Saturday, December 22, 2012

Lit Bits: Dec 22, 2012

From the recent medical literature...

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. 

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. 

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. 

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). 

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.”  

·         An evidence-based reply by Nishijima DK et al suggests that such an approach is scientifically ungrounded and would result in misplaced healthcare resources:

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):

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," 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. 

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.

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? …. 

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… 

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. 

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. 

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. 

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. 

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.” 

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. 

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:  

The original article on the one physician/one nurse model:

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. 

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:

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. 

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):

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.

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. 

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:  

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. 

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. 

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!"