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.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)00591-4/fulltext
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.
ClinicalTrials.gov identifier: NCT00773175.
[More articles on hypodermoclysis can be found in the April
12, 2011 issue of Lit Bits, number 19: http://drvinsonlitbits.blogspot.com/2011/04/lit-bits-april-12-2011.html
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]
Full-text (free): http://www.cmaj.ca/content/early/2012/10/09/cmaj.120675.long
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): http://www.wjh.harvard.edu/~dtg/DUNN%20GILBERT%20&%20WILSON%20(2011).pdf
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?
Nope.
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.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)00159-X/fulltext
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?
Yes.
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?
Yes.
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.
Full-text (free): http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4.htm
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): http://www.nejm.org/doi/full/10.1056/NEJMsb1209858
…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…
The remainder of the article: http://www.reuters.com/article/2012/10/15/usa-adhd-idUSL1E8LFMOW20121015
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: http://www.ncbi.nlm.nih.gov/pubmed/23071214
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): http://www.nejm.org/doi/full/10.1056/NEJMp1208498
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.
The remainder of the essay: http://www.pbs.org/wgbh/nova/body/is-multitasking-bad.html
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.
