From the recent medical literature...
1. Drug Combo Boosts Neurologically Intact Survival after Inpatient CPR
Sue Hughes. Medscape Medical News. Jul
18, 2013
Giving a combination of vasopressin,
steroids, and epinephrine (VSE) during cardiopulmonary resuscitation (CPR) and
then treating survivors with daily steroids was associated with more than a
doubling in the likelihood of being discharged with a neurologically favorable
outcome vs standard care with epinephrine alone in a new study.
The study, published in the July 17
issue of JAMA, was led by Spyros D. Mentzelopoulos, MD, Evaggelismos General
Hospital, Athens, Greece.
"Our results are very
promising," he commented to Medscape Medical News. "I would say that
theycorrespond to a level B recommendation, because there was a limited
population and just one randomized trial. We will have to wait for the
guidelines committees to decide if this treatment should be recommended for
wider use, but I would definitely want it if it was me or one of my relatives
as the patient."
Avoiding Secondary Neurologic Damage
The study evaluated the use of the 3
agents during CPR as well as continued treatment with intravenous steroids for
up to a week in those surviving but hemodynamically unstable.
Dr. Mentzelopoulos believes both
periods of treatment are important. "We need to improve resuscitation as
much as possible as survival rates after cardiac arrest are so low. We must
focus on post-resuscitation care as well as that during CPR to get better
outcomes. When spontaneous circulation comes back we need to avoid secondary
neurological damage so we need to make sure the brain stays infused."
In the JAMA paper, the researchers
note that a previous study of a similar regimen has shown improved overall
survival to hospital discharge, but this study did not reliably assess
neurologically favorable survival. They add that this is a key outcome because
among cardiac arrest survivors, the prevalence of severe cerebral disability or
vegetative state ranges from 25% to 50%.
In the current study, 268 patients
with in-hospital cardiac arrest requiring epinephrine according to
resuscitation guidelines were randomly assigned to the combination treatment of
vasopressin (20 IU/CPR cycle) plus epinephrine (VSE group) or saline placebo
plus epinephrine (control group) for the first 5 CPR cycles after randomization.
In addition, during the first CPR
cycle, patients in the VSE group received methylprednisolone (40 mg) and
patients in the control group received saline placebo. And VSE patients who
were successfully resuscitated but still hemodynamically unstable were treated
with an intravenous infusion of hydrocortisone (300 mg daily for 7 days).
Control patients were given saline placebo.
Results showed that patients in the
VSE group had a higher probability of return of spontaneous circulation of 20
minutes or longer after CPR and a higher chance of survival to hospital
discharge with a neurologically favorable outcome (CPC score of 1 or 2).
Among patients surviving after CPR
but with post-resuscitation shock, those in the VSE group had a higher
probability of survival to hospital discharge with CPC scores of 1 or 2.
The VSE patients also had improved
hemodynamics and central venous oxygen saturation, and less organ dysfunction. Dr.
Mentzelopoulos said, "We have more than doubled the number of patients
with a successful outcome, although these patients still make up a very low
percentage."
He explained to Medscape Medical News
that vasopressin is a vasoconstrictor-like epinephrine. "To maximize
perfusion of vital organs, especially the brain, we thought combination of
vasopressin and epinephrine would be optimal as they are both vasoconstrictors
but stimulate different vascular receptors — epinephrine acts on the A1
adrenergic receptor while vasopressin acts on the B1 receptor, so they should
give and additive vasoconstrictive action."
He added that the rationale for
steroid treatment after cardiac arrest is that the peripheral organs such as
adrenal glands become ischemic after cardiac arrest so the steroid level would
be low, especially in a stressful situation. "So we thought it would be
meaningful to supplement with steroids. In addition, steroids potentiate the
effects of the vasoconstrictors by facilitating signals through vasoconstrictor
receptors."
Dr. Mentzelopoulos said he could not
precisely quantify the relative contribution to the final outcome of the VSE
treatment given during resuscitation vs the hydrocortisone treatment given in
the post-resuscitation period. "The VSE protocol was associated with a
greater likelihood of successful resuscitation, but we don't know how much this
contributed to the end result. It appears that both protocols are contributing
something."
He noted that a limitation of the
study was that because of small numbers a difference in survival at 1 year
could not be reliably determined. This study was funded by the Greek Society of
Intensive Care Medicine and the Greek Ministry of Education.
Music
might have charms to soothe children undergoing painful and distressing EM procedures.
Hartling
L, et al. JAMA Pediatr. 2013;():-. doi:10.1001/jamapediatrics.2013.200.
Importance Many medical procedures aimed at helping
children cause them pain and distress, which can have long-lasting negative
effects. Music is a form of distraction that may alleviate some of the pain and
distress experienced by children while undergoing medical procedures.
Objective To compare music with standard care to manage
pain and distress.
Design,
Setting, and Participants Randomized
clinical trial conducted in a pediatric emergency department with appropriate
sequence generation and adequate allocation concealment from January 1, 2009,
to March 31, 2010. Individuals assessing the primary outcome were blind to
treatment allocation. A total of 42 children aged 3 to 11 years undergoing
intravenous placement were included.
Interventions Music (recordings selected by a music
therapist via ambient speakers) vs standard care.
Main
Outcomes and Measures The primary
outcome was behavioral distress assessed blinded using the Observational Scale
of Behavioral Distress–Revised. The secondary outcomes included child-reported
pain, heart rate, parent and health care provider satisfaction, ease of
performing the procedure, and parental anxiety.
Results With or without controlling for potential
confounders, we found no significant difference in the change in behavioral
distress from before the procedure to immediately after the procedure. When
children who had no distress during the procedure were removed from the
analysis, there was a significantly less increase in distress for the music
group (standard care group = 2.2 vs music group = 1.1, P below .05). Pain
scores among children in the standard care group increased by 2 points, while
they remained the same in the music group (P = .04); the difference was
considered clinically important. The pattern of parent satisfaction with the
management of children’s pain was different between groups, although not
statistically significant (P = .07). Health care providers reported that it was
easier to perform the procedure for children in the music group (76% very easy)
vs the standard care group (38% very easy) (P = .03). Health care providers
were more satisfied with the intravenous placement in the music group (86% very
satisfied) compared with the standard care group (48%) (P = .02).
Conclusions
and Relevance Music may have a positive
impact on pain and distress for children undergoing intravenous placement.
Benefits were also observed for the parents and health care providers.
3. CT Scans May Not Be Necessary for Abdominal Stab
Wounds
By
Will Boggs, MD. Reuters Health Information. Jul 09, 2013.
NEW
YORK (Reuters Health) Jul 09 - Physical examinations may trump CT scans when it
comes to determining which patients need laparotomy for abdominal stab wounds,
a new study suggests.
"For
patients who have sustained an abdominal stab wound and have no indication for
immediate laparotomy, serial physical examination can determine with a high
degree of sensitivity and specificity whether or not the patient has a
clinically significant injury," Dr. Kenji Inaba from University of
Southern California, Los Angeles, told Reuters Health by email.
"A
CT does not impact the clinical decision-making process, and our group has
stopped using it as part of the work-up for these patients," he said.
For
gunshot wounds, CT is able to track bullet trajectories through the soft
tissue, whereas the lack of soft tissue disruption with stab wounds makes
visualizing the track of the stab wound and any associated injuries by CT difficult.
Dr.
Inaba and colleagues, whose findings appeared online July 3 in JAMA Surgery,
sought to prospectively evaluate the diagnostic contribution made by CT in 249
patients who sustained stab wounds isolated to the abdomen. Forty-five patients
(18.1%) required emergent surgery, 27 (10.8%) with superficial injuries
underwent local wound care and were discharged home from the emergency
department, and the remaining 177 patients (71.1%) underwent CT and observation
for 24 hours in a dedicated observation unit.
Of
these 177 patients, 154 (87.0%) were managed successfully with observation and
no requirement for laparotomy, although nine underwent diagnostic laparoscopy,
all of which were negative for diaphragm injury. Thirty of the 154 patients had
a low-grade solid organ injury detected on their CT that was managed
nonoperatively. All 154 patients were successfully discharged to home within 48
hours.
Twenty-three
(13.0%) of the 177 patients in the study underwent delayed operation, including
three patients who had thoracic procedures and 20 who underwent abdominal
exploration based on deterioration of their physical examination. Two patients
underwent laparotomy solely based on CT findings; both were negative.
Physical
examination was 100% sensitive and 98.7% specific for clinically significant
injuries, compared to 31.3% sensitivity and 84.2% specificity for CT imaging. "Adding
a CT, which comes with a cost and time penalty and increases patient radiation
burden, does not contribute to clinical decision making and should therefore
not be performed routinely for these patients," Dr. Inaba concluded.
"Although
the University of Southern California group is not the first to report the
success of observing patients with anterior abdominal stab wounds, this
contribution remains important because it represents an example of how
critically analyzing an established center's data can change practices,"
writes Dr. Martin A. Schreiber from Oregon Health & Science University,
Portland, in an editorial. "The question remains: have they changed
enough?"
Dr.
Schreiber told Reuters Health by email that his institution participated in the
Western Trauma Association studies evaluating the management of patients with
anterior abdominal stab wounds and bases its protocols on the results.
"Patients
with anterior abdominal stab wounds who are either hemodynamically unstable or
who present with peritonitis are taken to the operating room," he said.
"Stable patients without evidence of peritonitis undergo local wound
exploration to evaluate for penetration of the anterior fascia. If there is no
penetration and the patient has no other indication for further observation
like alcohol intoxication, they are discharged from the hospital. If there is
fascial penetration, the patient undergoes observation for up to 24 hours. If
they develop any instability or peritonitis, they go to the OR."
"CT
scan is not currently in our algorithm for anterior abdominal stab
wounds," he added. In his editorial, Dr. Schreiber cautioned, "It is
important to realize that observation of stable stab wound patients may not be
feasible in all settings because it is resource intensive."
4. Parents Want CT Cancer Risk Info in ED
By
Crystal Phend, Senior Staff Writer, MedPage Today. Jul 8, 2013
Most
parents want to know about the lifetime cancer risk posed by doing a CT scan on
their child in the emergency department (ED), although it seldom stops them
from giving consent for the scan, a study showed. About half of parents
surveyed when their child was seen for a head injury in the ED already knew
something about the risk from ionizing radiation with CT scans (47%), Kathy
Boutis, MD, of the University of Toronto and its Hospital for Sick Children,
and colleagues found.
More
than 90% wanted to be informed of potential malignancy risks before proceeding
with the scan, but after that disclosure only 6% decided to refuse the CT, the
researchers reported in the August issue of Pediatrics. In order to have those
discussions, "we strongly recommend that physicians be well informed of
the benefits and potential risks of CT imaging," they wrote.
CT
scans in the ED have risen fivefold despite the higher radiation dose that
children are particularly sensitive to, the group noted. "It has been
suggested that parental desire for a rapid diagnosis is contributing to the
increasing use of CT in children and is occurring without their full
understanding of the potential risks," they added.
Their
study included 742 parents surveyed when their children (median age 4 years)
presented to a tertiary care pediatric ED with an isolated head injury, before
any recommendation had been made for CT. Nearly all the children ended up
diagnosed with a minor head injury or concussion (97%).
Despite
the fact that 12% of the children had a history of prior CT scans, 63% of the
parents underestimated the lifetime risk of cancer from the imaging exam.
Parents
estimated the risk of a skull radiograph series as similar to that of CT,
although the best available evidence from long-term research puts x-ray lower
at one in 1,000,000 compared with one in 10,000. "The latter could result
in an inappropriately equal level of concern about radiation exposure and
potential malignancy risks when a physician recommends radiographs or CT, which
may affect how often parents raise verbal conversations about potential risks
from CT," Boutis and colleagues noted.
"Clinicians
may therefore have a greater responsibility to initiate conversations with
families about the risks/benefits of CT rather than doing so only when prompted
by the patient." Initially, 90% of the parents said they were "very
willing" or "willing" to proceed with a head CT if the emergency
physician thought it necessary.
That
proportion dropped to 70% (P below 0.0001) after being told "although we
are not sure, it has been estimated that a head CT scan in a child may carry an
increased lifetime cancer risk around one in 10,000. It is very important to
remember that the information from a CT scan may help a doctor decide how to
best care for a child."
After
disclosure, 35% said they would not have second thoughts about CT testing if
the doctor thought it was important, whereas 41% would want further discussion
with a physician. Of the 42 parents (6%) who said they would refuse CT testing
in the survey based on the disclosure of lifetime cancer risk, eight subsequently
got a recommendation from the physician for CT imaging of their child. All went
through with it.
Limitations
of the study included lack of data on parents' experience with cancer and that
the risk information given was brief and without a personal or detailed
clinical context, which "may not reflect what would happen in clinical
reality." The English-speaking, largely college-educated population of
parents surveyed might not generalize to other sociodemographic and clinical
scenarios, where knowledge of radiation risks from imaging may be lower, the
researchers noted.
The
study was supported by the Pediatric Research Academic Initiative at SickKids
Emergency (PRAISE) program, funded internally from the Hospital for Sick
Children. The researchers reported having no conflicts of interest to disclose.
Source:
Boutis K, et al. Parental knowledge of potential cancer risks from exposure to
computed tomography. Pediatrics 2013; 132. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/23837174
[Related
resource: A different group tried to quantify the risk associated with
various imaging studies as a tool to help patients with shared decision
making. http://www.xrayrisk.com/index.php
I can’t speak to the reliability of these
estimations.]
5. Comparison of success and pain levels of
supination-flexion and hyperpronation maneuvers in childhood nursemaid's elbow
cases
Gunaydin
YK, et al. Amer J Emerg Med. 2013;31:1078-1081.
Objective:
The aim of this study was to compare the hyperpronation (HP) and the
supination-flexion (SF) reduction techniques for reducing nursemaid's elbow in
terms of efficacy and pain.
Methods:
This prospective, pseudorandomized, controlled, nonblinded study was conducted
in an urban tertiary care emergency department between October 1, 2009, and
October 1, 2010. A total of 150 patients (51 males [34%] and 99 females [66%]
between the ages of 0 to 6 years) were included in the study. When the first
reduction attempt failed, second attempt was performed using the same
technique. After failure of the second attempt, reduction technique was changed
to an alternate technique. Level of pain was evaluated using the Modified
Children's Hospital of Eastern Ontario Pain Scale in 113 patients older than 1
year who had a successful reduction process on the first attempt.
Results:
Successful reduction was accomplished in 121 (80.7%) of the patients during the
first attempt, in 56 (68.3%) of the patients using the SF technique and in 65
(95.6%) of the patients using the HP technique (P below .001). At the end of
total attempts, we found that the SF (59/84) technique was less successful than
the HP (91/93) technique (P below .001). The pain levels of the both techniques
were not statistically different.
Conclusion:
The HP technique was found to be more successful compared with the SF technique
in achieving reduction. We were unable to find any significant difference in
pain levels observed between the 2 techniques.
6. How Often Do We Place IV Catheters We Don't Use?
Half
of all IV catheters placed in an Australian emergency department were never
used to infuse fluids or medications.
Limm
EI, et al. Ann Emerg Med. 2013 Apr 23. [Epub ahead of print]
Study
objective: Our study aims to determine the incidence of unused peripheral
intravenous cannulas inserted in the emergency department (ED).
Methods:
A retrospective cohort study using a structured electronic medical record
review was performed in a 640-bed tertiary care hospital in Melbourne,
Australia. During a 30-day period, all patients who had a peripheral
intravenous cannula recorded as a procedure on their electronic medical record
in the ED were included in this study.
Results:
Fifty percent of peripheral intravenous cannulas inserted in the ED were
unused. Patients presenting with obstetric and gynecologic and neurologic
symptoms were significantly more likely to have an unused cannula. Forty-three
percent of patients admitted to the hospital with unused peripheral intravenous
cannulas in the ED continued to have them unused 72 hours later.
Conclusion:
There is a high incidence of unused peripheral intravenous cannulas inserted in
the ED. The risk of having an unused peripheral intravenous cannula is
associated with the patient's presenting complaint. Efforts should be directed
to reduce this rate of unused peripheral intravenous cannula insertion,
especially in patients being admitted, to minimize the risk of complications.
7. H&P plus Labs for the Diagnosis of Adult Female
UTI
Meister
L, et al. Acad Emerg Med 2013;20:631-645.
Background:
Emergency physicians often encounter females presenting with symptoms suggestive
of urinary tract infections (UTIs). The diagnostic accuracy of history,
physical examination, and bedside laboratory tests for female UTIs in emergency
departments (EDs) have not been quantitatively described.
Objectives:
This was a systematic review to determine the utility of history and physical
examination (H&P) and urinalysis in diagnosing uncomplicated female UTI in
the ED.
Methods:
The medical literature was searched from January 1965 through October 2012 in
PUBMED and EMBASE using the following criteria: Patients were females greater
than 18 years of age in the ED suspected of having UTIs. Interventions were
H&P and urinalysis used to diagnose a UTI. The comparator was UTI confirmed
by a positive urine culture. The outcome was operating characteristics of the
interventions in diagnosing a UTI. Study quality was assessed using Quality
Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2). Sensitivity,
specificity, and likelihood ratios (LRs) were calculated using Meta-DiSc.
Results:
Four studies (pooled n = 948) were included with UTI prevalence ranging from
40% to 60%. H&P variables all had positive LRs (+LR, range = 0.8 to 2.2)
and negative LRs (–LR, range = 0.7 to 1.0) that are insufficient to
significantly alter pretest probability of UTI. Only a positive nitrite
reaction (+LR = 7.5 to 24.5) was useful to rule in a UTI. To rule out UTI, only
a negative leukocyte esterase (LE; −LR = 0.2) or blood reaction on urine
dipstick (–LR = 0.2) were significantly accurate. Increasing pyuria directly
correlated with +LR, and moderate pyuria (urine white blood cells [uWBC] over
50 colony-forming units [CFUs]/ml) and moderate bacteruria were good predictors
of UTI (+LR = 6.4 and 15.0, respectively).
Conclusions:
No single H&P finding can accurately rule in or rule out UTI in symptomatic
women. Urinalysis with a positive nitrite or moderate pyuria and/or bacteruria
are accurate predictors of a UTI. If the pretest probability of UTI is
sufficiently low, a negative urinalysis can accurately rule out the diagnosis.
8. Identifying Children at Very Low Risk of Clinically
Important Blunt Abdominal Injuries
Holmes
JF, et al for the PECARN. Ann Emerg Med. 2013;62:107-116.e2
Study
objective
We
derive a prediction rule to identify children at very low risk for
intra-abdominal injuries undergoing acute intervention and for whom computed
tomography (CT) could be obviated.
Methods
We
prospectively enrolled children with blunt torso trauma in 20 emergency
departments. We used binary recursive partitioning to create a prediction rule
to identify children at very low risk of intra-abdominal injuries undergoing
acute intervention (therapeutic laparotomy, angiographic embolization, blood
transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal
injuries). We considered only historical and physical examination variables
with acceptable interrater reliability.
Results
We
enrolled 12,044 children with a median age of 11.1 years (interquartile range
5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203
(26.7%) received acute interventions. The prediction rule consisted of (in
descending order of importance) no evidence of abdominal wall trauma or seat
belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness,
no evidence of thoracic wall trauma, no complaints of abdominal pain, no
decreased breath sounds, and no vomiting. The rule had a negative predictive
value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%),
sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of
11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07
(95% CI 0.03 to 0.15).
Conclusion
A
prediction rule consisting of 7 patient history and physical examination
findings, and without laboratory or ultrasonographic information, identifies
children with blunt torso trauma who are at very low risk for intra-abdominal
injury undergoing acute intervention. These findings require external
validation before implementation.
9. Images in Clinical Medicine
Simultaneous
Gangrene of Both Left Extremities
Tinea
corporis in a mixed martial arts fighter
Palmoplantar
pustulosis
Trousseau
syndrome
Reversible
Cerebral Vasoconstriction after Preeclampsia
Simultaneous
Gangrene of Both Left Extremities
Man with
Right Eye Pain
Two
Patients with Frostbite
A Half
Red Baby
10. ED Case in NEJM: A 54-Year-Old Woman with Abdominal
Pain, Vomiting, and Confusion
Presentation
of Case
Dr.
Sara R. Schoenfeld (Medicine): A 54-year-old woman was admitted to this
hospital because of abdominal pain, vomiting, and confusion.
The
patient was in her usual health until approximately 3 days before admission,
when she reportedly began to feel unwell, with weakness, chills, and skin that
was abnormally warm to the touch. She self-administered aspirin, without
improvement. During the next 2 days, her oral intake decreased. Approximately
22 hours before presentation, vomiting occurred. Nine hours before
presentation, she began to travel home to Italy from the eastern United States.
During the next 2 hours, increasing abdominal pain occurred, associated with
vomiting and shortness of breath, and she took additional aspirin for pain.
Approximately 2 hours before presentation, while the patient was in flight,
abdominal pain markedly worsened, vomiting increased, and she became confused
and unresponsive. The flight was diverted to Boston. On examination by
emergency medical services personnel, she was nonverbal and was moaning continuously.
The blood pressure was 120/70 mm Hg, the pulse 52 beats per minute, and the
respiratory rate 26 breaths per minute. The capillary blood glucose level was
116 mg per deciliter (6.4 mmol per liter). She was brought to the emergency
department at this hospital by ambulance.
The
patient's history was obtained from her husband through an interpreter. She had
non–insulin-dependent (type 2) diabetes mellitus, hypertension,
nephrolithiasis, and chronic kidney disease. Medications included enalapril,
metformin, glimepiride, nimesulide, imipramine, aspirin, and ibuprofen. She had
no known allergies. She was married and had children. She lived in Italy and
did not speak English. She had vacationed in North America for 10 days,
traveling to urban areas. She did not smoke, drink alcohol, or use illicit
drugs, and there was no history of unusual ingestions.
On
examination, the patient was incoherent and appeared agitated and
uncomfortable, with frequent groaning. She was oriented to person only and
opened her eyes to command. The blood pressure was 120/70 mm Hg, the pulse 52
beats per minute, the temperature 36.7°C, the respiratory rate 18 breaths per
minute, and the oxygen saturation 95% while she was breathing ambient air. The
pupils were 3 mm in diameter and minimally reactive to light; the oral mucous
membranes were dry, and the neck was supple. The abdomen was soft, without
distention, rebound tenderness, or guarding. The skin was cool. The remainder
of the general examination was normal. The neurologic examination was limited
because of the patient's inability to follow commands; she withdrew all
extremities to pain, and cranial nerves and strength appeared normal. Normal
saline was rapidly infused, and dextrose, insulin, ondansetron, and morphine
sulfate were administered intravenously. An electrocardiogram revealed atrial
fibrillation at a rate of 115 beats per minute and a QRS duration of 94 msec,
with a tremulous baseline possibly obscuring ST-segment depression in the
inferior leads. Blood levels of calcium, triglycerides, glycated hemoglobin,
and haptoglobin were normal, as were the results of liver-function tests; other
test results are shown in Table 1. Placement of an indwelling urinary catheter
was followed by placement of intravascular catheters in the right external
jugular vein and the femoral artery.
Within
2 hours after the patient's arrival in the ED, tachypnea and increasing
somnolence developed; results of venous oximetry are shown in Table 1. The
trachea was intubated after the administration of etomidate and rocuronium, and
100% oxygen was administered and bicarbonate was infused. A chest radiograph
showed no evidence of pneumonia or pleural effusion. There were ill-defined
calcifications in the soft tissue of the left breast.
Approximately
3 hours after the patient's arrival, the rectal temperature decreased to 31.7°C
and the blood pressure to 84/43 mm Hg. Norepinephrine bitartrate and
bicarbonate were administered; fluids were warmed before infusion, and a
blanket warmer was placed. Dark-brown gastric secretions that were positive for
occult blood were aspirated through an orogastric tube; the gastric pH was 5.7…
For
the remainder of the discussion, along with images, link: http://www.nejm.org/doi/full/10.1056/NEJMcpc1208154
11. Emergency Physicians Accurately Interpret Video
Capsule Endoscopy Findings in Suspected UGI Hemorrhage: A Video Survey
Meltzer
AC, et al. Acad Emerg Med 2013;20:711-715.
Background
Acute
upper gastrointestinal (GI) hemorrhage is a common emergency department (ED)
presentation whose severity ranges from benign to life-threatening and the best
tool to risk stratify the disease is an upper endoscopy, either by scope or by
capsule, a procedure performed almost exclusively by gastroenterologists.
Unfortunately, on-call gastroenterology specialists are often unavailable, and
emergency physicians (EPs) currently lack an alternative method to
endoscopically visualize a suspected acute upper GI hemorrhage. Recent reports
have shown that video capsule endoscopy is well tolerated by ED patients and
has similar sensitivity and specificity to endoscopy for upper GI hemorrhage.
Objectives
The
study objective was to determine if EPs can detect upper GI bleeding on capsule
endoscopy after a brief training session.
Methods
A
survey study was designed to demonstrate video examples of capsule endoscopy to
EPs and determine if they could detect upper GI bleeding after a brief training
session. All videos were generated from a prior ED-based study on patients with
suspected acute upper GI hemorrhage. The training session consisted of less
than 10 minutes of background information and capsule endoscopy video examples.
EPs were recruited at the American College of Emergency Physicians Scientific
Assembly in Denver, Colorado, from October 8, 2012, to October 10, 2012.
Inclusion criteria included being an ED resident or attending physician and the
exclusion criteria included any formal endoscopy training. The authors analyzed
the agreement between the EPs and expert adjudicated capsule endoscopy readings
for each capsule endoscopy video. For the outcome categories of blood (fresh or
coffee grounds type) or no blood detected, the sensitivity and specificity were
calculated.
Results
A
total of 126 EPs were enrolled. Compared to expert gastroenterology-adjudicated
interpretation, the sensitivity to detect blood was 0.94 (95% confidence
interval [CI] = 0.91 to 0.96) and specificity was 0.87 (95% CI = 0.80 to 0.92).
Conclusions
After
brief training, EPs can accurately interpret video capsule endoscopy findings
of presence of gross blood or no blood with high sensitivity and specificity.
12. Improving Treatment for Head Lice
Single
Application of 4% Dimeticone Liquid Gel versus Two Applications of 1%
Permethrin Creme Rinse for Treatment of Head Louse Infestation: A Randomised
Controlled Trial
Burgess
IF, et al. BMC Dermatol. 2013;13(5)
Background:
A previous study indicated that a single application of 4% dimeticone liquid
gel was effective in treating head louse infestation. This study was designed
to confirm this in comparison with two applications of 1% permethrin.
Methods:
We have performed a single centre parallel group, randomised, controlled, open
label, community based trial, with domiciliary visits, in Cambridgeshire, UK.
Treatments were allocated through sealed instructions derived from a computer
generated list. We enrolled 90 children and adults with confirmed head louse
infestation analysed by intention to treat (80 per-protocol after 4 drop outs
and 6 non-compliant). The comparison was between 4% dimeticone liquid gel
applied once for 15 minutes and 1% permethrin creme rinse applied for 10
minutes, repeated after 7 days as per manufacturer's directions. Evaluated by
elimination of louse infestation after completion of treatment application
regimen.
Results:
Intention to treat comparison of a single dimeticone liquid gel treatment with
two of permethrin gave success for 30/43 (69.8%) of the dimeticone liquid gel
group and 7/47 (14.9%) of the permethrin creme rinse group (OR 13.19, 95% CI
4.69 to 37.07) (p below 0.001). Per protocol results were similar with 27/35
(77.1%) success for dimeticone versus 7/45 (15.6%) for permethrin. Analyses by
household gave essentially similar outcomes.
Conclusions:
The study showed one 15 minute application of 4% dimeticone liquid gel was
superior to two applications of 1% permethrin creme rinse (p below 0.001). The
low efficacy of permethrin suggests it should be withdrawn.
13. For STEMI Skip ED, Go Right to Cath Lab
By
Chris Kaiser, Cardiology Editor, MedPage Today. Published: Jul 23, 2013
Bypassing
the emergency department (ED) and heading straight to the cath lab resulted in
faster reperfusion times for more patients with a severe heart attack, a
statewide analysis found. Three-quarters of patients with ST-segment elevation
myocardial infarction (STEMI) taken directly to the cath lab by emergency
medical services were treated within the 90-minute recommended time frame,
compared with only half of those who were evaluated in the ED first (P below 0.001),
according to Akshay Bagai, MD, of the Duke Clinical Research Institute, and
colleagues.
The
time from first medical contact to angioplasty was a median 75 minutes for
those who bypassed the ED, versus 90 minutes for those triaged in the ED before
going to the cath lab (P below 0.001), they wrote in the study published online
in Circulation: Cardiovascular Interventions.
The
median time spent in the ED was 30 minutes, "which contributes
significantly to the failure to achieve timely reperfusion," researchers
noted. "In Europe, chest pain patients call for an ambulance, but in the
U.S., only half of them do. The remainder drive themselves to the ED or are
driven by family members," said William O'Neill, MD, medical director of
the Center for Structural Heart Disease at the Henry Ford Hospital in Detroit.
"That's
a real problem, because it adds minutes to the time needed for the patient to
be reperfused," O'Neill told MedPage Today. "We can potentially save
up to 90 minutes from the time of symptom onset to reperfusion if more chest
pain patients called for an ambulance." Even when investigators excluded
patients who needed resuscitation or intubation before percutaneous coronary
intervention (PCI), the transfer time from first medical contact to device
activation remained faster for those who bypassed the ED (76 versus 89 minutes,
P below 0.001) and more of them were treated within the 90-minute
guideline-recommended time frame (74% versus 52%, P below 0.001).
In
addition, Bagai and colleagues found that emergency medical services bypassed
the ED more often during working hours compared with off-hours (28% versus 8%).
And when patients were triaged in the ED, the lag time for landing in the cath
lab was shorter during working hours (24 versus 34 minutes for off-hours).
Also,
patients who bypassed the ED had a lower rate of in-hospital mortality (1.8%
versus 4.6%, P=0.02), but this metric lost significance when researchers
excluded those with cardiac arrest or intubation before PCI.
For
the study, Bagai and colleagues included 1,687 patients who were identified by
emergency medical services during pre-hospital transport as experiencing a
STEMI. A total of 83% were triaged in the ED, while 17% went directly to the
cath lab. The patients were part of the RACE (Reperfusion in Acute Myocardial
Infarction in Carolina Emergency Departments) project, which comprises 119
North Carolina hospitals and about 540 emergency medical service agencies.
Patients
in the study were transported to 21 PCI-capable hospitals from July 2008 to
December 2009, either directly to the cath lab or triaged first in the ED
before being taken to the cath lab. Patients who were transferred from a
non-PCI-capable hospital to a PCI-capable hospital were not included in the
study.
The
average age of patients was 60, the majority were men, and most were white.
Whether
a hospital's ED was bypassed or not varied widely among the 21 hospitals in the
study. The range of variation went from no patients bypassing the ED to nearly
two-thirds (68%) of patients skipping the ED, depending on the hospital
involved. Whether a hospital was able to treat patients in less than 90 minutes
also varied widely, ranging from 28% of patients at a particular hospital to
80%, despite the fact that emergency medical services was capable of
transmitting ECGs to the ED in 15 hospitals and directly to the cath lab in
eight hospitals.
They
noted that the "30-30-30" rule has been suggested as a way to achieve
the 90-minute benchmark: 30 minutes spent by emergency medical services, 30
minutes in the ED, and 30 minutes in the cath lab. But in this study, even when
researchers excluded those who needed resuscitation or intubation before PCI,
"patients still spent more than 30 minutes in the ED."
Researchers
said the study is limited because it is observational and registry-based. Also,
there were several limitations that precluded the ability to determine patient
and system factors independently associated with the timing of reperfusion
therapy.
14. Predictors of Progression of Recently Diagnosed AF in
REgistry on Cardiac Rhythm DisORDers: Assessing the Control of AF (RecordAF)--US
Cohort
Zhang
Y, et al. Am J Cardiol 2013;112:79e84
The
progression of atrial fibrillation (AF) to a more sustained form is associated
with increased symptoms and morbidity. The aims of the REgistry on Cardiac
Rhythm DisORDers Assessing the Control of Atrial Fibrillation (RecordAF)-United
States (US) cohort study were to identify the risk factors of AF progression
and the effects of management approaches. RecordAF is the first worldwide,
1-year observational study of the treatment of community-based patients with
recent-onset AF.
We
assessed AF progression at 12 months in the US cohort. AF progression was
defined as a change of AF to a more sustained form (either paroxysmal becoming
persistent or permanent, or persistent becoming permanent). The US cohort
included 955 patients, with mean age of 68.9 years; 56.8% were men and 88.8%
were white. At entry, 59.6% of patients were selected for rate-control and
40.4% for rhythm-control therapy. At 12 months, the management strategy was
unchanged for 68.2% of the patients in the rate- and 77.7% of the patients in the
rhythm-control groups.
Overall,
AF progression had occurred in 18.6% of patients at 12 months. The progression
rate was significantly greater in the rate-control (27.6%) than in the
rhythm-control (5.8%) group (p below 0.001). Progression to permanent AF occurred
in 16.4% of patients. In addition to a rate-control strategy, older age, AF
rhythm at entry, persistent AF at baseline, and a history of stroke or
transient ischemic attack independently predicted AF progression. Rate control
was associated with AF progression, with a propensity score adjusted odds ratio
of 2.67 (p below 0.001).
In
conclusion, rate control was the preferred treatment of recent-onset AF in the
US but was associated with more AF progression than rhythm control.
15. Ultrasound in the ED: HPS and Appy
A. Evaluation
of Hypertrophic Pyloric Stenosis by Pediatric Emergency Physician Sonography
Sivitz
AB, et al. Acad Emerg Med. 2013;20:646-651.
Objectives:
The objective was to evaluate the accuracy of pediatric emergency physician
(EP) sonography for infants with suspected hypertrophic pyloric stenosis (HPS).
Methods:
This was a prospective observational pilot study in an urban academic pediatric
emergency department (PED). Patients were selected if the treating physician
ordered an ultrasound (US) in the department of radiology for the evaluation of
suspected HPS.
Results:
Sixty-seven patients were enrolled from August 2009 through April 2012. When
identifying the pylorus, pediatric EPs correctly identified all 10 positive
cases, with a sensitivity of 100% (95% confidence interval [CI] = 62% to 100%)
and specificity of 100% (95% CI = 92% to 100%). There was no statistical
difference between the measurements obtained by pediatric EPs and radiology
staff for pyloric muscle width or length (p = 0.5 and p = 0.79, respectively).
Conclusions:
Trained pediatric EPs can accurately assess the pylorus with US in the
evaluation of HPS with good specificity.
B.
Performance of US in the Diagnosis of Appendicitis in Children in a Multicenter
Cohort
Mittal
MK, et al. Acad Emerg Med 2013;20:697-702.
Objectives
The
objectives were to assess the test characteristics of ultrasound (US) in
diagnosing appendicitis in children and to evaluate site-related variations
based on the frequency of its use. Additionally, the authors assessed the test
characteristics of US when the appendix was clearly visualized.
Methods
This
was a secondary analysis of a prospective, 10-center observational study.
Children aged 3 to 18 years with acute abdominal pain concerning for
appendicitis were enrolled. US was performed at the discretion of the treating
physician.
Results
Of
2,625 patients enrolled, 965 (36.8%) underwent abdominal US. US had an overall
sensitivity of 72.5% (95% confidence interval [CI] = 58.8% to 86.3%) and
specificity 97.0% (95% CI = 96.2% to 97.9%) in diagnosing appendicitis. US
sensitivity was 77.7% at the three sites (combined) that used it in 90% of
cases, 51.6% at a site that used it in 50% of cases, and 35% at the four
remaining sites (combined) that used it in 9% of cases. US retained a high
specificity of 96% to 99% at all sites. Of the 469 (48.6%) cases across sites
where the appendix was clearly visualized on US, its sensitivity was 97.9% (95%
CI = 95.2% to 99.9%), with a specificity of 91.7% (95% CI = 86.7% to 96.7%).
Conclusions
Ultrasound
sensitivity and the rate of visualization of the appendix on US varied across
sites and appeared to improve with more frequent use. US had universally high
sensitivity and specificity when the appendix was clearly identified. Other
diagnostic modalities should be considered when the appendix is not
definitively visualized by US.
16. Two Studies on Post-Trauma Transfusion Strategies
A. Changes
in Transfusion Protocols Linked to Improved Outcomes
Joe
Barber Jr, PhD. Medscape Medical News. Jul 18, 2013
Changes
in transfusion practices for patients with traumatic injury are associated with
reductions in mortality, according to the findings of a prospective cohort
study.
Matthew
E. Kutcher, MD, from the Department of Surgery, San Francisco General Hospital,
University of California, and colleagues present their findings in an article
published online July 17 in JAMA Surgery.
The
researchers evaluated the outcomes of 174 trauma patients who received a
massive transfusion (10 units or more of red blood cells [RBCs] in 24 h) or
required activation of the institutional massive transfusion protocol between
February 2005 and June 2011. Univariate analysis identified increasing
transfusion requirements (hazard ratio [HR], 1.01; 95% confidence interval
[CI], 1.01 - 1.02) and a higher RBC-to-fresh frozen plasma (FFP) ratio (HR,
1.91; 95% CI, 1.47 - 2.48) as predictors of mortality.
The
authors excluded patients if they were younger than 18 years, had more than 5%
surface area burns, received more than 2 L intravenous fluid before admission,
were transferred from another institution, or had nontraumatic mechanisms of
hemorrhage.
The
included patients had a mean Injury Severity Score of 28.4 ± 16.2, a mean base
deficit at admission of −9.8 ± 6.3, and a median international normalized ratio
of 1.3 (interquartile range, 1.2 - 1.6). Clinicians activated the institutional
massive transfusion protocol for 76.4% of the patients. The overall in-hospital
mortality rate was 40.8% for the patient cohort.
During
the study period, the median number of blood products administered in the first
24 h declined from 57 units in 2006 to 22 units in 2011 (P = .03), and the mean
RBC:FFP ratio declined nonsignificantly from 1.84:1 in 2007 to 1.55:1 in 2011.
In Cox regression analysis adjusted for age, Injury Severity Score, Glasgow
Coma Scale at admission, and base deficit at admission, the investigators found
that increasing transfusion requirements (HR, 1.02; 95% CI, 1.01 - 1.03) and a
higher RBC:FFP ratio (HR, 1.71; 95% CI, 1.16 - 2.52) remained significantly
predictive of mortality.
"Overall,
the data presented herein provide both an informative exposition of trauma
resuscitation trends, reflecting a sea change in the conduct of trauma
resuscitation, and a clear statement that clinical equipoise exists and, in
fact, demands well-designed multicenter clinical trials on the resuscitation of
the critically injured," the authors write. "In the meantime, despite
the unavailability of high-quality evidence, it appears that clinicians who
care for injured patients are forging ahead, regardless of the controversies in
clinical evidence, by migrating toward crystalloid- restricted, more
plasma-based MT practices."
The
limitations of the study included residual confounding and the
single-institution nature of the study. The study was supported by the National
Institutes of Health. The authors have disclosed no relevant financial
relationships.
B. Fixed-Ratio
Transfusion OK after Trauma
By
Nancy Walsh, Staff Writer, MedPage Today. Jul 17, 2013
Action
Points
·
Note that this randomized trial found that treating trauma
patients with a 1:1:1 ratio of red cells to plasma to platelets is a feasible
strategy.
·
Be aware that, while not statistically significant, the trend
in mortality results favored the standard lab-based dosing practice.
Blood
transfusion using a fixed ratio of red blood cells, plasma, and platelets is a
feasible approach for patients with severe trauma, though at a cost of wasting
plasma, a randomized trial found.
A
total of 57% of patients assigned to receive fixed-ratio transfusions
successfully achieved a ratio of 1:1:1 for the three components, compared with
6% of patients treated according to a standard protocol, which was an absolute
difference of 51% (95% CI 32-68), according to Sandro Rizoli, MD, PhD, and
colleagues from the University of Toronto. However, 22% of the total number of
plasma units were wasted in the fixed-ratio group compared with only 10% in the
control group, the researchers reported online in CMAJ.
The
use of fixed-ratio transfusion, rather than basing treatment decisions on
repeat lab test results, has grown in popularity for trauma patients, despite a
lack of reliable data on feasibility, safety, or efficacy. "This balanced
transfusion strategy aims to correct both the early coagulopathy of trauma and
the volume status of patients in hemorrhagic shock, thus targeting preventable
hemorrhage-related deaths," they wrote.
An
advantage of the fixed-ratio approach is that it avoids delays while awaiting
test results, they explained. However, adoption of this strategy offers
challenges in that it requires thawing of frozen type AB blood, which is found in
only 4% of donors. Fixed-ratio transfusions also have been associated with an
increased likelihood of lung injury and organ failure.
"The
full and widespread implementation of such a protocol will challenge blood
suppliers because of the increased demand (and wastage) of plasma," they
stated.
With
the goal of providing initial feasibility data, Rizoli's team enrolled 69
trauma patients between 2009 and 2011 who were expected to require 10 or more
units of red blood cells during the first 24 hours. Those assigned to receive
fixed-ratio transfusions were given red blood cell units as indicated until the
frozen plasma was thawed, at which time four units of plasma, a single pool of
platelets, and four additional units of red blood cells were administered.
Controls
were transfused according to a standard protocol with blood work being done
every 2 hours. Red blood cells were given if hemoglobin fell below 7.0 g/dL,
plasma transfusion aimed to maintain the international normalized ratio below
1.8, and platelets were transfused if the platelet count was lower than 50 x
109/L. Patients were determined to have reached the 1:1:1 ratio if they were
given 0.8 to 1.3 units of red blood cells and 0.8 units of platelets for each
unit of frozen plasma.
Two-thirds
of the patients were men, and most were in their 30s. The median time elapsed
after the injury until arrival at the hospital was 45 minutes, and median
systolic blood pressure was 81 mm Hg. As with the 1:1:1 ratio, more patients in
the fixed-ratio group had a 1:1 ratio of red blood cells to frozen plasma (73%
versus 22%), for an absolute difference of 51% (95% CI 31-71), Rizoli and
colleagues reported. "These findings suggest that a fixed-ratio
transfusion protocol is feasible," they observed.
The
researchers also assessed the safety of the two approaches and found all-cause
mortality at 1 month to be 32% in the fixed-ratio group and 14% among controls
(relative risk 2.27, 95% CI 0.98-9.63).
Excessive
bleeding was the cause of death in 22% of the fixed-ratio group and in 9% of
controls, while event-free survival occurred in 54% of the fixed-ratio group
and in 78% of controls. There were no cases of transfusion-related reactions or
pulmonary injury in either treatment group. A higher proportion of patients
achieving the fixed-ratio transfusions might have occurred if pre-thawed plasma
had been available, the researchers noted. When the study began, thawed plasma
could be used only within 24 hours, but this has since been extended to 5 days
in Canada.
A
limitation of the study was the possibility of "survivorship bias,"
with some patients dying before the fixed-ratio transfusions could be
administered. In addition, cautious interpretation of the clinical data is
needed because of the preliminary nature of the study.
"A
larger trial (the Pragmatic, Randomized Optimal Platelet and Plasma Ratios
[PROPPR] trial), powered to evaluate the efficacy and safety of ratio-based
transfusion strategies has begun ... and may clarify the role of a 1:1:1
transfusion strategy," Rizoli and colleagues concluded.
The
study was funded by the Canadian Forces Health Services, Defense Research and
Development Canada, and the American Association of Blood Banks. Rizoli
reported relationships with NovoNordisk, CSL, and Behring. One co-author has
received a grant from the National Blood Foundation, and a second has ties to a
registry funded by NovoNordisk.
Nascimento
B, et al. CMAJ 2013; DOI: 10.1503/cmaj.121986. Full-text (free): http://www.cmaj.ca/content/early/2013/07/15/cmaj.121986.full.pdf+html
17. Does the Absence of Cardiac Activity on US Predict
Failed Resus in Cardiac Arrest?
Cohn
B. Ann Emerg Med. 2013;62:180-181.
Take-Home
Message: The absence of cardiac activity on ultrasonography does not
universally lead to failure of resuscitation in cardiac arrest.
18. Slow Ideas: Some innovations spread fast. How do you
speed the ones that don’t?
by
Atul Gawande, MD (best-selling author of The
Checklist Manifesto). The New Yorker. July 29, 2013.
Why do
some innovations spread so swiftly and others so slowly? Consider the very
different trajectories of surgical anesthesia and antiseptics, both of which
were discovered in the nineteenth century. The first public demonstration of
anesthesia was in 1846. The Boston surgeon Henry Jacob Bigelow was approached
by a local dentist named William Morton, who insisted that he had found a gas
that could render patients insensible to the pain of surgery. That was a
dramatic claim. In those days, even a minor tooth extraction was excruciating.
Without effective pain control, surgeons learned to work with slashing speed.
Attendants pinned patients down as they screamed and thrashed, until they
fainted from the agony. Nothing ever tried had made much difference. Nonetheless,
Bigelow agreed to let Morton demonstrate his claim.
On
October 16, 1846, at Massachusetts General Hospital, Morton administered his
gas through an inhaler in the mouth of a young man undergoing the excision of a
tumor in his jaw. The patient only muttered to himself in a semi-conscious
state during the procedure. The following day, the gas left a woman, undergoing
surgery to cut a large tumor from her upper arm, completely silent and
motionless. When she woke, she said she had experienced nothing at all.
Four
weeks later, on November 18th, Bigelow published his report on the discovery of
“insensibility produced by inhalation” in the Boston Medical and Surgical
Journal. Morton would not divulge the composition of the gas, which he called
Letheon, because he had applied for a patent. But Bigelow reported that he
smelled ether in it (ether was used as an ingredient in certain medical
preparations), and that seems to have been enough. The idea spread like a
contagion, travelling through letters, meetings, and periodicals. By
mid-December, surgeons were administering ether to patients in Paris and
London. By February, anesthesia had been used in almost all the capitals of
Europe, and by June in most regions of the world.
There
were forces of resistance, to be sure. Some people criticized anesthesia as a
“needless luxury”; clergymen deplored its use to reduce pain during childbirth
as a frustration of the Almighty’s designs. James Miller, a nineteenth-century
Scottish surgeon who chronicled the advent of anesthesia, observed the
opposition of elderly surgeons: “They closed their ears, shut their eyes, and
folded their hands. . . . They had quite made up their minds that pain was a
necessary evil, and must be endured.” Yet soon even the obstructors, “with a
run, mounted behind—hurrahing and shouting with the best.” Within seven years,
virtually every hospital in America and Britain had adopted the new discovery.
Sepsis—infection—was
the other great scourge of surgery….
19. Gains Made, but U.S. Still Lags in Life Expectancy
By
David Pittman, Washington Correspondent, MedPage Today. Jul 10, 2013
Americans
are living longer, but that longevity includes more aches, pains, and
disability compared with comparably wealthy nations, a study of population
health in 34 countries found.
The
overall life expectancy in the U.S. increased from 75 to 78 years during the
period of 1990 to 2010, but with an increase in expected years lost to
disability (9.4 to 10.1 years), according to Christopher Murray, MD, DPhil, of
the Institute for Health Metrics and Evaluation at the University of Washington
in Seattle.
Compared
with other countries, the U.S. dropped in its rankings in terms of life
expectancy at birth (going from No. 20 to No. 27), life years lost to premature
death (moving from 23rd to 28th), healthy life expectancy (jumping from 14th on
the list to 26th), and age-standardized death rate (18th to 27th) between 1990
and 2010, they wrote in the study published in the July 10 issue of the Journal
of the American Medical Association.
"Despite
a level of health expenditures that would have seemed unthinkable a generation
ago, the health of the U.S. population has improved only gradually and has
fallen behind the pace of progress in many other wealthy nations," Harvey
Fineberg, MD, PhD, president of the Institute of Medicine, wrote in an accompanying
editorial.
The
U.S. also lost a little ground in years living with disability, moving from
fifth to sixth out of 34 comparable countries. Only Japan (No. 1), Mexico, (2),
South Korea (3), Spain (4), and Chile (5) scored a better rank for people living
with disability.
Low
back pain, major depressive disorder, other musculoskeletal disorders, neck
pain, and anxiety disorders -- in that order -- are the five conditions topping
the disability list of 30 items. That ranking did not change from 1990 to 2010.
Here's how other major disabilities placed: diabetes (8th on the list), asthma
(10th), Alzheimer's disease (12th), ischemic heart disease (16th), stroke
(17th), diarrheal diseases (29th), and epilepsy (30th).
The
U.S. saw declines of 5 to 9 ranks in various mortality-based metrics, while
other countries with a lower gross domestic product -- such as Chile, Portugal,
and South Korea -- had better mortality-based metrics than the U.S.
Murray's
research team consisted of 488 scientists from 50 countries who quantified the
health loss from 291 diseases and injuries, 1,160 clinical sequelae, and 67
risk factors from 1990 to 2010 for 34 countries. "This is the first
comprehensive box score of American health that's ever been published,"
JAMA Editor-in-Chief Howard Bauchner, MD, said at a press conference Wednesday,
calling the study a "landmark paper."
The
researchers hope the report -- called the Global Burden of Disease 2010 -- can
outline which diseases, injuries, and risk factors result in the greatest losses
of health and life to better target public health and medical care. To that
end, the study found heart disease -- despite significant gains in reduced
mortality -- was still the leading cause of reducing life years in 2010. Lung
cancer, stroke, chronic obstructive pulmonary disease, and road injuries such
as motor vehicle crashes followed suit.
Rates
of premature death increased for drug use, chronic kidney disease, kidney
cancer, and diabetes -- which jumped from the 15th to 7th leading cause of life
years lost. Alzheimer's disease moved from 32th to 9th in premature death. "As
the U.S. population has aged, years lived with disability have comprised a
larger share of disability-adjusted life-years than have [years of life lost to
premature death]," the authors wrote.
They
found avoidable risk factors -- such as poor diet, tobacco and alcohol use,
obesity, high blood pressure, high blood sugar, and physical inactivity --
contributed greatly to the rising disease burden.
Source:
Murray CJL, et al. The state of US health, 1990-2010: Burden of diseases,
injuries, and risk factors" JAMA 2013; DOI:10.1001/jama.2013.13805.
20. Pediatric Care in ED Not Equal Across U.S.
By
Salynn Boyles, MedPage Today. Jul 22, 2013
There
are significant variations in the treatment of children at U.S. emergency
departments (ED) for some of the most common conditions leading to pediatric
hospitalizations, including pneumonia and diabetic ketoacidosis, new research
found.
ED
settings that used more testing in diagnosing community-acquired pneumonia
(CAP) in kids had higher hospitalization rates than EDs that utilized less
diagnostic testing, reported Todd Florin, MD, of the Cincinnati Children's
Hospital Medical Center, and colleagues. However, the authors also found that
ED revisit rates were not significantly different between high- and
low-utilizing departments.
In
addition, the use of x-rays in the ED for children with asthma increased
significantly from 1995 to 2009 with variations across U.S. regions, reported
Jane Knapp, MD, of the University of Missouri-Kansas City School of Medicine,
and colleagues. Finally, readmission for diabetic ketoacidosis (DKA) within a
year hospitalization was common, accounting for one-fifth of all DKA admissions,
stated Joel Tieder, MD, of University of Washington and Seattle Children's
Hospital, and colleagues.
Taken
together, the three studies published in Pediatrics confirmed major differences
in the utilization of services from hospital to hospital, suggesting that
costly overtreatment and overuse of unnecessary diagnostic services is common
in pediatric medicine. The findings made a clear case for greater utilization
of evidence-based "best-care strategies" in treatment of the most
frequent causes of pediatric hospitalization, with the goal of both improving
patient care and reducing costs, wrote Mark Neuman, MD, MPH, and Vincent
Chiang, MD, in an accompanying commentary.
"There
are over 5,700 hospitals in the United States and the total expense for these
institutions was over $770 billion in 2011. There has never been a more
important time or a greater societal mandate to reduce healthcare costs than
right now," wrote Neuman, who is from Boston Children's Hospital and Chiang
who is at the Boston-based Harvard Medical School.
Pediatric
Pneumonia
Florin
and colleagues retrospectively examined variations in the testing and treatment
of children evaluated for CAP at 36 hospitals between 2007 and 2010. The
analysis included 100,615 ED visits. After adjustment for patient
characteristics, the authors found significant variation (P below.001) for the
most commonly ordered diagnostic tests including complete blood count
(performed in 28.7% of patients), blood culture (27.9%), and chest radiograph
(75.7%).
Hospitals
performing the most tests (high-test utilization) also admitted more pediatric
patients than low test-utilizing hospitals (odds ratio 1.86, 95% CI 117-2.94,
P=0.008). But there was no significant difference in ED revisits between high-
and low-test utilizing hospitals (OR 1.21, 95% CI 0.97-1.51, P=0.09).
"Although
it might be expected that hospitals which test less might miss cases and thus
have higher ED revisit rates, our results demonstrate that low utilization was
not associated with increased revisit rates," they explained. They
concluded that the findings suggest high-utilizing hospitals may be able to
decrease utilization and hospitalization without missing children who would
benefit from hospital admission.
However,
they acknowledged some study limitations, including the use of administrative
data where tests and outcomes may have been miscoded, leading to
misclassification bias.
Upward
Trend for X-Rays
Knapp's
group examined the use of radiographs for asthma, bronchiolitis, and croup in
the ED setting at hospitals across the nation between 1995 and 2009. These
three common pediatric respiratory illnesses account for nearly 1 million ED
visits each year, they pointed out. The retrospective, cross-sectional study
included data from the National Hospital Ambulatory Medical Care Survey.
Their
investigation found a significant increase in the use of this test during the
time period for asthma (OR 1.06, 95% CI 1.03-1.09, P below 0.001 for trend),
but not for bronchiolitis (OR 0.37, 95% CI 0.23-0.59), and croup (OR 0.34, 95%
CI: 0.17-0.68). There were also significant regional differences in the
utilization of x-ray testing for these conditions, with the test performed
significantly more often for all three conditions in EDs in the Midwest and
South than in the Northeast.
Compared
with the Northeast, EDs in the South were around twice as likely to perform
radiographs for asthma (OR 2.27, 95% CI 1.52-3.38) and bronchiolitis (OR 1.92,
95%: CI 1.06-3.47), and more than three times as likely to perform the test for
croup (OR 3.14, 95% CI 1.81-5.46). In the western U.S., radiograph use was
higher than in the Northeast in children with asthma (OR 1.67, 95% CI 1.7-2.60)
and bronchiolitis (OR 2.94, 95% CI 1.48-5.87). The authors noted that
pediatric-focused EDs performed significantly fewer radiographs for all three
conditions. Nonetheless, they concluded there was a clear trend toward
increased use of the test for the evaluation of moderate-to-severe asthma in
the ED setting.
They
also noted that changes to to guidelines, such as the National Asthma Education
and Prevention Program, from 1991 on did not account for the trend. Also, CDC
data from the study time period did not support an increased severity of
childhood asthma.
"Reversing
this trend could improve ED efficiency, decrease costs, and decrease radiation
exposure," they wrote. The authors cautioned that the data analyzed from
the national survey did not give specific provider information on the
indications for x-ray which was a study limitation.
Resources
for DKA
Tieder
and colleagues examined variations in resource utilization and hospital
readmissions for DKA, which is one of the most common reasons for hospital
admissions in children with type 1 diabetes. The study included a retrospective
cohort of 24,890 children and teens admitted for DKA at 38 children's hospitals
between 2004 and 2009.
They
found that the the mean adjusted 1-year readmission rate at the hospitals
ranged from 6.5% to 41.1%. Also, the adjusted mean standardized cost of
treating a child with DKA at the most costly hospital was nearly $8,000 more
than at the least costly hospital.
Additionally,
one in five (20.3%) DKA admissions involved children readmitted for the
condition within a year of initial treatment. The mean hospital-level total
cost of an DKA admission was $7,143 (range $4,125 to $11,916). Even after
adjusting for patient characteristics, big differences existed across hospitals
in total cost of DKA treatment, length of hospital stay and readmission rates
(P below 0.001).
"This
study demonstrates, by virtue of a 20.3% readmission rate with a range of 6.5%
to 41.1% across 38 children's hospitals that diabetes control and
self-management is not optimal in the United States," the authors wrote. The
study had some limitations: The authors were not able to assess patient
characteristics, such as glycated hemoglobin levels, insulin regimen and
adherence, and diabetes education level.
Experience
Trumps Evidence?
All of
the studies highlight the potential for improving treatment and bring down
costs by minimizing unnecessary variations in pediatric care, Neuman and Chiang
wrote. They noted that many clinicians still reject evidence-based treatment
guidelines, believing that their experience "trumps evidence-based
literature in guiding management decisions."
While
the editorialists acknowledged that these guidelines should not always drive
decisions about treatment, they wrote that practitioners can't ignore them if
they want to provide optimal care. "As practitioners, we need to use
evidence-based guidelines to reduce unnecessary variation in care," they
wrote
Abstracts:
Florin: http://pediatrics.aappublications.org/content/early/2013/07/17/peds.2013-0179.abstract; Knapp: http://pediatrics.aappublications.org/content/early/2013/07/17/peds.2012-2830.abstract ; Tieder: http://pediatrics.aappublications.org/content/early/2013/07/17/peds.2013-0359.abstract
21. Researchers Look At Why Poor Patients Prefer ED Care
By
Ankita Rao. July 8th, 2013, 5:30 PM
Long
wait times, jammed schedules, confusing insurance plans – there’s no shortage
of obstacles between a patient and her doctor. That is, if she has a doctor.
But a
Health Affairs study published [earlier in July] says the barriers for poor
people looking to get care are even higher, and it’s leading them away from
preventive doctor visits and toward emergency rooms and costly, hospital-based
care. “This was like holding up a magnifying lens to the problems of our health
care system,” said Dr. Shreya Kangovi, lead author and a physician at the
Philadelphia Veterans Affairs Medical Center.
Researchers
interviewed 40 patients of low socioeconomic status in the qualitative study to
document how and where they receive health care. The patients fell into two
groups: socially dysfunctional or disabled patients who sought hospital care
five or more times a month, and those who were socially stable but found it
hard to access ambulatory care. The researchers identified the study subjects
by their zip codes and hospital usage.
The
study found that common themes driving the group to hospitals included how they
perceived their ability to pay for care, location of facilities and
availability of treatment based on their schedules. “Transportation is hard,”
said one respondent. Another woman said she and her husband were treated for
years at “a wellness center” but their high blood pressure was not treated
aggressively or brought under control. “I went to the hospital, and they had it
under control in four days,” she told researchers.
Kangovi
said the study was meant to inform the efforts to create a more efficient
health care system.Measuring readmissions, for example, is one way that the
government currently gauges hospital efficiency by tracking when patients need
to return to the hospital within 30 days. But the study, Kangovi said, could
shed light on other factors keeping hospital beds full, like patient preference
and perceptions of quality care.
Some
programs are tackling the problems of low-income patients and primary care
directly. “An ER is not preventive. It’s not a good system for continuous
care,” said Vincent Keane, CEO of Unity Health Care Inc., which includes about
30 community health clinics across the D.C. metropolitan area.
As
part of Unity’s goal of serving marginalized communities, the health system
started a program supported by Blue Cross Blue Shield to divert frequent
emergency users to a clinical setting. They employ social workers, regular
wellness visits and testing in an effort to provide long-term care.
For
patients like those interviewed in the study, and the health care reformers
looking to rein in hospital costs, these new models could be the answer for
patients getting lost in the health care system. “It’s not that patients have
the wrong perception – they are the ones educating us that these are the
results our system is producing,” Kangovi said.
22. ED administration of thienopyridines in non–STEMI:
results from the NCDR
[DRV’s
definition: Thienopyridines are a class of ADP receptor/P2Y12 inhibitors used
for their anti-platelet activity. E.g., prasugrel (Effient), ticlopidine
(Ticlid), & clopidogrel (Plavix).]
Diercks
DB, et al. Amer J Emerg Med. 2013;31:1005-1011.
Objective:
American Heart Association/American College of Cardiology guidelines recommend
that patients with definite unstable angina or non–ST-segment elevation
myocardial infarction (NSTEMI) receive dual antiplatelet therapy on
presentation to the hospital when undergoing early invasive management or “as
soon as possible” after admission when being managed conservatively. The
guidelines do not specify whether these medications should be administered in
the emergency department (ED). Our aim was to determine whether ED
administration of a thienopyridine was associated with clinical outcomes among
patients with NSTEMI.
Methods:
We examined thienopyridine use in 39454 patients with NSTEMI who received a
thienopyridine within 24 hours of presentation in the National Cardiovascular
Data Registry's Acute Coronary Treatment and Intervention Outcomes Network–Get
With The Guidelines Registry from January 2007 to June 2010. Patients who were
not seen initially in the ED, were transferred in, or were missing time data
were excluded. We analyzed the association between ED administration of
thienopyridines and outcomes and patient demographics.
Results:
Of the cohort receiving a thienopyridine within 24 hours, 9534 (24.2%) received
it in the ED. Emergency department administration of a thienopyridine was not
associated with in-hospital major bleeding (multivariable adjusted odds ratio,
0.99; 95% confidence interval, 0.91-1.09) or in-hospital mortality (adjusted
1.02; 95% confidence interval, 0.86-1.20). Independent predictors most strongly
associated with ED thienopyridine administration were elevated troponin, ED
length of stay, prior percutaneous coronary intervention, and initial
electrocardiogram showing ischemic changes.
Conclusions:
There was no association between ED thienopyridine administration and
in-hospital major bleeding or mortality. Emergency department length of stay,
electrocardiographic changes, and elevated troponin were associated with ED
thienopyridine administration.
Excerpt
from Discussion
In
this study, we did not find any association between ED administration of
thienopyridines and in-hospital mortality or major bleeding. Despite current
guidelines recommending thienopyridine administration as soon as possible in
high-risk patients in whom and invasive strategy is planned, most EDs (over
75%) administer thienopyridines less than one-third of the time. The result is
that among individuals who receive a thienopyridine within 24 hours of
presentation for NSTEMI, only a quarter of patients with NSTEMI receive it in
the ED. Ischemic ECG changes, higher troponin elevations, and longer ED length
of stay were associated with ED thienopyridine administration, whereas home
thienopyridine use, renal dysfunction, and a history of heart failure and
stroke were associated with later administration of a thienopyridine. Our
findings suggest that patients with objective findings of ACS in the ED and
without complicating factors were most likely to receive a thienopyridine in
the ED. Thus, patients at highest risk for cardiac ischemia were appropriately
identified for ED thienopyridine administration.
Perceived
risks of ED administration of a thienopyridine
Data
from the CURE trial demonstrated that patients who received clopidogrel
compared with those treated with placebo received a significant clinical
benefit, without increasing life-threatening bleeding [1]. Despite this
benefit, administration of clopidogrel is often delayed. The explanation often
given for deferring thienopyridine administration in the ED is the concern
regarding increased risk of bleeding if the patient needs CABG [15], [16],
[17]. Although only a minority of patients will require emergent CABG, the
ability to identify these patients is limited [18], [19], [20]. Concerns about
potential CABG-related bleeding may guide local practices at individual
institutions. Similar to prior descriptive studies of patients with NSTEMI, we
noted that only a small percentage (5.1%) of the patients who received a
thienopyridine within 24 hours of presentation underwent CABG [21], [22], [23].
Consistent with our data that patients with more obvious ischemia were more
likely to receive a thienopyridine in the ED, we found a 3-fold higher
in-hospital CABG rate in patients who received a thienopyridine in the ED. It
is notable that we did not observe either a delay in time to CABG or an
increase in major bleeding in this group. In our study, ED administration of a
thienopyridine did not appear to be associated with a delay to CABG. Our data
suggest that ED thienopyridine administration in collaboration with cardiology
consultation should be considered for patients who are at high risk for cardiac
ischemia based on their ECG and troponin findings.
Conclusions and clinical implications
We did
not find an association between ED administration of thienopyridines and
in-hospital mortality or major bleeding. Only 25% of all NSTEMI patients who
presented to the ED and received a thienopyridine within 24 hours of
presentation received their first dose in the ED. Patients most likely to
receive ED administration of thienopyridines are those with high-risk features
such as ischemic ECG changes or elevated initial cardiac biomarkers and those
patients with a longer ED stay. To improve the likelihood that guidelines
contain evidence-based recommendations relevant to upstream management of
patients, studies need to be specifically designed to determine the role of ED
medical management and to address outcomes other than mortality, such as
recurrent ischemia or reinfarction.
23. Very Many Tib Bits
A. A
Set Bedtime Is Good for a Child’s Brain
A
regular bedtime may be important for the cognitive development of young
children, researchers found.
Source:
Kelly Y, et al. Time for bed: associations with cognitive performance in
7-year-old children: a longitudinal population-based study. J Epidemiol
Community Health 2013; DOI: 10.1136/jech-2012-202024.
B. Living
Longer Comes with a Price
Longevity
may come with a myriad of bothersome symptoms and a greater risk of disability
that will increase caregiving needs in the last years of life, data from a
large cohort study suggest.
C.
Pneumonia vaccine has averted thousands of hospitalizations in U.S.
Annual
pneumonia-related hospitalizations dropped by an estimated 54.8
hospitalizations per 100,000 people since the introduction of the 7-valent
pneumococcal vaccine into the childhood vaccination schedule in 2000, a study
showed. Individuals aged 85 years and older and children younger than 2 years
had the steepest declines in hospitalization rates, researchers reported in the
New England Journal of Medicine.
D. Oregon
program connects frequent ED users with physicians
A
pilot project to reduce Medicaid costs in Oregon uses care coordinators to help
patients who are frequent users of hospital emergency departments find regular
physicians and solve other daily living problems, including housing. The
federal government has given Oregon $2 billion and five years to determine
whether the program can reduce medical inflation by 2%.
National
Public Radio/Shots blog: http://www.npr.org/blogs/health/2013/07/10/200406181/how-oregon-is-getting-frequent-fliers-out-of-the-er
E.
Zapping Renal Nerves Also Zaps Milder HTN
Renal
denervation works against moderate treatment-resistant hypertension, according
to one of the first studies to attempt treating less than severe cases with the
procedure.
F. Antibodies
in Mom Linked to Autism in Kids
Maternal
autoantibodies that target key proteins in the fetal brain could explain almost
one in four cases of autism, according to two studies published online this
week in the journal Translational Psychiatry.
G. Study
Confirms Cognitive Loss with Menopause
Certain
aspects of cognitive function related to memory declined significantly in women
during the transition from pre- to postmenopausal status, a comprehensive
neuropsychiatric assessment showed.
H. Parents’
TV Habits Rub Off on Kids
How
much time parents spend watching television is the single biggest determinant
of how much their kids watch, a survey showed.
I. Decongestant
use in first trimester may raise risk of birth defects
Babies
born to women who took the decongestant phenylephrine during their first
trimester of pregnancy were eight times more likely to have endocardial cushion
defect than unexposed peers, while first-trimester use of phenylpropanolamine
was associated with an eightfold increased risk of ear and stomach defects.
Researchers also found first-trimester use of pseudoephedrine was tied to a
threefold higher risk of so-called limb reduction defects. The findings were
published in the American Journal of Epidemiology.
J. Dr.
Google may have a place in health care after all, experts say
According
to a Philips North America survey, more than 40% of Americans say they feel
comfortable searching online to evaluate their own medical symptoms, although
experts have often warned of the inherent problems in doing so. However, some
physicians are now embracing certain online self-diagnosing tools and even
urging patients to use them ahead of appointments to save time and possibly
help uncover a diagnosis that might have otherwise been missed.
The
Wall Street Journal (tiered subscription model) (7/22): http://online.wsj.com/article/SB10001424127887324328904578621743278445114.html
