Thursday, September 13, 2012

Lit Bits: Sept 13, 2012

From the recent medical literature...

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.  

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:  

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… 

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 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. 

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. 

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

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. 

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. 

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?.... 

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.