Saturday, April 13, 2013

Lit Bits: April 13, 2013

From the recent medical literature...

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

 Penaloza A, et al. Ann Emerg Med. 2013 Feb 20. [Epub ahead of print] 

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. 

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. 

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. 

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:  

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 ( 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. ( 


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 . . . 

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):  

B. Alternative Treatments of Pneumothorax 

Repanshek ZD, et al. J Emerg Med. 2013;44(2):457-466. 

Full-text free (with registration): 

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):  

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. 

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. 

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… 

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):  

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:  

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): 

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.