1. Painful Speed Bumps? Could Be Appendicitis
Diagnostic uncertainty surrounding appendicitis could turn
into a small bump in the road, according to a study showing a high correlation
between appendicitis and pain on driving over speed bumps on the way to the
hospital.
Ashdow HF, et al. BMJ 2012;345:e8012
Objective To assess the diagnostic accuracy of pain on
travelling over speed bumps for the diagnosis of acute appendicitis.
Design Prospective questionnaire based diagnostic accuracy
study.
Setting Secondary care surgical assessment unit at a
district general hospital in the UK.
Participants 101 patients aged 17-76 years referred to the
on-call surgical team for assessment of possible appendicitis.
Main outcome measures Sensitivity, specificity, positive and
negative predictive values, and positive and negative likelihood ratios for
pain over speed bumps in diagnosing appendicitis, with histological diagnosis
of appendicitis as the reference standard.
Results The analysis included 64 participants who had
travelled over speed bumps on their journey to hospital. Of these, 34 had a
confirmed histological diagnosis of appendicitis, 33 of whom reported increased
pain over speed bumps. The sensitivity was 97% (95% confidence interval 85% to
100%), and the specificity was 30% (15% to 49%). The positive predictive value
was 61% (47% to 74%), and the negative predictive value was 90% (56% to 100%).
The likelihood ratios were 1.4 (1.1 to 1.8) for a positive test result and 0.1
(0.0 to 0.7) for a negative result. Speed bumps had a better sensitivity and
negative likelihood ratio than did other clinical features assessed, including
migration of pain and rebound tenderness.
Conclusions Presence of pain while travelling over speed
bumps was associated with an increased likelihood of acute appendicitis. As a
diagnostic variable, it compared favourably with other features commonly used
in clinical assessment. Asking about speed bumps may contribute to clinical
assessment and could be useful in telephone assessment of patients.
Full-text (free): http://www.bmj.com/content/345/bmj.e8012
2. Pediatric Corner
A. Febrile Status
Epilepticus Does Not Cause CSF Pleocytosis in Children
Cerebrospinal fluid findings were normal in children with
febrile status epilepticus and no central nervous system infection.
To investigate if fever-associated status epilepticus (FSE)
alone causes cerebrospinal fluid (CSF) pleocytosis, researchers characterized
CSF findings in children enrolled in the Febrile Status Epilepticus Study, a
prospective, multicenter study of children presenting to one of five emergency
departments (EDs) with FSE but no identified central nervous system infection
or other pathologic condition. FSE was defined as a single seizure or a series
of seizures without interim recovery lasting at least 30 minutes associated
with fever above 38.4°C.
Of 200 children (age range, 1 month through 5 years; median
age, 16 months), 154 (77%) underwent lumbar puncture (LP) at the discretion of
the ED attending physician. Children who underwent LP were significantly younger
than those who did not (median age, 15 vs. 23 months), less likely to have had
prior febrile seizures, and more likely to have longer duration of FSE and
presence of focality. Of 136 children with nontraumatic LPs (less than 1000 CSF
red blood cells), 126 (93%) had CSF with 3 white blood cells/mm3. Mean CSF
protein and glucose levels were within normal limits (22 mg/dL and 90 mg/dL,
respectively).
Comment: The authors correctly conclude that CSF pleocytosis
in children with fever-associated status epilepticus cannot be attributed to an
ictal phenomenon. Children with FSE and CSF pleocytosis should receive prompt
intravenous antibiotics for potential bacterial etiologies as well as
antivirals for suspected herpes simplex virus.
— Katherine Bakes, MD. Published in Journal Watch Emergency
Medicine December 14, 2012.
Citation: Frank LM et al. Cerebrospinal fluid findings in
children with fever-associated status epilepticus: Results of the consequences
of prolonged febrile seizures (FEBSTAT) study. J Pediatr 2012 Dec; 161:1169.
B. The use of
ondansetron for nausea and vomiting after head injury and its effect on return
rates from the pediatric ED
Sturm JJ, et al. Amer J Emerg Med. 2013;31:166-172.
Background: The use of ondansetron in children with vomiting
after a head injury has not been well studied. Concern about masking serious
injury is a potential barrier to its use.
Objective: The aim of this study was to evaluate the use of
ondansetron in children with head injury and symptoms of vomiting in the
pediatric emergency department (PED) and its effect on return rates and masking
of more serious injuries.
Design/Methods: Visits to 2 PEDs from 2003 to 2010 with a
diagnosis of head injury were evaluated retrospectively. Patients discharged
home after a head computed tomography (CT) are the primary cohort for the
study. A logistic regression model was used to analyze ondansetron's effects on
the likelihood of return to the PED within 72 hours for persistent symptoms. A
secondary analysis was performed on patients with a diagnoses of head injury
who did not receive a head CT and were discharged.
Results: A total of 6311 patients had a diagnosis of head
injury, had a head CT performed, and were discharged from the PED. The use of
ondansetron increased significantly from 3.7% in 2003 to 22% in 2010 (P less
than .001). After controlling for demographic/acuity differences, receiving
ondansetron in the PED was associated with a lower likelihood of returning
within 72 hours (0.49, 95% confidence interval [0.26-0.92]). In patients with
head injury who did not have a head CT performed and were sent home, the use of
ondansetron in the PED was not associated with an increased risk of missed
diagnoses.
Conclusion: Ondansetron use in children with a CT scan who
are dispositioned home is relatively safe, does not appear to mask any
significant conditions, and significantly reduces return visits to the PED.
C. Long-term Follow-up
of Patients after Childhood UTI
Hannula A, et al. Arch Pediatr Adolesc Med.
2012;166(12):1117-1122.
Objective To evaluate
the long-term outcome of children with urinary tract infection (UTI).
Design Follow-up
examination 6 to 17 years after childhood UTI.
Setting Secondary to
tertiary referral center.
Patients From an
original population-based cohort of 1185 children with a history of UTI on whom
both ultrasonography (US) and voiding cystourethrography had been performed
between January 1, 1993, and December 31, 2003, we excluded 24 cases with major
renal dysplasia or obstruction of the urinary tract to form a study cohort of
1161 patients. We took a stratified random sample of 228 patients for
follow-up, and a total of 193 (85%) participated. Of the 193 participating
patients, 103 (53%) had received antibiotic prophylaxis and 42 (22%) had
undergone surgery.
Main Exposure Urinary
tract infection.
Main Outcome Measures
Renal growth and parenchymal damage in US examination, kidney function,
and blood pressure.
Results Unilateral
renal parenchymal defect was found in 22 of the 150 patients (15%) studied with
US at follow-up, and unilateral kidney growth retardation was found in 5
patients (3%). All but 1 of the renal parenchymal defects seen on US were in
patients with grade III to V vesicoureteral reflux. Despite the parenchymal
defects seen on US, the serum cystatin C concentration, estimated glomerular
filtration rate, and blood pressure were within the normal ranges in all
patients.
Conclusions The risk
of long-term consequences from childhood UTI seems to be very low. Owing to the
observational nature of our study, we cannot exclude the effects of the given
treatment on the outcome of our patients.
D. Healthy snacks
more filling for youths [and maybe us adults too], with fewer calories
Children who were given a snack combination of vegetables
and cheese ate about 170 calories before becoming full, compared with 620
calories consumed by children who ate potato chips, Cornell University
researchers reported on the website of the journal Pediatrics. Children who
were overweight or obese saw a greater effect, research showed.
E. Predicting
Postconcussion Syndrome after Mild Traumatic Brain Injury in Children and
Adolescents Who Present to the Emergency Department
Babcock L, et al. Arch Pediatr Adolesc Med. 2012 December.
[Epub ahead of print]
Objective To
determine the acute predictors associated with the development of
postconcussion syndrome (PCS) in children and adolescents after mild traumatic
brain injury.
Design Retrospective
analysis of a prospective observational study.
Setting Pediatric
emergency department (ED) in a children's hospital.
Participants Four
hundred six children and adolescents aged 5 to 18 years.
Main Exposure Closed
head trauma.
Main Outcome Measures
The Rivermead Post Concussion Symptoms Questionnaire administered 3
months after the injury.
Results Of the
patients presenting to the ED with mild traumatic brain injury, 29.3% developed
PCS. The most frequent PCS symptom was headache. Predictors of PCS, while
controlling for other factors, were being of adolescent age, headache on
presentation to the ED, and admission to the hospital. Patients who developed
PCS missed a mean (SD) of 7.4 (13.9) days of school.
Conclusions
Adolescents who have headache on ED presentation and require hospital
admission at the ED encounter are at elevated risk for PCS after mild traumatic
brain injury. Interventions to identify this population and begin early
treatment may improve outcomes and reduce the burden of disease.
F. The Utility of Adding
Expiratory or Decubitus Chest Radiographs to the Radiographic Evaluation of
Suspected Pediatric Airway Foreign Bodies
Brown JC, et al. Ann Emerg Med. 2013;61:19-26.
Study objective
This study aimed to compare test characteristics of standard
(lateral and posteroanterior or anteroposterior) chest radiographs with and
without special views (expiratory or bilateral decubitus) in the emergency
department evaluation of children with suspected airway foreign bodies.
Methods
From 1997 to 2008, 328 patients with a suspected airway
foreign body had standard and special view chest radiographs: 192 with left and
right decubitus views, 133 with expiratory views, and 3 with both. Patients
were excluded for cardiorespiratory disease, chest wall deformity, visible airway
foreign bodies on standard views, or spontaneously expelled airway foreign
bodies. After blinded radiologist review, standard plus special view test
characteristics were compared to standard views.
Results
Nine upper airway and 70 tracheobronchial airway foreign
bodies were identified by direct visualization or bronchoscopy, and the
remainder were ruled out by bronchoscopy (50 patients) or clinically (199
patients). The sensitivity and specificity of the radiographs were,
respectively, decubitus cohort, standard views, 56% and 79% and
standard+decubitus views, 56% and 64%; expiratory radiograph cohort, standard
views, 33% and 70% and standard+expiratory views, 62% and 72%. For standard
plus decubitus views versus standard views alone, the relative sensitivity was
1.0 (0.56/0.56; 95% confidence interval [CI] 0.81 to 1.23) and the relative
1–specificity was 1.76 (0.36/0.21; 95% CI 1.3 to 2.37). For standard plus
expiratory views versus standard views alone, the relative sensitivity was 1.87
(0.62/0.33; 95% CI 1.23 to 2.83) and the relative 1–specificity was 0.93
(0.28/0.3; 95% CI 0.6 to 1.44).
Conclusion
The addition of decubitus to standard views increases false
positives without increasing true positives and lacks clinical benefit. The
addition of expiratory to standard views increases true positives without
increasing false positives, but test accuracy remains low and the clinical
benefit is uncertain.
3. Do Subsets of Mild Head Injury Patients on Pre-injury Warfarin with
Negative ED CT Necessarily Require Admission for Observation and 24-hour Rescan?
An exchange of letters in response to Nishijima DK, et al.
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.
·
A proposal by Frank Rasler to admit and re-scan
in 24 hours those with “an international normalized ratio (INR) greater than 3,
advanced age (perhaps over 80 years), or the physician's suspicion of greater
traumatic force.” http://www.annemergmed.com/article/S0196-0644(12)01405-9/fulltext
·
An evidence-based reply by Nishijima DK et al
suggests that such an approach is scientifically ungrounded and would result in
misplaced healthcare resources: http://www.annemergmed.com/article/S0196-0644(12)01406-0/fulltext
4. A RCT of Patient-controlled Analgesia Compared with Boluses of Analgesia
for the Control of Acute Traumatic Pain in the ED
Rahman NH, et al. J Emerg Med. 2012;43:951-957.
Background: The use of patient-controlled analgesia (PCA)
has been reported to provide effective pain relief, often resulting in less
opioid consumption, and is associated with greater patient satisfaction when it
is compared to other techniques of analgesia delivery.
Objectives: This study was done to compare the effectiveness
of pain relief and patient satisfaction between PCA and the conventional method
of administering boluses of analgesia for acute pain of traumatic origin in the
Emergency Department (ED).
Methods: Study patients were randomized into two groups
after being given a bolus of morphine. The PCA group was then given morphine
via the PCA system, whereas the control group was given the conventional
boluses of morphine via titration method. Pain levels were measured using the
visual analogue scale at intervals of 0, 15, 30, 45, 60, 90, and 120 min. Any
adverse events were also noted. Finally, within 24 h, these patients completed
questionnaires regarding their experience with regard to the pain relief they
experienced.
Results: The PCA group experienced faster and greater pain
relief. No life-threatening events were encountered. The satisfaction
questionnaire revealed that the PCA group was more satisfied using the PCA
method of pain relief than those receiving standard boluses for delivery of
analgesia.
Conclusion: PCA provides more effective pain relief and more
patient satisfaction when compared to the conventional method of titrated bolus
intravenous injection for the relief of traumatic pain in the ED setting.
5. Found Unresponsive: A NEJM Interactive Case
An 18-year-old woman was found in an unresponsive state in a
park near her college campus. When paramedics arrived, the patient was not
talking or communicating but her eyes were open, with the pupils equal in size
and reactive to light. She was breathing, had a palpable and rapid pulse, and
was moving her arms and legs. High-flow oxygen was administered through a face
mask, and the patient was transported to the ED. On arrival, she vomited, with
no improvement in her mental status. Endotracheal intubation was performed…
Fully engage here (no subscription required): http://www.nejm.org/doi/full/10.1056/NEJMimc1204403
6. The Holiday-Suicide Link Is a Myth
Megan Brooks. Medscape Medical News, Psychiatry. Dec 17,
2012
The widely held belief that suicides spike around the
holidays is false, and the media may be partly to blame for fueling this
ongoing misconception, according to the Annenberg Public Policy Center (APPC).
Since 2000, the APPC, based at the University of
Pennsylvania, in Philadelphia, has been tracking reports in the media about the
notion that more people commit suicide during the end-of-year holidays than at
other times during the year.
For the year 1999, they identified more than 60 news reports
that ran during the holiday period stating that suicides do indeed spike during
the holidays. These stories accounted for 77% of the stories that talked about
suicide potentially being related to the holidays.
After efforts by the APPC to debunk this misconception, the
number of such stories dropped, and stories debunking the myth grew in number,
they report.
However, their latest look at stories that ran during the
last holiday season (2011-2012) shows that the number is once again rising. The
proportion of stories making the holiday-suicide link is "once again at
the same high level as in 1999 (76%)," the APPC notes in a statement
released this month.
"Truly a Myth"
The APPC also tracked daily suicide rates to determine
whether they are higher during the holiday season. On the basis of official
suicide deaths in the United States, the months of November, December, and
January typically have the lowest daily rates of suicide in the year, they
report.
"Despite what many believe, the holiday-suicide link is
truly a myth," the APPC says. There is clearly a seasonal pattern to
suicide rates, with rates highest usually in the spring and summer months.
"The return of the holiday-suicide connection may be
related to the fact that the adult (ages 25+) suicide rate has increased in
recent years in step with the great recession," noted APPC's Dan Romer,
PhD, who has directed the study since its inception. "With more people
affected by suicide, news stories about suicide may be more common over the
holidays, bringing the myth back to our attention."
The APPC cautions that stories in the media that make
suicide appear more common during the holidays may encourage vulnerable
individuals to consider it. "Although we have no direct evidence for such
an effect of the holiday myth, other evidence indicates that the media can
influence vulnerable people to attempt suicide. This has led various public
health agencies and organizations to encourage more accurate reporting about
suicide by the news media (see www.reportingonsuicide.org)," the APPC said
in a statement.
According to the Centers for Disease Control and Prevention,
suicide is the tenth leading cause of death in the United States. It is the
second leading cause of death for people aged 15 to 25 years and the fourth
leading cause of death for those between the ages of 25 and 44 years. It is now
a greater cause of death than traffic fatalities.
APPC. Published online December 4, 2012: http://www.annenbergpublicpolicycenter.org/NewsDetails.aspx?myId=502
7. Isolated sternal fractures treated on an outpatient basis
Kouritas VK, et al. Amer J Emerg Med 2013;31:227-230.
Aim: The aim of this study is to investigate the need for
admission of patients with isolated sternal fracture (ISF) by prospectively and
randomly discharging or admitting them.
Methods: Patients with ISF after the completion of
investigations were randomly discharged or admitted. Investigations performed
included lateral chest x-ray; chest computed tomography; electrocardiogram;
cardiac ultrasound; definition of C-reactive protein; and cardiac enzymes, such
as creatine phosphokinase, myocardial branch of creatine phosphokinase, and
troponin I (cardiac specific). These investigations were repeated after 6 hours
in the admission and the next day in both groups.
Results: Forty-two patients were included in the study.
Twenty-one were admitted, whereas 21 were discharged. Electrocardiogram and
ultrasound were normal in both groups upon presentation and the next day.
Creatine phosphokinase and myocardial branch of creatine phosphokinase,
although elevated at presentation, were normal the next day and similar in both
groups. There was no morbidity, need for surgery, or mortality in both groups
during a 6-month follow-up.
Conclusions: Patients with ISF can be discharged safely as
soon as investigations are completed. Extensive myocardial assessment is not
needed on the posttraumatic period. Myocardial involvement seems unlikely in
patients with ISF, who can be treated with oral analgesics.
8. Cool Images in Clinical Practice
Abdominal Ectopic Pregnancy
Lipoma of the Tongue
Infant with Limpness
A Desquamating Rash
Woman with Severe Chest Pain
9. Crowded EDs May Be Serious Health Hazard
By Crystal Phend, Senior Staff Writer, MedPage Today.
December 12, 2012
The busiest days in Emergency Departments are linked to
higher inpatient mortality risk and higher costs, a population-based study
affirmed.
Patients seen on days when EDs were so full they turned away
ambulances had a 5% greater risk of death before discharge than those admitted
at other times, Benjamin Sun, MD, MPP, of Oregon Health and Science University
in Portland, and colleagues found.
These patients also faced slightly but significantly longer
stays and higher costs for their admission in the analysis of statewide
hospital discharge and ambulance diversion data for California, reported online
in the Annals of Emergency Medicine.
"Our study provides additional evidence that ED
crowding is a marker for worse care for all ED patients who might require
hospital admission," the group wrote, adding that the study
"strengthens the argument to end the practice of ED boarding," which
is the practice of having patients stay in the the ED until a hospital bed
becomes available.
Smaller studies without the extensive controls for
comorbidity and case mix used in the statewide analysis have also suggested
risks for patients.
One reason may be delays in needed care for time-critical
conditions such as heart attack and pneumonia, Sun's group pointed out. Also,
"continuity of care in the ED may be compromised by frequent nursing and
physician shift changes, and ED priority on evaluating new patients may divert
attention from ongoing care of boarded patients," they added.
With an aging population, the situation isn't likely to get
better any time soon, regardless of healthcare reform, the researchers
suggested.
Their retrospective study linked discharge data, which
California hospitals are required to report to the state hospital planning
office, together with daily electronic ambulance diversion logs provided by
emergency medical services agencies covering the state. After excluding
children and children's hospitals, centers without emergency departments,
federal hospitals, transfers, and centers prohibited from diverting ambulances
by local emergency services policy, the analysis included 995,379 ED visits
resulting in admission to 187 hospitals in 2007.
Less than a quarter of days overall were so busy that
ambulances were diverted to other facilities, excluding other reasons for
diversion (such as disasters or temporary lack of subspecialty or imaging
services). Diversion lasted for a median of 7 hours on days considered crowded,
averaging each hospital's top quartile of days for number of hours of
diversion.
Patients admitted through the ED on such days had slightly
poorer outcomes after adjustment for primary diagnosis and 30 different
comorbidities. Compared with patients admitted after a visit to the ED on all
other days, the results with crowding were:
·
5% higher likelihood of inhospital mortality
(95% CI 2% to 8%)
·
0.8% longer hospital length of stay (95% CI 0.5%
to 1%)
·
1% increased costs per admission (95% CI 0.7% to
2%)
Thus, overcrowded EDs appeared to be responsible for 300
excess deaths in California hospitals over the 1-year period along with 6,200
extra days in the hospital and $17 million in costs, the authors calculated.
The researchers cautioned that ambulance diversion may not
have been a perfect surrogate for ED crowding because some hospitals may rarely
request it regardless of patient saturation, and it may not reflect crowding
experienced by an individual patient.
Also, their study was not designed to assess potential
causal mechanisms, which should be explored in future research, they stated.
"However, all of these concerns generate a conservative
bias toward the null hypothesis, and we believe that the true effect of ED
crowding is greater than our reported estimates," Sun's group wrote. Other
limitations were inability to completely eliminate potential confounding or
reverse causation (if patients with worse outcomes lead to ED crowding).
The study was supported by the Agency for Healthcare
Research and Quality and the Emergency Medicine Foundation. Sun reported
support by NIH/NIA grants and the UCLA Older Americans Independence Center.
10. Narcotic Bowel Syndrome
Grover CA, et al. J Emerg Med. 2012;43:992-995.
Background: Narcotic bowel syndrome is characterized by
chronic or recurrent abdominal pain associated with escalating doses of
narcotic pain medications. It may occur in as many as 4% of all patients taking
opiates, and yet few physicians are aware that the syndrome exists.
Objectives: The objectives of this case report are to raise
awareness of narcotic bowel syndrome among emergency physicians, as well as
review the clinical features, diagnosis, pathophysiology, and emergency department
(ED) management of the syndrome.
Case Report: We report a case of narcotic bowel syndrome
diagnosed in a 24-year-old woman after more than 1 year of ED visits for
recurrent abdominal pain of unknown origin.
Conclusions: It is particularly important for emergency
physicians to be familiar with this syndrome, as many patients with narcotic
bowel syndrome seek evaluation and treatment in the ED. Although the diagnosis
is unlikely to be made in the ED, timely referral for evaluation of this
syndrome may help patients to receive definitive treatment for their recurrent
and chronic pain.
For a full free-text review, see Grunkemeier DM, et al. Clin
Gastroenterol Hepatol. 2007;5(10):1126-39. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2074872/
11. Comparison of risk scoring systems in predicting clinical outcome at
UGI bleeding patients in an emergency unit
Dicu D, et al. Amer J Emerg Med. 2013;31:94-99.
Background: Admission Rockall score (RS), full RS, and
Glasgow-Blatchford Bleeding Score (GBS) can all be used to stratify the risk in
patients presenting with upper gastrointestinal bleeding (UGIB) in the
emergency department (ED). The aim of our study was to compare both admission
and full RS and GBS in predicting outcomes at UGIB patients in a Romanian ED.
Patients and Methods: A total of 229 consecutive patients
with UGIB were enrolled in the study. Patients were followed up 60 days after
admission to ED because of UGIB episode to determine cases of rebleeding or
death during this period. By using areas under the curve (AUCs), we compared
the 3 scores in terms of identifying the most predictive score of unfavorable
outcomes.
Results: Rebleeding rate was 40.2% (92 patients), and
mortality rate was 18.7% (43 patients). For the prediction of mortality, full
RS was superior to GBS (AUC, 0.825 vs 0.723; P = .05) and similar to admission
RS (AUC, 0.792). Glasgow-Blatchford Bleeding Score had the highest accuracy in
detecting patients who needed transfusion (AUC, 0.888) and was superior to both
the admission RS and full RS (AUC, 0.693 and 0.750, respectively) (P less than
.0001). In predicting the need for intervention, the GBS was superior to both
the admission RS and full RS (AUC, 0.868, 0.674, and 0.785, respectively) (P less
than .0001 and P = .04, respectively).
Conclusions: The GBS can be used to predict need for
intervention and transfusion in patients with UGIB in our ED, whereas full RS
can be successfully used to stratify the mortality risk in these patients.
12. Ultrasound Wizardry
A. The ‘No-CT Appy’
by Brady Pregerson, et al. EP Monthly, on December 21, 2012
You just heard a great lecture on minimizing radiation
exposure from diagnostic testing and your next patient may give you the
opportunity to put the lecturer’s plan into practice. The patient is a
19-year-old male who thinks he may have food poisoning due to the fact that he
developed abdominal pain last night after eating a burrito at a local “Roach
Coach”. He said it tasted fine, but soon after developed abdominal pain in his
right lower abdomen. He denies any fever, vomiting, nausea or diarrhea, but did
say he hasn’t been hungry this morning. The pain is constant, non-migratory and
is gradually getting worse. He motions to a specific localized area with two
fingers as he describes the pain. The pain has been present for about 14 hours.
He tried some Pepto-Bismol but it didn’t help, but at least hasn’t caused any
dark stool or salicylate induced duodenal ulcers.
On exam the patient has normal vital signs with a
temperature of 98.2°F. There is no scleral icterus and his exam is essentially
normal except for some tenderness to palpation in one small area in the right
lower quadrant. Rovsing’s sing is negative. You check a psoas sign to check for
retrocecal appendix inflammation and it is also negative. Thinking back to the
lecture you just heard you wonder if this is a patient that your surgeon might
take to the OR without the almost obligatory CT scan of the abdomen. You order
labs and even consider adding a sed-rate, hoping if it is high it might buff
your argument to skip the CT if the white count happens to come back normal.
Finally, you place a call to your surgeon. You explain to the patient that you
plan to give him some pain medication, but if the pain is only mild, it might
be better to wait until you talk to the surgeon. You also briefly explain the
risks and benefits of having surgery versus having a CT scan first. You don’t
want him to think you are cutting corners or rushing so you make sure to tell
him that it is always safer for you as a doctor to do more tests and you are
more than happy to do it if he wants, but that you think it is safer for him to
dodge the radiation bullet in this instance.
You weigh things in your head. The history and exam are not
necessarily “textbook classic” but they are pretty suggestive, and you don’t
really suspect any alternative diagnosis. The history of progressively
worsening right lower quadrant pain, focal RLQ tenderness and the absence of
ovaries are, in your mind, the most important elements of the true triad for
acute appendicitis, even if the patient doesn’t have many associated symptoms.
As you are mulling all of this over in your head, the on-call surgeon calls
back. You make your case, emphasizing that this is a young patient and that
avoiding radiation is therefore more important than in an older patient. The
surgeon agrees with your reasoning, but states that he recently read a study
that shows that CT scans decreases the risk of a negative laparotomy. (No duh,
you think to yourself). He says, “Hold off on the CT for now. I’m upstairs.
I’ll be down in fifteen minutes.”
Your labs come back ten minutes later showing a white count
of 12.1 with 75% PMN’s. Unfortunately, you wish you hadn’t ordered the sed rate
because it was only 5. The surgeon waltzes in just then, says hi, and sees the
patient. Your optimism barometer takes a small dive when he comes out of the
room and requests a CT scan. “Why try?” you think to yourself. It’s easier to
just do what everyone else does; it’s harder to do the right thing. With your
bubble burst, you walk back to your desk and your white coat accidentally
catches on one of the handles of the ED ultrasound machine, catapults it across
the floor right into the room the surgeon came from. The plug flies off the
holder and miraculously makes a flawless entry into the wall outlet and turns
itself on. You look down at the floor and see the bottle of ultrasound gel
spinning at your feet. Could this be some sort of a sign? ….
The remainder of the essay: http://www.epmonthly.com/clinical-skills/ultrasound/the-no-ct-appy/
B. A Sharp, Tearing
Pain in the Abdomen
by Brady Pregerson, et al. EP Monthly, on November 6, 2012
“Nothing in medicine is black and white,” you hear your
colleague explain to one of the rotating medical students. She looks perplexed
as he goes on to explain that there is an “art” to medicine and just because
she learned how to evaluate and manage a certain type of patient presentation
one way, doesn’t mean there aren’t other “right” ways to do it. The overeager
medical student has her mouth half-open to retort back in response, when she
sees you out of the corner of her eye subtly shaking your head to warn her to
stop before she puts her foot in her mouth. You decide this would be a good
opportunity to ask her to follow one of your senior residents as he gets ready
to perform a bedside aorta ultrasound on another patient in the department.
The patient who needs the scan is a 56-year-old otherwise
healthy female who presented to the ED with a chief complaint of “severe
abdominal pain” after she finished lifting boxes of heavy books at her job the
day before. She states her pain is worse with movement and is better when she
lies still. She has never had pain like this before, and today, it is 10 out of
10 in severity. The pain is described as sharp and tearing, but it does not
radiate to her chest or back. She has no other associated symptoms, and she has
tried Ibuprofen without any relief.
Her vital signs are all completely within normal limits and
her physical exam is only remarkable for tenderness to palpation over her left
rectus muscles, and a seemingly pulsatile aorta palpable through her thin
abdominal wall. She has no rebound or guarding on abdominal exam, and she has
no other abnormal findings. Given her symptoms and her palpable aorta, your
senior resident decides it would be prudent to do a quick scan of her aorta to make
sure nothing catastrophic is imminent…
For the remainder of the essay (with images): http://www.epmonthly.com/clinical-skills/ultrasound/a-sharp-tearing-pain-in-the-abdomen/
C. Use of the
sonographic diameter of optic nerve sheath to estimate ICP
Amini A, et al. Amer J Emerg Med. 2013;31:236-239.
Background and aims: An increase in the intracranial
pressure (ICP) might aggravate patient outcomes by inducing neurologic
injuries. In patients with increased ICP the optic nerve sheath diameter (ONSD)
increases due to its close association with the flow of cerebrospinal fluid.
The present study was an attempt to evaluate the efficacy of sonographic ONSD
in estimating ICP of patients who are candidates for lumbar puncture (LP).
Materials and methods: In this descriptive prospective
study, the ONSD was measured before LP using an ultrasonography in 50
nontraumatized patients who were candidates for LP due to varies diagnoses.
Immediately after the sonography, the ICP of each patient was measured by LP.
Correlation tests were used to evaluate the relationship between ICP and the
sonographic diameter of the optic nerve sheath. Receiver operating characteristic
curve was used to find the optimal cut-off point in order to diagnose ICP
values higher than 20 cm H2O.
Results: The means of the ONSD were 5.17 ± 1.01 and 5.19 ±
1.06 mm on the left and right sides, respectively (P = .552). The mean ONSD for
the patients with increased ICP and normal individuals were 6.66 ± 0.58 and
4.60 ± 0.41 mm, respectively (P less than .001). This mean was significantly
correlated with ICP values (P less than .05; r = 0.88). The ONSD of greater
than 5.5 mm predicted an ICP of ≥20 cm H2O with sensitivity and specificity of
100% (95% CI, 100-100) (P less than .001).
Conclusion: The sonographic diameter of the optic nerve
sheath might be considered a strong and accurate predicting factor for
increased intracranial pressure.
D. Prospective
Evaluation of Point-of-Care Ultrasonography for the Diagnosis of Pneumonia in
Children and Young Adults
Shah VP, et al. Arch Pediatr Adolesc Med. 2012 [Epub ahead
of print]
Objective To
determine the accuracy of point-of-care ultrasonography for the diagnosis of
pneumonia in children and young adults by a group of clinicians.
Design Prospective
observational cohort study.
Setting Two urban
emergency departments.
Participants Patients
from birth to age 21 years undergoing chest radiography for suspected
community-acquired pneumonia.
Intervention After
documenting clinical examination findings, clinicians with 1 hour of focused
training used ultrasonography to diagnose pneumonia in children and young
adults.
Main Outcomes Measures
Test performance characteristics for the ability of ultrasonography to
diagnose pneumonia were determined using chest radiography as a reference
standard. Subgroup analysis was performed in patients having lung consolidation
exceeding 1 cm with sonographic air bronchograms detected on ultrasonography;
specificity and positive likelihood ratio (LR) were calculated to account for
lung consolidation of 1 cm or less with sonographic air bronchograms
undetectable by chest radiography.
Results Two hundred
patients were studied (median age, 3 years; interquartile range, 1-8 years);
56.0% were male, and the prevalence of pneumonia by chest radiography was
18.0%. Ultrasonography had an overall sensitivity of 86% (95% CI, 71%-94%),
specificity of 89% (95% CI, 83%-93%), positive LR of 7.8 (95% CI, 5.0-12.4),
and negative LR of 0.2 (95% CI, 0.1-0.4) for diagnosing pneumonia by
visualizing lung consolidation with sonographic air bronchograms. In subgroup
analysis of 187 patients having lung consolidation exceeding 1 cm,
ultrasonography had a sensitivity of 86% (95% CI, 71%-94%), specificity of 97%
(95% CI, 93%-99%), positive LR of 28.2 (95% CI, 11.8-67.6) and negative LR of
0.1 (95% CI, 0.1-0.3) for diagnosing pneumonia.
Conclusion Clinicians
are able to diagnose pneumonia in children and young adults using point-of-care
ultrasonography, with high specificity.
E. Accuracy of
Point-of-Care Ultrasonography for Diagnosis of Elbow Fractures in Children
Rabiner JE, et al. Ann Emerg Med. 2013;61:9-17.
Study objective
We determine the test performance characteristics for point-of-care
ultrasonography performed by pediatric emergency physicians compared with
radiographic diagnosis of elbow fractures and compare interobserver agreement
between enrolling physicians and an experienced pediatric emergency medicine
sonologist.
Methods
This was a prospective study of children aged up to 21 years
and presenting to the emergency department (ED) with elbow injuries requiring
radiographs. Before obtaining radiographs, pediatric emergency physicians
performed focused elbow ultrasonography. An ultrasonographic result positive
for fracture at the elbow was defined as the pediatric emergency physician's
determination of an elevated posterior fat pad or lipohemarthrosis of the
posterior fat pad. All patients received an elbow radiograph in the ED and
clinical follow-up. The criterion standard for fracture was fracture on initial
or follow-up radiographs.
Results
One hundred thirty patients with a mean age of 7.5 years
were enrolled by 26 sonologists. Forty-three (33%) patients had a radiograph result
positive for fracture. A positive elbow ultrasonographic result had a
sensitivity of 98% (95% confidence interval [CI] 88% to 100%), specificity of
70% (95% CI 60% to 79%), positive likelihood ratio of 3.3 (95% CI 2.4 to 4.5),
and negative likelihood ratio of 0.03 (95% CI 0.01 to 0.23) for fracture. The
interobserver agreement (κ) was 0.77. The use of elbow ultrasonography would
reduce radiographs in 48% of patients but would miss 1 fracture.
Conclusion
Point-of-care ultrasonography is highly sensitive for elbow
fractures, and a negative ultrasonographic result may reduce the need for
radiographs in children with elbow injuries. Elbow ultrasonography may be
useful in settings in which radiography is not readily accessible or is time
consuming to obtain.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01297-8/fulltext
13. Many health apps are based on flimsy science at best, and they often do
not work
By Rochelle Sharpe | New England Center for Investigative
Reporting, Published: November 12
When the iTunes store began offering apps that used
cellphone light to cure acne, federal investigators knew that hucksters had
found a new spot in cyberspace.
“We realized this could be a medium for mischief,” said
James Prunty, a Federal Trade Commission attorney who helped pursue the
government’s only cases against health-app developers last year, shutting down
two acne apps.
Since then, the Food and Drug Administration has been mired
in a debate over how to oversee these high-tech products, and government
officials have not pursued any other app developers for making medically
dubious claims. Now, both the iTunes store and the Google Play store are
riddled with health apps that experts say do not work and in some cases could
even endanger people.
These apps offer quick fixes for everything from flabby abs
to alcoholism, and they promise relief from pain, stress, stuttering and even
ringing in the ears. Many of these apps do not follow established medical
guidelines, and few have been tested through the sort of clinical research that
is standard for less new-fangled treatments sold by other means, a probe by the
New England Center for Investigative Reporting has found.
While some are free, thousands must be purchased, at prices
ranging from 69 cents to $999. Nearly 247 million mobile phone users around the
world are expected to download a health app in 2012, according to
Research2Guidance, a global market research firm.
In an examination of 1,500 health apps that cost money and
have been available since June 2011, the center found that more than one out of
five claims to treat or cure medical problems. Of the 331 therapeutic apps,
nearly 43 percent relied on cellphone sound for treatments. Another dozen used
the light of the cellphone, and two others used phone vibrations. Scientists
say none of these methods could possibly work for the conditions in question.
‘Bogus’ claims
“Virtually any app that claims it will cure someone of a disease,
condition or mental health condition is bogus,” says John Grohol, an expert in
online health technology, pointing out that the vast majority of apps have not
been scientifically tested. “Developers are just preying on people’s
vulnerabilities.”
Satish Misra, a physician and the managing editor of the app
review Web site iMedicalApps, adds: “They take some therapeutic method that is
real — and in some cases experimental — and create a grossly simplified version
of that therapy using the iPhone. Who knows? Maybe it works.” But until testing
shows otherwise, “my feeling would be that it doesn’t.”
To be sure, there are many outstanding health apps,
particularly those intended for doctors and hospitals, that are helping to
revolutionize medical care, according to physicians and others. Among the most
well-regarded apps for consumers: Lose It for weight loss, Azumio to measure
heart rates, and iTriage to check symptoms and locate hospitals with the
shortest emergency room wait times.
But consumers have almost no way of distinguishing great
high-tech tools from what Prunty called the “snake oil.” Without government
oversight or independent testing of apps, people mainly must rely on
developers’ advertisements and anonymous online reviews, many of which are positive
but some, such as this one, are not: “Shame on Apple for even allowing this
piece of crap on here. . . . It preys on people with health issues.”
The remainder of the essay: http://www.washingtonpost.com/national/health-science/many-health-apps-are-based-on-flimsy-science-at-best-and-they-often-do-not-work/2012/11/12/11f2eb1e-0e37-11e2-bd1a-b868e65d57eb_story.html
14. Four Secrets to Video Laryngoscopy
Despite the expanding array of video and other imaging
laryngoscopes there are some fundamental principles that apply to all new
airway devices that emergency physicians should know. Below we review four
critical concepts: epiglottoscopy and suctioning, lifting to expand the viewing
area, tilting the optics toward the ET tube, and two-stage tube delivery.
Rich Levitan, EP monthly, December 2012: http://www.epmonthly.com/features/current-features/four-secrets-to-video-laryngoscopy-/
15. If Dental Assistants can Push Propofol, Why Can’t Emergency Nurses?
Campbell and Froese responded to a recent article published
on the number of personnel needed for ED procedural sedation: Sedation-assisted
orthopedic reduction in Emergency Medicine: The safety and success of a one
physician/one nurse model. West J Emerg Med. September 2012 [Epub ahead of
print]. An excerpt from the exchange of
letters-to-the-editor reads:
…The safety of the one physician/one nurse model is further
supported by its broad use in non-acute care settings. We cited a number of
references in our paper of its safe use by gastroenterologists.2,3 Casting the
net even wider, many dentists in this country are trained to perform procedural
sedation, and they include propofol in their pharmacopeia.4 The American Dental
Association requires the presence of one additional person beyond the dentist
for moderate sedation and two additional persons for deep sedation and general
anesthesia.5 These ancillary personnel are required only to have completed a
Basic Life Support course for the healthcare provider. Also, “when the same
individual administering the deep sedation or general anesthesia is performing
the dental procedure, one of the additional appropriately trained team members
must be designated for patient monitoring.”5 And in the dental office, this
monitor is customarily a dental assistant, or occasionally a registered nurse.4
In fact, with additional training, the dental assistant in some states is
authorized to draw up and administer intravenous agents for deep sedation under
direct supervision of a dentist.6 Strangely, the same drug administration that
is entrusted to dental assistants is being questioned as unsuitable for
sedation-trained registered nurses who specialize in emergency care.7
As the evidence suggests, a two person team is often all
that is needed for sedation-assisted procedures in emergency medicine. Studies
show that the one physician/one nurse-equivalent model is both safe and
effective. And in these days of limited resources and growing cost consciousness,
this leaner approach has even more going for it.
The full-text (free) of the letters with references can be
found here: http://escholarship.org/uc/item/1p8962kw
The original article on the one physician/one nurse model: http://escholarship.org/uc/item/55x763sq
16. Applying the Boston Syncope Criteria to Near Syncope
Grossman SA, et al. J Emerg Med. 2012;43:958-963.
Background: We recently demonstrated that near-syncope
patients are as likely as syncope patients to experience adverse outcomes. The
Boston Syncope Criteria (BSC) identify patients with syncope unlikely to have
adverse outcomes and reduce hospitalizations. It is unclear whether these
guidelines could reduce hospitalization in near syncope as well.
Objective: To determine if BSC accurately predict which
near-syncope patients require hospitalization.
Methods: A prospective observational study enrolled from
August 2007 to October 2008 consecutive emergency department (ED) patients
(aged over 18 years) with near syncope. BSC were first employed assuming that
any patient with risk factors for adverse outcomes should be admitted, and then
utilized using a modified rule: if the etiology of near syncope is dehydration
or vasovagal, and ED work-up is normal, patients may be discharged even with
risk factors. Outcomes were identified by chart review and 30-day follow-up
calls.
Results: Of 244 patients with near syncope, 111 were
admitted, with 49 adverse outcomes. No adverse outcomes occurred among
discharged patients. If BSC had been followed strictly, another 41 patients
with risk factors would have been admitted and 34 discharged, a 3% increase in
admission rate. However, using the modified criteria, only 68 patients would
have required admission, a 38% reduction in admission, with no missed adverse
outcomes on follow-up.
Conclusion: Although near-syncope patients may have risk
factors for adverse outcomes similar to those with syncope, if the etiology of
near syncope is dehydration or vasovagal, and ED work-up is normal, these
patients may be discharged even with risk factors.
The Boston Syncope Criteria: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2276584/table/T1/
17. Hands-Only CPR Saves More Lives
By Crystal Phend, Senior Staff Writer, MedPage Today.
December 10, 2012
When bystanders performed chest compression-only CPR and
used a public-access defibrillator, 40.7% of out-of-hospital cases survived at
least a month without needing assistance in daily living, Taku Iwami, MD, PhD,
of the Kyoto University Health Service in Kyoto, Japan, and colleagues found.
That rate was a third higher than with conventional CPR
group and a defibrillator shock, at 32.9%, the group reported online in
Circulation: Journal of the American Heart Association.
"This is one of the highest survival rates with
neurologically-favorable outcomes reported and should be the target survival
after out-of-hospital cardiac arrest," they noted.
Chest compressions alternating with rescue breathing remains
the standard for trained rescuers, but recommendations for untrained bystanders
switched in 2010 to only chest compressions regardless of emergency dispatch
assistance. The reason is that "rescue breathing is so difficult to
perform that it can interrupt chest compressions," which animal and
clinical studies have linked to survival, Iwami's group explained.
The hands-only technique may be more effective than
conventional CPR in the early phase of sudden cardiac arrest, which may be all
that is needed if an automated external defibrillator (AED) is available
nearby, they added.
These findings would likely generalize to other countries,
like the U.S., where AEDs are widespread, according to a statement from the
American Heart Association. "Across the U.S., too many people are dying
from sudden cardiac arrest because family members and friends of the victim are
unsure how to help. This study confirms that hands-only CPR is highly
effective. Plus it's easy to do," Michael Sayre, MD, of the University of
Washington in Seattle, said in the release as a spokesperson for the AHA.
The study analyzed all consecutive out-of-hospital cardiac
arrests of presumed cardiac origin that were witnessed and received CPR and AED
shocks as recorded prospectively in the All-Japan Utstein Registry of the Fire
and Disaster Management Agency.
The population-based registry included 1,376 such cases
among the total 547,153 confirmed out-of-hospital cardiac arrests that occurred
in Japan over a 5-year period, basing CPR characteristics on bystander
interviews with emergency responders on the scene.
In this country where 1.6 million individuals each year get
conventional CPR training offered by fire departments and the emergency
dispatch gives conventional CPR instructions, chest compression-only CPR
accounted for just 34% of cases in the analysis. That proportion rose over time
from just 5% of eligible patients in 2005 when the registry started to 44% in
2009 (P less than 0.001 for trend).
But outcomes were better after chest compression-only CPR
than when it involved rescue breathing for several key endpoints:
·
Prehospital return of spontaneous circulation
(50% versus 40%, P less than 0.001)
·
One-month survival, based on follow-up by
emergency responders (46% versus 40%, P=0.018)
·
Survival to at least 1 month with no more than
moderate cerebral disability (41% versus 33%, P=0.003)
The odds of 1-month survival with favorable neurological
outcomes remained 33% more likely (95% CI 1.03 to 1.70) for the hands-only
group after adjustment for age, sex, time from collapse to public-access AED
shock or initiation of CPR by bystanders, and year.
The study couldn't determine the quality of bystander CPR or
what biases might have led some to do chest compressions only, since only
conventional CPR was taught in Japan at the time. Nor could the results be
extrapolated to the 97% of witnessed out-of-hospital cardiac arrests with CPR
by bystanders that didn't get shocked by public-access AEDs.
Nevertheless, the superiority of hands-only CPR in the study
"strongly suggests the need for implementation of public-access
defibrillation programs with attempts to increase the number of lay rescuers
who can at least perform chest compression CPR and use an AED," the
researchers concluded.
Conventional CPR with rescue breathing is still recommended
for children, since their cardiac arrests are less likely to be of cardiac
origins, so a dual training program may be warranted.
Iwami's group proposed chest compression-only training as
standard for most people and conventional CPR training as an option for medical
professionals, lifeguards, school teachers, and families with children. They
pointed to a successful public campaign in Arizona that "has consistently
and carefully advocated conventional CPR for suspected noncardiac and pediatric
arrests and successfully demonstrated that most pediatric out-of-hospital
cardiac arrest patients had received conventional CPR."
Iwami T, et al. Chest compression-only cardiopulmonary
resuscitation for out-of-hospital cardiac arrest with public-access defibrillation:
A nationwide cohort study. Circulation 2012;126:2844-2851. Abstract: http://circ.ahajournals.org/content/126/24/2844.abstract
18. Mind wandering and driving: responsibility case-control study
Galéra C, et al. BMJ 2012;345:e8105
Objective To assess the association between mind wandering
(thinking unrelated to the task at hand) and the risk of being responsible for
a motor vehicle crash.
Design Responsibility case-control study.
Setting Adult emergency department of a university hospital
in France, April 2010 to August 2011.
Participants 955 drivers injured in a motor vehicle crash.
Main outcome measures Responsibility for the crash, mind
wandering, external distraction, negative affect, alcohol use, psychotropic
drug use, and sleep deprivation. Potential confounders were sociodemographic
and crash characteristics.
Results Intense mind wandering (highly
disrupting/distracting content) was associated with responsibility for a
traffic crash (17% (78 of 453 crashes in which the driver was thought to be
responsible) v 9% (43 of 502 crashes in which the driver was not thought to be
responsible); adjusted odds ratio 2.12, 95% confidence interval 1.37 to 3.28).
Conclusions Mind wandering while driving, by decoupling
attention from visual and auditory perceptions, can jeopardise the ability of
the driver to incorporate information from the environment, thereby threatening
safety on the roads.
Full-text (free): http://www.bmj.com/content/345/bmj.e8105
19. Silencing the Science on Gun Research
Kellermann AL, et al. JAMA. 2012;():1-2. Online First
On December 14, a 20-year-old Connecticut man shot and
killed his mother in the home they shared. Then, armed with 3 of his mother's
guns, he shot his way into a nearby school, where he killed 6 additional adults
and 20 first-grade children. Most of those who died were shot repeatedly at
close range. Soon thereafter, the killer shot himself. This ended the carnage
but greatly diminished the prospects that anyone will ever know why he chose to
commit such horrible acts.
In body count, this incident in Newtown ranks second among
US mass shootings. It follows recent mass shootings in a shopping mall in
Oregon, a movie theater in Colorado, a Sikh temple in Wisconsin, and a business
in Minnesota. These join a growing list of mass killings in such varied places
as a high school, a college campus, a congressional constituent meeting, a day
trader's offices, and a military base. But because this time the killer's
target was an elementary school, and many of his victims were young children,
this incident shook a nation some thought was inured to gun violence.
As shock and grief give way to anger, the urge to act is
powerful. But beyond helping the survivors deal with their grief and
consequences of this horror, what can the medical and public health community
do? What actions can the nation take to prevent more such acts from happening,
or at least limit their severity? More broadly, what can be done to reduce the
number of US residents who die each year from firearms, currently more than 31
000 annually?1
The answers are undoubtedly complex and at this point, only
partly known. For gun violence, particularly mass killings such as that in
Newtown, to occur, intent and means must converge at a particular time and
place. Decades of research have been devoted to understanding the factors that
lead some people to commit violence against themselves or others. Substantially
less has been done to understand how easy access to firearms mitigates or
amplifies both the likelihood and consequences of these acts.
For example, background checks have an effect on
inappropriate procurement of guns from licensed dealers, but private gun sales
require no background check. Laws mandating a minimum age for gun ownership
reduce gun fatalities, but firearms still pass easily from legal owners to
juveniles and other legally proscribed individuals, such as felons or persons
with mental illness. Because ready access to guns in the home increases, rather
than reduces, a family's risk of homicide in the home, safe storage of guns
might save lives.2 Nevertheless, many gun owners, including gun-owning parents,
still keep at least one firearm loaded and readily available for self-defense.3
The nation might be in a better position to act if medical
and public health researchers had continued to study these issues as diligently
as some of us did between 1985 and 1997. But in 1996, pro-gun members of
Congress mounted an all-out effort to eliminate the National Center for Injury
Prevention and Control at the Centers for Disease Control and Prevention (CDC).
Although they failed to defund the center, the House of Representatives removed
$2.6 million from the CDC's budget—precisely the amount the agency had spent on
firearm injury research the previous year. Funding was restored in joint
conference committee, but the money was earmarked for traumatic brain injury.
The effect was sharply reduced support for firearm injury research.
To ensure that the CDC and its grantees got the message, the
following language was added to the final appropriation: “none of the funds
made available for injury prevention and control at the Centers for Disease
Control and Prevention may be used to advocate or promote gun control.”4…
The remainder of the essay (free for now): http://jama.jamanetwork.com/article.aspx?articleID=1487470&utm
20. Clinical Features of Patients With Pulmonary Embolism and a Negative
PERC Rule Result
Kline JA, et al. Ann Emerg Med. 2013;61:122-124.
To the Editor:
We write with reference to the case report by Hennessey et
al1 of a patient with a radiographically large pulmonary embolism that was
represented as a case of a false-negative result of the pulmonary embolism
rule-out criteria (PERC). The authors concluded that “further characterization
of the types of pulmonary embolism missed by PERC and their associated outcomes
would be desirable.” In an accompanying editorial, Green and Yealy2 warned,
“Case reports often highlight anomalies that alone should not necessarily
change practice or thinking.” We agree that a case report provides only a
pinhole view of a much broader clinical landscape.
To offer a larger and more scientifically valid view of the
clinical features of patients with a negative PERC rule result but with
pulmonary embolism diagnosed, we performed a secondary analysis of a
prospectively collected registry of 1,880 emergency department (ED) patients
receiving a diagnosis of acute pulmonary embolism.3 Because these patients were
enrolled after the diagnosis of pulmonary embolism was established, we lack a
reliable assessment of gestalt suspicion of pulmonary embolism. Accordingly, we
present results of patients who tested negative for the 8 objective criteria of
PERC (younger than 50 years, pulse <100 beats="beats" min="min" sao2="sao2">94%, no previous
venous thromboembolism, no recent surgery, no unilateral limb swelling, no
hemoptysis, and no estrogen use).
Of the 1,880 patients with pulmonary embolism in the
registry, 114 (6.1%; 95% confidence interval [CI] 5.0% to 7.2%) had negative
results for all 8 objective factors of the PERC rule. The Table compares the
proportions of 26 clinical variables between PERC negative and PERC positive.
Pleuritic chest pain, pregnancy, and postpartum status were the only 3
variables that demonstrated a true difference in their proportions and were
more frequent in the PERC-negative group. PERC-negative patients also had a
lower frequency of respiratory distress and right ventricular strain; we did
not collect data about size of pulmonary embolism on computed tomography (CT)
scan. The only significant difference we observed in outcomes was that
objective PERC-negative patients had a lower all-cause mortality rate at 30
days: 0 of 114 (0%) versus 108 of 1,776 (5.7%) (95% CI for 5.7% difference 2.5%
to 6.9%).
We interpret these data as having several implications.
First, we are reminded that pleuritic chest pain significantly increases the
probability of a filling defect on CT scan diagnostic for pulmonary embolism in
ED patients with suspected pulmonary embolism.4 Assuming that pleuritic chest
pain marks the presence of lung ischemia, pulmonary infarction may increase the
risk of a false-negative PERC result. Patients with pulmonary infarction tend
to have fewer and smaller pulmonary arterial filling defects on pulmonary
angiography, higher blood oxygenation, and lower pulse rate than patients with
pulmonary embolism and no pulmonary infarction.5 PERC-negative pulmonary
embolism patients tended to have a more benign clinical course than PERC-positive
patients. In contrast to the case report by Hennessey et al,1 data from this
large sample suggest that PERC is more likely to miss small, distal pulmonary
embolism. The data also suggest that PERC should not be used in isolation to
rule out pulmonary embolism in patients with pregnancy and postpartum status.
Table and references: http://www.annemergmed.com/article/S0196-0644(12)01344-3/fulltext
21. Antibiotics not effective for most coughs, study finds
The antibiotic amoxicillin was not better than placebo in
relieving symptoms or duration of cough, according to a study published online
in The Lancet Infectious Diseases. Patients who took amoxicillin were also more
likely to report nausea, rash and other side effects than those who received
placebo. "The main message here is that antibiotics are usually not
necessary for respiratory infections, if pneumonia is not suspected," said
Dr. Philipp Schuetz, who wrote an editorial that accompanied the study.
22. Health workers don't always practice healthy behaviors
Health care workers were more likely than nonhealth workers
to drink in the past 30 days, more likely to use smokeless tobacco and less
likely to get mammograms within the last two years, according to a report in
the Archives of Internal Medicine. However, health workers were less likely to
report a lack of physical activity and drunk driving in the last 30 days.
Full-text (requires subscription): http://archinte.jamanetwork.com/article.aspx?articleid=1483956
23. Unusual Studies (or Unusually Seasonal)
A. Novel ’Pet Scan’
Quickly Scents C. Difficile
Man's Best Friend Sniffs Out C. difficile
A trained dog identified toxigenic strains of Clostridium
difficile with 100% accuracy in stool and 83% sensitivity and 98% specificity
when near patients.
Infection with toxigenic strains of Clostridium difficile
(CD) causes significant morbidity and mortality and is a large and growing
problem in hospitalized patients. The available tests to reveal the presence of
these strains require several days to complete, increasing the likelihood of
nosocomial spread.
Noting the characteristic "horse manure–like" odor
of diarrheic stool from patients infected with toxigenic CD, researchers in the
Netherlands postulated that dogs — whose sense of smell is far superior to that
of humans — might be able to detect this odor with great sensitivity and
specificity. (One of the researchers is owner and chair of Scent Detection
Academy and Research, Animal Behaviour and Cognition, HL&HONDEN, Edam,
Netherlands.)
A 2-year-old male beagle was trained to identify the odor of
toxin-producing CD and to sit or lie down on detection of this scent. In
preliminary testing involving 50 CD-positive and 50 CD-negative stools, the
dog's sensitivity and specificity were 100%. Using a case-control method, the
dog was then put in proximity to one CD-positive and nine CD-negative patients
on detection rounds in two hospitals. This process was repeated 29 times so the
dog was exposed to a total of 30 CD-positive and 270 CD-negative inpatients.
The dog correctly identified 25 of the 30 case-patients (sensitivity, 83%; 95%
confidence interval, 65%–94%) and 265 of the 270 controls (specificity 98%; 95%
CI, 95%–99%).
Comment: The authors note several limitations of this
proof-of-principle study, including the variability of both trainers and dogs
and, more importantly, the fact that many of the CD-positive patients had been
moved to a single room (which could have influenced the trainer — and thus the
dog's response). Further experience in this method is warranted and may prove
very rewarding.
— Stephen G. Baum, MD. Published in Journal Watch Infectious
Diseases December 19, 2012
Full-text (free) at BMJ: http://www.bmj.com/content/345/bmj.e7396
Associated video: http://www.bmj.com/multimedia/video/2012/12/14/cliff-and-c-diff
B. The tooth fairy
and malpractice
Ludman S, et al. BMJ 2012;345:e3027
We are concerned that the actions of the mythical character
at the root of this report must be brought to the attention of the medical
community, as it seems to represent the first signs of a worrying new trend in
malpractice.1 2 Previous anecdotal evidence suggests the tooth fairy is
benevolent, but this opinion may need revising in light of mounting reports of
less child-friendly activity.
An 8 year old boy was referred to a specialist allergy
clinic with a history of profuse mucopurulent rhinorrhoea. After a failure of
first line medical treatment, computed tomography of the sinuses was performed.
This revealed clear evidence of changes consistent with sinusitis but also a
calcified foreign body in the left external auditory meatus (figure: see link below).
The family spoke of an occasion three years earlier when the
boy had woken from sleep, extremely distressed because the tooth fairy had put
a tooth in his left ear. The tooth had initially been left under his pillow for
the tooth fairy to collect and to leave some money in its place. Thinking this
was a bad dream, the parents initially reassured the boy but were unable to
locate the tooth. Nevertheless, his concerns continued, and on two occasions
advice was sought from different general practitioners, when the auroscopy was
thought to be normal.
Repeat auroscopy by the allergist confirmed the presence of
a deciduous tooth in the auditory canal. The tooth was removed by an ENT
surgeon under microscopic vision, and the patient decided to keep the tooth for
posterity rather than taking the risk of attempting a further pecuniary reward.
He kindly gave his consent for us to disseminate this information to save other
children from going through this ordeal.
In the United Kingdom it is customary for children to put
deciduous teeth under their pillow at night in order to receive a financial
reward from the tooth fairy. In addition to our case, there are two other
reports of possible malpractice on the part of the tooth fairy. The other cases
involve a tooth in the upper oesophagus causing tracheal obstruction in a
trauma situation,1 and a man who developed a nipple abscess after inserting his
child’s milk tooth into the hole of his nipple piercing to keep his child’s
tooth near to his heart.2
As far as we are aware, there is no revalidation procedure
for the tooth fairy and no clear guidance or standard operating procedures in
place to ensure adverse outcomes are avoided. We advise that medical
practitioners should have a high index of suspicion with tooth related
presenting complaints.
References and image: http://www.bmj.com/content/345/bmj.e3027
C. Why Rudolph’s nose
is red: observational study
Ince C, et al. BMJ 2012;345:e8311
Objective To characterise the functional morphology of the
nasal microcirculation in humans in comparison with reindeer as a means of
testing the hypothesis that the luminous red nose of Rudolph, one of the most
well known reindeer pulling Santa Claus’s sleigh, is due to the presence of a
highly dense and rich nasal microcirculation.
Design Observational study.
Setting Tromsø, Norway (near the North Pole), and Amsterdam,
the Netherlands.
Participants Five healthy human volunteers, two adult
reindeer, and a patient with grade 3 nasal polyposis.
Main outcome measures Architecture of the microvasculature
of the nasal septal mucosa and head of the inferior turbinates, kinetics of red
blood cells, and real time reactivity of the microcirculation to topical
medicines.
Results Similarities between human and reindeer nasal
microcirculation were uncovered. Hairpin-like capillaries in the reindeers’
nasal septal mucosa were rich in red blood cells, with a perfused vessel
density of 20 (SD 0.7) mm/mm2. Scattered crypt or gland-like structures
surrounded by capillaries containing flowing red blood cells were found in
human and reindeer noses. In a healthy volunteer, nasal microvascular
reactivity was demonstrated by the application of a local anaesthetic with
vasoconstrictor activity, which resulted in direct cessation of capillary blood
flow. Abnormal microvasculature was observed in the patient with nasal
polyposis.
Conclusions The nasal microcirculation of reindeer is richly
vascularised, with a vascular density 25% higher than that in humans. These
results highlight the intrinsic physiological properties of Rudolph’s legendary
luminous red nose, which help to protect it from freezing during sleigh rides
and to regulate the temperature of the reindeer’s brain, factors essential for
flying reindeer pulling Santa Claus’s sleigh under extreme temperatures.
Full-text (free): http://www.bmj.com/content/345/bmj.e8311
D. Santa’s Deer May
Deliver Eyeful of Myiasis
Kan B, et al. N Engl J Med 2012;367:2456-2457.
Children hoping to catch Santa landing his present-packed
sleigh may want to think twice about getting too close: Kids in Sweden wound up
with fly larvae burrowing in their eyes after visiting with some reindeer.
By Todd Neale, Senior Staff Writer, MedPage Today. December
19, 2012
Children hoping to catch Santa landing his present-packed
sleigh at their house this Christmas may want to think twice about getting too
close to his trusty reindeer.
That's because the reindeer -- the same species as caribou
(Rangifer tarandus) in North America -- could be carrying the larvae of a
bumblebee-like fly called Hypoderma tarandi.
As the fly's name suggests, its eggs laid in the hair of
reindeer hatch into larvae that penetrate the skin like a hypodermic needle.
After the larvae mature, flies burst out of the skin to begin the cycle again.
A fact relevant to kids looking to sneak out of bed upon
hearing bells jingling outside their houses next week is that the flies have no
problem with using humans as their breeding ground.
In a letter in the New England Journal of Medicine, Boris
Kan, MD, of Karolinska University Hospital in Stockholm, and colleagues
reported on five children who developed dermal swellings and ocular injury
after visiting reindeer herding areas in subarctic regions of Norway and
Sweden.
Infestation with H. tarandi was confirmed in each child
"by assaying serum samples for antibodies against hypodermin C, an enzyme
released by the larvae during migration in the host," the researchers
wrote.
That adds to the 12 other human cases of myiasis -- human
tissue becoming infested with fly larvae -- caused by H. tarandi reported in
the literature since 1980.
Three-quarters of the previously reported patients developed
ophthalmomyiasis. Of the five new patients, two developed the infestation of
the eye, one of whom lost vision in the affected eye. Although all five of the
children visited reindeer herding areas, only four said they actually saw the
animals. None recalled being attacked by a fly.
The patients developed swelling of the occipital lymph nodes
and dermal swellings 2 to 5 cm in size that appeared 15 days to 3 months after
exposure. The swellings appeared one at a time, lasted for up to 3 days, and
then reappeared after 2 to 34 days. In two siblings, the symptoms developed 3
months apart, even though they were exposed at the same time.
Four of the children required treatment with ivermectin
(Stromectol) at doses of 200 to 350 µg/kg. One required three treatments and
three required five treatments, including one child who underwent eye surgery.
After ivermectin treatment, the dermal swellings turned into
hard nodules, "probably because of a 'foreign-body' reaction against the
dead larva," according to the researchers.
They concluded, "Myiasis due to H. tarandi should be
considered in patients presenting with migratory dermal swelling if they
recently had visited an area frequented by reindeer."
So a peek at Rudolph and his buddies may not be such a good
idea after all.
The authors reported no conflicts of interest with the North
Pole.
E. Twas the Night
Before Christmas...
Dr. Robert Brandt. ACEP News. December 19, 2012
Twas the night before Christmas, the ED was quiet,
Not a creature was stirring, there wasn’t a riot.
The patients slept soundly, so snug in their cots,
With some having dreams of free vodka shots.
When out rang a noise, the silence was broke.
A priority one is incoming it spoke.
The voice on the phone was all crackled and manic,
Our poor EMS seemed to be in a panic.
The report filtered in and I soon became hot,
As responders reported that Santa’s been shot.
They rushed in Saint Nick still smiling his greeting:
"Oh no! Ho-ho-ho I am certainly bleeding!"
"Santa!" I cried in the foulest of moods,
"Who did this?" I asked. He whispered "two
dudes."
I stifled emotions; good Santa just hissed--
"They both made the top of my naughty list."
We stripped him and flipped him to find bullet holes.
Our tasks were quite clear, accomplish our goals.
I acted quite quickly and did ABC’s,
Looking him over from red hat to knees.
A hole in the leg and the belly and chest,
Such violence to Santa was hard to digest!
His cap had been shot, the slug count to four,
Its white fluffy ball fell off to the floor.
I did a quick rectal and to my surprise,
Amazing the sight I beheld with my eyes,
I pulled out my finger and felt at a loss,
For it now was covered with rich chocolate sauce.
We threw in a chest tube and I went insane,
The tube changed right there into sweet candy cane!
The nurses inserted the Foley agog,
And from his new catheter poured some eggnog.
We worked fifty minutes our pulses were dashing,
Just trying to keep the man’s vitals from crashing.
We poured in the saline, but nothing would last,
As candy poured from his holes just as fast.
His pressure came down; his heart rate did too,
And then it occurred to me just what to do.
"This man is of magic and candy and dreams,
Perhaps we should try some ulterior means."
I opened D50, the strongest we had,
And to that container we started to add:
Our dreams and our hopes, strong coffee as well,
More sugar, some glitter and the sound of a bell.
We poured our concoction right into his heart.
And all we could hope was that magic would start.
At first there was nothing, and then just a blip,
He stirred, then he fluttered and then he did grip.
He yanked out the cane that I’d thrust in his side,
He crunched off a bite and he took it in stride.
The chest hole now healed, the abdomen too,
He yanked out his Foley and winked at our crew.
Now off from the bed, he sprung like a lemur,
Despite on the X-ray he’d broken his femur.
That magical elf had healed himself true,
He ran out the door saying "Got work to do,"
Then quickly I woke, from my dark working desk,
I’d fallen asleep, quite lacking in rest.
"It all was a dream," I said, wiping my eyes,
But something seemed odd, and to my surprise,
I saw something white that fell to my lap
The perfect round puff-ball from kind Santa’s hat.
I ran outside hearing, as he flew out of sight,
"Merry Christmas to all, and to all a safe night!"
