to evaluate the efficacy of low-dose corticosteroid administration in patients with septic shock. 

Methods: The Sepsis Sub-committee of the American Academy of Emergency Medicine Clinical Practice Committee performed an extensive search of the contemporary literature and identified seven relevant trials. 

Results: Six of the seven trials reported a mortality outcome of patients in septic shock. Analysis of the data revealed that the relative risk (RR) of 28-day all-cause mortality in septic shock patients who received low-dose corticosteroids was 0.92 (95% confidence interval [CI] 0.79–1.07). All seven trials reported data concerning shock reversal or the withdrawal of vasopressors. Pooled results revealed that the RR of shock reversal is 1.17 (95% CI 1.07–1.28), which suggests that there may be significant improvement in shock reversal after corticosteroid administration. It is important to understand that two of the seven studies reviewed were disproportionately represented and accounted for 799 of 1005 patients (80%) considered for this recommendation. 

Conclusions: The evidence suggests that low-dose corticosteroids may reverse shock faster; however, mortality is not improved for the overall population. 

14. Stroke Mimics and Intravenous Thrombolysis (Maybe Not So Safe) 

Durston W. Ann Emerg Med. 2012;60:246. 

To the Editor: 

In their report on stroke mimics and intravenous thrombolysis, Artto et al1 conclude that patients with stroke mimics were infrequent in their study and that none of the 14 patients with diagnoses of stroke mimic was harmed by receiving tissue plasminogen activator (tPA).1 They acknowledge a potential bias in their study, though, toward misclassifying stroke mimics as actual strokes, noting that “…the diagnosis might have been biased toward ischemic stroke because making an alternative diagnosis after applying intravenous thrombolysis may have been difficult.” Artto et al1 state in the introduction to their article that 5 other small studies, including a total of 145 stroke mimic cases treated with tPA, also reported no symptomatic intracranial hemorrhage in such patients. Artto et al1 fail to note, though, that the other 5 studies also used the same retrospective methodology and are subject to the same bias toward misclassifying stroke mimics as actual strokes. Such a bias is even more likely in patients who develop intracranial hemorrhage after receiving tPA. As difficult as it might be to recognize and acknowledge that a patient who improves after receiving tPA actually had a stroke mimic, it is undoubtedly more difficult to recognize and acknowledge that a patient who deteriorates because of an intracranial hemorrhage shortly after receiving tPA was not actually having a stroke when he or she initially presented. 

Large studies of administration of tPA for acute myocardial infarction have reported that about 1% of patients develop clinically symptomatic intracranial hemorrhage.2, 3 One might reasonably expect a similar incidence in patients with stroke mimics who receive tPA. 

The greatest bias in the report by Artto et al,1 though, is in the sweeping statement in the introduction: “Intravenous thrombolysis is an effective and safe treatment for acute ischemic stroke when current guidelines are followed properly.”1 As a reference for this statement, the authors cite a report of a pooled analysis of data from the Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke, European Cooperative Acute Stroke Study, and National Institute of Neurological Disorders and Stroke studies.4 In the disclosures of the funding sources, affiliations, and potential conflicts of interests for the participants in the original studies and the pooled analysis, the names “Genentech” and “Boehringer Ingelheim” (the US and European manufacturers of tPA, respectively) occur a combined 25 times. One of the coauthors in the study by Artto et al1 also reports receiving honoraria and consulting fees from Boehringer Ingelheim.1 

A graphic reanalysis of the NINDS data by Hoffman and Schriger5 has been published in this journal. This reanalysis showed that there was no significant difference between tPA patients and controls in the degree of improvement at 90 days when baseline differences in stroke severity were taken into account. Physicians who treat patients with strokelike symptoms should not be reassured by the results reported by Artto et al1 that it is safe to administer tPA to patients with stroke mimics, and they should remain skeptical of the claim repeated by Artto et al1 that tPA has been shown to be safe and effective in treating patients who actually do have acute ischemic strokes. 

15. Effective Discharge Communication in the Emergency Department 

Samuels-Kalow ME, et al. Ann Emerg Med. 2012;60:152-159.  

Communication at discharge is an important part of high-quality emergency department (ED) care. This review describes the existing literature on patient understanding and implementation of discharge instructions, discusses previous interventions aimed at improving the discharge process, and recommends best practices and future research. MEDLINE and Cochrane databases were searched, using combinations of key terms. Literature from both the adult and pediatric ED populations was reviewed. Multiple reports have shown deficient comprehension at discharge, with patients or parents frequently unable to report their diagnosis, management plan, or reasons to return. Interventions to improve discharge communication have been, at best, moderately successful. Patients need structured content, presented verbally, with written and visual cues to enhance recall. Written instructions need to be provided in the patient's language and at an appropriate reading level. Understanding should be confirmed before the patient leaves the ED. Further research is needed to describe the optimal content, channel, and timing for the ED discharge process and the relationship between discharge process and outcomes. 

16. Consider Emergent Angiography for Exsanguinating Pelvic Fracture 

Angioembolization reduced mortality from exsanguination compared with conventional treatment for hemorrhage control. 

Hauschild O et al. J Trauma Acute Care Surg. 2012 Jun 14. [Epub ahead of print] 

BACKGROUND: Hemorrhage from pelvic vessels is a potentially lethal complication of pelvic fractures. There is ongoing controversy on the ideal treatment strategy for patients with pelvic hemorrhage. The aim of the study was to analyze the role of angiography and subsequent embolization in patients with pelvic fractures and computed tomography scan-proven vascular injuries. 

METHODS: The data from the prospective multicenter German pelvic injury registry were analyzed. Of 5,040 patients with pelvic fractures, 152 patients with associated vascular injuries were identified. Patients undergoing angioembolization (n = 17) were compared with those undergoing conventional measures for hemorrhage control (n = 135) with regard to demographic and physiologic parameters, fracture type distribution, and treatment measures. Outcome measures were mortality, requirement for blood transfusions, complications, and hospital length of stay. 

RESULTS: Embolization and nonembolization groups were comparable with regard to age, sex, Injury Severity Score, Hannover Polytrauma Score, initial hemoglobin levels, blood pressure, fracture distribution, and conventional measures. Blood transfusion requirement was significantly prolonged in the embolization group. This resulted in a higher adult respiratory distress syndrome incidence and a tendency toward increased multiple organ failure rate in this group. There was no significant difference in overall mortality rate when compared with the nonembolization group (17.6% vs. 32.6%, respectively; p = 0.27). None of the patients undergoing embolization died from exsanguination when compared with 20.6% in the nonembolization group (p = 0.038). 

CONCLUSION: Angioembolization alongside with conventional measures is an effective complementary means for hemorrhage control in patients sustaining pelvic fracture-related vascular lesions. It might prove even more effective when performed early enough to avoid prolonged blood transfusion requirement. Further studies without the mentioned limitations of the study are desired. 

17. Hypotension after Medical Termination of Pregnancy: Think Outside of the Uterus 

Butt S, et al. J Emerg Med. 2012;43:50-53.  

Background: Under usual circumstances, an ectopic pregnancy would not be generally considered in the initial differential diagnosis of shock after voluntary termination of pregnancy. 

Objective: To present a rare case of a young woman with shock after voluntary termination of pregnancy due to undiagnosed ectopic pregnancy with concealed hemorrhage. 

Case Report: A 37-year-old woman presented to the Emergency Department (ED) 3 days after termination of pregnancy with clinical features of shock. The patient had some evidence of infection and was initially managed as a case of septic shock secondary to possible complication of recent termination of pregnancy. Subsequent work-up led to suspicion of internal bleeding, and ruptured ectopic pregnancy was confirmed and managed successfully. 

Conclusion: Ruptured ectopic pregnancy can present with a wide range of symptoms and under variable circumstances. Recognition of subtle signs of hemorrhage and consideration of the diagnosis of ruptured pregnancy in the ED will lead to early diagnosis and appropriate management. 

18. The LVAD: Walking, Talking … and Pulseless  

by Stuart Swadron, MD on July 10, 2012. Emergency Physicians Monthly 

Sharp Memorial’s Dr. Zach Shinar explains how to manage the care of the patient with a left ventricular assist device (LVAD) 

You walk into your next code and it’s a man in his 60s who collapsed on his way to his cardiologist’s office. His wife insists that he doesn’t need CPR because he has a kind of artificial heart, an LVAD. No one in the department has ever seen a patient with one of these before…

For me, I will always associate the LVAD with former vice-president Dick Cheney. I remember the television interview that he did in 2010 where he showed the whole nation his LVAD and the extra batteries that he carried in his fishing vest. After almost two years on the LVAD, he received a heart transplant and is doing well. 

So, who qualifies for an LVAD?... 

For the remainder of the essay with pictures, link here:  

19. What Primary Care Providers Need to Know About Preexposure Prophylaxis for HIV Prevention: A Narrative Review  

Krakower D, et al. Ann Intern Med. 22 July 2012. Online First 

As HIV prevalence climbs globally, including more than 50 000 new infections per year in the United States, we need more effective HIV prevention strategies. The use of antiretrovirals for preexposure prophylaxis (PrEP) among high-risk persons without HIV is emerging as 1 such strategy. Randomized, controlled trials have demonstrated that once-daily oral PrEP decreased HIV incidence among at-risk men who have sex with men and African heterosexuals, including serodiscordant couples. An additional randomized, controlled trial of a topical pericoital antiretroviral microbicide gel decreased HIV incidence among at-risk heterosexual South African women. Two other studies in African women did not demonstrate the efficacy of oral or topical PrEP, raising concerns about adherence patterns and efficacy in this population. 

The U.S. Food and Drug Administration (FDA) Antiviral Drugs Advisory Committee reviewed these studies and additional data in May 2012 and voted to advise the approval of oral tenofovir–emtricitabine for PrEP in high-risk populations. On 16 July 2012, the FDA recommended that this combination medication be approved for use as PrEP in high-risk persons without HIV. Patients may seek PrEP from their primary care providers, and those receiving PrEP require monitoring. Thus, primary care providers should become familiar with PrEP. This review outlines current knowledge about PrEP as it pertains to primary care, including identifying persons likely to benefit from PrEP; counseling to maximize adherence and reduce potential increases in risky behavior; and monitoring for potential drug toxicities, HIV acquisition, and antiretroviral drug resistance. Issues related to cost and insurance coverage are also discussed. Recent data suggest that PrEP, combined with other prevention strategies, holds promise in helping to curtail the HIV epidemic. 

Human immunodeficiency virus continues to spread, with more than 2 million new infections globally (1) and 50 000 new infections in the United States per year (2). Thus, more effective HIV prevention strategies are urgently needed. Administration of antiretroviral medications to uninfected persons at high risk to protect against HIV acquisition, known as preexposure prophylaxis (PrEP), has recently emerged as a promising prevention strategy. 

Over the past 2 years, randomized, controlled trials have demonstrated that PrEP can decrease HIV incidence in high-risk populations (3 - 6). With the FDA's approval of oral tenofovir–emtricitabine for PrEP in high-risk populations (7), clinicians can now prescribe PrEP to prevent HIV acquisition in their at-risk patients. Thus, it is important that practicing physicians understand this new evidence and its implications. 

20. “Cool down” before Lap Chole in Gallstone Pancreatitis May Not be Best 

Falor AE, et al. Early Laparoscopic Cholecystectomy for Mild Gallstone Pancreatitis: Time for a Paradigm Shift. Arch Surg. 2012;():1-5. [Epub date] doi:10.1001/archsurg.2012.1473 

Acute biliary pancreatitis is a common clinical scenario encountered by the general surgeon. The etiology can be explained by the “common channel” theory, in which the ampulla of Vater is transiently obstructed by a gallstone, leading to pancreatic inflammation and autodigestion.1 Because most of the offending stones are passed into the feces, the ensuing pancreatitis is generally mild and can often be managed supportively.2 To prevent further episodes, elective laparoscopic cholecystectomy (LC) is routinely performed during the same hospital admission to remove the source of calculi. The time to surgery after admission, however, is still greatly debated..

Historically, the symptomatic management of gallstone pancreatitis involved the delay of a cholecystectomy until the normalization of laboratory values and the resolution of abdominal pain.3 Ranson's earlier articles3 - 4 in the era of the open cholecystectomy investigated the timing of biliary surgery in mild (<3 Ranson signs) and severe (≥3 Ranson signs) pancreatitis. He concluded that “definitive correction of cholelithiasis should usually be carried out as soon as evidence of acute pancreatitis has resolved”4 (p661) to avoid exacerbating the severity or recurrence of disease. Recent evidence, with the introduction of laparoscopic surgery, has suggested that patients with mild gallstone pancreatitis, which comprises 80% to 90% of all patients with gallstone pancreatitis, may be better served with earlier intervention.5 .

Two previous studies5 - 6 from our institution demonstrated that, in patients with mild gallstone pancreatitis, an LC could be safely performed within 48 hours of admission regardless of resolution of abdominal pain or normalization of serum enzyme levels. This approach resulted in a significant decrease in length of hospitalization without increasing complications.5 - 6 There remains continued concern, however, that prediction of mild pancreatitis is uncertain and that some patients may incur an exacerbation of their disease as a result of early operative intervention..

To further address these concerns and to minimize the possible bias of a single-institution study, we set out to expand our database by collecting patient data from 2 university-affiliated urban medical centers during a 5-year period, with the goal of reaffirming the results of our previous, more limited investigations. Hospital lengths of stay, perioperative complications, and readmission rates were examined to determine the efficacy and safety of an early LC in patients with mild gallstone pancreatitis.

Hypothesis  Patients with mild gallstone pancreatitis may undergo an early laparoscopic cholecystectomy (LC) within 48 hours of hospital admission without awaiting the normalization of pancreatic and liver enzyme levels. This may decrease the hospital stay without increasing morbidity or mortality and may minimize the unnecessary use of endoscopic retrograde cholangiopancreatography. 

Design  A retrospective review. 

Setting  Two university-affiliated urban medical centers. 

Patients  A total of 303 patients with mild gallstone pancreatitis, of whom 117 underwent an early LC and 186 underwent a delayed LC. 

Main Outcome Measures  Hospital length of stay, morbidity and mortality rates, and the use of endoscopic retrograde cholangiopancreatography. 

Results  Similar hospital admission variables were observed in the early and delayed LC groups, although the delayed group was older (P = .006). The median hospital length of stay was significantly less for the early group than for the delayed group (3 vs 6 days; P < .001). There were no patients who died, and the complication rates were similar for both groups. However, the patients who underwent an early LC were less likely than patients who underwent a delayed LC to undergo endoscopic retrograde cholangiopancreatography (P = .02). 

Conclusions  An early LC may be safely performed for patients with mild gallstone pancreatitis, without concern for increased morbidity and mortality, resulting in shortened hospital stays and a decrease in the use of endoscopic retrograde cholangiopancreatography. The practice of delaying an LC until normalization of laboratory values appears to be unnecessary. 

21. ER vs. ED: A Comparison of Televised and Real-life Emergency Medicine 

Primack BA, et al. J Emerg Med 2012; in press. 

Background: Although accurate health-related representations of medical situations on television can be valuable, inaccurate portrayals can engender misinformation. 

Objective: The purpose of this study was to compare sociodemographic and medical characteristics of patients depicted on television vs. actual United States (US) Emergency Department (ED) patients. 

Methods: Two independently working coders analyzed all 22 programs in one complete year of the popular “emergency room” drama ER. Inter-rater reliability was excellent, and all initial coding differences were easily adjudicated. Actual health data were obtained from the National Heath and Ambulatory Medical Care Survey from the same year. Chi-squared goodness-of-fit tests were used to compare televised vs. real distribution across key sociodemographic and medical variables. 

Results: Ages at the extremes of age (i.e., ≤ 4 and≥45 years) were less commonly represented on television compared with reality. Characters on television vs. reality were less commonly women (31.2% vs. 52.9%, respectively), African-American (12.7% vs. 20.3%), or Hispanic (7.1% vs. 12.5%). The two most common acuity categories for television were the extreme categories “non-urgent” and “emergent,” whereas the two most common categories for reality were the middle categories “semi-urgent” and “urgent.” Televised visits compared with reality were most commonly due to injury (63.5% vs. 37.0%, respectively), and televised injuries were less commonly work-related (4.2% vs. 14.8%, respectively). 

Conclusions: Comparison of represented and actual characteristics of ED patients may be valuable in helping us determine what types of patient misperceptions may exist, as well as what types of interventions may be beneficial in correcting that potential misinformation.