1. New European STEMI Guidelines Emphasize Care Coordination
Reed Miller. Heartwire. August 26, 2012 (Munich, Germany) —
Authors of the new European Society of Cardiology (ESC) guidelines for the
management of patients with acute ST-elevation MI (STEMI) hope their
recommendations spur efforts to improve the speed and efficiency of STEMI care
in Europe.
The new guidelines were announced here today at the European
Society of Cardiology 2012 Congress by Dr Gabriel Steg (Hôpitaux de Paris,
France), chair of the task force that wrote the new recommendations. The new
document, also published in the European Heart Journal,supplants the guidelines
released in 2008 and complements the non-STEMI treatment guidelines released at
last year's ESC congress.
The new guidelines "emphasize the need to have
geographic networks to care for patients so that the decisions and protocols
are not simply coordinated at one site or one department, but across geographic
regions between the various stakeholders," Steg told heartwire.
It is hoped that better coordination and organization of
STEMI care will reduce delays in the treatment of this urgent population. The
new guidelines are "much more demanding [than the 2008 guidelines] in
terms of delays," he said. The new standard for time from medical contact
to ECG is 10 minutes, and "the fact that you use primary PCI should not
lead to complacency about the delays. You should target 60 minutes." Two
hours is the limit of acceptable delay for a patient transferred from a non-PCI
center to a PCI center, but the target should be 90 minutes, Steg said. If PCI
within two hours of presentation appears to be impossible, then fibrinolysis
should be administered within 30 minutes.
The guidelines also advise interventionalists to monitor and
report their performance, including door-to-balloon times and any other treatment
delays. "I think that's quite novel for Europe to encourage widespread
reporting of that." Europe does not yet have a pan-European STEMI
registry, but some countries have national registries, he pointed out.
The guidelines recommend that if fibrinolysis succeeds,
angiography can begin with the expectation of PCI within three to 24 hours. If
fibrinolysis fails, the interventionalist should consider PCI immediately, the
guidelines suggest.
The new guidelines recommend implanting drug-eluting instead
of bare-metal stents in patients who are not contraindicated for dual
antiplatelet therapy and are likely to stick to their prescribed regimen. The
guidelines advise newer antiplatelet drugs, such as prasugrel (Effient, Daiichi
Sankyo/Lilly) or ticagrelor (Brilinta, AstraZeneca) over clopidogrel.
The guidelines also support employing transradial
catheterization rather than the transfemoral approach, but only in the hands of
experienced operators.
Many areas in need of further research are identified in the
guidelines, ranging from questions about early prehospital care to long-term
management. But Steg said that if he had to pick one area as the most critical,
he'd highlight the challenge of integrating the various concomitant drug
therapies, especially triple therapy in stent recipients who have to have
anticoagulation. "That's a vexing clinical problem for which we have very
little data."
[1] Steg G, et al. ESC guidelines for the management of
acute myocardial infarction in patients presenting with ST-segment elevation:
The Task Force on the management of ST-segment elevation acute myocardial
infarction of the European Society of Cardiology (ESC). Eur Heart J 2012;
DOI:10.1093/eurheartj/ehs215.
Full-text (free): http://eurheartj.oxfordjournals.org/content/early/2012/09/11/eurheartj.ehs215.long
2. Impact of
Door-to-Activation Time on Door-to-Balloon Time in Primary Percutaneous
Coronary Intervention for ST-Segment Elevation Myocardial Infarctions: A Report
From the Activate-SF Registry.
McCabe JM, et al. Circ Cardiovasc Qual Outcomes. 2012 Sep 4.
[Epub ahead of print]
Background—Little is known about the components of
door-to-balloon time among patients with ST-segment elevation myocardial
infarction undergoing primary percutaneous coronary intervention. We assessed
the role of time from hospital arrival to ST-segment elevation myocardial
infarction diagnosis (door-to-activation time) on door-to-balloon time in
contemporary practice and evaluated factors that influence door-to-activation
times.
Methods and Results—Registry data on 347 consecutive patients
diagnosed with a ST-segment elevation myocardial infarction in the emergency
department over 30 months at 2 urban primary percutaneous coronary intervention
centers were analyzed. The primary study end point was the time from hospital
arrival to catheterization laboratory activation by the emergency department
physician, and we assessed factors associated with this period. Door-to-balloon
time and its other components were secondary study end points. The median
door-to-activation time was 19 minutes (interquartile range, 9–54). Variation
in door-to-activation times explained 93% of the variation in door-to-balloon
times and demonstrated the strongest correlation with door-to-balloon times
(r=0.97). Achieving a door-to-activation time of ≤20 minutes resulted in an 89%
chance of achieving a door-to-balloon time of ≤90 minutes compared with only
28% for patients with a door-to-activation time above 20 minutes. Factors
significantly associated with door-to-activation time include the following:
prehospital ECG use (61% shorter, 95% confidence interval, −50 to −72%; P less
than 0.001) and computed tomography scan use in the emergency department (245%
longer, 95% confidence interval, +50 to +399%; P=0.001).
Conclusions—The interval from hospital arrival to ST-segment
elevation myocardial infarction diagnosis and catheterization laboratory
activation (door-to-activation time) is a strong driver of overall
door-to-balloon times. Achieving a door-to-activation time ≤20 minutes was key
to achieving a door-to-balloon time ≤90 minutes. Delays in door-to-activation
time are not associated with delays in other aspects of the primary
percutaneous coronary intervention process.
See also related Heartwire essay: http://www.medscape.com/viewarticle/770528
3. Overtreatment Is
Taking a Harmful Toll
Tara Parker-Pope. New York Times. August 27, 2012
When it comes to medical care, many patients and doctors
believe more is better.
But an epidemic of overtreatment — too many scans, too many
blood tests, too many procedures — is costing the nation’s health care system
at least $210 billion a year, according to the Institute of Medicine, and
taking a human toll in pain, emotional suffering, severe complications and even
death.
“What people are not realizing is that sometimes the test
poses harm,” said Shannon Brownlee, acting director of the health policy
program at the New America Foundation and the author of “Overtreated: Why Too
Much Medicine Is Making Us Sicker and Poorer.”
“Sometimes the test leads you down a path, a therapeutic
cascade, where you start to tumble downstream to more and more testing, and
more and more invasive testing, and possibly even treatment for things that
should be left well enough alone.”
Have you experienced too much medicine? As part of The New
York Times’s online series The Agenda, I asked readers to share their stories.
More than 1,000 responded, with examples big and small.
Some complained that when they switch doctors they are
required to undergo duplicate blood work, scans or other tests that their
previous doctor had only recently ordered. Others told of being caught in a
unending maze of testing and specialists who seem to forget the patient’s
original complaint. I heard from doctors and nurses, too — health professionals
frustrated by a system that encourages these excesses…
The remainder of the article (full-text free): http://well.blogs.nytimes.com/2012/08/27/overtreatment-is-taking-a-harmful-toll/?hp
4. Compared to
Aspirin Alone, Taking Plavix with Aspirin Increases Risk of Bleeding, Death and
Does Not Help Prevent Second Stroke, Study Says
Effects of Clopidogrel Added to Aspirin in Patients with
Recent Lacunar Stroke. The SPS3 Investigators. N Engl J Med 2012; 367:817-825
Background: Lacunar infarcts are a frequent type of stroke
caused mainly by cerebral small-vessel disease. The effectiveness of
antiplatelet therapy for secondary prevention has not been defined.
Methods: We conducted a double-blind, multicenter trial
involving 3020 patients with recent symptomatic lacunar infarcts identified by
magnetic resonance imaging. Patients were randomly assigned to receive 75 mg of
clopidogrel or placebo daily; patients in both groups received 325 mg of
aspirin daily. The primary outcome was any recurrent stroke, including ischemic
stroke and intracranial hemorrhage.
Results: The participants had a mean age of 63 years, and
63% were men. After a mean follow-up of 3.4 years, the risk of recurrent stroke
was not significantly reduced with aspirin and clopidogrel (dual antiplatelet
therapy) (125 strokes; rate, 2.5% per year) as compared with aspirin alone (138
strokes, 2.7% per year) (hazard ratio, 0.92; 95% confidence interval [CI], 0.72
to 1.16), nor was the risk of recurrent ischemic stroke (hazard ratio, 0.82;
95% CI, 0.63 to 1.09) or disabling or fatal stroke (hazard ratio, 1.06; 95% CI,
0.69 to 1.64). The risk of major hemorrhage was almost doubled with dual
antiplatelet therapy (105 hemorrhages, 2.1% per year) as compared with aspirin
alone (56, 1.1% per year) (hazard ratio, 1.97; 95% CI, 1.41 to 2.71; P less
than 0.001). Among classifiable recurrent ischemic strokes, 71% (133 of 187)
were lacunar strokes. All-cause mortality was increased among patients assigned
to receive dual antiplatelet therapy (77 deaths in the group receiving aspirin
alone vs. 113 in the group receiving dual antiplatelet therapy) (hazard ratio,
1.52; 95% CI, 1.14 to 2.04; P=0.004); this difference was not accounted for by
fatal hemorrhages (9 in the group receiving dual antiplatelet therapy vs. 4 in
the group receiving aspirin alone).
Conclusions: Among patients with recent lacunar strokes, the
addition of clopidogrel to aspirin did not significantly reduce the risk of
recurrent stroke and did significantly increase the risk of bleeding and death.
(Funded by the National Institute of Neurological Disorders and Stroke and
others; SPS3 ClinicalTrials.gov number, NCT00059306.)
5. Less painful ABG
sampling using jet injection of 2% lidocaine: a randomized controlled clinical
trial
Hajiseyedjavady H, et al. Amer J Emerg Med.
2012;30:1100-1104.
Objective: The aim of this study was to compare pain levels
from arterial blood gas (ABG) sampling performed with or without application of
lidocaine via jet injector.
Background: Pain is still a primary concern in the emergency
department. Arterial blood gas sampling is a very painful procedure. No better
technique for decreasing the pain of the ABG procedure has been presented. An
ideal local anesthesia procedure for ABG sampling should be rapid, easily
learned, inexpensive, and free of needlestick risk.
Materials and Methods: We evaluated the effectiveness of a
lidocaine jet injection technique in achieving satisfactory pain control in
patients undergoing ABG sampling. Forty-two patients were randomized to 2
groups: group A, which received lidocaine by jet injection (0.2 mL of lidocaine
2%), and group B, a control group that received a topical application of 1 mL
of lidocaine gel 2% 2 minutes before the ABG sampling. Pain was assessed on a
10-cm visual analog scale (0, absence of pain; 10, greatest imaginable pain).
Results: The pain visual analog scale score during ABG
sampling was considerably lower in group A compared with group B (1.29 ± 0.90
vs 4.19 ± 1.43; P less than .001). The number of attempts required for ABG
sampling was significantly lower in group A compared with group B (1.29 ± 0.46
vs 2.1 ± 0.12; P = .009). All residents reported ease of use with the lidocaine
jet injection procedure (P less than .05).
Conclusion: Lidocaine jet injection provides beneficial and
rapid anesthesia, resulting in less pain and a greater rate of successful ABG
sampling. Therefore, it is recommended for use before ABG sampling to decrease
the patient's pain and the number of unsuccessful attempts and to enhance the
patient's satisfaction.
6. Out-of-hospital
treatment for PE safe for selected patients
Sep 12, 2012 | Reuters Health News. By Will Boggs, MD. NEW
YORK (Reuters Health)
Selected patients with newly diagnosed pulmonary embolism
(PE) may be safely treated as outpatients, a new systematic review suggests.
Dr. David R. Vinson from Kaiser Permanente Roseville Medical
Center in Roseville, California, who led the study, described the evolution of
the concept in an email to Reuters Health.
“In the late 1990s our Sacramento, California emergency
department was among the first in the country to implement an outpatient
management treatment pathway for select patients with acute deep vein
thrombosis,” he said. “This shift in treatment venue was a welcome change for
patients.”
“A similar approach to low-risk patients with pulmonary
embolism is possible,” he continued, “but the higher morbidity and mortality
that attends pulmonary embolism will require more work upfront to insure that
such a process employs the highest safety standards and is carefully
monitored.”
In the meantime, the existing data on the safety of
exclusive ambulatory management of acute symptomatic PE aren’t very strong.
Most of the evidence is from observational studies, Dr. Vinson and colleagues
found.
Ultimately, their systematic review included eight studies
involving 777 patients. Only one was a randomized controlled trial.
As reported by the research team online September 3rd in
Annals of Emergency Medicine, all eight studies objectively confirmed the
diagnosis of PE, but only three studies undertook explicit risk stratification
with various instruments.
Treatment included subcutaneous low-molecular-weight heparin
for at least five days while waiting for an oral vitamin K antagonist, if
prescribed, to reach therapeutic limits.
Seven studies (including 741 patients) reported 90-day
outcomes; in these studies there were no cases of venous thromboembolic-related
or hemorrhage-related death. In the one study that reported only 180-day
outcomes, there were two deaths related to venous thromboembolism and
hemorrhage.
Nonfatal major hemorrhage rates in the seven studies with
90-day follow-up ranged from 0% to 1.2%. Nonfatal recurrent venous
thromboembolic event rates in these studies ranged from 0% to 6.2%.
Patient satisfaction rates were similar for outpatients and
inpatients (92% vs 95%, respectively), but the proportion of patients from the
inpatient control arm who would have preferred home therapy was higher than the
proportion of outpatients who would have preferred inpatient care.
“The results of this systematic review show us that
outpatient management of patients with acute symptomatic PE is feasible and can
be undertaken safely if patients are carefully screened for eligibility and if
a system is in place for patient education and timely follow-up,” Dr. Vinson
concluded.
“Home therapy has many advantages,” he said. “Leading the
list are increased patient comfort and satisfaction, lower healthcare costs,
and avoiding exposure to hospital-acquired infections.”
“Further studies are needed to better characterize the risks
and benefits of selective outpatient PE management in day-to-day practice,
outside the constraints of a randomized clinical trial,” Dr. Vinson added. “Our
research team at Kaiser Permanente will be studying several prognostic
instruments among this population in the community setting. We also hope to
study the real-world effects of a simplified prediction model as an electronic
clinical decision support tool to aid physicians in choosing the optimal site
of initial patient management.”
Vinson DR, Zehtabchi S, Yealy DM. Ann Emerg Med. 2012 August
31. [Epub ahead of print] doi:10.1016/j.annemergmed.2012.05.041
7. Diagnosis of
Intussusception by Physician Novice Sonographers in the Emergency Department
Riera A, et al. Ann Emerg Med 2012;60:264-268.
Study objective: We investigate the performance
characteristics of bedside emergency department (ED) ultrasonography by
nonradiologist physician sonographers in the diagnosis of ileocolic
intussusception in children.
Methods: This was a prospective, observational study
conducted in a pediatric ED of an urban tertiary care children's hospital.
Pediatric emergency physicians with no experience in bowel ultrasonography
underwent a focused 1-hour training session conducted by a pediatric
radiologist. The session included a didactic component on sonographic
appearances of ileocolic intussusception, review of images with positive and
negative results for intussusceptions, and a hands-on component with a live
child model. On completion of the training, a prospective convenience sample
study was performed. Children were enrolled if they were to undergo diagnostic
radiology ultrasonography for suspected intussusception. Bedside
ultrasonography by trained pediatric emergency physicians was performed and
interpreted as either positive or negative for ileocolic intussusception.
Ultrasonographic studies were then performed by diagnostic radiologists, and
their results were used as the reference standard. Test characteristics
(sensitivity, specificity, positive and negative predictive values) and
likelihood ratios were calculated.
Results: Six pediatric emergency physicians completed the
training and performed the bedside studies. Eighty-two patients were enrolled.
The median age was 25 months (range 3 to 127 months). Thirteen patients (16%)
received a diagnosis of ileocolic intussusception by diagnostic radiology.
Bedside ultrasonography had a sensitivity of 85% (95% confidence interval [CI]
54% to 97%), specificity of 97% (95% CI 89% to 99%), positive predictive value
of 85% (95% CI 54% to 97%), and negative predictive value of 97% (95% CI 89% to
99%). A positive bedside ultrasonographic result had a likelihood ratio of 29
(95% CI 7.3 to 117), and a negative bedside ultrasonographic result had a
likelihood ratio of 0.16 (95% CI 0.04 to 0.57).
Conclusion: With limited and focused training, pediatric
emergency physicians can accurately diagnose ileocolic intussusception in
children by using bedside ultrasonography.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)00152-7/fulltext
8. Pictorial Guide:
Hematoma Blocks for Reduction of Distal Radius Fractures
A 43-year-old male presents after a mechanical fall down
five stairs with a fall on outstretched hand injury to his left wrist. There is
an obvious deformity. The Denver EM Residency breaks the procedure down with a
series of instructional photos.
Full-text (free): http://www.epmonthly.com/features/current-features/hematoma-blocks-for-reduction-of-distal-radius-fractures-/
9. False-Negative
FAST Examination: Associations with Injury Characteristics and Patient Outcomes
Laselle BT, et al. Ann Emerg Med 2012;60: 326-334.e3
Study objective: Focused assessment with sonography in
trauma (FAST) is widely used for evaluating patients with blunt abdominal
trauma; however, it sometimes produces false-negative results. Presenting
characteristics in the emergency department may help identify patients at risk
for false-negative FAST result or help the physician predict injuries in
patients with a negative FAST result who are unstable or deteriorate during
observation. Alternatively, false-negative FAST may have no clinical
significance. The objectives of this study are to estimate associations between
false-negative FAST results and patient characteristics, specific abdominal
organ injuries, and patient outcomes.
Methods: This was a retrospective cohort study including
consecutive patients who presented to an urban Level I trauma center between
July 2005 and December 2008 with blunt abdominal trauma, a documented FAST, and
pathologic free fluid as determined by computed tomography, diagnostic peritoneal
lavage, laparotomy, or autopsy. Physicians blinded to the study purpose used
standardized abstraction methods to confirm FAST results and the presence of
pathologic free fluid. Multivariable modeling was used to assess associations
between potential predictors of a false-negative FAST result and false-negative
FAST result and adverse outcomes.
Results: During the study period, 332 patients met inclusion
criteria. Median age was 32 years (interquartile range 23 to 45 years), 67%
were male patients, the median Injury Severity Score was 27 (interquartile
range 17 to 41), and 162 (49%) had a false-negative FAST result. Head injury
was positively associated with false-negative FAST result (odds ratio [OR] 4.9;
95% confidence interval [CI] 1.5 to 15.7), whereas severe abdominal injury was
negatively associated (OR 0.3; 95% CI 0.1 to 0.5). Injuries to the spleen (OR
0.4; 95% CI 0.24 to 0.66), liver (OR 0.36; 95% CI 0.21 to 0.61), and abdominal
vasculature (OR 0.17; 95% CI 0.07 to 0.38) were also negatively associated with
false-negative FAST result. False-negative FAST result was not associated with
mortality (OR 0.89; 95% CI 0.42 to 1.9), prolonged ICU length of stay (relative
risk 0.88; 95% CI 0.69 to 1.12), or total hospital length of stay (relative
risk 0.92; 95% CI 0.76 to 1.12). However, patients with false-negative FAST
results were substantially less likely to require therapeutic laparotomy (OR
0.31; 95% CI 0.19 to 0.52).
Conclusion: Patients with severe head injuries and minor
abdominal injuries were more likely to have a false-negative than true-positive
FAST result. On the other hand, patients with spleen, liver, or abdominal
vascular injuries are less likely to have false-negative FAST examination
results. Adverse outcomes were not associated with false-negative FAST
examination results, and in fact patients with false-negative FAST result were
less likely to have a therapeutic laparotomy. Further studies are needed to
assess the strength of these findings.
10. Images in
Clinical Medicine
Cerebral Air Embolism
Cerebral Fat Embolism
Chvostek’s and Trousseau’s Signs
Voluntary Nystagmus
Burton's Line
Corneal Dendrites
Foot Pain and Fever
11. Evaluating the
Quality of Decision-making for Diagnostic Tests: A [CMS] Methodological
Misadventure
Sox HC. Ann Emerg Med 2012;60:291-292.
This [September] issue of Annals contains an article about
evaluating hospitals' use of computed tomography (CT) scans for patients
presenting to emergency departments (EDs) with acute headache.1 The authors
tested a system devised by the Centers for Medicare & Medicaid Services
(CMS) to measure the number of unwarranted CT scans, an intent that responds to
the increasing number of brain CT scans being obtained in EDs. The purpose of
this editorial is to describe the system used by CMS, summarize its
performance, and suggest better solutions to the problem that CMS is trying to
address.
This program is part of a CMS initiative to identify
poor-quality decisionmaking about imaging tests in hospital-associated
outpatient services. The CMS has a statutory requirement to collect outpatient
quality measures from hospitals and to make the findings public. Rather than
require hospitals to report the results of their quality measurements to CMS,
the agency uses Medicare claims data, which include the name of the hospital
and the ordering clinician, the identity of the imaging procedure and other
tests, and, as a proxy for clinical data, the primary and secondary diagnoses.
The CMS initiative will also track the use of abdominal CT with contrast,
thoracic CT or magnetic resonance imaging (MRI) with contrast, follow-up of mammograms,
simultaneous use of brain and sinus CT scans, lumbar spine CT or MRI for back
pain, and cardiac testing for risk assessment before low-risk noncardiac
surgery. The agency's stated goal is to reduce “waste,” to reduce unnecessary
exposure to radiation and contrast dye, and to increase adherence to
evidence-based practice. CMS will report the results to the public on Hospital
Compare, a consumer-oriented Web site.
The CMS “efficiency measure” of head CT use in ED patients
with acute headache is the proportion of such patients who had an uncalled-for
same-day brain CT scan.2, 3 To be included, patients must have had a headache
diagnosis code for tension headaches, migraine headaches, cluster headaches,
and other headache diagnoses that can be readily diagnosed without brain
imaging.3 The CMS appears to be seeking a measure of CT scan use when the
patient does not have one of the widely accepted indications for imaging in
headache patients (eg, history of intracranial aneurysm, “thunderclap”
headache, CT in a patient subsequently admitted to the hospital). Therefore,
starting with the fraction of all ED headache patients who had a brain CT scan,
CMS excludes from the denominator and numerator those who had a Medicare
billing claim that contained a diagnostic code for an accepted CT scan
indication in patients with acute headache. Ideally, therefore, the numerator
of the CT scan efficiency measure would be the number of patients who had a
discharge diagnosis of a benign headache and had a brain CT; the denominator
would be number of patients with a benign headache.
This approach has a serious weakness: it relies on
diagnostic codes in the Medicare billing claim for the ED CT scan to identify
patients who, because they had “reasonable” brain CT indications (so-called
exclusions), would be excluded from the CMS measure. If the hospital failed to
code an appropriate indication for CT scan, the patient would be added to the
list of those with an inappropriate CT scan. If coding errors were common, the
CMS measure would substantially overestimate the hospital's use of uncalled-for
brain scans. The authors of the article in this month's issue of Annals
measured undercoding by hand-searching for appropriate CT scan indications in
the medical records of patients who CMS had reported had had an inappropriate
scan. The authors' measure of the “reliability” of the CMS measure was the
proportion of denominator-eligible patients (ie, those who CMS found had no
acceptable indication for a brain CT) whose medical record contained no
acceptable indication as defined by CMS. Therefore, reliability was a measure
of the agency's ability to use diagnostic codes in a Medicare claim to detect
patients with acceptable reasons to have a CT scan. The authors found that the
CMS measure was 34.6% reliable. In other words, the medical record did not show
a diagnostic code for a valid indication for a brain CT in 34% of the patients
whose Medicare billing claim for the CT scan showed no valid indication.
The CMS approach has a second weakness: its list of good
reasons for receiving a brain CT may have been incomplete. In that case, the
chart reviewers would have scored some patients as having no good reason to
have a brain CT when they did actually have a good reason. The authors developed
a consensus list of indications for CT in patients with headache; it listed
some indications that the CMS list did not include (eg, patient is receiving
heparin, warfarin, or aspirin). They found that nearly half of the patients who
did not have a CMS indication for brain CT had a “consensus clinical
indication” in the medical record. The bottom line is that the CMS process of
relying on diagnostic coding in Medicare billing claims missed many patients
who had a valid indication for CT, as measured by the CMS list of indications
or by the expanded list of clinical consensus indications.
The study was well planned and executed. The principal
shortcoming is that reviewers knew that they were reviewing charts of patients
whom CMS had identified as having had a CT scan for inappropriate reasons. A
better study design would have used a study population comprised of patients
with both appropriate and inappropriate CT scans, blinded the reviewers to the
purpose of the study, presented reviewers with the list of valid indications
for CT, and asked reviewers to search the medical record for a valid
indication.
The present study shows that the CMS method for evaluating
the use of brain CT in ED patients with headache systematically overestimates
inappropriate test ordering. The most serious flaw in the CMS method is the use
of Medicare billing claims to identify patients who had a reasonable indication
for a brain CT. Only 34% of patients whose Medicare billing claim listed none
of the CMS indications for brain CT had none of those indications in their
medical record.
This problem is solvable in principle: a computer-based
physician ordering system could display the consensus list of indications for
brain CT in a patient with headache. The physician would check off any
indications that applied to the patient. If the patient had no valid
indications for brain CT, the computer would remind the ordering physician to
reconsider the plan to order the CT scan. As the authors note, this approach
facilitates “gaming the system.” The physician who really wanted to obtain the
brain CT scan would be sorely tempted to check off the indication that was
closest to being true. In that direction lies a slippery slope.
As a process, using administrative codes to detect valid indications
for a CT scan is flawed because instructing a computer to search for a
diagnosis code in a Medicare billing claim is an unacceptably poor substitute
for reading the patient's medical record. A natural language search of the text
of the medical record might be better than searching Medicare claims data. Even
this approach has a fundamental conceptual flaw, which is to substitute a
simplistic measure of quality—the presence of an indication for testing—for a
far more clinically relevant measure: asking whether conducting the test could
have altered the management of the patient. Computer-based decision models can
answer this question by using the sensitivity and specificity of the test and
the patient's clinical features and preferences for outcome states.4, 5
The main contribution of this study is to force the CMS to
rethink its approach to evaluating ED test-ordering practices. Using what is
now revealed as a flawed measure of inappropriate brain CT scan ordering, the
agency has planned to monitor test ordering, penalize poor performance, and
publish the results. Arguably, the CMS ran one stop sign when it proceeded
without first validating the use of Medicare billing claims to detect valid
indications for brain CT scans. The agency ran a second stop sign when it
proceeded with its plans after the National Quality Forum declined to endorse
its measure of inappropriate brain scan ordering. With the publication of the
article by Schuur et al,1 the agency has encountered a barrier that imperils
the credibility of its hospital outpatient quality measures program. The CMS
should postpone implementation of its plan and regroup, not just for measures
of brain CT scan use but for any of its measures that rely on Medicare claims
data.
Ironically, if Medicare were asked to cover a test in which
the posttest probability of the target condition was only 34% after a positive
test result, it would refuse to pay for the test. The time has come for CMS to
hold its quality measures to its own performance standards.
See also Schuur JD, et al. Assessment of Medicare's Imaging
Efficiency Measure for Emergency Department Patients with Atraumatic Headache.
Ann Emerg Med 2012; 280-290.e4
Full-text (free): http://www.annemergmed.com/article/S0196-0644(11)01989-5/fulltext
12. Clinical and
radiographic characteristics associated with abusive and nonabusive head
trauma: a systematic review.
Piteau SJ, et al. Pediatrics. 2012 Aug;130(2):315-23.
BACKGROUND AND OBJECTIVE: To systematically review the
literature to determine which clinical and radiographic characteristics are
associated with abusive head trauma (AHT) and nonabusive head trauma (nAHT) in
children.
METHODS: We searched MEDLINE, EMBASE, PubMed, conference
proceedings, and reference lists to identify relevant studies. Two reviewers
independently selected studies that compared clinical and/or radiographic
characteristics including historical features, physical exam and imaging
findings, and presenting signs or symptoms in hospitalized children ≤6 years
old with AHT and nAHT.
RESULTS: Twenty-four studies were included. Meta-analysis
was complicated by inconsistencies in the reporting of characteristics and high
statistical heterogeneity. Notwithstanding these limitations, there were 19
clinical and radiographic variables that could be meta-analyzed and odds ratios
were determined for each variable. In examining only studies deemed to be high
quality, we found that subdural hemorrhage(s), cerebral ischemia, retinal
hemorrhage(s), skull fracture(s) plus intracranial injury, metaphyseal
fracture(s), long bone fracture(s), rib fracture(s), seizure(s), apnea, and no
adequate history given were significantly associated with AHT. Epidural
hemorrhage(s), scalp swelling, and isolated skull fracture(s) were
significantly associated with nAHT. Subarachnoid hemorrhage(s), diffuse axonal
injury, cerebral edema, head and neck bruising, any bruising, and vomiting were
not significantly associated with either type of trauma.
CONCLUSIONS: Clinical and radiographic characteristics
associated with AHT and nAHT were identified, despite limitations in the
literature. This systematic review also highlights the need for consistent
criteria in identifying and reporting clinical and radiographic characteristics
associated with AHT and nAHT.
13. The motor
component does not convey all the mortality prediction capacity of the Glasgow
Coma Scale in trauma patients
Vivien B, et al. Amer J Emerg Med 2012;30:1032-1041.
Purpose: We tested the hypothesis that the motor component
of the Glasgow Coma Scale (GCS) conveys most of the predictive information of
triage scores (Triage Revised Trauma Score [T-RTS] and the Mechanism, GCS, Age,
arterial Pressure score [MGAP]) in trauma patients.
Method: We conducted a multicenter prospective observational
study and evaluated 1690 trauma patients in 14 centers. We compared the GCS,
T-RTS, MGAP, and Trauma Related Injury Severity Score (reference standard)
using the full GCS or its motor component only using logistic regression model,
area under the receiver operating characteristic curve, and reclassification
technique.
Results: Although some changes were noted for the GCS itself
and the Trauma Related Injury Severity Score, no significant change was observed
using the motor component only for T-RTS and MGAP when considering (1) the odds
ratio of variables included in the logistic model as well as their
discrimination and calibration characteristics, (2) the area under the receiver
operating characteristic curve (0.827 ± 0.014 vs 0.831 ± 0.014, P = .31 and
0.863 ± 0.011 vs 0.859 ± 0.012, P = .23, respectively), and (3) the
reclassification technique. Although the mortality rate remained less than the
predetermined threshold of 5% in the low-risk stratum, it slightly increased
for MGAP (from 1.9% to 3.9%, P = .048).
Conclusion: The use of the motor component only of the GCS
did not change the global performance of triage scores in trauma patients.
However, because a subtle increase in mortality rate was observed in the
low-risk stratum for MGAP, replacing the GCS by its motor component may not be
recommended in every situation.
14. New Guidelines
for Lightning Injury Prevention, Treatment
Laurie Barclay, MD. Medscape Medical News. August 30, 2012 —
The Wilderness Medical Society has updated their 2006 evidence-based practice
guidelines describing precautions that can reduce risk for lightning injury, as
well as effective medical treatments for lightning-related injuries. The
updated recommendations, which aim to inform clinicians regarding best
practices, appear in the September issue of Wilderness and Environmental
Medicine.
"Lightning occurs nearly 50 times per second
worldwide," write Chris Davis, MD, wilderness fellow and clinical
instructor at the Department of Emergency Medicine, University of Colorado
Hospital, Aurora, and colleagues. "Approximately one fifth of these
flashes result in ground strikes. Internationally, an estimated 24,000
fatalities with 10 times as many injuries occur annually as a result of
lightning."
The expert panel, which reviewed the available evidence
concerning the prevention and treatment of lightning injury, primarily found
small, retrospective case reports or series. Because prospective research
regarding lightning injury is neither feasible nor ethical, this is hardly
surprising.
In the United States, lightning-related fatalities have
declined consistently during the past 5 decades to about 40 per year. Most of
these deaths occur in men aged 20 to 45 years.
"With some basic prevention strategies and common sense
the vast majority of lightning injuries can be prevented," Dr. Davis said
in a news release.
Prevention Strategies
The expert panel convened by the Wilderness Medical Society
strategies issued 5 stronger and 2 weaker recommendations for prevention, as
classified using American College of Chest Physicians criteria. The guidelines
recommend:
·
Individuals should find shelter when hearing
thunder and should avoid bodies of water during lightning activity.
·
Individuals should delay resuming outdoor
activity for at least 30 minutes after hearing the last thunderclap.
·
When lightning strikes are imminent, individuals
should assume a sitting or crouching position with knees and feet close
together, sitting on insulating material if available. If they are standing,
their feet should touch, and if they are sitting, they should lift their feet
off the ground.
·
To limit potential mass casualties, group
members caught outdoors in a lightning storm should separate more than 20 feet
from one another.
·
Commercial services can automatically notify
subscribers when the National Lightning Detection Network detects nearby
lightning.
·
In a mountain environment, peaks and ridgelines
should be avoided in the afternoon
Treatment Strategies
Regarding treatment of lightning-related injuries, the
committee included 18 specific recommendations. Especially noteworthy is a
reverse triage recommendation for lightning strike victims, in which those
lacking vital signs or spontaneous respirations receive top priority. The
rationale is that simultaneous cardiac and respiratory arrest may result in
sudden death from lightning strike, and that a second cardiac arrest may occur
in many victims who have return of spontaneous circulation if ventilation is
not supported.
Basic and advanced life support algorithms are the standard
of care for lightning strike victims requiring resuscitation.
Patients incurring a direct strike, those with chest pain or
shortness of breath, and other high-risk patients should undergo a screening
electrocardiogram and echocardiography.
Long-term neurorehabilitation is often the only available
treatment option for patients with permanent neurologic disability caused by
lightning strikes.
The updated guidelines also discuss lightning-related
injuries to the skin, eye, or ear, as well as considerations regarding
psychiatric and neurocognitive function, pregnancy, disposition, and
evacuation.
"Although the strength of the overall evidence is
limited, the authors believe that many recommendations can be strongly
supported as there is little risk of associated harm," the authors
conclude. "Improved reporting to a national or international database
could help with future epidemiological studies. Consensus on injury classification
systems would also simplify the reporting process and allow data to be more
easily combined for future study."
The authors have disclosed no relevant financial
relationships.
Davis C, et al. Wilderness Environ Med. 2012;23:260-269.
Full-text (free): http://www.wemjournal.org/article/S1080-6032(12)00180-9/fulltext
15. Predictive
accuracy of ST depression during rapid AF on the presence of obstructive CAD
Pradhan R, et al. Amer J Emerg Med. 2012;30:1042-1047.
Background; Rapid atrial fibrillation (AF) is commonly
associated with ST-segment depressions. ST-segment depression during a chest
pain episode or exercise stress testing in sinus rhythm is predictive of
obstructive coronary artery disease (CAD), but it is unclear if the presence or
magnitude of ST-segment depression during rapid AF has similar predictive
accuracy.
Methods: One hundred twenty-seven patients with rapid AF
(heart rate ≥120 beats per minute) who had cardiac catheterization performed
during the same hospital admission were retrospectively reviewed. Variables to
compute thrombolysis in myocardial infarction (TIMI) risk score, demographic
profiles, ST-segment deviation, cardiac catheterization results, and cardiac
interventions were collected.
Results: Thirty-five patients had ST-segment depression of 1
mm or more, and 92 had no or less than 1 mm ST depression. Thirty-one patients
were found to have obstructive CAD. In the group with ST-segment depression, 11
(31%) patients had obstructive CAD and 24 (69%) did not. In the group with less
than 1 mm ST-segment depression, 20 (22%) had obstructive CAD and 72 (78%) did
not (P = .25). Sensitivity, specificity, and positive and negative predictive
values for presence of obstructive CAD were 35%, 75%, 31%, and 78%,
respectively. The presence of ST-segment depression of 1 mm or more was not
associated with presence of obstructive CAD before or after adjustment of TIMI
variables. The relationship between increasing grades of ST-segment depression
and obstructive CAD showed a trend toward significance (P = .09), which did not
persist after adjusting for TIMI risk variables (P = .36).
Conclusion: ST-segment depression during rapid AF is not
predictive for the presence of obstructive CAD.
16. Betting on
Intensive BP Reduction to Improve Outcomes after ICH
An analysis of INTERACT1 raises the hope that intensive
blood pressure reduction ultimately will be shown to improve clinical outcomes.
Intracerebral hemorrhage (ICH) often acutely increases blood
pressure (BP). This hypertensive response may promote ongoing bleeding, but we
do not know whether BP reduction improves clinical outcomes. To address this
uncertainty, researchers conducted the INTERACT1 trial, randomizing 404 patients
with ICH to intensive BP reduction (systolic BP target, 140 mm Hg) or standard
BP control (180 mm Hg systolic). This pilot trial showed that intensive BP
reduction decreased hematoma growth an average 1.7 mL more than standard BP
control, but the trial lacked power to detect a significant difference in
clinical outcomes, prompting the larger, ongoing INTERACT2 trial.
To gauge the likelihood that INTERACT2 will demonstrate a
clinical benefit, the same investigators have now analyzed the association
between hematoma growth and outcomes in INTERACT1. In models controlling for
numerous potential confounders such as age, stroke severity, and hematoma
volume, each 1-mL increase in hematoma growth was associated with a 5% greater
risk for death or dependency (modified Rankin Scale score of 3–5) at 90 days.
Therefore, the approximately 2-mL reduction in hematoma growth achieved by
intensive BP reduction in INTERACT1 would, theoretically, result in a 10%
improvement in clinical outcomes.
Comment: This analysis reinforces prior reports of an
association between hematoma growth and poor outcomes after ICH. Hematoma
growth might simply reflect more-severe illness and greater comorbidity, in
which case reducing hematoma growth by lowering BP would not improve outcomes.
Still, this study highlights the potential clinical payoff of reducing hematoma
growth and raises hope for the success of INTERACT2. In the meantime,
clinicians should follow the 2010 American Heart Association guidelines, which
essentially advise a systolic BP target of 140–160 mm Hg. In selected patients
at high risk for hematoma growth (e.g., those on anticoagulants or with a spot
sign on computed tomographic angiography), aiming for the lower end of that
range for the first 24 hours is reasonable.
— Hooman Kamel, MD. Published in Journal Watch Neurology
August 14, 2012. Citation: Delcourt C et al. Hematoma growth and outcomes in
intracerebral hemorrhage: The INTERACT1 study. Neurology 2012 Jul 24; 79:314.
17. Update:
Antiemetics for Vomiting Associated with Acute Gastroenteritis in Children
Carter B, et al. Ann Emerg Med 2012;60:e5-e6.
Take-Home Message: Oral or intravenous ondansetron is an
effective treatment for the management of children with vomiting from acute
gastroenteritis.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)00121-7/fulltext
18. Revised
Definition Recommended for Wrist Sprain
Larry Hand. Medscape Medical News. August 30, 2012 — Wrist
sprain turned out to be an inaccurate diagnosis in 80% of patients with
negative X-rays during a 1-year study at a Norwegian outpatient clinic,
prompting researchers to call for a revised definition of wrist sprain,
according to a study published in the October 2012 issue of Injury. The
researchers also write that magnetic resonance imaging (MRI) should be used to
make accurate diagnoses for wrist injuries.
Torbjørn H. Bergh, assistant professor in the Department of
Surgical Sciences, University of Bergen, Norway, and colleagues conducted a
prospective study involving 155 patients presenting to the Bergen Accident and
Emergency Department with acute wrist trauma that required X-rays between
November 5, 2009, and November 4, 2010. All 155 patients had normal X-rays.
Subsequent MRIs were administered within a median of 1 day (range, 0 - 31
days).
The patients ranged in age from 18 to 49 years (median, 28
years); 85 were men and 70 were women. The right wrists were injured in 85
patients and the left wrist in 70 patients. Falls caused most of the wrist
injuries and, again, all of the X-rays were normal. Ordinarily, such injuries
are diagnosed as wrist sprain, the researchers write.
Of the 155 MRIs, 125 (4/5) showed pathological findings
despite negative X-rays. Per the International Wrist Investigator Workshop
sprain is defined as a partial ligament tear or injury. Thirty MRIs were
normal.
The researchers found that 44 patients (28%) had a total of
54 fractures and 33 (22%) had a total of 56 bone bruises. Other injuries
included 15 ligament injuries, 13 partial tendon ruptures, 8 muscle contusions,
23 uniloculated ganglions of the wrist, and 69 cases of synovitis. The
researchers found that only 13% of the patients had ligament tears, or wrist
sprain as currently defined.
"Consequently, the clinical and radiological
investigations fail to adequately diagnose the complete pathology in wrist
sprains," the researchers write. "Alternatively, the diagnosis and
definition of a sprained wrist are incomplete and inaccurate according to the
present definition and ought to be changed."
They continue, "We also find, like others, MRI to be a
good diagnostic tool to identify injuries associated with wrist sprain. Proper
MRI modalities enable simultaneous diagnosis of the soft tissue-, ligament- and
bone injuries."
Limitations of the study include the possible loss of
patients that could have been included, as well as the "various degrees of
clinical and radiological experience" of the doctors on call who conducted
the examinations, the researchers write.
Nevertheless, they recommend that the current International
Wrist Investigator Workshop definition of wrist sprain be revised to
"occult partial or complete soft tissue (ligament, tendon, muscle) or bony
injury in relation to a trauma with negative X-ray."
They also conclude, "Based on this study, we recommend
early MRI of acute wrist sprains with pain or functional symptoms that does not
settle within 2 weeks. This will provide a more specific diagnosis, which
hopefully will lead to more appropriate treatment."
The authors disclosed support from research grants from the
University of Bergen and the Norwegian Research Council.
Bergh TH, et al. Injury. 2012;43:1732-1742.
19. Comparative
Effectiveness of Warfarin and New Oral Anticoagulants for the Management of
Atrial Fibrillation and Venous Thromboembolism: A Systematic Review
Adam SS, et al. Ann Intern Med. 28 August 2012
Background: New oral anticoagulants (NOACs), including
direct thrombin inhibitors (DTIs) and factor Xa (FXa) inhibitors, are emerging
alternatives for prophylaxis and treatment of atrial fibrillation (AF) and
venous thromboembolism (VTE).
Purpose: To compare the benefits and harms of NOACs versus
warfarin for AF and VTE.
Data Sources: MEDLINE, EMBASE, and the Cochrane Database of
Systematic Reviews from January 2001 through July 2012; U.S. Food and Drug
Administration (FDA) database for adverse event reports.
Study Selection: English-language, randomized, controlled
trials (RCTs) comparing NOACs with warfarin for management of AF or VTE and
observational studies and FDA reports on adverse effects.
Data Extraction: Two independent reviewers abstracted data
and rated study quality and strength of evidence.
Data Synthesis: Six good-quality RCTs compared NOACs (2 DTI
studies, 4 FXa inhibitor studies) with warfarin. In AF, NOACs decreased
all-cause mortality (risk ratio [RR], 0.88 [95% CI, 0.82 to 0.96]); in VTE,
NOACs did not differ for mortality or VTE outcomes. Across indications, adverse
effects of NOACs compared with warfarin were fatal bleeding (RR, 0.60 [CI, 0.46
to 0.77]), major bleeding (RR, 0.80 [CI, 0.63 to 1.01]), gastrointestinal
bleeding (RR, 1.30 [CI, 0.97 to 1.73]), and discontinuation due to adverse events
(RR, 1.23 [CI, 1.05 to 1.44]). Subgroup analyses suggest a higher risk for
myocardial infarction with DTIs than with FXa inhibitors. Bleeding risk for
NOACs may be increased in persons older than 75 years or those receiving
warfarin who have good control.
Limitation: There were no head-to-head comparisons of NOACs
and limited data on harms.
Conclusion: New oral anticoagulants are a viable option for
patients receiving long-term anticoagulation. Treatment benefits compared with
warfarin are small and vary depending on the control achieved by warfarin
treatment.
20. Effect of Bedside
US on the Certainty of Physician Clinical Decision-making for Septic Patients
in the ED
Haydar SA, et al. Ann Emerg Med 2012;60;346-358.e4
Study objective: Sepsis protocols promote aggressive patient
management, including invasive procedures. After the provision of point-of-care
ultrasonographic markers of volume status and cardiac function, we seek to
evaluate changes in emergency physician clinical decisionmaking and physician
assessments about the clinical utility of the point-of-care ultrasonographic
data when caring for adult sepsis patients.
Methods: For this prospective before-and-after study,
patients with suspected sepsis received point-of-care ultrasonography to
determine cardiac contractility, inferior vena cava diameter, and inferior vena
cava collapsibility. Physician reports of treatment plans, presumed causes of
observed vital sign abnormalities, and degree of certainty were compared before
and after knowledge of point-of-care ultrasonographic findings. The clinical
utility of point-of-care ultrasonographic data was also evaluated.
Results: Seventy-four adult sepsis patients were enrolled:
27 (37%) sepsis, 30 (40%) severe sepsis, 16 (22%) septic shock, and 1 (1%)
systemic inflammatory response syndrome. After receipt of point-of-care
ultrasonographic data, physicians altered the presumed primary cause of vital
sign abnormalities in 12 cases (17% [95% confidence interval {CI} 8% to 25%])
and procedural intervention plans in 20 cases (27% [95% CI 17% to 37%]).
Overall treatment plans were changed in 39 cases (53% [95% CI 41% to 64%]).
Certainty increased in 47 (71%) cases and decreased in 19 (29%). Measured on a
100-mm visual analog scale, the mean clinical utility score was 65 mm (SD 29;
95% CI 58 to 72), with usefulness reported in all cases.
Conclusion: Emergency physicians found point-of-care
ultrasonographic data about cardiac contractility, inferior vena cava diameter,
and inferior vena cava collapsibility to be clinically useful in treating adult
patients with sepsis. Increased certainty followed acquisition of point-of-care
ultrasonographic data in most instances. Point-of-care ultrasonography appears
to be a useful modality in evaluating and treating adult sepsis patients.
21. Single-Use Vials:
Safety, Cost, and Availability
Laura A. Stokowski, RN, MS. Medscape Infectious Diseases.
Posted: 08/02/2012
The problem of reuse of single-use medical items and devices
is not new. Almost as soon as healthcare began adopting single-use and
disposable items in the 1970s for purposes of infection control, the reuse of
such items began as a cost-saving measure. Despite infection control guidance
to the contrary, in 2008, 20%-30% of US hospitals reported that they reused at
least 1 type of single-use device.[1]
Evidence suggests that reuse practices extend to sterile
vials of injectable drugs intended for one-time use. For example, some nurses
and other healthcare providers admit to practices such as re-entering
single-dose/single-use sterile vials after the initial access, either for the
same or different patients, or inappropriately diluting contents of single-dose
vials. A 2012 online survey[2] of 5446 healthcare practitioners found that 6%
of respondents sometimes or always used single-dose/single-use vials for
multiple patients, 15% used the same syringe to re-enter multidose vials, and
9% sometimes or always used a common bag or bottle of intravenous solution as a
source of flushes and drug diluents for multiple patients. Comments made by
respondents suggest that healthcare practitioners have many misconceptions
about injection safety with single-use vials.
Why would educated healthcare professionals, committed to
patient safety, do such a thing? The reasons are many. Efficiency, time
constraints, conservation of resources, avoidance of waste, and cost
considerations have all been cited to rationalize the misuse of single-dose
vials. Of significance, however, most healthcare professionals who regularly
use single-use vials inappropriately don't fully realize how dangerous it is to
do so. If aseptic technique is maintained, they reason, what's the problem?....
Continued here: http://www.medscape.com/viewarticle/768187
22. Ketamine sedation
is not associated with clinically meaningful elevation of intraocular pressure
Drayna PC, et al. Amer J Emerg Med. 2012;30:1215-1218.
Background: Ketamine is widely used for procedural sedation,
but there is limited knowledge on whether ketamine use is associated with
elevated intraocular pressure (IOP).
Objective: The aim of this study was to examine whether
there are clinically important elevations of IOP associated with ketamine use during
pediatric procedural sedation.
Methods: We prospectively enrolled children without ocular
abnormalities undergoing procedural sedation that included ketamine for
nonperiorbital injuries. We measured IOP for each eye before and at 1, 3, 5,
15, and 30 minutes after initial intravenous ketamine administration. We
performed Bland-Altman plots to determine if IOP measurements in both eyes were
in agreement. Linear regression was used to model the mean IOP of both eyes as
a function of time, dose, and age, with a robust sandwich estimator to account
for repeated measures.
Results: Among 25 participants, median (interquartile range)
age was 11 (9-12) years, and 18 (72%) were male. Median ketamine dose was 1.88
mg/kg (interquartile range, 1.43-2.03 mg/kg; range 0.96-4 mg/kg). Bland-Altman
plots demonstrated a mean difference of IOP between eyes near zero at all time
points. The largest predicted difference from baseline IOP occurred at 15
minutes, with an estimated change of 1.09 mm Hg (95% confidence interval, −0.37
to 2.55). The association between ketamine dose and mean IOP was not
statistically significant or clinically meaningful (P = .90; estimated slope,
0.119 [95% confidence interval, −1.71 to 1.95]). There were no clinically
meaningful levels of increased measured average IOP reached at any time point.
Conclusions: At dosages of 4 mg/kg or less, there are not
clinically meaningful associations of ketamine with elevation of IOP.
23. Droperidol: Time
to Drop the Blackbox Warning
Faine B, Hogrefe C. News Flash: Old Mother Hubbard Reports
the Cupboard is Bare...Time for the FDA to Let Droperidol Out of the (Black)
Box. Ann Pharmacother. 2012 Jul 24. [Epub ahead of print]
A quick way for a clinical pharmacist to eliminate himself
or herself from "employee of the month" consideration is to mention
the term medication shortage. Even with training geared toward maximizing
resources, the cumulative disappearance of a plethora of medications for the
treatment of nausea, vomiting, and/or primary headaches is almost too much for
emergency medicine physicians to manage. With prochlorperazine, metoclopramide,
promethazine, and ondansetron in increasingly short supply, it is time for the
Food and Drug Administration to revisit droperidol's black box warning driven by
QTc interval prolongation, given its questionable validity, and restore
droperidol's place in the armamentarium of emergency medicine physicians.
24. Cardiac Benefits
of Red Wine Not From the Alcohol
By Todd Neale, Senior Staff Writer, MedPage Today. September
06, 2012
Drinking moderate amounts of nonalcoholic red wine -- but
not its intoxicating equivalent -- lowered blood pressure in men with a high
cardiovascular risk, a randomized, crossover study showed.
After 4 weeks of drinking the nonalcoholic wine, blood
pressure fell by an average of 5.8/2.3 mm Hg (P less than 0.02), according to
Ramon Estruch, PhD, of the University of Barcelona in Spain, and colleagues. In
contrast, drinking standard red wine for 4 weeks and gin during another 4-week
period had no significant effect, although blood pressure did decrease a bit
with the wine, the researchers reported online in Circulation Research.
The changes in blood pressure with nonalcoholic red wine
correlated significantly with changes in plasma nitric oxide, which increased
by 4.1 µmol/L (P=0.041). Nitric oxide levels were not affected by the alcoholic
beverages.
"Therefore, the blood pressure-lowering and nitric
oxide-raising effects should be attributed to the red wine polyphenols and not
to alcohol, which seems to counteract the effects of the nonalcoholic fraction
of red wine," Estruch and colleagues wrote. "The daily consumption of
dealcoholized red wine could be useful for the prevention of low-to-moderate
hypertension," they concluded.
Moderate alcohol consumption has been associated with
reduced cardiovascular risk, and red wine in particular is believed to be
protective because of the high polyphenol content. In vitro and experimental
studies have suggested that the polyphenols found in red wine might lower blood
pressure and increase endothelial nitric oxide, but the effects in humans had
remained unclear.
The current study included 67 men (mean age 60) who had a
high cardiovascular risk, defined as the presence of diabetes or at least three
cardiovascular risk factors. After a 2-week, alcohol-free, run-in period, the
men were randomized to complete three 4-week intervention periods -- without
washout periods in between -- while maintaining a constant diet:
·
30 grams of alcohol per day in the form of red
wine (about 9 ounces)
·
About 9 ounces of nonalcoholic red wine per day
·
30 grams of alcohol per day in the form of gin
(about 3.4 ounces)
The nonalcoholic and alcoholic red wines contained similar
amounts of polyphenols. Gin does not contain polyphenols.
During the study, there were no significant changes in body
mass index, waist-to-hip ratio, or heart rate. The only significant changes
observed were in systolic and diastolic blood pressure and plasma nitric oxide
when the men were consuming nonalcoholic red wine. The researchers found
significant differences in blood pressure and nitric oxide when comparing the
nonalcoholic red wine group with the gin group.
Although the reduction in blood pressure with nonalcoholic
red wine was modest, decreases of 4 or 2 mm Hg in systolic or diastolic blood
pressure, respectively, have been associated with a 14% relative reduction in
the risk of coronary heart disease and a 20% relative reduction in stroke risk,
lending clinical significance to the findings, according to the authors.
The results of the study were largely the same when
excluding individuals with hypertension and those taking antihypertensives, the
researchers reported.
They acknowledged some limitations of the study, including
the lack of information on the effects of longer-term consumption of the
various drinks, the lack of measurements of endothelial function, and the
inability to pinpoint the specific substances in red wine responsible for the
observed effects.
Chiva-Blanch G, et al. Circ Res 2012; DOI:
10.1161/CIRCRESAHA.112.275636. http://circres.ahajournals.org/content/early/2012/09/06/CIRCRESAHA.112.275636.abstract
