A collection of assorted summaries, highlights, and abstracts from the recent medical literature.
Saturday, June 22, 2013
Lit Bits: June 22, 2013
From the recent medical literature...
1. One in 604 flights have medical emergencies
7,198,118 flights between January 2008 and October 2010, 11,920 had in-flight
medical emergencies, or 1 in every 604 flights, according to a study published
in the New England Journal of Medicine. A health care provider was available to
help in 75% of cases. Researchers said that the most common causes of in-flight
emergencies were syncope, respiratory symptoms and gastrointestinal problems.
DC, et al. Outcomes of Medical Emergencies on Commercial Airline Flights. N
Engl J Med 2013; 368:2075-2083.
Worldwide, 2.75 billion passengers fly on commercial airlines annually. When
in-flight medical emergencies occur, access to care is limited. We describe
in-flight medical emergencies and the outcomes of these events.
We reviewed records of in-flight medical emergency calls from five domestic and
international airlines to a physician-directed medical communications center
from January 1, 2008, through October 31, 2010. We characterized the most
common medical problems and the type of on-board assistance rendered. We
determined the incidence of and factors associated with unscheduled aircraft
diversion, transport to a hospital, and hospital admission, and we determined
the incidence of death.
There were 11,920 in-flight medical emergencies resulting in calls to the
center (1 medical emergency per 604 flights). The most common problems were
syncope or presyncope (37.4% of cases), respiratory symptoms (12.1%), and
nausea or vomiting (9.5%). Physician passengers provided medical assistance in
48.1% of in-flight medical emergencies, and aircraft diversion occurred in
7.3%. Of 10,914 patients for whom postflight follow-up data were available,
25.8% were transported to a hospital by emergency-medical-service personnel,
8.6% were admitted, and 0.3% died. The most common triggers for admission were
possible stroke (odds ratio, 3.36; 95% confidence interval [CI], 1.88 to 6.03),
respiratory symptoms (odds ratio, 2.13; 95% CI, 1.48 to 3.06), and cardiac
symptoms (odds ratio, 1.95; 95% CI, 1.37 to 2.77).
Most in-flight medical emergencies were related to syncope, respiratory
symptoms, or gastrointestinal symptoms, and a physician was frequently the
responding medical volunteer. Few in-flight medical emergencies resulted in
diversion of aircraft or death; one fourth of passengers who had an in-flight
medical emergency underwent additional evaluation in a hospital. (Funded by the
National Institutes of Health.)
associated animated video for crisp summary (link above).
2. Inhaled Adrenaline No Better than Inhaled Saline for
Infants with Acute Bronchiolitis
HO, et al. N Engl J Med 2013; 368:2286-2293.
Acute bronchiolitis in infants frequently results in hospitalization, but there
is no established consensus on inhalation therapy — either the type of
medication or the frequency of administration — that may be of value. We aimed
to assess the effectiveness of inhaled racemic adrenaline as compared with
inhaled saline and the strategy for frequency of inhalation (on demand vs.
fixed schedule) in infants hospitalized with acute bronchiolitis.
In this eight-center, randomized, double-blind trial with a 2-by-2 factorial
design, we compared inhaled racemic adrenaline with inhaled saline and
on-demand inhalation with fixed-schedule inhalation (up to every 2 hours) in
infants (younger than 12 months of age) with moderate-to-severe acute
bronchiolitis. An overall clinical score of 4 or higher (on a scale of 0 to 10,
with higher scores indicating more severe illness) was required for study
inclusion. Any use of oxygen therapy, nasogastric-tube feeding, or ventilatory
support was recorded. The primary outcome was the length of the hospital stay,
with analyses conducted according to the intention-to-treat principle.
The mean age of the 404 infants included in the study was 4.2 months, and 59.4%
were boys. Length of stay, use of oxygen supplementation, nasogastric-tube
feeding, ventilatory support, and relative improvement in the clinical score
from baseline (preinhalation) were similar in the infants treated with inhaled
racemic adrenaline and those treated with inhaled saline (P above 0.1 for all
comparisons). On-demand inhalation, as compared with fixed-schedule inhalation,
was associated with a significantly shorter estimated mean length of stay —
47.6 hours (95% confidence interval [CI], 30.6 to 64.6) versus 61.3 hours (95%
CI, 45.4 to 77.2; P=0.01) — as well as less use of oxygen supplementation (in
38.3% of infants vs. 48.7%, P=0.04), less use of ventilatory support (in 4.0%
vs. 10.8%, P=0.01), and fewer inhalation treatments (12.0 vs. 17.0, P less than
In the treatment of acute bronchiolitis in infants, inhaled racemic adrenaline
is not more effective than inhaled saline. However, the strategy of inhalation
on demand appears to be superior to that of inhalation on a fixed schedule.
(Funded by Medicines for Children; ClinicalTrials.gov number, NCT00817466;
EudraCT number, 2009-012667-34.)
3. Biomarkers May Diagnose Mild Brain Injury
Nancy Walsh, Staff Writer, MedPage Today. June 20, 2013
combination of two biomarkers helped identify patients with mild traumatic
brain injury (TBI), and one of the markers also could predict which patients
would have abnormalities on head CT, researchers reported, opening the
possibility for reducing the number of scans performed in emergency
area under the receiver operator characteristic curve (AUC) for the markers
S100B plus apolipoprotein A1 (apoA-1) in diagnosing TBI was 0.738 (95% CI
0.71-0.77), which was higher than for S100B alone (0.709, 95% CI 0.68-0.74,
P=0.001) or for apoA-1 alone (0.645, 95% CI 0.61-0.68, P less than 0.0001),
according to Jeffrey J. Bazarian, MD, of the University of Rochester in New
York, and colleagues. In addition, the AUC for predicting abnormalities on an
initial head CT scan for S100B was 0.694 (95% CI 0.62 to 0.77). With a cutoff
level for S100B of 0.060 mcg/L, which represents a sensitivity level of 98%,
22.9% of CT scans would not be needed, the researchers reported online in the
Journal of Neurotrauma.
year, an estimated 1.7 million Americans experience a TBI and are at subsequent
risk for long-term morbidities including cognitive disability and neurologic
disorders. To date, diagnosis has relied on patient or witness reports and
subjective symptoms, and no objective diagnostic test is available in the U.S.
an emergency provider, I think we could have used a test like this a long time
ago," Bazarian told MedPage Today. "Most of the time with patients
who may have concussion I'm guessing. They often can't tell me if they've been
knocked out because they're intoxicated, demented, or otherwise can't
remember," he said.
S100B is a protein derived from astrocytes that is already used to screen
patients before head CT scanning in 17 countries in Europe and Asia. "We
are learning more about the importance of astrocytes, such as that they are
responsible for the care and feeding of neurons," Bazarian explained. When
measured within 3 hours of the head injury, S100B has been shown to be highly
sensitive for CT abnormalities, but lacks in specificity because of its
presence in melanocytes and adipocytes and its release after non-cranial
is the protein that carries high-density lipoprotein particles. Unlike S100B,
it's not a brain protein, but is intimately involved in recovery from brain
injury through its ability to help clear broken down neurons, which consist
mainly of fat, he said.
proteomic screen of patients with mild TBI suggested that levels of S100B and
ApoA-1 might help increase the accuracy of prediction, so the researchers
prospectively studied 787 patients with mild TBI, comparing them with 467
levels of S-100B were higher in cases than controls (0.149 mcg/L versus 0.071
mcg/L, P less than 0.0001), while mean levels of apoA-1 were lower in cases
(0.834 mg/mL versus 0.950 mg/mL, P less than 0.0001).
alone correctly diagnosed mild TBI in 38.1% of cases using a cutoff of 90% for
both sensitivity and specificity, while apoA-1 alone identified 30.4%. But the
number correctly identified with both markers at that cutoff for sensitivity
and specificity increased to 45.2%, which was a significant difference (P less
evaluating the efficacy for predicting abnormalities on head CT, the
researchers found that only S100B was predictive, and that adding apoA-1 didn't
increase the AUC of S100B alone.
sensitivity cutoff for S100B, with a threshold level of 0.097 mcg/L, could have
avoided head CT in 30.5% of patients, but would have missed six cases, which
included intraventricular hemorrhages, subdural hemorrhages, and edema. But
with the higher cutoff of 98% sensitivity and a threshold of 0.060 mcg/L, only
one case would have been missed -- a patient with a small cerebral contusion
whose S100B level was 0.06 mcg/L. If the threshold were lowered further, to
0.10 mcg/L, the sensitivity for correctly predicting abnormalities on head CT
would be 86% (95% CI 73-95). The choice of which cutoff to use would depend on
the clinician's tolerance for uncertainty in specific circumstances, Bazarian
down on the need for CT scans for head-injured patients would be beneficial in
reducing radiation exposure and also for unclogging emergency departments,
Bazarian noted. "Much of the delay in emergency departments is caused by
patients waiting for CT scans, and 95% of concussion patients have an
absolutely normal head CT. A blood test could greatly reduce the number of
patients needing the imaging test," he said.
researchers also found that the AUC for S100B was higher in adults than
children and among whites compared with blacks (P less than 0.0001 for both). Accordingly,
development of a multivariate model that includes not only marker levels but
also adjusts for age and race could be useful, he noted.
study is notable for several 'firsts.' It is the first large, multicentered
brain marker study in North America, the first brain marker study to combine
the clinical utility of two markers, the first to determine marker accuracy in
ethnic and racial subgroups, and the first to employ the peripheral protein,
apoA-1," Bazarian and colleagues wrote.
FDA were to consider approving a biomarker test for mild TBI, they would be
looking for data accumulated in North America. "This study is a first step
toward trying to get approval in the U.S.," he said.
of the study included the possibility of inter-reader variations in CT scan
interpretation and demographic differences between the patient and control
groups. Bazarian and one co-author have a patent pending for a method of
diagnosing mild TBI. Bazarian also has consulted for Banyan Biomarkers and
J, et al. Classification accuracy of serum apoA-1 and S100B for the diagnosis
of mild TBI and prediction of abnormal initial head CT scan" J Neurotrauma
2013 June 13 [Epub ahead of print] Abstract: http://www.ncbi.nlm.nih.gov/pubmed/23758329
4. Contrast Is Unnecessary for Most Abdominal CTs: Lit
Bukata, MD, Emergency Physicians Monthly, June 10, 2013
growing body of research flies in the face of this common radiology practice.
routine use of contrast (both oral and IV, and certainly rectal) is unnecessary
for the majority of abdominal CT scans performed in the ED.At least that is what the literature says
over and over.
many radiologists disagree.Is their
objection based on a sound analysis of the literature?Hardly.In most cases it is a matter of personal preference.They have been using contrast since their
residency, or at least since CTs came on the scene, and just feel more
comfortable with it. Have they made an honest effort to compare results with
and without contrast ?Probably
not.Do they care that oral contrast
will add about two hours to an ED stay and, even when given, frequently doesn’t
get to the cecum?Probably not.
when the use of contrast is subject to the intense searchlight of scientific
inquiry, the answer seems to be pretty clear.It is the atypical patient with nontraumatic abdominal pain who needs
we take on the “contrast, no contrast” arm wrestle, we need to take a major
step back and ask, “Why are we doing so many abdominal CTs in the first place?”
I won’t spend this column making the case for why clinical exam can make many
CTs unnecessary. That could be an entire column. What I want to talk about is
the use of ultrasonography as a first test to visualize the abdominal contents
and then, and only then, considering CT if results are equivocal and imaging is
still felt to be necessary. This would be a dramatic departure from our current
testing culture, where CTs are the new CBCs (don’t call the surgeon without
the American College of Radiology has taken the radical position that, at least
in children with suspected appendicitis, an ultrasound should be considered as
an option. Why not in all ages and why not use some stronger language than
“should be considered”? We’ll need to be satisfied with baby steps since it
would likely be the uncommon radiologist in the U.S. who would actively promote
following this advice. But here’s exactly what the ACR says. (As an aside, this
is one of the ACR’s five “Choosing Wisely” recommendations.)
do computed tomography (CT) for the evaluation of suspected appendicitis in
children until after ultrasound has been considered as an option.
CT is accurate in the evaluation of suspected appendicitis in the pediatric
population, ultrasound is nearly as good in experienced hands. Since ultrasound
will reduce radiation exposure, ultrasound is the preferred initial
consideration for imaging examination in children. If the results of the
ultrasound exam are equivocal, it may be followed by CT. This approach is
cost-effective, reduces potential radiation risks and has excellent accuracy,
with reported sensitivity and specificity of 94 percent.
American radiologists don’t have nearly the experience (read: skill +
confidence) of their European brethren in embracing this “ultrasound first”
approach, but a two week course in Cancun would likely go a long way towards
solving the problem. EPs can help them get this experience by ordering the
correct test in these cases – an ultrasound and not a CT.EPs need to stop aiding and abetting this
process.And we need to cite the support
of the ACR so we don’t look like a bunch of no-nothing radicals.
we’ll stick with the issue at hand – contrast in abdominal CTs. So, how about
some papers indicating that oral contrast is a waste of time in the setting of
suspected appendicitis – the most common setting in which oral contrast is
of tediously going through study after study on this topic, here are two
analyses, one published in 2010 involving seven high-quality trials and another
in 2005 involving 23 trials. And yes, if you’re wondering, the answer to this
dilemma was clearly known as far back as 2005! And catch the concluding
sentence in the 2005 paper: the diagnostic accuracy of CT without contrast “was
at least as comparable” as with contrast in assessing appendicitis. In fact, the
data shows it was a little better…
prescription of statins and antibiotics linked to extra deaths
AM, et al. Ann Intern Med. 2013 Jun 18;158(12):869-76.
Clarithromycin and erythromycin, but not azithromycin, inhibit cytochrome P450
isoenzyme 3A4 (CYP3A4), and inhibition increases blood concentrations of
statins that are metabolized by CYP3A4.
To measure the frequency of statin toxicity after coprescription of a statin
with clarithromycin or erythromycin.
Population-based cohort study.
Ontario, Canada, from 2003 to 2010.
Continuous statin users older than 65 years who were prescribed clarithromycin
(n = 72 591) or erythromycin (n = 3267) compared with those prescribed
azithromycin (n = 68 478).
The primary outcome was hospitalization with rhabdomyolysis within 30 days of
the antibiotic prescription.
Atorvastatin was the most commonly prescribed statin (73%) followed by
simvastatin and lovastatin. Compared with azithromycin, coprescription of a
statin with clarithromycin or erythromycin was associated with a higher risk
for hospitalization with rhabdomyolysis (absolute risk increase, 0.02% [95% CI,
0.01% to 0.03%]; relative risk [RR], 2.17 [CI, 1.04 to 4.53]) or with acute
kidney injury (absolute risk increase, 1.26% [CI, 0.58% to 1.95%]; RR, 1.78
[CI, 1.49 to 2.14]) and for all-cause mortality (absolute risk increase, 0.25%
[CI, 0.17% to 0.33%]; RR, 1.56 [CI, 1.36 to 1.80]).
Only older adults were included in the study. The absolute risk increase for
rhabdomyolysis may be underestimated because the codes used to identify it were
In older adults, coprescription of clarithromycin or erythromycin with a statin
that is metabolized by CYP3A4 increases the risk for statin toxicity.
may raise kidney injury risk, study says
who took fluoroquinolones had a twofold greater risk of developing serious
kidney problems than nonusers, according to a study published online in the
Canadian Medical Association Journal. The risk of kidney injury was nearly five
times higher in men who simultaneously took a fluoroquinolone and an ACE
inhibitor compared with those who didn't take fluoroquinolones.
6. The Clinical Use of Prothrombin Complex Concentrate
J, et al. J Emerg Med. 2013;44:1201-1210.
Prothrombin complex concentrate (PCC) is an inactivated concentrate of factors
II, IX, and X, with variable amounts of factor VII. Guidelines recommend the
use of PCC in the setting of life-threatening bleeds, but little is known on
the most effective dosing strategies and how the presenting international
normalized ratio affects response to therapy.
This review aims to highlight available data on monitoring techniques, address
shortcomings of currently available data, the reversal of life-threatening and
critical bleeds with PCC, and how this product compares to other therapeutic
options used in critically ill patients.
PCC has been identified as a potential therapy for critically bleeding
patients, but patient-specific factors, product availability, and current data
should weigh the decision to use it. Most data exist regarding patients
experiencing vitamin K antagonist-induced bleeding, more specifically, those
with intracranial hemorrhage. PCC has also been studied in trauma-induced hemorrhage;
however, it remains controversial, as its potential benefits have the abilities
to become flaws in this setting.
Health care professionals must remain aware of the differences in products and
interpret how three- versus four-factor products may affect patients, and
interpret literature accordingly. The clinician must be cognizant of how to
progress when treating a bleeding patient, propose a supported dosing scheme,
and address the need for appropriate factor VII supplementation. At this point,
PCC cannot be recommended for first-line therapy in patients with traumatic
hemorrhage, and should be reserved for refractory bleeding until more data are
7. A Hospitalist Goes Viral -- On Purpose
satire, rap, and sometimes a Michael Jackson glove, hospitalist Zubin Damania
takes his alter ego, ZDoggMD, to YouTube to sing about everything from
insurance paperwork to prostate cancer.
of thousands of people have been treated by ZDoggMD – at least to a few laughs.
satire, rap and sometimes, a Michael Jackson glove, hospitalist Dr. Zubin
Damania takes his alter ego, ZDoggMD, to YouTube to sing about everything from
insurance paperwork to prostate cancer.
result is hundreds of thousands of online views, and comedy that parodies pop
culture (he does an excellent Yoda impersonation) and pushes some boundaries
(bodily fluids are not off limits).
I stop and think: Are we getting in trouble?" Damania says of the often
indelicate videos he creates with coworkers and friends. "But the more we
push it, the more positive the outcome."
when the opportunity arose, he decided to put his critique into action by
heading up a new clinic in Las Vegas that he hopes will address the many
drawbacks of the health system he noticed while treating seriously ill patients
as a Stanford hospitalist.
Small bowel obstruction (SBO) is a clinical condition that is often initially
diagnosed and managed in the emergency department (ED). The high rates of
potential complications that are associated with an SBO make it essential for
the emergency physician (EP) to make a timely and accurate diagnosis.
The primary objective was to perform a systematic review and meta-analysis of
the history, physical examination, and imaging modalities associated with the
diagnosis of SBO. The secondary objectives were to identify the prevalence of
SBO in prospective ED-based studies of adult abdominal pain and to apply Pauker
and Kassirer's threshold approach to clinical decision-making to the diagnosis
and management of SBO.
MEDLINE, EMBASE, major emergency medicine (EM) textbooks, and the
bibliographies of selected articles were scanned for studies that assessed one
or more components of the history, physical examination, or diagnostic imaging
modalities used for the diagnosis of SBO. The selected articles underwent a
quality assessment by two of the authors using the Quality Assessment of
Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data used to compile
sensitivities and specificities were obtained from these studies and a
meta-analysis was performed on those that examined the same historical
component, physical examination technique, or diagnostic test. Separate
information on the prevalence and management of SBO was used in conjunction
with the meta-analysis findings of computed tomography (CT) to determine the
test and treatment threshold.
The prevalence of SBO in the ED was determined to be approximately 2% of all
patients who present with abdominal pain. Having a previous history of
abdominal surgery, constipation, abnormal bowel sounds, and/or abdominal
distention on examination were the best history and physical examination
predictors of SBO. X-ray was determined to be the least useful imaging modality
for the diagnosis of SBO, with a pooled positive likelihood ratio (+LR) of 1.64
(95% confidence interval [CI] = 1.07 to 2.52). On the other hand, CT and
magnetic resonance imaging (MRI) were both quite accurate in diagnosing SBO
with +LRs of 3.6 (5- to 10-mm slices, 95% CI = 2.3 to 5.4) and 6.77 (95% CI =
2.13 to 21.55), respectively. Although limited to only a select number of
studies, the use of ultrasound (US) was determined to be superior to all other
imaging modalities, with a +LR of 14.1 (95% CI = 3.57 to 55.66) and a negative
likelihood ratio (–LR) of 0.13 (95% CI = 0.08 to 0.20) for formal scans and a
+LR of 9.55 (95% CI = 2.16 to 42.21) and a –LR of 0.04 (95% CI = 0.01 to 0.13)
for beside scans. Using the CT results of the meta-analysis for the 5- to 10-mm
slice subgroup as well as information on intravenous (IV) contrast reactions and
nasogastric (NG) intubation management, the pretest probability threshold for
further testing was determined to be 1.5%, and the pretest probability
threshold for beginning treatment was determined to be 20.7%.
The potentially useful aspects of the history and physical examination were
limited to a history of abdominal surgery, constipation, and the clinical
examination findings of abnormal bowel sounds and abdominal distention. CT,
MRI, and US are all adequate imaging modalities to make the diagnosis of SBO.
Bedside US, which can be performed by EPs, had very good diagnostic accuracy
and has the potential to play a larger role in the ED diagnosis of SBO. More
ED-focused research into this area will be necessary to bring about this
9. High-Frequency Users of ED Care
EJ, et al. J Emerg Med. 2013;44:1167-1173.
The heterogeneous group of patients who frequently use the Emergency Department
(ED) have been of interest in public health care reform debate, but little is
known about the subgroup of the highest frequency users.
Objectives: We sought to describe the demographic and utilization
characteristics of patients who visit the ED 20 or more times per year.
We retrospectively studied patients who visited a large, urban ED over a 1-year
period, identifying all patients using the department 20 or more times. Age,
gender, insurance, psychosocial factors, chief complaint, and visit disposition
were described for all visits. Inferential tests assessed associations between
demographic variables, insurance status, and admission rates.
Of the 59,172 unique patients to visit the ED between December 1, 2009 and
November 30, 2010, 31 patients were identified as high-frequency ED users,
contributing 1.1% of all visits. Patients were more likely to be 30–59 years of
age (52%), stably insured (81%), and have at least one significant psychosocial
cofactor (65%). Their admission rate was 15%, as compared to 21% for all other
High-frequency users are patients with significant psychiatric and social
comorbidities. Given their small proportion of visits, lower admission rates,
and favorable insurance status, the impact of high-frequency users of the ED
may be out of proportion to common perceptions.
12. A Comparison of US-guided 3-in-1 Femoral Nerve Block
Versus Parenteral Opioids Alone for Analgesia in ED Patients with Hip
Fractures: A RCT
FL, et al. Acad Emerg Med. 2013;20:584-91.
The primary objective was to compare the efficacy of ultrasound (US)-guided
three-in-one femoral nerve blocks to standard treatment with parenteral opioids
for pain control in elderly patients with hip fractures in the emergency
A randomized controlled trial was conducted at a large urban academic ED over
an 18-month period. A convenience sample of older adults (age ≥ 55 years) with
confirmed hip fractures and moderate to severe pain (numeric rating score ≥ 5)
were randomized to one of two treatment arms: US-guided three-in-one femoral
nerve block plus morphine (FNB group) or standard care, consisting of placebo
(sham injection) plus morphine (SC group). Intravenous (IV) morphine was
prescribed and dosed at the discretion of the treating physician; physicians
were advised to target a 50% reduction in pain or per-patient request. The
primary outcome measure of pain relief, or pain intensity reduction, was
derived using the 11-point numerical rating scale (NRS) and calculated as the
summed pain-intensity difference (SPID) over 4 hours. Secondary outcome
measures included the amount of rescue analgesia and occurrence of adverse
events (respiratory depression, hypotension, nausea, or vomiting). Outcome
measures were compared between groups using analysis of variance for continuous
variables and Fisher's exact test for categorical data.
Thirty-six patients (18 in each arm) completed the study. There was no
difference between treatment groups with respect to age, sex, fracture type,
vital signs (baseline and at 4 hours), ED length of stay (LOS), pre-enrollment analgesia,
or baseline pain intensity. In comparing pain intensity at the end of the study
period, NRS scores at 4 hours were significantly lower in the FNB group (p less
than 0.001). Over the 4-hour study period, patients in the FNB group
experienced significantly greater overall pain relief than those in the SC
group, with a median SPID of 11.0 (interquartile range [IQR] = 4.0 to 21.8) in
the FNB group versus 4.0 (IQR = −2.0 to 5.8) in the SC group (p = 0.001). No
patient in the SC group achieved a clinically significant reduction in pain.
Moreover, patients in the SC group received significantly more IV morphine than
those in the FNB group (5.0 mg, IQR = 2.0 to 8.4 mg vs. 0.0 mg, IQR = 0.0 to
1.5 mg; p = 0.028). There was no difference in adverse events between groups.
Ultrasound-guided femoral nerve block as an adjunct to SC resulted in 1)
significantly reduced pain intensity over 4 hours, 2) decreased amount of
rescue analgesia, and 3) no appreciable difference in adverse events when
compared with SC alone. Furthermore, standard pain management with parenteral
opioids alone provided ineffective pain control in our study cohort of patients
with severe pain from their hip fractures. Regional anesthesia has a role in
the ED, and US-guided femoral nerve blocks for pain management in older adults
with hip fractures should routinely be considered, particularly in cases of
refractory or severe pain.
13. Rapid Blood-Pressure Lowering in Patients with Acute
CS, et al. N Engl J Med 2013 Jun 20;368(25):2355-65.
Whether rapid lowering of elevated blood pressure would improve the outcome in
patients with intracerebral hemorrhage is not known.
We randomly assigned 2839 patients who had had a spontaneous intracerebral
hemorrhage within the previous 6 hours and who had elevated systolic blood
pressure to receive intensive treatment to lower their blood pressure (with a
target systolic level of less than 140 mm Hg within 1 hour) or
guideline-recommended treatment (with a target systolic level of less than 180
mm Hg) with the use of agents of the physician's choosing. The primary outcome
was death or major disability, which was defined as a score of 3 to 6 on the
modified Rankin scale (in which a score of 0 indicates no symptoms, a score of
5 indicates severe disability, and a score of 6 indicates death) at 90 days. A
prespecified ordinal analysis of the modified Rankin score was also performed.
The rate of serious adverse events was compared between the two groups.
Among the 2794 participants for whom the primary outcome could be determined,
719 of 1382 participants (52.0%) receiving intensive treatment, as compared
with 785 of 1412 (55.6%) receiving guideline-recommended treatment, had a
primary outcome event (odds ratio with intensive treatment, 0.87; 95%
confidence interval [CI], 0.75 to 1.01; P=0.06). The ordinal analysis showed
significantly lower modified Rankin scores with intensive treatment (odds ratio
for greater disability, 0.87; 95% CI, 0.77 to 1.00; P=0.04). Mortality was 11.9%
in the group receiving intensive treatment and 12.0% in the group receiving
guideline-recommended treatment. Nonfatal serious adverse events occurred in
23.3% and 23.6% of the patients in the two groups, respectively.
In patients with intracerebral hemorrhage, intensive lowering of blood pressure
did not result in a significant reduction in the rate of the primary outcome of
death or severe disability. An ordinal analysis of modified Rankin scores
indicated improved functional outcomes with intensive lowering of blood
pressure. (Funded by the National Health and Medical Research Council of
Australia; INTERACT2 ClinicalTrials.gov number, NCT00716079.)
14. The Implications of Missed Opportunities to Diagnose
Appendicitis in Children
JA, et al. Acad Emerg Med. 2013;20:592–596.
The purpose of this study was to determine the fraction of children with acute
appendicitis who had recent false-negative diagnoses and to analyze the
association of a missed diagnosis of appendicitis with patient outcome.
The records of all 816 patients who underwent appendectomy for suspected
appendicitis at a free-standing children's hospital between 2007 and 2010 were
reviewed. A patient admitted or evaluated in the emergency department (ED),
discharged without a diagnosis of appendicitis, and then readmitted with
histopathologically confirmed appendicitis within 3 days was considered to have
a “missed diagnosis.” Outcomes for this missed group were compared to those of
the remainder of the appendectomy cohort.
Thirty-nine patients with appendicitis (4.8%) were missed at initial
presentation. The most common initial discharge diagnoses were acute
gastroenteritis (43.6%), constipation (10.3%), and emesis (10.3%). The median
duration from the initial evaluation to the appendicitis admission was 28.3
hours (interquartile range [IQR] = 17.0 to 39.6 hours). A missed diagnosis was
associated with a longer median hospitalization (5.8 days [IQR = 4.0 to 8.1
days] vs. 2.5 days [IQR = 1.8 to 4.6 days]; p less than 0.001), higher rate of
perforation (74.4% vs. 29.0%; p less than 0.001), higher complication rate
(28.2% vs. 10.4%; p = 0.002), and higher rate of reintervention (20.5% vs.
6.2%; p = 0.003).
Of children diagnosed with appendicitis, 4.8% may have had a missed opportunity
for earlier diagnosis. These false-negative diagnoses are associated with
higher rates of perforation, postoperative complications, and need for
postoperative interventions, as well as longer hospitalizations.
15. Early Detection and Treatment of Patients with Severe
Sepsis by Prehospital Personnel
WF, et al. J Emerg Med. 2013;44:1116-25.
Severe sepsis is a condition with a high mortality rate, and the majority of
patients are first seen by Emergency Medical Services (EMS) personnel.
This research sought to determine the feasibility of EMS providers recognizing
a severe sepsis patient, thereby resulting in better patient outcomes if
standard EMS treatments for medical shock were initiated.
We developed the Sepsis Alert Protocol that incorporates a screening tool using
point-of-care venous lactate meters. If severe sepsis was identified by EMS
personnel, standard medical shock therapy was initiated. A prospective cohort
study was conducted for 1 year to determine if those trained EMS providers were
able to identify 112 severe sepsis patients before arrival at the Emergency
Department. Outcomes of the sample of severe sepsis patients were examined with
a retrospective case control study.
Trained EMS providers transported 67 severe sepsis patients. They identified 32
of the 67 severe sepsis patients correctly (47.8%). Overall mortality for the
sample of 112 severe sepsis patients transported by EMS was 26.7%. Mortality
for the sample of severe sepsis patients for whom the Sepsis Alert Protocol was
initiated was 13.6% (5 of 37), crude odds ratio for survival until discharge
was 3.19 (95% CI 1.14–8.88; p = 0.040).
This pilot study is the first to utilize EMS providers and venous lactate
meters to identify patients in severe sepsis. Further research is needed to
validate the Sepsis Alert Protocol and the potential associated decrease in
16. Parenteral sedation of elderly patients with acute
behavioral disturbance in the ED
L, et al. Amer J Emerg Med. 2013;31:970-3.
This study aimed to investigate sedation of elderly patients with acute
behavioral disturbance (ABD) in the emergency department (ED), specifically the
safety and effectiveness of droperidol.
Procedures: This was a prospective study of elderly patients (over 65 years)
with ABD requiring parenteral sedation and physical restraint in the ED.
Patients were treated with a standardized sedation protocol that included
droperidol. Drug administration, time to sedation, additional sedation, and
adverse effects were recorded. Effective sedation was defined as a drop in the
sedation assessment tool score by 2 or a score of zero or less.
Findings: There were 49 patients with median age of 81 years (range, 65-93
years); 33 were males. Thirty patients were given 10 mg droperidol, 15 were
given 5 mg droperidol, 2 were given 2.5 mg, and 2 were given midazolam. Median
time to sedation for patients receiving 10 mg droperidol was 30 minutes
(interquartile range, 18-40 minutes), compared with 21 minutes (interquartile
range, 10-55 minutes; P = .55) for patients receiving 5 mg droperidol. Three
patients were not sedated within 120 minutes. Eighteen patients required
additional sedation—10 of 30 (33%; 95% confidence interval, 18%-53%) given
droperidol 10 mg compared with 7 of 15 (47%; 95% confidence interval, 22%-73%)
given 5 mg. Fourteen patients required resedation. Adverse effects occurred in
5 patients (hypotension , oversedation , hypotension/oversedation )—2
of 30 given 10 mg droperidol and 3 of 19 not treated according to protocol.
Midazolam was given initially or for additional sedation in 2 of 5 adverse
effects. No patient had QT prolongation.
Conclusions: Droperidol was effective for sedation in most elderly patients
with ABD, and adverse effects were uncommon. An initial 5-mg dose appears
prudent with the expectation that many will require another dose.
17. How to use Paraspinous Injections for Complex
in their right mind would take an inch and a half needle, fill it with some bupivacaine,
and stab somebody in the back of the neck to get rid of their headache?”
McCormick, MD & Stuart P. Swadron, MD on May 28, 2013
18. The Use of CT in Pediatrics and the Associated
Radiation Exposure and Estimated Cancer Risk
DL, et al. JAMA Pediatr. 2013;():1-8. doi:10.1001/jamapediatrics.2013.311.
ImportanceIncreased use of computed tomography (CT) in
pediatrics raises concerns about cancer risk from exposure to ionizing
ObjectivesTo quantify trends in the use of CT in
pediatrics and the associated radiation exposure and cancer risk.
DesignRetrospective observational study.
SettingSeven US health care systems.
ParticipantsThe use of CT was evaluated for children
younger than 15 years of age from 1996 to 2010, including 4 857 736 child-years
of observation. Radiation doses were calculated for 744 CT scans performed
between 2001 and 2011.
Outcomes and MeasuresRates of CT use,
organ and effective doses, and projected lifetime attributable risks of cancer.
ResultsThe use of CT doubled for children younger
than 5 years of age and tripled for children 5 to 14 years of age between 1996
and 2005, remained stable between 2006 and 2007, and then began to decline.
Effective doses varied from 0.03 to 69.2 mSv per scan. An effective dose of 20
mSv or higher was delivered by 14% to 25% of abdomen/pelvis scans, 6% to 14% of
spine scans, and 3% to 8% of chest scans. Projected lifetime attributable risks
of solid cancer were higher for younger patients and girls than for older
patients and boys, and they were also higher for patients who underwent CT
scans of the abdomen/pelvis or spine than for patients who underwent other types
of CT scans. For girls, a radiation-induced solid cancer is projected to result
from every 300 to 390 abdomen/pelvis scans, 330 to 480 chest scans, and 270 to
800 spine scans, depending on age. The risk of leukemia was highest from head
scans for children younger than 5 years of age at a rate of 1.9 cases per 10
000 CT scans. Nationally, 4 million pediatric CT scans of the head,
abdomen/pelvis, chest, or spine performed each year are projected to cause 4870
future cancers. Reducing the highest 25% of doses to the median might prevent
43% of these cancers.
and RelevanceThe increased use of CT in
pediatrics, combined with the wide variability in radiation doses, has resulted
in many children receiving a high-dose examination. Dose-reduction strategies
targeted to the highest quartile of doses could dramatically reduce the number
of radiation-induced cancers.
19. Time to Treatment with Intravenous tPA and Outcome
From Acute Ischemic Stroke
JL, et al. JAMA. 2013;309(23):2480-2488.
ImportanceRandomized clinical trials suggest the
benefit of intravenous tissue-type plasminogen activator (tPA) in acute
ischemic stroke is time dependent. However, modest sample sizes have limited
characterization of the extent to which onset to treatment (OTT) time influences
outcome; and the generalizability of findings to clinical practice is
ObjectiveTo evaluate the degree to which OTT time is
associated with outcome among patients with acute ischemic stroke treated with
Setting, and PatientsData were analyzed
from 58 353 patients with acute ischemic stroke treated with tPA within 4.5
hours of symptom onset in 1395 hospitals participating in the Get With The
Guidelines-Stroke Program, April 2003 to March 2012.
Outcomes and MeasuresRelationship
between OTT time and in-hospital mortality, symptomatic intracranial
hemorrhage, ambulatory status at discharge, and discharge destination.
ResultsAmong the 58 353 tPA-treated patients, median
age was 72 years, 50.3% were women, median OTT time was 144 minutes
(interquartile range, 115-170), 9.3% (5404) had OTT time of 0 to 90 minutes,
77.2% (45 029) had OTT time of 91 to 180 minutes, and 13.6% (7920) had OTT time
of 181 to 270 minutes. Median pretreatment National Institutes of Health Stroke
Scale documented in 87.7% of patients was 11 (interquartile range, 6-17).
Patient factors most strongly associated with shorter OTT included greater
stroke severity (odds ratio [OR], 2.8; 95% CI, 2.5-3.1 per 5-point increase),
arrival by ambulance (OR, 5.9; 95% CI, 4.5-7.3), and arrival during regular
hours (OR, 4.6; 95% CI, 3.8-5.4). Overall, there were 5142 (8.8%) in-hospital
deaths, 2873 (4.9%) patients had intracranial hemorrhage, 19 491 (33.4%)
patients achieved independent ambulation at hospital discharge, and 22 541
(38.6%) patients were discharged to home. Faster OTT, in 15-minute increments,
was associated with reduced in-hospital mortality (OR, 0.96; 95% CI, 0.95-0.98;
P less than .001), reduced symptomatic intracranial hemorrhage (OR, 0.96; 95%
CI, 0.95-0.98; P less than .001), increased achievement of independent
ambulation at discharge (OR, 1.04; 95% CI, 1.03-1.05; P less than .001), and
increased discharge to home (OR, 1.03; 95% CI, 1.02-1.04; P less than .001).
and RelevanceIn a registry representing
US clinical practice, earlier thrombolytic treatment was associated with
reduced mortality and symptomatic intracranial hemorrhage, and higher rates of
independent ambulation at discharge and discharge to home following acute
ischemic stroke. These findings support intensive efforts to accelerate
hospital presentation and thrombolytic treatment in patients with stroke.
20. Increasingly Sensitive Assays for Cardiac Troponins:
Lemos JA. JAMA. 2013;309(21):2262-2269.
troponins are the preferred biomarkers for diagnosis of myocardial infarction
because of their high sensitivity and specificity for myocardial injury.
However, acute and chronic conditions distinct from acute coronary syndromes
(ACS) commonly lead to small elevations in troponin levels, with few data
available regarding management of care for patients with such conditions.
developed highly sensitive troponin assays will likely lead to a substantial
increase in the proportion of detectable troponin levels attributable to
non-ACS conditions. Novel algorithms with highly sensitive assays,
incorporating baseline troponin values and changes in values over 1 to 2 hours,
may allow rapid exclusion of myocardial infarction and help to address specificity
concerns but must be validated in appropriate target populations. Enhanced
detection of very low troponin levels with highly sensitive assays has made
feasible several potential new indications for troponin testing, including in
the ambulatory setting, where assessment for low-level chronic myocardial
injury may enhance risk stratification for heart failure and cardiac death.
21. From Great Grandma to You: Epigenetic changes reach
down through the generations
Tina Hesman Saey. Science News. March 20, 2013
Susan Murphy, a researcher at Duke University, studies links between a mother’s
diet and chemical exposures during pregnancy with the child’s later health. She
and others have established that what happens (in the womb) can influence a
child’s health for life.
animal studies and a smattering of human data suggest such prenatal effects
could reach farther down the family tree: The vices, virtues, inadvertent
actions and accidental exposures of a pregnant mother may pose health consequences
for her grandchildren and great-grandchildren, and perhaps even their
resulting health effects are not produced by altering DNA itself. Rather they
stem from changes in chemical tags on DNA or its associated proteins, or to actions
by RNA, another type of genetic molecule. All of these are exactly the types of
changes that scientists have always assumed cannot be inherited. Their very
name, epigenetic, literally means “over and above” or “beyond” genetics.
of your risk of disease may be determined by what your great-grandparents ate,
not just the genes they passed on. One implication is that epigenetic
programming becomes permanent and gets passed along to future generations.
CDC: 1 in 5 Americans visit an ED at least once each year
percent of Americans make at least one emergency department visit every year,
with Medicaid-covered children and adults being more likely to make such visits
than the privately insured or uninsured, CDC researchers said. The most common
causes of ED visits between 2009 and 2010 were injuries for adults and cold
symptoms for children, according to the report.
taking aspirin or warfarin (Coumadin) for prevention after a stroke don't need
to stop the drug for dental procedures, the American Academy of Neurology
MJ, et al. Summary of evidence-based guideline: Periprocedural management of
antithrombotic medications in patients with ischemic cerebrovascular disease. Report
of the Guideline Development Subcommittee of the American Academy of Neurology.
ties high doses of some NSAIDs to heart risks
meta-analysis in The Lancet found high doses of some frequently used
nonsteroidal anti-inflammatory drugs were associated with an elevated risk of
major vascular events, primarily heart attack. However, researchers said the
findings "indicate that the effects of different regimens in particular
patients can be predicted, which may help physicians choosing between
alternative NSAID regimens to weigh up which type of NSAID is safest in
G.Obesity should be considered, treated as a
disease, AMA says
move that could focus more attention on the condition and pave the way for
better treatment and reimbursement, the American Medical Association has voted
to designate obesity as a disease. A council had recommended against doing so,
partly because body mass index, the usual metric for defining obesity, is
flawed, but delegates overrode the recommendation.