Saturday, February 02, 2013

Lit Bits: Feb 2, 2013

From the recent medical literature...

1. New Guidelines Published on Sepsis, Stroke, and Immunizations 

A. 2012 Sepsis Guidelines  

A revised and updated edition of "Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012​" were officially released at the Society of Critical Care Medicine's 42nd Congress in San Juan on January 20. Thirty international professional organizations supported the content of the new guidelines. 

Dellinger RP, et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Crit Care Med. 2013 Feb;41(2):580-637. 

OBJECTIVE: To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008.  

DESIGN: A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.  

METHODS: The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations.  

RESULTS: Key recommendations and suggestions, listed by category, include… 

B. New American Stroke Association Guidelines  

By Chris Kaiser, Cardiology Editor, MedPage Today. January 31, 2013 

Stroke treatment within 60 minutes, telestroke networks, and expanded eligibility for clot-buster therapy are among the topics outlined in the new stroke guidelines from the American Stroke Association published in Stroke: Journal of the American Heart Association. Many of the so-called new guidelines are a simple statement of accepted clinical practice, such as treating eligible stroke patients with IV tissue plasminogen activator (tPA) within 60 minutes of arriving at the hospital, Edward C. Jauch, MD, lead author of the document, told MedPage Today. 

But it has been 6 years since the last stroke treatment guidelines were published and the new document contains 21 new recommendations as well as 50 revisions of existing recommendations. Another 42 recommendations remain unchanged. "The guidelines are a progression of what the stroke community is learning and a nod toward the direction we're heading," said Jauch, director of the division of emergency medicine at the Medical University of South Carolina in Charleston. 

One of the new recommendations states that tPA can be administered to stroke patients where the treatment was previously contraindicated. These include those with a minor stroke, a rapidly improving stroke, recent major surgery, or a recent heart attack (class IIb, level of evidence C). 

"Several studies have now reported that approximately one third of patients who are not treated with intravenous tPA because of mild or rapidly improving stroke symptoms on hospital arrival have a poor final stroke outcome," according to the guidelines. Guidelines also noted that patients may have "potentially disabling symptoms even though their NIH Stroke Scale score is just 2." 

One of the biggest changes in stroke care is the involvement of whole regions to offer coordinated care rather than relying on a single hospital to do everything. "Different hospitals have different capabilities for taking care of our sickest stroke patients," Andrew Russman, DO, of the Cleveland Clinic, who was not on the writing committee, told MedPage Today. "Some of the new guidelines suggest that we should reroute patients from hospitals that have lesser capability to those that have more capabilities." 

Emergency medical personnel should be aware of the various levels of stroke care offered in their community, including 

·         Comprehensive stroke centers -- which offer 24/7, highly specialized treatment for all types of stroke
·         Primary stroke centers -- which provide 24/7 specialized care mainly for ischemic stroke
·         Acute stroke-ready hospitals -- which can evaluate and treat most strokes but lack highly specialized capabilities 

Also new is an emphasis on creation of acute stroke-ready hospitals in regional systems of care (class IIa, level of evidence C). EMS also need to be ready to bypass hospitals that may not offer certain procedures, such as advanced CT or MRI imaging (which is recommended before IV tPA [class I, level of evidence A]). 

When none of these hospitals are available, the guidelines state that telestroke consultation can be used to access stroke treatment expertise (class IIa, level of evidence C). Along with telestroke, the guidelines also recommend the use of teleradiology systems for fast and accurate image interpretation. 

During an acute stroke, physicians must quickly evaluate and diagnose the patient as soon as possible to determine if patients are eligible to receive tPA, which can be given within 4.5 hours of symptom onset. The FDA has approved tPA to be given within a 3-hour window of symptom onset. In Europe, the clot-busting drug is approved for up to 4.5 hours. Genentech, maker of tPA, asked the FDA to approve the drug for the extended 4.5-hour time frame and provided the agency with additional data. But the FDA last spring declined the request. That move by the FDA interested the guideline writing committee because it had endorsed the extended therapeutic window in 2009, Jauch told MedPage Today. "We wanted to be sure we weren't advocating something for our patients that would harm them." 

A few members of the writing committee reviewed the additional data with representatives of Genentech. Although the FDA gave no reason for declining the request, the writing committee was satisfied the reason was not based on safety concerns, Jauch said. "We felt we should continue to maintain our recommendation that the administration of tPA could be considered for up to 4.5 hours of symptom onset in select patients," he said. 

Other new recommendations: 

·         Multidisciplinary quality improvement committees should be created within hospitals to review and monitor stroke care quality (class I, level of evidence B)
·         Recently introduced stent retrievers could potentially remove large blood clots more completely and quickly than tPA. Solitaire FR and Trevo are preferred for coil retrievers over the Merci device when mechanical thrombectomy is used (class I, level of evidence A)
·         Patients already on statins when presenting with stroke can continue taking them during the acute phase (class IIa, level of evidence B)
·         The use tPA in patients taking direct thrombin inhibitors, such as dabigatran (Pradaxa) or direct factor Xa inhibitors, such as rivaroxaban (Xarelto) or apixaban (Eliquis) is not recommended unless certain tests are conducted beforehand such as activated partial thromboplastin time or ecarin clotting time (class III, level of evidence C) 

"Time is brain when it comes to the onset of stroke symptoms," Russman emphasized. "For each minute the brain goes without blood flow, there are 1.9 million nerve cells that are dying, that affect 14 billion nerve connections and 7.5 miles worth of never fibers. "What this tells us is we should treat patients as quickly as possible to reduce the likelihood they will have disability from a stroke." 

C. ACEP Policy on tPA for Stroke 

ACEP/ANA. Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the ED. Ann Emerg Med 2013;61:225-243.  

Critical Questions 
1. Is IV tPA safe and effective for acute ischemic stroke patients if given within 3 hours of symptom onset? 

2. Is IV tPA safe and effective for acute ischemic stroke patients treated between 3 to 4.5 hours after symptom onset?

Patient Management Recommendations  

Level A recommendations

In order to improve functional outcomes, IV tPA should be offered to acute ischemic stroke patients who meet National Institute of Neurological Disorders and Stroke (NINDS) inclusion/exclusion criteria and can be treated within 3 hours after symptom onset. 

Level B recommendations

In order to improve functional outcomes, IV tPA should be considered in acute ischemic stroke patients who meet European Cooperative Acute Stroke Study (ECASS) III inclusion/exclusion criteria and can be treated between 3 to 4.5 hours after symptom onset.

Note: Within any time window, once the decision is made to administer IV tPA, the patient should be treated as rapidly as possible. As of this writing, tPA for acute ischemic stroke in the 3- to 4.5-hour window is not FDA approved. 

D. New 2013 Immunization Guidelines 

ACIP Issues 2013 Adult Immunization Schedule and Guidelines

Ann Intern Med (full-text free): 

AAP Issues 2013 Child/Adolescent Immunization Schedule 

2. Selective DVT Testing Called Safe, Efficient 

By Charles Bankhead, Staff Writer, MedPage Today. January 15, 2013 

Action Points

·         Clinically guided D-dimer testing for suspected deep vein thrombosis (DVT) based on clinical pretest probability significantly reduced testing frequency and use of confirmatory ultrasonography compared with unselected testing.
·         Note that the 3-month DVT rate was identical in patients who were selectively tested or universally tested by D-dimer testing.
·         Clinically guided D-dimer testing for suspected deep vein thrombosis (DVT) significantly reduced testing frequency and use of confirmatory ultrasonography compared with universal testing, a randomized trial showed. 

Selective testing led to a 21.8% absolute reduction in testing frequency and a 7.6% absolute reduction in ultrasound use. The 3-month DVT rate was identical in patients who were selectively tested or universally tested, wrote Lori-Ann Linkins, MD, of McMaster University in Hamilton, Ontario, and colleagues, in the Annals of Internal Medicine online. 

"This study supports the use of a higher D-dimer threshold to exclude first DVT in outpatients with low clinical pretest probability (C-PTP) than that used in outpatients with moderate C-PTP and that D-dimer testing should be avoided in outpatients with high C-PTP and in all inpatients," they wrote. "Future studies to determine whether this diagnostic strategy can be applied to patients who present with suspected recurrence DVT or pulmonary embolism are required." 

The 0.5 µg/mL cutoff for D-dimer test results has good accuracy for excluding DVT, but a test value ≥0.5µg/mL mandates additional workup, usually ultrasound, which often proves negative for DVT. 

DVT is uncommon in patients with a low C-PTP, and a high C-PTP is associated with a high rate of DVT. Most hospitalized patients have elevated D-dimer levels, irrespective of C-PTP, usually because of comorbid conditions, and D-dimer test results usually will be negative. 

In an earlier retrospective study, Linkins and colleagues showed that use of a higher D-dimer cutoff for patients with low C-PTP improved specificity from 54% to 95% and maintained a negative predictive value of 98% (J Thromb Haemost 2004; 2: 1256-1260). 

The current study was a prospective, multicenter, randomized trial involving patients with a suspected first acute DVT. By use of the 9-point Wells clinical prediction rule, patients were classified as having a low, moderate, or high C-PTP of DVT. 

All patients randomized to the control group underwent D-dimer testing. A negative test ended the workup for DVT. A positive test was followed by ultrasonography. Patients with a low C-PTP and normal ultrasound results had no further workup. Patients with moderate or high C-PTP and normal ultrasound had repeat ultrasound 6 to 8 days later. Patients with low or moderate C-PTP underwent selective D-dimer testing and patients with a high C-PTP underwent immediate ultrasonography without D-dimer measurement. For patients with low C-PTP, a positive result was defined as a D-dimer level ≥1 µg/mL, whereas the cutoff for patients with moderate C-PTP was 0.5 µg/mL. 

A negative result ended the workup and a positive result triggered ultrasonography of the proximal veins of the symptomatic leg. Negative ultrasonography ended the DVT workup in patients with low C-PTP, while patients with moderate C-PTP had repeat ultrasound. 

The primary outcome was the proportion of patients who initially had a negative DVT workup but had objectively confirmed DVT within 90 days. Analysis of the primary outcome included 1,723 patients. Of 863 patients assigned to uniform testing, 772 were outpatients (334 low C-PTP, 319 moderate, and 119 high), and 91 were inpatients. D-dimer test results were positive in 506 patients, negative in 353 patients, and four patients did not have the test. 

Subsequently, 11.1% of the 506 patients with positive D-dimer tests had DVT confirmed by ultrasound during the initial workup. Four patients (0.8%) with negative D-dimer results and ultrasonography had confirmed DVT during follow-up. Less than 1% of 798 patients who did not have DVT on initial workup and remained in the study. No patient with a negative D-dimer test developed DVT during follow-up. 

The 860 patients randomized to selective testing comprised 770 outpatients (360 low C-PTP, 310 moderate, and 100 high) and 90 inpatients. The low C-PTP subgroup had negative D-dimer results in 80% of cases and none developed VTE during follow-up. Of the 72 patients with positive D-dimer results, 11% had DVT confirmed by ultrasonography during the initial workup. No patient with normal ultrasound findings developed DVT during follow-up. 

The authors found that 176 patients with moderate C-PTP had positive D-dimer test results, and 13% of those patients had DVT confirmed by ultrasonography during the initial workup. One patient with negative D-dimer results developed DVT during follow-up. Of 153 moderate C-PTP patients with a positive D-dimer test and normal ultrasound, one developed DVT during follow-up. 

The results showed that 10.5% of the 190 high C-PTP outpatients and inpatients had DVT confirmed during the initial workup. Two patients with normal ultrasonography developed DVT during follow-up. Overall, 5.9% of 860 patients in the selective-testing group had DVT confirmed during initial testing, and 0.5% who had negative results during the initial workup subsequently developed DVT during follow-up. 

"The selective strategy was more efficient insofar as an absolute 21.8% fewer patients required D-dimer testing and 7.7% fewer required ultrasonography compared with uniform testing," the authors wrote. 

"Using a D-dimer threshold of 1.0 µg/mL rather than 0.5 µg/mL to exclude DVT in outpatients with low C-PTP halved the number of those who required ultrasonography," they continued. "This savings, which corresponded to 10% of all patients in the selective group, accounted for the overall reduction in ultrasonography in this randomly assigned group." 

The study had some limitations. First, the results may not be generalizable to patients with a history of DVT or to other D-dimer tests (the MDA D-dimer assay and the STA-Liatest D-Di assay were used in this study). Also, patients and study personnel were not blinded to trial interventions. 

3. Eating a Larger Number of High-Salt Foods is Not Associated with Short-Term Risk of Acute Decompensation in Patients with CHF 

Borke JA, et al. J Emerg Med. 2013;44:36-45.  

Background: Risk factors for exacerbation of congestive heart failure have not been consistently validated. 

Objective: Our objective was to examine the role of short-term dietary sodium intake in acute decompensated heart failure. 

Methods: Patients with chronic congestive heart failure presenting to the Emergency Department for either acute decompensated heart failure (cases) or for other reasons (controls) were included in a case-control study. Cases and controls were compared with respect to age, smoking, recent sodium intake, medication nonadherence, coronary artery disease, and hypertension. A food frequency questionnaire was utilized to estimate recent sodium intake, defined as the number of food types consumed in the previous 3 days from the 12 highest-sodium food categories. 

Results: There were 182 patients enrolled. One patient was excluded due to uncertainty about the primary diagnosis. When adjusted for age, smoking, medication nonadherence, coronary artery disease, and hypertension, acute decompensated heart failure was not associated with short-term dietary sodium intake. The odds ratio for acute decompensated heart failure for each increase in the number of high-sodium food types consumed was 1.1 (95% confidence interval 0.9–1.3; p = 0.3). Acute decompensated heart failure was associated with medication nonadherence, with an odds ratio for decompensation of 2.5 (95% confidence interval 1.2–5.1; p = 0.01). 

Conclusions: Patients with chronic congestive heart failure who presented to the Emergency Department with acute decompensated heart failure were no more likely to report consuming a greater number of high-sodium foods in the 3 days before than were patients with chronic congestive heart failure who presented with unrelated symptoms. On the other hand, those who presented with acute decompensated heart failure were significantly more likely to report nonadherence with medications. 

4. Bouncing Back 

A. ED Visits Common After Hospital Stay 

Vashi A, et al. Use of hospital-based acute care among patients recently discharged from the hospital. JAMA 2013;309:364-371. 

By John Gever, Senior Editor, MedPage Today. January 22, 2013 

Among some 5 million hospitalizations, involving about 4 million unique patients in California, Florida, and Nebraska over a 15-month period in 2008 and 2009, 17.9% (95% CI 17.9% to 18.0%) of discharges were followed within 30 days by a "treat-and-release" ER visit or readmission, according to Anita Vashi, MD, MPH, of Yale University, and colleagues. 

Treat-and-release ER visits accounted for 39.8% of the follow-up care (95% CI 39.7% to 39.9%), the researchers reported in the Jan. 23/30 issue of the Journal of the American Medical Association. 

Moreover, for the 10 most common medical and 10 most common surgical conditions that were the basis for hospitalization, follow-up ER visits "were always related to the index hospitalization," the researchers wrote. 

On the medical side, such conditions were led by vaginal childbirth, psychosis, heart failure and shock, chest pain, and chronic obstructive pulmonary disease. Common surgical conditions included cesarean delivery, joint replacement, uterine and adnexa procedures for nonmalignancies, complicated cesarean sections, and percutaneous interventions with stent placement. 

Vashi and colleagues argued that the current policy focus on readmissions for judging hospital care quality may miss part of the problem, as relatively minor ER visits after discharge "are another important outcome," often representing uncoordinated follow-up care. "These emergency department visits are likely to result in fragmented care following discharge and consequently contribute to duplication of services, conflicting care recommendations, medication errors, patient distress, or higher costs," they wrote. 

The study examined outcomes of 5,032,245 discharges from acute care hospitals in the three states from July 2008 through September 2009, as reflected in the Healthcare Cost and Utilization Project databases. 

These databases included patient-level information on the primary diagnoses for the index hospitalizations as well as the timing and chief reasons for acute care rendered after discharge. 

Besides tracking the number and type of post-discharge acute care visits, Vashi and colleagues also calculated a "condition-specific ED index" as a simple measure of the likelihood that a return visit was to the emergency department versus readmission.  

Conditions for which treat-and-release visits outnumbered readmissions would receive a value greater than 1, whereas the index would be less than 1 for those in which readmissions predominate. The analysis showed ED index values of 2 or greater for vaginal childbirth, standard and complicated cesarean delivery, and appendectomy. Values of 0.5 or less were calculated for heart failure and shock, septicemia, stroke, and complicated hip and femoral procedures. 

Vashi and colleagues also reported the three top reasons for treat-and-release ER visits for each of the 20 high-volume conditions associated with the index hospitalizations. In every case, all three appeared at least superficially related to the condition at original admission. For example, the three most common reasons for ER visits following discharges of septicemia patients were urinary tract infection, genitourinary symptoms, and abdominal pain. 

Likewise, patients who had undergone angioplasty with stenting sought emergency treatment for complaints including nonspecific chest pain, heart conditions including coronary atherosclerosis, and abdominal pain. 

Rates of post-discharge ER visits ranged from 22.4 per 1,000 discharges (95% CI 4.6 to 65.4) involving breast cancer patients to 282.5 per 1,000 discharges (95% CI 209.7 to 372.4) of patients originally treated for uncomplicated benign prostatic hypertrophy. 

In an accompanying editorial, Mark Williams, MD, of Northwestern University in Chicago, agreed that post-discharge ER visits are an important outcome to track in addition to readmissions. "Developing care process approaches that serve patients and ensure adequate coordinated care should be the goal. Visits to the emergency department after hospitalization should also be monitored and assessed as a quality measure to complement 30-day readmissions," Williams wrote. 

Study authors reported relationships with CMS, the Pew Charitable Trusts, Medtronic (through Yale's Open Access project to analyze Medtronic clinical trial data), and FAIR Health. 

B. Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, AMI, or Pneumonia  

Dharmarajan K, et al. JAMA. 2013;309(4):355-363.  

Importance  To better guide strategies intended to reduce high rates of 30-day readmission after hospitalization for heart failure (HF), acute myocardial infarction (MI), or pneumonia, further information is needed about readmission diagnoses, readmission timing, and the relationship of both to patient age, sex, and race. 

Objective  To examine readmission diagnoses and timing among Medicare beneficiaries readmitted within 30 days after hospitalization for HF, acute MI, or pneumonia. 

Design, Setting, and Patients  We analyzed 2007-2009 Medicare fee-for-service claims data to identify patterns of 30-day readmission by patient demographic characteristics and time after hospitalization for HF, acute MI, or pneumonia. Readmission diagnoses were categorized using an aggregated version of the Centers for Medicare & Medicaid Services' Condition Categories. Readmission timing was determined by day after discharge. 

Main Outcome Measures  We examined the percentage of 30-day readmissions occurring on each day (0-30) after discharge; the most common readmission diagnoses occurring during cumulative periods (days 0-3, 0-7, 0-15, and 0-30) and consecutive periods (days 0-3, 4-7, 8-15, and 16-30) after hospitalization; median time to readmission for common readmission diagnoses; and the relationship between patient demographic characteristics and readmission diagnoses and timing. 

Results  From 2007 through 2009, we identified 329 308 30-day readmissions after 1 330 157 HF hospitalizations (24.8% readmitted), 108 992 30-day readmissions after 548 834 acute MI hospitalizations (19.9% readmitted), and 214 239 30-day readmissions after 1 168 624 pneumonia hospitalizations (18.3% readmitted). The proportion of patients readmitted for the same condition was 35.2% after the index HF hospitalization, 10.0% after the index acute MI hospitalization, and 22.4% after the index pneumonia hospitalization. Of all readmissions within 30 days of hospitalization, the majority occurred within 15 days of hospitalization: 61.0%, HF cohort; 67.6%, acute MI cohort; and 62.6%, pneumonia cohort. The diverse spectrum of readmission diagnoses was largely similar in both cumulative and consecutive periods after discharge. Median time to 30-day readmission was 12 days for patients initially hospitalized for HF, 10 days for patients initially hospitalized for acute MI, and 12 days for patients initially hospitalized for pneumonia and was comparable across common readmission diagnoses. Neither readmission diagnoses nor timing substantively varied by age, sex, or race. 

Conclusion and Relevance  Among Medicare fee-for-service beneficiaries hospitalized for HF, acute MI, or pneumonia, 30-day readmissions were frequent throughout the month after hospitalization and resulted from a similar spectrum of readmission diagnoses regardless of age, sex, race, or time after discharge. 

5. Airway Devices May Not Help in Cardiac Arrest 

By Todd Neale, Senior Staff Writer, MedPage Today, January 15, 2013 

Action Points

·         Note that most emergency medical services systems in prioritize the use of advanced airways (endotracheal intubation or a supraglottic airway) but recent studies have challenged the survival benefit of advanced airway management compared with conventional bag-valve-mask ventilation.
·         In this large observational study of adults with out-of-hospital cardiac arrest in Japan, neurologically favorable survival was higher among those who received bag-valve-mask ventilation alone compared with those who received endotracheal intubation or supraglottic airway insertion. 

Advanced airway management -- endotracheal intubation or the use of supraglottic airway devices -- may not be beneficial to emergency medical services personnel when trying to resuscitate patients who've had an out-of-hospital cardiac arrest, an observational study suggested. 

The percentage of patients with a favorable neurological outcome 1 month after the arrest was significantly lower among those who received advanced airway management than among those who received conventional bag-valve-mask ventilation (1.1% versus 2.9%; OR 0.38, 95% CI 0.36 to 0.39), according to Kohei Hasegawa, MD, MPH, of Massachusetts General Hospital in Boston, and colleagues. 

Similarly, use of advanced airway management was associated with a lower likelihood of a return to spontaneous circulation (OR 0.67, 95% CI 0.66 to 0.69) and of surviving to 1 month (OR 0.73, 95% CI 0.71 to 0.75), the researchers reported in the Jan. 15 issue of the Journal of the American Medical Association. 

"Our observations contradict the assumption that aggressive airway intervention is associated with improved outcomes and provide an opportunity to reconsider the approach to pre-hospital airway management in this population," the authors wrote. 

The findings are provocative and "at least suggestive that this study should prompt further prospective randomized trials," Joseph Ornato, MD, chairman of the department of emergency medicine at VCU Medical Center in Richmond, Va., said in an interview. 

He noted that the Resuscitation Outcomes Consortium sponsored by the National Institutes of Health is currently designing a trial to explore the impact of advanced airway management on patient outcomes.  

Although survival following out-of-hospital cardiac arrest has improved in recent years, it remains low overall, at just 8% to 10%. "Better survival has been associated with the improvement in early access to emergency medical care, early cardiopulmonary resuscitation (CPR), rapid defibrillation, and integrated post-cardiac arrest care," Hasegawa and colleagues wrote. "Early advanced life support is often considered of benefit in that it provides intravenous drug therapy and advanced airway management." 

Recent studies, however, have raised questions about whether advanced airway management actually improves outcomes. To explore the issue, the researchers looked at data from the nationwide All-Japan Utstein Registry of the Fire and Disaster Management Agency. The current analysis included 649,359 Japanese adults (mean age 73) who had an out-of-hospital cardiac arrest and who had resuscitation attempted by emergency responders in the pre-hospital setting from 2005 through 2010. 

Most of the patients (57%) underwent bag-valve-mask ventilation and 43% underwent advanced airway management, including 6% with endotracheal intubation and 37% with supraglottic airways. 

The primary outcome was a favorable neurological status, defined as Glasgow-Pittsburgh cerebral performance category 1 (good performance) or 2 (moderate disability), 1 month after the arrest. The poorer outcomes among patients who received advanced airway management remained after adjustment for numerous potential confounders, including age, sex, arrest etiology, first documented rhythm, witnessed status, type of bystander CPR, use of a public access automated external defibrillator, epinephrine administration, and time intervals from the call to CPR initiation by EMS personnel and to hospital arrival. 

Although these observational data cannot establish a causal relationship between advanced airway management and outcomes, there are some plausible mechanisms tying them together, according to the researchers. 

"It has been well documented that pre-hospital intubation is a complex psychomotor task and that EMS personnel have difficulty gaining and maintaining competency in this skill," they wrote, noting that intubation by unskilled practitioners could lead to a variety of adverse events such as unrecognized esophageal intubation, tube dislodgement, iatrogenic hypoxemia, and bradycardia. The intubation process may also interfere with the performance of effective chest compressions, they said. 

Ornato pointed out that a variable that could have affected the findings was the difference between the groups in the median time to a return of spontaneous circulation (14 minutes with advanced airway management versus 6 minutes with conventional ventilation). 

"It could very well be that the group of patients who restarted with a more prolonged resuscitation effort would in fact be expected to have less of a survival and a neurologically intact outcome," he said. 

"Some may view the results [of the current study] as evidence to cease all emergency medical services endotracheal intubation or supraglottic airway insertion in out-of- hospital cardiac arrest," Henry Wang, MD, of the University of Alabama at Birmingham, and Donald Yealy, MD, of the University of Pittsburgh, wrote in an accompanying editorial. "However, this interpretation should be tempered by the limits and potential biases of the study." 

Hasegawa and colleagues acknowledged that the findings may be limited by confounding by unmeasured factors, by the lack of information about the intubation process, by concerns about data integrity and validity and about ascertainment bias, and by the uncertain generalizability to other countries besides Japan. 

Because of those limitations, a randomized clinical trial is the best way to explore the utility of advanced airway management in out-of-hospital cardiac arrest, Wang and Yealy wrote, adding that such a study could be difficult because the belief that the techniques work is entrenched in current practice. 

Without a commitment for a large clinical trial, "the emergency medical services community risks turning a blind eye and embracing ineffective or harmful airway interventions," they wrote. "Patients with cardiac arrest and the out-of-hospital rescuers who care for them deserve to know what is best." 

6. Therapeutic Hypothermia after Cardiac Arrest 

Scirica BM, et al, Circulation 2013;127:244-250. 

Case 1
A 63-year-old man was at home watching television when his roommate noticed him gurgle and lose consciousness. He started cardiopulmonary resuscitation (CPR) and called emergency medical services. The initial rhythm was ventricular fibrillation (VF). A perfusing rhythm was obtained within 15 minutes, but there were repeated episodes of VF requiring multiple defibrillations and repeated episodes of cardiopulmonary resuscitation. With restoration of circulation, he was not responsive. Initial ECG revealed inferior ST-segment elevations. In the emergency department, he required further defibrillations and was then taken for primary coronary intervention. Emergency medical personnel started intravenous iced saline, and ice packs were placed while he was in the emergency department and remained in place during cardiac catheterization. A stent was placed in a thrombotic right coronary artery. On arrival at the cardiac intensive care unit, surface cooling pads were placed, and he received therapeutic hypothermia (TH) for 24 hours, at which point he was rewarmed. He initially remained comatose, but by day 5, he was awake, alert, and interactive. He was discharged home.  

Case 2
A 54-year-old woman was found unresponsive by coworkers. It was not clear how long she had been down. Cardiopulmonary resuscitation was started, and an automated external defibrillator recommended no shock. Emergency medical personnel identified asystole as the initial rhythm. After 25 minutes of advanced cardiac life support, a perfusing rhythm was obtained. There were no ischemic changes on the ECG. She was unresponsive on arrival at the emergency department. Computed tomographs of the head and pulmonary arteries were normal. She received TH for 24 hours and, when rewarmed, had no change in her mental status by day 5. Magnetic resonance imaging did not reveal any major abnormalities, but she had incomplete recovery of brainstem reflexes and bilaterally absent sensory stimulatory evoked potentials. After extensive discussions with her family, continued support was withdrawn, and she expired.  

Cardiac arrest (CA) remains one of the most unexpected, dramatic, and life-threatening events in medicine. Survival and neurological recovery vary widely, depending on whether an arrest was witnessed or unwitnessed and the initial cardiac rhythm during resuscitation. Even among patients with successful return of spontaneous circulation (ROSC) who are admitted to an intensive care unit, survival until hospital discharge has historically been less than 10%.1 Fortunately, recent data suggest a steady trend toward improved survival. However, in 2009, mortality remained at almost 60%.2,3 

Improvements in the survival and neurological outcomes of patients with CA have focused on 2 principal areas of treatment. The first is increased education to improve immediate post-CA perfusion via national efforts promoting the 4 links in the chain of survival that include early access to emergency medical care, early cardiopulmonary resuscitation, early defibrillation, and early advanced cardiac life support.4 

The second area is greater emphasis on postresuscitation care, which includes optimizing oxygenation and ventilation, avoiding hypotension (systolic blood pressure less than 90 mm Hg), treating immediate precipitants of CA such as acute coronary ischemia, and initiating TH when appropriate.5 The American Heart Association (Figure 1), the International Liaison Committee of Resuscitation, and the European Resuscitation Council recently published guidelines and recommendations covering the entire spectrum of postresuscitation care.5–7 This review focuses on the practical aspects of implementing TH, one of the key therapeutic procedures in postresuscitation care… 

7. Pediatric Corner 

A. Management of the Child after Enema-Reduced Intussusception: Hospital or Home? 

Chien M, et al. J Emerg Med. 2013;44:53-57.  

Background: Standard practice has been to admit children for an observation period after enema-reduced intussusception. However, the utility of such routine practice has not been clearly justified. 

Study Objectives: The main objective was to determine the rate and timing of recurrent intussusception after successful enema reduction and describe any associated complications. 

Methods: The study was a retrospective chart review identifying children with enema-reduced intussusception during a 7-year period from 2002 through 2008. Subjects were children ages 0 to 17 years presenting to the Emergency Department (ED) of a tertiary care, free-standing children’s hospital with confirmed and uncomplicated enema-reduced intussusception. 

Results: During the study period there were 98 children with successful enema reduction of intussusception. There were 10 episodes of recurrence in 7 patients, for an overall recurrence rate of 7.1%. Three patients had two recurrences each, and the remainder had single recurrences. Two patients had early recurrences (less than 48h) at 3 and 5h, for an early recurrence rate of 2.0%. The late recurrence rate (over 48h) was 5.1%. No adverse events were noted in any of the recurrences. 

Conclusions: Given the low early recurrence rate for enema-reduced intussusception and the minimal risk of adverse outcomes, ED observation for a 6-h period seems to be a safe alternative to inpatient management. These results support previous work and suggest that these patients can be managed on an outpatient basis. 

B. Metabolic Syndrome in 40s Linked to TV, Exercise at Age 16 

Lisa Nainggolan, Medscape Medical News. Jan 25, 2013 

Television viewing habits and leisure-time physical activity at the age of 16 years independently predicts the metabolic syndrome at age 43, according to the first prospective study to examine this. 

The work "supports previous findings" and, for TV viewing and subsequent metabolic risk, "provides new evidence that this association may stretch over a considerable proportion of the lifespan: from adolescence to mid-adulthood," say Patrik Wennberg, PhD, from Umeå University, Sweden, and colleagues in their article published online January 22 in Diabetes Care. 

The researchers also believe that separate mechanisms may be at play here for TV-viewing and physical-activity habits, because these activities were linked to different metabolic-syndrome components. 

Nevertheless, the findings "suggest that reduced TV viewing in adolescence, in addition to regular physical activity, may contribute to cardiometabolic health later in life," they state… 

8. Effectiveness of IV Dexamethasone versus Propofol for pain relief in the migraine headache: A prospective double blind RCT 

Soleimanpour H, BMC Neurol. 2012 Sep 29;12:114. 

BACKGROUND: There are many drugs recommended for pain relief in patients with migraine headache. 

METHODS: In a prospective double blind randomized clinical trial, 90 patients (age 18 or older) presenting to Emergency medicine Department with Migraine headache were enrolled in two equal groups. We used intravenous propofol (10 mg every 5-10 minutes to a maximum of 80 mg, slowly) and intravenous dexamethasone (0.15 mg/kg to a maximum of 16 mg, slowly), in group I and II, respectively. Pain explained by patients, based on VAS (Visual Analogue Scale) was recorded at the time of entrance to ED, and after injection. Data were analyzed by paired samples t test, using SPSS 16. P less than 0.05 was considered to be statistically significant. 

RESULTS: The mean of reported pain (VAS) was 8 ± 1.52 in propofol group and 8.11 ± 1.31 in dexamethasone group at presenting time (P above 0.05). The VAS in propofol group was obviously decreased to 3.08 ± 1.7, 1.87 ± 1.28 and 1.44 ± 1.63 after 10, 20 and 30 minutes of drug injection, respectively. The VAS in dexamethasone group was 5.13 ± 1.47, 3.73 ± 1.81 and 3.06 ± 2 after 10, 20 and 30 minutes of drug injection, respectively. The mean of reported VAS in propofol group was less than dexamethasone group at the above mentioned times (P less than  0.05). The reduction of headache in propofol group, also, was very faster than dexamethasone group (P less than  0.05). There were no adverse side effects due to administration of both drugs. 

CONCLUSIONS: Intravenous propofol is an efficacious and safe treatment for patients presenting with Migraine headache to the emergency department. 

9. Point-of-Care US in Assessing Fluid Responsiveness in Sepsis Patients: Sonographer Characteristics, Noninferential Statistics, and Study Design: Answers to the September 2012 Journal Club Questions 

Chiem A. Ann Emerg Med. 2013;61:244-250.  

Below is a sampling of the questions answered in this helpful review: 

Q1.a Several articles have assessed probe positioning in relation to IVC measurement and its correlation with CVP. Describe potential patient-specific or operator-specific issues that might confound the accurate measurement of the inferior vena cava in septic patients. 

Q1.b Discuss the evidence for using bedside ultrasonographic measurements of IVC variability to estimate fluid responsiveness. Are ultrasonographic measurements a more accurate measure of fluid responsiveness than CVP, urine output, jugular venous distention, or continuous pulse rate and blood pressure monitoring? What is the criterion standard for measuring the success of fluid resuscitation in patients with septic shock? 

Q2.d How would you design a study that fully incorporates the use of ultrasonography in managing sepsis patients? What is the unit of analysis for an emergency department–based ultrasonographic research investigation? How does one calculate the required sample size for such an investigation? 

Q3.a What sonographic measures of cardiac contractility provide the best estimation of ejection fraction? 

Q3.c How does the clinician apply various findings on ultrasonography, such as IVC variation greater than 50% and normal ejection fraction or IVC variation less than 50% and low ejection fraction, in septic shock patients? 

10. The Association between Self-reported Exercise Intensity and ACS in ED Chest Pain Patients 

Singer AJ, et al. J Emerg Med. 2013;44:17-22.  

Background: Regular exercise is thought to be protective against coronary artery disease. As a result, some physicians believe that the likelihood of acute coronary syndrome (ACS) in patients with acute chest pain is reduced in those who exercise regularly. We studied the association between self-reported frequency of exercising and the likelihood of ACS in patients presenting to the Emergency Department (ED) with chest pain. 

Methods: A multi-center prospective, descriptive, cohort study design was used in ED patients to determine whether the risk of ACS was reduced in patients who self-reported regular exercise. 

Results: There were 1093 patients enrolled. Median (interquartile range) age was 57 (48–67) years; 506 (45.7%) were female. ACS was diagnosed in 248 (22.7%) patients. Patients who did not exercise at least monthly were more likely to be diagnosed with ACS than those who did (129/466 [27.7%] vs. 119/627 [19.0%]; odds ratio 1.63, 95% CI 1.23–2.17). After adjusting for age, gender, body mass index, smoking, and prior history, limited exercise was still associated with ACS (adjusted odds ratio 1.52, 95% CI 1.10–2.10). There was no apparent association between frequency and intensity of exercise and risk of ACS. 

Conclusion: Although self-reported frequency of exercise was significantly associated with a decrease in ACS in ED patients with chest pain, it should not be used to exclude ACS in symptomatic ED patients. 

11. Images in Clinical Medicine 

Bilateral Internuclear Ophthalmoplegia in Multiple Sclerosis 

Young Man With Scratches on His Back

Woman With Right Lower Quadrant Pain

Hemifacial Flushing 

Perioral Myokymia (for you tox-minded and wilderness medicine docs)

12. How Long Does a Cough Last? Comparing Patients’ Expectations with Data From a Systematic Review of the Literature 

Ebell MH, et al. Ann Fam Med 2013;11:5-13 

PURPOSE We hypothesized that antibiotic overuse for acute cough illness (ACI) is in part due to a mismatch between patients’ expectations and the natural history of ACI. 

METHODS We performed a population-based random digit dialing survey of 493 adults in Georgia to determine their expectations regarding the duration of ACI. We also performed a systematic review of observational studies and the placebo or untreated control groups of randomized controlled trials to determine the duration of ACI from the published medical literature. We included studies of otherwise healthy adults with undifferentiated ACI, no clear bacterial cause, data on at least 1 cough outcome, and at least 1 week of follow-up. 

RESULTS The mean duration of cough in the published literature was 17.8 days. Survey respondents reported a median duration of 5 to 7 days and a mean duration of 7.2 to 9.3 days depending on the specific scenario. Patients expecting a longer duration of illness were more likely to be white, female, and have self-reported asthma or chronic lung disease. Independent predictors of the belief that antibiotics are always helpful included nonwhite race (OR = 1.82, 95% CI, 1.14–2.92), some college education or less (OR = 2.08, 95% CI, 1.26–3.45), and previous antibiotics for ACI (OR = 2.20, 95% CI, 1.34–3.55). 

CONCLUSIONS There is a mismatch between patients’ expectations regarding the duration of ACI and the actual duration based on the best available evidence. Efforts to reduce inappropriate antibiotic use should target this discrepancy. 

13. The Future of Antibiotics and Resistance 

Spellberg B, et al. N Engl J Med 2013; 368:299-302  

In its recent annual report on global risks, the World Economic Forum (WEF) concluded that “arguably the greatest risk . . . to human health comes in the form of antibiotic-resistant bacteria. We live in a bacterial world where we will never be able to stay ahead of the mutation curve. A test of our resilience is how far behind the curve we allow ourselves to fall.”1 

Traditional practices in infection control, antibiotic stewardship, and new antibiotic development are cornerstones of society's approach to combating resistance and must be continued. But the WEF report underscores the facts that antibiotic resistance and the collapse of the antibiotic research-and-development pipeline continue to worsen despite our ongoing efforts on all these fronts. If we're to develop countermeasures that have lasting effects, new ideas that complement traditional approaches will be needed. 

New ideas are often based on the recognition of old truths. Prokaryotes (bacteria) “invented” antibiotics billions of years ago, and resistance is primarily the result of bacterial adaptation to eons of antibiotic exposure. What are the fundamental implications of this reality? First, in addition to antibiotics' curative power, their use naturally selects for preexisting resistant populations of bacteria in nature. Second, it is not just “inappropriate” antibiotic use that selects for resistance. Rather, the speed with which resistance spreads is driven by microbial exposure to all antibiotics, whether appropriately prescribed or not. Thus, even if all inappropriate antibiotic use were eliminated, antibiotic-resistant infections would still occur (albeit at lower frequency). 

Third, after billions of years of evolution, microbes have most likely invented antibiotics against every biochemical target that can be attacked — and, of necessity, developed resistance mechanisms to protect all those biochemical targets. Indeed, widespread antibiotic resistance was recently discovered among bacteria found in underground caves that had been geologically isolated from the surface of the planet for 4 million years.2 Remarkably, resistance was found even to synthetic antibiotics that did not exist on earth until the 20th century. These results underscore a critical reality: antibiotic resistance already exists, widely disseminated in nature, to drugs we have not yet invented. 

Thus, from the microbial perspective, all antibiotic targets are “old” targets. Yet since the early 1930s, when Gerhard Domagk and colleagues discovered that chemical red dyes (the sulfonamides) can kill bacteria, the singular arc of antibiotic research and development has been to discover “new” targets to attack in order to kill the microbes. This strategy has saved countless lives. Ironically, it has also driven the resistance that threatens the very miracle of antibiotics. Ultimately, over centuries or millennia of selective pressure, we will run out of targets, and resistance mechanisms will become so prevalent as to preclude effective clinical deployment of antibiotics… 

The rest of the essay (full-text free):  

See also Audio Interview Online with Dr. Robert Moellering on the evolution of antibiotic resistance and strategies for combating it:. 

14. EMS Triage and Transport of Intoxicated Individuals to a Detoxification Facility Instead of an ED 

Ross DW, et al. Ann Emerg Med. 2013;61:175-184. .

Study objective: We evaluate the effectiveness and safety of emergency medical services (EMS) provider use of a checklist to triage alcohol-inebriated patients directly to a detoxification facility, rather than an emergency department (ED). 

Methods: A retrospective cohort study was conducted of all patients evaluated during a 2-year period, from 2003 to 2005, by EMS providers who used a detoxification evaluation checklist to aid in triage decisionmaking. Patients who did not meet detoxification evaluation checklist criteria were transported to an ED. Twelve-hour follow-up was solicited for patients taken to the detoxification center. Hospital records of inebriated patients transported to an ED were reviewed to assess ultimate need for ED care. 

Results: Seven hundred eighteen patient encounters were reviewed. One hundred thirty-eight of these patients (19.2%) were transported to the detoxification facility, whereas 580 (80.8%) were transported to an ED; 339 patients transported to an ED were ultimately deemed to have required ED care. The criteria that most commonly excluded transport to the detoxification center were an inability to ambulate with minimal assistance (N=334) and an unwillingness to cooperate with the physical examination (N=195). Low-acuity adverse events were observed in 4 subjects (0.6%) initially transported to the detoxification center who then required subsequent transport to an ED. No high-acuity clinical complications were identified at any time. The use of the detoxification evaluation checklist resulted in high sensitivity (99%; 95% confidence interval 97% to 100%) and low specificity (42%; 95% confidence interval 37% to 48%) in predicting need for ED care. 

Conclusion: Our analysis suggests that field triage criteria can be used effectively to safely divert inebriated patients to a detoxification facility rather than an ED, with minimal adverse events. Use of the detoxification evaluation checklist resulted in substantial ED overtriage, and further refinement of the detoxification evaluation checklist criteria is needed to reduce it. 

15. A Normal ECG That Should Have Been Frightening 

Kyuhyun Wang, MD, Medscape Cardiology: ECG of the Week, Jan 11, 2013 

A 58-year-old truck driver from out of town checked into a hotel after a long day of driving. While resting in bed, he was suddenly seized by a sharp jaw pain that felt like a "shock" and which soon spread to the anterior chest. He had never had a similar pain before. It did not abate and he reported to the emergency room at a nearby hospital. At the hospital he was still in acute distress with chest pain. He was taking medicine for hypertension but otherwise his medical history was unremarkable. His pulse was 90 beats/min and his blood pressure was 150/90 mm Hg; otherwise the physical examination, chest x-ray, and blood tests, including troponin, were unremarkable.  

The ECG tracing (Figure 1) did not show any findings of acute coronary syndrome (ACS). 

Tracing and discussion:  

16. Little Utility of the Cardiac Component of FAST in Blunt Trauma 

Press GM, et al. J Emerg Med. 2013;44:9-16.  

Background: Focused assessment with sonography in trauma (FAST) is widely used and endorsed by guidelines, but little evidence exists regarding the utility of the cardiac portion in blunt trauma. The traditional FAST includes the routine performance of cardiac sonography, regardless of risk for hemopericardium. 

Study Objectives: Our goal was to estimate the prevalence of hemopericardium due to blunt trauma and determine the sensitivity of certain variables for the presence of blunt hemopericardium. 

Methods: We performed a retrospective chart review of two institutional databases at a large urban Level I trauma center to determine the prevalence of blunt hemopericardium and cardiac rupture and incidental or insignificant effusions. We evaluated the sensitivity of major mechanism of injury, hypotension, and emergent intubation for blunt hemopericardium and cardiac rupture. 

Results: Eighteen patients had hemopericardium and cardiac rupture (14 and 4, respectively) out of 29,236 blunt trauma patients in the Trauma Registry over an 8.5-year period. The prevalence was 0.06% (95% confidence interval [CI] 0.04–0.09%). The prevalence of incidental or insignificant effusions was 0.13% (95% CI 0.09–0.18%). One case of blunt hemopericardium was identified in the emergency ultrasound database out of 777 cardiac ultrasounds over a 3-year period. No patient with blunt hemopericardium or cardiac rupture presented without a major mechanism of injury, hypotension, or emergent intubation. 

Conclusion: Blunt hemopericardium is rare. High-acuity variables may help guide the selective use of echocardiography in blunt trauma. 

17. Implications of new anticoagulants in primary practice. 

Perez A, et al. Int J Clin Pract. 2013 Feb;67(2):139-56.  

Background:  Effective prophylaxis and treatment of thromboembolic disorders remain suboptimal in many healthcare systems, partly owing to limitations of traditional anticoagulants. New oral anticoagulants have been developed and among these, rivaroxaban, apixaban and dabigatran etexilate are in the most advanced stage of clinical development.  

Method:  A literature search using the PubMed and databases was performed to identify English-language publications. The search was performed up to 31 December 2011 with the terms rivaroxaban OR Xarelto, apixaban OR Eliquis and dabigatran OR Pradaxa. Ongoing, completed and published phase III randomised controlled trials were selected as the primary source of information for the clinical development programme of each drug.  

Results:  The new oral agents demonstrate several advantages over traditional anticoagulants, including administration at fixed doses and no requirement for routine coagulation monitoring On the basis of phase III clinical trials, rivaroxaban, apixaban and dabigatran etexilate have been approved in many countries for the prevention of venous thromboembolism after hip and knee replacement surgery. Dabigatran etexilate and rivaroxaban have also been approved for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation in Europe and the US. In addition, rivaroxaban has been approved in Europe for the treatment of acute deep vein thrombosis and prevention of recurrent venous thromboembolism. Approval of these agents and postapproval monitoring of their safety and efficacy will have implications for primary care.  

Conclusion:  Rivaroxaban, apixaban and dabigatran etexilate offer the possibility of simplified prevention and treatment strategies for thromboembolic disorders in the outpatient setting. 

18. Extremely Low Risk for Acquisition of a Respiratory Viral Infection in the ED of a Large Pediatric Hospital during the Winter Season 

Maltezou HC, et al. Influenza Resp Viruses. 2013;7(1):14-17. 

The aim of this study was to investigate the rate of transmission of respiratory viral infections to children visiting the emergency room of a large pediatric hospital during winter. A total of 615 children were prospectively studied. Twenty-two (3·6%) children developed at least one symptom compatible with a respiratory viral infection within 1-7 days after the visit, including cough (12 children), fever (8), rhinorrhea (7), and/or respiratory distress (1). Three children (0·49%) developed an influenza-like illness. These findings indicate that transmission of respiratory viral infections to children visiting an emergency room during the winter season is extremely low. 

19. The Ultrasound-guided “Peripheral IJ”: Internal Jugular Vein Catheterization using a Standard Intravenous Catheter 

Teismann NA, et al. J Emerg Med. 2013;44:150-154. 

Background: Obtaining vascular access is difficult in certain patients. When routine peripheral venous catheterization is not possible, several alternatives may be considered, each with its own strengths and limitations. 

Discussion: We describe a novel technique for establishing vascular access in Emergency Department (ED) patients: the placement of a standard catheter-over-needle device into the internal jugular vein using real-time ultrasound guidance. We present a series of patients for whom this procedure was performed after other attempts at vascular access were unsuccessful. In all cases, the procedure was performed quickly and without complications. 

Conclusion: Although further study of this technique is required, we believe this procedure may be a valuable option for ED patients requiring rapid vascular access. 

20. Medical Malpractice (Video Journalism on PBS) 

·         Do no harm: Every year, one in 14 doctors in America will be sued for malpractice. Most lawsuits will be dismissed, or resolved in favor of the doctor; but the cost of insuring against such suits can be huge. 

·         The Danish option: A closer look at how medical malpractice is handled in Denmark, by taking litigation out of the equation completely. Supporters of the system say it makes it easier for doctors to practice medicine, and for injured patients to get compensated quickly. 

·         Prescriptive policies for medical malpractice: Can the U.S. change its costly court-based way of dealing with medical mistakes?  Stuck between tort reform and patient’s rights — see what some states are trying. 

21. ED Imaging Concerns Raised for Academic Medical Centers 

Mitka M. JAMA. 2013;309(4):329-330. 

Chicago—Academic medical centers are often considered the top facilities for delivering health care, but some observers think the majority of these institutions should do more to ensure expert radiology coverage in the emergency department at all times. In most centers, coverage during the off hours is usually provided by a radiology resident, who is more likely than an experienced attending radiologist to make errors when assessing imaging tests. 

At the November meeting of the Radiology Society of North America held here, Stephen M. Ledbetter, MD, MPH, an assistant professor of radiology at the Harvard Medical School and chief of radiology at Brigham and Women's Hospital in Boston, said that only 10% of academic medical centers have 24-hour coverage 7 days a week by attending radiologists (Hunter TB et al. J Am Coll Radiol. 2007;4[10]:716-719). He called on his colleagues to establish such comprehensive coverage of emergency departments… 

Academic medical centers are urged to have an experienced radiologist available for emergency department coverage at all times, rather than relying on a radiology resident during off hours. 

“If we talk about patient-centered care, the people who argue for 24/7 coverage would say this is the highest form of care we can deliver; the radiologist is always there, not just for interpreting studies but also for bringing his or her expertise in overseeing the resident and technologist to make sure the study was done properly with the least radiation possible,” said Ledbetter in an interview. “For someone like me, an advocate for establishing emergency radiology, the physical presence of a radiologist, engaging with the emergency physician to provide emergency radiology, is the right way to go.” 

Ledbetter's call for comprehensive radiology coverage in academic medical center emergency departments also resonates in the emergency medicine community, including with Sandra M. Schneider, MD, a professor of emergency medicine at the University of Rochester Medical Center's School of Medicine and Dentistry in Rochester, NY, and past president of the American College of Emergency Physicians. “Traditionally, academic medical centers used residents and their judgment on emergency imaging tests during the off hours,” Schneider said. “As an attending, I’m less comfortable with this, and as a patient, I’d be even less comfortable with it.” 

Given the significantly increased use of advanced radiologic imaging in the emergency department in recent years, lacking full-time coverage with radiologists in the emergency setting is a quality-of-care issue, agreed Frederick K. Korley, MD, an assistant professor of emergency medicine at Johns Hopkins Medical School in Baltimore. For example, the prevalence of computed tomography or magnetic resonance imaging during emergency department visits for injury-related conditions increased from 6% in 1998 to 15% in 2007 (Korley FK et al. JAMA. 2010;304[13]:1465-1471). 

“The emergency department never sleeps, so we're seeing patients 24 hours a day, and they don't choose when they get sick and need important imaging studies,” Korley said. “There have been some small radiology studies looking at the discrepancy rate in reads between residents and attendings that found the error rate is pretty low, but ‘low’ still means someone's mother or father is being wrongly diagnosed. And even if the condition is not life threatening, you may inconvenience the patient if he or she needs to come back to the hospital.”… 

The remainder of the essay (full-text free):  

22. Patients Suffer if Hospitalists Overworked 

Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists  

Michtalik HJ, et al.  JAMA Intern Med. 2013;():1-2. [Epub ahead of print] 

Many attending physicians said they feel overburdened to the point where it negatively impacts patient evaluations, satisfaction, and possibly safety outcomes. 

Point out that nearly one-quarter of hospitalists reported that excess workload adversely impacted patient outcomes by preventing full discussion of treatment options. 

23. CDC: Produce Biggest Player in Foodborne Illness

By Cole Petrochko, Staff Writer, MedPage Today, January 30, 2013 

Nearly half of all foodborne illnesses are caused by tainted produce, but the greatest number of attributable deaths are caused by poultry consumption, according to data released by the CDC. 

Leafy vegetables were the source of the most foodborne illnesses from 1998 to 2008 -- accounting for some 22% of illnesses and 14% of hospitalizations -- and made up part of the 46% of produce-based foodborne illnesses during that decade, according to John Painter, PhD, of the CDC, and colleagues. 

The analysis, released Tuesday, showed that poultry was responsible for nearly one fifth of all foodborne illness-related deaths (19.1%), mostly a result of contamination from Listeria monocytogenes or Salmonella bacteria, they wrote online in Emerging Infectious Diseases. 

The researchers noted that over an estimated 9 million foodborne illnesses are acquired in the U.S. annually, but that "preventing these illnesses is challenging because resources are limited and linking individual illnesses to a particular food is rarely possible except during an outbreak." 

In order to establish this first national estimate of foodborne illness, the CDC organized all state and local health departments' foodborne disease outbreak reports from 1998 to 2008 under 17 "mutually exclusive" food categories, such as leafy vegetables, vine vegetables, fruits and nuts, pork, fish, and eggs. 

Reports contained information on whether an agent was confirmed or suspected and how that agent was confirmed, such as statistical evidence from an epidemiologic investigation, laboratory results, supporting data, previous similar experience, or other types of data. The authors noted that a "large proportion" of these reports were missing tests or documentation. 

Also included in reports were the number of acquired illnesses, hospitalizations, and deaths based on published estimated or available data. 

Over the 10-year period, there were 13,352 foodborne disease outbreaks that caused 271,974 illnesses. Over one-third of the outbreaks -- 4,589 -- were associated with nearly half of all outbreak illnesses -- 120,321 -- and were sourced to a food vehicle with a single etiology. These illnesses were caused by a total of 36 viruses or bacteria. 

Almost half of the included outbreaks contained complex food agents (49%) -- food agents that contained ingredients from more than one food group. 

"Norovirus caused the most outbreaks (1,419) and outbreak-associated illnesses (41,257)," they wrote, noting that it was well above the median of all agents. 

Outbreak data was used to form estimates of the 9.6 million estimated food-based illnesses. The investigators attributed 4.9 million illnesses to plant sources, 4 million to land animal sources, and 600,000 to aquatic animal sources.

Nearly half of all illnesses were the result of produce consumption -- sources from the fruits and nuts group as well as five vegetable categories -- and meat and poultry illnesses accounted for less than a quarter (22%). However, by individual category of food agent, dairy was the second most common source of foodborne illness (14%) after leafy vegetables. 

"The high estimate for illnesses attributable to leafy vegetables was many times higher than the low estimate, which indicates that leafy vegetables were frequently found in complex foods," they noted. 

Most hospitalizations due to foodborne illness were caused by dairy (16%), leafy vegetables (14%), poultry (12%), or fruits and nuts (10%). Most deaths were due to poultry (19%), dairy (10%), vine-grown vegetables (7%), fruits and nuts (6%), and leafy vegetables (6%). 

Bacterial illnesses were most commonly spread through dairy, poultry, and beef sources, while plant sources were the most common source of viral pathogens. 

The authors noted that overall illness data was based on a number of assumptions, such as the assumption that using the number of outbreak-associated illnesses "would enable better assignment of illnesses to commodities," that outbreak illnesses represented all illnesses, and that complex food-based outbreaks' agents of illness were proportional to the frequency of illnesses tied to individual agents. 

They also noted that additional data on specific foods consumed would be needed to measure per-serving risks for various foods, but added that even foods with low risks for pathogens can result in large numbers of illnesses if consumed frequently enough. 

"The risk for foodborne illness is just one part of the risk-benefit equation for foods; other factors, such as health benefits of consuming a diet high in fruits and vegetables, must be considered," they concluded. 

The authors said the study was limited by the absence of outbreaks caused by some agents, such as some that cause fatal illnesses. Other limitations included lack of credible intervals for estimated illnesses, hospitalizations, and deaths; lack of data on chemical-based illnesses; and absent quality and quantity of data in some reports. 

The authors declared no conflicts of interest. 

Painter JA, et al. Attribution of foodborne illnesses, hospitalizations, and deaths to food commodities by using outbreak data, United States, 1998-2008. Emerg Infect Dis 2013; DOI: 10.3201/eid1903.1111866. 

See also: Major Foodborne Illness Outbreaks of 2012 

Division of Foodborne, Waterborne, and Environmental Diseases,

National Center for Emerging and Zoonotic Infectious Diseases, CDC, January 29, 2013