Sunday, May 26, 2013

Lit Bits: May 26, 2013

From the recent medical literature...

1. Tissue Injury Has Lead in New Stroke Definition

By Chris Kaiser, Cardiology Editor, MedPage Today. May 14, 2013

Action Points 

·         Even when no symptoms exist, if neuroimaging shows brain tissue injury, the insult should be called a stroke, according to an expert consensus document from the American Heart Association/American Stroke Association (AHA/ASA).
·         Point out that brain tissue injury rather than a fixed time designation should now be the primary distinguishing factor between stroke and transient ischemic attack. 

If neuroimaging shows brain tissue injury, the insult should be called a stroke, even if no symptoms exist, according to an expert consensus document from the American Heart Association/American Stroke Association (AHA/ASA).  

"A tissue-based definition of ischemic stroke and transient ischemic attack enhances diagnostic criteria and relies on utilization of various imaging techniques in the acute phase of the stroke," according to writing committee co-chair Scott E. Kasner, MD, of the University of Pennsylvania in Philadelphia, and colleagues.  

The experts correlated the updated stroke definition with a similar update to the definition of myocardial infarction, in which the term "acute coronary syndrome" is used before the determination of infarction has been made. "Nevertheless, these [cardiac] patients receive urgent evaluations and treatments intended to avert or minimize permanent myocardial tissue damage," they wrote in the statement published online in Stroke: Journal of the American Heart Association. 

Comparatively, the term "acute cerebrovascular syndromes" would not be inappropriate for the potential diagnosis of cerebral infarction, transient ischemic attack (TIA), or hemorrhage "in patients presenting within the first 24 hours from onset and before the completion of imaging tests." 

"The most important message here is that advances in neuroimaging, and in medical science in general, allow us to define stroke as any permanent injury to the central nervous system caused by a vascular disorder, whether there are symptoms or not," Kasner told MedPage Today. "If we have objective evidence of tissue injury, the insult should be called an ischemic stroke. If there is no objective evidence of tissue injury, it should be called a transient ischemic attack. But a transient event with evidence of tissue injury is now considered a stroke," Kasner explained. "The main difference from the standing definition of stroke is that we no longer base the determination of stroke on event duration, but rather on evidence of tissue injury," he said. 

Kasner, along with co-chair Ralph L. Sacco, MD, of the University of Miami, and other members of the team, were convened by the Stroke Council of the AHA/ASA to develop an expert consensus document for an "updated definition of stroke for the 21st century." 

One of the concerns of the committee was that the term "stroke" was not consistently defined in clinical practice, clinical research, or in assessments of the public health. The new definition, however, incorporates clinical and tissue criteria that will be useful in these three domains, researchers wrote. 

Kasner and colleagues outlined how the term "stroke" should be defined:
·         Central nervous system (CNS) infarction -- CNS infarction is brain, spinal cord, or retinal cell death attributable to ischemia based on pathological, imaging, or other objective evidence or clinical evidence including symptoms that persist more than 24 hours
·         Ischemic stroke -- An episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction
·         Silent CNS infarction -- Imaging or neuropathological evidence of CNS infarction, without a history of acute neurological dysfunction attributable to the lesion
·         Intracerebral hemorrhage -- Focal collection of blood in the brain that is not caused by trauma (includes parenchymal hemorrhages after CNS infarction, types I and II) 

Other types of brain insults the committee defined were stroke caused by intracerebral hemorrhage; cerebral hemorrhage; subarachnoid hemorrhage; stroke caused by subarachnoid hemorrhage; stroke caused by cerebral venous thrombosis; and stroke not otherwise specified. 

Particularly troubling to the writing committee were silent infarctions -- those discovered during routine MRI exams for non-stroke purposes such as dementia or head injury. "What should we do with patients who have silent infarcts? Should we treat them? Perform more carotid surgery or be more aggressive with medications?" Kasner asked. Treating them could be a slippery slope because for every one clinically identified stroke, there are five times as many silent infarctions, he said. 

There is little evidence about the long-term outcomes associated with silent infarctions. Ultimately, the writing group decided that its task was more about the definition of stroke, not its treatment. 

Overall, this update solidifies knowledge known for about a decade and increasingly incorporated into clinical practice. "Regarding silent infarcts, however, we probably need more time," Kasner commented. 

One of the challenges for hospitals is to have an MRI scanner available for diagnosing acute stroke. A head CT is a common imaging test in the acute setting, but MRI scanners are not as ubiquitous in U.S. emergency departments. "The CT scan can help rule out hemorrhage, but an MRI exam can tell us exactly what is wrong, especially in patients with transient symptoms," Kasner said. 

"No matter how transient, evidence of tissue injury puts those patients at a much higher risk of subsequent stroke in the short term. We need to have a high level of suspicion for stroke and identify those with tissue injury so secondary preventive measures can be taken," he concluded. 

Sacco RL, et al. An Updated Definition of Stroke for the 21st Century: A Statement for Healthcare Professionals From the AHA/American Stroke Association. 2013 7 May. [Epub ahead of print] 

2. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians
Mathews JD, et al. BMJ 2013;346:f2360 

Objective To assess the cancer risk in children and adolescents following exposure to low dose ionising radiation from diagnostic computed tomography (CT) scans. 

Design Population based, cohort, data linkage study in Australia. 

Cohort members 10.9 million people identified from Australian Medicare records, aged 0-19 years on 1 January 1985 or born between 1 January 1985 and 31 December 2005; all exposures to CT scans funded by Medicare during 1985-2005 were identified for this cohort. Cancers diagnosed in cohort members up to 31 December 2007 were obtained through linkage to national cancer records. 

Main outcome Cancer incidence rates in individuals exposed to a CT scan more than one year before any cancer diagnosis, compared with cancer incidence rates in unexposed individuals. 

Results 60 674 cancers were recorded, including 3150 in 680 211 people exposed to a CT scan at least one year before any cancer diagnosis. The mean duration of follow-up after exposure was 9.5 years. Overall cancer incidence was 24% greater for exposed than for unexposed people, after accounting for age, sex, and year of birth (incidence rate ratio (IRR) 1.24 (95% confidence interval 1.20 to 1.29); P less than 0.001). We saw a dose-response relation, and the IRR increased by 0.16 (0.13 to 0.19) for each additional CT scan. The IRR was greater after exposure at younger ages (P less than 0.001 for trend). At 1-4, 5-9, 10-14, and 15 or more years since first exposure, IRRs were 1.35 (1.25 to 1.45), 1.25 (1.17 to 1.34), 1.14 (1.06 to 1.22), and 1.24 (1.14 to 1.34), respectively. The IRR increased significantly for many types of solid cancer (digestive organs, melanoma, soft tissue, female genital, urinary tract, brain, and thyroid); leukaemia, myelodysplasia, and some other lymphoid cancers. There was an excess of 608 cancers in people exposed to CT scans (147 brain, 356 other solid, 48 leukaemia or myelodysplasia, and 57 other lymphoid). The absolute excess incidence rate for all cancers combined was 9.38 per 100 000 person years at risk, as of 31 December 2007. The average effective radiation dose per scan was estimated as 4.5 mSv. 

Conclusions The increased incidence of cancer after CT scan exposure in this cohort was mostly due to irradiation. Because the cancer excess was still continuing at the end of follow-up, the eventual lifetime risk from CT scans cannot yet be determined. Radiation doses from contemporary CT scans are likely to be lower than those in 1985-2005, but some increase in cancer risk is still likely from current scans. Future CT scans should be limited to situations where there is a definite clinical indication, with every scan optimised to provide a diagnostic CT image at the lowest possible radiation dose. 

3. Critical Care in the ED Is Increasing — It's Not Just Your Imagination!

 A. National Growth in ICU Admissions From EDs in the US from 2002 to 2009 

Mullins PM, et al. Acad Emerg Med. 2013;20:479-486.  

Objectives: The authors describe national trends in use, reasons for visit, most common diagnoses, and resource utilization in patients admitted to intensive care units (ICUs) from hospital-based emergency departments (EDs) in the United States. 

Methods: This was an observational study using data from the National Hospital Ambulatory Care Survey, a nationally representative, weighted sample of U.S. hospital-based EDs from 2002 through 2009. The sample comprised a total of 4,267 patients aged 18 years or older admitted to the ICU from the ED, which represent over 14.5 million ED encounters from 2002 through 2009. 

Results: Over the study period, ICU admissions from EDs increased from 2.79 million in 2002/2003, to 4.14 million in 2008/2009, an absolute increase of 48.8% and a mean biennial increase of 14.2%. By comparison, overall ED visits increased a mean of 5.8% per biennial period. The three most common diagnoses for ICU admissions were unspecified chest pain, congestive heart failure, and pneumonia. Utilization rates of most tests and services delivered to patients admitted to the ICU from the ED increased, with the largest increase occurring in computed tomography (CT) and magnetic resonance imaging (MRI), which increased from 16.8% in 2002/2003 to 37.4% in 2008/2009, a 6.9% mean biennial increase. Across all years, mean ED length of stay (LOS) for ICU admissions was 304 minutes (95% confidence interval [CI] = 286 to 323 minutes), and mean hospital LOS was 6.6 days (95% CI = 6.2 to 7.0 days). There was no significant change in either mean ED or hospital LOS over the study period. 

Conclusions: Intensive care unit admissions from EDs are increasing at a greater rate than both population growth and overall ED visits. ED resource use, specifically advanced diagnostic imaging, has increased markedly among ICU admissions. While mean ED and hospital LOS have not changed significantly, the mean ICU admission spends over 5 hours in the ED prior to transfer to an ICU bed. A greater emphasis on the ED–ICU interface and critical care delivered in the ED may be warranted. 

B. Increasing critical care admissions from U.S. EDs, 2001-2009. 

Herring AA, et al. Crit Care Med. 2013; May;41(5):1197-204 

OBJECTIVES: Little is known about how recent system-wide increases in demand for critical care have affected U.S. emergency departments (EDs). This study describes changes in the amount of critical care provided in U.S. EDs between 2001 and 2009. 

DESIGN: Analysis of data from the National Hospital Ambulatory Medical Care Survey for the years 2001-2009. 

SETTING: National multistage probability sample of U.S. ED data. U.S. ED capacity was estimated using the National Emergency Department Inventory-United States. 

PATIENTS: ED patients admitted a critical care unit. 


MEASUREMENTS: Annual hours of ED-based critical care and annual number critical care ED visits. Clinical characteristics, demographics, insurance status, setting, geographic region, and ED length of stay for critically ill ED patients. 

MAIN RESULTS: Annual critical care unit admissions from U.S. EDs increased by 79% from 1.2 to 2.2 million. The proportion of all ED visits resulting in critical care unit admission increased from 0.9% to 1.6% (ptrend less than 0.001). Between 2001 and 2009, the median ED length of stay for critically ill patients increased from 185 to 245 minutes (+ 60 min; ptrend less than 0.02). For the aggregated years 2001-2009, ED length of stay for critical care visits was longer among black patients (12.6% longer) and Hispanic patients (14.8% longer) than among white patients, and one third of all critical care ED visits had an ED length of stay greater than 6 hrs. Between 2001 and 2009, total annual hours of critical care at U.S. EDs increased by 217% from 3.2 to 10.1 million (ptrend less than 0.001). The average daily amount of critical care provided in U.S. EDs tripled from 1.8 to 5.6 hours per ED per day. 

CONCLUSIONS: The amount of critical care provided in U.S. EDs has increased substantially over the past decade, driven by increasing numbers of critical care ED visits and lengthening ED length of stay. Increased critical care burden will further stress an already overcapacity U.S. emergency care system. 

4. Preparing the United States for High-Sensitivity Cardiac Troponin Assays

 Korley FK, et al. J Am Coll Cardiol. 2013;61(17):1753-1758. 

It is only a matter of time before the use of high-sensitivity cardiac troponin assays (hs-cTn) becomes common throughout the United States. In preparation for this inevitability, this article raises a number of important issues regarding these assays that deserve consideration. These include: the need for the adoption of a universal nomenclature; the importance of defining uniform criteria for reference populations; the challenge of discriminating between acute and nonacute causes of hs-cTn elevations, and between type 1 and type 2 acute myocardial infarction (AMI); factors influencing the analytical precision of hs-cTn; ascertaining the optimal duration of the rule-out period for AMI; the need for further evaluation to determine the causes of a positive hs-cTn in non-AMI patients; and the use of hs-cTn to risk-stratify patients with disease conditions other than AMI. This review elaborates on these critical issues as a means of educating clinicians and researchers about them. 

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5. Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain

 Ahern TL, et al. Amer J Emerg Med. 2013;31:847-851. 

Objective: We assessed the analgesic effect and feasibility of low-dose ketamine combined with a reduced dose of hydromorphone for emergency department (ED) patients with severe pain. 

Methods: This was a prospective observational study of adult patients with severe pain at an urban public hospital. We administered 0.5 mg of intravenous (IV) hydromorphone and 15 mg of IV ketamine, followed by optional 1 mg hydromorphone IV at 15 and 30 minutes. Pain intensity was assessed at 12 intervals over 120 minutes using a 10-point verbal numerical rating scale (NRS). Patients were monitored throughout for adverse events. Dissociative side effects were assessed using the side effects rating scale for dissociative anesthetics. 

Results: Of 30 prospectively enrolled patients with severe pain (initial mean NRS, 9), 14 reported complete pain relief (NRS, 0) at 5 minutes; the mean reduction in NRS pain score was 6.0 (SD, 3.2). At 15 minutes, the mean reduction in NRS pain score was 5.0 (SD, 2.8). The summed pain intensity difference and percent summed pain intensity difference scores were 25 (95% confidence interval [CI], 21-30) and 58% (95% CI, 49-68) at 30 minutes and 41 (95% CI, 34-48) and 50% (95% CI, 42-58) at 60 minutes, respectively. Most patients (80%) reported only weak or modest side effects. Ninety percent of patients reported that they would have the medications again. No significant adverse events occurred. 

Conclusions: Low-dose ketamine combined with a reduced dose hydromorphone protocol produced rapid, profound pain relief without significant side effects in a diverse cohort of ED patients with acute pain. 

6. Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis

 Schouten HJ, et al. BMJ 2013;346:f2492

Objective To review the diagnostic accuracy of D-dimer testing in older patients (above 50 years) with suspected venous thromboembolism, using conventional or age adjusted D-dimer cut-off values.

Design Systematic review and bivariate random effects meta-analysis.  

Data sources We searched Medline and Embase for studies published before 21 June 2012 and we contacted the authors of primary studies.  

Study selection Primary studies that enrolled older patients with suspected venous thromboembolism in whom D-dimer testing, using both conventional (500 µg/L) and age adjusted (age×10 µg/L) cut-off values, and reference testing were performed. For patients with a non-high clinical probability, 2×2 tables were reconstructed and stratified by age category and applied D-dimer cut-off level. 

Results 13 cohorts including 12 497 patients with a non-high clinical probability were included in the meta-analysis. The specificity of the conventional cut-off value decreased with increasing age, from 57.6% (95% confidence interval 51.4% to 63.6%) in patients aged 51-60 years to 39.4% (33.5% to 45.6%) in those aged 61-70, 24.5% (20.0% to 29.7% in those aged 71-80, and 14.7% (11.3% to 18.6%) in those aged over 80. Age adjusted cut-off values revealed higher specificities over all age categories: 62.3% (56.2% to 68.0%), 49.5% (43.2% to 55.8%), 44.2% (38.0% to 50.5%), and 35.2% (29.4% to 41.5%), respectively. Sensitivities of the age adjusted cut-off remained above 97% in all age categories.  

Conclusions The application of age adjusted cut-off values for D-dimer tests substantially increases specificity without modifying sensitivity, thereby improving the clinical utility of D-dimer testing in patients aged 50 or more with a non-high clinical probability. 

7. Palliative Care in the ED?

A. Hospital Administrators' Views on Barriers and Opportunities to Delivering Palliative Care in the ED

Grudzen CR, et al. Ann Emerg Med. 2013;61:654-660. 

Study objective: We identify hospital-level factors from the administrative perspective that affect the availability and delivery of palliative care services in the emergency department (ED). 

Methods: Semistructured interviews were conducted with 14 key informants, including hospital executives, ED directors, and palliative care directors at a tertiary care center, a public hospital, and a community hospital. The discussions were digitally recorded and transcribed to conduct a thematic analysis using grounded theory. A coding scheme was iteratively developed to subsequently identify themes and subthemes that emerged from the interviews. 

Results: Barriers to integrating palliative care and emergency medicine from the administrative perspective include the ED culture of aggressive care, limited knowledge, palliative care staffing, and medicolegal concerns. Incentives to the delivery of palliative care in the ED from these key informants' perspective include improved patient and family satisfaction, opportunities to provide meaningful care to patients, decreased costs of care for admitted patients, and avoidance of unnecessary admissions to more intensive hospital settings, such as the ICU, for patients who have little likelihood of benefit. 

Conclusion: Though hospital administration at 3 urban hospitals on the East coast has great interest in integrating palliative care and emergency medicine to improve quality of care, patient and family satisfaction, and decrease length of stay for admitted patients, palliative care staffing, medicolegal concerns, and logistic issues need to be addressed. 

B. Demonstrations of Clinical Initiatives to Improve Palliative Care in the ED: A Report From the IPAL-EM Initiative 

Quest T, et al. Ann Emerg Med. 2013;61:661-667.  

Study objective: We describe 11 clinical demonstrations of emergency department (ED) and palliative care integration to include traditional consultation services with hospital-based palliative care consultants through advanced integration demonstrations in which the ED provides subspecialty palliative care practice. 

Methods: An interview guide was developed by the Improving Palliative Care in Emergency Medicine board that consists of emergency clinicians and palliative care practitioners. Structured interviews of 11 program leaders were conducted to describe the following key elements of the ED–palliative care integration, to include structure, function, and process of the programs, as well as strengths, areas of improvement, and any tools or outcome measures developed. 

Results: In this limited number of programs, a variety of strategies are used to integrate palliative care in the ED, from traditional consultation to well-defined partnerships that include board-certified emergency clinicians in hospice and palliative medicine. 

Conclusion: A variety of methods to integrate palliative care in the emergency setting have emerged. Few programs collect outcomes-based metrics, and there is a lack of standardization about what metrics are tracked when tracking occurs. 

8. Decision Aids for Low-Risk Chest Pain

The combination of TIMI score and HEART score identifies patients at less than 1% risk for death or cardiac events within 30 days. 

Marcoon S et al. Crit Pathw Cardiol 2013 Mar; 12:1 

OBJECTIVE: The ability to risk stratify patients presenting to the emergency department (ED) with potential acute coronary syndrome (ACS) is critical. The thrombolysis in myocardial infarction (TIMI) risk score can risk stratify ED patients with potential ACS but cannot identify patients safe for ED discharge. The symptom-based HEART score identifies very low-risk patients. Our hypothesis was that patients with a TIMI score of 0 or 1 may be stratified further with the HEART score to identify a group of patients at less than 1% risk of 30-day cardiovascular events. 

METHODS: We conducted a secondary analysis of a prospective cohort study in a tertiary care hospital ED. Patients with potential ACS who were greater than 30 years of age were included. Data collected included demographics, history, electrocardiogram, laboratories, and components of the TIMI and HEART scores. Follow-up was conducted by structured record review and phone. The main outcome was a composite of death, acute myocardial infarction, or revascularization at 30 days. 

RESULTS: There were 8815 patients enrolled (mean age, 52.8 ± 15.1 years; 57% women, and 69% black). At 30 days, the composite event rate was 8.0% (660 patients): 108 deaths, 410 acute myocardial infarction, and 301 revascularizations. Of the 485 patients with both a TIMI score of 0 and a HEART score of 0, there were no cardiovascular events (95% confidence interval, 0-0.8%); but no other score combination had an upper limit confidence interval less than 1%. 

CONCLUSION: At all levels of TIMI score, the HEART score was able to further substratify patients with respect to 30-day risk. A HEART score of 0 in a patient with a TIMI of 0 identified a group of patients at less than 1% risk for 30-day adverse events 

9. FFP for Progressive and Refractory ACE Inhibitor-induced Angioedema

Hassen GW, et al. J Emerg Med. 2013;44(4):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. 

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10. Antipyretics neither slow nor hasten recovery process in children

Although children who were given fever-reducing antipyretic medications returned to normal body temperature four hours earlier, on average, than those without such drugs, the recovery time for both groups was the same, a review in the Journal of Pediatrics showed. Experts said that the findings show antipyretics do not slow the recovery process but that parents may be too willing to use them without evidence of much benefit. 

11. Prevalence and Clinical Importance of Alternative Causes of Symptoms Using a Renal Colic CT Protocol in Patients With Flank or Back Pain and Absence of Pyuria

Moore CL, et al. Acad Emerg Med. 2013;20:470-478.  

Objectives: The study was undertaken to determine the prevalence and clinical importance of alternative causes of symptoms discovered in patients undergoing flank pain protocol (FPP) computed tomography (CT) scans in patients with classic symptoms of kidney stone (flank pain, back pain, or both) without evidence of urine infection. 

Methods: This was a retrospective observational analysis of all adult patients undergoing FPP CT scans at two emergency departments (EDs) between April 2005 and November 2010. All CTs (N = 5,383) were reviewed and categorized as “no cause of symptoms seen on CT,” “ureteral stone as cause of symptoms,” or “non–kidney stone cause of symptoms.” Non–kidney stone scans were further categorized as “acutely important,” “follow-up recommended,” or “unimportant cause,” based on a priori diagnostic classifications. All nonstone causes of pain and a random subset of subjects (n = 1,843; 34%) underwent full record review blinded to CT categorization to determine demographics, whether flank and/or back pain was present, and whether there was objective evidence of pyuria. 

Results: Of all FPP CT scans during the study period, a ureteral stone was found to cause symptoms in 47.7% of CTs, with no cause of symptoms found in 43.3% of CTs. A non–kidney stone diagnosis was found in 9.0% of all CTs, with 6.1% being categorized as “acutely important,” 2.2% as “follow-up recommended,” and 0.65% with symptoms from an “unimportant cause.” In the randomly selected subset undergoing full record review, categorizations were similar, with 49.0% of CTs showing kidney stone as cause of pain and 9.0% a non–kidney stone cause (5.9% “acutely important”). When subjects with evidence of urine infection or without flank or back pain were excluded, ureteral stone was identified as the cause of pain in 54.9% of CTs, while non–kidney stone cause of symptoms was found in 5.4% of scans and acutely important alternate causes in 2.8% of scans. 

Conclusions: While a non–kidney stone cause for a patient's symptoms are found in nearly 10% of CTs done using a FPP, acutely important findings occur in less than 3% of scans done in patients with flank or back pain and absence of pyuria. 

12. A descriptive study of myoclonus associated with etomidate procedural sedation in the ED

Yates AM, et al. Amer J Emerg Med. 2013;31:852-854. 

Background: Myoclonus is a well-recognized side effect of etomidate when given in induction doses for rapid sequence intubation. Most of the data reported on myoclonus with emergency department (ED) sedation doses are reported as a secondary finding. 

Study objectives: Our objective was to prospectively quantify the incidence and duration of myoclonus associated with the administration of etomidate in the lower doses given for procedural sedation in the ED. 

Methods: This was a prospective descriptive study performed between September 2008 and September 2010 at an urban teaching hospital ED with approximately 50000 patient visits per year. Procedural sedation was performed at the discretion of the treating emergency physician, and adult patients receiving etomidate were eligible for enrollment. The occurrence and duration of myoclonus were observed and recorded. Any interference of myoclonus with the ability to complete the procedure was recorded, and adverse effects were identified. 

Results: Thirty-four eligible subjects were enrolled, and 36 separate sedation procedures were performed. The mean initial etomidate dose was 0.13 mg/kg (range, 0.077-0.20), and the mean total etomidate dose was 0.15 mg/kg (range, 0.077-0.29). Myoclonus was noted in 26 (72%) of 36 sedations. Mean time to onset of myoclonus was 50 seconds (range, 15-146), and the mean duration was 93 seconds (range, 03-557). Myoclonus interfered with the procedure in only 1 (3%) of 36 attempted procedures, and no procedure was unsuccessful because of myoclonus. 

Conclusion: Myoclonus associated with sedation doses of etomidate was common but rarely interfered with the completion of a procedure. 

13. Images in Clinical Medicine

A Ticking Time Bomb

Nutcracker Esophagus


An Adolescent Male with a Large Palatal Mass

A Child with Blunt Head Injury

14. Therapeutic Hypothermia Advances: A Summary

Amal Mattu, MD. Ice Ice Baby! A Decade of Therapeutic Hypothermia. Medscape EM Apr 12, 2013

Indications for TH 

• Initial rhythm 

    TH was originally studied in patients with ROSC after VF/VT cardiac arrest and is now considered a class I intervention for these patients. However, the recommendation for implementation of TH has been extended to patients with ROSC after cardiac arrest associated with other rhythms, according to the AHA (class IIb recommendation) and the recommendations from the European Resuscitation Council and the International Liaison Committee on Resuscitation.
   All 3 organizations acknowledge a lower level of evidence for the recommendation to implement TH in patients with ROSC after nonshockable rhythms. 

• Candidates for TH are those who remain comatose following ROSC. "Comatose" in this setting is generally regarded as failing "to meaningfully respond to verbal commands." 

• These indications apply to adult victims of presumed primary cardiac arrest. If cardiac arrest is due to other conditions such as intracranial hemorrhage, exsanguination, severe sepsis, or if the patient is pregnant or remains hypotensive despite the use of multiple vasopressors, the risk of using TH may exceed the benefit. In nonprimary cardiac arrest conditions, the use of TH should be determined on a case-by-case basis. 

Initiation and Maintenance of TH 

• TH should be initiated as soon as possible after ROSC. Scirica cites a 20% increase in mortality for every hour of delay in initiation of TH; this same increase in mortality was cited in a 2011 research article.[3]  

• There are multiple methods to induce TH. The easiest and most inexpensive method is the use of cooled IV fluids (eg, 30 mL/kg over 30 minutes of 4°C lactated ringer's) during or immediately after resuscitation. 

• Maintenance of TH can be accomplished using external cooling techniques such as ice packs on the groin, neck, and axilla; water-soaked towels with fanning; or cooling blankets. More advanced (and expensive) methods that allow closer titration and maintenance of core temperature in the 32°C-34°C range can be accomplished using endovascular catheters, cooling helmets, and other novel techniques or devices. 

• Patients should be maintained in the hypothermic state for 12-24 hours. 

Consequences and Complications 

• Shivering is the most common complication and must be treated in order to avoid thermogenesis. 

    Sedation and analgesia should be provided to reduce shivering. Benzodiazepines are typically used for sedation and opiates for analgesia.
    Magnesium sulfate can raise the shivering threshold. Scirica reports the routine use of a 4-g IV bolus dose of magnesium sulfate to all patients receiving TH.
    If shivering persists despite use of medications noted above, neuromuscular blockade with paralytics is recommended.

• Hemodynamics 

    TH typically induces bradycardia and prolongation of the QT interval. These are typically well-tolerated but should be treated if they result in hemodynamic instability.
    Hypotension is common in patients receiving TH. Underlying causes of hypotension should be sought out and treated aggressively (eg, intravascular depletion is common in these patients). A mean arterial pressure should be maintained at goals of 80-100 mm Hg in order to improve cerebral perfusion. Early use of vasopressors will help in achieving this goal.

• Hyperglycemia is common during TH because of impaired insulin secretion and increased insulin resistance. During rewarming, blood glucose typically falls. Therefore, blood glucose should be measured frequently. Insulin therapy is typically not needed unless glucose levels exceed 200 mg/mL. 

• TH causes mild suppression of the immune system, although this has not been linked to an increase in mortality. Note, however, that more than two thirds of patients experience an infectious complication, especially pulmonary infections, which are likely due to aspiration during cardiac arrest. 


Scirica BM. Therapeutic Hypothermia after Cardiac Arrest. Circulation. 2013;127:244-250 

Delhaye C, et al. Hypothermia Therapy: Neurological and Cardiac Benefits. J Am Coll Cardiol. 2012;59:197-210 

15. ED Physician-level and Hospital-level Variation in Admission Rates 

 Abualenain J, et al. Ann Emerg Med. 2013;61:638-643. 

Study objective: We explore the variation in physician- and hospital-level admission rates in a group of emergency physicians in a single health system. 

Methods: This was a cross-sectional study that used retrospective data during various periods (2005 to 2010) to determine the variation in admission rates among emergency physicians from 3 emergency departments (EDs) within the same health system. Patients who left without being seen or left against medical advice, patients treated in fast-track departments, patients with primary psychiatric complaints, and those younger than 18 years were excluded, as were physicians with fewer than 500 ED encounters during the study period. Emergency physician–level and hospital-level admission rates were estimated with hierarchic logistic regression, which adjusted for patient age, sex, race, chief complaint, arrival mode, and arrival day and time. 

Results: A total of 389,120 ED visits were included in the analysis, and patients were treated by 89 attending emergency physicians. After adjusting for patient and clinical characteristics, the hospital-level admission rate varied from 27% to 41%. At the physician level, admission rates varied from 21% to 49%. 

Conclusion: There was 2.3-fold variation in emergency physician adjusted admission rates and 1.7-fold variation at the hospital level. In the new era of cost containment, wide variation in this common, costly decision requires further exploration. 

16. Update on the Management of Subarachnoid Hemorrhage

Wartenberg KE. Future Neurology. 2013;8(2):205-224.

Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular disease. Outcome after SAH is mainly determined by the initial severity of the hemorrhage. Neuroimaging, in particular computed tomography, and aneurysm repair techniques, such as coiling and clipping, as well as neurocritical care management, have improved during the last few years. The management of a patient with SAH should have an interdisciplinary approach with case discussions between the neurointensivist, interventionalist and the neurosurgeon.  

The patient should be treated in a specialized neurointensive care unit of a center with sufficient SAH case volume. Poor-grade patients can be observed for complications and delayed cerebral ischemia through continuous monitoring techniques in addition to transcranial Doppler ultrasonography such as continuous electroencephalography, brain tissue oxygenation, cerebral metabolism, cerebral blood flow and serial vascular imaging. Neurocritical care should focus on neuromonitoring for delayed cerebral ischemia, management of hydrocephalus, seizures and intracranial hypertension, as well as of medical complications such as hyperglycemia, fever and anemia. 

Full-text (free registration required):  

17. Yield of Routine Provocative Cardiac Testing among Patients in an ED-Based CP Unit  

Hermann LK, et al. JAMA Intern Med. 2013 May 20. Epub ahead of print.  

Importance  The American Heart Association recommends routine provocative cardiac testing in accelerated diagnostic protocols for coronary ischemia. The diagnostic and therapeutic yield of this approach are unknown. 

Objective  To assess the yield of routine provocative cardiac testing in an emergency department–based chest pain unit. 

Design and Setting  We examined a prospectively collected database of patients evaluated for possible acute coronary syndrome between March 4, 2004, and May 15, 2010, in the emergency department–based chest pain unit of an urban academic tertiary care center. 

Participants  Patients with signs or symptoms of possible acute coronary syndrome and without an ischemic electrocardiography result or a positive biomarker were enrolled in the database. 

Exposures  All patients were evaluated by exercise stress testing or myocardial perfusion imaging. 

Main Outcomes and Measures  Demographic and clinical features, results of routine provocative cardiac testing and angiography, and therapeutic interventions were recorded. Diagnostic yield (true-positive rate) was calculated, and the potential therapeutic yield of invasive therapy was assessed through blinded, structured medical record review using American Heart Association designations (class I, IIa, IIb, or lower) for the potential benefit from percutaneous intervention. 

Results  In total, 4181 patients were enrolled in the study. Chest pain was initially reported in 93.5%, most (73.2%) were at intermediate risk for coronary artery disease, and 37.6% were male. Routine provocative cardiac testing was positive for coronary ischemia in 470 (11.2%), of whom 123 underwent coronary angiography. Obstructive disease was confirmed in 63 of 123 (51.2% true positive), and 28 (0.7% overall) had findings consistent with the potential benefit from revascularization (American Heart Association class I or IIa). 

Conclusions and Relevance  In an emergency department–based chest pain unit, routine provocative cardiac testing generated a small therapeutic yield, new diagnoses of coronary artery disease were uncommon, and false-positive results were common. 

18. Helping Coping with Death in the ED 

A. Dying, Naturally, in the Emergency Department

How to walk a dying patient and their family through an unimpeded natural death in the emergency department   

by  Kei Ouchi, MD & Ashley Shreves, MD. EP Monthly on May 6, 2013 

B. Supporting the family after the death of a child. 

Wender E; Committee on Psychosocial Aspects of Child and Family Health. Pediatrics. 2012 Dec;130(6):1164-9. 

The death of a child can have a devastating effect on the family. The pediatrician has an important role to play in supporting the parents and any siblings still in his or her practice after such a death. Pediatricians may be poorly prepared to provide this support. Also, because of the pain of confronting the grief of family members, they may be reluctant to become involved. This statement gives guidelines to help the pediatrician provide such support. It describes the grief reactions that can be expected in family members after the death of a child. Ways of supporting family members are suggested, and other helpful resources in the community are described. The goal of this guidance is to prevent outcomes that may impair the health and development of affected parents and children. 

19. Ultrasound in EM 

A. Role of IVC and RV diameter in assessment of volume status: a comparative study 

Zengin S, et al. Amer J Emerg Med. 2013;31:763-767. 

Objective: Ultrasonography has been suggested as a useful noninvasive tool for the detection and follow-up for hypovolemia. Two possible sonographic markers as a surrogate for hypovolemia are the diameters of the inferior vena cava (dIVC) and the right ventricle (dRV). The goal of this study was to evaluate IVC and RV diameters and diameter changes in patients treated for hypovolemia and compare these findings with healthy volunteers. 

Methods: Fifty healthy volunteers and 50 consecutive hypovolemic patients were enrolled in the study. The dIVC, both during inspiration (IVCi) and expiration (IVCe), was measured in hypovolemic patients both before and after fluid resuscitation, and they were also measured in healthy volunteers during the time they participated in the study. The dIVC, in hypovolemic patients both before and after fluid resuscitation, was measured ultrasonographically by M-mode in the subxiphoid area. The dRV was measured ultrasonographically by B-mode in the third and fourth intercostals spaces. 

Results: The average diameters of the IVCe, IVCi, and dRV in hypovolemic patients upon arrival were significantly lower compared with healthy volunteers (P = .001). After fluid resuscitation, there was a significant increase in the mean diameters of the IVCe, IVCi, and RV in hypovolemic patients (P = .001). 

Conclusions: The results indicate that the dIVC and dRV are consistently low in hypovolemic subjects when compared with euvolemic subjects. Bedside serial measurements of dIVC and dRV could be a useful noninvasive tool for the detection and follow-up of patients with hypovolemia and evaluation of the response to the treatment. 

B. US guidance for radial arterial puncture: a RCT

Bobbia X, et al. Amer J Emerg Med. 2013;31:810-815. 

Study Objective and Background: Arterial puncture for blood gas analysis is a frequent procedure and could be difficult in the emergency setting. The aim of the study was to compare ultrasonographically guided arterial radial puncture vs conventional sampling. 

Materials and Methods: This is a prospective, randomized study. The inclusion criteria are all patients needing arterial blood gas at admission in the emergency unit. The exclusion criteria are the following: Hallen test positive, local sepsis, local trauma, known sever local arteriopathy, refusal of consent by the patient, participation in another study, and cardiac arrest. Patients were randomized into 2 groups: radial arterial puncture obtained through an ultrasonographically guided technique (group 1) or radial arterial puncture by conventional method (group 2). The main objective is the number of attempts after enrollment. The secondary objectives are time to success, patient satisfaction and pain, and physician satisfaction. Immediate complications were collected. Groups were compared with nonparametric analysis. 

Results: The data were usable for 72 of 74 patients included. Lung disease (acute exacerbation of chronic obstructive pulmonary disease and pneumonia) at 45% (n = 32) and suspicion of pulmonary embolism in 31% (n = 22) were the most common reasons. Demographics data were comparable in the 2 groups. In group 1, the number of attempts significantly increased (2.35 [1-3] vs 1.66 [1-2] [P = .017]), and the sample was 2.4 times longer (132 seconds [50-200] vs 55 [20-65] [P less than .01] by standard method). There was no significant difference in terms of pain (visual analog scale [VAS], 3.6 [2-5] for both groups [P = .743]), patient satisfaction (VAS, 7.2 [5-9] vs 6.8 [5-9] [P = .494]), and physician satisfaction (VAS, 6.0 [3.5-8] vs 6.9 [5-9] [P = .233]). No immediate complications were found in the 2 groups. 

Conclusion: Ultrasonographically guided arterial puncture increases the number and duration of implementations. This technique, however, does not alter the patient's pain, the number of immediate complications, or patient and physician satisfaction. 

C. Diagnostic Accuracy of US Examination in the Management of Shoulder Dislocation in the ED 

Abbasi S, et al. Ann Emerg Med. 2013 Mar 8. [Epub ahead of print] 

STUDY OBJECTIVE: Emergency physicians frequently encounter shoulder dislocation in their practice. The objective of this study is to assess the diagnostic accuracy of ultrasonography in detecting shoulder dislocation and confirming proper reduction in patients presenting to the emergency department (ED) with possible shoulder dislocation. We hypothesize that ultrasonography could be a reliable alternative for pre- and postradiographic evaluation of shoulder dislocation. 

METHODS: This was a prospective observational study. A convenience sample of patients suspected of having shoulder dislocation was enrolled in the study. Ultrasonography was performed before and after reduction procedure with a 7.5- to 10-MHz linear transducer. Shoulder dislocation was confirmed by taking radiographs in 3 routine views as a criterion standard. The operating characteristics of ultrasonography to detect dislocation in patients with possible shoulder dislocation and to confirm reduction in patients with definitive dislocation were calculated as the primary endpoints. 

RESULTS: Seventy-three patients were enrolled. The ultrasonography did not miss any dislocation. The results of ultrasonography and radiography were identical and the sensitivity of ultrasonography in detection of shoulder dislocation was 100% (95% confidence interval 93.4% to 100%). The sensitivity of ultrasonography for assessment of complete reduction of the shoulder joint reached 100% (95% confidence interval 93.2% to 100%) in our study as well. 

CONCLUSION: We suggest that ultrasonography be performed in all patients who present to the ED with a clinical impression of shoulder dislocation on admission time. The results of this study provide promising preliminary support for the ability of ultrasonography to detect shoulder dislocation. However, further investigation is necessary to validate the results and assess the ability of ultrasonography in detecting fractures associated with dislocation. 

D. Case Study: Demented 72 Year Old with Distended Abdomen  

by  Teresa S. Wu, MD & Brady Pregerson, MD. Emergency Physician Monthly, April 28, 2013 

“I need a breath of fresh air,” your senior resident states. He has had a pretty rough night. He missed an LP on a rather robust woman with “the worst headache of her life” and then the trauma team swooped in and “stole” his thoracotomy on a GSW that was dropped off at the ambulance door. You tell him to take all the time he needs as you turn your attention to the intern that has been patiently awaiting your emergence from the critical care bay. 

Jealous that she hasn’t had a single procedure yet during the shift, your intern is eager to tell you about the next patient she saw. It sounds like a relatively straightforward case: a 72-year-old male brought in by his nursing home aide for abdominal distension. He has a history of dementia and is primarily bedridden at baseline. The patient cannot give any reliable history, but on physical exam, his otherwise thin abdomen shows obvious signs of suprapubic distension. Your intern recaps his vital signs, which include tachycardia at 120 bpm, a blood pressure of 190/86 mmHg, a respiratory rate of 20/min, and a normal temperature and O2 saturation. 

“What should we be worried about?” you ask. Your intern rattles off a differential diagnosis straight out of Tintinalli. Without missing a beat, she continues to explain how she plans to rule-out the scary etiologies such as acute intraperitoneal hemorrhage or ascites, AAA, mesenteric ischemia, perforated bowel, acute cholecystitis, appendicitis, and SBO. Her initial orders are spot-on, and before you can utter another syllable, she grabs the ultrasound machine and wheels it over to the patient’s bedside. You follow a few steps behind her, and observe with pride as she performs a scan of Morrison’s pouch, followed by a quick look at the gallbladder, aorta, splenorenal space and right-lower quadrant. She gently calms the agitated patient as she slides the probe down towards his suprapubic region… 

20. NEJM Interactive Case: A Pain in the Brain

Redig AJ, et al. N Engl J Med 2013; 368:e20 

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 . . . 

21. Multicenter Observational Study of the Development of Progressive Organ Dysfunction and Therapeutic Interventions in Normotensive Sepsis Patients in the ED 

Arnold RC, et al. Acad Emerg Med. 2013;20:433-440.  

Objectives: Progressive organ dysfunction is the leading cause of sepsis-associated mortality; however, its incidence and management are incompletely understood. Sepsis patients with moderately impaired perfusion (serum lactate 2.0 to 3.9 mmol/L) who are not in hemodynamic shock (“preshock” sepsis patients) may be at increased risk for progressive organ dysfunction and increased mortality. The objectives of this study were to: 1) quantify the occurrence of progressive organ dysfunction among preshock sepsis patients, 2) examine if there were baseline differences in demographic and physiologic parameters between preshock sepsis patients who experienced progressive organ dysfunction and those who did not, and 3) examine if intravenous (IV) fluid administered in the emergency department (ED) differed between these two groups of patients. 

Methods: This was a prospective, observational study in four urban EDs targeting the preshock sepsis population, defined as adults (18 years or older) with suspected infection, serum lactate between 2.0 and 3.9 mmol/L, and without hypotension (systolic blood pressure [sBP] below 90 mm Hg or mean arterial pressure [MAP] below 70 mm Hg) or requiring mechanical ventilation at ED presentation. The primary composite outcome was progressive organ dysfunction, defined as a rise in the Sequential Organ Failure Assessment (SOFA) score of ≥1, vasopressor use, mechanical ventilation use within 72 hours after ED presentation, or in-hospital death. The secondary outcomes were any intensive care unit (ICU) admission, and total ICU and hospital lengths of stay (LOS). 

Results: Among 94 preshock sepsis patients, the primary composite outcome occurred in 24 of 94 (26%). In patients with the primary outcome, 22 of 24 (92%) experienced a rise in SOFA score of ≥1, five of 24 (21%) received vasopressor agents, and seven of 24 (30%) required mechanical ventilation. There were no baseline demographic or physiologic parameter differences between patients who met the primary outcome versus those who did not, while patients with the primary outcome had a higher average SOFA score at admission (2.4 vs. 1.3, p = 0.011) and at all subsequent time points. Median IV fluid volume administered to all preshock sepsis patients during their ED stay was 1,225 mL (interquartile range [IQR] = 712 to 2,000 mL) and did not differ significantly between patients with (1,150 mL, IQR = 469 to 2,000 mL) or without (1,250 mL, IQR = 750 to 2,000 mL) the primary outcome (p = 0.73). Patients with progressive organ dysfunction or death were more likely to be admitted to an ICU (50% vs. 20%, p less than 0.01) and have an increased median hospital LOS (6 days vs. 3 days, p = 0.005), compared to those without progressive organ dysfunction. 

Conclusions: Over one-quarter of preshock sepsis patients developed progressive organ dysfunction with associated increased resource use. Demographic and physiologic parameters were unable to differentiate patients with progressive organ dysfunction, while the initial SOFA score was increased in patients meeting the outcome. Overall, these patients received relatively little IV fluid therapy during their ED stays. Further research to determine if more aggressive therapy can prevent progressive organ dysfunction in this population is warranted. 

22. 5-day Steroid Burst Best for COPD Exacerbations: The REDUCE RCT   

Leuppi JD, et al. JAMA 2013 May 21. Epub ahead of print.  

Importance  International guidelines advocate a 7- to 14-day course of systemic glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease (COPD). However, the optimal dose and duration are unknown. 

Objective  To investigate whether a short-term (5 days) systemic glucocorticoid treatment in patients with COPD exacerbation is noninferior to conventional (14 days) treatment in clinical outcome and whether it decreases the exposure to steroids. 

Design, Setting, and Patients  REDUCE (Reduction in the Use of Corticosteroids in Exacerbated COPD), a randomized, noninferiority multicenter trial in 5 Swiss teaching hospitals, enrolling 314 patients presenting to the emergency department with acute COPD exacerbation, past or present smokers (≥20 pack-years) without a history of asthma, from March 2006 through February 2011. 

Interventions  Treatment with 40 mg of prednisone daily for either 5 or 14 days in a placebo-controlled, double-blind fashion. The predefined noninferiority criterion was an absolute increase in exacerbations of at most 15%, translating to a critical hazard ratio of 1.515 for a reference event rate of 50%. 

Main Outcome and Measure  Time to next exacerbation within 180 days. 

Results  Of 314 randomized patients, 289 (92%) of whom were admitted to the hospital, 311 were included in the intention-to-treat analysis and 296 in the per-protocol analysis. Hazard ratios for the short-term vs conventional treatment group were 0.95 (90% CI, 0.70 to 1.29; P = .006 for noninferiority) in the intention-to-treat analysis and 0.93 (90% CI, 0.68 to 1.26; P = .005 for noninferiority) in the per-protocol analysis, meeting our noninferiority criterion. In the short-term group, 56 patients (35.9%) reached the primary end point; 57 (36.8%) in the conventional group. Estimates of reexacerbation rates within 180 days were 37.2% (95% CI, 29.5% to 44.9%) in the short-term; 38.4% (95% CI, 30.6% to 46.3%) in the conventional, with a difference of −1.2% (95% CI, −12.2% to 9.8%) between the short-term and the conventional. Among patients with a reexacerbation, the median time to event was 43.5 days (interquartile range [IQR], 13 to 118) in the short-term and 29 days (IQR, 16 to 85) in the conventional. There was no difference between groups in time to death, the combined end point of exacerbation, death, or both and recovery of lung function. In the conventional group, mean cumulative prednisone dose was significantly higher (793 mg [95% CI, 710 to 876 mg] vs 379 mg [95% CI, 311 to 446 mg], P less than .001), but treatment-associated adverse reactions, including hyperglycemia and hypertension, did not occur more frequently. 

Conclusions and Relevance  In patients presenting to the emergency department with acute exacerbations of COPD, 5-day treatment with systemic glucocorticoids was noninferior to 14-day treatment with regard to reexacerbation within 6 months of follow-up but significantly reduced glucocorticoid exposure. These findings support the use of a 5-day glucocorticoid treatment in acute exacerbations of COPD. 

23.1 Book of the Month

Sonja Lyubomirsky's The Myths of Happiness: What Should Make You Happy, but Doesn't, What Shouldn't Make You Happy, but Does (New York: Penguin Press, 2013). She brings the best of today's experimental psychology to bear on the big milestones and crises of life: e.g., relationships, singleness, work, money, aging, regret. It's an excellent book, as applicable as it accessible.

If you want to get a feel for the author, below is a video presentation she gave at Google on her first book, The How of Happiness: A New Approach to Getting the Life You Want (New York: Penguin, 2008).


Related NY Times article:

23.2 Tid Bits  

A. Primary care physicians can use Q-and-A to form pain prognosis 

Primary care physicians who asked patients with musculoskeletal pain three questions, in addition to doing a normal work-up, more accurately predicted those who still would have pain six months later than those who just did a work-up, U.K. researchers said. The study in JAMA Internal Medicine said patients were asked when they last were pain free for a month or longer, whether pain had interfered with daily activities in the past month, and if they had pain anywhere else within that time.

B. Hastings Center updates recommendations for end-of-life care 

The Hastings Center updated its 1987 guidelines for the ethical care of terminally ill patients, adding decision-making for dying children, specific issues for patients with disabilities and the use of palliative sedation, among other changes. The guidelines say a physician's offer or a family's request to "do everything" to keep a patient alive may not respect patient rights or ensure good care.

C. Texting while driving linked to other risky behaviors among teens 

About 45% of 8,505 high-school students said they have texted while driving at least once over the past month, while nearly 12% reported doing it on a daily basis, according to a study in the journal Pediatrics. Researchers noted that these teens had a greater likelihood of engaging in other risky activities such as driving after drinking alcohol and not wearing seat belts. 

D. Cause of Death: 50% of Medical Residents Fib 

E. Doctors have lowest overweight, absenteeism rates in study

Physicians had the lowest rate of being overweight or having at least one chronic condition compared with other job types, data from a Gallup survey showed. Researchers also found physicians had low absenteeism levels and incurred absenteeism costs of only $250 million annually, compared with $15.7 billion per year among managers and executives. 

F. Sleep drugs tied to 19,000 ED visits in 2010 

The number of emergency department visits linked to Ambien and other zolpidem-based sleep medications increased from around 6,000 in 2005 to more than 19,000 in 2010, with women more often affected than men, researchers from the U.S. Substance Abuse and Mental Health Services Administration found. Total cases of adverse reactions to zolpidem jumped nearly 220% between 2005 and 2010, according to the report.

G. Predicting Difficult Intubations — Easier to Say Who Isn't at Risk  

A new scoring system predicts low-risk intubations fairly well. 

De Jong A et al. Am J Respir Crit Care Med 2013 Apr 15; 187:832 

H. Just 2 Months' Exposure to Anticholinergics Affects Cognition 

I. Snack (Healthily) Before Shopping 

Shopping for groceries on an empty stomach does in fact influence food choices.

Anahad O’Connor. NY Times Blog. May 13, 2013 

Most people know the age-old diet advice about grocery shopping when you are hungry: You are more likely to buy fattening, unhealthy foods. So avoid it. 

But the weight loss maxims found in diet books do not always hold up in the real world. So two researchers at Cornell University recently devised an experiment that put this notion to the test.  

The study, published in JAMA Internal Medicine, was carried out in two phases. In the first, 68 men and women were brought into a lab on two separate days after having been told not to eat for five hours. Then they were allowed to “shop” for food in a simulated grocery store, which offered low-calorie options like fruits, vegetables and chicken breasts, as well as higher-calorie junk foods.  

Before shopping, half of the subjects were given a snack. Both groups ultimately purchased a similar number of items, but those who shopped while hungry picked the highest-calorie foods.  

In the second phase of the study, the researchers followed 82 actual shoppers in a grocery store. Once again, they found that people shopping at times when they were most likely to be hungry opted for the foods that were more calorically dense. 

In an accompanying editorial, Dr. Rita F. Redberg, a cardiologist, said the findings provided scientific support for common-sense advice. 

“I think all diet guides include the advice to ‘never go grocery shopping when you are hungry,’ ” she wrote, “and when I had young children, I added ‘and never with young children’ – because either of these factors seem to lead to less wise food choices.”