Sunday, January 13, 2013

Lit Bits: Jan 13, 2013

From the recent medical literature... 

1. New US STEMI Guidelines Are More User Friendly 

Lisa Nainggolan, Heartwire. Dec 18, 2012 

BOSTON — Newly issued US guidelines for the treatment of ST-elevation MI (STEMI) are "much more user friendly for practicing cardiologists and get quickly to the bottom line," says one member of the writing committee, Dr James Fang (University Hospitals Case Medical Center, Cleveland, OH) [1,2]. 

Fang told heart wire that prior US STEMI recommendations have been "much more encyclopedic," but this time the writing committee tried to focus on what people were going to use. "It can be as authoritative as any document, but if nobody is going to bother picking it up, then we really haven't succeeded in our purpose. We wanted more synthesis of available evidence in our conclusions." 

The new 2013 ACCF/AHA guidelines for the management of STEMI are published simultaneously in Circulation and the Journal of the American College of Cardiology, by Dr Patrick O'Gara (Brigham and Women's Hospital, Boston, MA) and colleagues; they were developed in collaboration with the American College of Emergency Physicians (ACEP) and Society for Cardiovascular Angiography and Interventions (SCAI). 

Improving Symptom Recognition and Big Emphasis on Cardiac Rehab 

Fang says there are a number of key points in the new recommendations: improving recognition of the symptoms of heart attack; advising that ECGs are done in the field by ambulance personnel to facilitate more rapid triage and quicker treatment; stronger endorsement of the use of hypothermia for cardiac-arrest victims; and a bigger push for better cardiac rehabilitation and postprocedural care. 

"We have focused on the concept of 'total ischemic time'--not only the technical aspects in terms of the procedure itself and adjuvant therapies, but really concentrating on things like care of the patient prior to arrival and the need to try to get the patient assessed quickly. We can't open a vessel until the patient is identified, and one of the greatest delays in the management of this particular condition is time to recognition, because once it's recognized, we can move quickly. 

"We've also addressed the issues of patients who have a cardiac arrest, who become unconscious, with the idea of hypothermia--which has become reasonably well-established, and the guidelines also speak to that," adds Fang. This is the first time the STEMI guidelines have endorsed hypothermia "to this degree," he says, but he cautions that there are many more details that remain to be ironed out (eg, the degree of hypothermia). 

Finally, the document puts an overriding emphasis on better cardiac rehabilitation, improving the care of the patient after the procedure. "We wanted to focus on the transition from postprocedure to home, from having a heart attack to the care afterward. This needs to be carefully orchestrated," Fang stresses. 

This includes ensuring referral for cardiac rehabilitation, with a table in the new guidelines itemizing considerations such as smoking cessation, cholesterol management, social needs, depression, and cultural and gender-related factors that may contribute to outcomes. 

O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of st-elevation myocardial infarction. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012 [Epub ahead of print] 

2. IV Lidocaine Beats IV Morphine for Patients with Renal Colic in the ED 

Soleimanpour H, et al. BMC Urol. 2012;12(13)  


Affecting 1–5 % of the population in industrialized countries, renal colic is considered as a major concern in medicine. Renal colic has been reported to be experienced by 20 % of white males and 5-10 % of white females. [1] The classic presentation of acute renal colic includes sudden pain onset radiating from the flank to the lower extremities which is usually accompanied by microscopic hematuria (85 % of cases), nausea and vomiting. Costovertebral angle tenderness is a common finding as well. [2] 

To relieve the pain until being discharged or undergoing the required operation is mostly performed in emergency departments. [1] To achieve this, numerous medications including antiemetics, narcotics, non-steroidal anti-inflammatory drugs, antispasmodics, anti-diuretics, ketorolac, nifedipine, prednisone, acetaminophen and prochlorperazine have been introduces. [2] 

Lidocaine, being an appropriate choice in treating visceral and central pain, might also be useful wherever narcotics are inefficient or lead to undesirable side effects. Intravenous lidocaine is effective in controlling neuropathic pains such as: diabetic neuropathy, post-operative pain, post-herpetic pain, headaches and neurological malignancies. [3,4] Therefore we aimed at investigating and reviewing the analgesic effects of intravenous lidocaine compared with intravenous morphine in patients with renal colic. 


Background: Despite the fact that numerous medications have been introduced to treat renal colic, none has been proven to relieve the pain rapidly and thoroughly. In this study, we aimed at comparing the effects of intravenous lidocaine versus intravenous morphine in patients suffering from renal colic. 

Methods: In a prospective randomized double-blind clinical trial performed in the emergency department of Imam Reza educational hospital of Tabriz, Iran, we studied 240 patients, 18–65 years old, who were referred due to renal colic. Patients were divided into two groups. In group I (120 people) single-dose intravenous lidocaine (1.5 mg/kg) was administered and in group II (120 people) single-dose intravenous morphine (0.1 mg/kg) was administered slowly. Visual Analogue Pain Scale (VAS) was recorded while admission, 5, 10, 15 and 30 minutes after injection. Statistical data and results were studied using descriptive statistics as percentage and Mean ± SD. To compare the response to treatment, Mann–Whitney U-test was used in two groups. Consequently, the data were analyzed using the SPSS16 software. 

Results Pain score measured in two groups five minutes after the injection of lidocaine and morphine were 65 % and 53 % respectively (95% CI 0.60 - 0.69, CI 0.48 – 0.57, p = 0.0002).108 (90 %) patients (95 % CI 0.84 – 0.95) from group I and 84 (70%) patients (95 % CI 0.62 - 0.78) from group II responded appropriately at the end of the complete treatment. The difference was statistically significant (p = 0.0001). 

Conclusions Changing the smooth muscle tone and reducing the transmission of afferent sensory pathways, lidocaine causes a significant reduction in pain. 

3. Emerging concepts in the diagnosis and treatment of patients with undifferentiated angioedema 

Bernstein JA, et al. Internat J Emerg Med 2012, 5:39 

Angioedema is a sudden, transient swelling of well-demarcated areas of the dermis, subcutaneous tissue, mucosa, and submucosal tissues that can occur with or without urticaria. Up to 25% of people in the US will experience an episode of urticaria or angioedema during their lifetime, and many will present to the emergency department with an acute attack. Most cases of angioedema are attributable to the vasoactive mediators histamine and bradykinin. 

Histamine-mediated (allergic) angioedema occurs through a type I hypersensitivity reaction, whereas bradykinin-mediated (non-allergic) angioedema is iatrogenic or hereditary in origin.

Although their clinical presentations bear similarities, the treatment algorithm for histamine-mediated angioedema differs significantly from that for bradykinin-mediated angioedema.

Corticosteroids, and epinephrine are effective in the management of histamine-mediated angioedema but are ineffective in the management of bradykinin-mediated angioedema. Recent advancements in the understanding of angioedema have yielded pharmacologic treatment options for hereditary angioedema, a rare hereditary form of bradykinin-mediated angioedema. These novel therapies include a kallikrein inhibitor (ecallantide) and a bradykinin β2 receptor antagonist (icatibant).  

The physician’s ability to distinguish between these types of angioedema is critical in optimizing outcomes in the acute care setting with appropriate treatment. This article reviews the  pathophysiologic mechanisms, clinical presentations, and diagnostic laboratory evaluation of angioedema, along with acute management strategies for attacks. 

4. What is the incidence of major adverse cardiac events in ED CP patients with a normal ECG, TIMI score of zero and initial troponin ≤99th centile? An observational study 

Kelly AM. Emerg Med J 2013;30:15-18 

Objective To determine the rate of major adverse cardiac events (MACE) in patients assessed in an emergency department (ED) for chest pain with a non-ischaemic ECG, Thrombolysis in Myocardial Infarction (TIMI) score of 0 and initial troponin I (TnI) ≤99th centile.  

Methods This was a sub-study of a prospective observational study of adult patients with potentially cardiac chest pain who underwent evaluation for acute coronary syndrome in an urban teaching hospital. Adult patients with non-traumatic chest pain were eligible for inclusion. Those with ECG evidence of acute ischaemia or an alternative diagnosis were excluded. Data collected included demographic, clinical, ECG, biomarker and outcome data. Low risk was defined as a TIMI risk score of 0 and initial TnI ≤99th centile. Primary outcome of interest was defined as MACE within 7 days. MACE included death, cardiac arrest, revascularisation, cardiogenic shock, arrhythmia, and prevalent (cause of presentation) and incident (occurring within the follow-up period) myocardial infarction (MI). Analysis was by descriptive and clinical performance analyses.  

Results 651 patients were studied of whom 215 met the low risk criteria. There was one MACE in this group (0.47%, 95% CI 0.08% to 2.6%)—a revascularisation within 7 days without prevalent MI. Negative predictive value of low risk classification was 99.5% (95% CI 97% to 100%) at both 7 and 30 days. Negative likelihood ratio, weighted by prevalence, was 0.005 at both intervals.  

Conclusion Risk stratification for early discharge based on ECG, TIMI score of 0 and presentation TnI ≤99th centile appears to identify a group at very low risk of MACE. Research to prospectively validate this is warranted. 

5. Adherence to PIOPED II Investigators' Recommendations for CT Pulmonary Angiography 

Adams DM, et al. Amer J Med 2013;126:36-42. 


Computed tomography (CT) pulmonary angiography use has increased dramatically, raising concerns for patient safety. Adherence to recommendations and guidelines may protect patients. We measured adherence to the recommendations of Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED II) investigators for evaluation of suspected pulmonary embolism and the rate of potential false-positive pulmonary embolism diagnoses when recommendations of PIOPED II investigators were not followed.


We used a structured record review to identify 3500 consecutive CT pulmonary angiograms performed to investigate suspected pulmonary embolism in 2 urban emergency departments, calculating the revised Geneva score (RGS) to classify patients as “pulmonary embolism unlikely” (RGS≤10) or “pulmonary embolism likely” (RGS over10). CT pulmonary angiograms were concordant with PIOPED II investigator recommendations if pulmonary embolism was likely or pulmonary embolism was unlikely and a highly sensitive D-dimer test result was positive. We independently reviewed 482 CT pulmonary angiograms to measure the rate of potential false-positive pulmonary embolism diagnoses. 


A total of 1592 of 3500 CT pulmonary angiograms (45.5%) followed the recommendations of PIOPED II investigators. The remaining 1908 CT pulmonary angiograms were performed on patients with an RGS≤10 without a D-dimer test (n=1588) or after a negative D-dimer test result (n=320). The overall rate of pulmonary embolism was 9.7%. Potential false-positive diagnoses of pulmonary embolism occurred in 2 of 3 patients with an RGS≤10 and a negative D-dimer test result. 


Nonadherence to recommendations for CT pulmonary angiography is common and exposes patients to increased risks, including potential false-positive diagnoses of pulmonary embolism. 

6. Repeat CT Scans in Transferred Trauma Patients 

Nearly 40% of patients transferred to a trauma center had repeat computed tomography scans for various reasons. 

Trauma patients transferred from one hospital to another often undergo repeat computed tomography (CT) scans, some of which are clinically important (e.g., to assess progression of an intracranial hemorrhage) and some of which have no clear indication. To determine the frequency of repeat CT scanning, investigators reviewed charts from a consecutive convenience sample of 211 trauma patients transferred to the emergency department at a level 1 trauma center in Virginia. 

Overall, 39% of patients underwent at least one repeat scan. Cervical spine scans were the most frequently repeated (39%), followed by chest (37%), pelvic (32%), abdominal (30%), maxillofacial (20%), and head (16%) CT scans. Additional charges averaged $1762 per patient with at least one repeat scan. The average additional radiation dose for repeat-scan patients was 21.5 mSv — almost half the 50 mSv level found to predict an elevated cancer risk among atomic bomb survivors. 

Comment: More than a third of trauma transfers in this study had repeat scans. Given that cervical spine scans were the most frequently repeated type of scan, we can't chalk this up to clinically indicated repeat scans. Community hospitals and trauma centers should work together to send images with patients. Not being able to load an imaging disk or unwillingness to interpret images from another institution are not valid excuses. Another elephant in the room is billing: radiologists may not get paid for two interpretations of the same scan. Insurers need to ensure fair compensation for specialists who provide expert image interpretation at the receiving center in order to guide clinical decision making.

— Daniel J. Pallin, MD, MPH. Published in Journal Watch Emergency Medicine January 11, 2013. Citation(s): Jones AC et al. Repeated computed tomographic scans in transferred trauma patients: Indications, costs, and radiation exposure. J Trauma Acute Care Surg 2012 Dec; 73:1564. 

7. Continued rise in the use of mid-level providers in US EDs, 1993–2009 

Brown DFM, et al. Interna J Emerg Med. 2012;5:21.  

Background: Emergency department (ED) visits in the US have risen dramatically over the past 2 decades. In order to meet the growing demand, mid-level providers (MLPs) – both physician assistants (PAs) and nurse practitioners (NPs) – were introduced into emergency care. Our objective was to test the hypothesis that MLP usage in US EDs continues to rise. 

Findings: We analyzed ED data from the National Hospital Ambulatory Medical Care Survey to identify trends in ED visits seen by MLPs. We also compared MLP-only visits (defined as visits where the patient was seen by a MLP without being seen by a physician) with those seen by physicians only. During 1993 to 2009, 8.4% (95%CI, 7.6–9.2%) of all US ED visits were seen by MLPs. These summary data include marked changes in MLP utilization: PA visits rose from 2.9% to 9.9%, while NP visits rose from 1.1% to 4.7% (both Ptrend less than 0.001). Together, MLP visits accounted for almost 15% of 2009 ED visits and 40% of these were seen without involvement of a physician. Compared to physician only visits, those seen by MLPs only were less likely to arrive by ambulance (16% vs 6%) and be admitted (14% vs 3%). 

Conclusions: Mid-level provider use is rising in US EDs. By 2009, approximately one in seven visits involved MLPs, with PAs managing twice as many visits as NPs. Although patients seen by MLPs only are generally of lower acuity, these nationally representative data confirm that MLP care extends beyond minor presentations. 

8. ECG Electrode Misplacement, Misconnection, and Artifact 

Harrigan RA, et al. J Emerg Med. 2012;43(6):1038-1044.  

Background: Electrocardiograms (ECGs) are performed by humans, and thus are subject to human error. An underappreciated source of electrocardiographic abnormality is electrode misconnection, both limb and precordial, and improper placement, which is principally an issue with the precordial electrodes due to anatomic variation. Patterns of abnormality exist; recognition allows the emergency physician to avoid mistaking the resulting electrocardiographic findings for true pathology. 

Objectives: The purpose of this clinical review is to describe the patterns of electrocardiographic electrode reversal, misplacement, and artifact and thus make them recognizable to the Emergency Physician. 

Discussion: Common limb electrode reversals feature distinctive patterns manifesting as unexpected morphologic and frontal plane axis changes in the QRS complexes in the limb and augmented leads. Precordial electrode misplacement (improper positioning of the electrodes on the chest) is common and may mimic a pseudoinfarction pattern, or ST-segment/T-wave changes, which must be recognized as the result of the misplacement rather than true cardiac ischemia. Precordial electrode reversal should be suspected when the normal R/S wave amplitude transition is violated. Electrocardiographic artifact must be distinguished from dysrhythmia to avoid a potentially hazardous progression to unnecessary diagnostics and therapeutics. 

Conclusions: The hallmarks of electrode misconnection, misplacement, and electrocardiographic artifact can be easily mastered by the Emergency Physician; recognition of these findings can positively impact patient care by avoiding unnecessary intervention secondary to misattribution of findings on the 12-lead ECG to cardiac pathology. 

Full-text (free if registered):  

9. A Model of Cost-effectiveness of tPA in Patient Subgroups 3 to 4.5 Hours after Onset of Acute Ischemic Stroke 

Boudreau DM, et al. Ann Emerg Med. 2013;61:46-55. .

Study objective 

The European Cooperative Acute Stroke Study III (ECASS III) showed that recombinant tissue plasminogen activator (rtPA) administered 3 to 4.5 hours after acute ischemic stroke led to improvement in patient disability versus placebo. We evaluate the long-term incremental cost-effectiveness of rtPA administered 3 to 4.5 hours after acute ischemic stroke onset versus no treatment according to patient clinical and demographic factors. 


We developed a disease-based decision analytic model to project lifetime outcomes of patients post–acute ischemic stroke from the payer perspective. Clinical data were derived from the ECASS III trial, longitudinal cohort studies, and health state preference studies. Cost data were based on Medicare reimbursement and other published sources. We performed probabilistic sensitivity analyses to evaluate uncertainty in the analysis. 


rtPA in a hypothetical cohort resulted in a gain of 0.07 years of life (95% credible range 0.0005 to 0.17) and 0.24 quality-adjusted life-years (95% credible range 0.01 to 0.60) and a difference in cost of $1,495 (95% credible range –$4,637 to $6,100) compared with placebo. The incremental cost-effectiveness ratio for all patients was $6,255 per quality-adjusted life-year gained; for patients younger than 65 years, cost saving; for patients aged 65 years or older, $35,813 per quality-adjusted life-year; for patients with baseline National Institutes of Health Stroke Scale (NIHSS) score 0 to 9, $16,322 per quality-adjusted life-year; for patients with NIHSS score 10 to 19, $37,462 per quality-adjusted life-year; and for patients with NIHSS score greater than or equal to 20, $2,432 per quality-adjusted life-year. The majority of other subgroups such as sex, history of stroke, and history of hypertension were either cost saving or cost-effective, with the exceptions of diabetes and atrial fibrillation. 


The results indicate that rtPA in the 3- to 4.5-hour therapeutic window provides improvement in long-term patient outcomes in most patient subgroups and is a good economic value versus no treatment. 

10. Restrictive transfusion strategy superior for severe acute GI bleeding 

By Mary Ann Moon, IMNG Medical News 1/2/2013  

For patients with severe acute GI bleeding, outcomes are significantly better when a restrictive transfusion strategy is used - limiting the hemoglobin threshold to 7 g/dL - rather than a liberal transfusion strategy allowing a 9 g/dL threshold, according to a report published online Jan. 2 in the New England Journal of Medicine. 

In a single-center randomized controlled trial involving 889 patients, the restrictive transfusion strategy resulted in significantly lower mortality, lower rates of rebleeding, less frequent need for rescue therapy, fewer complications, and shorter hospitalizations than did the liberal transfusion strategy. "Our results suggest that in patients with acute GI bleeding, a strategy of not performing transfusion until the hemoglobin concentration falls below 7 g/dL is a safe and effective approach," said Dr. Càndid Villanueva of Hospital de Sant Pau, Barcelona, and his associates. 

"Current international guidelines recommend decreasing the hemoglobin threshold level for transfusion ... from 10g/dL to 7 g/dL" in such patients, but these recommendations are based on trials involving critically ill patients with normovolemic anemia that did not include subjects with acute bleeding. "Transfusion requirements may be different for patients with acute hemorrhage due to factors such as hemodynamic instability or rapid onset of anemia" resulting from extremely low hemoglobin levels.

In particular, results of animal studies suggest that transfusion can be especially harmful in patients with bleeding from portal hypertension sources, "since restitution of blood volume after hemorrhage can lead to a rebound increase in portal pressure, which is associated with a risk of rebleeding," the investigators noted. 

To examine the effects of different transfusion strategies in this setting, Dr. Villanueva and his colleagues enrolled adults who presented with hematemesis, melena, or both, randomly assigning 444 to receive restrictive transfusion (with a target range for the posttransfusion hemoglobin level of 7-9 g/dL) and 445 to receive liberal transfusion (with a target range of 9-11 g/dL). 

The study protocol permitted transfusions to be administered at the discretion of the attending physician any time symptoms or signs of anemia developed, massive bleeding occurred, or surgical intervention was needed, as well as when hemoglobin levels dipped below the assigned threshold. 

All the study subjects underwent emergency gastroscopy within 6 hours of presentation, with appropriate treatment when the source of the bleeding was identified. Diagnoses included peptic ulcer, esophageal varices, cirrhosis, portal hypertension, and nonvariceal lesions. 

The primary outcome measure, mortality from any cause at 45 days, was significantly lower in the restrictive-strategy group (5%) than the liberal-strategy group (9%). Death resulted from uncontrolled bleeding in 0.7% vs 3.1% of the 2 groups, respectively, the researchers said (N. Engl. J. Med. 2013 Jan. 2 [doi:10.1056/NEJMoa1211801]). 

The rate of rebleeding also was significantly lower with the restrictive strategy (10% vs. 16%), and length of hospital stay was significantly shorter. In addition, rescue therapy for esophageal varices with balloon tamponade or a transjugular intrahepatic portosystemic shunt was required less often in the restrictive-strategy group than in the liberal-strategy group, as was emergency surgery to control further bleeding from peptic ulcer. 

The rate of overall complications was significantly lower with the restrictive strategy (40%) than with the liberal strategy (48%), as was the rate of serious adverse events. In addition, transfusion reactions and cardiac events such as pulmonary edema were more frequent with the liberal strategy. 

"Our results are consistent with those from previous observational studies and randomized trials performed in other settings, which have shown that a restrictive transfusion strategy did not increase, and even decreased, the mortality observed with a liberal transfusion strategy," Dr. Villanueva and his associates said. 

The facts are in 

Dr. Loren Laine comments: This important study "provides long-awaited evidence to guide practice and justify current recommendations for the management of upper GI bleeding," said Dr. Laine. 

A restrictive transfusion strategy reduced the relative risk of mortality at 45 days by 45%. Extrapolating the study findings, only 25 patients would have to be treated with a restrictive rather than a liberal transfusion strategy to avert one additional death. 

Dr. Laine is at Yale University, New Haven, Conn., and the Veterans Affairs Connecticut Healthcare System, West Haven. He reported no financial conflicts of interest. These remarks were taken from his editorial accompanying Dr. Villanueva's report (N. Engl. J. Med. 2013 Jan. 2 [doi:10.1056/NEJMe1212009]). 

11. Less Is Better for Treating Whiplash 

By Charles Bankhead, Staff Writer, MedPage Today. December 21, 2012 

Active clinical management that included physical therapy showed a small advantage over usual care after 4 months, as assessed by the Neck Disability Index (NDI). The advantage had disappeared by 8 months, and outcomes in the treatment groups remained similar at 12 months. 

An economic analysis showed that active management cost more and provided less quantitative benefit compared with usual care, as reported online in The Lancet. "Our findings show that no additional benefit exists to providing active management consultations in the emergency department," said Sarah E. Lamb, DPhil, of the University of Warwick in Coventry, England. A package of physiotherapy has a modest effect on early recovery of persisting symptoms but is not cost effective from a U.K. National Health Services perspective." Extensive reviews of interventions for whiplash injury have found little or no data to support many of the treatments employed. 

Following its review of the evidence, the Quebec Task Force on Whiplash Injury suggested a stepped-care approach, beginning with advice and positive reinforcement and moving on to other interventions, including physical therapy, if symptoms persist (Spine 1995; 20(8 suppl): 1S-73S). A similar approach has been used successfully in the management of back pain, the authors noted. Some clinical guidelines recommend physical therapy, which lacks supporting evidence, they added. 

Borrowing elements from several different clinical strategies, Lamb and colleagues conducted a two-phase randomized study involving emergency departments at 12 hospitals that treated patients with grade I-III acute whiplash-associated disorder. 

In the first phase, investigators randomized the hospitals to usual care or active management, which included distribution of a patient education booklet to augment active-management consultations that focused on changing beliefs and negative health behaviors. Investigators trained emergency-department personnel in active management, which was applied during clinical visits with patients who came to the hospitals randomized to active management. Staff members were instructed to limit treatments to those that would be appropriate for soft-tissue injury. The first phase lasted 12 months. 

During the second phase of the study, investigators randomized patients from the first phase to six sessions of physical therapy or a single advice session. The sessions included reinforcement of advice provided during the emergency-department visit. The primary outcome was the change in Neck Disability Index (NDI) at the end of each phase of the study. The NDI assesses pain-related activity restriction across 10 domains. A secondary outcome was the change in score on the Short Form-12 and in other instruments that addressed neck-specific symptoms, work restriction and lost compensation, and healthcare resource use. 

The investigators randomized 3,851 patients, of whom 2,704 provided follow-up data to 12 months. The results showed a 0.5-point difference between groups on the mean NDI score, which did not reach statistical significance. 

During the second phase of the study, investigators randomized 599 volunteers from the first phase to usual-care consultations and a single physical therapy advice session or to six sessions of physical therapy that included reinforcement of clinical advice as well as hands-on therapy targeted to soft tissue injury. The NDI was completed after 4, 8, and 12 months.Blinding of patients and clinicians to treatment group assignments at all phases of the study was not possible. 

After 4 months, the patients assigned to the more intensive treatment arm showed a net treatment effect of 3.7 points on the NDI compared with the usual-care group (P=0.0029). By 8 months, the difference had dwindled to 1 point and then increased to 2 points at 12 months, neither of which was statistically significant. 

A 4-day (adjusted) difference in lost work days favored active intervention at all time points. Patients' self-rated benefit was significantly higher at 4 months with active intervention (P less than 0.0001) but not at the other assessments. Other secondary endpoints did not differ significantly between groups at any assessment. 

The economic analysis produced a higher cost for active intervention during both phases of the study. The estimated cost of active intervention averaged about $500 per patient during the first phase and $675 during the second phase. Corresponding costs for usual care were $450 and $580. Comparison of quality-adjusted life years showed a lower average gain for active treatment during phase I (0.755 versus 0.758) and during the second phase (0.691 versus 0.702). 

The author of an accompanying commentary suggested that meaningful improvement in whiplash management will occur only when expectations and behaviors change. "Part of the issue might be that people with whiplash should not be attending an emergency department," Robert Ferrari, MD, of the University of Alberta in Edmonton, wrote. "It is unlikely that most whiplash victims have any need for radiological studies, and what the emergency physician otherwise has to offer these patients is not clear." 

Expectations and beliefs could be the key to better outcomes after whiplash, he continued. A Canadian study showed that whiplash patients who expected to "get better soon" recovered three times as quickly compared with patients who thought they would never get better. "Those who hold expectations of a poor outcome might be having those expectations reinforced by the experience of a presentation to an accident and emergency department," Ferrari wrote. 

Legislative action could effect changes in expectations surrounding whiplash by reducing "the extent to which expectations can be met -- i.e., less contact with lawyers, insurers, and the treatment industry could reduce the encouragement of these expectations and the behavior that follows." 

The study was supported by the National Institute for Health Research. The authors and Ferrari had no relevant disclosures. 

Abstract: Lamb SE, et al Lancet 2012;  

See also: 12-minute educational video reduces pain and recidivism for ED patients with whiplash:

12. Images in Clinical Medicine 

Large Right Inguinal Hernia 

Clonus after a Stroke 

Superior mesenteric artery syndrome

13. Pediatric Corner 

A. (In)Efficacy of Intravenous Lidocaine to Reduce Pain and Distress associated with Propofol Infusion in Pediatric Patients During Procedural Sedation

Depue K, et al. Pediatr Emerg Care. 2013;29:13-16 

Background: Research suggests that young children experience an increased incidence and severity of discomfort during propofol infusion. Evaluations of varied interventions to reduce or eliminate this discomfort with adult subjects suggest that premedication with intravenously administered lidocaine (0.5 mg/kg) offers the best overall effectiveness. 

Objective: Because this regimen’s efficacy in a pediatric population is undocumented, we conducted a randomized, double-blind, placebo-controlled study to determine the effectiveness of intravenous lidocaine pretreatment to alleviate pain in pediatric subjects before propofol infusion. 

Methods: Subjects (aged 2–7 years) scheduled for painless diagnostic procedures received either a saline placebo or 1 of 2 lidocaine doses before administering propofol. To capture the patient’s baseline behavioral state, a trained observer administered the validated Face, Legs, Activity, Cry, Consolability Pain Assessment Scale before propofol infusion. During deep sedation induction, the sedating physician, a trained research assistant, and the patient’s parent documented maximum distress using a 100-mm visual analog scale (VAS). 

Results: Ninety-one subjects participated. We found no difference in VAS pain scores between groups pretreated with lidocaine 0.25 mg/kg, lidocaine 0.5 mg/kg, and placebo. Statistical analysis also found no interrater differences between parents, physician, or observer VAS scores. 

Conclusions: Our data do not support using lidocaine pretreatment to alleviate pain/discomfort in pediatric patients during propofol infusion. 

B. Appendicitis: CT Scan vs Ultrasound Depends on Hospital Type 

Yael Waknine. Medscape Medical News. Dec 24, 2012 

Community hospitals are more than 4 times more likely than pediatric institutions to use radiation-exposing computed tomography (CT) scans and 80% less likely to use ultrasound for pre-appendectomy evaluations in children, study results suggest. 

Jacqueline M. Saito, MD, MSCI, and colleagues from Washington University School of Medicine in St. Louis, Missouri, also found that both diagnostic tools were less sensitive for appendicitis in the community hospital setting. 

As previously reported by Medscape Medical News, CT screening of children with abdominal pain has skyrocketed while appendicitis rates remain unchanged, adding to growing concerns regarding the link between excessive radiation exposure and cancer risk later in life. 

"Broadly-applicable strategies to systematically maximize diagnostic accuracy for childhood appendicitis, while minimizing ionizing radiation exposure, are urgently needed," the authors write, noting that evaluations may be streamlined by using algorithms developed with broad validity to decrease reliance on preoperative imaging and radiation exposure while avoiding unnecessary hospital transfers, admissions, operations, and missed diagnoses. 

The retrospective study was published online December 24 in Pediatrics. 

C. Comparison of Rectal, Axillary, Tympanic, and Temporal Artery Thermometry in the Pediatric Emergency Room 

Batra P, et al. Pediatr Emerg Care. 2013;29:63-66.  

Background: Accurate measurement of temperature in the emergency room is important for diagnosis as well as investigating a patient. Various noninvasive methods thermometry are available today, but there is no consensus on the most accurate method of thermometry. 

Study Objective: The present study was conducted to compare different methods of temperature measurement available in the emergency room, that is, rectal, axillary, and temporal artery and tympanic membrane. 

Design: This was a cross-sectional observational study 

Patients: Fifty febrile and 50 afebrile children aged 2 to 12 years attending the pediatric emergency room of a tertiary care hospital were included. Temperatures were measured using rectal, axillary, tympanic (right and left), and temporal artery thermometers and were compared. 

Results: All the temperatures correlated well with rectal temperature, with temporal artery temperature showing the best correlation (correlation coefficients, 0.99 in the febrile and 0.91 in the afebrile group). 

Conclusions: Temporal artery thermometry has the potential to replace rectal thermometry in a busy emergency room setting. 

D. AAP: All Work and No Play Bad for Kids

Recess during school offers children cognitive, social, emotional, and physical benefits they don't get through academics alone, according to the American Academy of Pediatrics.

Note that recess allows a space between classes outside of concentrated classroom work, which aids cognitive processing and academic performance, and should not be withheld for punitive or academic reasons. 

Recess during school offers children cognitive, social, emotional, and physical benefits they don't get through academics alone, the American Academy of Pediatrics (AAP) wrote in a policy statement. 

E. Pediatric UTI: Does the Evidence Support Aggressively Pursuing the Diagnosis? 

Newman DH, et al. Ann Emerg Med 2013 [Epub ahead of print] 

The epidemiology of pediatric fever has changed considerably during the past 2 decades with the development of vaccines against the most common bacterial pathogens causing bacteremia and meningitis. The decreasing incidence of these 2 conditions among vaccinated children has led to an emphasis on urinary tract infection as a remaining source of potentially hidden infections in febrile children.  

Emerging literature, however, has led to questions about both the degree and nature of the danger posed by urinary tract infection in nonverbal children, whereas the aggressive pursuit of the diagnosis consumes resources and leads to patient discomfort, medical risks, and potential overdiagnosis. We review both early and emerging literature to examine the utility and efficacy of early identification and treatment of urinary tract infection in children younger than 24 months. We conclude that in well children of this age, it may be reasonable to withhold or delay testing for urinary tract infection if signs of other sources are apparent or if the fever has been present for fewer than 4 to 5 days.

F. Prevalence of Abusive Fractures of the Hands, Feet, Spine, or Pelvis on Skeletal Survey: Perhaps “Uncommon” Is More Common Than Suggested 

Lindberg DM, et al. Pediatr Emerg Care 2013;29:26-29. 

Objective: Recently, it has been suggested that views of the hands, feet, spine, and pelvis should be omitted from routine skeletal surveys (SSs) because these fractures are rarely identified by SS. Our objective was to describe the prevalence of fractures to the hands, feet, spine, or pelvis among SSs obtained for children in a large, multicenter population who underwent consultation for physical abuse. 

Methods: This was a retrospective secondary analysis of data from the Examining Siblings To Recognize Abuse research network, a consortium of 20 US child abuse teams who collected data for all children younger than 10 years who underwent consultation for concerns of physical abuse. This secondary analysis included data only from index children and excluded data from siblings and contacts. Consulting child abuse physicians reported the number of fractures identified and those that were detected by SS. 

Results: Among 2049 initial SSs, 471 (23.0%) showed at least 1 previously unknown fracture including 49 (10.4%) that showed a fracture to the hands, feet, spine, or pelvis. In 10 cases, the SS identified at least 1 fracture of the hands, feet, spine, or pelvis when no other fractures were identified. 

Conclusions: A significant number of occult, abusive fractures would have been missed if SSs had omitted or deferred views of the hands, feet, spine, and pelvis. Given the risks associated with missed abuse, these views should be routinely included in the radiographic SS. 

G. Implementation of an evidence based guideline reduces blood tests and LOS for the limping child in a paediatric ED  

McCanny PJ, et al. Emerg Med J 2013;30:19-23 

Introduction Acute non-traumatic limp is a common reason for children to present to the emergency department (ED). There is a wide differential diagnosis for these patients, and there are certain serious conditions which cannot be missed. An evidence based guideline for the ‘limping child’ was designed and the impact of guideline implementation on a number of specific, predefined quantitative outcomes was assessed.  

Methods An initial retrospective chart review over 3 months was carried out for all patients presenting with acute non-traumatic limp. Following guideline introduction and implementation, information was gathered prospectively for a further 3 month period. Data outcomes between the two patient groups were then compared.  

Results 110 patients met the criteria for inclusion: 56 pre-guideline and 54 post-guideline implementation. Baseline characteristics and diagnosis breakdown were similar in both groups. The rate of laboratory investigations was significantly reduced following guideline implementation (68% of patients pre-guideline, vs 48% post-guideline; (χ2), p=0.03). The number of x-rays carried out was similar in each group (74 pre- vs 67 post-guideline, mean 1.32 vs 1.28; (χ2), p=0.53). Length of time spent in the ED was significantly reduced following guideline implementation (median time 150 min pre- vs 82.5 min post-guideline; (χ2), p=0.04). No cases of serious pathology were missed using the guideline.  

Conclusion Implementation of an evidence based clinical practice guideline for the limping child in a paediatric ED reduced the overall time patients spent in the ED, reduced the need for unnecessary laboratory investigations and ensured that appropriate investigations were carried out on an individual patient basis. 

H. Pediatric DKA: Is Fluid Replacement Rate Associated with Cerebral Edema? 

Development of subclinical cerebral edema did not differ between children who received slower versus more rapid fluid replacement. 

Glaser NS et al. Pediatrics 2013 Jan; 131:e73 

OBJECTIVE: Previous studies show that vasogenic cerebral edema (CE) occurs during diabetic ketoacidosis (DKA) treatment in children, but the role of intravenous fluids in contributing to CE is unclear. We used magnetic resonance diffusion weighted imaging to quantify subclinical CE in children with DKA randomized to 2 intravenous fluid regimens. 

METHODS: Children with DKA were randomized to receive fluids at a more rapid rate (n = 8) or a slower rate (n = 10), with all other aspects of DKA treatment kept identical. Children underwent diffusion weighted imaging 3 to 6 hours and 9 to 12 hours after beginning DKA treatment and after recovery from DKA (≥72 hours after beginning treatment). We calculated brain apparent diffusion coefficient (ADC) values as the average of measurements in the basal ganglia, thalamus, frontal white matter, and hippocampus and determined the mean brain ADC value during DKA treatment by averaging data from the 3- to 6-hour and 9- to 12-hour measurements. The difference in mean brain ADC between DKA treatment and postrecovery was used as an index of the severity of CE during DKA treatment. 

RESULTS: Mean brain ADC values during DKA treatment were significantly higher than postrecovery values, consistent with vasogenic CE (842 ± 38 vs 800 ± 41×10(-6) mm(2)/second, P = .002). We did not detect significant differences in ADC elevation in children treated with more rapid versus slower rehydration (β coefficient 0.11 for 1 SD change in ADC, 95% confidence interval: -0.91 to 1.13). 

CONCLUSIONS: ADC changes during DKA treatment (reflective of vasogenic CE) do not appear to be substantially affected by the rate of intravenous fluid administration..

14. Energy Drinks Promise Edge, but Experts Say Proof Is Scant 

By Barry Meier, New York Times, January 1, 2013  

Energy drinks are the fastest-growing part of the beverage industry, with sales in the United States reaching more than $10 billion in 2012 — more than Americans spent on iced tea or sports beverages like Gatorade. Their rising popularity represents a generational shift in what people drink, and reflects a successful campaign to convince consumers, particularly teenagers, that the drinks provide a mental and physical edge. 

The drinks are now under scrutiny by the Food and Drug Administration after reports of deaths and serious injuries that may be linked to their high caffeine levels. But however that review ends, one thing is clear, interviews with researchers and a review of scientific studies show: the energy drink industry is based on a brew of ingredients that, apart from caffeine, have little, if any benefit for consumers. 

“If you had a cup of coffee you are going to affect metabolism in the same way,” said Dr. Robert W. Pettitt, an associate professor at Minnesota State University in Mankato, who has studied the drinks. 

Energy drink companies have promoted their products not as caffeine-fueled concoctions but as specially engineered blends that provide something more. For example, producers claim that “Red Bull gives you wings,” that Rockstar Energy is “scientifically formulated” and Monster Energy is a “killer energy brew.” Representative Edward J. Markey of Massachusetts, a Democrat, has asked the government to investigate the industry’s marketing claims.

Promoting a message beyond caffeine has enabled the beverage makers to charge premium prices. A 16-ounce energy drink that sells for $2.99 a can contains about the same amount of caffeine as a tablet of NoDoz that costs 30 cents. Even Starbucks coffee is cheap by comparison; a 12-ounce cup that costs $1.85 has even more caffeine. 

As with earlier elixirs, a dearth of evidence underlies such claims. Only a few human studies of energy drinks or the ingredients in them have been performed and they point to a similar conclusion, researchers say — that the beverages are mainly about caffeine. 

Caffeine is called the world’s most widely used drug. A stimulant, it increases alertness, awareness and, if taken at the right time, improves athletic performance, studies show. Energy drink users feel its kick faster because the beverages are typically swallowed quickly or are sold as concentrates. 

“These are caffeine delivery systems,” said Dr. Roland Griffiths, a researcher at Johns Hopkins University who has studied energy drinks. “They don’t want to say this is equivalent to a NoDoz because that is not a very sexy sales message.”… 

15. Post-Hospital Syndrome — An Acquired, Transient Condition of Generalized Risk 

Krumholz HM. N Engl J Med 2013; 368:100-102.  

To promote successful recovery after a hospitalization, health care professionals often focus on issues related to the acute illness that precipitated the hospitalization. Their disproportionate attention to the hospitalization's cause, however, may be misdirected. Patients who were recently hospitalized are not only recovering from their acute illness; they also experience a period of generalized risk for a range of adverse health events. Thus, their condition may be better characterized as a post-hospital syndrome, an acquired, transient period of vulnerability. This theory would suggest that the risks in the critical 30-day period after discharge might derive as much from the allostatic and physiological stress that patients experience in the hospital as they do from the lingering effects of the original acute illness. At the time of discharge, physiological systems are impaired, reserves are depleted, and the body cannot effectively defend against health threats. 

Nearly one fifth of Medicare patients discharged from a hospital — approximately 2.6 million seniors — have an acute medical problem within the subsequent 30 days that necessitates another hospitalization. These recently discharged patients have heightened risks of myriad conditions, many of which appear to have little in common with the initial diagnosis. For example… 

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16. Presenting symptoms of MI predict short- and long-term mortality: The MONICA/KORA Myocardial Infarction Registry. 

Kirchberger I, et al. Am Heart J. 2012 Dec;164(6):856-61. 

BACKGROUND: It is unknown whether clinical outcomes differ with specific symptoms of an acute myocardial infarction (AMI). The objective of this study was to investigate the association between 13 self-reported symptoms and 28-day case fatality or long-term all-cause mortality in patients with AMI. 

METHODS: The sample consisted of 1,231 men and 415 women aged 25 to 74 years hospitalized with a first-time AMI recruited from a population-based AMI registry. Multivariable logistic regression modeling was used to assess the relationship between symptom occurrence and 28-day case fatality. Cox proportional hazards models were used to determine the effects on long-term mortality. Analyses were adjusted for sex, age, type of AMI, diabetes, prehospital delay time, and reperfusion therapy. 

RESULTS: The median observation time was 4.1 years (interquartile range 15 years). Twenty-eight-day case fatality was 6.1%, and long-term mortality was 10.6%. Patients who experienced fear of death (odds ratio [OR] 0.11, 95% confidence interval [CI] 0.03-0.47), diaphoresis (OR 0.45, 95% CI 0.25-0.82), or nausea (OR 0.45, 95% CI 0.22-0.95) had a significantly decreased risk of dying within 28 days, whereas syncope (OR 5.36, 95% CI 2.65-10.85) was associated with a higher risk. A decreased risk for long-term mortality was found for people with pain in the upper abdomen (hazard ratio 0.43, 95% CI 0.19-0.97), whereas dyspnea was related to an increased risk (hazard ratio 1.50, 95% CI 1.11-2.06). The absence of chest symptoms was associated with a 1.85-fold risk for long-term mortality (95% CI 1.13-3.03).

CONCLUSIONS: Specific symptoms are associated with mortality. Further research is required to illuminate the reasons for this finding. 

17. Evidence-based Review by Ann Emerg Med 

A. Are There Pharmacologic Agents That Safely and Effectively Treat Post–Lumbar Puncture Headache? 

Hunter BR, et al. Ann Emerg Med. 2013;61:84-85.  

Take-Home Message

Although intravenous caffeine has demonstrated efficacy for post–lumbar puncture headache in patients who have received spinal anesthesia, its efficacy and safety remain uncertain in patients presenting to the emergency department (ED) after a typical diagnostic lumbar puncture. 

The spinal dura is punctured during a diagnostic lumbar puncture or spinal anesthesia. Penetration of the dura may also occur as an unintended complication of epidural anesthesia. Post–lumbar puncture headache has been reported to occur in 3% to 36% of lumbar punctures4 (with higher rates occurring when a traumatic needle is used) and may require symptomatic therapy. Although epidural blood patching is effective,5 it is an invasive treatment that is typically performed by an anesthesiologist or interventional radiologist. Because specialty consultation is not readily available in many ED settings, a safe and effective pharmacologic intervention for post–lumbar puncture headache would be a preferable alternative. 

Unfortunately, this Cochrane review found only 1 small, high-quality study3 reporting results indicating that intravenous caffeine is effective for treating post–lumbar puncture headache. In this trial of 41 patients with post–lumbar puncture headache, a single intravenous dose of 500 mg of caffeine sodium benzoate resulted in an absolute risk reduction of 61% in persistent headache at 1 to 2 hours. Although the magnitude of effect is impressive (number needed to treat=1.6), 30% of the caffeine-treated patients had post–lumbar puncture headache recurrence, though no timeframe was specified, and other adverse events were not recorded. In addition, the applicability of these results to the ED setting is limited because the majority of enrolled patients were postpartum women who had received spinal anesthesia. Included in this review was another randomized trial6 evaluating caffeine for post–lumbar puncture headache in postpartum women that did not demonstrate a statistically significant difference in visual analog scale at 4 or 24 hours between patients treated with oral caffeine or placebo. 

Individual trials reported statistically significant and clinically meaningful reductions in visual analog scale pain scores for gabapentin,7 theophylline,8 and hydrocortisone.9 These trials, however, suffered from a high risk of bias and would have limited application in an ED setting. 

Intravenous caffeine appears to be the most promising pharmacologic agent for patients with post–lumbar puncture headache. However, to date its efficacy has been demonstrated only in a single trial of patients receiving spinal anesthesia. 

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B. How Accurate Are Rapid Influenza Diagnostic Tests? 

Jacobus CH, et al. Ann Emerg Med. 2013;61:89-90.  

Take-Home Message

The results of rapid influenza diagnostic tests can be used to rule in but not rule out influenza. 

Patients with influenza-like illness commonly present to emergency departments (EDs) during the winter, significantly increasing ED crowding during those times.1 Seasonal influenza also carries a substantial burden of morbidity and mortality, killing 24,000 people per year and hospitalizing 370,000; those chronically ill or at the extremes of age are at particular risk.2, 3 The ability to rapidly diagnose influenza may help decrease further diagnostic testing and inappropriate antibiotic use, as well as increase timely antiviral administration to appropriate patients. 

This high-quality diagnostic meta-analysis used state-of-the-art methods to examine the accuracy of commercially available rapid influenza diagnostic tests. Sensitivity, pooled across the different tests examined, was moderate but specificity was high. According to the likelihood ratio estimates, the use of rapid influenza diagnostic tests in the ED will be highly dependent on the pretest probability of the patient population being tested. If confirmation is needed for a patient with a high clinical suspicion for acute influenza and a negative rapid test result, a specimen should be sent for reverse transcriptase polymerase chain reaction or viral culture. Head-to-head comparisons of the different brands of tests were not performed, but no test was noted to outperform any other. 

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18. New Strategy May Cut HF Admissions from ED 

By Charles Bankhead, Staff Writer, MedPage Today. January 08, 2013 

A heart failure observation unit might reduce hospital admissions from emergency departments (EDs) by half, authors of a viewpoint article suggest. 

An alternative approach would be a two-level targeted ED evaluation to determine a patient's risk and eligibility for discharge, according to Sean P. Collins, MD, of Vanderbilt University in Nashville, and co-authors who published their viewpoint online in the Journal of the American College of Cardiology. 

The first level would comprise three broad areas representing high risk:
·         Key precipitating factors, including ischemia, uncontrolled arrhythmias, and infection
·         Hemodynamic status, such as hypoxia, hypotension, and cardiogenic shock
·         Other confounders/contributors, such as renal dysfunction, hyponatremia, COPD, and diabetes 

Therapy begins concurrently with the workup, primarily intravenous diuretics and topical or sublingual nitroglycerin. Depending on response to treatment, most patients follow one of three clinical pathways:
·         Low-risk patients who respond to therapy -- possibly eligible for discharge after observation
·         High-risk patients -- worsening in response to therapy (~20% of patients)
·         Intermediate-risk patients -- partial response to therapy, no high-risk features 

The investigators suggested seven interventions that could be performed in an observation unit for heart failure:
·         Observe response to therapy
·         Identify high-risk traits
·         Conduct routine diagnostic testing
·         Educate patients and caregivers
·         Perform guideline-directed therapy
·         Arrange early follow-up
·         Optimize medical therapy 

"The interventions in the observation unit are not complex or costly and in fact conserve significant resources compared with admission," the authors wrote. 

"We estimate that up to 50% of patients with heart failure could be safely discharged from the ED after a brief period of observation, thus avoiding unnecessary admissions and minimizing readmissions," they wrote. 

In an accompanying editorial, Akshay S. Desai, MD, and Lynne W. Stevenson, MD, of Brigham and Women's Hospital in Boston, wrote, "The term 'observation' is partly strategic, as observation unit stays (less than 24 hours) are currently exempt from [payer] penalties imposed on 30-day readmissions and might therefore provide a lower-cost alternative to hospitalization for selected patients." 

The editorialists acknowledged the need for alternate routes of heart failure treatment that will reduce hospitalization but noted that performing randomized trials to test the incremental value of this approach presents challenges. 

For example, there are no data about patient risk that could inform the decision of ED personnel to admit a patient to an observation unit. And, conversely, similar data are lacking to make informed decisions about discharge from such an observation unit. 

19. Why You Should Sometimes Prescribe a Placebo 

Arthur L. Caplan, PhD. Jan 03, 2013 

Hi. I'm Art Caplan, from the NYU Langone Medical Center Division of Medical Ethics in New York City. Today I want to talk about a tough moral challenge that many physicians face: Should I ever prescribe a placebo to somebody, knowing that it is a placebo? Should I ever give something to a patient just because I want to give them something, even though I know that it is ineffective? 

There are 2 types of placebos that we will be talking about. One is literally a sugar pill, something that is absolutely inert and is not expected to do anything. The other is sometimes aspirin or maybe a pill that has a mild effect, but is more or less still irrelevant as any type of treatment that one would seriously give. Interestingly, Medscape conducted a survey in which roughly 50% of doctors said that they would never do this; about one quarter said that they would; and the remainder, nearly 20%, said that it depends. 

I faced this issue myself. A few years ago, we had people coming into the hospital from different cultures who expected to get some kind of a pill. If they went to the doctor and they didn't get something, they thought it was a sign of disrespect, and they would absolutely go to somebody else. Even though we thought that their anxiety was not particularly related to any underlying disease or that they had some type of a cold and didn't need further follow-up, our doctors were giving aspirin to these people just as a way to make sure that they maintained a relationship with them and that they would come back for future care, instead of turning to alternative medicine or just not returning because they thought they were not being taken seriously. 

Sometimes, culturally, the use of placebo is something that you have to really consider. It is part of what patient expectations are. You can certainly try to talk them out of that expectation, but in my experience with this particular population in New York City, that wasn't going to happen. I can at least think of some areas where a placebo is justified. 

I also believe that sometimes there is such a thing as a placebo effect. You can make people feel better sometimes just because they took a pill. An enormous number of people actually respond to pain medication in part due to the placebo effect, so I can imagine situations where a doctor might say, "I don't want to give you a dangerous drug. Let's see if this helps your chronic pain or your complaint about feeling anxious," and then give a placebo and see if it goes away. 

What becomes ethically challenging about that behavior is whether you then debrief the patient later. And I think you have to. I think you have to say, "I gave you a placebo. It did help and you did feel better. Maybe that's the placebo effect, but I don't think you have an underlying disease and there isn't something here to treat." You don't want to leave the patient feeling that they have a pill and there is a real disease if they are responding to the placebo. Part of placebo use, if you are going to do it, is debriefing the patient or coming clean later about what is going on and what was done. They might get angry and say that you deceived them or tricked them. You may say, "No, I just wanted to see whether there was a placebo effect. It is real, and I wanted to see if you responded to it, because that is part of what I need to know in order to treat you better." 

In general, I don't think placebo should be off-limits. What I think is off-limits is not telling the truth in the long run to your patient. If you are going to try placebo approaches with particular patients, I think you should have a strategy for debriefing them and for letting them know what was done, so that trust can still be maintained between you and your patient. 

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20. Essays from the NEJM 

A. Ensuring Physicians' Competence — Is Maintenance of Certification the Answer? 

John K. Iglehart, and Robert B. Baron, M.D.
N Engl J Med 2012; 367:2543-2549.  

Pressed by their leaders, external stakeholders, and a public troubled by lapses in the quality of care and unsustainable cost increases, physicians are facing stiffer challenges in initiatives designed to link more closely the goals of learning with the delivery of better care and measures of greater accountability. The initiatives are works in progress being implemented by national accrediting organizations, state medical licensing boards, the federal government, and others,1-5 but the most contentious among them (and the focus of this article) is the maintenance of certification (MOC) program sponsored by the American Board of Medical Specialties (ABMS) and its 24 member boards, which promote continuous professional development.6 MOC requires most certified specialists to seek recertification on a periodic basis — typically every 10 years — by successfully completing a four-part assessment designed to test their medical knowledge, clinical competence, and skills in communicating with patients. The MOC program was initiated in 2000, but the pace of recertification has accelerated since 2009. Approximately 375,000 board-certified specialists and subspecialists (about half the number that the 24 boards certified initially) meet MOC requirements, according to the ABMS. 

Although the number of specialists engaged in the process grows by about 50,000 diplomates a year, the exercise also draws strong criticism from physicians who assert that MOC is too expensive and the process is too time-consuming. Another concern is a requirement that a secure examination (one of MOC's four parts) be completed without access to outside sources of information. This condition contradicts what medical students and residents are currently taught: they should take advantage of the best sources of information rather than rely entirely on their memory. Younger physicians also suggest that so-called grandfathers7 (generally specialists who were certified before 1990 and received time-unlimited credentials) should also face the rigors of recertification (Eggen M: personal communication). Among 66,689 diplomates of the American Board of Internal Medicine (ABIM) who hold only time-unlimited certificates, only 1% have chosen to become recertified through MOC. The ABIM also certifies physicians who practice in 19 subspecialties. Since 1990, all certificates issued by the ABIM have required diplomates to complete MOC to remain certified. Two ABIM areas of specialty actually were established before 1990 without ever having issued time-unlimited certificates — critical care medicine in 1987 and geriatrics in 1988. Like ABIM, other specialties also report low recertification rates among their diplomates with time-unlimited certificates, including dermatology (8%), nuclear medicine (12%), plastic surgery (5%), and urology (1%). One of us holds a time-unlimited certificate and is enrolled in MOC. 

More than 75 years ago, the ABMS and its predecessor organization began to build a national system of standards for educating medical specialists.8 As originally conceived, securing board certification was considered a once-in-a-lifetime challenge designed to show a doctor's competence after completion of residency training. Until 1969, all the ABMS-member boards issued lifetime specialty certificates, but as the skills necessary to practice medicine grew exponentially and research showed that, on average, the clinical skills of physicians decline over time,9 time-unlimited certification was called into question. Since its founding in 1969, the American Board of Family Medicine (ABFM) issued only time-limited certificates. Initially these certificates were valid for 7 years, but now they remain valid as long as a diplomate meets MOC requirements.10,11 As of 2000, the ABMS adopted MOC as a policy with general standards for all of its member boards. Subsequently, the 24 boards began issuing time-limited certificates that were usually good for 10 years, but each board was on its own schedule, and the American Board of Pathology was the last to issue certificates, in 2006…. 

B. Higher-Complexity ED Billing Codes — Sicker Patients, More Intensive Practice, or Improper Payments? 

Stephen R. Pitts, M.D., M.P.H. N Engl J Med 2012; 367:2465-2467.  

A recent analysis of Medicare billing data for evaluation-and-management services, conducted by the Office of Inspector General (OIG) of the Department of Health and Human Services, showed that between 2001 and 2010, the proportion of claims for lower reimbursement categories decreased while the use of higher-paid categories increased across all visit types.1 The largest increase reported was in level 5 emergency department (ED) visits (Current Procedural Terminology [CPT] code 99285; average reimbursement, $173) — from 27% to 48% of Medicare discharges… 

21. As Nurse Lay Dying, Offering Herself as Instruction in Caring 

By Abby Goodnough, New York Times, January 11, 2013  

A nurse terminally ill with cancer volunteers to be a subject of research for students from her alma mater. 

SOUTH HADLEY, Mass. — It was early November when Martha Keochareon called the nursing school at Holyoke Community College, her alma mater. She had a proposal, which she laid out in a voice mail message. 

“I have cancer,” she said after introducing herself, “and I’m wondering if you’ll need somebody to do a case study on, a hospice patient.” 

Perhaps some nursing students “just want to feel what a tumor feels like,” she went on. Or they could learn something about hospice care, which aims to help terminally ill people die comfortably at home. “Maybe you’ll have some ambitious student that wants to do a project,” Ms. Keochareon (pronounced CATCH-uron) said after leaving her phone number. “Thank you. Bye.” 

Kelly Keane, a counselor at the college who received the message, was instantly intrigued. Holyoke’s nursing students, like most, learn about cancer from textbooks. They get some experience with acutely ill patients during a rotation on the medical-surgical floor of a hospital. They practice their skills in the college’s simulation lab on sophisticated mannequins that can “die” of cancer, heart attacks and other ailments. But Ms. Keochareon, 59, a 1993 graduate of Holyoke’s nursing program, was offering students something rare: an opportunity not only to examine her, but also to ask anything they wanted about her experience with cancer and dying. 

“She is allowing us into something we wouldn’t ever be privy to,” Ms. Keane said. 

So it was that a few weeks later, two first-year nursing students, Cindy Santiago, 26, and Michelle Elliot, 52, arrived at Ms. Keochareon’s tiny house, a few miles from the college. She was bedbound, cared for by a loyal band of relatives, hospice nurses and aides. Both students were anxious. 

“Sit on my bed and talk to me,” Ms. Keochareon said. The students hesitated, saying they had been taught not to do that, to prevent transmission of germs. What they knew of nursing in hospitals — “I’m here to take your vitals, give you your medicine, O.K., bye,” as Ms. Santiago put it — was different, after all. 

They had come with a list of questions. Ms. Keochareon was suffering from pancreatic cancer, and they had researched the disease ahead of time. They were particularly curious about why she had survived for so long. She had lived with her illness for more than six years — an extraordinary span for pancreatic cancer, which often kills within months after diagnosis. 

Why, the students asked, had she managed to keep eating and keep on weight? What was she taking for the pain? How long had it taken for doctors to give her a diagnosis? 

“They ask good questions,” Ms. Keochareon said one morning, her lips stained red from the liquid oxycodone she was sipping frequently between doses of other drugs. “I forget half the stuff I learned as a nurse, but I remember everything about pancreatic cancer. Because I’m living it.” 

For Ms. Keochareon, this was a chance to teach something about the profession she had found late and embraced — she became a nurse at 40, after raising her daughter and working for years on a factory floor…