Saturday, December 08, 2012

Lit Bits: Dec 8, 2012

From the (mostly) recent literature...

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. 

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. 

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. 

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. 

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). 

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– … –Beh├žet’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. 

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… 

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.