1. Angina? Heartache Is Same in Men and Women
By Todd Neale, Senior Staff Writer, MedPage Today. April 08,
2013
Contrary to widespread belief, symptoms of obstructive
coronary artery disease are generally similar in men and women, researchers
found.
The three most common terms used by men and women to
describe obstructive CAD were the same -- chest pain (used by 82% of men and
84% of women), pressure (54% and 58%), and tightness (43% and 58%) -- with no
significant between-sex differences, according to Catherine Kreatsoulas, PhD,
of the Harvard School of Public Health, and colleagues.
Women were more likely than men to use some terms but,
overall, the symptoms largely overlapped, the investigators reported online in
a research letter in JAMA Internal Medicine.
"In the past, the terminology of typical and atypical
angina has been a source of controversy in understanding coronary artery
disease in women, and we really hope that this research and our findings show
that men and women have an enormous overlap of symptoms ...," Kreatsoulas
said in an interview.
In their paper, she and her colleagues noted that "the
choice of terms used to describe a symptom may be a function of gendered
language rather than of conventionally portrayed biological sex
difference."
Although rates of angina and the proportion of deaths from
CAD are higher in women, there remains a perception that CAD is not as big a
problem in women as in men, a belief perpetuated by "historic faulty
assumptions in the construct of angina, failure to systematically include women
in clinical studies, and differences in age-specific incidence rates,"
according to the researchers. Thus, in practice, the term "typical
angina" has been used to describe symptoms in men and the term "atypical
angina" has been used to describe women's symptoms.
To explore whether the distinction is real, the researchers
examined symptoms among 128 men and 109 women who were undergoing their first
coronary angiogram because of suspected CAD and/or angina and who had had at least
one previous abnormal cardiac test result. The women were less likely to have
obstructive CAD (46% versus 70%, P less than 0.001), defined as having at least one
vessel with a diameter of 2 mm or more with at least 70% stenosis.
Although the three most common terms used to describe
symptoms were similar among men and women with obstructive CAD, women were more
likely to use the following terms: discomfort (46% versus 28%), crushing (24%
versus 9%), pressing (28% versus 14%), and bad ache (30% versus 15%). Men and
women overwhelmingly used the same terms to describe pain in parts of the body
aside from the chest and other symptoms associated with the chest-related
symptoms. Women did, however, report having dry mouth at a higher rate (34%
versus 18%, P=0.04).
"This information can help clinicians to better
contextualize symptoms associated with obstructive CAD rather than adhering to
the conventional 'typical' and 'atypical' angina distinction," Kreatsoulas
and colleagues wrote.
In an accompanying note, Rita Redberg, MD, of the University
of California San Francisco, an editor for the journal, wrote that the study
reassures "us that women and men are more alike than we think in
presentation of CAD, and both are most likely to experience chest pain, pressure,
and tightness. It is likely that atypical symptoms represent women who do not
have ischemic CAD."
"These findings should be a great relief to the many
women who have been concerned that they could be having a myocardial infarction
unbeknownst to them because they would not get the typical warning symptoms of
chest pain," Redberg wrote.
2. Comparison of the Unstructured Clinician Gestalt,
the Wells Score, and the Revised Geneva Score to Estimate Pretest Probability
for Suspected PE
Study objective: The assessment of clinical probability (as
low, moderate, or high) with clinical decision rules has become a cornerstone
of diagnostic strategy for patients with suspected pulmonary embolism, but little
is known about the use of physician gestalt assessment of clinical probability.
We evaluate the performance of gestalt assessment for diagnosing pulmonary
embolism.
Methods: We conducted a retrospective analysis of a
prospective observational cohort of consecutive suspected pulmonary embolism
patients in emergency departments. Accuracy of gestalt assessment was compared
with the Wells score and the revised Geneva score by the area under the curve
(AUC) of receiver operating characteristic curves. Agreement between the 3
methods was determined by κ test.
Results: The study population was 1,038 patients, with a
pulmonary embolism prevalence of 31.3%. AUC differed significantly between the
3 methods and was 0.81 (95% confidence interval [CI] 0.78 to 0.84) for gestalt
assessment, 0.71 (95% CI 0.68 to 0.75) for Wells, and 0.66 (95% CI 0.63 to
0.70) for the revised Geneva score. The proportion of patients categorized as
having low clinical probability was statistically higher with gestalt than with
revised Geneva score (43% versus 26%; 95% CI for the difference of 17%=13% to
21%). Proportion of patients categorized as having high clinical probability
was higher with gestalt than with Wells (24% versus 7%; 95% CI for the
difference of 17%=14% to 20%) or revised Geneva score (24% versus 10%; 95% CI
for the difference of 15%=13% to 21%). Pulmonary embolism prevalence was
significantly lower with gestalt versus clinical decision rules in low clinical
probability (7.6% for gestalt versus 13.0% for revised Geneva score and 12.6%
for Wells score) and non–high clinical probability groups (18.3% for gestalt
versus 29.3% for Wells and 27.4% for revised Geneva score) and was
significantly higher with gestalt versus Wells score in high clinical
probability groups (72.1% versus 58.1%). Agreement between the 3 methods was
poor, with all κ values below 0.3.
Conclusion: In our retrospective study, gestalt assessment
seems to perform better than clinical decision rules because of better
selection of patients with low and high clinical probability.
3. Clinical prediction model to aid emergency
doctors managing febrile children at risk of serious bacterial infections:
diagnostic study
Nijman RG, et al. BMJ 2013;346:f1706
Objective To derive, cross validate, and externally validate
a clinical prediction model that assesses the risks of different serious
bacterial infections in children with fever at the emergency department.
Design Prospective observational diagnostic study.
Setting Three paediatric emergency care units: two in the
Netherlands and one in the United Kingdom.
Participants Children with fever, aged 1 month to 15 years,
at three paediatric emergency care units: Rotterdam (n=1750) and the Hague
(n=967), the Netherlands, and Coventry (n=487), United Kingdom. A prediction
model was constructed using multivariable polytomous logistic regression
analysis and included the predefined predictor variables age, duration of
fever, tachycardia, temperature, tachypnoea, ill appearance, chest wall
retractions, prolonged capillary refill time (over 3 seconds), oxygen saturation
below 94%, and C reactive protein.
Main outcome measures Pneumonia, other serious bacterial
infections (SBIs, including septicaemia/meningitis, urinary tract infections, and
others), and no SBIs.
Results Oxygen saturation below 94% and presence of tachypnoea
were important predictors of pneumonia. A raised C reactive protein level
predicted the presence of both pneumonia and other SBIs, whereas chest wall
retractions and oxygen saturation below 94% were useful to rule out the presence
of other SBIs. Discriminative ability (C statistic) to predict pneumonia was
0.81 (95% confidence interval 0.73 to 0.88); for other SBIs this was even
better: 0.86 (0.79 to 0.92). Risk thresholds of 10% or more were useful to
identify children with serious bacterial infections; risk thresholds less than
2.5% were useful to rule out the presence of serious bacterial infections.
External validation showed good discrimination for the prediction of pneumonia
(0.81, 0.69 to 0.93); discriminative ability for the prediction of other SBIs
was lower (0.69, 0.53 to 0.86).
Conclusion A validated prediction model, including clinical
signs, symptoms, and C reactive protein level, was useful for estimating the
likelihood of pneumonia and other SBIs in children with fever, such as
septicaemia/meningitis and urinary tract infections.
Full-text (free): http://www.bmj.com/content/346/bmj.f1706
4. Evaluation for Bleeding Disorders in Suspected
Child Abuse
New guidelines in the journal Pediatrics say physicians
should be aware that blood disorders can cause bruising and bleeding that may
raise alarms about the possibility of abuse or neglect. Comprehensive lab and physical
screenings and a medical history can help distinguish illness from abuse,
according to the report from the American Academy of Pediatrics' Section on
Hematology/Oncology and Committee on Child Abuse and Neglect.
Anderst JD, et al. Pediatrics 2013; Published online March
25, 2013
Abstract: Bruising or bleeding in a child can raise the
concern for child abuse. Assessing whether the findings are the result of
trauma and/or whether the child has a bleeding disorder is critical. Many
bleeding disorders are rare, and not every child with bruising/bleeding
concerning for abuse requires an evaluation for bleeding disorders. In some
instances, however, bleeding disorders can present in a manner similar to child
abuse. The history and clinical evaluation can be used to determine the
necessity of an evaluation for a possible bleeding disorder, and prevalence and
known clinical presentations of individual bleeding disorders can be used to
guide the extent of the laboratory testing. This clinical report provides
guidance to pediatricians and other clinicians regarding the evaluation for
bleeding disorders when child abuse is suspected.
Full-text (free): http://pediatrics.aappublications.org/content/early/2013/03/26/peds.2013-0195.full.pdf+html
5. The Prevalence of Traumatic Brain Injuries after
Minor Blunt Head Trauma in Children with Ventricular Shunts
Nigrovic LE, et al. with the PECARN. Ann Emerg Med.
2013;61:389-393.
Study objective: We compare the prevalence of clinically
important traumatic brain injuries and the use of cranial computed tomography
(CT) in children with minor blunt head trauma with and without ventricular
shunts.
Methods: We performed a secondary analysis of a prospective
observational cohort study of children with blunt head trauma presenting to a
participating Pediatric Emergency Care Applied Research Network emergency
department. For children with Glasgow Coma Scale (GCS) scores greater than or
equal to 14, we compared the rates of clinically important traumatic brain
injuries (defined as a traumatic brain injury resulting in death, neurosurgical
intervention, intubation for more than 24 hours, or hospital admission for at least
2 nights for management of traumatic brain injury in association with positive
CT scan) and use of cranial CT for children with and without ventricular
shunts.
Results: Of the 39,732 children with blunt head trauma and
GCS scores greater than or equal to 14, we identified 98 (0.2%) children with
ventricular shunts. Children with ventricular shunts had more frequent CT use:
(45/98 [46%] with shunts versus 13,858/39,634 [35%] without; difference 11%;
95% confidence interval 1% to 21%) but a similar rate of clinically important
traumatic brain injuries (1/98 [1%] with shunts versus 346/39,619 [0.9%]
without; difference 0.1%; 95% confidence interval −0.3% to 5%). The one child
with a ventricular shunt who had a clinically important traumatic brain injury
had a known chronic subdural hematoma that was larger after the head trauma
compared with previous CT; the child underwent hematoma evacuation.
Conclusion: Children with ventricular shunts had higher CT
use with similar rates of clinically important traumatic brain injuries after
minor blunt head trauma compared with children without ventricular shunts.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01497-7/fulltext
6. Physician-Assisted Suicide Program Wins Praise
By John Gever, Deputy Managing Editor, MedPage Today. April
10, 2013
Patients, their families, and physicians have been satisfied
with a "death with dignity" physician-assisted suicide program made
available to terminal cancer patients at a Seattle clinic, clinicians there
reported.
Among 114 patients who asked about the program at the
Seattle Cancer Care Alliance, the outpatient clinic for the city's major cancer
treatment centers, 40 passed screening examinations and ultimately received
lethal prescriptions for secobarbital, although only 24 actually took the drug,
according to Elizabeth Trice Loggers, MD, PhD, and colleagues at the clinic and
its affiliated centers.
"Patients, caregivers, and family members have
frequently expressed gratitude after the patient obtained the prescription,
regardless of whether it was ever filled or ingested, typically referencing an
important sense of control in an uncertain situation," the authors wrote
in the April 11 issue of the New England Journal of Medicine.
"Our Death with Dignity program both allows patients
with cancer who wish to consider this option to do so within the context of
their ongoing care and accommodates variation in clinicians' willingness to
participate," they added. "The program ensures that patients (and
families) are aware of all the options for high-quality, end-of-life care,
including palliative and hospice care, with the opportunity to have any
concerns or fears addressed, while also meeting state requirements."
"I think what they have done is both very responsible
and really improves the quality of the safeguards that are already in the
law," said Linda Ganzini, MD, MPH, of the Oregon Health and Science
University in Portland, in an interview with MedPage Today.
Ganzini, who had helped the Seattle group in designing their
program, noted that the report had certain limitations -- mainly that it didn't
address the larger experience in Washington and Oregon with physician-assisted suicide,
and that the report was not an independent, outside assessment of the Seattle
clinic's implementation. The program was instituted following Washington
state's enactment of legislation in 2008 allowing physician-assisted suicide.
Loggers and colleagues explained that the law set certain ground rules to be
followed before a physician could write a lethal prescription.
Patients must make two oral requests, with an interval of at
least 15 days between, plus a written request in order to begin the process.
Prescribing physicians as well as a different consulting physician must then
confirm that the patient's disease is terminal (life expectancy 6 months or
less), and also that the patient is competent and voluntarily requesting the
prescription. An informed consent process is required, and, when the
prescription is being written, physicians must give the patient a chance to
rescind the request. Prescriptions must be given directly to a pharmacist, who
gives the lethal drug directly to the patient or an authorized agent.
However, after what Loggers and colleagues called
"considerable internal debate," officials at the Seattle Cancer Care
Alliance added additional safeguards.
For example, the clinic will not accept patients who come
with the sole purpose of obtaining a lethal drug dose. It also adopted a policy
against advertising or promoting the program, with no information about it
posted in public spaces. In addition, whereas the state legislation indicated
that physicians should "recommend" that patients not take the lethal
dose in a public area, the clinic requires that patients sign a statement
promising not to do so.
And the clinic decided that it would permit staff and
faculty physicians to opt out of participating in the program. A preliminary
survey in which 81 clinicians responded found that nearly 40% were either
unwilling or undecided about serving as prescribing or consulting physicians.
Some 26% indicated that would act as consulting physicians but would not write
prescriptions themselves…
See related article of alternative viewpoints: http://www.nejm.org/doi/full/10.1056/NEJMclde1302615
7. New Neurosurgical Guidelines Warn of Harm from
Steroids in Acute Spinal Injury
Comprehensive consensus guidelines contain 112
evidence-based recommendations, including that methylprednisolone should not be
used for treatment of acute spinal cord injury.
The Congress of Neurological Surgeons and the American
Association of Neurological Surgeons released a revised version of the original
2002 evidence-based guidelines for management of acute cervical spine and
spinal cord injuries (http://journals.lww.com/neurosurgery/toc/2013/03002). Of
112 recommendations (the previous version contained 76), 19 are classified as
level I recommendations, 16 as level II, and 77 as level III. Due to lack of
evidence, the panel offered no recommendations on certain topics of interest
such as, for example, the benefit or harm of hypothermia in patients with
spinal cord injury.
Changes most relevant to emergency medicine include:
• Methylprednisolone is not recommended for acute spinal
cord injury, because no class I or II evidence supports its benefit. Class I,
II, and III evidence indicate a higher incidence of infection, sepsis,
complications, increased intensive care unit length of stay, and death with
steroid use. (Level 1 recommendation)
• Computed tomography is the imaging study of choice for
obtunded or un-evaluable patients with potential cervical spine injuries.
(Level I)
• Computed tomographic angiography is recommended to assess
for vertebral artery injury in selected patients who meet the modified Denver
Screening Criteria after blunt cervical trauma. (Level I)
• Spinal immobilization and imaging are not recommended in
patients with penetrating or blunt trauma who have normal mentation, no neck
pain or tenderness, no focal neurologic findings, and no distracting injuries.
(Level II)
Comment: Another indication for steroids bites the dust! For
those of us who were not convinced by the original data, we now have expert
consensus to put an end, once and for all, to the misguided notion that steroid
treatment is indicated for patients with acute spinal injury.
— Kristi L. Koenig, MD, FACEP, FIFEM
Published in Journal Watch Emergency Medicine April 12,
2013. Citation(s): Resnick DK. Updated guidelines for the management of acute
cervical spine and spinal cord injuries. Neurosurgery 2013 Mar; 72:1.
(http://dx.doi.org/10.1227/NEU.0b013e318276ee7e)
Full-text (free): http://journals.lww.com/neurosurgery/toc/2013/03002
8. Fresh Frozen Plasma for Progressive and
Refractory Angiotensin-Converting Enzyme Inhibitor-induced Angioedema
Hassen GW, et al. J Emerg Med. 2013;44:764-772.
Background: Angioedema secondary to angiotensin-converting
enzyme inhibitors (ACEI) is a commonly encountered problem in the Emergency
Department (ED). The treatment of ACEI-induced edema with conventional methods
such as epinephrine, steroids, and antihistamines is usually not effective.
There is limited experience using bradykinin receptor blockers and fresh frozen
plasma (FFP) as a treatment modality for ACEI-induced angioedema.
Objective: To emphasize alternative treatment option for
ACEI-induced angioedema in the ED.
Case Reports: We report a case series of progressive and
refractory presumed ACEI-induced angioedema that all improved in temporal
association with administration of FFP, with a brief review of the literature.
Conclusion: There was a temporal association between the
administration of FFP and improvement in angioedema in seven cases of presumed
ACEI-induced angioedema that were refractory to antihistamines, corticosteroids,
and epinephrine.
9. Clinical Decision Tool Identifies Boys at Low
Risk for Testicular Torsion
No child with a normal testicular lie, age less than 11 years, and
absence of nausea or vomiting had torsion.
Shah MI et al. Acad Emerg Med 2013 Mar; 20:271-278.
Objective: The purpose of this study was to derive a pilot
clinical decision tool with 100% negative predictive value for testicular
torsion based on prospectively collected data in children with acute scrotal
pain.
Methods: This was a prospective cohort study of a
convenience sample of newborn to 21-year-old males evaluated for acute (72
hours or less) scrotal pain at an urban children's hospital emergency
department (ED). A pediatric emergency medicine fellow or attending physician
documented history and examination findings on a standardized data collection
form. The study investigators used ultrasound (US), operative reports, or
clinical follow-up to identify patients who had testicular torsion. Pearson's
chi-square test and odds ratios (OR) were used to identify factors associated
with the diagnosis of testicular torsion. The authors also used a recursive
partitioning model to create a low-risk decision tool for testicular torsion.
Results: Of the 450 eligible patients, 228 (51%) were enrolled,
with a mean (±SD) age of 9.9 (±4.1) years, including 21 (9.2%, 95% confidence
interval [CI] = 5.8% to 13.7%) with testicular torsion. The derived clinical
decision tool consisted of three variables: horizontal or inguinal testicular
lie (OR = 18.17, 95% CI = 6.2 to 53.2), nausea or vomiting (OR = 5.63, 95% CI =
2.08 to 15.22), and age 11 to 21 years (OR = 3.9, 95% CI = 1.27 to 11.97).
These variables had a sensitivity of 100% (95% CI = 98% to 100%) and negative
predictive value of 100% (95% CI = 98% to 100%) for the diagnosis of testicular
torsion.
Conclusions: Based on a decision tool derived with recursive
partitioning, study patients with all of the following characteristics had no
risk of testicular torsion: normal testicular lie, lack of nausea or vomiting,
and age 0 to 10 years. Future research should focus on externally validating
this tool to optimize emergent evaluation when testicular torsion is likely,
while minimizing routine sonographic evaluation when patients are unlikely to
have a serious condition requiring immediate management.
10. Images in Clinical Medicine
Young Child with Cyst on Tongue
Young Man with Fever and Shortness of Breath
Melanoma in the Oral Cavity
Bulimia Nervosa
Torus Palatinus
Pneumatosis Intestinalis
Primary Raynaud’s Phenomenon
11. Interactive Medical Case in NEJM
A 54-year-old woman presented with a headache that had
started 8 days earlier. She had awoken with stabbing, squeezing pain around her
entire head. She rated the pain at 10 on a scale of 0 to 10 (known as 10/10),
with 10 representing the worst pain imaginable. The pain was not alleviated by
nonsteroidal antiinflammatory drugs (NSAIDs). She reported having had no
headache on going to sleep . . .
Full-text (free): http://www.nejm.org/doi/full/10.1056/NEJMimc1208949
12. Medscape’s J
Emerg Med Clinical Reviews
A. Emergency
Department Management of Pediatric Patients with Cyanotic Heart Disease and
Fever
Tibbles CD, et al. J Emerg Med. 2013;44(3):599-604.
Full-text free (with registration): http://www.medscape.com/viewarticle/780704
B. Alternative
Treatments of Pneumothorax
Repanshek ZD, et al. J Emerg Med. 2013;44(2):457-466.
Full-text free (with registration): http://www.medscape.com/viewarticle/779392
C. Synthetic
Cannabinoid Intoxication: A Case Series and Review
Harris CR, et al. J Emerg Med. 2013;44(2):360-366.
Full-text free (with registration): http://www.medscape.com/viewarticle/779391
13. Fibrinolysis or
Primary PCI in STEMI?
Armstrong PW, et al, for the STREAM Investigative Team
N Engl J Med 2013; 368:1379-1387.
Background: It is not known whether prehospital
fibrinolysis, coupled with timely coronary angiography, provides a clinical
outcome similar to that with primary percutaneous coronary intervention (PCI)
early after acute ST-segment elevation myocardial infarction (STEMI).
Methods: Among 1892 patients with STEMI who presented within
3 hours after symptom onset and who were unable to undergo primary PCI within 1
hour, patients were randomly assigned to undergo either primary PCI or
fibrinolytic therapy with bolus tenecteplase (amended to half dose in patients
≥75 years of age), clopidogrel, and enoxaparin before transport to a
PCI-capable hospital. Emergency coronary angiography was performed if
fibrinolysis failed; otherwise, angiography was performed 6 to 24 hours after
randomization. The primary end point was a composite of death, shock,
congestive heart failure, or reinfarction up to 30 days.
Results: The primary end point occurred in 116 of 939
patients (12.4%) in the fibrinolysis group and in 135 of 943 patients (14.3%)
in the primary PCI group (relative risk in the fibrinolysis group, 0.86; 95%
confidence interval, 0.68 to 1.09; P=0.21). Emergency angiography was required
in 36.3% of patients in the fibrinolysis group, whereas the remainder of
patients underwent angiography at a median of 17 hours after randomization.
More intracranial hemorrhages occurred in the fibrinolysis group than in the
primary PCI group (1.0% vs. 0.2%, P=0.04; after protocol amendment, 0.5% vs.
0.3%, P=0.45). The rates of nonintracranial bleeding were similar in the two
groups
Conclusions: Prehospital fibrinolysis with timely coronary
angiography resulted in effective reperfusion in patients with early STEMI who
could not undergo primary PCI within 1 hour after the first medical contact.
However, fibrinolysis was associated with a slightly increased risk of
intracranial bleeding.
14. Annals of
Emergency Medicine Take-homes
A. Are Thrombolytics
Indicated for [all] Pulmonary Embolism?
Morton MJ, et al. Ann Emerg Med. 2013;61:455-57.
Take-Home Message: There is a lack of evidence to support
the routine administration of thrombolytics for the undifferentiated pulmonary
embolism patient.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)00131-X/fulltext
B. What Is the
Accuracy of Screening Instruments for Alcohol and Cannabis Misuse Disorders
Among Adolescents and Young Adults in the ED?
Louis M, et al. Ann Emerg Med. 2013;61:404-406.
Take-Home Message: The Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV) 2-item screen for alcohol misuse and
1-item Diagnostic Interview Schedule for Children question for cannabis abuse
are simple tools that could be adopted for emergency department (ED) use;
however, their performance requires validation.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01510-7/fulltext
15. Case Discussion: A
30-Year-Old Man with Fever, Myalgias, Arthritis, and Rash
Stone JH, Murali MR. N Engl J Med 2013; 368:1239-1245.
A 30-year-old man with a history of intravenous drug use was
admitted to this hospital because of fever, myalgias, arthritis, and rash.
The patient was in his usual state of health until 12 days
before admission, when 2 days after discharge from a detoxification clinic, he
reportedly self-administered heroin intravenously. Two days later, fever,
chills, cough, myalgias, anorexia, and malaise occurred and were associated
with the gradual onset of joint swelling and pain, an erythematous and
nonpruritic rash, and episodes of severe diaphoresis. The joint symptoms first
developed in the ankles, and during the 3 days before admission, they affected
his knees, hands, and elbows and were accompanied by weakness of the arms and
legs.
Two days before admission, the patient went to the emergency
department of another hospital. On examination…
Full-text (free): http://www.nejm.org/doi/full/10.1056/NEJMcpc1210260
16. Ketorolac in the
Treatment of Acute Migraine: A Systematic Review
Taggart E, et al. Headache. 2013;53(2):277-287.
This systematic review examined the effectiveness of
parenteral ketorolac (KET) in acute migraine. Acute migraine headaches are
common emergency department presentations, and despite evidence for various
treatments, there is conflicting evidence regarding the use of KET.
Searches of MEDLINE, EMBASE, Cochrane, CINAHL, and gray
literature sources were conducted. Included studies were randomized controlled
trials in which KET alone or in combination with abortive therapy was compared
with placebo or other standard therapy in adult patients with acute migraine.
Two reviewers assessed relevance, inclusion, and study quality independently,
and agreement was measured using kappa (k). Weighted mean differences (WMD) and
relative risks are reported with 95% confidence intervals (CIs).
Overall, the computerized search identified 418 citations
and 1414 gray literature citations. From a list of 34 potentially relevant
studies (k = 0.915), 8 trials were included, involving over 321 (141 KET)
patients. The median quality scores were 3 (interquartile range: 2–4), and two
used concealed allocation. There were no baseline differences in 10-point pain
scores (WMD = 0.07; 95% CI: −0.39, 0.54). KET and meperidine resulted in
similar pain scores at 60 minutes (WMD = 0.31; −0.68, 1.29); however, KET was
more effective than intranasal sumatriptan (WMD = −4.07; 95% CI: −6.02 to
−2.12). While there was no difference in pain relief at 60 minutes between KET
and phenothiazine agents (WMD = 0.82; 95% CI: −1.33 to 2.98), heterogeneity was
high (I2 = 70%). Side effect profiles were similar between KET and comparison
groups.
Overall, KET is an effective alternative agent for the
relief of acute migraine headache in the emergency department. KET results in
similar pain relief, and is less potentially addictive than meperidine and more
effective than sumatriptan; however, it may not be as effective as
metoclopramide/phenothiazine agents.
Full-text (c registration): http://www.medscape.com/viewarticle/780359
17. Age-related
Differences in Propofol Dosing for Procedural Sedation in the ED
Patanwala AE, et al. J Emerg Med. 2013;44:823-828.
Background: Propofol dose requirements may differ in the
elderly due to age-related changes in pharmacokinetic or pharmacodynamic
variables.
Objective: The objective of this study was to determine the
effect of patient age on propofol dose required for procedural sedation in the
Emergency Department (ED).
Methods: This was a retrospective cohort study conducted in
a tertiary hospital ED. Adult patients who underwent procedural sedation in the
ED using propofol were grouped a priori by age into three categories: 18–40
years, 41–64 years, and ≥65 years. The median induction dose and total dose of
propofol required for the procedure was compared between the three age group
categories. Multivariate linear regression analyses were used to adjust for
confounders.
Results: A total of 170 patients were included in the final
analyses: 18–40 years (n = 66), 41–64 years (n = 59), and ≥65 years (n = 45).
The median induction dose was 1.4, 1, and 0.9 mg/kg, respectively; and the
median total propofol dose was 2, 1.7, and 1.2 mg/kg, respectively. The ≥65
year-old group required significantly less propofol (mg/kg) for induction
(compared to the 18–40-year-old group) and for the entire procedure (compared
to all other groups) (p < 0.001). In the multivariate linear regression
analyses, patient age was negatively predictive of induction dose (coefficient
−0.011, 95% confidence interval [CI] −0.017 to −0.005) and total dose
(coefficient −0.014, 95% CI −0.022–0.007) after adjusting for confounders.
Conclusion: Elderly patients may require lower doses of
propofol for procedural sedation in the ED, compared to younger adults
18. Ceftriaxone an
alternative to gent for infective endocarditis
In a recent study, the combination of ampicillin and
ceftriaxone was shown to be as effective as the combination of ampicillin and
gentamicin for treating Enterococcus faecalis infective endocarditis. In this
observational study, mortality rates did not differ significantly between the 2
treatments either during antimicrobial therapy or at 3-month follow-up. There
were also no significant differences in treatment failures resulting in a
change of antimicrobials or in disease relapses. According to study findings,
the need to interrupt antibiotic treatment as a result of adverse events
occurred significantly more often in patients treated with the
ampicillin/gentamicin combination, primarily because of newly developed renal
failure
For a review of infective endocarditis: http://emedicine.medscape.com/article/216650-overview
19. Medscape Slideshow
Case Presentations
Sampling of Cases
·
A Methamphetamine User with a Serious Underlying
Syndrome
·
A Teenage Girl with Acutely Worsening Abdominal
Pain
·
A 76-Year-Old Woman with Diffuse, Severe
Abdominal Pain
·
Persistent Projectile Vomiting in a Newborn
·
A Confused 24-Year-Old with Slurred Speech
Full-access (c registration): http://reference.medscape.com/features/slideshow/
20. Just FYI
A. Sticking to Meds
for Heart Disease Pays Dividends
Greater adherence to medications for primary and secondary
prevention of coronary artery disease appears to improve outcomes and lower
costs, a systematic review showed.
B. Let's Get
Physical: The Psychology of Effective Workout Music
New research clarifies why music and exercise make such a
good team, and how to create an optimal workout playlist
C. Docs Misinterpret
Trial Results
Primary care physicians need to interpret results of
randomised controlled trials assessing the efficacy of screening tests, but
there is no evidence that they interpret screening-related statistics
correctly.
D. Hemorrhagic
Complications in ED Patients Who Are Receiving Dabigatran Are Less Frequent and
More Benign Than with Warfarin
CONCLUSION: Our patients with dabigatran-induced bleeding
had a more benign clinical course with a shorter length of stay compared with
patients with warfarin-induced bleeding. As was the case in previous published
reports, there were fewer intracranial hemorrhages in patients receiving
dabigatran than warfarin. Sustaining an acute kidney injury potentially
predisposes patients to bleeding while receiving dabigatran.
E. Video Capsule
Endoscopy in the ED: A Prospective Study of Acute UGI Hemorrhage
Conclusion: Video capsule endoscopy is a sensitive way to
identify upper gastrointestinal hemorrhage in the ED. It is well tolerated and
there is excellent agreement in interpretation between gastroenterologists and
emergency physicians.
F. Heart Failure: Is
There a Breath Test?
Kathleen Struck, Senior Editor, MedPage Today. March 25,
2013
This was a prospective, single-center cohort study to assess
the feasibility of exhaled breath analysis to identify patients admitted for
acute decompensated heart failure.
Investigators were able to identify five ion peaks that were
incorporated into a canonical discriminant analysis model that successfully
distinguished patients with acute decompensated heart failure from control
patients.
Samara MA, et al. Single Exhaled Breath Metabolomic Analysis
Identifies Unique Breathprint in Patients with Acute Decompensated Heart
Failure. J Am Coll Cardiol. 2013 Mar 13. [Epub ahead of print]
G. AAN Releases New
Sports Concussion Guidelines
H. US for LP?
Ultrasound imaging can reduce the risk of failed or traumatic lumbar punctures and epidural catheterisations, as well as the number of needle insertions and redirections. Ultrasound may be a useful adjunct for these procedures.
Ultrasound imaging can reduce the risk of failed or traumatic lumbar punctures and epidural catheterisations, as well as the number of needle insertions and redirections. Ultrasound may be a useful adjunct for these procedures.
Full-text (free): http://www.bmj.com/content/346/bmj.f1720
