Sunday, August 12, 2012

Lit Bits: Aug 12, 2012

From the recent medical literature...

1. QI Program Can Cut Unneeded Cardiac CT 

By Chris Kaiser, Cardiology Editor, MedPage Today. August 09, 2012 

Inappropriate coronary CT angiography (CCTA) exams can be curtailed if physicians are educated as to when the test should be ordered, researchers found. 

Follow-up after physicians underwent a 2-year continuous quality improvement program revealed a significant 60.3% decrease in inappropriate orders for CCTA tests (14.5% to 5.8%, P less than 0.0001), reported Kavitha M. Chinnaiyan, MD, from William Beaumont Hospital in Royal Oak, Mich., and colleagues. That decrease was accompanied by a significant 23.4% increase in the amount of appropriate scans ordered (61.3% to 80%, P less than 0.0001), according to the study published online in the Journal of the American College of Cardiology. 

Researchers also noted a significant 40.8% decrease in exam scenarios classified as "uncertain" and a significant 41.7% decrease in "unclassifiable" tests. Uncertain tests are those where the evidence is not sufficient to definitively classify them as appropriate or not. Unclassifiable exams are those that were not covered in the appropriate use criteria or where was not enough information provided to classify them. 

Chinnaiyan told MedPage Today that they worked to improve the reporting of tests in order to reduce the number of unclassifiable scans. The appropriate use criteria for CCTA are a response to the burgeoning use of CT for cardiac imaging, which the authors said was the "fastest growing application of CT scanners in the United States." 

The appropriateness of CCTA has been questioned by a number of stakeholders including private payers, the government, and medical specialty groups. Researchers sought to determine whether a continuous quality improvement intervention would make a difference in practice patterns among those who order CCTA exams. 

The study is part of the Advanced Cardiovascular Imaging Consortium, one of 13 statewide continuous quality improvement initiatives sponsored by Blue Cross Blue Shield of Michigan. The study cohort included 25,387 patients, with a mean age of 58. Slightly more than half (54%) of the patients were male. 

A total of 47 centers performing clinical CCTA were enrolled; a pre-intervention period spanned from July 2007 to June 2008. During this time, the sites received quarterly CCTA utilization reports, but there was no emphasis on the appropriate use criteria. During an intervention period, from July 2008 to June 2010, the sites participated in educational endeavors that stressed appropriate use of CCTA. In addition, letters were sent to referring physicians emphasizing appropriate use criteria and a potential loss of insurance coverage for inappropriate scans. 

Each site had the autonomy to conduct intervention in its own way. For example, 19 sites began a program of real-time feedback to referring physicians following prospective evaluation of patient indications. 

All sites chose a clinical champion who was responsible for keeping the team members motivated and closely monitoring the results. During the 2-year intervention, each site received quarterly feedback regarding the amount of appropriate and inappropriate scans relative to other participating sites.  

After the intervention period, researchers followed the sites for another 6 months. Researchers found that the most common appropriate indication for ordering a CCTA test was to detect coronary artery disease in symptomatic low- and intermediate-risk patients (30%) and in patients with prior cardiac tests (29%). 

The most common inappropriate indications were to detect coronary disease in asymptomatic patients (69%), while the most common uncertain indication was to find coronary disease in low-risk symptomatic patients (84%). 

Compared with the pre-intervention period, physicians ordered fewer inappropriate scans during the follow-up period. In particular, they ordered fewer CT exams for low-risk asymptomatic patients (from 73% to 57%) and for high-risk patients with acute symptoms (from 16.7% to 13%). Both decreases were significant at P less than 0.0001. Researchers saw similar significant changes in ordering patterns from the intervention period through the follow-up. Of particular importance, Chinnaiyan said, was that these changes were significant for all specialties including cardiology, internal medicine, emergency medicine, and others such as urgery and nephrology. Each group had a significant decrease in inappropriate exam orders. 

"One of the important take-home messages is that physicians need to be cognizant about testing in general," Chinnaiyan said. "There is a huge overutilization of CCTA studies and any place that does any kind of testing should be constantly evaluating itself to ensure it is ordering the right test for the right patient." 

The study was limited by the lack of a control group, the estimating of Framingham risk score, and limitations of the appropriate use criteria themselves, researchers said. The study was funded by Blue Cross/Blue Shield/Blue Care Network of Michigan. 

2. Does This Adult Patient with Suspected Bacteremia Require Blood Cultures? 

Coburn B, et al. JAMA. 2012;308(5):502-511.  

Context  Clinicians order blood cultures liberally among patients in whom bacteremia is suspected, though a small proportion of blood cultures yield true-positive results. Ordering blood cultures inappropriately may be both wasteful and harmful. 

Objective  To review the accuracy of easily obtained clinical and laboratory findings to inform the decision to obtain blood cultures in suspected bacteremia. 

Data Sources and Study Selection  A MEDLINE and EMBASE search (inception to April 2012) yielded 35 studies that met inclusion criteria for evaluating the accuracy of clinical variables for bacteremia in adult immunocompetent patients, representing 4566 bacteremia and 25 946 negative blood culture episodes. 

Data Extraction  Data were extracted to determine the prevalence and likelihood ratios (LRs) of findings for bacteremia. 

Data Synthesis  The pretest probability of bacteremia varies depending on the clinical context, from low (eg, cellulitis: 2%) to high (eg, septic shock: 69%). Elevated temperatures alone do not accurately predict bacteremia (for 38°C and above [over 100.3°F], LR, 1.9 [95% CI, 1.4-2.4]; for 38.5°C and above [over 101.2°F], LR, 1.4 [95% CI, 1.1-2.0]), nor does isolated leukocytosis (LR, less than 1.7). The severity of chills graded on an ordinal scale (shaking chills, LR, 4.7; 95% CI, 3.0-7.2) may be more useful. Both the systemic inflammatory response syndrome (SIRS) and a multivariable decision rule with major and minor criteria are sensitive (but not specific) predictors of bacteremia (SIRS, negative LR, 0.09 [95% CI, 0.03-0.26]; decision rule, negative LR, 0.08 [95% CI, 0.04-0.17]). 

Conclusions  Blood cultures should not be ordered for adult patients with isolated fever or leukocytosis without considering the pretest probability. SIRS and the decision rule may be helpful in identifying patients who do not need blood cultures. These conclusions do not apply to immunocompromised patients or when endocarditis is suspected. 

3. Necrotising fasciitis: A Review from the BMJ

Sultan HY, et al. BMJ 2012;345:e4274 

Necrotising fasciitis is one of a group of highly lethal infections that cause rapidly spreading necrosis of fascia and subcutaneous tissues, sometimes involving muscles and skin. They were previously known by such names as hospital gangrene, gas gangrene, and Fournier’s gangrene and are now referred to by the generic term “necrotising soft tissue infections.” We review the clinical features and highlight the potential pitfalls in diagnosis.

Learning points
·         Necrotising fasciitis is a lethal and rapidly progressive soft tissue infection, which can occur in healthy young patients
·         People with diabetes, those who inject drugs, and patients with haematological malignancy are particularly at risk
·         Diagnosis requires a high index of suspicion. Consider necrotising fasciitis especially when the presentation is “not quite right” or the patient is not responding to treatment
·         Early surgical exploration of the soft tissues has little morbidity and may be the only means to reach a definitive diagnosis and expedite treatment
·         In established necrotising fasciitis, surgery gives a 60-80% chance of survival. The earlier the first exploration and subsequent debridement, the less extensive the resection and postoperative morbidity is likely to be 

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4. Warning Symptoms and Family History in Children and Young Adults with Sudden Cardiac Arrest 

Drezner JA, et al. J Am Board Fam Med 2012;25:408-415.   

Background: Children and young adults with undiagnosed cardiovascular disorders at risk for sudden death may have warning symptoms or significant family history that is detectable through screening. The objective of this study was to determine the prevalence of warning symptoms and family history in a cohort of children and young adults who suffered sudden cardiac arrest (SCA).  

Methods: A retrospective survey investigating warning symptoms and family history of cardiovascular disease was completed by families with a child or young adult who suffered SCA. 

Results: Eighty-seven of 146 families (60%) returned a completed survey. The SCA victims were an average age of 16 years (range, 5–29 years), 69% male, and 68% white. Seventy-two percent of SCA victims were reported by their parents to have at least one cardiovascular symptom before SCA, with fatigue (44%) and near-syncope/lightheadedness (30%) the two most common. Twenty-four percent of SCA victims had one or more (average 2.6; range, 1 to 10) events of syncope or unexplained seizure that remained undiagnosed as a cardiac disorder before SCA. Parents reported that cardiovascular symptoms first occurred, on average, 30 months (range, 19 to 71 months) before SCA; a symptom was brought to the attention of the child's physician in 41% of cases. Twenty-seven percent of families reported a family member had suffered sudden death before age 50 because of a heart condition.  

Conclusions: Many children and young adults who suffered SCA are reported to have cardiac symptoms or a family history of premature cardiac death. Syncope and unexplained seizure activity are distinct events but often go unrecognized as ominous signs of underlying cardiovascular disease. Physician education and increased public awareness regarding cardiovascular warning signs in the young may improve early detection of those at risk and prevent tragedies. 

5. Intensive Care Unit Admitting Patterns in the Veterans Affairs Health Care System 

Chen LM, et al. Arch Intern Med. 2012;():1-7. doi:10.1001/archinternmed.2012.2606 

Background  Critical care resource use accounts for almost 1% of US gross domestic product and varies widely among hospitals. However, we know little about the initial decision to admit a patient to the intensive care unit (ICU). 

Methods  To describe hospital ICU admitting patterns for medical patients after accounting for severity of illness on admission, we performed a retrospective cohort study of the first nonsurgical admission of 289 310 patients admitted from the emergency department or the outpatient clinic to 118 Veterans Affairs acute care hospitals between July 1, 2009, and June 30, 2010. Severity (30-day predicted mortality rate) was measured using a modified Veterans Affairs ICU score based on laboratory data and comorbidities around admission. The main outcome measure was direct admission to an ICU. 

Results  Of the 31 555 patients (10.9%) directly admitted to the ICU, 53.2% had 30-day predicted mortality at admission of 2% or less. The rate of ICU admission for this low-risk group varied from 1.2% to 38.9%. For high-risk patients (predicted mortality above 30%), ICU admission rates also varied widely. For a 1-SD increase in predicted mortality, the adjusted odds of ICU admission varied substantially across hospitals (odds ratio = 0.85-2.22). As a result, 66.1% of hospitals were in different quartiles of ICU use for low- vs high-risk patients (weighted κ = 0.50). 

Conclusions  The proportion of low- and high-risk patients admitted to the ICU, variation in ICU admitting patterns among hospitals, and the sensitivity of hospital rankings to patient risk all likely reflect a lack of consensus about which patients most benefit from ICU admission. 

6. No Return of Pulses in the Field Portends Dismal Survival 

This study's findings support use of prehospital termination-of-resuscitation protocols. 

Prehospital cardiac arrest patients who do not achieve return of spontaneous circulation (ROSC) continue to be transported to the hospital despite the existence of prehospital termination-of-resuscitation protocols (JW Emerg Med Oct 17 2008). To determine survival rates in such patients, researchers analyzed data from two urban emergency medical service systems for patients who experienced cardiac arrest presumed to be of medical etiology from 2008 to 2010. 

Among 2483 patients in whom resuscitation was attempted, survival to hospital discharge was 6.6%. ROSC in the field occurred in 36% of patients. Survival rates were 17.2% in patients with ROSC in the field versus 0.7% in those without ROSC. None of the 11 patients who survived without ROSC in the field had an initial rhythm of asystole. 

Comment: If termination-of-resuscitation protocols that are based on ROSC had been followed in this study, the transport rate would have been halved. Although the authors' recommendation for no transport of patients without field ROSC or shockable rhythm would save critical resources and reduce risks to prehospital providers and the public from collisions, nonmedical indications such as family wishes sometimes mandate transport of nonviable patients. When such patients are transported, these data are useful for receiving-hospital emergency physicians to determine whether to continue resuscitative efforts on arrival. 

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine August 10, 2012. Citation: Wampler DA et al. Cardiac arrest survival is rare without prehospital return of spontaneous circulation. Prehosp Emerg Care 2012 Jul 26; [e-pub ahead of print]. ( 

7. Shift work and vascular events: systematic review and meta-analysis 

Vyas MV, et al. BMJ 2012;345:e4800 

Objective To synthesise the association of shift work with major vascular events as reported in the literature. 

Data sources Systematic searches of major bibliographic databases, contact with experts in the field, and review of reference lists of primary articles, review papers, and guidelines. 

Study selection Observational studies that reported risk ratios for vascular morbidity, vascular mortality, or all cause mortality in relation to shift work were included; control groups could be non-shift (“day”) workers or the general population. 

Data extraction Study quality was assessed with the Downs and Black scale for observational studies. The three primary outcomes were myocardial infarction, ischaemic stroke, and any coronary event. Heterogeneity was measured with the I2 statistic and computed random effects models. 

Results 34 studies in 2 011 935 people were identified. Shift work was associated with myocardial infarction (risk ratio 1.23, 95% confidence interval 1.15 to 1.31; I2=0) and ischaemic stroke (1.05, 1.01 to 1.09; I2=0). Coronary events were also increased (risk ratio 1.24, 1.10 to 1.39), albeit with significant heterogeneity across studies (I2=85%). Pooled risk ratios were significant for both unadjusted analyses and analyses adjusted for risk factors. All shift work schedules with the exception of evening shifts were associated with a statistically higher risk of coronary events. Shift work was not associated with increased rates of mortality (whether vascular cause specific or overall). Presence or absence of adjustment for smoking and socioeconomic status was not a source of heterogeneity in the primary studies. 6598 myocardial infarctions, 17 359 coronary events, and 1854 ischaemic strokes occurred. On the basis of the Canadian prevalence of shift work of 32.8%, the population attributable risks related to shift work were 7.0% for myocardial infarction, 7.3% for all coronary events, and 1.6% for ischaemic stroke. 

Conclusions Shift work is associated with vascular events, which may have implications for public policy and occupational medicine. 

8. Are patients willing to remove, and capable of removing, their own nonabsorbable sutures? 

Macdonald P, et al. CJEM 2012;14(4):218-223 

Objectives: Providing patients with instructions and equipment regarding self-removal of nonabsorbable sutures could represent a new efficiency in emergency department (ED) practice. The primary outcome was to compare the proportion of patients successfully removing their own sutures when provided with suture removal instructions and equipment versus the standard advice and follow-up care. Secondary outcomes included complication rates, number of physician visits, and patient comfort level. 

Methods: This prospective, controlled, single-blinded, pseudorandomized trial enrolled consecutive ED patients who met the eligibility criteria (age above 19 years, simple lacerations, nonabsorbable sutures, immunocompetent). The study group was provided with wound care instructions, a suture removal kit, and instructions regarding suture self-removal. The control group received wound care instructions alone. Outcomes were assessed by telephone contact at least 14 days after suturing using a standardized questionnaire. 

Results: Overall, 183 patients were enrolled (93 in the intervention group; 90 in the control group). Significantly more patients performed suture self-removal in the intervention group (91.5%; 95% CI 85.4–97.5) compared to the control group (62.8%; 95% CI 52.1–73.6) (p less than 0.001). Patients visited their physician less often in the intervention group (9.8%; 95% CI 3.3–16.2) compared to the control group (34.6%; 95% CI 24.1–45.2%) (p less than 0.001). Complication rates were similar in both groups. 

Conclusion: Most patients are willing to remove, and capable of removing, their own sutures. Providing appropriate suture removal instructions and equipment to patients with simple lacerations in the ED appears to be both safe and acceptable. 

9. Honey Seems to Soothe Coughs in Toddlers 

By Todd Neale, Senior Staff Writer, MedPage Today. August 06, 2012. 

Parents of young children who have a cough that keeps them up at night may want to try giving their little ones honey for some relief, a randomized trial showed. Compared with placebo, single doses of three different types of honey resulted in significantly greater gains on a number of subjective outcomes, including cough frequency, in children with a median age of 2.4 years, according to Herman Avner Cohen, MD, of Tel Aviv University in Israel, and colleagues. 

There were few adverse events, the researchers reported online ahead of the September issue of Pediatrics. 

"Honey may be a preferable treatment of cough and sleep difficulties associated with childhood upper respiratory tract infections," they wrote, noting that honey should not be used in infants because of the risk of infantile botulism. 

Parents have limited options when it comes to treating cough and cold symptoms, as most over-the-counter medications sold in the U.S. state that they should not be used in children younger than 4. In Canada, use is restricted to children 6 and older. 

Many home and herbal remedies have been used to treat a nagging cough, including honey, which the World Health Organization lists as a potential treatment. However, evidence supporting that use for honey is limited. Of two studies showing a benefit for honey, one tested only buckwheat honey and the other was not blinded. 

To further explore the issue, Cohen and colleagues conducted a double-blind, randomized, controlled trial involving 300 children, ages 1 to 5, who had upper respiratory tract infections, a nocturnal cough, and an illness duration of less than a week. The participants were enrolled from six general pediatric community clinics. The placebo in the study was a silan date extract, chosen because its structure, color, and taste are similar to those of honey. The three types of honey evaluated were eucalyptus, citrus, and labiatae. 

The patients were randomized to receive a single 10-gram dose of placebo or one of the honey products within 30 minutes of bedtime. Parents completed a survey the day before the intervention and the day after. It contained five questions covering the frequency and severity of the child's cough, how bothered the child was by the cough, and how the cough affected both the child's and the parents' sleep. Each measure was rated on a seven-point Likert scale. 

Placebo and all three types of honey were associated with improvements from 1 day to the next, which could be indicative of the natural course of upper respiratory tract infections. However, the gains were larger in the honey groups for all of the outcomes. 

Cough frequency, for example, improved by 1.77 to 1.95 points in the honey groups compared with 1.00 point in the placebo group (P less than 0.001). When all of the outcomes were combined together, the improvements were 9.88 points with eucalyptus honey, 10.10 points for citrus honey, and 9.51 points for labiatae honey. All of those gains were significantly larger than the 5.82-point improvement with the date extract (P less than 0.001). 

Adverse events included stomach ache, nausea, and vomiting. There were two cases in the citrus honey group and one each in the other two honey groups and the placebo group. 

The researchers noted that it is unclear what characteristic of honey is responsible for the improvements, adding, however, that honey has been found to have both antioxidant and antimicrobial properties. It also was not likely that the date extract worsened cough and cold symptoms because those patients did show some improvement. In addition, "there is also no reason to believe silan caused allergic symptoms or bronchospasm because dates are not a common food allergen in the Israeli population," they said. 

Another possible factor to explain at least part of the effect of honey could involve the central nervous system; there is a close anatomic relationship between the sensory nerve fibers involved in coughing and the gustatory nerve fibers involved in tasting sweetness. 

"This theory may explain some of the observed effect in patients treated with silan date extract because this is also a sweet substance," the authors wrote. 

They acknowledged some limitations of their study, including the use of a single dose of honey, subjective assessments of outcomes, and the inability to ensure compliance with honey and placebo administration. They also pointed out that the dropout rate was higher for children receiving citrus and eucalyptus honey, possibly because both of those substances are more aromatic, which the children may not have liked. 

The study was supported in part by a research grant from the Israel Ambulatory Pediatric Association, Materna Infant Nutrition Research Institute, and the Honey Board of Israel. The authors reported no conflicts of interest. 

Cohen H, et al "Effect of honey on nocturnal cough and sleep quality: A double-blind, randomized, placebo-controlled study" Pediatr 2012; DOI: 10.1542/peds.2011-3075. Abstract: 

10. Shocker: Doctors Work When They're Sick

by Scott Hensley. NPR’s Health Blog. June 19, 2012 

How do doctors work around so many ill people without getting sick? Well, they don't. 

Even if they scrub their hands like crazy, which certainly helps, they succumb to germs every once in a while, just like the rest of us. And also like lots of the rest of us, they'll go to work sick, a survey of medical residents finds. 

A little more than half of the 150 residents surveyed at an Illinois medical meeting in 2010 said they'd worked while having flu-like symptoms in the previous year. And about one-quarter said they'd done so at least three times. 

Why? They were just being responsible. More than half — 56 percent — said they felt a responsibility to take care of their patients. Fifty-seven percent said they didn't want to make their colleagues cover for them. 

The results were published in the latest Archives of Internal Medicine. In a note about them, Dr. Deborah Grady wrote: "Working while sick may demonstrate an admirable sense of responsibility to patients and colleagues, but clinicians also need to worry about the real danger of infecting vulnerable patients as well as colleagues and staff." 

Now, don't you sometimes feel the same way when the cougher in the next cube won't take a sick day? We did our own survey in 2010 and found that almost three-quarters of people had gone to work sick in the past year. 

The top reason, cited by 25 percent of people, was that they wouldn't get paid for the absence. That was followed by people saying they weren't sick enough to stay home and "work ethic" came in third at 19 percent. 

Archives’s article (subscription required):  

11. Images in Clinical Medicine 

Unexpected Swallowing of a Knife

Hernia through the Foramen of Winslow

Halitosis and Sensory Loss

Green Teeth in Neonatal Sepsis

Left Upper Quadrant Abdominal Pain

12. Distinguishing Between Causes of Cardiac Troponin Elevations 

The absolute change in troponin levels between presentation and 1 hour can distinguish between acute myocardial infarction and nonischemic disease states. 

Haaf P et al. Circulation 2012 Jul 3; 126:31-40. 

BACKGROUND: We hypothesized that high-sensitivity cardiac troponin (hs-cTn) and its early change are useful in distinguishing acute myocardial infarction (AMI) from acute cardiac noncoronary artery disease. 

METHODS AND RESULTS: In a prospective, international multicenter study, hs-cTn was measured with 3 assays (hs-cTnT, Roche Diagnostics; hs-cTnI, Beckman-Coulter; hs-cTnI Siemens) in a blinded fashion at presentation and serially thereafter in 887 unselected patients with acute chest pain. Accuracy of the combination of presentation values with serial changes was compared against a final diagnosis adjudicated by 2 independent cardiologists. AMI was the adjudicated final diagnosis in 127 patients (15%); cardiac noncoronary artery disease, in 124 (14%). Patients with AMI had higher median presentation values of hs-cTnT (0.113 μg/L [interquartile range, 0.049-0.246 μg/L] versus 0.012 μg/L [interquartile range, 0.006-0.034 μg/L]; P less than 0.001) and higher absolute changes in hs-cTnT in the first hour (0.019 μg/L [interquartile range, 0.007-0.067 μg/L] versus 0.001 μg/L [interquartile range, 0-0.003 μg/L]; P less than 0.001) than patients with cardiac noncoronary artery disease. Similar findings were obtained with the hs-cTnI assays. Adding changes of hs-cTn in the first hour to its presentation value yielded a diagnostic accuracy for AMI as quantified by the area under the receiver-operating characteristics curve of 0.94 for hs-cTnT (0.92 for both hs-cTnI assays). Algorithms using ST-elevation, presentation values, and changes in hs-cTn in the first hour accurately separated patients with AMI and those with cardiac noncoronary artery disease. These findings were confirmed when the final diagnosis was readjudicated with the use of hs-cTnT values and validated in an independent validation cohort. 

CONCLUSION: The combined use of hs-cTn at presentation and its early absolute change excellently discriminates between patients with AMI and those with cardiac noncoronary artery disease. 

13. Defining abnormal ECG in adult ED syncope patients: the Ottawa ECG Criteria 

Thiruganasambandamoorthy V, et al. CJEM 2012;14(4):248-258 

Background: Previous studies have indicated that the suboptimal performance of the San Francisco Syncope Rule (SFSR) is likely due to the misclassification of the “abnormal electrocardiogram (ECG)” variable. We sought to identify specific emergency department (ED) ECG and cardiac monitor abnormalities that better predict cardiac outcomes within 30 days in adult ED syncope patients. 

Methods: This health records review included patients 16 years or older with syncope and excluded patients with ongoing altered mental status, alcohol or illicit drug use, seizure, head injury leading to loss of consciousness, or severe trauma requiring admission. We collected patient characteristics, 22 ECG variables, cardiac monitoring abnormalities, SFSR “abnormal ECG” criteria, and outcome (death, myocardial infarction, arrhythmias, or cardiac procedures) data. Recursive partitioning was used to develop the “Ottawa Electrocardiographic Criteria.” 

Results: Among 505 included patient visits, 27 (5.3%) had serious cardiac outcomes. We found that patients were at risk for cardiac outcomes within 30 days if any of the following were present: second-degree Mobitz type 2 or third-degree atrioventricular (AV) block, bundle branch block with first-degree AV block, right bundle branch with left anterior or posterior fascicular block, new ischemic changes, nonsinus rhythm, left axis deviation, or ED cardiac monitor abnormalities. The sensitivity and specificity of the Ottawa Electrocardiographic Criteria were 96% (95% CI 80–100) and 76% (95% CI 75–76), respectively. 

Conclusion: We successfully identified specific ED ECG and cardiac monitor abnormalities, which we termed the Ottawa Electrocardiographic Criteria, that predict serious cardiac outcomes in adult ED syncope patients. Further studies are required to identify which adult ED syncope patients require cardiac monitoring in the ED and the optimal duration of monitoring and to confirm the accuracy of these criteria. 

14. (No) Association Between Evidence-Based Standardized Protocols in EDs with Childhood Asthma Outcomes: A Canadian Population-Based Study  

Li P, et al. Arch Pediatr Adolesc Med. 2012;():1-7. doi:10.1001/archpediatrics.2012.1195 

Objective  To determine whether children treated in emergency departments (EDs) with evidence-based standardized protocols (EBSPs) containing evidence-based content and format had lower risk of hospital admission or ED return visit and greater follow-up than children treated in EDs with no standardized protocols in Ontario, Canada. 

Design  Retrospective population-based cohort study of children with asthma. We used multivariable logistic regression to estimate risk of outcomes. 

Setting  All EDs in Ontario (N = 146) treating childhood asthma from April 2006 to March 2009. 

Participants  Thirty-one thousand one hundred thirty-eight children (aged 2 to 17 years) with asthma. 

Main Exposure  Type of standardized protocol (EBSPs, other standardized protocols, or none). 

Main Outcome Measures  Hospital admission, high-acuity 7-day return visit to the ED, and 7-day outpatient follow-up visit. 

Results  The final cohort made 46 510 ED visits in 146 EDs. From the index ED visit, 4211 (9.1%) were admitted to the hospital. Of those discharged, 1778 (4.2%) and 7350 (17.4%) had ED return visits and outpatient follow-up visits, respectively. The EBSPs were not associated with hospitalizations, return visits, or follow-up (adjusted odds ratio, 1.17 [95% CI, 0.91-1.49]; adjusted odds ratio, 1.10 [95% CI, 0.86-1.41]; and adjusted odds ratio, 1.08 [95% CI, 0.87-1.35], respectively). 

Conclusions  The EBSPs were not associated with improvements in rates of hospital admissions, return visits to the ED, or follow-up. Our findings suggest the need to address gaps linking improved processes of asthma care with outcomes. 

15. Risk of Falls and Major Bleeds in Patients on Oral Anticoagulation Therapy: No Connection 

Donzé J, et al. Amer J Med 2012;125:773-778. 

Background: The risk of falls is the most commonly cited reason for not providing oral anticoagulation, although the risk of bleeding associated with falls on oral anticoagulants is still debated. We aimed to evaluate whether patients on oral anticoagulation with high falls risk have an increased risk of major bleeding. 

Methods: We prospectively studied consecutive adult medical patients who were discharged on oral anticoagulants. The outcome was the time to a first major bleed within a 12-month follow-up period adjusted for age, sex, alcohol abuse, number of drugs, concomitant treatment with antiplatelet agents, and history of stroke or transient ischemic attack. 

Results: Among the 515 enrolled patients, 35 patients had a first major bleed during follow-up (incidence rate: 7.5 per 100 patient-years). Overall, 308 patients (59.8%) were at high risk of falls, and these patients had a nonsignificantly higher crude incidence rate of major bleeding than patients at low risk of falls (8.0 vs 6.8 per 100 patient-years, P=.64). In multivariate analysis, a high falls risk was not statistically significantly associated with the risk of a major bleed (hazard ratio 1.09; 95% confidence interval, 0.54-2.21). Overall, only 3 major bleeds occurred directly after a fall (incidence rate: 0.6 per 100 patient-years). 

Conclusions: In this prospective cohort, patients on oral anticoagulants at high risk of falls did not have a significantly increased risk of major bleeds. These findings suggest that being at risk of falls is not a valid reason to avoid oral anticoagulants in medical patients. 

16. Ultrasound Guidance Improves Diagnosis of Peritonsillar Abscess 

Costantino TG, et al. Randomized Trial Comparing Intraoral Ultrasound to Landmark-based Needle Aspiration in Patients with Suspected Peritonsillar Abscess. Acad Emerg Med. 2012 Jun;19(6):626-31. 

Objectives:  Traditionally, emergency physicians (EPs) have used anatomic landmark-based needle aspiration to drain peritonsillar abscesses (PTAs). If this failed, an imaging study and/or consultation with another service to perform the drainage is obtained. Recently, some EPs have used ultrasound (US) to guide PTA drainage. This study seeks to determine which initial approach leads to greater successful drainage. The primary objective of this study was to compare the diagnostic accuracy of EPs for detecting PTA or peritonsillar cellulitis (PTC) using either intraoral US or initial needle aspiration after visual inspection (the landmark technique [LM]). Secondary objectives included the successful aspiration of purulent material in those patients with a PTA in each arm, the use of computed tomography (CT) scanning in each arm, and the otolaryngology (ENT) consultation rate in each arm.  

Methods:  This was a prospective, randomized, controlled clinical trial of a convenience sample of adult patients who presented to a single, large, urban university hospital. Patients were enrolled if they presented with a constellation of signs and symptoms that were judged to be a PTA. These patients were randomized to receive intraoral US or to undergo LM drainage. The US was performed using an 8-5 MHz intracavitary transducer immediately prior to the procedure. The probe was then withdrawn and the provider who did the US also performed the needle aspiration. The LM was performed using visual landmarks in a superior to inferior approach until pus was obtained or at least two sticks were performed. Anesthesia was standardized. Patients returned for follow-up in 2 days where a final diagnosis was rendered.

Results:  There were 28 patients enrolled, with 14 in each arm. US established the correct diagnosis more often than LM [(100%, 95% confidence interval [CI] = 75% to 100% vs. 64%, 95% CI = 39% to 84%; p = 0.04)]. US also led to more successful aspiration of purulent material by the EP than LM in patients with PTA [(100%, 95% CI = 63% to 100% vs. 50%, 95% CI = 24% to 76%; p = 0.04)]. The ENT consult  rate was 7% (95% CI = 0% to 34%) for US versus 50% (95% CI = 27% to 73%) for LM (p = 0.03). The CT usage rate was 0% for US versus 35% for LM (p = 0.04).  

Conclusions:  An initial intraoral US performed by EPs can reliably diagnose PTC and PTA. Additionally, using intraoral US to assist in the drainage of PTAs with needle aspiration leads to greater success compared to the traditional method of LM relying on physical exam alone. 

17. Validation and Refinement of a Prediction Rule to Identify Children at Low Risk for Acute Appendicitis 

Kharbanda AB, et al; for the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Arch Pediatr Adolesc Med. 2012;166(8):738-744.  

Objective  To validate and refine a clinical prediction rule to identify which children with acute abdominal pain are at low risk for appendicitis (Low-Risk Appendicitis Rule). 

Design  Prospective, multicenter, cross-sectional study. 

Setting  Ten pediatric emergency departments. 

Participants  Children and adolescents aged 3 to 18 years who presented with suspected appendicitis from March 1, 2009, through April 30, 2010. 

Main Outcome Measures  The test performance of the Low-Risk Appendicitis Rule. 

Results  Among 2625 patients enrolled, 1018 (38.8% [95% CI, 36.9%-40.7%]) had appendicitis. Validation of the rule resulted in a sensitivity of 95.5% (95% CI, 93.9%-96.7%), specificity of 36.3% (33.9%-38.9%), and negative predictive value of 92.7% (90.1%-94.6%). Theoretical application would have identified 573 (24.0%) as being at low risk, misclassifying 42 patients (4.5% [95% CI, 3.4%-6.1%]) with appendicitis. We refined the prediction rule, resulting in a model that identified patients at low risk with (1) an absolute neutrophil count of 6.75 × 103/μL or less and no maximal tenderness in the right lower quadrant or (2) an absolute neutrophil count of 6.75 × 103/μL or less with maximal tenderness in the right lower quadrant but no abdominal pain with walking/jumping or coughing. This refined rule had a sensitivity of 98.1% (95% CI, 97.0%-98.9%), specificity of 23.7% (21.7%-25.9%), and negative predictive value of 95.3% (92.3%-97.0%). 

Conclusions  We have validated and refined a simple clinical prediction rule for pediatric appendicitis. For patients identified as being at low risk, clinicians should consider alternative strategies, such as observation or ultrasonographic examination, rather than proceeding to immediate computed tomographic imaging. 

18. Bilateral lower cervical paraspinous bupivacaine injections for all kinds of headache (Larry Mellick’s work was brought to my attention by EM-RAP) 

Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. 

Mellick LB, et al. Headache. 2006 Oct;46(9):1441-9. 

OBJECTIVE: The primary objective of this retrospective chart review is to describe 1 year's experience of an academic emergency department (ED) in treating a wide spectrum of headache classifications with intramuscular injections of 0.5% bupivacaine bilateral to the spinous process of the lower cervical vertebrae. 

BACKGROUND: Headache is a common reason that patients present to an ED. While there are a number of effective therapeutic interventions available for the management of headache pain, there clearly remains a need for other treatment options. The intramuscular injection of 1.5 mL of 0.5% bupivacaine bilateral to the sixth or seventh cervical vertebrae has been used to treat headache pain in our facility since July 2002. The clinical setting for the study was an academic ED with an annual volume of over 75,000 patients. 

METHODS: We performed a retrospective review of over 2805 ED patients with the discharge diagnosis of headache and over 771 patients who were coded as having had an anesthetic injection between June 30, 2003 and July 1, 2004. All adult patients who had undergone paraspinous intramuscular injection with bupivacaine for the treatment of their headache were gleaned from these 2 larger databases and were included in this retrospective chart review. A systematic review of the medical records was accomplished for these patients. 

RESULTS: Lower cervical paraspinous intramuscular injections with bupivacaine were performed in 417 patients. Complete headache relief occurred in 271 (65.1%) and partial headache relief in 85 patients (20.4%). No significant relief was reported in 57 patients (13.7%) and headache worsening was described in 4 patients (1%). Overall a therapeutic response was reported in 356 of 417 patients (85.4%). Headache relief was typically rapid with many patients reporting complete headache relief in 5 to 10 minutes. Associated signs and symptoms such as nausea, vomiting, photophobia, phonophobia, and allodynia were also commonly relieved. 

CONCLUSION: Our observations suggest that the intramuscular injection of small amounts of 0.5% bupivacaine bilateral to the sixth or seventh cervical spinous process appears to be an effective therapeutic intervention for the treatment of headache pain in the outpatient setting. 

Also useful in kids: Mellick LB ,et al. Pediatr Emerg Care. 2010 Mar;26(3):192-6. Abstract:  
Wanna see how it’s done? Online video demonstrations:

19. Validation of treatment strategies for enterohaemorrhagic E coli O104:H4 induced haemolytic uraemic syndrome: case-control study 

Menne J, et al. BMJ 2012;345:e4565 

Objective To evaluate the effect of different treatment strategies on enterohaemorrhagic Escherichia coli O104:H4 induced haemolytic uraemic syndrome. 

Design Multicentre retrospective case-control study. 

Setting 23 hospitals in northern Germany. 

Participants 298 adults with enterohaemorrhagic E coli induced haemolytic uraemic syndrome. 

Main outcome measures Dialysis, seizures, mechanical ventilation, abdominal surgery owing to perforation of the bowel or bowel necrosis, and death. 

Results 160 of the 298 patients (54%) temporarily required dialysis, with only three needing treatment long term. 37 patients (12%) had seizures, 54 (18%) required mechanical ventilation, and 12 (4%) died. No clear benefit was found from use of plasmapheresis or plasmapheresis with glucocorticoids. 67 of the patients were treated with eculizumab, a monoclonal antibody directed against the complement cascade. No short term benefit was detected that could be attributed to this treatment. 52 patients in one centre that used a strategy of aggressive treatment with combined antibiotics had fewer seizures (2% v 15%, P=0.03), fewer deaths (0% v 5%, p=0.029), required no abdominal surgery, and excreted E coli for a shorter duration. 

Conclusions Enterohaemorrhagic E coli induced haemolytic uraemic syndrome is a severe self limiting acute condition. Our findings question the benefit of eculizumab and of plasmapheresis with or without glucocorticoids. Patients with established haemolytic uraemic syndrome seemed to benefit from antibiotic treatment and this should be investigated in a controlled trial. 

20. Improving Time to Antibiotics for Pediatric Neutropenic Patients 

A multidisciplinary effort decreased mean time to antibiotics by 50 minutes.  

Investigators conducted a multidisciplinary quality improvement effort to reduce time to antibiotics for pediatric oncology patients presenting to a pediatric emergency department (ED) with fever (axillary temperature 38.3°C once or 38.0°C for more than 2 hours in a 24-hour period) and either neutropenia (absolute neutrophil count 500 cells/mm3) or possible neutropenia. Target goals were ceftazidime delivery within 60 minutes for patients with known neutropenia and ceftriaxone within 90 minutes for patients with possible neutropenia. 

The investigators identified areas for improvement and corresponding action plans. ED nurses and physicians teamed with ED quality nurse leaders, hospital staff nurses, ED pharmacists, ED administrators, security directors, oncology clinicians, and hospital quality improvement experts. Families of children receiving chemotherapy were given bright orange placards that acted as a visual alert for security personnel and triage staff to expedite patients into the ED. Additional measures included clinician reeducation on electronic ordering, pharmacist prioritization of antibiotic preparation, nurse education on Port-a-Cath® access, real-time clinician coaching and feedback with monthly progress reports, and monthly root cause analyses of patients who did not reach target goals. 

The study involved 137 children (mean age, 8.9 years) who presented before implementation and 288 children (mean age, 8.4 years) who presented after. Mean time to antibiotics decreased from 99 minutes to 49 minutes for patients with neutropenia and from 90 minutes to 81 minutes for patients with possible neutropenia (60% were ultimately found to be neutropenic). The proportion of patients meeting the target time increased from 50% to 89%. 

Comment: This study clearly demonstrates that a structured multidisciplinary process improvement initiative can have a significant impact on emergency department processes and delivery of care. 

— Katherine Bakes, MD. Published in Journal Watch Emergency Medicine August 3, 2012. Citation: Volpe D et al. Improving timeliness of antibiotic delivery for patients with fever and suspected neutropenia in a pediatric emergency department. Pediatrics 2012 Jul; 130:e201.

21. Cunningham Technique for Shoulder Reduction 

From EM-RAP TV. This episode Rob Orman reviews the Cunningham technique for shoulder relocation 

Want other cool videos on various EM diagnostic and management challenges from orthopedic procedures to ECG conundrums? This site’s for you:  

22. Why Do We Get Brain Freeze? Scientists Explain 

Medical News Today. 2012  

Harvard Medical School scientists who say they have a better idea of what causes brain freeze, believe that their study could eventually pave the way to more effective treatments for various types of headaches, such as migraine-related ones, or pain caused by brain injuries. 

Brain freeze, also known as an ice-cream headache, cold-stimulus headache, or sphenopalatine ganglioneuralgia, is a kind of short-term headache typically linked to the rapid consumption of ice-cream, ice pops, or very cold drinks. Brain freeze occurs when something extremely cold touches the upper-palate (roof of the mouth). It normally happens when the weather is very hot, and the individual consumes something too fast. 

Dr. Jorge Serrador, a cardiovascular electronics researcher, who presented the team's finding at the Experimental Biology 2012 meeting, San Diego, explained that until now, scientists have not been able to fully understand what causes brain freeze. 

Dr. Serrador and team recruited 13 healthy adult volunteers. They were asked to sip ice-cold water through a straw, so that the liquid would hit their upper palate. Blood flow in their brain was monitored using a transcranial Doppler test. They found that the sensation of brain freeze appears to be caused by a dramatic and sudden increase in blood flow through the brain's anterior cerebral artery. As soon as the artery constricted, the brain-freeze pain sensation wore off. The scientists were able to trigger the artery's constriction by giving the volunteers warm water to drink.  

Migraine sufferers more susceptible to brain freeze 

Dr. Serrador explained that we already know that migraine sufferers are more likely to suffer brain freeze after drinking or eating very cold foods/drinks, compared to people who never have migraines. He suggests that some of what occurs during brain freeze may be similar to what causes migraines, and possibly other kinds of headaches, including those caused by traumatic brain injuries. 

Serrador and team believe that local changes in brain blood flow may be causing other types of headaches. If this can be confirmed in further studies, new medications that prevent or reverse vasodilation (widening of the blood vessels) may help treat headaches. 

Brain freeze can occur if you eat an ice cream too fast. Vasodilation is probably part of a self-defense mechanism, Dr. Serrador said: "The brain is one of the relatively important organs in the body, and it needs to be working all the time. It's fairly sensitive to temperature, so vasodilation might be moving warm blood inside tissue to make sure the brain stays warm." 

If dilated arteries cause a sudden rush of blood to the brain, which raises pressure and causes pain, a drug that constricts the blood vessel should reduce pressure and eliminate the pain. Also, constricting the blood vessels that supply the brain could help prevent pressure building up dangerously high. 

23. Rudeness on the Internet  

Mean comments arise from a lack of eye contact more than from anonymity. 

By Melinda Wenner Moyer,  Scientific American | August 8, 2012 

Read any Web forum, and you'll agree: people are meaner online than in “real life.” Psychologists have largely blamed this disinhibition on anonymity and invisibility: when you're online, no one knows who you are or what you look like. A new study in Computers in Human Behavior, however, suggests that above and beyond anything else, we're nasty on the Internet because we don't make eye contact with our compatriots.

Researchers at the University of Haifa in Israel asked 71 pairs of college students who did not know one another to debate an issue over Instant Messenger and try to come up with an agreeable solution. The pairs, seated in different rooms, chatted in various conditions: some were asked to share personal, identifying details; others could see side views of their partner's body through webcams; and others were asked to maintain near-constant eye contact with the aid of close-up cameras attached to the top of their computer. 

Far more than anonymity or invisibility, whether or not the subjects had to look into their partner's eyes predicted how mean they were. When their eyes were hidden, participants were twice as likely to be hostile. Even if the subjects were both unrecognizable (with only their eyes on screen) and anonymous, they rarely made threats if they maintained eye contact. Although no one knows exactly why eye contact is so crucial, lead author and behavioral scientist Noam Lapidot-Lefler, now at the Max Stern Yezreel Valley College in Israel, notes that seeing a partner's eyes “helps you understand the other person's feelings, the signals that the person is trying to send you,” which fosters empathy and communication.