Thursday, November 01, 2012

Lit Bits: Nov 1, 2012

From the recent medical literature...

1. Bedside Focused Echocardiography as Predictor of Survival in Cardiac Arrest Patients: A Systematic Review 

Blyth L, et al. Acad Emerg Med. 2012;19:1119-1126.  

Objectives:  The objective was to determine if focused transthoracic echocardiography (echo) can be used during resuscitation to predict the outcome of cardiac arrest. 

Methods:  A literature search of diagnostic accuracy studies was conducted using MEDLINE via PubMed, EMBASE, CINAHL, and Cochrane Library databases. A hand search of references was performed and experts in the field were contacted. Studies were included for further appraisal and analysis only if the selection criteria and reference standards were met. The eligible studies were appraised and scored by two independent reviewers using a modified quality assessment tool for diagnostic accuracy studies (QUADAS) to select the papers included in the meta-analysis. 

Results:  The initial search returned 2,538 unique papers, 11 of which were determined to be relevant after screening criteria were applied by two independent researchers. One additional study was identified after the initial search, totaling 12 studies to be included in our final analysis. The total number of patients in these studies was 568, all of whom had echo during resuscitation efforts to determine the presence or absence of kinetic cardiac activity and were followed up to determine return of spontaneous circulation (ROSC). Meta-analysis of the data showed that as a predictor of ROSC during cardiac arrest, echo had a pooled sensitivity of 91.6% (95% confidence interval [CI] = 84.6% to 96.1%), and specificity was 80.0% (95% CI = 76.1% to 83.6%). The positive likelihood ratio for ROSC was 4.26 (95% CI = 2.63 to 6.92), and negative likelihood ratio was 0.18 (95% CI = 0.10 to 0.31). Heterogeneity of the results (sensitivity) was nonsignificant (Cochran’s Q: χ2 = 10.63, p = 0.16, and I2 = 34.1%). 

Conclusions:  Echocardiography performed during cardiac arrest that demonstrates an absence of cardiac activity harbors a significantly lower (but not zero) likelihood that a patient will experience ROSC. In selected patients with a higher likelihood of survival from cardiac arrest at presentation, based on established predictors of survival, echo should not be the sole basis for the decision to cease resuscitative efforts. Echo should continue to be used only as an adjunct to clinical assessment in predicting the outcome of resuscitation for cardiac arrest.

2. The Effect of Abdominal Pain Duration on the Accuracy of Diagnostic Imaging for Pediatric Appendicitis 

Bachur RG, et al. Ann Emerg Med. 2012;60:582-590.e3. 

Study objective: Advanced imaging with computed tomography (CT) or ultrasonography is frequently used to evaluate for appendicitis. The duration of the abdominal pain may be related to the stage of disease and therefore the interpretability of radiologic studies. Here, we investigate the influence of the duration of pain on the diagnostic accuracy of advanced imaging in children being evaluated for acute appendicitis. 

Methods: A secondary analysis of a prospective multicenter observational cohort of children aged 3 to 18 years with suspected appendicitis who underwent CT or ultrasonography was studied. Outcome was based on histopathology or telephone follow-up. Treating physicians recorded the duration of pain. Imaging was coded as positive, negative, or equivocal according to an attending radiologist's interpretation. 

Results: A total of 1,810 children were analyzed (49% boys, mean age 10.9 years [SD 3.8 years]); 1,216 (68%) were assessed by CT and 832 (46%) by ultrasonography (238 [13%] had both). The sensitivity of ultrasonography increased linearly with increasing pain duration (test for trend: odds ratio=1.39; 95% confidence interval 1.14 to 1.71). There was no association between the sensitivity of CT or specificity of either modality with pain duration. The proportion of equivocal CT readings significantly decreased with increasing pain duration (test for trend: odds ratio=0.76; 95% confidence interval 0.65 to 0.90). 

Conclusion: The sensitivity of ultrasonography for appendicitis improves with a longer duration of abdominal pain, whereas CT demonstrated high sensitivity regardless of pain duration. Additionally, CT results (but not ultrasonographic results) were less likely to be equivocal with longer duration of abdominal pain. 

Implications for Practice: With these findings, clinicians should not rely on ultrasonography early in the course of illness. When an ultrasonographic result is obtained and negative, clinicians might choose a period of observation, potentially followed by repeated ultrasonography (or CT) if clinical suspicion remains. The improved performance of ultrasonography over time indicates that this strategy of repeated ultrasonography should be considered as an option rather than performance of a CT subsequent to an inconclusive ultrasonographic result. For patients with mild focal right lower quadrant pain for less than 24 hours but an otherwise well appearance, another option would be to forgo imaging and monitor the patient with repeated examinations to avoid multiple imaging studies or overreliance on CT. In practice, other diagnoses besides appendicitis (eg, ovarian torsion) might be under consideration and driving the urgency of diagnostic imaging. Likewise, when complicated appendicitis (perforation or abscess) is suspected, there should be no purposeful delay in imaging even if the duration of pain is relatively short. 

3. In the Child With Gastroenteritis Who Is Unable to Tolerate Oral Fluids, Are There Effective Alternatives to Intravenous Hydration? (A Review) 

Barker LT. Ann Emerg Med. 2012;60:607-608.  

Take-Home Message: Nasogastric hydration is an effective alternative to intravenous hydration when oral hydration fails. 

Commentary: Acute gastroenteritis is a common pediatric diagnosis, generating more than 1.5 million outpatient visits and 200,000 hospitalizations annually in the United States.2 Despite limited data, the Centers for Disease Control and Prevention recommendations that were endorsed in 2004 by the American Academy of Pediatrics list hydration by the oral or nasogastric tube route as the preferred therapy for children exhibiting mild to moderate dehydration.2 This recommendation has been echoed for patients with diarrheal illness and poor oral intake by a pediatric multidisciplinary panel in the United Kingdom.3 

Although demonstrated as a safe procedure in children, nasogastric tube placement has also been ranked as a highly painful and distressing procedure,4 with the potential for this adverse effect to be magnified by multiple insertion attempts. This risk may be outweighed by the benefit of earlier rehydration by the nasogastric tube route when the oral route has failed and intravenous access is difficult to obtain. In this context, nasogastric tube placement may also help avoid more invasive vascular access such as intraosseous or central line placement. The decision to use nasogastric tube or intravenous hydration should be considered in the context of the patient's clinical condition, the available resources, and the ease of intravenous or nasogastric tube placement in each patient. Given the routine availability of intravenous hydration as a treatment option in US emergency departments, it is unlikely that subcutaneous infusion or intraperitoneal hydration will gain consideration as an alternative. 

Consider also Subcutaneous Rehydration

A RCT of Recombinant Human Hyaluronidase-Facilitated Subcutaneous Versus Intravenous Rehydration in Mild to Moderately Dehydrated Children in the ED 

Spandorfer PR, et al. Increased Flow Utilizing Subcutaneously-Enabled Pediatric Rehydration II (INFUSE-Peds II) Study Group. Clin Ther. 2012 Oct 10. pii: S0149-2918(12)00533-4. doi: 10.1016/j.clinthera.2012.09.011. [Epub ahead of print] 

BACKGROUND: Alternative treatment of dehydration is needed when intravenous (IV) or oral rehydration therapy fails. Subcutaneous (SC) hydration facilitated by recombinant human hyaluronidase offers an alternative treatment for dehydration. This clinical trial is the first to compare recombinant human hyaluronidase-facilitated SC (rHFSC) rehydration with standard IV rehydration for use in dehydrated children. 

OBJECTIVE: This Phase IV noninferiority trial evaluated whether rHFSC fluid administration can be given safely and effectively, with volumes similar to those delivered intravenously, to children who have mild to moderate dehydration. 

METHODS: The study included mild to moderately dehydrated children (Gorelick dehydration score) aged 1 month to 10 years. They were randomized to receive 20 mL/kg of isotonic fluids using rHFSC or IV therapy over 1 hour and then as needed until clinically rehydrated. The primary outcome was total volume of fluid administered (emergency department [ED] plus inpatient hospitalization). Secondary outcomes included mean volume infused in the ED alone, postinfusion dehydration scores and weight changes, line placement success and time, safety, and provider and parent/guardian questionnaire. 

RESULTS: 148 patients (mean age, 2.3 [1.91] years]; white, 53.4%; black, 31.8%) were enrolled in the intention-to-treat population (73 rHFSC; 75 IV). The primary outcome, mean total volume infused, was 365.0 (324.6) mL in the rHFSC group over 3.1 hours versus 455.8 (597.4) mL in the IV group over 6.6 hours (P = 0.51). The secondary outcome of mean volume infused in the ED alone was 334.3 (226.40) mL in the rHFSC group versus 299.6 (252.33) mL in the IV group (P = 0.03). Dehydration scores and weight changes postinfusion were similar. Successful line placement occurred in all 73 rHFSC-treated patients and 59 of 75 (78.7%) IV-treated patients (P less than 0.0001). All IV failures occurred in patients aged under 3 years; rHFSC rescue was successful in all patients in whom it was attempted. Both treatments were well tolerated. Clinicians rated fluid administration as easy to perform in 94.5% (69 of 73) of the rHFSC group versus 65.3% (49 of 75) of the IV group (P less than 0.001). Parents/caregivers were satisfied or very satisfied with fluid administration in 94.5% (69 of 73) of rHFSC-treated patients and 73.3% (55 of 75) of IV-treated patients. 

CONCLUSIONS: In mild to moderately dehydrated children, rHFSC was inferior to IV hydration for the primary outcome measure. However, rHFSC was noninferior in the ED phase of hydration. Additional benefits of rHFSC included time and success of line placement, ease of use, and satisfaction. SC hydration facilitated with recombinant human hyaluronidase represents a reasonable addition to the treatment options for children who have mild to moderate dehydration, especially those with difficult IV access. identifier: NCT00773175. 

[More articles on hypodermoclysis can be found in the April 12, 2011 issue of Lit Bits, number 19:

4. Decorative Contact Lenses Particular Scare around Halloween 

Troy Brown. Medscape Medical News. Oct 29, 2012 

Adolescent patients with pinkeye may actually be the latest victims of illegally purchased decorative contact lenses. 

Despite the passing of a federal law in 2005 requiring the US Food and Drug Administration (FDA) to regulate decorative lenses as medical devices in the way that vision-correcting contact lenses are regulated, decorative lenses can be found on the Internet, in beauty salons, and in convenience stores without a prescription for as little as $5 to $10 per pair.  

Illegally obtained lenses can cause injuries and infections of the eye and can result in permanent vision loss. The American Optometric Association and the American Academy of Ophthalmology are working to educate the public and medical professionals about the dangers of using them and the need for prompt treatment if problems do occur from their use.  

According to a 2012 consumer survey by the American Optometric Association, 18% of Americans use noncorrective, decorative, or colored contact lenses. Of those patients 28% purchased them without a prescription.  

What Physicians Must Know 

Thomas Steinemann, MD, a professor of ophthalmology at MetroHealth Medical Center and Case Western Reserve University in Cleveland, Ohio, and a clinical correspondent for the American Academy of Ophthalmology, spoke with Medscape Medical News about what physicians need to know about decorative contact lenses.  

Dr. Steinemann has seen many of these injuries. In a survey at his hospital of 159 teenagers, about 23% reported use of decorative contact lenses and about half of those patients obtained them without a prescription. "There's no end to places where you can buy these, and you can buy them cheaply," Dr. Steinemann cautioned.  

The American Academy of Ophthalmology is partnering with the FDA to study the issue systematically. Because the unregulated sale of decorative contact lenses is illegal, it is difficult to know the exact extent of their use, but Dr. Steinemann believes it is more prevalent than current estimates. "Unfortunately, a lot of people don't know that what they're doing is very dangerous, and many sellers that are selling lenses don't know that what they're doing is illegal, and dangerous too," Dr. Steinemann said.  

Permanent Vision Loss Possible 

Problems can range from mild irritation to permanent vision loss. "When a lens doesn't fit right, a lot of people end up with abrasions, scratches on the eye, iritis...light sensitivity. [In the] worst-case scenario, you could end up with a corneal ulcer on the eye; that's a potentially blinding infection in the eye.... [There's] a potential for permanent loss of vision, because when the infection heals, many times people are left with a visually significant scar," Dr. Steinemann explained.  

"I had 1 case of a 14-year-old that had pseudomonas in her eye from 1 of these decorative lenses. She ended up with a blinding scar, and I [did] a corneal transplant on her. That's a terrible price to pay for something as silly as going out with some friends and buying a contact lens at a video store, which is what she did," Dr. Steinemann added.  

Infections More Common and More Severe 

Recent research suggests that infections may be more frequent and more severe when they result from the use of decorative contact lenses compared with vision-correcting lenses. "Maybe that has to do with ignorance on the part of the wearer, or maybe they have a more casual attitude. We know that the wearers are probably younger and probably a little more risk-taking," Dr. Steinemann noted.  

"[A] fairly large study done at several hospitals in France in 2011...showed the risk for decorative lens wear compared to vision-correcting lens wear was probably higher, and if you ended up with infection...your final vision was probably poorer from decorative lenses than it was from vision-correcting lenses," Dr. Steinemann explained.  

Geoffrey Goodfellow, OD, an associate professor of optometry at the Illinois College of Optometry in Chicago and a member of the American Optometric Association, spoke with Medscape Medical News about what to look for in patients who have used decorative contact lenses.  

"This time of year, we always see a resurgence in [this]. [T]he biggest thing to look for is patients complaining of a red eye or a painful eye or if they've lost any vision at all. Usually, in anyone who has a bad-fitting contact lens or infection in their eye, their eye looks pretty red and angry," Dr. Goodfellow explained.  

Patients who come in with their parents may not always be forthcoming about the source of their symptoms. "Clinicians should be thinking of this when they see kids with pinkeye, red eye — that type of thing," Dr. Steinemann noted. Dr. Steinemann said there could be issues related to quality control with unregulated decorative lenses, but the majority of problems associated with their use results from misuse and improper contact lens care.  

Urgent Treatment Needed 

Patients with symptoms that are clearly caused by contact lenses need to be seen by an eye physician promptly, Dr. Goodfellow and Dr. Steinemann agree.  

"The best thing to do is to encourage the patient to stop wearing contact lenses immediately and go back to wearing their glasses, if they have them. [M]ake sure that that patient [gets] in to see an eye doctor as soon as possible. It's not something that you want to wait to see if it goes away. It needs to be treated pretty urgently to make sure that the infection doesn't cause any long-term damage to the eye," Dr. Goodfellow said.  

"If it's a clear-cut thing, that the child did in fact get a pair of lenses or borrow a pair of lenses...they should make a referral to an ophthalmologist. That demands a prompt evaluation. If it's less clear, then you have to guide it by things like, 'is there a change in vision, is the patient having pain, is the patient having problems such that they can't keep their eye open?' " Dr. Steinemann explained.  

"The urgency of the referral depends upon the symptoms of the patient and also the history. If there is a history of contact lens problem, that demands further evaluation by an ophthalmologist," Dr. Steinemann said.  

Notify Licensing Authorities 

Eye professionals agree that even short-term use of unregulated contact lenses is dangerous. 

"Contact lenses are a medical device. Patients who [want] contact lenses [should] see their eye doctor to make sure that they fit the right way, and that they're taught how to clean and care for them, even for the patient that just wants to wear contact lenses once for Halloween," Dr. Goodfellow noted. "The other part of the equation is that if there's a clear-cut history that the lenses were obtained over the counter or illegally...the eye care professional should notify the licensing authorities in their state," Dr. Steinemann added.  

FDA Consumer Recommendations 

According to the FDA, individuals who desire decorative contact lenses should: 
·         Get an eye exam from a licensed eye care professional, even if you feel your vision is perfect.
·         Get a valid prescription that includes the brand and lens dimensions.
·         Buy the lenses from an eye care professional or from a vendor who requires that you provide prescription information for the lenses.
·         Follow directions for cleaning, disinfecting, and wearing the lenses, and visit your eye care professional for follow-up eye exams. 

The survey was created and commissioned in conjunction with Penn, Schoen & Berland Associates. Dr. Steinemann and Dr. Goodfellow have disclosed no relevant financial relationships.

5. Comparing Screening Tools that Predict which Neck Injuries Require Imaging 

By Crystal Phend, Senior Staff Writer, MedPage Today. October 11, 2012 

There's a better way to screen for cervical spine injury in the emergency department, a systematic review comparing two decision rules showed. 

The Canadian C-spine rule had better sensitivity and specificity for clinically important cases than the NEXUS (National Emergency X-Radiography Utilization Study) criteria, Zoe A. Michaleff, BAppSc, of the George Institute for Global Health at the University of Sydney, Australia, and colleagues reported online in CMAJ. 

Both methods use patient history, physical exam characteristics, and simple diagnostic tests to determine the probability of fracture, dislocation, or ligament instability that can lead to spinal cord injury or death if missed. 

Screening helps reduce the number of unnecessary referrals for imaging, cutting down on costs, radiation exposure, and psychological stress for the patient, they noted. Many international guidelines recommend using clinical decision rules to assess the need for imaging cervical spine injuries after car accidents and other blunt trauma but without consensus on which to use. 

For a comparison, the review included 15 cohort studies of patients with blunt trauma looking at a differential diagnosis of clinically important cervical spine injury detectable by diagnostic imaging. Eight of the studies used NEXUS criteria only, which recommends diagnostic imaging for patients with neck trauma unless they meet all of the following:
·         No tenderness in the posterior midline cervical spine
·         No evidence of intoxication
·         No focal neurologic deficit
·         No painful distracting injuries
·         Normal alertness with a score of 15 or better on the Glasgow Coma Scale 

Six of the studies used only the Canadian C-spine rule, which uses the following criteria to send alert patients to radiography:
·         Any high-risk factor, including age 65 or older, a dangerous mechanism of trauma (such a high-speed crash or fall from more than 3 ft. elevation), or paresthesias in extremities
·         Absence of a low-risk factor that allows for safe assessment of range of motion (such as being ambulatory at any point, delayed onset of neck pain, or a simple rear-end car crash)
·         Inability to rotate the neck 45° to the left and right 

Both tests were highly sensitive with ranges from 0.83 to 1.0 for NEXUS and 0.90 to 1.0 for the Canadian C-spine rule. False negative rates were low at 1.0% or less across all studies. 

These rates suggested "that a negative test result is highly informative in excluding a clinically important cervical spine injury and, therefore, the need for radiographic examination," Michaleff's group explained. 

Both also showed similar potential to reduce imaging rates, by an average 31% with NEXUS and 42% with the Canadian criteria, without missing a clinically important cervical spine injury. "However, the lower specificity and false-positive results indicate that many people will continue to undergo unnecessary imaging," the researchers noted. Specificity ranged from 0.13 to 0.46 with NEXUS criteria and 0.01 to 0.77 with the Canadian C-spine rule. 

Only one study directly compared the two screening tools, and it gave the edge to the Canadian C-spine rule for diagnostic accuracy in terms of sensitivity, specificity, likelihood ratios, and reduction in unnecessary imaging. 

The researchers cautioned about the modest methodologic quality of the studies, inability to pool data for comparison, and within-trial variations in how the rules were interpreted and applied.

"Future studies of diagnostic test accuracy need to ensure that rigorous methodologic procedures are followed to reduce bias" and to test use outside of the emergency department and in pediatric and older populations, they noted. 

The researchers reported having no conflicts of interest to declare. 

Michaleff ZA, et al. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review.

CMAJ. 2012 Oct 9. [Epub ahead of print] 

Need a memory aid to help with NEXUS C-spine criteria?
Vinson DR. Ann Emerg Med 2001;37:237-238. 
To the Editor: Hoffman and colleagues (July 13 issue) 1 are to be commended for their well-designed, monumental study of cervical spine radiography in patients with blunt trauma. Highly sensitive in detecting clinically important injuries and reliable when used by different practitioners, their decision instrument also appears “straightforward, logical and easy to remember.” 1 To make the five NEXUS cervical-spine criteria easier to use in clinical practice and easier to transmit to colleagues and residents, I have devised an acronym (N.S.A.I.D.; see Figure). Like the CAGE questionnaire2 used in the screening of alcoholism, its simplicity is to its advantage. Also of help is that the drug class the acronym represents (non-steroidal anti-inflammatory drugs) is commonly employed in the treatment of the disorder in question (blunt cervical-spine trauma).   
Figure. The NEXUS cervical spine criteria as represented by the NSAID acronym.
N         Neurological examination: any focal deficit?
S          Spine examination: any tenderness at the posterior midline of the cervical spine?
A         Alertness: any alteration?
I           Intoxication: any evidence?
D         Distracting injury: any painful injury that might distract the patient from the pain of a cervical-spine injury?  
If a patient with blunt trauma is clinically stable and all five questions of the acronym can be answered in the negative, then the patient is considered to have an extremely low probability of cervical-spine injury.1 Such a patient may be spared radiographic evaluation. However, should any one of the NSAID questions receive an affirmative answer, cervical-spine radiographs are indicated. This acronym may facilitate the applicability of the NEXUS cervical-spine criteria.

6. The Impact of Watching Cartoons for Distraction during Painful Procedures in the Emergency Department 

Barney the Purple Dinosaur as an Analgesic Aid 

Downey LA, et al. Pediatr Emerg Care 2012;28:1033-1035.  

Objective: The purpose of this study was to determine whether the viewing of cartoons in the acute care setting reduces the perception of pain by pediatric patients. 

Methods: A convenience prospective study of pediatric patients in pain was performed at a community teaching level I pediatric and adult emergency department, with 44,000 patient visits per year. The inclusion criteria for entry into the study were any child who presented to the emergency department in acute pain from any cause. The younger children were randomized to watch a Barney cartoon in Spanish or English, and the older children were randomized to view a Tarzan cartoon in Spanish or English. The younger children were assessed 5 minutes before the procedure, during the procedure, and 5 minutes after the procedure using Poker Chip Tool and Faces Scale. The older children were assessed at the same time interval using self-reporting and a visual analog scale. The study was internal review board approved. A difference of 20% or greater was considered a significant difference. The data were analyzed using a general linear model-repeated measures a priori level of significance of P less than 0.05. 

Results: There was a significant difference within subject effects: F1= 9.268, significant at 0.03, with observed power at 0.85 or 85%, with the α set at 0.05 or less. A comparison of the groups revealed that there were no differences in the causes of pain (F1 = 0.301, P = 0.585), pain duration (F1 = 0.062, P = 0.084), or type of anesthesia, if used (F1 = 0.064, P = 0.804) between groups. This lack of difference was upheld for age (F1 = 3.0407, P = 0.068), race (F1 = 0.537, P = 0.466), and sex (F1 = 0.002, P = 0.964). 

Conclusions: The finding that cartoon viewing was effective does illustrate 1 more pain relief tool for use in the ED when pediatric patients present. It is useful because of the fact that it does not interfere with assessment of patients’ presenting or underlying problems. The need for more ways in which to address pediatric pain persists.

7. Adjunctive Atropine Versus Metoclopramide: Can We Reduce Ketamine-associated Vomiting in Young Children? [No] A Prospective, Randomized, Open, Controlled Study. 

Lee JS, et al. Acad Emerg Med. 2012 Oct;19(10):1128-1133. 

Objectives: Pediatric procedural sedation and analgesia (PPSA) with ketamine administration occurs commonly in the emergency department (ED). Although ketamine-associated vomiting (KAV) is a less serious complication of ketamine administration, it seems to be cumbersome and not uncommon. The authors evaluated the incidence of KAV and the prophylactic effect of adjunctive atropine and metoclopramide in children receiving ketamine sedation in the ED setting.  

Methods: This prospective, randomized, open, controlled study was conducted in children receiving ketamine sedation in the ED of a university-affiliated, tertiary hospital with 85,000 ED visits, including 32,000 pediatric patients from October 2010 to September 2011. The primary outcome was a measure of the incidence of KAV in the ED and after discharge according to the adjunctive drug administered. Secondary outcome measures included the time to resumption of a normal diet after ketamine sedation.  

Results: Of the 1,883 children administered ketamine for primary wound repair during the study period, a convenience sample of 338 patients aged 4 months to 5 years was enrolled. The incidences of KAV were 28.4% in the ketamine alone group, 27.9% in the ketamine with adjunctive atropine group, and 31.2% in the ketamine with adjunctive metoclopramide group (p = 0.86). The vomiting rate after discharge was 9.2% in the ketamine alone group. The nothing-by-mouth (NPO) status before sedation did not influence the incidence of KAV in any of the groups. Mean times to resumption of normal diet after ketamine administration were 7 hours 59 minutes in the ketamine alone group, 7 hours 35 minutes in the ketamine with atropine group, and 8 hours 1 minute in the ketamine with metoclopramide group (p = 0.64).  

Conclusions: In this study, a high rate (28.4%) of KAV was observed, consistent with prior reports using the intramuscular (IM) route. However, the authors were unable to reduce KAV using adjunctive atropine or metoclopramide. Parents or caregivers should be given more detailed discharge instructions about vomiting and diet considering the relatively long time to resuming a normal diet after ketamine sedation and the fact that KAV often occurred after ED discharge.

8. Transfusion of Packed Red Blood Cells is Not Associated with Improved Central Venous Oxygen Saturation or Organ Function in Patients with Septic Shock 

Fuller BM, et al. J Emerg Med 2012;43:593-598.  

Background: The exact role of packed red blood cell (PRBC) transfusion in the setting of early resuscitation in septic shock is unknown. 

Study Objective: To evaluate whether PRBC transfusion is associated with improved central venous oxygen saturation (ScvO2) or organ function in patients with severe sepsis and septic shock receiving early goal-directed therapy (EGDT). 

Methods: Retrospective cohort study (n=93) of patients presenting with severe sepsis or septic shock treated with EGDT. 

Results: Thirty-four of 93 patients received at least one PRBC transfusion. The ScvO2 goal above 70% was achieved in 71.9% of the PRBC group and 66.1% of the no-PRBC group (p=0.30). There was no difference in the change in Sequential Organ Failure Assessment (SOFA) score within the first 24h in the PRBC group vs. the no-PRBC group (8.6–8.3 vs. 5.8–5.6, p=0.85), time to achievement of central venous pressure above 8mm Hg (732min vs. 465min, p=0.14), or the use of norepinephrine to maintain mean arterial pressure above 65mm Hg (81.3% vs. 83.8%, p=0.77). 

Conclusions: In this study, the transfusion of PRBC was not associated with improved cellular oxygenation, as demonstrated by a lack of improved achievement of ScvO2 above 70%. Also, the transfusion of PRBC was not associated with improved organ function or improved achievement of the other goals of EGDT. Further studies are needed to determine the impact of transfusion of PRBC within the context of early resuscitation of patients with septic shock.

9. Symptom-Triggered Dosing Is Better Than Fixed Dosing for Treating Alcohol Withdrawal 

Cassidy EM et al. Emerg Med J 2012 Oct; 29:802 

INTRODUCTION  Alcohol withdrawal is a common clinical problem. The standard detoxification regimen involves a tapered dosage of a benzodiazepine (typically chlordiazepoxide) over a 5 to 7-day period. Such an approach may result in undertreatment of severely dependent subjects or overtreatment of those with milder dependence. Symptom-triggered benzodiazepine therapy for alcohol withdrawal syndrome (AWS) could potentially avoid some of these pitfalls. This approach has been found to reduce cumulative benzodiazepine dosage and duration of detoxification in alcohol dependent subjects in addiction treatment centres.1 Despite this, the symptom-triggered approach is not widely used. We know of one small pilot study in a UK inpatient substance detoxification unit2 and one study in a medical admissions unit3 that have examined the effectiveness of this approach. To our knowledge, no study has examined the use of symptom-triggered alcohol detoxification in the emergency department (ED) setting. 

AIM  The aim of the study was to compare the cumulative benzodiazepine dosage and number of days in hospital among patients with alcohol dependence in the Cork University Hospital (CUH). We compared patients treated in the ED clinical decision unit (CDU) using a symptom-triggered regimen with patients admitted to a hospital treated with a fixed dosage of benzodiazepines. 

METHOD  The study was conducted in a teaching hospital ED CDU. Symptom-triggered therapy was in use in the ED for 18 months prior to the study. With this (symptom-triggered) approach, the patient has a standardised assessment of severity of withdrawal at regular intervals (90 min in our protocol). Patients with significant features of withdrawal are given a single dose of a benzodiazepine. Repeat doses of benzodiazepine are given only if the follow-up assessment indicates the need. When there are no significant features of withdrawal on two consecutive assessments, the detoxification programme is deemed complete and benzodiazepine administration is discontinued. We used the Clinical Institute Withdrawal Assessment for Alcohol scale,4 which is a reliable and validated 10-item scale… 

RESULTS  Length of stay was 50% shorter in the symptom-triggered group (median 2 days, range 1 to 9) compared with the fixed dose detoxification group (median 3 days, range 1 to 12). Cumulative benzodiazepine dose was 50% lower in the symptom-triggered group (median 80 mg diazepam, range 0 to 900 mg) compared with the fixed dose detoxification group…

10. Clinical Practice Pointers 

A. Knee Effusion via Ultrasound: ‘Doc, are you sure you have to aspirate?’  

by Brady Pregerson, MD & Teresa S. Wu, MD. Emergency Physicians Monthly on October 9, 2012.  

B. Regional Nerve Blocks from Medscape 

11. On Child Abuse Screening  

A. Practices Vary in Pediatric Hospitals 

Ricki Lewis, PhD. Medscape Medical News. October 15, 2012 — Hospitals vary in the implementation of recommended screening for occult fractures in young children, according to a study published online October 15 in Pediatrics. 

One third of children younger than 2 years who have been physically abused have occult fractures. Documenting and dating these events can aid child protective services and law enforcement authorities in identifying abusers. The information can also help healthcare providers identify patterns that may guide them in distinguishing accidental from intentional fractures in the future. 

The American Academy of Pediatrics recommends a skeletal survey for all children younger than 2 years who are suspected of being abuse victims. Children's hospitals vary in how their child abuse services operate, and the variability has not been assessed. Prior reports have indicated that a patient's socioeconomic group and/or race may play a role in whether screening is conducted. 

Joanne N. Wood, MD, MSHP, from the Division of General Pediatrics and PolicyLab, the Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, and colleagues performed a retrospective study of children younger than 2 years who were diagnosed with physical abuse and of infants younger than 1 year who have femur fracture or traumatic brain injury (TBI) not associated with motor vehicle accidents. Patients were admitted to 40 children's hospitals selected from the Pediatric Health Information System database from January 1, 1999, to December 31, 2009. 

The researchers compared the type of child abuse service at each hospital with rates of compliance with guidelines. Primary outcome was procedure or billing code for skeletal survey or radionuclide bone scan. 

The investigators used data from a survey by the National Association of Children's Hospitals and Related Institutions from 2008 to create a scale representing the level of child abuse detection effort: 1, no services; 2, child abuse services; 3, child abuse team; and 4, child abuse program. Data were available for 22 of the 40 surveyed institutions: 19 hospitals had level 4 services and 3 had level 3 detection efforts. 

Screening was conducted for 83% of 10,170 children younger than 2 years with a diagnosis of child abuse, for 68% (95% confidence interval [CI], 68% - 69%) of 9942 infants with TBI, and for 77% (95% CI, 76% - 79%) of 2975 infants with femur fractures. The researchers adjusted for injury severity (using injury diagnosis coding software), patient characteristics (including age, sex, race, and Medicaid status), and year of admission. The investigators used logistic regression to analyze the association between child abuse services category and rate of occult fracture screening. 

The hospitals varied significantly in their adherence to guidelines, from 55% (95% CI, 24% - 85%) to 93% (95% CI, 89% - 97%). The presence of a comprehensive child abuse program (n = 19) vs a child abuse team (n = 3) was associated with increased screening for occult fractures (odds ratio, 2.42; 95% CI, 1.41 - 4.16; P = .001). 

Rates of screening varied almost 2-fold among infants who had TBI and more than 2-fold among infants with femur fractures after adjusting for patient characteristics. Therefore, the findings do not support past suggestions that screening is more likely in institutions that primarily serve black and low-socioeconomic-level populations, the researchers conclude. 

Limitations of the study include its reliance on coding information and a lack of information on previous screenings at other locations. Dr. Wood's institution has been paid for her testimony in child abuse cases. The other authors have disclosed no relevant financial relationships. 

Pediatrics. Published online October 15, 2012 

B. Prevalence of abusive injuries in siblings and household contacts of physically abused children. 

Lindberg DM, et al. Pediatrics. 2012 Aug;130(2):193-201.  

OBJECTIVE: Siblings and other children who share a home with a physically abused child are thought to be at high risk for abuse, but rates of injury in these contact children are unknown and screening of contacts is highly variable. Our objective was to determine the prevalence of abusive injuries identified by a common screening protocol among contacts of physically abused children. 

METHODS: This is an observational, multicenter cross-sectional study of children evaluated for physical abuse, and their contacts, by 20 US child abuse teams who used a common screening protocol for the contacts of physically abused children with serious injuries. Contacts underwent physical examination if they were younger than 5 years old, physical examination and skeletal survey (SS) if they were less than 24 months old, and physical examination, SS, and neuroimaging if they were less than 6 months old. 

RESULTS: Protocol-indicated SS identified at least 1 abusive fracture in 16 of 134 contacts (11.9%, 95% confidence interval [CI] 7.5-18.5) less than 24 months of age. None of these fractures had associated findings on physical examination. No injuries were identified by neuroimaging in 19 of 25 eligible contacts (0.0%, 95% CI 0.0-13.7). Twins were at substantially increased risk of fracture relative to nontwin contacts (odds ratio 20.1, 95% CI 5.8-69.9). 

CONCLUSIONS: SS should be obtained in the contacts of injured, abused children for contacts who are less than 24 months old, regardless of physical examination findings. Twins are at higher risk of abusive fractures relative to nontwin contacts.

12. Bedside ultrasound performed by novices for the detection of abscess in ED patients with soft tissue infections. 

Berger T, et al. Am J Emerg Med. 2012 Oct;30(8):1569-73.  

OBJECTIVE: The objective was to compare bedside ultrasound (US) to clinical examination for the detection of abscess. 

METHODS: This is a 24-month prospective, observational emergency department (ED) study. Adults with suspected nondraining abscess with planned incision and drainage (I&D) are included in the study. Exclusion criteria are spontaneous drainage and perineal, perirectal, or intraoral location. Before I&D, a second ED physician conducts an US and records the presence or absence of findings suggestive of abscess. A positive I&D of the suspected abscess is the criterion standard. The treating practitioner is blinded to the US results. Ultrasound is performed by novice ED physicians. The findings of the US, the prediction of pus from the clinician and the ultrasonographer in 3 strata (low, indeterminate, definite), and the results of the I&D (pus/no pus) are recorded onto data sheets. Measures of association are reported and Fisher's Exact test is used. 

RESULTS: Forty patients were enrolled. The sensitivity of novice sonographers to predict a positive I&D with US was 0.97 (0.83-1.00), the specificity was 0.67 (0.24-0.94), the positive likelihood ratio was 2.90, the negative likelihood ratio was 0.04, and the area under the receiver operating characteristic curve was 0.85 (0.66-1.00). Clinical examination yielded a sensitivity of 0.76 (0.58-0.89), specificity of 0.83 (0.36-0.99), positive likelihood ratio of 4.50, negative likelihood ratio of 0.29, and area under the receiver operating characteristic curve of 0.75 (0.50-1.00). 

CONCLUSION: Novice ED sonographers can identify abscesses with only minimal US training. Identification of abscess on US may change management of cutaneous abscesses.

13. Images in Clinical Medicine 

Selective Intraarterial Thrombolysis for Cardioembolic Stroke

Hibernoma of the Neck

Mydriasis in the Garden

Mites in the External Auditory Canal

An Audible Case of Acute Pericarditis 

Disfiguring Angioedema

Young Boy With Eye Pain

10-year-old Female With a Subglottic Mass

14. Variability of ICU Use in Adult Patients with Minor Traumatic Intracranial Hemorrhage 

Nishijima DK, et al. Ann Emerg Med. 2012 Sep 26. [Epub ahead of print] 

STUDY OBJECTIVE: Patients with minor traumatic intracranial hemorrhage are frequently admitted to the ICU, although many never require critical care interventions. To describe ICU resource use in minor traumatic intracranial hemorrhage, we assess (1) the variability of ICU use in a cohort of patients with minor traumatic intracranial hemorrhage across multiple trauma centers, and (2) the proportion of adult patients with traumatic intracranial hemorrhage who are admitted to the ICU and never receive a critical care intervention during hospitalization. In addition, we evaluate the association between ICU admission and key independent variables. 

METHODS: A structured, historical cohort study of adult patients (aged 18 years and older) with minor traumatic intracranial hemorrhage was conducted within a consortium of 8 Level I trauma centers in the western United States from January 2005 to June 2010. The study population included patients with minor traumatic intracranial hemorrhage, defined as an emergency department (ED) Glasgow Coma Scale (GCS) score of 15 (normal mental status) and an Injury Severity Score less than 16 (no other major organ injury). The primary outcome measure was initial ICU admission. The secondary outcome measure was a critical care intervention during hospitalization. Critical care interventions included mechanical ventilation, neurosurgical intervention, transfusion of blood products, vasopressor or inotrope administration, and invasive hemodynamic monitoring. ED disposition and the proportion of ICU patients not receiving a critical care intervention were compared across sites with descriptive statistics. The association between ICU admission and predetermined independent variables was analyzed with multivariable regression. 

RESULTS: Among 11,240 adult patients with traumatic intracranial hemorrhage, 1,412 (13%) had minor traumatic intracranial hemorrhage and complete ED disposition data (mean age 48 years; SD 20 years). ICU use within this cohort across sites ranged from 50% to 97%. Overall, 847 of 888 patients (95%) with minor traumatic intracranial hemorrhage who were admitted to the ICU did not receive a critical care intervention during hospitalization (range between sites 80% to 100%). Three of 524 (0.6%) patients discharged home or admitted to the observation unit or ward received a critical care intervention. After controlling for severity of injury (age, blood pressure, and Injury Severity Score), study site was independently associated with ICU admission (odds ratios ranged from 1.5 to 30; overall effect P less than.001). 

CONCLUSION: Across a consortium of trauma centers in the western United States, there was wide variability in ICU use within a cohort of patients with minor traumatic intracranial hemorrhage. Moreover, a large proportion of patients admitted to the ICU never required a critical care intervention, indicating the potential to improve use of critical care resources in patients with minor traumatic intracranial hemorrhage.

15. Clinical and Epidemiologic Characteristics as Predictors of Treatment Failures in Uncomplicated Skin Abscesses within Seven Days after Incision and Drainage 

Olderog CK, at al. J Emerg Med 2012;43:605-611. 

Background: Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is now the leading cause of superficial abscesses seen in the Emergency Department. 

Study Objectives: Our primary aim was to determine if an association exists between three predictor variables (abscess size, cellulitis size, and MRSA culture) and treatment failure within 7 days after incision and drainage in adults. Our secondary aim was to determine if an association exists between two clinical features (abscess size and size of surrounding cellulitis) and eventual MRSA diagnosis by culture. 

Methods: Logistic regression models were used to examine clinical variables as predictors of treatment failure within 7 days after incision and drainage and MRSA by wound culture. 

Results: Of 212 study participants, 190 patients were analyzed and 22 were lost to follow-up. Patients who grew MRSA, compared to those who did not, were more likely to fail treatment (31% to 10%, respectively; 95% confidence interval [CI] 8–31%). The failure rates for abscesses ≥ 5 cm and less than 5 cm were 26% and 22%, respectively (95% CI −11–26%). The failure rates for cellulitis ≥ 5 cm and less than 5 cm were 27% and 16%, respectively (95% CI −2–22%). Larger abscesses were no more likely to grow MRSA than smaller abscesses (55% vs. 53%, respectively; 95% CI −22–23%). The patients with larger-diameter cellulitis demonstrated a slightly higher rate of MRSA-positive culture results compared to patients with smaller-diameter cellulitis (61% vs. 46%, respectively; 95% CI −0.3–30%), but the difference was not statistically significant. 

Conclusion: Cellulitis and abscess size do not predict treatment failures within 7 days, nor do they predict which patients will have MRSA. MRSA-positive patients are more likely to fail treatment within 7 days of incision and drainage.

16. If money doesn't make you happy then you probably aren't spending it right  

Dunn EW, et al. J Consumer Psychology. 2011;21:115-125. 

Scientists have studied the relationship between money and happiness for decades and their conclusion is clear: Money buys happiness, but it buys less than most people think. The correlation between income and happiness is positive but modest, and this fact should puzzle us more than it does. After all, money allows people to do what they please, so shouldn't they be pleased when they spend it? Why don't a whole lot more money make us a whole lot more happy? One answer to this question is that the things that bring happiness simply aren't for sale. This sentiment is lovely, popular, and almost certainly wrong. Money allows people to live longer and healthier lives, to buffer themselves against worry and harm, to have leisure time to spend with friends and family, and to control the nature of their daily activities—all of which are sources of happiness. Wealthy people don't just have better toys; they have better nutrition and better medical care, more free time and more meaningful labor—more of just about every ingredient in the recipe for a happy life. And yet, they aren't that much happier than those who have less. If money can buy happiness, then why doesn't it? 

Because people don't spend it right. Most people don't know the basic scientific facts about happiness—about what brings it and what sustains it—and so they don't know how to use their money to acquire it. It is not surprising when wealthy people who know nothing about wine end up with cellars that aren't that much better stocked than their neighbors', and it should not be surprising when wealthy people who know nothing about happiness end up with lives that aren't that much happier than anyone else's. Money is an opportunity for happiness, but it is an opportunity that people routinely squander because the things they think will make them happy often don't. 

When people make predictions about the hedonic consequences of future events they are said to be making affective forecasts, and a sizeable literature shows that these forecasts are often wrong. Errors in affective forecasting can be traced to two basic sources. First, people's mental simulations of future events are almost always imperfect. For example, people don't anticipate the ease with which they will adapt to positive and negative events, they don't fully understand the factors that speed or slow that adaptation, and they are insufficiently sensitive to the fact that mental simulations lack important details. Second, context exerts strong effects on affective forecasts and on affective experiences, but people often fail to realize that these two contexts are not the same; that is, the context in which they are making their forecasts is not the context in which they will be having their experience. These two sources of error cause people to mispredict what will make them happy, how happy it will make them, and how long that happiness will last. 

In this article, we will use insights gleaned from the affective forecasting literature to explain why people often spend money in ways that fail to maximize their happiness, and we will offer eight principles that are meant to remedy that. 

For the remainder of the essay and links to references, see the full-text (free):

17. More Full-text Literature Reviews Courtesy of November’s Ann Emerg Med 

A. Do Febrile Infants Aged 60 to 90 Days With Bronchiolitis Require a Septic Evaluation?  


Swaminathan A, et al. Ann Emerg Med. 2012;60:605-606.  

Commentary: When evaluating infants with symptoms consistent with bronchiolitis, physicians are often concerned with ensuring the lack of more serious bacterial infections, including urinary tract infection, occult bacteremia, and meningitis. As a result, many of these infants, particularly those younger than 60 to 90 days, are screened for occult bacterial infections with blood cultures, urine culture, and spinal fluid analysis.1 

For infants who present with typical bronchiolitis symptoms, lumbar punctures and blood cultures are unnecessary. Routine blood cultures show a less than 1% rate of occult bacteremia, whereas false-positive blood culture rates range from 0.9% to 3.6%.2 These recommendations cannot be applied to toxic-appearing infants. 

In contrast, there is a 3.3% rate of concomitant urinary tract infection in patients receiving a diagnosis of bronchiolitis. A large prospective study of febrile children reported a similar urinary tract infection rate.1 This review was unable to rule out the possibility of asymptomatic bacteriuria (above 100,000 colony-forming units in the urine, without urinary tract infection symptoms) primarily because of patient age. Previous study has shown the rate of asymptomatic bacteriuria to be 2.5% for boys and 0.9% for girls in the first year of life.3 Clinical judgment should be exercised to determine whether additional testing is warranted for these children. 

B. Does Antibiotic Prophylaxis Prevent Meningitis in Patients With Basilar Skull Fracture? 

Who knows. Your call. 

Ross M, et al. Ann Emerg Med. 2012;60:624-625.  

Commentary: Basilar skull fracture (BSF) occurs in approximately 7% to 15% of all nonpenetrating head trauma and is associated with cerebrospinal fluid (CSF) leakage in 2% to 20.8% of patients.6 Signs that may raise clinical suspicion of BSF include otorrhea, rhinorrhea, raccoon eye's, Battle's sign, facial nerve palsy, hemotympanum, and vertigo. CSF leakage can be associated with a dural tear and if present puts patients at higher risk of developing meningitis.7 

Two previous meta-analyses8, 9 on this topic showed disparate results, had significant methodological flaws, and did not include recent literature. 

The Cochrane review by Ratilal et al highlights a need for continued research into the use of prophylactic antibiotics in patients with BSF. The studies included in this review were few and underpowered and had risk of selection bias. However, this review highlights that the current evidence does not permit strong recommendations for the use of antibiotic prophylaxis in patients with BSF irrespective of the presence of CSF leakage. In the absence of strong evidence of either harm or benefit, antibiotic prophylaxis can be used at the discretion of the practicing physician. 

C. Is Water Effective for Wound Cleansing? 


Cooper DC, et al. Ann Emerg Med. 2012;60:626-627.  

Commentary: In acute wound management, wound cleansing may be the most important step in preventing infection and promoting healing.1 Although there are many options for wound cleansing, there has not been a clear consensus on which solution is “best.” The use of antiseptics, such as iodine and alcohol, remains controversial because of toxic effects on tissue and lack of significant clinical benefit.2 This systematic review found tap water to be as effective as other solutions in wound cleansing. In fact, tap water demonstrated a significant reduction in infection rates for acute adult wounds. Other water preparations, distilled or cooled boiled water, were also as effective as saline solution. In addition, there was no statistically significant difference in other clinically important outcomes when tap water was used. 

This is not the first study to question wound care dogma in the ED. A small randomized controlled trial from 1989 found no significant difference in healing or infection rates when a surgically clean technique (hand washing, no mask, no drapes, no sterile gloves) was used compared with full sterile technique (antiseptic hand washing, mask, sterile drapes, sterile gloves) in simple laceration repair.3 Another randomized controlled trial in 2004 showed no difference in infection rates when clean gloves were used compared with sterile gloves.4 

Because of its availability, low cost, efficiency, and effectiveness, tap water should be strongly considered for wound cleansing in the ED. 

D. Is Continuous Nebulized β-Agonist Therapy More Effective Than Intermittent β-Agonist Therapy at Reducing Hospital Admissions in Acute Asthma? 


Gregory AK, et al. Ann Emerg Med. 2012;60:663-664.  

Bottom Line: Continuous nebulized β-agonist therapy reduces hospital admissions compared with intermittent β-agonist treatments in moderate to severe asthma exacerbations. 

Commentary: Acute asthma exacerbations are common, accounting for nearly 1.7 million ED visits in 2006 to 2007.1 Inhaled β-agonist administration forms the cornerstone of treatment. Continuous albuterol has been found safe and effective for asthma exacerbations.2 This review focuses on whether there is a benefit compared with intermittent nebulized β-agonist administration for adult patients. Only 2 studies included children, and though these conclusions could apply to children, this systematic review could not reach that conclusion. 

Continuous β-agonist treatments resulted in significantly improved peak flow rates, and changes in peak flow have been found to be a significant contributing factor in hospital admissions.3 Therefore, hospitalization rates were also decreased in severe asthma exacerbations. Mild to moderate exacerbations showed no noticeable change in admission rates. However, it was difficult to separate these data into categories of disease severity because not all studies categorized severity similarly. 

Despite continuous nebulization's being found safe overall, there has been concern that it increases the incidence of hypokalemia.4 Potassium concentrations were reported in only 3 trials, but no significant difference was observed between treatment groups. There was also no significant increase in tachycardia or tremors in the continuous β-agonist groups. It is still important to consider possible adverse effects, as well as slightly increased cost, when considering continuous nebulization. As always, clinical judgment is necessary, but in severe exacerbations, continuous nebulization appears to be more beneficial.

18. Fetal outcomes in first trimester pregnancies with an indeterminate ultrasound. 

Juliano ML, Sauter BM. J Emerg Med. 2012 Sep;43(3):417-22.  

BACKGROUND: Pregnant women commonly present to the Emergency Department (ED) for evaluation during their first trimester. These women have many concerns, one of which is the viability of their pregnancy and the probability of miscarriage. 

STUDY OBJECTIVES: We sought to determine fetal outcomes of women with an indeterminate ultrasound who present to the ED during the first trimester of pregnancy. 

METHODS: A retrospective analysis of consecutive ED patient encounters from December 2005 to September 2006 was performed to identify patients who were pregnant and who had an indeterminate transvaginal ultrasound performed by an emergency physician or through the Radiology Department during their ED visit. Demographic data, obstetric/gynecologic history, and presenting symptoms were recorded onto a standardized patient chart template designed to be used for any first trimester pregnancy. Outcomes (spontaneous abortion, ectopic pregnancy, and 20-week gestation) were determined via computerized medical records. 

RESULTS: During the study timeframe, a total of 1164 patients were evaluated in the ED during the first trimester of their pregnancy; 359 patients (30.8%) met inclusion criteria and had a diagnosis of indeterminate ultrasound. Outcome data were obtained for 293 patients. Carrying the pregnancy to ≥20 weeks occurred in 70 patients (23.9%). Spontaneous abortion occurred in 193 women (65.9%), and 30 women (10.2%) were treated for an ectopic pregnancy. Total fetal loss incidence was 89.2% in patients presenting with any vaginal bleeding, compared to 34.7% in patients with pain only. 

CONCLUSION: Indeterminate ultrasounds in the setting of first trimester symptomatic pregnancy are indicative of poor fetal outcomes. Vaginal bleeding increased the risk of fetal loss. These data will assist emergency physicians in counseling women in the ED who are found to have an indeterminate ultrasound.

19. New Immunization Guidelines from the CDC: Use of PCV13 and PPSV23 Vaccine for Adults with Immunocompromising Conditions 

Morbidity and Mortality Weekly Report (MMWR) 2012;61(40);816-819. 

On June 20, 2012, the Advisory Committee on Immunization Practices (ACIP) recommended routine use of 13-valent pneumococcal conjugate vaccine (PCV13; Prevnar 13, Wyeth Pharmaceuticals, Inc., a subsidiary of Pfizer, Inc.) for adults aged ≥19 years with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid (CSF) leaks, or cochlear implants (Table). PCV13 should be administered to eligible adults in addition to the 23-valent pneumococcal polysaccharide vaccine (PPSV23; Pneumovax 23, Merck & Co. Inc.), the vaccine currently recommended for these groups of adults (1). The evidence for the benefits and risk of PCV13 vaccination of adults with immunocompromising conditions was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and designated as a Category A recommendation (2,3). This report outlines the new ACIP recommendations for PCV13 use; explains the recommendations for the use of PCV13 and PPSV23 among adults with immunocompromising conditions, functional or anatomic asplenia, CSF leaks, or cochlear implants; and summarizes the evidence considered by ACIP to make its recommendations. 

20. Legislative Interference with the Patient–Physician Relationship 

Weinberger SE, et al. N Engl J Med 2012; 367:1557-1559 

Increasingly in recent years, legislators in the United States have been overstepping the proper limits of their role in the health care of Americans to dictate the nature and content of patients' interactions with their physicians…. 

The missing middle section can be found here. Full-text (free):  

…Unfortunately, laws and regulations are blunt instruments. By reducing health care decisions to a series of mandates, lawmakers devalue the patient–physician relationship. Legislators, regrettably, often propose new laws or regulations for political or other reasons unrelated to the scientific evidence and counter to the health care needs of patients. Legislative mandates regarding the practice of medicine do not allow for the infinite array of exceptions — cases in which the mandate may be unnecessary, inappropriate, or even harmful to an individual patient. For example, a patient may already have undergone the test in question or may have specific contraindications to it. Lawmakers would also do well to remember that patient autonomy and individual needs, values, and preferences must be respected. 

Laws that specifically dictate or limit what physicians discuss during health care encounters also undermine the patient–physician relationship. Physicians must have the ability and freedom to speak to their patients freely and confidentially, to provide patients with factual information relevant to their health, to fully answer their patients' questions, and to advise them on the course of best care without the fear of penalty. 

Federal, state, and local governments have long played valued and important roles in our nation's health care. Various levels of government are appropriately involved in providing essential health care services, licensing health care professionals, protecting public health, determining the safety of drugs and medical devices, and investing in medical education and research. Government plays a particularly important role in ensuring health care access for vulnerable and special-needs populations, including the elderly and disabled (Medicare), the poor (Medicaid), children (the Children's Health Insurance Program), and veterans (the Veterans Health Administration). We are fortunate to have a broad-based and extensive health care system, whose improvement and future excellence depend on a continued partnership between health care professionals and government. 

None of the concerns raised above imply that we object to these governmental roles. But we believe that health legislation should focus on public health measures that extend beyond the individual patient and are outside the capacity of individual physicians or patients to control. In contrast, government must avoid regulating the content of the individual clinical encounter without a compelling and evidence-based benefit to the patient, a substantial public health justification, or both. 

Our objection to legislatively mandated health care decisions does not translate into an argument that physicians can do whatever they want. Physicians are still bound by broadly accepted ethical and professional values.13 The fundamental principles of respect for autonomy, beneficence, nonmaleficence, and justice dictate physicians' actions and behavior and shape the interactions between patients and their physicians. When physicians adhere to these principles, when patients are empowered to make informed decisions about their care, and when legislators avoid inappropriate interference with the patient–physician relationship, we can best balance and serve the health care needs of individual patients and the broader society.

21. Kids with ADHD have dimmer prospects as adults 

By Frederik Joelving. CHICAGO, Oct 15 (Reuters Health) - Children with ADHD symptoms tend to fare worse as adults than do kids without problems in school, according to the longest follow-up study of the disorder to date. 

They have less education and lower income, on average, and higher rates of divorce and substance abuse, according to findings released Monday in the Archives of General Psychiatry. 

"A lot of them do fine, but there is a small proportion that is in a great deal of difficulty," said Rachel Klein, a professor of child and adolescent psychiatry at New York University Langone Medical Center in New York. 

"They go to jail, they get hospitalized," said Klein, whose study is the longest to date to follow people with attention deficit hyperactivity disorder or ADHD. 

Children with the condition are excessively restless, impulsive and easily distracted, and often have trouble in school. There is no cure, but the symptoms can be kept in check by a combination of behavioral therapy and medication. 

Klein and colleagues followed 135 white men who had been rated hyperactive by their school teachers back in the 1970s and referred to Klein's hospital. According to the researcher, the children did not have aggressive or antisocial behaviors and would have been diagnosed with ADHD today. 

They all came from ordinary, middle-class homes, Klein said, and had "well-meaning" parents. When the boys were 18, the researchers established a comparison group of age-matched white boys who had visited their medical center for unrelated reasons and had not had any problems at school… 

22.  Use of CT in the ED for the Diagnosis of Pediatric Peritonsillar Abscess  

Baker KA, et al. Pediatr Emerg Care. 2012;28(10):962-965.  

Objective: The objective of this study was to review our pediatric emergency department’s (ED’s) utilization of computed tomography (CT) in the diagnosis of peritonsillar abscess (PTA) and treatment outcomes. 

Methods: This study used case series with chart review. 

Results: From January 2007 to January 2009, 148 patients were seen in our ED for possible PTA. Mean age at presentation was 11.8 years (range, 10 months to 18 years); 81 (54.7%) of 148 were females. Computed tomography was ordered in 96 (64.9%) of 148 patients, of which 73 (49.3%) 148 were confirmed to have PTA. Mean age of patients who underwent CT was younger when compared with those who did not have CT performed (mean, 11 vs 13 years; P = 0.02). Unilateral PTA was found in 65 (43.9%) of 148, bilateral in 8 (5.4%) of 148, and intratonsillar in 25 patients (16.9%). Concomitant CT findings of parapharyngeal space involvement were found in 19 (12.8%), and retropharyngeal space involvement in 11 (7.4%). Admission was necessary for 104 (71.2%) of 148 patients, whereas 42 were discharged from the ED. Transoral needle aspiration and/or incision and drainage were performed in the ED in 41 patients, with purulence identified in 33 (80.5%) of 41. Rapid strep testing was positive in 40 (32%) of 124 patients tested. Operative treatment was necessary in 44 patients (29.7%), 34 underwent incision and drainage, and 10 underwent quinsy tonsillectomy. 

Conclusions: Computed tomography is commonly utilized in the ED for the evaluation of PTA and is ordered more often in younger children.

23. Indications and performance of pelvic radiography in patients with blunt trauma. 

Holmes JF, et al. Am J Emerg Med.  2012;30(7):1129-33. 

OBJECTIVES: The objectives of this study are to validate a set of clinical variables to identify patients with pelvic fractures and to determine the sensitivity of anteroposterior (AP) pelvic radiographs in patients with pelvic fractures.  

METHODS: We conducted a prospective observational cohort study of adults (older than 18 years) with blunt torso trauma evaluated with abdominal/pelvic computed tomography. Physicians providing care in the emergency department documented history and physical examination findings after initial evaluation. High-risk variables included any of the following: hypotension (systolic blood pressure less than 90 mm Hg), Glasgow Coma Scale score less than 14, pelvic bone tenderness, or instability. Pelvic fractures were present if the orthopedic faculty documented a fracture to the pubis, ilium, ischium, or sacrum.  

RESULTS: We enrolled 4737 patients, including 289 (6.1%; 95% confidence interval [CI], 5.4%-6.8%) with pelvic fractures. Of the 289 patients, 256 (88.6%; 95% CI, 84.3%-92.0%) had at least one of the high-risk variables identified. Initial plain AP radiographs identified 234 (81.0%; 95% CI, 76.0%-85.3%) of 289 patients with pelvic fractures. The high-risk variables identified all 87 patients (100%; 95% CI, 96.6%-100%) undergoing surgery, whereas plain AP pelvic radiography identified a fracture in 83 patients (95.4%; 95% CI, 88.6%-98.7%) undergoing surgery.  

CONCLUSION: Previously identified high-risk variables for pelvic fracture identify most but not all patients with pelvic fractures. However, these high-risk variables identify all patients undergoing surgery and may be implemented as screening criteria for pelvic radiography. Anteroposterior pelvic radiographs fail to demonstrate a fracture in a substantial number of patients with pelvic fracture including patients who undergo surgery.

24. More Zzzs Earn A's for Behavior at School 

By Crystal Phend, Senior Staff Writer, MedPage Today. October 15, 2012 

A little extra sleep can make a big difference in kids' behavior at school, an experimental study showed. 

Giving children an average of just 27 more minutes of sleep than they usually got on school nights improved their emotional stability and cut down on restless and impulsive behavior at school, Reut Gruber, PhD, of McGill University in Montreal, and colleagues found. Taking away about an hour of sleep from a similar group of healthy 7- to 11-year-0lds had the opposite effect in the experiments reported in the November issue of Pediatrics. 

"Healthy sleep is essential for supporting alertness and other key functional domains required for academic success," the group wrote. "Sleep must be prioritized, and sleep problems must be eliminated." 

Previous, mostly observational studies have linked more sleep to better grades among teens and less sleep to development of psychiatric problems in children. An estimated 43% of boys ages 10 to 11 don't get the recommended amount each night, and almost two-thirds of school-age kids don't get to bed by 9 p.m., Gruber and colleagues noted. 

Moderately increasing children's sleep is both feasible and beneficial, they concluded, arguing for parents, teachers, and students to be educated about "the critical impact of sleep on daytime function." 

For their study, the researchers randomized 34 healthy children ages 7 to 11 who had no sleep problems or behavioral or academic troubles to receive an extra hour of sleep at home each night for 5 nights or to have 1 hour taken away from their usual nightly sleep time for 5 nights. No napping was allowed. 

Actinography showed that the children in the sleep extension group actually got only an average of 27 minutes more than their baseline of 9.3 hours, while the sleep-restriction group had 54 minutes cut from their similar baseline sleep time. Those who slept less than usual had a drop in sleep fragmentation (P less than 0.03) reflecting better quality sleep, but they were still more sleepy during the day than before the experiment, with Modified Epworth Sleepiness Scale score rising to a mean of 6 from 4 at baseline on the 24-point scale. 

Their behavior in school also worsened as assessed by their teachers, who were unaware of study group assignment, using the Conners' Global Index Scale. Total normalized T-scores rose from an average of 50 at baseline to 54 after sleep restriction, whereas they fell to an average of 47 points from 50 at baseline among the group that got extra sleep all week (P less than 0.05 for interaction). A score of 60 or above is considered clinically significant, the researchers pointed out. 

Likewise, the component T-scores for "emotional lability" -- crying, losing one's temper, or becoming easily frustrated -- rose from 48 to 51 after sleep reduction but fell from 50 to 47 after extended sleep. The restless and impulsive behavior subscale T-scores rose from 52 to 55 for those who got less sleep and fell from 50 to 47 for those who got extra sleep. 

The researchers cautioned about the relatively small size of the study and convenience sample used and thus suggested that the results be considered preliminary in nature. The study was supported by the Natural Sciences and Engineering Research Council of Canada and the Canadian Institutes of Health Research. 

Gruber R, et al. Impact of sleep extension and restriction on children's emotional lability and impulsivity. Pediatrics 2012; DOI: 10.1542/peds.2012-0564. Abstract:

25. Why Doctors Prescribe Opioids to Known Opioid Abusers 

Lembke A. N Engl J Med 2012; 367:1580-1581. 

Prescription opioid abuse is an epidemic in the United States. In 2010, there were reportedly as many as 2.4 million opioid abusers in this country, and the number of new abusers had increased by 225% between 1992 and 2000.1 Sixty percent of the opioids that are abused are obtained directly or indirectly through a physician's prescription. In many instances, doctors are fully aware that their patients are abusing these medications or diverting them to others for nonmedical use, but they prescribe them anyway. Why? Recent changes in medicine's philosophy of pain treatment, cultural trends in Americans' attitudes toward suffering, and financial disincentives for treating addiction have contributed to this problem. 

Throughout the 19th century, doctors spoke out against the use of pain remedies.2 Pain, they argued, was a good thing, a sign of physical vitality and important to the healing process. Over the past 100 years, and especially as the availability of morphine derivatives such as oxycodone (Oxycontin) increased, a paradigm shift has occurred with regard to pain treatment. Today, treating pain is every doctor's mandated responsibility. In 2001, the Medical Board of California passed a law requiring all California-licensed physicians (except pathologists and radiologists) to take a full-day course on “pain management.” It was an unprecedented injunction. Earlier this year, Pizzo and Clark urged health care providers as well as “family members, employers, and friends” to “rely on a person's ability to express his or her subjective experience of pain and learn to trust that expression,” adding that the “medical system must give these expressions credence and endeavor to respond to them honestly and effectively.”3 It seems that the patient's subjective experience of pain now takes precedence over other, potentially competing, considerations. In contemporary medical culture, self-reports of pain are above question, and the treatment of pain is held up as the holy grail of compassionate medical care. 

The prioritization of the subjective experience of pain has been reinforced by the modern practice of regularly assessing patient satisfaction. Patients fill out surveys about the care they receive, which commonly include questions about how adequately their providers have addressed their pain. Doctors' clinical skills may also be evaluated on for-profit doctor-grading websites for the world to see. Doctors who refuse to prescribe opioids to certain patients out of concern about abuse are likely to get a poor rating from those patients. In some institutions, patient-survey ratings can affect physicians' reimbursement and job security. When I asked a physician colleague who regularly treats pain how he deals with the problem of using opioids in patients who he knows are abusing them, he said, “Sometimes I just have to do the right thing and refuse to prescribe them, even if I know they're going to go on Yelp and give me a bad rating.” His “sometimes” seems to imply that at other times he knowingly prescribes opioids to abusers because not doing so would adversely affect his professional standing. If that's the case, he is by no means alone… 

The remainder of the essay (full-text free):

26. Is Multitasking Bad For Us? 

By Brandon Keim. Posted 10.04.12. NOVA scienceNOW 

For people of a certain age—well, okay, for myself, but I suspect I'm not alone—multitasking is something done capably though not comfortably. We juggle the multiple screens, the simultaneous text messages and emails and other momentary claims to attention, yet it never quite feels right. 

We feel distracted, like we're not functioning as effectively as possible. Focus no longer has clarity. Yet when, at the end of the day or while on vacation, we finally have a chance to concentrate, it no longer comes easily. The mind strays, fingers wander to a missing keyboard. We close the book, open a laptop, and fill a screen with windows.

27. Low Back Pain Guidelines Aid in Management 

Laurie Barclay, MD. Medscape Medical News. October 3, 2012 — Radiologists have developed evidence-based guidelines for management of low back pain, according to a report in the October issue of the Journal of the American College of Radiology. The accompanying order set templates should help clinicians decide on appropriate imaging, laboratory tests, and/or referral for surgery or other invasive procedures. 

"The approach to the workup and management of low back pain by physicians and other practitioners is inconstant," lead author Scott E. Forseen, MD, from the Department of Radiology, Neuroradiology Section at Georgia Health Sciences University in Augusta, said in a news release. "In fact, there is significant variability in the diagnostic workup of back pain among physicians within and between specialties." 

Low back pain is one of the most frequent presenting symptoms at outpatient visits. The authors note that the results of one study showed that more than one quarter (26.4%) of adults reported episodes of acute low back pain within the past 3 months. 

In the United States, annual total direct and indirect costs of back pain are estimated to exceed $100 billion, with increased use of medical imaging contributing significantly to these costs, according to the authors. However, rising spine care expenditures for medical imaging are not linked to a corresponding improvement in patient outcomes. 

Management Strategy 

To facilitate clinical management of low back pain, the new guidelines suggest the following strategy:
·         Perform a complete history and physical examination at the initial visit, including duration and nature of symptoms, presence of red flags, and symptoms of spinal stenosis or radiculopathy. Red flags include history of trauma or cancer, unintentional weight loss, immunosuppression, use of steroids or intravenous drugs, osteoporosis, age older than 50 years, focal neurologic deficit, and progression of symptoms.
·         Categorize patients into 1 of 3 groups: nonspecific low back pain, low back pain potentially caused by radiculopathy or spinal stenosis, or low back pain potentially associated with another specific cause suggested by the presence of red flags.
·         Use the evidence-based order sets provided for each category to guide the initial visit process of assessment, management, and follow-up.
·         Use evidence-based order set templates at the 4-week follow-up visit to guide decisions regarding appropriate imaging, laboratory testing, referral for invasive procedures, and/or surgical consultation. 

"We have presented a logical method of choosing, developing and implementing clinical decision support interventions that is based on the best available evidence," Dr. Forseen said in the news release. "These templates may be reasonably expected to improve patient care, decrease inappropriate imaging utilization, reduce the inappropriate use of steroids and narcotics, and potentially decrease the number of inappropriate invasive procedures." 

Order Set Templates 

For nonspecific low back pain present for less than 4 weeks without red flags, pharmacotherapy may include acetaminophen, nonsteroidal antiinflammatory drugs, and/or skeletal muscle relaxants. In some cases, tramadol, opioids, and/or benzodiazepines may be appropriate. 

Activity level could be normal or with specific restrictions. Other interventions could include giving the patient an educational back pain pamphlet, physical or occupational therapy consult, and follow-up in 4 weeks. 

For low back pain due to radiculopathy or spinal stenosis, any or all of the above interventions could be appropriate. Use of gabapentin could be considered. 

Imaging procedures and laboratory testing are generally reserved for low back pain potentially associated with another specific cause suggested by the presence of red flags. Suspected causes warranting imaging are malignancy, discitis/osteomyelitis, and fracture. 

Magnetic resonance imaging (MRI) of the lumbar spine without and with contrast is the preferred imaging workup, but computed tomography (CT) of the lumbar spine without contrast is suitable if MRI is unavailable or contraindicated. Other tests may include lumbar spine radiography, technetium 99m bone scanning, erythrocyte sedimentation rate, and/or C-reactive protein. 

Workup of low back pain associated with focal neurologic deficit and progressive or disabling symptoms may include MRI of the lumbar spine without contrast (and with contrast in some cases), myelography and postmyelography CT of the lumbar spine, lumbar spine CT with or without intravenous contrast, and/or electromyography/nerve conduction velocity. 

"A carefully designed [clinical decision support] system may be reasonably expected to improve patient care, decrease inappropriate imaging utilization, reduce the inappropriate use of steroids and narcotics, and potentially decrease the number of inappropriate invasive procedures," the guideline authors conclude. "Ideally, these templates could also be used to develop transparent criteria for payer coverage determinations with regard to imaging, medications, procedures, and surgical interventions." 

The guideline authors have disclosed no relevant financial relationships.  

Forseen SE. J Am Coll Radiol. 2012;9:704-712.