1. Patients with Rib Fractures Do Not Develop Delayed Pneumonia: A
Prospective, Multicenter Cohort Study of Minor Thoracic Injury
Chauny J, et al. Ann Emerg Med. 2012;60:726-731.
Study objective
Patients admitted to emergency departments (EDs) for minor
thoracic injuries are possibly at risk of delayed pneumonia. We aimed to
evaluate the incidence of delayed pneumonia post–minor thoracic injury and the
associated risk factors.
Methods
A prospective, multicenter cohort study was conducted in 4
Canadian EDs, from November 2006 to November 2010. All consecutive patients
aged 16 years and older with minor thoracic injury who were discharged from the
ED were screened for eligibility. Uniform clinical and radiologic evaluations
were performed on the initial ED visit and were repeated at weeks 1 and 2.
Relative risk analyses quantified incidence with comparison by age, sex,
smoking status, alcohol intoxication, pulmonary comorbidity, ability to cough
atelectasis, pain level, and number of rib fractures.
Results
Of the 1,057 participants recruited, 347 (32.8%) had at
least 1 rib fracture, 87 (8.2%) had asthma, and 36 (3.4%) had chronic
obstructive pulmonary disease. Only 6 patients (0.6%; 95% confidence interval
0.24% to 1.17%) developed pneumonia during the follow-up period. The relative
risk for patients with preexistent pulmonary disease and radiologically proven
rib fractures was 8.6 (P=.045; 95% confidence interval 1.05 to 70.9). Sex,
smoking habit, initial atelectasis, ability to cough, and alcohol intoxication
were not significantly associated with delayed pneumonia.
Conclusion
This prospective cohort study of nonhospitalized patients
with minor thoracic injuries revealed a low incidence of delayed pneumonia.
Nonetheless, our results support tailored follow-up for asthmatic or chronic
obstructive pulmonary disease patients with rib fracture.
2. New Guidelines: Carbon Monoxide Poisoning
Nicholas Gross, MD, PhD, Medscape Pulmonary Medicine, Nov 19, 2012
Summary
The first consensus guidelines for the management and
prevention of carbon monoxide (CO) poisoning have recently been published. The
toxicity of CO is not solely due to its binding to hemoglobin and thus reducing
hemoglobin's oxygen-carrying capacity. CO poisoning causes cellular changes,
including immunologic and inflammatory damage. The effects of this damage are
long-lasting, independent of hypoxia, and contribute to the morbidity of
patients who recover from CO poisoning. The guidelines point out that the
diagnosis is often missed in both emergency departments and clinics. [1]
Nonspecific symptoms such as headache, nausea, and fatigue are the rule, so a
high degree of suspicion by healthcare providers is warranted. The classic
description of "cherry-red" skin is only seen with lethal CO
poisoning. CO-oximetry on arterial blood is a more reliable test.
Oxygen accelerates the elimination of carboxyhemoglobin
(COHb) and should be administered at 100% to anyone suspected of CO poisoning
while the definitive measurement of the COHb level is being determined. The
former practice of adding carbon dioxide to the inspired air to hasten
elimination of COHb is no longer recommended. With 100% oxygen breathing, the
half-life of COHb is approximately 74 minutes. In theory, the use of high
partial pressures of oxygen by hyperbaric chamber should provide better
neurologic outcomes, although clinical proof of that concept is lacking. When
available, the authors recommend 3 treatments with hyperbaric oxygen in the
first 24 hours to avoid late cognitive sequelae, but the optimal dose and
frequency of treatments are unknown.
The late effects of neurologic damage are a particular
concern and can occur with relatively mild CO poisoning and in children as well
as adults. The risk for these was substantially reduced in the only objective
study of the use of hyperbaric oxygen. [2] As hyperbaric chambers are not
available in most hospitals, the risks of moving patients to another facility
must be considered. Similar considerations apply when, as is often the case, CO
poisoned patients have complicating factors such as burns or pregnancy. If
poisoning is due to attempted suicide, the presence of drugs and substances of
abuse should be considered. Metabolic acidosis and cyanide poisoning are
complications of house fires, for which empiric treatment with hydroxocobalamin
may be considered.
Follow-up care should consider the possibility of adverse sequelae
months or years later, including memory disturbance, mood changes, and
vestibular and motor problems. Survivors have been reported to be more likely
to experience problems such as falls, motor vehicle accidents, and increased
mortality.
Viewpoint
Carbon monoxide is well known to be a poisonous gas by the
public, yet 50,000 fatalities due to CO poisoning occur each year, and that
number is not declining. Indeed, it is one of the commonest poisoning
fatalities in both children and adults and, in adults, is commoner than heroin
fatalities. Only about half of all CO fatalities are accidental, many being due
to suicide. Although important advances in its prevention and management have
occurred in the last decade, the only authoritative consensus guidelines are
more than a decade old and were published in a specialty journal. [3] The
present review by 4 experts in the field is therefore timely.
Two issues seem of particular importance. Early diagnosis
leads to early institution of appropriate therapy, and the key to early
diagnosis is awareness and a high degree of suspicion on the part of healthcare
providers. The presenting symptoms, being vague, call for more frequent blood
analysis. Secondly, death is very uncommon in CO poisoned patients who arrive at
an emergency facility. This fact leads to 2 conclusions: delay in the
recognition and response to CO poisoning causes the fatalities. But for those
patients who do arrive at an emergency department, the avoidance of late
neurologic problems should be a goal.
In prevention, the importance of awareness programs and more
widespread employment of CO alarms are stressed. Additionally, CO poisoning can
occur in unexpected places such as ice rinks. [4]
References: [1] Harper A, et al. Age Ageing. 2004;33:105-109.
[2] Weaver LK, et al. N Engl J Med. 2002;347:1057-1067. [3] Hampson NB, et al.
Undersea Hyperb Med. 2001;28:157-164. [4] Pelham TW, et al. Occup Environ Med.
2002;59:224-233.
Abstract: Hampson NB, et al. Am J Respir Crit Care Med. 2012
Oct 18 [Epub ahead of print]: http://www.ncbi.nlm.nih.gov/pubmed/23087025
3. Exercise Stress Test: Is it necessary in low-risk ED CP patients after
normal ECG and biomarkers?
David Newman and Ashley Shreves of SMART EM.
Why Low Risk Chest Pain Management is totally Screwed.
The management of low risk chest pain in the US is founded
on a number of tenets:
·
If low risk chest pain patients are sent home
and they have unstable angina, they will do worse than if we admitted them
·
Provocative testing will identify patients who
are safe for discharge
·
A positive stress test identifies patients who
will have benefit from PCI
·
PCI is the standard of care for UA/NSTEMI as it
reduces patient important adverse events
The problem is that all of these are false. Really?
For the discussion notes and links to the podcasts: http://emcrit.org/chestpain/
4. First Year after Job Loss Has Same MI Risk as Smoking/Diabetes
Sue Hughes,
Heartwire. Nov 21, 2012. DURHAM, North Carolina — Loss of employment
carries a similar risk of MI as hypertension, diabetes, or smoking, a new study
suggests [1]. In addition, there appears to be a clear dose-related effect,
with the risk of MI increasing with each additional job loss.
The study, published online on November 19, 2012 in the
Archives of Internal Medicine, was conducted by Dr Matthew Dupre (Duke
University, Durham, NC).
Dupre told heart wire that this study was more detailed than
previous research on unemployment and heart disease risk, and to his knowledge,
it is the first to examine the cumulative effect of multiple dimensions of
unemployment on the risk of MI.
Interestingly, the effect of unemployment on MI risk was
most marked in the first year after the job loss occurred, suggesting that the
risk is tied to the actual event, rather than long-term factors.
Mediated by Stress
Dupre commented to heart wire : "It seems that the
transition itself is the most dangerous. We think the MI risk is probably
caused by the stress of becoming unemployed. But many other factors may come
into play, such as changes in diet and sleep, increased smoking, and loss of
control of other risk factors, such as diabetes and hypertension, as people are
thrown into a chaotic state. We would therefore urge physicians to be more
vigilant in terms of health awareness in patients who have recently become
unemployed."
The researchers analyzed data from the Health and Retirement
Study (HRS), a nationally representative sample of the older US adult
population (over 50 years). The sample for the current study included 13 451
people aged 51 to 75 years at baseline who reported ever having worked. They
underwent interviews every two years, which included detailed questions about
employment history, as well as health and socioeconomic information, and were
followed prospectively over an 18-year period. Patients who had had an MI
before baseline were excluded.
Results showed that there were 1061 AMI events (7.9%) during
the follow-up period. Among the participants, 14% were unemployed at baseline,
70% had had one or more job losses, and 35% had spent time unemployed.
Multivariate models showed that MI risk was significantly
higher among the unemployed and that risk increased with each job loss.
Risk of MI According to Unemployment Status and Each
Incremental Job Loss
HR
(95% CI)
Unemployment status 1.35
(1.10–1.66)
One job loss 1.22 (1.04–1.42)
Two job losses 1.27
(1.05–1.54)
Three job losses 1.52
(1.22–1.90)
Four job losses 1.63
(1.29–2.07)
Although the risk of AMI was greatest in the first year
after job loss, unemployment status, cumulative number of job losses, and
cumulative time unemployed were each independently associated with increased
risk of MI, even after adjusting for sociodemographic, socioeconomic,
behavioral, psychological, and clinical risk factors.
The type of work had no effect on the findings, and
voluntary loss of employment, such as retirement, was not associated with
increased MI risk.
Exact Mechanism Unclear
Noting that the exact mechanism behind the link is not
clear--although it does appear to be stress related--the researchers suggest
that future studies should consider whether other job-related factors, such as
seasonal employment, underemployment, multiple jobs, or family demands, may be
sources of employment instability, stress, and increased cardiovascular events.
"As rates of job instability continue to increase and
unemployment reaches 30-year highs . . . the cardiovascular costs of repeated
job losses in younger cohorts are yet unknown," they add.
In an accompanying editorial [2], Dr William Gallo (City
University of New York, NY), points out that the stressors involved in job loss
"are too many and too entangled to enumerate and describe," which
makes identifying the mechanisms linking loss of employment to health problems
extremely difficult.
He concludes that: "The next generation of studies
should identify reasonable pathways from job separation to illness so that
nonoccupational interventions may be developed and targeted to the most
vulnerable individuals."
5. National Trends in ED Occupancy, 2001 to 2008: Effect of Inpatient
Admissions versus ED Practice Intensity
Pitts SR, et al. Ann Emerg Med. 2012;60:679-686.e3.
Study objective
We evaluate recent trends in emergency department (ED)
crowding and its potential causes by analyzing ED occupancy, a proxy measure
for ED crowding.
Methods
We analyzed data from the annual National Hospital
Ambulatory Medical Care Surveys from 2001 to 2008. The surveys abstract patient
records from a national sample of hospital EDs to generate nationally
representative estimates of visits. We used time of ED arrival and length of ED
visit to calculate mean and hourly ED occupancy.
Results
During the 8-year study period, the number of ED visits
increased by 1.9% per year (95% confidence interval 1.2% to 2.5%), a rate 60%
faster than population growth. Mean occupancy increased even more rapidly, at
3.1% per year (95% confidence interval 2.3% to 3.8%), or 27% during the 8 study
years. Among potential factors associated with crowding, the use of advanced
imaging increased most, by 140%. But advanced imaging had a smaller effect on
the occupancy trend than other more common throughput factors, such as the use
of intravenous fluids and blood tests, the performance of any clinical
procedure, and the mention of 2 or more medications. Of patient
characteristics, Medicare payer status and the age group 45 to 64 years
accounted for small disproportionate increases in occupancy.
Conclusion
Despite repeated calls for action, ED crowding is getting
worse. Sociodemographic changes account for some of the increase, but practice
intensity is the principal factor driving increasing occupancy levels. Although
hospital admission generated longer ED stays than any other factor, it did not
influence the steep trend in occupancy.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)00507-0/fulltext
6. Is Culture-positive UTI in Febrile Children Accurately Identified by
Urine Dipstick or Microanalysis?
Perkins J, et al. J Emerg Med. 2012;43:1144-1159.
Background: Fever from a urinary tract source remains the
predominant etiology of serious bacterial infection in children ages 0–36
months. Urine culture is the gold standard for diagnosing a urinary tract infection
(UTI); however, urine dipstick (UDip) and urine microanalysis (UA) are
typically used real time by Emergency Physicians to diagnose and treat UTIs, as
cultures can take days to grow and be available. The purpose of this article is
to evaluate the literature on the accuracy and utility of the UDip and UA in
this pediatric population.
Methods: A structured review of the medical literature to
determine the accuracy of UDip and UA for the diagnosis of UTI in children
before the result of the urine culture.
Results: Upon comprehensive review and after applying
predefined inclusion criteria, a total of 13 articles met inclusion criteria,
addressed the clinical question, and were reviewed in detail.
Conclusions: The literature search did not conclusively
identify any component of either the UDip or the UA, which would allow a
practitioner to conclude definitively that the source of an infant's fever is a
UTI.
7. Burns from OTC Topical Pain Relievers
Kuehn BM. JAMA. 2012;308(20):2073.
Over-the-counter topical muscle and joint pain relievers may
cause serious burns (http://tinyurl.com/8ok5px7),
warns the US Food and Drug Administration (FDA).
The agency reviewed 43 cases of such burns in the medical
literature and the agency's Adverse Events Reporting System and found that some
patients using these products experienced first-, second-, and third-degree
burns, even after a single application of the product. Some of these patients
developed complications that required hospitalization.
8. Dysnatremias in the ED
Arampatzis S, et al. Amer J Med 2012;125: 1125.e1-1125.e7.
Objective
Dysnatremias are common in critically ill patients and
associated with adverse outcomes, but their incidence, nature, and treatment
rarely have been studied systematically in the population presenting to the
emergency department. We conducted a study in patients presenting to the
emergency department of the University of Bern.
Methods
In this retrospective case series at a university hospital
in Switzerland, 77,847 patients admitted to the emergency department between
April 1, 2008, and March 31, 2011, were included. Serum sodium was measured in
43,911 of these patients. Severe hyponatremia was defined as less than 121
mmol/L, and severe hypernatremia was defined as less than 149 mmol/L.
Results
Hypernatremia (sodium over 145 mmol/L) was present in 2% of
patients, and hyponatremia (sodium below 135 mmol/L) was present in 10% of
patients. A total of 74 patients had severe hypernatremia, and 168 patients had
severe hyponatremia. Some 38% of patients with severe hypernatremia and 64% of
patients with hyponatremia had neurologic symptoms. The occurrence of symptoms
was related to the absolute elevation of serum sodium. Somnolence and
disorientation were the leading symptoms in hypernatremic patients, and nausea,
falls, and weakness were the leading symptoms in hyponatremic patients. The
rate of correction did not differ between symptomatic and asymptomatic
patients. Patients with symptomatic hypernatremia showed a further increase in
serum sodium concentration during the first 24 hours after admission.
Corrective measures were not taken in 18% of hypernatremic patients and 4% of
hyponatremic patients.
Conclusions
Dysnatremias are common in the emergency department.
Hyponatremia and hypernatremia have different symptoms. Contrary to
recommendations, serum sodium is not corrected more rapidly in symptomatic
patients.
Full-text (free): http://www.amjmed.com/article/S0002-9343(12)00498-6/fulltext
9. Does CT Rule Out Clinically Significant Cervical Spine Injuries in
Patients With Obtunded or Intubated Blunt Trauma?
Kirschner J, et al. Ann Emerg Med. 2012;60:737-738.
Take-Home Message
Cervical spine computed tomography (CT) is highly sensitive
and may reliably exclude unstable injuries in patients with obtunded or
intubated blunt trauma.
Commentary
A missed cervical spine injury resulting in neurologic
compromise is an unacceptable outcome. Although most patients with blunt trauma
can be safely cleared of significant cervical spine injuries clinically, this
cannot be done in the tracheally intubated or obtunded patient. Should all of
these patients be evaluated by MRI or does CT suffice?
Although this meta-analysis reports an extremely high
sensitivity for the detection of unstable cervical spine injuries, many of the
studies included in this review suffer from significant methodologic flaws. Ten
of the 17 included observational trials were retrospective and prone to
verification bias. Several trials did not report outcomes of patients with
normal imaging results, and most did not collect data from radiologists blinded
to pertinent clinical information or results from previous imaging. None of the
trials were prospective randomized controlled trials. Last, the reported
heterogeneity was high (I2=78%). It may be inappropriate to calculate
heterogeneity for diagnostic test accuracy reviews because different positivity
thresholds may account for between-study variation. If in fact the same
thresholds are used between studies, the significant heterogeneity statistic (I2=78%)
suggests that chance alone cannot account for the variation in study results.1,
2
Though the validity of existing data on CT for cervical
spine injuries is not ideal, MRI is not clearly beneficial in obtunded patients
with normal CT scan results. Recent reports suggest MRI is far superior to CT
for the diagnosis of discoligamentous injury3, 4, 5; however, most injuries
diagnosed by MRI are treated conservatively and have unclear clinical
significance. Additionally, cervical spine MRI has a false-positive rate as
high as 25% to 50%,4, 5, 6 resulting in unnecessary spinal immobilization,
which has a reported complication rate as high as 67% in some trials.6, 7, 8, 9
Ultimately, CT appears to have a very high sensitivity for unstable cervical
spine injuries, yet the quality of the existing data does not definitively
eliminate the controversy over which imaging modality is best for the obtunded
or tracheally intubated trauma patient.
Full-text (including methods): http://www.annemergmed.com/article/S0196-0644(12)00116-3/fulltext
10. An International View of How Recent-onset AF Is Treated in the ED
Rogenstein C, et al. Acad Emerg Med. 2012
Nov;19(11):1255-60.
OBJECTIVES: This study was conducted to determine if there
is practice variation for emergency physicians' (EPs) management of
recent-onset atrial fibrillation (RAF) in various world regions (Canada, United
States, United Kingdom, and Australasia).
METHODS: The authors completed a mail and e-mail survey of
members from four national emergency medicine (EM) associations. One
prenotification letter and three survey letters were sent to members of the
Canadian Association of Emergency Physicians (CAEP; Canada-1,177 members
surveyed), American College of Emergency Physicians (ACEP; United States-500),
College of Emergency Medicine UK (CEM; United Kingdom-1,864), and Australasian
College for Emergency Medicine (ACEM; Australasia-1,188) as per the modified
Dillman technique. The survey contained 23 questions related to the management
of adult patients with symptomatic RAF (either a first episode or
paroxysmal-recurrent) where onset is less than 48 hours and cardioversion is
considered a treatment option. Data were analyzed using descriptive and
chi-square statistics.
RESULTS: Response rates were as follows: overall, 40.5%;
Canada, 43.0%; United States, 50.1%; United Kingdom, 38.1%; and Australasia,
38.0%. Physician demographics were as follows: 72% male and mean (±SD) age 41.7
(±8.39) years. The proportions of physicians attempting rate control as their
initial strategy are United States, 94.0%; Canada, 70.7%; Australasia, 61.1%;
and United Kingdom, 43.1% (p less than 0.0001). Diltiazem is the predominant
agent for rate control in Canada (65.36%) and the United States (95.22%), while
metoprolol is used in Australasia (65.94%) and the United Kingdom (67.64%).
Cardioversion is attempted at varying rates in Canada (65.9%), Australasia
(49.9%), United Kingdom (49.5%), and the United States (25.9%) (p less than
0.0001). Pharmacologic cardioversion is attempted first in all regions, with
the preferred drug being procainamide in Canada (61.93%) and amiodarone in
Australasia (63.39%), the United Kingdom (47.97%), and the United States
(22.41%; p less than 0.0001). If drugs fail, electrical cardioversion is then
attempted in Canada (70.64%), Australasia (46.19%), the United States (29.69%),
and the United Kingdom (27.78%; p less than 0.0001).
CONCLUSIONS: There is much variation in emergency department
(ED) management of RAF among world regions, most markedly for use of rate
versus rhythm control, choice of drugs, and use of electrical cardioversion.
Canadians are more likely to use an aggressive approach for management of RAF,
whereas Americans are more likely to employ conservative management. U.K. and
Australasian EPs fall somewhere in the middle. These differences demonstrate
the need for better evidence, or better synthesis of existing knowledge, to
create guidelines to guide ED management of this common dysrhythmia.
11. Cool Images in Clinical Practice
Young Woman With Vomiting, Dyspnea, and Chest Pain
Woman With White Patches on Tongue
A Four-year-old Male With Abdominal Pain
Charcot Foot
Fixed drug eruption due to fluconazole
Community-acquired pneumonia
Postherpetic pseudohernia
Sickle Cell Disease
Massive Splenomegaly in Hairy-Cell Leukemia
Sleep Apnea (video)
Subungual Tumor of the Thumb
Crowned Dens Syndrome
12. Utility of the Digital Rectal Examination in the ED: A Review
Kessler C, et al. J Emerg Med. 2012;43:1196-1204.
Background: The digital rectal examination (DRE) has been
reflexively performed to evaluate common chief complaints in the Emergency
Department without knowing its true utility in diagnosis.
Objective: Medical literature databases were searched for
the most relevant articles pertaining to: the utility of the DRE in evaluating
abdominal pain and acute appendicitis, the false-positive rate of fecal occult
blood tests (FOBT) from stool obtained by DRE or spontaneous passage, and the
correlation between DRE and anal manometry in determining anal tone.
Discussion: Sixteen articles met our inclusion criteria;
there were two for abdominal pain, five for appendicitis, six for anal tone,
and three for fecal occult blood. The DRE was shown to add no additional
diagnostic information and confounded the diagnosis in acute, undifferentiated
abdominal pain. The sensitivity, specificity, positive predictive value,
negative predictive value, and odds ratio for the DRE were too low to reliably
diagnose acute appendicitis in children and adults. No statistical differences
in the number of colonic pathologies were found between stool collection
methods in those with positive FOBT. The DRE correlation with anal manometry in
determining resting and squeeze anal tone ranged from 0.405 to 0.82 and 0.52 to
0.97, respectively.
Conclusion: We found the DRE to have a limited role in the
diagnosis of acute, undifferentiated abdominal pain and acute appendicitis.
Stool obtained by DRE doesn't seem to increase the false-positive rate of
FOBTs, and the DRE correlated moderately well with anal manometric measurements
in determining anal sphincter tone.
13. Diagnosis of STEMI in the Presence of Left BBB with the ST-Elevation to
S-Wave Ratio in a Modified Sgarbossa Rule
Smith SW, et al. Ann Emerg Med. 2012;60:766-776.
Study objective
Sgarbossa's rule, proposed for the diagnosis of acute
myocardial infarction in the presence of left bundle branch block, has had
suboptimal diagnostic utility. We hypothesize that a revised rule, in which the
third Sgarbossa component (excessively discordant ST-segment elevation as
defined by ≥5 mm of ST-segment elevation in the setting of a negative QRS) is
replaced by one defined proportionally by ST-segment elevation to S-wave depth
(ST/S ratio), will have better diagnostic utility for ST-segment elevation
myocardial infarction (STEMI) equivalent, using documented coronary occlusion
on angiography as reference standard.
Methods
We collected admission ECGs for all patients with an acutely
occluded coronary artery and left bundle branch block at 3 institutions. The
ECGs of emergency department patients with chest pain or dyspnea and left
bundle branch block, but without coronary occlusion, were used as controls. The
R or S wave, whichever was most prominent, and ST segments, relative to the PR
segment, were measured to the nearest 0.5 mm. The ST/S ratio was calculated for
each lead that has both discordant ST deviation of greater than or equal to 1 mm
and an R or S wave of opposite polarity; others were set to 0. The cut point
for the most negative ST/S ratio with at least 90% specificity was determined.
The revised rule is unweighted, requiring just 1 of 3 criteria. Diagnostic
utilities of the original and revised Sgarbossa rules were computed and
compared. McNemar's test was used to compare sensitivities and specificities.
Results
The study and control groups included 33 and 129 ECGs,
respectively. The cut point selected for relative discordant ST-segment
elevation was −0.25. Excessive absolute discordant ST-segment elevation of 5 mm
was present in at least one lead in 30% of ECGs in patients with confirmed
coronary occlusion versus 9% of the control group, whereas excessive relative
discordant ST-segment elevation less than −0.25 was present in 58% versus 8%.
Sensitivity of the revised rule in which ST-segment elevation with an ST/S
ratio less than or equal to −0.25 replaces ST-segment elevation greater than or
equal to 5 mm was significantly greater than either the weighted (P less than.001)
or unweighted (P=.008) Sgarbossa rule: 91% (95% confidence interval [CI] 76% to
98%) versus 52% (95% CI 34% to 69%) versus 67% (95% CI 48% to 82%). Specificity
of the revised rule was lower than that of the weighted rule (P=.002) and
similar to that of the unweighted rule (P=1.0): 90% (95% CI 83% to 95%) versus
98% (95% CI 93% to 100%) versus 90% (95% CI 83% to 95%). Positive and negative
likelihood ratios for the revised rule were 9.0 (95% CI 8.0 to 10) and 0.1 (95%
CI 0.03 to 0.3). The revised rule was significantly more accurate than both the
weighted (16% difference; 95% CI 5% to 27%) and unweighted (12% difference; 95%
CI 2% to 22%) Sgarbossa rules.
Conclusion
Replacement of the absolute ST-elevation measurement of greater
than or equal to 5 mm in the third component of the Sgarbossa rule with an ST/S
ratio less than −0.25 greatly improves diagnostic utility of the rule for
STEMI. An unweighted rule using this criterion resulted in excellent prediction
for acute coronary occlusion.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01368-6/fulltext
14. Zero-Mistake Medicine
Six-sigma medicine: Pitfalls and promises in the quest for
mistake-free healthcare
by Dr. Jesse M. Pines and Dr. Zachary Meisel. Emerg
Physicians Monthly on November 16, 2012
No mistakes! That’s the mantra these days for medical care
in the United States. Another term for reducing error rates to near zero is
“Six Sigma” a business strategy developed by Motorola back in the ‘80s, and
popularized by Jack Welch at General Electric in the mid-‘90s. Six Sigma is
about removing the causes for errors by minimizing the variation in how
specific tasks get done. In business-speak, the sigma refers to the percentage
of error-free products produced. A six sigma process is where 99.99966% of the
products are free of defects.
“Six sigma medicine” is about reducing error rates by
improving patient safety – such as eliminating error-prone systems problems
within hospitals – and avoiding really egregious errors, or “never events.”
Never events include performing the wrong surgery, operating on the wrong side
of a patient, or leaving a surgical instrument inside someone’s body. Improving
safety is also about ensuring people don’t get the wrong medicine, an erroneous
diagnosis, or have a preventable complication. The focus on errors started with
the release of the 2001 Institute of Medicine report, To Err is Human1, which
proposed the oft-quoted number of “44,000 to 98,000 deaths per year”
attributable to medical mistakes.
Since then, heaps of money has been spent on improving
patient safety and reducing errors. But has it been worth it?
While some progress has been made, it has been hard to show
that patients are really any safer. According to a 2010 New England Journal of
Medicine article2, patient harms are still very common in U.S. hospitals, and
there are no trends toward improvement.
Why can’t healthcare fix itself, despite the huge
investment?
Most important is the inherently complex nature of human
disease. As emergency physicians, we are trained to recognize common signs and
symptoms of a disease, so when an oddball case happens – as it not infrequently
does – it is sometimes misdiagnosed. Oddball cases are rare but often have bad
outcomes.
The second issue is that the expectation that healthcare
providers can’t ever make mistakes is unrealistic. People expect their care to
be error-free. A system that strives for perfection can be good. However, when
a mistake happens, the system can respond in ways that makes care better for
some, but worse for others.
Take the recent tragic case of the 12-year-old boy Rory
Staunton who was treated at the NYU emergency department. Based on news
reports, his symptoms seemed like a run-of-the-mill gastroenteritis, but
tragically he died three days later from sepsis. Many of the details of the
case are still under dispute, but his was almost certainly an “oddball” case. Clearly,
it seemed to his doctors that his symptoms were just a run-of-the mill
gastroenteritis. One of the issues was that his “bandemia” was reported by the
hospital lab after he’d left the hospital and his doctors never knew about it.
The problem comes in how our system responds to cases like
this. Instead of searching for and identifying the weak links in the system
that, if altered, could have possibly caught and prevented the tragic outcome,
the public goes on a witch-hunt.
In the Staunton case, there was a New York Times article
about the case written by a friend of the Staunton family3. This was followed
by about a week of continuous buzz in the lay-media and medical communities.
Here, the court of public opinion spoke. Was it that the emergency physicians
themselves made an inherently preventable thinking mistake? Or was it, as
others argued, that it was just an unpreventable oddball case?
When a media storm hits like this, it can be a game changer.
The problem is that the system sometimes responds in draconian, untested ways.
Hospital administrators feel compelled to do something, because of the fear
that inaction may be viewed as complacency.
To NYU’s credit, according to the Times, their response
focused on changing the system rather than rooting out individuals. The
hospital changed a policy: now the emergency physicians have to complete a
discharge checklist ensuring that all laboratory results and vital signs are
considered before the patient leaves the hospital. Also, when abnormal laboratory
results occur, the physicians get notified directly, and if the patient has
already been discharged, the patient gets a call.
The goal of the policy is to reduce the likelihood of
important information being missed. On its face this makes sense, and it may
actually prevent someone from being discharged in the future with a concerning
lab value or vital sign abnormalities.
But there are a few issues to consider…
For the remainder of the essay (full-text free): http://www.epmonthly.com/features/current-features/zero-mistake-medicine/
15. Fatal Laughter
Kadari R, et al. Ann Intern Med 2012;157:756.
Background: In the 5th century BCE, the Greek painter Zeuxis
reportedly died while laughing at his painting of Aphrodite, which was
commissioned by a woman who demanded that she be the model. In the 3rd century
BCE, the Greek philosopher Chrysippus reportedly died laughing after giving his
donkey wine and watching it try to eat figs (1). Although the expression “died
laughing” is a common colloquialism, we are not aware of any contemporary reports
of laughter-induced death, although there are reports of laughter-induced
seizures (2) and laughter-induced syncope (3).
Objective: To describe a case of laughter-induced death.
Case Report: Physicians referred a 50-year-old woman with a
prolonged rate-corrected QT (QTc) interval of 570 ms and an isolated incident
of polymorphic ventricular tachycardia (torsade de pointes) after starting
ziprasidone therapy for schizophrenia. She did not report syncope but did
report occasional palpitations for 20 years that had been diagnosed as
isolated, unifocal, premature ventricular contractions. Her medical history
included hepatitis C, but she had no history of hypertension, diabetes,
hyperlipidemia, or cardiovascular disease. Additional medications prescribed
included clonazepam, risperidone, and zolpidem. Her blood pressure was 118/86
mm Hg, and resting heart rate was 60 beats/min. Cardiovascular auscultation was
unremarkable. Echocardiography showed normal ventricular dimensions, wall
thickness, and systolic function without valvular lesions. Exercise myocardial
perfusion scintigraphy revealed normal regional wall motion without inducible
ischemia. Laboratory testing found normal levels of serum glucose, potassium,
magnesium, and calcium. We diagnosed ventricular ectopy with the acquired long
QT syndrome and strongly recommended discontinuation of antipsychotic therapy.
She declined, stating that her emotional well-being was more important than any
risk from life-threatening arrhythmia because she became “crazy” without the
medications. One month later, she was relaxing in the breakroom at work with
colleagues when someone told a joke. She had intense, sustained laughter that
continued for approximately 2 to 3 minutes until she suddenly collapsed.
Coworkers tried to revive her. Paramedics found fine ventricular fibrillation
followed by asystole and eventually discontinued resuscitation. A postmortem
examination was not performed.
Discussion: Laughter-induced syncope is analogous to
cough-induced syncope, which results from marked, transient elevation in
intrathoracic pressure from repetitive bursts of forced expiration that
decrease venous return and cardiac output (the Valsalva phenomenon) and lead to
cerebral hypoperfusion and syncope. We postulate that our patient's laughter
provoked a Valsalva phenomenon leading to enhanced vagal tone and bradycardia,
which is known to trigger early after-depolarization and incite torsade de
pointes in the setting of a prolonged QTc interval (4). For example, another case
report recently described torsade de pointes induced by the Valsalva maneuver
in the setting of QTc interval prolongation (5). We believe that ziprasidone
and risperidone prolonged the QTc interval in our patient and created the
setting in which bradycardia could trigger torsade de pointes. It is less
plausible yet possible that a central nervous system lesion was the trigger
instead of bradycardia, but this possibility cannot be excluded without
autopsy. Although humor and laughter can reduce emotional stress and protect
the heart (6), our report describes 1 example when laughter was not the best
medicine and the expression “died laughing” had a literal meaning.
16. ED Intubation Research
A. C-MAC Video
Laryngoscope Superior to the Macintosh Direct Laryngoscope for Intubation in
the ED
Sakles JC, et al. Ann Emerg Med. 2012;60:739-748.
Study objective
We determine the proportion of successful intubations with
the C-MAC video laryngoscope (C-MAC) compared with the direct laryngoscope in
emergency department (ED) intubations.
Methods
This was a retrospective analysis of prospectively collected
data entered into a continuous quality improvement database during a 28-month
period in an academic ED. After each intubation, the operator completed a standardized
data form evaluating multiple aspects of the intubation, including patient
demographics, indication for intubation, device(s) used, reason for device
selection, difficult airway characteristics, number of attempts, and outcome of
each attempt. Intubation was considered ultimately successful if the
endotracheal tube was correctly inserted into the trachea with the initial
device. An attempt was defined as insertion of the device into the mouth
regardless of whether there was an attempt to pass the tube. The primary
outcome measure was ultimate success. Secondary outcome measures were
first-attempt success, Cormack-Lehane view, and esophageal intubation.
Multivariate logistic regression analyses, with the inclusion of a propensity
score, were performed for the outcome variables ultimate success and
first-attempt success.
Results
During the 28-month study period, 750 intubations were
performed with either the C-MAC with a size 3 or 4 blade or a direct
laryngoscope with a Macintosh size 3 or 4 blade. Of these, 255 were performed
with the C-MAC as the initial device and 495 with a Macintosh direct
laryngoscope as the initial device. The C-MAC resulted in successful intubation
in 248 of 255 cases (97.3%; 95% confidence interval [CI] 94.4% to 98.9%). A direct
laryngoscope resulted in successful intubation in 418 of 495 cases (84.4%; 95%
CI 81.0% to 87.5%). In the multivariate regression model, with a propensity
score included, the C-MAC was positively predictive of ultimate success (odds
ratio 12.7; 95% CI 4.1 to 38.8) and first-attempt success (odds ratio 2.2; 95%
CI 1.2 to 3.8). When the C-MAC was used as a video laryngoscope, a
Cormack-Lehane grade I or II view (video) was obtained in 117 of 125 cases
(93.6%; 95% CI 87.8% to 97.2%), whereas when a direct laryngoscope was used, a
grade I or II view was obtained in 410 of 495 cases (82.8%; 95% CI 79.2% to
86.1%). The C-MAC was associated with immediately recognized esophageal
intubation in 4 of 255 cases (1.6%; 95% CI 0.4% to 4.0%), whereas a direct laryngoscope
was associated with immediately recognized esophageal intubation in 24 of 495
cases (4.8%; 95% CI 3.1% to 7.1%).
Conclusion
When used for emergency intubations in the ED, the C-MAC was
associated with a greater proportion of successful intubations and a greater
proportion of Cormack-Lehane grade I or II views compared with a direct
laryngoscope.
B. Association
Between Repeated Intubation Attempts and Adverse Events in ED: An Analysis of a
Multicenter Prospective Observational Study
Hasegawa K, et al. Ann Emerg Med 2012;60: 749-754.e2
Study objective
Although repeated intubation attempts are believed to
contribute to patient morbidity, only limited data characterize the association
between the number of emergency department (ED) laryngoscopic attempts and
adverse events. We seek to determine whether multiple ED intubation attempts
are associated with an increased risk of adverse events.
Methods
We conducted an analysis of a multicenter prospective
registry of 11 Japanese EDs between April 2010 and September 2011. All patients
undergoing emergency intubation with direct laryngoscopy as the initial device
were included. The primary exposure was multiple intubation attempts, defined
as intubation efforts requiring greater than or equal to 3 laryngoscopies. The
primary outcome measure was the occurrence of intubation-related adverse events
in the ED, including cardiac arrest, dysrhythmia, hypotension, hypoxemia,
unrecognized esophageal intubation, regurgitation, airway trauma, dental or lip
trauma, and mainstem bronchus intubation.
Results
Of 2,616 patients, 280 (11%) required greater than or equal
to 3 intubation attempts. Compared with patients requiring 2 or fewer
intubation attempts, patients undergoing multiple attempts exhibited a higher
adverse event rate (35% versus 9%). After adjusting for age, sex, principal
indication, method, medication, and operator characteristics, intubations
requiring multiple attempts were associated with an increased odds of adverse
events (odds ratio 4.5; 95% confidence interval 3.4 to 6.1).
Conclusion
In this large Japanese multicenter study of ED patients
undergoing intubation, we found that multiple intubation attempts were
independently associated with increased adverse events.
17. Probiotics for the Prevention of Clostridium difficile–Associated
Diarrhea: A Systematic Review and Meta-analysis
Johnston BC, et al. Ann Intern Med 13 November 2012 [Epub
ahead of print]
Background: Antibiotic treatment may disturb the resistance
of gastrointestinal flora to colonization. This may result in complications,
the most serious of which is Clostridium difficile–associated diarrhea (CDAD).
Purpose: To assess the efficacy and safety of probiotics for
the prevention of CDAD in adults and children receiving antibiotics.
Data Sources: Cochrane Central Register of Controlled
Trials, MEDLINE, EMBASE, CINAHL, Allied and Complementary Medicine Database,
Web of Science, and 12 gray-literature sources.
Study Selection: Randomized, controlled trials including
adult or pediatric patients receiving antibiotics that compared any strain or
dose of a specified probiotic with placebo or with no treatment control and
reported the incidence of CDAD.
Data Extraction: Two reviewers independently screened
potentially eligible articles; extracted data on populations, interventions,
and outcomes; and assessed risk of bias. The GRADE guidelines were used to
independently rate overall confidence in effect estimates for each outcome.
Data Synthesis: Twenty trials including 3818 participants
met the eligibility criteria. Probiotics reduced the incidence of CDAD by 66%
(pooled relative risk, 0.34 [95% CI, 0.24 to 0.49]; I2 = 0%). In a population
with a 5% incidence of antibiotic-associated CDAD (median control group risk),
probiotic prophylaxis would prevent 33 episodes (CI, 25 to 38 episodes) per
1000 persons. Of probiotic-treated patients, 9.3% experienced adverse events,
compared with 12.6% of control patients (relative risk, 0.82 [CI, 0.65 to
1.05]; I2 = 17%).
Limitations: In 13 trials, data on CDAD were missing for 5%
to 45% of patients. The results were robust to worst-plausible assumptions
regarding event rates in studies with missing outcome data.
Conclusion: Moderate-quality evidence suggests that
probiotic prophylaxis results in a large reduction in CDAD without an increase
in clinically important adverse events.
18. New Gout Management Guidelines: A Quick and Easy Guide
Bret S. Stetka, MD; Jonathan Kay, MD. November 19, 2012.
For the first time since its founding 78 years ago, the
American College of Rheumatology (ACR) has released guidelines for the
management of gout. The recommendations were released in 2 parts.[1,2] Part 1
addresses nonpharmacologic and pharmacologic treatment approaches to
hyperuricemia, including detailed dietary measures, and part 2 advises on
therapy and anti-inflammatory prophylaxis of acute gouty arthritis. To help
integrate the new recommendations into your clinical practice, we've
highlighted and summarized the primary management suggestions put forth by the
ACR task force panel (TFP).
Slide show review: http://www.medscape.com/features/slideshow/gout
19. A Useful Marker of Invasive Disease in Well-Appearing Febrile Infants
Procalcitonin is better than C-reactive protein and white
blood cell count for predicting bacterial infection in well-appearing infants
aged less than 3 months.
Differentiating between serious bacterial infection and
minor viral illness in febrile infants is often difficult. To date, no single
laboratory test or combination of tests has proven sensitive and specific
enough for identifying young infants with infections that require admission and
antibiotic treatment. Investigators retrospectively evaluated the diagnostic
value of procalcitonin (PCT) levels in 1112 well-appearing infants (age, less
than 3 months) who presented with fever without a source to emergency departments
at seven Spanish and Italian hospitals during a 3-year period.
The infants underwent urine dipstick testing, blood and
urine culture, measurement of white blood cell count, C-reactive protein, and
procalcitonin levels. If indicated, lumbar puncture and stool culture were also
obtained. Overall, 289 infants (26%) were diagnosed with serious bacterial
infections: 264 had urinary tract infection (UTI) only, 2 had bacterial
gastroenteritis, and 23 had invasive bacterial infections (IBIs; 22 had
bacteremia with or without UTI and 1 had meningitis). In multivariate analysis,
only PCT 0.5 ng/mL was significantly associated with IBI (odds ratio, 21.7). A
PCT level less than 0.5 ng/mL reduced the probability of invasive infection to
0.5%, and a PCT level above 2 ng/mL increased the probability of IBI to 19.3%.
Comment: Although this study is retrospective, the results
suggest that procalcitonin is the most useful blood test for identifying
invasive disease in infants who otherwise look well. The test is not available
in all U.S. hospital laboratories, so it might be worthwhile to ask your local
lab to consider adding it to their offerings. When procalcitonin measurement is
available, I find it to be a more useful indicator of severe illness in febrile
infants who look clinically well.
— Peggy Sue Weintrub, MD. Published in Journal Watch
Pediatrics and Adolescent Medicine November 28, 2012. Citation: Gomez B et al.
Diagnostic value of procalcitonin in well-appearing young febrile infants.
Pediatrics 2012 Nov; 130:815.
20. Sustained Benefit of Corticosteroid Therapy in Adults with Bacterial
Meningitis
The survival benefit lasted for more than a decade,
according to follow-up from a randomized, placebo-controlled trial of
dexamethasone.
Fritz D, et al. Neurology 2012;79:2177-9..
BACKGROUND: Data on the long-term effect of dexamethasone on
survival in bacterial meningitis are lacking.
METHODS: A long-term follow-up study of the European
Dexamethasone in Adulthood Bacterial Meningitis Study was performed. In this
double-blind, randomized clinical trial, 301 patients were randomly assigned to
receive adjunctive dexamethasone (n = 157) or placebo (n = 144) between June
1993 and December 2001. We obtained survival data of patients using the Dutch
Municipal Population Register.
RESULTS: Death had occurred in 32 of 301 included patients
(11%) at the primary outcome measurement 8 weeks after randomization. Follow-up
was obtained for 228 of 246 evaluable patients (93%), with median follow-up of
13 years. Overall, 31 of 144 patients (22%) in the dexamethasone group died and
44 of 134 patients (33%) in the placebo group died (log-rank p = 0.029). After
the primary end point of the study at 8 weeks, 20 patients in the dexamethasone
group died and 23 patients in the placebo group died (log-rank p = 0.27), with
age being the sole predictor of death (p less than 0.001).
CONCLUSIONS: In adults with community-acquired bacterial
meningitis, the survival benefit from adjunctive dexamethasone therapy is
obtained in the acute phase of the disease and remains for years.
CLASSIFICATION OF EVIDENCE: This study of a population of
Dutch patients shows Class III evidence that dexamethasone provides an extended
survival benefit in patients treated for bacterial meningitis, and this
survival benefit extends as long as 20 years.
21. AED Regulations Threaten Wider Use: States Grapple With Disparate
Regulatory Approaches
Greene J. Ann Emerg Med. 2012;60:A15-17.
Automated external defibrillators (AEDs) seem to be
everywhere, from ballparks to airports, but the patchwork of regulations meant
to encourage their lifesaving use may actually be hampering them.
Most states have regulatory schemes describing how owners of
AEDs in public places must maintain them, register them with local emergency
responders, and ensure that potential users are trained. Business owners
worried that they can't meet the regulatory requirements—or concerned about the
potential for legal liability—are keeping their AEDs locked away, advocates
complain.
Elizabeth Hunt, MD, a physician in the Johns Hopkins
Pediatric Intensive Care Unit, told a Maryland legislative committee in
February that her unit treats children who could have benefited from an AED in
the field, but the unit was locked away. “I know of several groups that today
do not have the AEDs … ready to use because they haven't yet gotten their staff
trained on how to use it,” Dr. Hunt testified. “They are afraid they will be
sued by someone if they use it wrong since they are not in compliance with the
laws.”
“When there is an AED nearby but it is locked up so no one
can get to it, or no one remembers it is there and the child dies … . [T]his is
an absolute travesty,” she said.
The Maryland legislature considered a bill that would ease
the training requirement in state law for owners of AEDs in public places. The
Maryland Institute for Emergency Medical Services Systems maintains an AED
registration program, which includes training requirement for all “expected
responders.”
That requirement is one of the reasons AEDs are locked away,
argued Dr. Hunt and Myron Weisfeldt, MD, chair of the Department of Medicine at
Johns Hopkins University School of Medicine. “We should be encouraging training
in every way we possibly can, short of making the person buying the AED legally
responsible for seeing that the training is done,” he argued.
Easy to Use
Because the devices are so simple to use—and there are many
people with medical training who already know how to use them—Dr. Weisfeldt
said there should be minimal training requirements to encourage as many people
as possible to step up and use an AED in the crucial few minutes after a
cardiac arrest. Dr. Weisfeldt is lead author of an article evaluating the
Resuscitation Outcomes Consortium, which involved a population base of 21
million people, of whom 13,769 experienced out-of-hospital cardiac arrests.
Survival was 9% with bystander cardiopulmonary resuscitation but no AED
compared with 38% with AED shock delivered.1
Maryland SB461, the subject of the hearing, did not move
forward, in part because of opposition from Maryland regulators, who maintain
that it's better for AEDs to have a plan in place so that the devices are well
maintained and usable when needed.
“We look at the literature, which says that AEDs can be very
effective, but that is dependent on somebody picking up the device and using
it, the device working, and also an appropriate and timely interface with the
local EMS [emergency medical services] system,” said Bob Bass, MD, an emergency
physician and executive director of the Maryland agency. “Our public program is
set up to address those issues.”
AED purchasers register with Maryland Institute for
Emergency Medical Services Systems (MIEMSS) at no charge and receive reminders
every 3 years to check batteries and pads and ensure that they train
individuals to use the devices.
“We recognize that somebody can come up to an AED and
successfully use it even if they've had no training,” Dr. Bass acknowledged.
“But somebody who's not had medical training is more likely to use it and more
quickly and do it correctly” if they've been trained, he said.
Dr. Bass said his agency has no indication that the
approximately 1,500 AED programs in the state, covering about 4,000 public
sites, have had trouble with program requirements. He said the number of
registered public AED programs continues to increase…
The remainder of the essay (full-text free): http://www.annemergmed.com/article/S0196-0644(12)01618-6/fulltext
22. Eponymy: Make that Hippocrates–Janin–Neumann–Reis–Bluthe– … –Behçet’s
disease
Collier R. CMAJ 2012;184(17):1878-80.
It is better to achieve immortality through not dying than
through your work, to paraphrase filmmaker Woody Allen. Unfortunately, physical
immortality is not an option for approximately 100% of humans (give or take
zero people). Having your name live on, therefore, is your best shot at
remaining relevant past your biological expiration date.
If you are a doctor or scientist, you might earn immorality
through an eponym. Perhaps, like German psychiatrist Dr. Alois Alzheimer, someone
will name a disease after you. Maybe, like American surgeon Dr. Henry Jay
Heimlich, someone will name a lifesaving intervention after you. Or perhaps
your name will be linked to some other condition, therapy, gene, theory or
scientific principle.
But what’s best for an individual’s legacy may not be what’s
best for science or medicine. In recent years, many have called for researchers
to abandon eponyms and use more descriptive titles in their place. Yet ridding
the language of science of eponyms will be difficult, if for no other reason
than sheer volume. A quick glance at an online repository (www.whonamedit.com)
reveals 13 pages of medical eponyms — and that’s only those beginning with the
letter A.
Besides honouring a pioneer in a particular field, why name
a scientific discovery after a person anyway?
“It’s chiefly done in an attempt to create a short-hand
reference,” says Dr. Alexander Woywodt, a consultant nephrologist and associate
dean of undergraduate education at Lancashire Teaching Hospitals in Preston,
United Kingdom.
And though many doctors, including Woywodt, suggest that the
golden age of eponyms is behind us, others believe they’re still valuable…
The remainder of the essay (free full-text): http://www.cmaj.ca/content/184/17/1878.full
23. Universal HIV Screening Recommended by USPSTF
The US Preventive Services Task Force (USPSTF) strongly
recommends that clinicians screen all people aged 15 to 65 years for HIV
infection, according to a draft recommendation statement posted online November
20. The statement also recommends HIV screening for all pregnant women,
including those who present at the time of labor, and for younger adolescents
and older adults who are at increased risk.
Full-text (free): http://www.uspreventiveservicestaskforce.org/draftrec.htm
24. Holiday Heart: In Rhyme
Dustin Ballard, Screened & Examined: ’Twas the Day After
Christmas. Emerg Med News 2012;34(12A).
’T is the season of holiday-related ED visits, and a common
one in my shop is “holiday heart.” We worked up a bit of verse to assist with
patient education. You might recognize the irregularly regular meter.
'Twas the day after Christmas, and all through the house,
Not a creature was stirring, not even a spouse.
Empty bottles lay strewn all around without care,
A sure sign that a blackout was already there.
When inside your chest, there arose such a clatter,
Pounding of the heart; something was the matter.
Up from bed you flew in a flash,
Off to the cabinet for your aspirin stash.
With a palpitation, you recall what you heard,
An irregular heartbeat louder than a bird.
The answer buzzed in your head and turned you around,
In your chest “holiday heart” had surely been found.
To the phone you went, moving not at all quick,
You knew in that moment you must phone Doc Tick.
More rapid than hummingbirds his answers they came.
He whistled, and sniffled, and called rhythms by name!
Could be afib! Flutter! Hyperthyroidism!
PVC or SVT? Or embolism?
The cause of the problem, yes, the cause of it all,
Is most certainly your intake of alcohol.
This information settled, you stifled a cry,
You took a deep breath, and asked Doctor Tick…why?
Ear to phone, you listened as his answer it flew.
Not sure. Stress hormones? Or fatty acids, too?
And then, in a twinkling, you heard his deep voice,
Reciting epidemiology, you had no choice.
Afib, he said, the most common by far.
Irregular atria picked up at a bar!
The statistics in studies jump all around,
A link of afib and alcohol's been found.
So there it was, the diagnosis so clear,
Just ask Doctor Tick to make it disappear.
It may pass, he now said, it may pass real soon,
But you must listen to my cautionary tune.
Now fluids, now rest, now healthy meal-fixing,
On aspirin, on moderation, no drink-mixing.
To the ER you should go if your chest feels tight,
Or you can't breathe or feel dizzy all through the night!
Your body handles stress when it is at its best:
Exercise, eat well, and get plenty of rest.
And as he was speaking, as quick as whistle,
The flutters flew like the down on a thistle.
I heard Doctor Tick say, in my head 'ere that night,
Happy Holidays! But holiday heart: good night!
25. “Pre-Cold”: New Poster Child for Disease-Mongering?
By Gary Schwitzer, MedPage Today. November 30, 2012
One of our readers tipped us off to what he called “a new poster
child for overtreatment.” We’ll call it disease-mongering.
It’s the website of the drug company promoting Zicam.The new pitch promotes Zicam for “pre-colds.”
What’s a Pre-Cold™? the website asks,
anticipating our astute question. Well, as you can see, it’s a term that the
drug company trademarked – they thought it was that clever.Their definition of their trademarked term on their website:
We’re glad you asked. You know that first sniffle, sneeze or
cough? That throat tickle, ache or unexplained tiredness? The “uh-oh” stage
before you get a full-blown monster of a cold? That’s a Pre-Cold™.
Know your first signs
We all have our own Pre-Cold™ signs. They’re the ones we usually
ignore and hope will just go away. That’s when you’ll find the Cold Monster™
waiting to pounce.
For some people it’s an itchy, scratchy throat or a runny nose.
For others it’s uncommon body aches or watery eyes. Whatever your first signs,
the next time you have them, take Zicam® within the first 24
hours. It’s a completely different™ kind of medicine that’s clinically proven
to shorten a cold.
Yes,
we ALL have signs of this monstrous pre-disease. So we are ALL potential
customers. And we should ALL start buying and using this product at the
first sign – making all of us worried “patients” for a few extra days. Or is it
just a few? The span of Pre-colds is, conveniently, never defined. We could
take this throughout the year!
Since
we like to look at the combined impact of advertising, marketing, public
relations and “journalism” messages, we took note of the website’s “News and
Events” tab, and how they were proud of how “Zicam® gets a monster of an
endorsement in Men’s Health Magazine.” Not quite a Pulitzer-winning
example of evidence-based health care journalism.
Let’s
get to the claims in the ads and on the website. “Clinically proven to shorten
a cold.” I spent quite a bit of time looking all over the website for any data
to back up that claim. I found a list of other products, a coupon offer, stores
in my area that carry it, a Cold Monster™ Tracker, some user testimonials,
“media buzz” – but no data.
I
loved this passage in the site’s FAQ section:
Is Zicam® regulated by the FDA?
The active ingredients in all Zicam® Cold Remedy
products – zinc gluconate and zinc acetate – are listed as drugs in the
Homoeopathic Pharmacopoeia of the United States (HPUS) which is a compendium
recognized in the Federal Food, Drug, Cosmetic Act [FD&C Act]); as such,
these products are classified by the FDA as OTC homeopathic drugs. All
Zicam® products are sold over-the-counter in accord with FDA’s
guidelines.
I looked
around a bit further and found what anyone could find online – that, yes,
indeed, there are studies suggesting some possible benefits of zinc. There were
also stories that poked holes in some of the claims for over-the-counter zinc
products, or that reminded readers that the FDA
warned consumers to stop using Zicam nasal sprays and swabs a while back.
Let’s not lose sight of some
important context: the common cold is usually self-limiting, often lasting only about a week, with usually mild symptoms. Any messages that try to
convince all of us to buy a product – without citing evidence – for something
that usually goes away on its own in about a week … well, caveat emptor as you
run from the Cold Monster™.
26. A Patient’s Perspective on Medical Procedures
Dave Barry: A journey
into my colon -- and yours
OK. You turned 50. You know you're supposed to get a
colonoscopy. But you haven't. Here are your reasons:
1. You've been busy.
2. You don't have a history of cancer in your family.
3. You haven't noticed any problems.
4. You don't want a doctor to stick a tube 17,000 feet up
your butt.
Let's examine these reasons one at a time. No, wait, let's
not. Because you and I both know that the only real reason is No. 4. This is
natural. The idea of having another human, even a medical human, becoming
deeply involved in what is technically known as your ''behindular zone'' gives
you the creeping willies.
I know this because I am like you, except worse. I yield to
nobody in the field of being a pathetic weenie medical coward. I become faint
and nauseous during even very minor medical procedures, such as making an
appointment by phone. It's much worse when I come into physical contact with
the medical profession. More than one doctor's office has a dent in the floor
caused by my forehead striking it seconds after I got a shot.
In 1997, when I turned 50, everybody told me I should get a
colonoscopy. I agreed that I definitely should, but not right away. By
following this policy, I reached age 55 without having had a colonoscopy. Then
I did something so pathetic and embarrassing that I am frankly ashamed to tell
you about it…
The remainder of the essay (full-text free): http://www.miamiherald.com/2009/02/11/427603/dave-barry-a-journey-into-my-colon.html
27. A Sampling of Recent Intriguing Non-fiction Reads
A. Paul Tough, How Children Succeed: Grit, Curiosity, and
the Hidden Power of Character (Boston: Houghton Mifflin Harcourt, 2012).
Why do some children succeed while others fail?
The story we usually tell about childhood and success is the
one about intelligence: success comes to those who score highest on tests, from
preschool admissions to SATs.
But in How Children Succeed, Paul Tough argues that the
qualities that matter most have more to do with character: skills like
perseverance, curiosity, conscientiousness, optimism, and self-control.
How Children Succeed introduces us to a new generation of
researchers and educators who, for the first time, are using the tools of
science to peel back the mysteries of character. Through their stories—and the
stories of the children they are trying to help—Tough traces the links between
childhood stress and life success. He uncovers the surprising ways in which
parents do—and do not—prepare their children for adulthood. And he provides us
with new insights into how to help children growing up in poverty.
Early adversity, scientists have come to understand, can not
only affect the conditions of children’s lives, it can alter the physical
development of their brains as well. But now educators and doctors around the
country are using that knowledge to develop innovative interventions that allow
children to overcome the constraints of poverty. And with the help of these new
strategies, as Tough’s extraordinary reporting makes clear, children who grow
up in the most painful circumstances can go on to achieve amazing things.
This provocative and profoundly hopeful book has the
potential to change how we raise our children, how we run our schools, and how
we construct our social safety net. It will not only inspire and engage
readers, it will also change our understanding of childhood itself.
Q&A with the author: http://www.amazon.com/dp/0547564651/
B. David DeSteno and
Piercarlo Valdesolo, Out of Character:
Surprising Truths about the Liar, Cheat, Sinner (and Saint) Lurking in All of
Us (New York: Crown Archetype, 2011).
Have you ever wondered why a trumpeter of family values
would suddenly turn around and cheat on his wife? Why jealousy would send an
otherwise level-headed person into a violent rage? What could drive a person to
blow a family fortune at the blackjack tables?
Or have you ever pondered what might make Mr. Right leave
his beloved at the altar, why hypocrisy seems to be rampant, or even why, every
once in awhile, even you are secretly tempted, to lie, cheat, or steal (or,
conversely, help someone you never even met)?
This book answers these questions and more, and in doing so,
turns the prevailing wisdom about who we are upside down. Our character, argue
psychologists DeSteno and Valdesolo, isn’t a stable set of traits, but rather a
shifting state that is subject to the constant push and pull of hidden
mechanisms in our mind. And it's the
battle between these dueling psychological forces that determine how we act at
any given point in time.
Drawing on the surprising results of the clever experiments
concocted in their own laboratory, DeSteno and Valdesolo shed new scientific
light on so many of the puzzling behaviors that regularly grace the
headlines. For example, you’ll learn:
·
Why Tiger Woods just couldn’t resist the allure
of his mistresses even though he had a picture-perfect family at home. And why
no one, including those who knew him best, ever saw it coming.
·
Why even the shrewdest of investors can be
tempted to gamble their fortunes away (and why risky financial behavior is
driven by the same mechanisms that compel us to root for the underdog in
sports).
·
Why Eliot Spitzer, who made a career of
crusading against prostitution, turned out to be one of the most famous johns
of all time.
·
Why Mel Gibson, a noted philanthropist and
devout Catholic, has been repeatedly caught spewing racist rants, even though
close friends say he doesn’t have a racist bone in his body.
·
And why any of us is capable of doing the same,
whether we believe it or not!
A surprising look at the hidden forces driving the saint and
sinner lurking in us all, Out of Character reveals why human behavior is so
much more unpredictable than we ever realized.
