Friday, November 23, 2012

Lit Bits: Nov 23, 2012

From the (mostly) recent literature...

1. Overuse of CT Pulmonary Angiography in the Evaluation of Patients with Suspected PE in the ED

Crichlow A, et al. Acad Emerg Med. 2012;19:1219-1226.

Background: Clinical decision rules have been developed and validated for the evaluation of patients presenting with suspected pulmonary embolism (PE) to the emergency department (ED).

Objectives: The objective was to assess the percentage of computed tomographic pulmonary angiography (CT-PA) procedures that could have been avoided by use of the Wells score coupled with D-dimer testing (Wells/D-dimer) or pulmonary embolism rule-out criteria (PERC) in ED patients with suspected PE.

Methods: The authors conducted a prospective cohort study of adult ED patients undergoing CT-PA for suspected PE. Wells score and PERC were calculated. A research blood sample was obtained for D-dimer testing for subjects who did not undergo testing as part of their ED evaluation. The primary outcome was PE by CT-PA or 90-day follow-up. Secondary outcomes were ED length of stay (LOS) and CT-PA time as defined by time from order to initial radiologist interpretation.

Results: Of 152 suspected PE subjects available for analysis (mean ± SD age = 46.3 ± 15.6 years, 74% female, 59% black or African American, 11.8% diagnosed with PE), 14 (9.2%) met PERC, none of whom were diagnosed with PE. A low-risk Wells score (≤4) was assigned to 110 (72%) subjects, of whom only 38 (35%) underwent clinical D-dimer testing (elevated in 33/38). Of the 72 subjects with low-risk Wells scores who did not have D-dimers performed in the ED, archived research samples were negative in 16 (22%). All 21 subjects with low-risk Wells scores and negative D-dimers were PE-negative. CT-PA time (median = 160 minutes) accounted for more than half of total ED LOS (median = 295 minutes).

Conclusions: In total, 9.2 and 13.8% of CT-PA procedures could have been avoided by use of PERC and Wells/D-dimer, respectively.

2. Safe exclusion of PE using the Wells rule and qualitative D-dimer testing in primary care: prospective cohort study

Geersing G, et al. BMJ 2012; 345:e6564

For many doctors, patients with unexplained shortness of breath or pleuritic chest pain pose a diagnostic dilemma. In particular doctors in primary care, who in many countries are the first to be consulted when patients have these symptoms, have to differentiate between common self limiting diseases, such as myalgia or respiratory tract infections, and the rarer life threatening diseases such as pulmonary embolism. As the symptoms of pulmonary embolism may be relatively mild, it can be easily missed,1 2 and because pulmonary embolism has a high mortality doctors do not always get another chance if it is misdiagnosed.3 As a result, most doctors in primary care have a low threshold for referring patients with suspected pulmonary embolism and only 10-15% of referred patients are actually diagnosed as having the condition.4

To stratify patients with suspected pulmonary embolism between a high probability (need for referral) of having the condition compared with a low probability, clinical decision rules (combining the different characteristics of patients and the disease into a score) have been developed. The clinical decision rule developed by Wells and colleagues is the most widely known, validated, and implemented tool for the detection of pulmonary embolism in secondary care. The Wells clinical decision rule combines seven items into a score ranging from 0 to 12.5. Based on many studies in secondary care, a threshold of below 2 or 4 or more was introduced into the rule.5 Below these levels patients are classified, respectively, as being at very low risk or low risk of having pulmonary embolism. A large diagnostic management study in secondary care concluded that a negative laboratory based quantitative D-dimer (degradation product of fibrin) test result in patients with a Wells score of ≤4 safely excluded pulmonary embolism without the need for additional investigations by imaging.6

Such a diagnostic strategy seems ideal in primary care to facilitate decisions on referral to secondary care, in particular since easy to use point of care D-dimer tests providing results within minutes are available for use at the doctor’s practice or in the patient’s home.7 Before such a diagnostic strategy can be implemented, however, it needs to be validated in the proper setting of primary care.8 9 Owing to differences in the spectrum of disease, symptoms, and doctors’ experience, encouraging results from referral centres may not be readily applicable in primary care.10 11

We carried out a formal external validation of the Wells pulmonary embolism rule combined with a point of care qualitative D-Dimer test to evaluate the safety and efficiency of using this clinical decision rule in primary care.

Objective To validate the use of the Wells clinical decision rule combined with a point of care D-dimer test to safely exclude pulmonary embolism in primary care.

Design Prospective cohort study.

Setting Primary care across three different regions of the Netherlands (Amsterdam, Maastricht, and Utrecht).

Participants 598 adults with suspected pulmonary embolism in primary care.

Interventions Doctors scored patients according to the seven variables of the Wells rule and carried out a qualitative point of care D-dimer test. All patients were referred to secondary care and diagnosed according to local protocols. Pulmonary embolism was confirmed or refuted on the basis of a composite reference standard, including spiral computed tomography and three months’ follow-up.

Main outcome measures Diagnostic accuracy (sensitivity and specificity), proportion of patients at low risk (efficiency), number of missed patients with pulmonary embolism in low risk category (false negative rate), and the presence of symptomatic venous thromboembolism, based on the composite reference standard, including events during the follow-up period of three months.

Results Pulmonary embolism was present in 73 patients (prevalence 12.2%). On the basis of a threshold Wells score of ≤4 and a negative qualitative D-dimer test result, 272 of 598 patients were classified as low risk (efficiency 45.5%). Four cases of pulmonary embolism were observed in these 272 patients (false negative rate 1.5%, 95% confidence interval 0.4% to 3.7%). The sensitivity and specificity of this combined diagnostic approach was 94.5% (86.6% to 98.5%) and 51.0% (46.7% to 55.4%), respectively.

Conclusion A Wells score of ≤4 combined with a negative qualitative D-dimer test result can safely and efficiently exclude pulmonary embolism in primary care.

3. Temporal and Safety Outcomes of Skipping Oral Contrast for Non-traumatic Abd CTs

A. IV contrast alone vs IV and oral contrast CT for the diagnosis of appendicitis in adult ED patients

Kepner AM, et al. Amer J Emerg Med. 2012;30:1765-1773.

Objective: When the diagnosis of appendicitis is uncertain, computerized tomography (CT) scans are frequently ordered. Oral contrast is often used but is time consuming and of questionable benefit. This study compared CT with intravenous contrast alone (IV) to CT with IV and oral contrast (IVO) in adult patients with suspected appendicitis.

Methods: This is a prospective, randomized study conducted in a community teaching emergency department (ED). Patients with suspected appendicitis were randomized to IV or IVO CT. Scans were read independently by 2 designated study radiologists blinded to the clinical outcome. Surgical pathology was used to confirm appendicitis in patients who went to the operating room (OR). Discharged patients were followed up via telephone. The primary outcome measure was the diagnosis of appendicitis. Secondary measures included time from triage to ED disposition and triage to OR.

Results: Both IV (n = 114) and IVO (n = 113) scans had 100% sensitivity (95% confidence interval [CI], 89.3-100 and 87.4-100, respectively) and negative predictive value (95% CI, 93.7-100 and 93.9-100, respectively) for appendicitis. Specificity of IV and IVO scans was 98.6 and 94.9 (95% CI, 91.6-99.9 and 86.9-98.4, respectively), respectively, with positive predictive values of 97.6 and 89.5 (95% CI, 85.9-99.9 and 74.2-96.6). Median times to ED disposition and OR were 1 hour and 31 minutes (P less than .0001) and 1 hour and 10 minutes (P = .089) faster for the IV group, respectively. Patients with negative IV scans were discharged nearly 2 hours faster (P = .001).

Conclusions: Computerized tomography scans with intravenous contrast alone have comparable diagnostic performance to IVO scans for appendicitis in adults. Patients receiving IV scans are discharged from the ED faster than those receiving IVO scans.

B. Does Limiting Oral Contrast Decrease ED Length of Stay?

You betcha!

Hopkins CL, et al. West J Emerg Med. 2012 [Epub ahead of print]

Introduction: The purpose of this study was to examine the impact on Emergency department (ED) length of stay (LOS) of a new protocol for intravenous (IV)-contrast only abdominal/pelvic computed tomography (ABCT) compared to historical controls.

Methods: This was a retrospective case-controlled study performed at a single academic medical center. Patients ≥ 18 undergoing ABCT imaging for non-traumatic abdominal pain were included in the study. We compared ED LOS between historical controls undergoing ABCT imaging with PO/IV contrast and study patients undergoing an IV-contrast-only protocol. Imaging indications were the same for both groups and included patients with clinical suspicion for appendicitis, diverticulitis, small bowel obstruction, or perforation. We identified all patients from the hospital’s electronic storehouse (imaging code, ordering department, imaging times), and we abstracted ED LOS and disposition from electronic medical records.

Results: Two hundred and eleven patients who underwent PO/IV ABCT prep were compared to 184 patients undergoing IV-contrast only ABCT prep. ED LOS was shorter for patients imaged with the IVcontrast only protocol (4:35 hrs vs. 6:39 hrs, p less than 0.0001).

Conclusion: Implementation of an IV-contrast only ABCT prep for select ED patients presenting for evaluation of acute abdominal pain significantly decreased ED LOS.

4. Make the ED Ouchless, Says AAP

By Nancy Walsh, Staff Writer, MedPage Today. Published: October 29, 2012

The systematic and comprehensive management of pain and anxiety is a crucial component of emergency department (ED) care for all children, a clinical report from the American Academy of Pediatrics (AAP) stated.

"Encouragingly, improvements in the recognition and treatment of pain in children have led to changes in the approach to pain management for acutely ill and injured pediatric patients," Joel A. Fein, MD, of the University of Pennsylvania in Philadelphia, and colleagues wrote in the November Pediatrics.

Many potential barriers exist in the treatment of pain in children in emergency situations, including the complexity of assessment, difficulties in communication, lack of staff, and medication concerns, such as adverse effects. To address these concerns and to provide up-to-date information on the use of analgesic and sedative drugs in the pediatric emergency setting, the AAP assembled evidence-based guidance on implementing and maintaining optimal care for use by hospital and transport staff. "Recent advances in the approach and support for pediatric analgesia and sedation, as well as new products and devices, have improved the overall climate of the ED for patients and families in search of the 'ouchless' ED," the report authors observed.

A first principle was that the initial evaluation of the child in the ED should include an assessment of pain, which can be done, depending on the child's age and developmental level, using numerical scales; the FACES pain scale, in which the child identifies which facial expression most resembles his or her degree of discomfort; or a neonatal pain scoring tool. Protocols should be in place to guide the administration of medications, such as ibuprofen, acetaminophen, or oral oxycodone, as well as for the use of topical anesthetics for any likely painful procedure, such as placement of an intravenous line, lumbar puncture, or suturing lacerations.

Provision should also be made for the safe administration of analgesics before the child reaches the hospital, the report noted. Even the administration of analgesia should be done in as painless a manner as possible. One useful approach is to use warmed lidocaine buffered with bicarbonate and administered slowly, according to the AAP report.

For neonates, pain can be alleviated with topical anesthetics, and also by having the infant suck sucrose solution from a pacifier immediately before a procedure. Having family members present can be another potentially comforting strategy, along with providing a child-friendly room or area with toys and potential distractions available.

Various methods of drug administration, such as transmucosal or inhaled, can further ease delivery of analgesia during evaluation and treatment, as well as using agents such as nitrous oxide that not only have analgesic properties but which are also anxiolytic. Many ED clinicians today are using short-acting agents such as propofol to provide sedation, which not only helps alleviate pain but can improve the likelihood that the child will remain still during procedures.

"The most important part of providing safe sedation for children is the establishment of appropriate sedation systems and sedation training programs with credentialing guidelines for sedation providers that specifically address the core competencies required for the care of pediatric patients," Fein and colleagues stated.

In addition, the AAP along with other medical societies has recommended that ED caregivers perform a structured risk stratification for each individual child before sedation is begun, including examination of the airway and consideration of any pre-existing conditions.

Specific discharge criteria also should be in place, so that children who have been sedated are not sent home at a time when adverse events could still occur. Written follow-up instructions should always be given to parents.

A particular concern in the clinical report was in evaluating and treating children with disabilities, who may have particular difficulties in communicating their feelings of pain, anxiety, and fear, and may exhibit poorly regulated behaviors and a lack of cooperation. So-called "child life specialists," who are trained in dealing with stressful situations in children, can be particularly helpful for children with these developmental or behavioral problems. And of utmost concern for these children, the report states, "Myths of pain insensitivity or indifference must be actively avoided."

Finally, the report emphasized, a regular quality improvement program that involves transport teams and all ED staff must continually review processes and outcomes associated with pediatric pain management.

"Multiple modalities are now available that allow pain and anxiety control for all age groups. Future research should concentrate on pharmacologic, nonpharmacologic, and device-related technology that can assist in reducing the pain and distress associated with medical procedures," the report concluded.

All authors have reported no conflicts of interest, and the AAP has not accepted any commercial involvement in the development of this clinical report.

Fein J, et al "Relief of pain and anxiety in pediatric patients in emergency medical systems" Pediatrics 2012; 130: e1391-e1405.

5. Gerontologists outline how doctors can bridge communication gap with older patients

By Carolyne Krupa, amednews staff. Posted Oct. 29, 2012.

With the elderly population expected to increase substantially in the next two decades, physicians need to be prepared for the unique challenges they will face treating these patients, says a new report from the Gerontological Society of America.

Nearly one in five Americans will be 65 or older by 2030, according to the U.S. Administration on Aging. People in this age group make nearly twice as many physician office visits per year than adults 45 to 65. Yet the Centers for Disease Control and Prevention estimates that two-thirds of older people are unable to understand the information given to them about their prescription medications.

The society’s report offers recommendations for physicians and other health professionals on how best to communicate with this growing patient population. It is intended to help dispel some of the myths and stereotypes physicians may have about older patients and give concrete suggestions for good communication strategies, said Jake Harwood, a professor in the Dept. of Communication at the University of Arizona in Tucson, who chaired the advisory board that oversaw the report’s development.

Assuming that all elderly patients are frail, dependent, hard of hearing or cognitively impaired can lead to a patronizing communication style that many older people find disrespectful, he said.

“The consequence would be medical encounters in which the patient is annoyed or dissatisfied,” Harwood said. “That is not an optimal environment for the patient to gather the information he or she needs, or for the patient to trust the physician and follow through on his or her recommendations.”

The report offers 29 recommendations for avoiding poor communication, such as recognizing one’s stereotypes, minimizing background noise, and monitoring and controlling arm movements and other nonverbal behavior when talking with patients. Clear physician-patient communication is essential, yet many health professionals don’t get enough training on interacting with elderly patients, Harwood said.

Other experts in patient communication say physicians need to be aware if a patient has any cognitive impairments, poor health literacy or sensory limitations such as poor hearing and eyesight.

Poor communication can be detrimental to a patients’ health, said Cynthia Boyd, MD, MPH, associate professor of medicine with the Dept. of Medicine Division of Geriatric Medicine and Gerontology at Johns Hopkins University School of Medicine in Baltimore. If there is bad communication, patients are more likely to miss appointments or fail to follow medical advice, such as properly taking medications, said Pam Mason, director of Audiology Professional Practices with the American Speech-Language-Hearing Assn.

The remainder of the article (full text free):

6. Screened & Examined: The Out-of-Control Patient Safety Pendulum (on verbal orders)

Ballard DW. Emerg Med News. 2012;34(11B).

Wait. What's that you say? You need an electronic order for that? OK, wait a second, let me find a computer … logging on … could I just get started without an official order? Not possible, eh? OK, here we go. It's in!

That's a typical communication in the ED. Latinphiles may recognize that the word “communication” has its origins in the Latin “communicare,” meaning to impart, share, or make common. A major component of ED communication is sharing and imparting treatment orders, and as we all know, we can do this in multiple ways — by pen, keystroke, and larynx. It is the latter on which I'd like to focus.

The spoken order, often sterilely called the “verbal order,” or VO, has become somewhat of an anathema at some U.S. hospitals. A recent systematic review described broad differences in verbal order policies across 40 acute care hospitals with many restricting the use of verbal orders and in some instances even simple face-to-face orders such as requesting a single dose of acetaminophen. (Jt Comm J Qual Patient Saf 2012;38[1]:24.) As best as I can tell, the rationale for such restrictive policies is threefold: the availability of emerging technology (computerized order entry), a litany of anecdotal evidence on patient safety risk, and a strong suggestion from the Joint Commission as part of their national patient safety goals. What I'd like to know is, where is the evidence?

Wait, what's that? You need another order. Why? Because I am changing the nature of this discussion? Really? OK, let me log in. Here we go. Just a moment to jump into intergalactic hyperspace. Typing it in now. Order up!

Where was I? As it turns out, the evidence for restrictive verbal order policies is almost purely anecdotal. I'm certain you've heard some variation of this anecdote before. It proceeds along the lines of the broken telephone game where kids whisper a phrase to each other around a circle and see what comes out the other side. “I took my dog for a walk today, and then I gave him some food” morphs into “I took Michael for a walk today, and then I shaved him something good.” Or like an iPhone autocorrect embarrassment, you text about your “neighbor's child prodigy,” but your iPhone turns it into a text about your “neighbor's child prostitute.” Broken communication anecdotes in the healthcare arena go like this (examples courtesy of the Institute of Safe Medication Practices):

“An emergency room physician verbally ordered 'morphine 2 mg IV,' but the nurse heard 'morphine 10 mg IV,' and the patient received a 10 mg injection and developed respiratory arrest.”

“[A] physician called in an order for 15 mg of hydralazine to be given IV every TWO hours. The nurse, thinking that he had said '50 mg,' administered an overdose to the patient who developed tachycardia and had a significant drop in blood pressure.” (Dynamics 2006;17[1]:20.)

Anecdotes can be powerful (as can Narcan), and we all have experienced moments of misdirected communication in the workplace. The danger of the spoken order seems to make intuitive sense. But is there actual evidence in the literature supporting a patient safety benefit for restrictive verbal order policies?

Huh? Another order? Are you sure? This should definitely be covered by the previous order. Yes, OK, I know you want to protect patient safety, and your license, too. Yes, I know management is tracking this closely. No, you don't want to take a verbal on it? OK, then, but I have to admit that these interruptions are distracting. And I've been reading a lot about the danger of interruptions in the ED. A significant source of error, you know. Sorry, you don't want to hear about this without a separate order, so we'll drop it. Logging back in. Waiting. It's in.

Now, here we go, the actual evidence. It's quite sparse. A 2009 review on the topic, by Wakefield and Wakefield, summarizes it nicely: “The literature consists primarily of nonsystematic and anecdotal evidence of the relationship between verbal order utilization and actual or potential patient harm. To our knowledge, the only large-scale study of hospital verbal order policies is a 1990 report of a survey of nursing and pharmacy leaders' self-report of selected features of their hospitals' verbal order policies.” (Qual Saf Health Care 2009;18[3]:165.)

The only study specifically looking at errors associated with verbal orders compared with handwritten or computer entry actually demonstrated a counterintuitive decrease in errors with verbal orders compared with other types. (Qual Saf Health Care 2009;18[3]:165; Arch Pediatr Adolesc Med 1994;148[12]:1322.)…

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

7. Review: Steroid shots offer limited benefit for sciatica

Steroid injection into the spine provides only small, short-term relief for sciatica-related leg and back pain, according to a review of 23 clinical trials involving more than 3,100 patients. "Given that the treatment effect is likely to be small and short term, patients with sciatica should discuss the potential risks involved in [steroid injections] with their doctor before agreeing to the procedure," according to the study co-author. The study appeared in the Annals of Internal Medicine.

8. Acute diverticulitis: demographic, clinical and laboratory features associated with CT findings in 741 patients.

Longstreth GF, et al. Aliment Pharmacol Ther. 2012 Sep 11. doi: 10.1111/apt.12047. [Epub ahead of print]

BACKGROUND: Computed tomography (CT) demonstrates diverticulitis severity.

AIM: To assess demographic, clinical and leucocyte features in association with severity.

METHODS: We reviewed medical records of 741 emergency department cases and in-patients with diverticulitis. CT findings were: (i) nondiagnostic; (ii) moderate (peri-colic inflammation); and (iii) severe (abscess and/or extra-luminal gas and/or contrast).

RESULTS: Patients with severe vs. nondiagnostic/moderate findings had fewer females (42.4% vs. 58.2%, P = .004), less lower abdominal pain only (74.7% vs. 83.7%, P = .042) and more constipation (24.4% vs. 12.5%, P = .002), fever (52.2% vs. 27.0%, P less than .0001), leucocytosis (81.5% vs. 55.2%, P less than .0001), neutrophilia (86.2% vs. 59.0%, P less than .0001), 'bandemia' (18.5% vs. 5.5%, P less than .0001) and the triad of abdominal pain, fever and leucocytosis (46.7% vs. 19.9%, P less than .0001) respectively. Severe vs. nondiagnostic/moderate findings occurred in 4.8% vs. 95.2% without fever or leucocytosis, 7.0% vs. 93.0% with fever, 12.3% vs. 87.7% with leucocytosis and 25.1% vs. 74.9% with fever and leucocytosis respectively (P less than .0001). The former group (odds ratio [95% CI]) included females less often (0.45 [0.26-0.76]) and had less lower abdominal pain only (0.54 [0.29-0.99]) and more constipation (2.32 [1.27-4.23]), fever (2.13 [1.27-3.57]) and leucocytosis (2.67 [1.43-4.99]).

CONCLUSIONS: Less than 50% of severe cases have the clinical/laboratory triad of abdominal pain, fever and leucocytosis, but only 1 of 20 with pain who lack fever and leucocytosis have severe diverticulitis. Male gender, pain not limited to the lower abdomen, constipation, fever and leucocytosis are independently associated with severe diverticulitis.

9. Dilemmas in the diagnosis of acute community-acquired bacterial meningitis

Brouwer MC, et al. The Lancet 2012;380:1684 – 1692. 

Rapid diagnosis and treatment of acute community-acquired bacterial meningitis reduces mortality and neurological sequelae, but can be delayed by atypical presentation, assessment of lumbar puncture safety, and poor sensitivity of standard diagnostic microbiology. Thus, diagnostic dilemmas are common in patients with suspected acute community-acquired bacterial meningitis. History and physical examination alone are sometimes not sufficient to confirm or exclude the diagnosis. Lumbar puncture is an essential investigation, but can be delayed by brain imaging. Results of cerebrospinal fluid (CSF) examination should be interpreted carefully, because CSF abnormalities vary according to the cause, patient's age and immune status, and previous treatment. Diagnostic prediction models that use a combination of clinical findings, with or without test results, can help to distinguish acute bacterial meningitis from other causes, but these models are not infallible. We review the dilemmas in the diagnosis of acute community-acquired bacterial meningitis, and focus on the roles of clinical assessment and CSF examination.

10.  Cost-(in)effectiveness of routine coagulation testing in the evaluation of CP in the ED

Kochert E, et al. Amer J Emerg Med. 2012;30:2034-2038.

Introduction: Approximately 5% of all US emergency department (ED) visits are for chest pain, and coagulation testing is frequently utilized as part of the ED evaluation.

Objective: The objective was to assess the cost-effectiveness of routine coagulation testing of patients with chest pain in the ED.

Methods: We conducted a retrospective chart review of patients evaluated for chest pain in a community ED between August 1, 2010, and October 31, 2010. Charts were reviewed to determine the number and results of coagulation studies ordered, the number of coagulation studies that were appropriately ordered, and the number of patients requiring a therapeutic intervention or change in clinical plan (withholding of antiplatelet/anticoagulant, delayed procedure, or treatment with fresh frozen plasma or vitamin K) based on an unexpected coagulopathy. We considered it appropriate to order coagulation studies on patients with cirrhosis, known/suspected coagulopathy, active bleeding, use of warfarin, or ST-elevation myocardial infarction.

Results: Of the 740 patients included, 406 (55%) had coagulation studies ordered. Of those 406, 327 (81%) patients with coagulation studies ordered had no indications for testing. One of the 327 patients (0.31%; 95% confidence interval, 0.05%-1.7%) tested without indication had a clinically significant coagulopathy (internationalized normalization ratio above 1.5, partial thromboplastin time above 50 seconds), but none (0%; 95% confidence interval, 0%-1.2%) of the patients with coagulation testing performed without indication required a therapeutic intervention or change in clinical plan. The cost of coagulation testing in these 327 patients was $16780.

Conclusions: Coagulation testing on chest pain patients in the ED is not cost-effective and should not be routinely performed.

11. Low-Dose Steroids in Sepsis Are Associated with Increased In-Hospital Mortality

This study from the Surviving Sepsis Campaign does not support use of steroids in septic shock.

Research has provided conflicting results regarding the benefit of steroids in septic shock. As part of the Surviving Sepsis Campaign, investigators analyzed data from 17,847 patients who were eligible for low-dose steroids because they required vasopressor therapy after fluid resuscitation. Eligible patients had at least two systemic inflammatory response syndrome criteria, at least one organ dysfunction criterion, and a suspected site of infection.

Just over half of patients received low-dose steroids (50 mg intravenously four times per day or 100 mg three times per day), most within 8 hours of presentation. Patients in Europe and South America were more likely to receive steroids than those in North America (59%, 52%, and 46%, respectively). Patients with pneumonia and those on mechanical ventilation were more likely to receive steroids than their counterparts.

Hospital mortality was significantly higher in patients who received low-dose steroids than in those who did not (41% vs. 35%; adjusted odds ratio, 1.18).

Comment: Although some patients with sepsis have diminished response to exogenous corticotropin despite normal glucocorticoid levels, this observational study shows that administering steroids to septic patients does not improve outcomes and is not indicated.

— Kristi L. Koenig, MD, FACEP, FIFEM. Published in Journal Watch Emergency Medicine November 2, 2012. Citation: Casserly B et al. Low-dose steroids in adult septic shock: Results of the Surviving Sepsis Campaign. Intensive Care Med 2012 Oct 12; [e-pub ahead of print].

12. Panel Lays Out Blueprint for Troponin Testing

By Chris Kaiser, Cardiology Editor, MedPage Today. Published: November 14, 2012

Action Points
  • Most current assays for cardiac troponin are robust with respect to both sensitivity and analytic performance around the lower limits of detectability. These assays are able to selectively detect cardiac troponin to the exclusion of troponin from other tissues.
  • It is important to recognize that elevated troponin in and of itself does not indicate myocardial infarction (MI); rather, it is a sensitive and specific determinant of myocardial necrosis that is nonspecific relative to the etiology of that necrosis, according to the authors of a consensus statement on the use of troponin assays.  Because it is not specific for MI, troponin evaluation should be performed only if clinically indicated for suspected MI. An elevated troponin level must always be interpreted in the context of the clinical presentation, the statement noted.
  • Highly sensitive troponin assays have made it necessary for professional societies to issue the first-ever consensus statement on troponin testing.
Newby LK, et al. ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations J Am Coll Cardiol. 2012
Abstract (and at the moment, full-text free):

13. (Non-)Utility of head CT in the evaluation of vertigo/dizziness in the ED

Lawhn-Heath C, et al. Emerg Radiol. 2012 Sep 2. [Epub ahead of print]

Acute dizziness (including vertigo) is a common reason to visit the emergency room, and imaging with head CT is often performed initially to exclude a central cause. In this study, consecutive patients presenting with dizziness and undergoing head CT were retrospectively reviewed to determine diagnostic yield.

Four hundred forty-eight consecutive head CTs in a representative sample of dizzy emergency room (ER) patients, including patients with other neurological symptoms, were reviewed to identify an acute or subacute cause for acute dizziness along with the frequency and modalities used in follow-up imaging.

The diagnostic yield for head CT ordered in the ER for acute dizziness is low (2.2 %; 1.6 % for emergent findings), but MRI changes the diagnosis up to 16 % of the time, acutely in 8 % of cases. Consistent with the American College of Radiology appropriateness criteria and the literature, this study suggests a low diagnostic yield for CT in the evaluation of acute dizziness but an important role for MRI in appropriately selected cases.

14. Low-Dose Aspirin for Preventing Recurrent Venous Thromboembolism?

 Brighton TA, et al. for the ASPIRE Investigators. N Engl J Med 2012; 367:1979-1987.

BACKGROUND: Patients who have had a first episode of unprovoked venous thromboembolism have a high risk of recurrence after anticoagulants are discontinued. Aspirin may be effective in preventing a recurrence of venous thromboembolism.

METHODS: We randomly assigned 822 patients who had completed initial anticoagulant therapy after a first episode of unprovoked venous thromboembolism to receive aspirin, at a dose of 100 mg daily, or placebo for up to 4 years. The primary outcome was a recurrence of venous thromboembolism.

RESULTS: During a median follow-up period of 37.2 months, venous thromboembolism recurred in 73 of 411 patients assigned to placebo and in 57 of 411 assigned to aspirin (a rate of 6.5% per year vs. 4.8% per year; hazard ratio with aspirin, 0.74; 95% confidence interval [CI], 0.52 to 1.05; P=0.09). Aspirin reduced the rate of the two prespecified secondary composite outcomes: the rate of venous thromboembolism, myocardial infarction, stroke, or cardiovascular death was reduced by 34% (a rate of 8.0% per year with placebo vs. 5.2% per year with aspirin; hazard ratio with aspirin, 0.66; 95% CI, 0.48 to 0.92; P=0.01), and the rate of venous thromboembolism, myocardial infarction, stroke, major bleeding, or death from any cause was reduced by 33% (hazard ratio, 0.67; 95% CI, 0.49 to 0.91; P=0.01). There was no significant between-group difference in the rates of major or clinically relevant nonmajor bleeding episodes (rate of 0.6% per year with placebo vs. 1.1% per year with aspirin, P=0.22) or serious adverse events.

CONCLUSIONS: In this study, aspirin, as compared with placebo, did not significantly reduce the rate of recurrence of venous thromboembolism but resulted in a significant reduction in the rate of major vascular events, with improved net clinical benefit. These results substantiate earlier evidence of a therapeutic benefit of aspirin when it is given to patients after initial anticoagulant therapy for a first episode of unprovoked venous thromboembolism.

15. Cool Images in Clinical Medicine

Dermoscopy of Nits and Pseudonits 


Giant Basilar-Artery Aneurysm   

Thoracolumbar Fracture with Preservation of Neurologic Function 

Hemolytic Anemia after Mitral-Valve Repair 

Anaphylaxis Associated with Blue Dye

Varicella pneumonia in an immunocompetent adult

Herpetic whitlow

Pituitary apoplexy masquerading as bacterial meningitis

Tongue hyperpigmentation during hepatitis C treatment

16. Inexperienced Physicians Practice More Expensive Medicine

Larry Hand Nov 05, 2012. Medscape Medical News

Less-experienced physicians practice more expensive medicine than more-experienced physicians do, according to a study published in the November issue of Health Affairs. The practice patters of less-experienced physicians may be a driving factor in rising healthcare costs.

Ateev Mehrotra, MD, MPH, associate professor of medicine at the University of Pittsburgh and a policy analyst at the RAND Corporation, Pittsburgh, Pennsylvania, and colleagues analyzed data provided by Massachusetts Health Quality Partners and 4 health insurance plans to compare cost profiles of 12,116 Massachusetts physicians who treated 1.13 million patients in 2004 and 2005.

The Affordable Health Care Act requires Medicare to develop physician cost profiles this year, and health insurance plans are using them to develop tiered provider networks, the researchers write. Cost profiles compare how a physician uses resources compared with how their peers do.

Compared with the most experienced physicians (40 or more years of practice), physicians with fewer than 10 years of experience had 13.2% higher cost profiles, physicians with 10 to 19 years of experience had 10.0% higher cost profiles, physicians with 20 to 29 years of experience had 6.5% higher cost profiles, and physicians with 30 to 39 years of experience had 2.5% higher cost profiles.

"This finding suggests that less-experienced physicians will, on average, be negatively affected by policies that use physician cost profiles unless they modify their practice patterns," the researchers write. "For example, it is more likely that less-experienced physicians will be excluded from high-value networks or will receive lower payments under Medicare's value-based payment modifier program, which is slated to begin in 2015."

Two possible explanations may explain the differences in cost profiles, the researchers write. First, newer physicians may practice in more costly patterns than more-experienced physicians, and second, differences in cost profiles "may reflect an issue with the cost-profiling methodology." Newer physicians may be more familiar with and may use the most expensive treatment modalities, and they also may treat sicker patients and in general treat more aggressively, the researchers write.

It is also possible, they add, that a "cohort effect" exists, with the less-experienced physicians as a group remaining more costly going forward rather than lowering costs as they gain experience. "If there is a cohort effect involved, our results suggest that postgraduate training programs and specialty boards need to educate physicians on their responsibility to be good stewards of health care resources," the researchers write.

Notable Exceptions

The researchers found no associations with cost profiles in 2 notable areas: They found no association between cost profiles and malpractice claims, which is consistent with previous study results, and they found no significant association between cost profiles and size of physician practices, even though recent incentives have been offered to encourage physicians to join larger groups or accountable care organizations.

Limitations of the study include the lack of measurement for quality of care and the fact that it was limited to Massachusetts, which has a high density of physicians and academic medical centers and higher healthcare costs than the national average. Also, the comparisons are across all specialties, which if taken individually would show "notable variations," the researchers write.

The study's policy implications include "the fact that there will be losers and winners in any cost-profiling effort," the researchers conclude. If the differences are derived from the methodology of cost-profile creation, they suggest development of a better methodology. If the differences are driven by actual practice differences, they suggest further research to understand the reasons for the practice patterns.

"Our findings cannot be considered final, but they do underscore the need to better understand physician practice patterns and what influences that behavior," Dr. Mehrotra said in a news release.

The study was funded by the Commonwealth Fund and the US Department of Labor. Dr. Mehrotra was supported by a grant from the National Center for Research Resources, National Institutes of Health. The other authors have disclosed no relevant financial relationships.

Health Affairs. 2012:31;2453-2463

17. Complaint-specific Predictors of High Patient/Parent Satisfaction

A. Predictors of Parent Satisfaction in Pediatric Laceration Repair.

Lowe DA, et al. Acad Emerg Med. 2012 Oct;19(10):1166-1172.

Objectives: Patient and parent satisfaction are important measures of quality of care. Data are lacking regarding satisfaction with emergency procedures, including laceration repair. The objective was to define the elements of care that are important to parents during a pediatric laceration repair and to determine the predictors of excellent parent satisfaction.

Methods: This was a cross-sectional observational study of a convenience sample of patients younger than 18 years of age presenting for laceration repair to an urban tertiary care children's hospital emergency department (ED). At the end of the ED visit, parents completed a survey developed for this study assessing ratings of their experience and their perception of how their child experienced the repair. Exploratory factor analysis was used to derive the factors comprising parents' perception of the laceration repair process. A separate factor analysis was performed for the 0- to 4-years age subgroup. Multivariate logistic regression was used to determine which of these factors predicted excellent parent satisfaction with the visit, and also satisfaction with the procedure itself, adjusting for sociodemographic factors.

Results: A total of 408 parents returned completed surveys (response rate = 76%). Factor analysis revealed that three factors provided a summary of the 16 survey items. They were labeled "provider performance,""anxiety and pain," and "cosmetic appearance," based on factor loading patterns. Provider performance was the only predictor of satisfaction with the visit (adjusted odds ratio [OR] = 11.6; 95% confidence interval [CI] = 6.2 to 21.6). Provider performance (adjusted OR = 4.7; 95% CI = 3.1 to 7.2) and cosmetic appearance (adjusted OR 2.7; 95% CI = 1.7 to 4.2) predicted satisfaction with the procedure. Anxiety and pain did not predict either outcome.

Conclusions: Provider performance, which comprises the elements of physician communication, caring attitude, confidence, and hygiene, is the strongest predictor of excellent parent satisfaction for pediatric patients with ED visits for laceration repair.

B. Factors Associated With High Levels of Patient Satisfaction with Pain Management

Shill J, et al. Acad Emerg Med. 2012;19:1212-1215.

Objectives:  The objective was to determine, among emergency department (ED) patients, the factors associated with a high level of satisfaction with pain management.

Methods:  This was a prospective cohort study in a single ED. Consecutive adult patients, with triage pain scores of ≥4 (numerical rating scale = 0 to 10), were enrolled. Variables examined included demographics, presenting complaint, pain scores, nurse-initiated analgesia, analgesia administered, time to first analgesia, specific pain communication, and whether “adequate analgesia” was provided (defined as a decrease in pain score to below 4 and a decrease from the triage pain score of ≥2). The level of patient satisfaction with their pain management (six-point scale: very unsatisfied to very satisfied) was determined by a blinded investigator 48 hours post discharge. Logistic regression analyses were undertaken.

Results:  Data were complete for 476 patients: mean (±standard deviation [SD]) age was 43.6 (±17.2) years, and 237 were males (49.8%, 95% confidence interval [CI] = 45.2% to 54.4%). A total of 190 (39.9%, 95% CI = 35.5% to 44.5%) patients were “very satisfied” with their pain management, and 207 (43.5%, 95% CI = 39.0% to 48.1%) patients received adequate analgesia. Three variables were associated with the patient being very satisfied: the provision of adequate analgesia (odds ratio [OR] = 7.8, 95% CI = 4.9 to 12.4), specific pain communication (OR = 2.3, 95% CI = 1.3 to 4.1), and oral opioid administration (OR = 2.0, 95% CI = 1.1 to 3.4). Notably, the provision of nurse-initiated analgesia to 211 patients (44.3%, 95% CI = 39.8% to 48.9%) and the short time to analgesia (median = 11.5 minutes; interquartile range [IQR] = 2.0 to 85.8 minutes) were not associated with being very satisfied.

Conclusions:  The receipt of adequate analgesia (as defined) is highly associated with patient satisfaction. This variable may serve as a clinically relevant and achievable target in the pursuit of best-practice pain management.

18. Ultrasound Updates (from ACEP News and EM News)

A. Bedside Ultrasound Assessment of Left Ventricular Function

By Siadecki S, et al. ACEP News October 2012

Emergency physicians must often manage critically ill patients whose hemodynamic status is unclear, especially early in the course of their disease.

Correct and timely diagnosis of the prevailing hemodynamic process is of utmost importance, and the physical exam and vital signs alone are often unreliable. Moreover, congestive heart failure is extremely prevalent in the emergency department population, andmore than half of patients with moderate to severe systolic dysfunction have never been diagnosed with heart failure.

Bedside echocardiography by the emergency physician offers a rapid, noninvasive, and inexpensive method to determine the role that the patient's systolic cardiac function may be playing in their disease process. Besides the diagnosis of heart failure, assessment of left ventricular (LV)function can help distinguish between cardiac and other etiologies of undifferentiated hypotension or shock. Multiple studies have demonstrated that emergency physicians with focused training in transthoracic echocardiography can accurately determine left ventricular ejection fraction (LVEF) in critically ill patients.

In combination with other common emergency department ultrasound applications such as evaluation of the inferior vena cava (IVC) as a marker of intravascular volumestatus, and evaluation of the lungs and pleura, assessment of LVEFcan be a valuable tool in the management of critically ill patients…

B. Focused Renal Ultrasonography

By Smith TY, et al. ACEP News August 2012

Renal ultrasonography has replaced more invasive radiographic assessments such as IVP (intravenous pyelogram) in the diagnosis of the more common kidney complaints. In the emergency department, bedside renal ultrasound has allowed the physician to quickly and accurately assess the kidneys and the bladder for obstruction. Goredlik et al. found that in the diagnosis of renal calculus, the sensitivity of renal ultrasound alone was 93% and specificity83%.1 When combined with kidney ultrasound biopsy (KUB),the specificity increased to 100%.

There are multiple chief complaints that can lead to the diagnosis of renal pathology, including flank pain, abdominal pain,back pain, urinary retention, dysuria, and/or hematuria. The emergency physician can easily bring the ultrasound machine to the bedside for quick assessment of the kidneys and the bladder to evaluate for renal pathology.

For the rest of the essay (free):

C. Pediatric Hip Ultrasound

By Martin J, et al. ACEP News July 2012

Acute onset of limp or refusal to bear weight is a common presenting complaint in the Pediatric Emergency Department (PED).1 History and physical examination may be limited by the child's age and ability to cooperate. With a broad differential, including infectious, traumatic, inflammatory, intra-abdominal, hematologic, and other musculoskeletal disorders as etiologies, it is imperative that the emergency department workup be thorough.

Even when the pain can be localized to the hip, the differential diagnosis remains broad (Table 1). The history and physical examination can help guide the differential diagnosis. When there is a high clinical suspicion for infectious or inflammatory pathology (fevers, painful range of motion, overlying erythema),laboratory studies, including a blood culture, complete blood cell count, C-reactive protein, and an erythrocyte sedimentation rate, are indicated.

Plain radiographs can screen for fractures, avascular necrosis and destructive lesions, but have limited utility for detectingjoint effusions.  Ultrasound is an excellent modality for identifying joint effusions, and detection of an effusion focuses the differential diagnosis toward osteomyelitis, transient synovitis, or septic arthritis, and away from neoplasms, avascular necrosis, slipped capital femoral epiphysis (SCFE) or Legg-Calvé-Perthes disease.

Point of care ultrasound to detect hip effusion can serve as an adjunct to the history and physical examination in the evaluation of hip pain in the pediatric population.  It is an ideal imaging modality in pediatric patients due to its ease of use, portability, reproducibility, low cost and, perhaps most important, lack of radiation exposure…

D. Ultrasound Effective (and Less Radiation) for Diagnosing Appendicitis

By Butts C. Emerg Med News 2012;34:7

A 25-year-old man presents to the ED complaining of pain in his lower abdomen for three days. He states that the pain initially began in his periumbilical area, and has now migrated to his lower abdomen. He describes subjective fevers, chills, and nausea.
His blood pressure is 110/80 mm Hg, heart rate is 100 bpm, respiratory rate is 12 bpm, and his temperature is 100.8°F. His exam reveals significant tenderness to his right lower quadrant with rebound. A bedside ultrasound reveals acute appendicitis, a commonly suspected diagnosis in patients with abdominal pain. Many practitioners rely on computed tomography to make the definitive diagnosis in suspicious cases, but this approach may not be feasible or advised. Obtaining a CT scan frequently requires intravenous and oral contrast, which may be time-consuming, and growing concerns about the long-term effects of routine CT scans may cause the emergency physician to reconsider this modality.

Bedside ultrasound of the appendix is typically considered a more advanced application, but it can be successfully performed by the emergency physician. Visualization of the features of acute appendicitis in the correct clinical scenario may allow the practitioner to make the diagnosis without additional imaging.

An inflamed appendix is best visualized with a high-frequency transducer, which allows for sufficient resolution of the area and identification of the organ. This transducer will provide excellent resolution but limited depth of penetration, so bedside ultrasound of the appendix may be limited by patient habitus.

A helpful starting point for the bedside sonographer to identify the appendix is to begin the exam at the area of maximal pain or tenderness. Alternatively, the transducer can be placed in the approximate location of McBurney's point. Gentle compression of the transducer should be applied to displace overlying bowel. The initial orientation of the transducer is less important because the orientation of the appendix is variable. The entire right lower quadrant should be scanned in both orientations.

An inflamed appendix typically appears as a “target” in transverse because of edema within its walls. The characteristic finger-like shape of the appendix can be seen in the longitudinal orientation. The appendix can be differentiated from other segments of bowel by its blind end. The total diameter will be greater than 6 mm and the lumen will not compress with pressure because it is fluid-filled. Anechoic (black) fluid may be seen surrounding the area, particularly with advancing appendicitis. Application of color Doppler may reveal increased flow, secondary to hyperemia. Finding an appendix with these characteristics can help to confirm an appendicitis diagnosis, but not localizing the appendix does not rule it out because patient habitus, bowel gas, or atypical positioning may hide it from view. A normal appendix is frequently difficult to localize to rule out acute appendicitis. Further evaluation and management is warranted in cases where appendicitis is clinically suspected without clear sonographic evidence.

19. ID Updates from James Roberts, MD, EM News

Dr. Roberts is the chairman of emergency medicine and the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine and toxicology at the Drexel University College of Medicine, both in Philadelphia.

A. Neisseria Gonorrhoeae: The New Superbug (October 2012)

The emergence of extended spectrum beta-lactamase-producing bacteria is worrisome. ESBLs make some rather nasty bacteria like E. coli and Klebsiella resistant to our most powerful and universally used antibiotics. So far, carbapenems are still effective, and they should be empirically used if ESBL organisms are suspected or prevalent, a scenario especially prominent in urosepsis.

Resistant organisms are a way of life in modern medicine, and primarily are the result of our own technology and clinical zeal that have produced and overused extremely powerful antimicrobials. But Mother Nature always wins out in the end. Bacteria are clever enough to develop resistance to even the most powerful antibiotics produced by the highly competitive and gargantuanly profitable pharmaceutical industry.

Perhaps unknown to other clinicians, Neisseria gonorrhoeae, AKA the wily gonococcus, has slowly developed antibiotic resistance that has morphed this once easy-to-treat organism into a potential superbug. This is not yet water cooler fodder in the ED, but this phenomenon has not escaped the watchful eye of the Centers for Disease Control and Prevention or publications in erudite but rarely read infectious disease journals. It's time for an update for emergency physicians who treat gonococcus regularly so they understand the rather scary scenario that may make gonococcal infections untreatable…

B. Treatment of Uncomplicated Pyelonephritis in Women (September 2012)

The Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases recently updated its guidelines for treating acute uncomplicated cystitis in women, recommending only three common antibiotics and eschewing fluoroquinolones. (See FastLinks.) The same article also pontificated on the treatment for uncomplicated acute pyelonephritis in women.

The guidelines were limited to premenopausal non-pregnant women with no known urological abnormalities and no significant comorbidities. The population had so-called uncomplicated pyelonephritis, but many decidedly complicated individuals populate the ED. The resistance and prevalence of the local flora and the collateral damage of antimicrobial therapy were considered important factors in making optimal empirical treatment decisions, just as they were with the recommendations for acute cystitis…

C. Uncomplicated Acute Cystitis: Times Have Changed (August 2012)

If you thought you knew all about the modern and up-to-date treatment of acute cystitis in women, think again. Times have changed, as have treatment regimens and the profile of infecting organisms. The overuse of antibiotics has culled out resistant bacteria that used to be easily controlled with even one or two doses of simple antibiotics, such as amoxicillin.

E. coli would readily die when the first few molecules of antibiotics filtered into the infected urinary bladder. But if you haven't reviewed this topic in the past few years and continue to use the same antibiotics you did when you were an intern, you're behind the times. Updated clinical practice guidelines for treating acute uncomplicated cystitis in women were published in 2010 by some prestigious infectious diseases societies. This month: garden-variety acute cystitis; next month: -pyelonephritis. Also read last month's column on the emergence of bacteria that produce extended spectrum -B-lactamase (ESBL), substances that inactivate once-invincible antibiotics, making some E. coli and Klebsiella -infections impossible to cure without using some rather exotic antimicrobials…

20. Medscape Emergency Medicine Cardiology Corner

A. Mattu’s Literature Update 2012: 3 Articles You've Gotta Know!

Amal Mattu, MD  Nov 15, 2012

His 3 favorite articles for 2012:
  • Canto JG, et al for the NRMI Investigators. Association of Age and Sex With Myocardial Infarction Symptom Presentation and In-Hospital Mortality. JAMA. 2012;307:813-822.
  • Than M, et al. 2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker: The ADAPT Trial. J Am Coll Cardiol. 2012;59:2091-2098.
  • Nishijima DK, et al, for the KP CREST Network. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and pre-injury warfarin or clopidogrel use. Ann Emerg Med. 2012;59(6):460-468.e7.

His discussion (full-text free):


1. What Life-Threatening Condition Does This Tracing Show?

Wang K. Medscape Cardiology: ECG of the Week

2. Three Questions for 1 Tracing

Wang K. Medscape Cardiology: ECG of the Week

21. Hospitals Slash Central Line Infections with Program That Empowers Nurses

Kuehn BM. JAMA. 2012;308(16):1617-1618.

It's been 31 months since a patient in the intensive care unit has developed a central line–associated bloodstream infection (CLABSI) at the Peterson Regional Medical Center in Kerrville, Tex, said nurse educator Theresa Hickman, RN, during a press briefing in September.

Comprehensive Unit-based Safety Program (CUSP) has helped hospital units drastically reduce or eliminate central line infections.

Hickman credits this achievement—eliminating infections that were once considered inevitable—to the staff of the 125-bed rural hospital, which implemented the Comprehensive Unit-based Safety Program (CUSP), an initiative being rolled out at hospitals nationwide to curb hospital-acquired infections. Hickman described it as the most powerful quality improvement effort she's encountered in her 32-year career. What makes it different from many other efforts is that it empowers nurses and other frontline caregivers to identify and fix problems that may compromise patient safety.

“We listen to the wisdom of our frontline caregivers,” she said.

And she's not alone in singing the praises of the program. Over the past 4 years, CUSP has been rolled out at 1100 intensive care units across the country, and preliminary data suggest that the effort has cut the rate of CLABSIs nationally by 40%, reducing the rate of infections per 1000 central-line days from 1.9 to 1.1. According to Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), which sponsored the project, the program has prevented 2000 infections, saved 500 lives, and saved $34 million in health costs.

“This could be health care's man-on-the-moon moment,” said Peter Pronovost, MD, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, who created the program with colleagues at Hopkins and has been testing its effectiveness.

Pronovost explained that the program was inspired by the death of an 18-month-old girl at Hopkins as a result of a CLABSI. Infection rates were high at the hospital when the girl died. The hospital implemented a series of improvements, including nurse-administered checklists to ensure infection prevention practices were followed, hospital-wide culture about infection prevention underwent a change, and performance measures to gauge implementation were put in place.

“It worked,” he said. “Infections were virtually eliminated.”

The toolkit derived from this effort became CUSP, and with funding from the AHRQ, Pronovost has systematically tested its implementation on an increasingly larger scale. First, a 2-year, $500 000 project to implement the program at Michigan hospitals, led by the Michigan Health and Hospital Association, reduced CLABSIs by 66% at 100 intensive care units across the state within 6 months, eliminating such infections in 65% of the units. The latest results come from a 4-year effort to roll out the program in 44 states.

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

22. Topical Ivermectin Lotion for Treatment of Head Lice

One 10-minute application was very effective and could help avoid systemic medication.

Although head lice do not transmit disease, infestation causes pruritus, eczematization, social stigmatization, and school absence. Use of the first- line agents permethrin and pyrethrins is limited by emerging resistance. Lindane is disfavored because of neurologic toxicity, and malathion is flammable. Two recently approved agents, spinosad and benzyl alcohol lotion, are relatively expensive. Oral ivermectin has known efficacy when other treatments have failed. These researchers report the findings of two manufacturer-supported studies of topical ivermectin.

In multicenter, randomized, double-blinded, vehicle-controlled trials of a single dose of ivermectin 0.5% lotion without nit combing, a total of 132 index patients aged 6 months and older with three or more live lice (and more than 600 family members who had 1 or more live lice) received ivermectin lotion or vehicle alone. The primary end point was the number of patients who were louse-free by day 2 and remained louse-free through days 8 and 15. Ivermectin or vehicle was applied to dry hair and rinsed out after 10 minutes. In the intention-to-treat population, significantly more ivermectin recipients than vehicle recipients were louse-free on day 2 (95% vs. 31%), day 8 (85% vs. 21%), and day 15 (74% vs. 18%; P less than 0.001 for each comparison). Adverse events, including pruritus, excoriation, and erythema, occurred equally often with ivermectin and control (in approximately 1% of both groups).

Comment: Results of this large, rigorous study indicate that single-dose topical ivermectin 0.5% lotion without nit combing is well-tolerated and very effective. The day 15 louse-free rate of 74% resembles rates with other two-application topical agents and may reflect imperfect application, viable eggs, or reinfestation. A second application may improve prolonged clearance rates. Head-to-head studies, resistance data, postmarketing data, and cost-benefit analysis are needed to determine which topical agents should be first-line therapy, which should be reserved for certain populations, and when oral pediculicides are appropriate. Lastly, changes in no-nit policies are needed to prevent unnecessary school absenteeism.

— Mary Wu Chang, MD. Published in Journal Watch Dermatology October 31, 2012.
Citation: Pariser DM et al. N Engl J Med 2012 Nov 1; 367:1687-1693.

23. Prehospital Computer Interpretation of ECGs Is Inaccurate

Nearly half of patients with STEMI were missed in this single-site retrospective study.

Bhalla MC et al. Prehosp Emerg Care 2012 Oct 15

Background. Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.

Objectives. To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.

Methods. Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was “acute MI suspected.” Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.

Results. Zero control patients were incorrectly labeled “acute MI suspected.” The specificity was 100% (100/100; 95% CI 0.96–1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48–0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was “data quality prohibits interpretation,” followed by “abnormal ECG unconfirmed.”

Conclusions. Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.

24. Nasal FBs: Efficacy and safety of the “mother’s kiss” technique: a systematic review of case reports and case series

Cook S, et al. CMAJ 2012:184.E904-E912

Background: Foreign bodies lodged in the nasal cavity are a common problem in children, and their removal can be challenging. The published studies relating to the “mother’s kiss” all take the form of case reports and case series. We sought to assess the efficacy and safety of this technique.

Methods: We performed a comprehensive search of the Cochrane library, MEDLINE, CINAHL, Embase, AMED Complementary and Allied Medicine and the British Nursing Index for relevant articles. We restricted the results to only those studies involving humans. In addition, we checked the references of relevant studies to identify further possibly relevant studies. We also checked current controlled trials registers and the World Health Organization search portal. Our primary outcome measures were the successful extraction of the foreign object from the nasal cavity and any reported adverse effects. We assessed the included studies for factors that might predict the chance of success of the technique. We assessed the validity of each study using the Newcastle–Ottawa scale.

Results: Eight relevant published articles met our inclusion criteria. The overall success rate for all of the case series was 59.9% (91/152). No adverse effects were reported.

Interpretation: Evidence from case reports and case series suggests that the mother’s kiss technique is a useful and safe first-line option for the removal of foreign bodies from the nasal cavities of children.

25. The Price of False Beliefs: Unrealistic Expectations as a Contributor to the Health Care Crisis

Woolf SH. Ann Fam Med. 2012;10:491-494.

The alarming rise in health care costs haunts our society. The United States now spends $2.6 trillion per year on health care,1 and the spiraling costs are placing unsustainable burdens on employers and workers, Medicare and Medicaid, state and local governments, and American families. A growing proportion of Americans are now foregoing health care to pay for other household needs or are facing bankruptcy.2 A variety of strategies have been proposed to slow medical cost inflation, such as realigning financial incentives to discourage costly procedures, accountable care organizations, the patient-centered medical home, and malpractice reforms. Evidence that any of these ideas will bend the cost curve remains limited.

A more basic but possibly neglected strategy for reducing demand for health services is to confront unrealistic beliefs about their benefits. Health care expenditures ultimately begin with a decision to use the service, a decision that may rest on false expectations—among patients, clinicians, or both. Removing the need for the service by correcting such misperceptions is a potentially more effective way to curb costs than many current reforms can achieve. Financial incentives are important, but they are weak when pitted against core beliefs. If patients and clinicians widely hold that a procedure is life-saving and harmless, any reform is unlikely to curb demand until those misconceptions are addressed.

Studies suggest that patients, clinicians, and society often hold unrealistic expectations about the effectiveness of tests and treatments. Two articles in this issue add to that literature. In New Zealand, Hudson et al3 surveyed 977 primary care patients and found that many overestimated the benefits of cancer screening and chemopreventive medications. The minimum benefit from screening that respondents deemed acceptable was less than their known benefit. The survey had a modest sample size and low response rate (36%), and its findings might not be fully applicable to other countries, but US studies have reported a similar problem. For example, a variety of studies document Americans' appetite for procedures of dubious effectiveness and their overestimation of benefits.4,5 Many Americans underestimate the probability of harms and are quite willing to receive false-positive results and unnecessary biopsies for the chance to detect cancer.6,7 Public complacency about the safety of health care is only occasionally shaken, as when a conspicuous tragedy or disclosures of industry wrongdoing draw attention to specific dangers.

Physicians are not immune to false beliefs about clinical efficacy or complication rates.8 Correcting such misperceptions has always been part of the impetus for the evidence-based medicine movement and its promulgation of systematic evidence reviews, practice guidelines, and other tools that present the facts on benefits, safety, and scientific uncertainties. Even these tools, however, can reflect the misconceptions of those who produce them. The specialists who serve on expert panels derive much of their clinical case knowledge from the patients with advanced disease who fill their clinics. Having seen the worst of the worst, they are less sympathetic to expressions of concern about the potential harms of interventions or imperfections in efficacy studies.9 Whereas epidemiologists consider the population denominator to put the numerator in perspective, the world of specialists is confined to the numerator, giving them a skewed basis for judging the population prevalence of diseases or benefit-risk ratios. Were this not enough, the preeminent scientists who often serve on guideline panels bring additional biases, such as being the authors of key studies under review or having financial ties to industry.10...

The remainder of the essay (free):