Sunday, July 28, 2013

Lit Bits: July 28, 2013

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. 
2. Music to Reduce Pain and Distress in the Pediatric ED: A Randomized Clinical Trial  

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:  

[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.  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. 

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. 

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). 

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:  

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.  

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. 

The study objective was to determine if EPs can detect upper GI bleeding on capsule endoscopy after a brief training session. 

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. 

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). 

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.  

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. 

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. 

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%). 

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):  

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 

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%.  

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.  

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