1.
Does Size Really Matter? The Pathophysiology of ACS
Amal Mattu, MD. Medscape Emergency Medicine,
Jul 26, 2013.
Introduction
For many years, 2 axioms have ruled
our thoughts and discussions of coronary atherosclerosis. The first axiom was
that patients were at risk for acute coronary syndromes (ACS) if their coronary
plaques were very large; more specifically, if the plaques produced a critical
degree of luminal stenosis (eg, above 50%-75% occlusion).
Large plaques were at highest risk
for rupture by virtue of their size, and these were the plaques that produced
subintimal bleeding, leading to platelet aggregation, thrombus formation, and
myocardial infarction (MI). The second axiom was that these large,
"risky" plaques would generally manifest with clinical symptoms prior
to the MI by producing exertional angina via coronary flow limitation when
myocardial oxygen demand increased. Therefore, stress testing could predict
which patients were at risk of developing ACS and which patients were not.
However, these axioms did not explain why seemingly fit people who exercised
regularly or had negative stress tests would occasionally, without warning,
drop dead of heart attacks. Despite this apparent paradox, for years we
continued to believe that atherosclerosis and risk for MI were all about plaque
size.
Of note, pathologists have been
saying for decades that plaque size is not the key determinant of MI.
Histologic sections from patients who died revealed to them interesting
information regarding atherogenesis that other physicians are only recently
beginning to learn. A recent publication in the New England Journal of Medicine
has finally brought to the forefront what had been common knowledge primarily
only to the pathologists. (Libby P. Mechanisms of Acute Coronary Syndromes and
Their Implications for Therapy. N Engl J Med 2013; 368:2004-2013).
Study Summary
The traditional model of how
atherosclerosis develops into ACS is that progressive stenosis eventually
produces luminal occlusion and infarction. Dr. Libby, however, cites
angiographic studies over the past 2 decades that have shown that in up to 50%
of cases, the artery in which infarction occurs is often only mildly occluded
prior to infarction. These relatively small occlusions are not sufficiently
severe to limit flow and probably would result in a negative stress test if the
test were done in the days or weeks prior to infarction. They could also allow
a patient to perform routine cardio-type exercises (not to mention daily
activities) without symptoms. A recent emergency department-based study
confirmed what other studies and anecdotal experience have demonstrated: A
recent negative stress test cannot reliably rule out ACS in a patient
presenting with chest pain.[1] Does this mean that plaque size is truly
irrelevant?
To be fair, size does matter
somewhat. Larger plaques are more likely to cause ACS, but it's important to
distinguish size vs stenosis. We've traditionally assumed that as plaques grow,
they grow inward from the vessel wall into the lumen, causing luminal stenosis.
What is now understood, however, is that during the majority of the life of a
plaque, growth occurs outward into the vessel wall, producing wall expansion
and remodeling to accommodate the plaque. This remodeling process preserves the
lumen patency. The result is that relatively large plaques may grow in a vessel
but produce only mild stenosis. Significant stenosis may not develop until much
later in the life of the plaque. Patients can therefore have significant
disease, but because of preserved luminal flow, they lack exertional angina
symptoms. These patients also are likely to have negative stress tests.
So, size does matter to some extent,
but how do we account for the fact that some patients with known large plaques
do not go on to infarct? Recent data over the past 2 decades have highlighted
the concept of plaque vulnerability. In other words, there are certain
characteristics of the plaque that increase its vulnerability, or likelihood to
rupture; and these are likely more important than total plaque size.
Specifically, 3 factors play a major role in plaque vulnerability: the
thickness and strength of the fibrous cap that overlies the plaque; the size of
the lipid core of the plaque; and the plaque's content of inflammatory cells
and macrophages. The New England Journal of Medicine article discusses these 3
factors in much greater physiologic detail than I will in this brief review.
Suffice to say, however, that plaque composition appears to be far greater in
importance than plaque size.
I will, however, highlight a point
regarding inflammation. Systemic inflammatory conditions produce accelerated
atherogenesis and induce greater plaque instability. Such inflammatory
conditions include systemic lupus erythematosus, chronic kidney disease, HIV,
and so on. Patients with conditions that produce systemic inflammatory states
should be considered to be at increased risk for both coronary atherosclerosis
and ACS.
The author also briefly discusses how
this newer understanding of atherogenesis is influencing treatment strategies.
Percutaneous coronary intervention (PCI) is focused on reducing luminal
stenosis. However, if stenosis is less important than composition, it should be
no surprise that studies have shown that medical therapies are as effective as
PCI at preventing future cardiac events in patients with stable angina; PCI
appears to only be superior in the treatment of acute coronary occlusions. The
author also discusses the success of statins, which target plaque inflammation
and lipid content and appear to have a stabilizing effect on plaques.
Viewpoint
What consequences does this
information have for emergency physicians? First, it's important to realize the
limitations of relying on recent negative stress tests when evaluating patients
presenting with acute chest pain or angina equivalents. Second, it's important
to remember that coronary angiography, which has long been considered the gold
standard in the evaluation of coronary atherosclerotic disease, may actually be
more of a tarnished bronze standard: Angiography provides information only
regarding luminal stenosis, but it provides no information regarding artery
remodeling or plaque composition.
In the future, we may see the rise of
other imaging technologies that provide more useful key information regarding
plaque composition and intramural plaques. Finally, it's important to add
systemic inflammatory conditions, including lupus and chronic kidney disease,
to the list of independent risk factors for the development of premature
atherosclerosis. As our understanding of atherogenesis and ACS evolves, we will,
we hope, move beyond the myth of plaque size and appreciate the importance of
plaque composition.
2.
Lactate Clearance for Assessing Response to Resuscitation in Severe Sepsis
Jones AE. Acad Emerg Med.
2013;20:844-847.
Severe sepsis remains a major public
health problem both with a high hospital mortality rate and with staggering
associated health care expenditures. The past decade has seen new insights into
the early resuscitation of severe sepsis and this is an important,
controversial, and constantly changing topic to emergency physicians.
In this article, the recent support
for lactate clearance as a measure of early sepsis resuscitation effectiveness
is summarized, lactate-derived to oxygen-derived resuscitation variables are
compared, and the shortcomings of lactate-derived variables are described. As
summarized in this article, the best available experimental evidence suggests
that lactate clearance of at least 10% at a minimum of 2 hours after
resuscitation initiation is a valid way to assess initial response to
resuscitation in severe sepsis. Associative data suggest that lactate
normalization during resuscitation is a more powerful indicator of
resuscitative adequacy; however, further research on the optimal lactate
clearance parameters to use during resuscitation is needed, and many other
important questions have yet to be answered.
3.
Blog Nuts Love ALiEM
The ALiEM (Academic Life in EM) blog is
one of the most popular free online EM educational sites. It encompasses a wide
array of clinical and medical education topics in EM in this new era of
open-access learning and collaboration.
What is the site about?
The blog aims to disrupt how medical
providers and trainees can gain public access to high-quality, educational
content while also engaging in a dialogue about best-practices in Emergency
Medicine and medical education. We strive to reshape medical education and
academia in their evolution beyond the traditional classroom. We hope you join
us in the FOAM movement (Free Open Access to Meducation).
Editor-in-Chief: Michelle Lin, MD
Associate Professor of Emergency
Medicine
University of California San
Francisco (UCSF)
San Francisco General Hospital (SFGH)
She writes: “I practice emergency
medicine at SFGH with an academic niche in technology and how it can transform
the landscape of medical education. I was a columnist for ACEP News on “Tricks
of the Trade” for 4 years and am one of the founders of the Clerkship Directors
of Emergency Medicine (CDEM). Through this blog, I hope to share some of my
experiences and blunders, as well as introduce you to inspiring people whom
I’ve met along the way, while navigating the academic and clinical waters of
EM.”
Best Of: The following are the best
of the 1,000+ blog posts since 2009.
Tricks
of the Trade
Nursemaid elbow reduction
Parents bring in their child because
they pulled on their arm, and now the child is not using it. Parents are
thoroughly convinced that the child’s arm is either broken or dislocated. We
all recognize this as radial head subluxation or “nursemaid’s elbow” and
immediately attempt to reduce it. The provider takes the injured arm, supinates
at the wrist and flexes at the elbow. Does the child scream? What if nothing
happens? Is there an alternative technique to reducing a nursemaid elbow?
Peritonsillar abscess aspiration
When evaluating a patient with a sore
throat and “hot potato voice,” peritonsillar abscess (PTA) is at the top of the
differential diagnosis list. As with all abscesses, the definitive treatment
involves drainage of pus. This can be done either by incision and drainage or,
more commonly, by needle aspiration.
Clinical
Topic Review
NG lavage: Indicated or outdated?
Nasogastric lavage (NGL) seems to be
a logical procedure in the evaluation of patients with suspected upper GI
bleeding, but does the evidence support the logic? Most studies state that
endoscopy should occur within 24 hours of presentation, but the optimal timing
within the first 24 hours is unclear… So what are the arguments for and against
NGL?
Is the 6-12-12 adenosine approach
always correct?
The ACLS-recommended dosing strategy
of 6 mg, 12 mg, and 12 mg for adenosine may not be appropriate in every
situation. There are a few instances when lower or higher dosing should be
considered.
Medical
Education
Is it time to trash the stethoscope?
The age of ultrasound
It is important to do and teach a
thorough physical exam. I cautioned against the overreliance on diagnostic
testing in lieu of a physical exam, which can be initially burdensome and
prolonged. But perhaps our difficulty with the physical exam is not the exam
itself, but the tools that we have at our disposal to perform an exam, rather
than the exam itself.
Top 10 reasons why Yoda would be a
terrible mentor and teacher in Medicine
This is based on an article from
GeekWire that lists the top ten reasons why Yoda would make a terrible teacher.
Let’s see if I can make a derivation and convert these reasons as to why Yoda
would make a terrible mentor/teacher in medicine.
To read more, link here: http://academiclifeinem.com/
4.
A Sad Performance by the SADPERSONS Scale
Diane M. Birnbaumer, MD, FACEP, Journal Watch Emerg Med 2013
The scale, which is designed to
evaluate potential self-harm patients, misses so many at-risk patients it may
actually be harmful.
To evaluate the performance of the
SADPERSONS Scale for predicting whether self-harm patients would repeat self-harm,
need hospitalization, or need referral for psychiatric care, researchers
administered the scale to 126 consecutive self-harm patients presenting to a
general hospital emergency department in the U.K.
Of these patients, 25% repeated
self-harm within 6 months, 4% were admitted to the hospital, and 55% were
referred for psychiatric aftercare. While the scale was more than 90% specific
for all three outcomes, sensitivity was very low, ranging from 2.0%
(hospitalization) to 6.6% (repeated self-harm).
Comment: The Joint Commission's
Hospital National Patient Safety Goal 15 includes identifying patients at risk
for suicide, and it applies to patients being treated for emotional or
behavioral disorders in general hospitals. Using a simple tool such as the SADPERSONS
Scale to assess risk is tempting. Unfortunately, this study shows that trying
to distill a complex issue such as suicidality into to a scoring system may
actually cause harm by missing many patients at risk. At this point, the best
way to assess suicide risk is by listening to patients and their loved ones,
seeking corroborative information, and then using your judgment.
Citation(s): Saunders K et al. The
sad truth about the SADPERSONS Scale: An evaluation of its clinical utility in
self-harm patients. Emerg Med J 2013 Jul 29 [e-pub ahead of print].
5.
Efficacy of pain control with topical LET during lac repair with tissue
adhesive in children: a RCT
Harman S, et al. CMAJ 2013; July 29,
2013
Background: Some children feel pain
during wound closures using tissue adhesives. We sought to determine whether a
topically applied analgesic solution of lidocaine-epinephrine-tetracaine would
decrease pain during tissue adhesive repair.
Methods: We conducted a randomized,
placebo-controlled, blinded trial involving 221 children between the ages of 3
months and 17 years. Patients were enrolled between March 2011 and January 2012
when presenting to a tertiary-care pediatric emergency department with
lacerations requiring closure with tissue adhesive. Patients received either
lidocaine-epinephrine-tetracaine or placebo before undergoing wound closure.
Our primary outcome was the pain rating of adhesive application according to
the colour Visual Analogue Scale and the Faces Pain Scale - Revised. Our
secondary outcomes were physician ratings of difficulty of wound closure and
wound hemostasis, in addition to their prediction as to which treatment the
patient had received.
Results: Children who received the
analgesic before wound closure reported less pain (median 0.5, interquartile
range [IQR] 0.25- 1.50) than those who received placebo (median 1.00, IQR
0.38-2.50) as rated using the colour Visual Analogue Scale (p = 0.01) and Faces
Pain Scale - Revised (median 0.00, IQR 0.00-2.00, for analgesic v. median 2.00,
IQR 0.00-4.00, for placebo, p less than 0.01). Patients who received the
analgesic were significantly more likely to report having or to appear to have
a pain-free procedure (relative risk [RR] of pain 0.54, 95% confidence interval
[CI] 0.37-0.80). Complete hemostasis of the wound was also more common among
patients who received lidocaine-epinephrine-tetracaine than among those who received
placebo (78.2% v. 59.3%, p = 0.008).
Conclusion: Treating minor
lacerations with lidocaine-epinephrine-tetracaine before wound closure with
tissue adhesive reduced ratings of pain and increased the proportion of
pain-free repairs among children aged 3 months to 17 years. This low-risk
intervention may benefit children with lacerations requiring tissue adhesives
instead of sutures.
6.
Diagnosing HF among acutely dyspneic patients with cardiac, IVC, and lung US
Anderson KL, et al. Amer J Emerg Med
2013;31:1208-1214
Background
Rapid diagnosis (dx) of acutely
decompensated heart failure (ADHF) may be challenging in the emergency
department (ED). Point-of-care ultrasonography (US) allows rapid determination
of cardiac function, intravascular volume status, and presence of pulmonary
edema. We test the diagnostic test characteristics of these 3 parameters in
making the dx of ADHF among acutely dyspneic patients in the ED.
Methods
This was a prospective observational
cohort study at an urban academic ED. Inclusion criteria were as follows:
dyspneic patients, at least 18 years old and able to consent, whose
differential dx included ADHF. Ultrasonography performed by emergency
sonologists evaluated the heart for left ventricular ejection fraction (LVEF),
the inferior vena cava for collapsibility index (IVC-CI), and the pleura
sampled in each of 8 thoracic regions for presence of B-lines. Cutoff values
for ADHF were LVEF less than 45%, IVC-CI less than 20%, and at least 10
B-lines. The US findings were compared with the final dx determined by 2
emergency physicians blinded to the US results.
Results
One hundred one participants were
enrolled: 52% male, median age 62 (25%-75% interquartile, 53-91). Forty-four
(44%) had a final dx of ADHF. Sensitivity and specificity (including 95%
confidence interval) for the presence of ADHF were as follows: 74 (65-90) and
74 (62-85) using LVEF less than 45%, 52 (38-67) and 86 (77-95) using IVC-CI
less than 20%, and 70 (52-80) and 75 (64-87) using B-lines at least 10. Using
all 3 modalities together, the sensitivity and specificity were 36 (22-51) and
100 (95-100). As a comparison, the sensitivity and specificity of brain
natriuretic peptide greater than 500 were 75 (55-89) and 83 (67-92).
Conclusion
In this study, US was 100% specific
for the dx of ADHF.
7.
US Confirms Tube Position During CPR
In this small study, the positive
predictive value of ultrasound to confirm endotracheal tube placement during
active compressions was 98.8%.
Chou HC, et al. Resuscitation. 2013
Jul 9 [Epub ahead of print]
OBJECTIVE: This study aimed to
evaluate the accuracy of tracheal ultrasonography for assessing endotracheal
tube position during cardiopulmonary resuscitation (CPR).
METHODS: We performed a prospective
observational study of patients undergoing emergency intubation during CPR.
Real-time tracheal ultrasonography was performed during the intubation with the
transducer placed transversely just above the suprasternal notch, to assess for
endotracheal tube positioning and exclude esophageal intubation. The position
of trachea was identified by a hyperechoic air-mucosa (A-M) interface with
posterior reverberation artifact (comet-tail artifact). The endotracheal tube
position was defined as endotracheal if single A-M interface with comet-tail
artifact was observed. Endotracheal tube position was defined as intraesophageal
if a second A-M interface appeared, suggesting a false second airway (double
tract sign). The gold standard of correct endotracheal intubation was the
combination of clinical auscultation and quantitative waveform capnography. The
main outcome was the accuracy of tracheal ultrasonography in assessing
endotracheal tube position during CPR.
RESULTS: Among the 89 patients
enrolled, 7 (7.8%) had esophageal intubations. The sensitivity, specificity,
positive predictive value, and negative predictive value of tracheal
ultrasonography were 100% (95% confidence interval [CI]: 94.4-100%), 85.7% (95%
CI: 42.0-99.2%), 98.8% (95% CI: 92.5-99.0%) and 100% (95% CI: 54.7-100%),
respectively. Positive and negative likelihood ratios were 7.0 (95% CI:
1.1-43.0) and 0.0, respectively.
CONCLUSIONS: Real-time tracheal
ultrasonography is an accurate method for identifying endotracheal tube
position during CPR without the need for interruption of chest compression.
Tracheal ultrasonography in resuscitation management may serve as a powerful
adjunct in trained hands.
8.
Emergency Physicians Monthly
Ultrasound Tips
A.
Dead on Arrival: Post-Mortem Ultrasound
by
Brady Pregerson, MD and Teresa S. Wu, MD on August 1, 2013
Paramedics bring in a 60-year-old
male who collapsed at work and remained unresponsive. They state that there was
bystander CPR and a lot of freaking out by coworkers. The only past history
they have was from a coworker who thought he had high blood pressure. There was
also a witness who told them he was just walking, then doubled over and
collapsed without saying a thing. No one knew if he had any symptoms earlier in
the day. Paramedics state he was initially in a PEA rhythm at a rate of 120 bpm
on the monitor. They started an IV, gave him a 500cc saline bolus, intubated
him, and have given three rounds of epi. They estimate a 15 minute down time
prior to their arrival and a 10 minute transport time with no return of
spontaneous circulation. In fact, things are going in the opposite direction as
he has been in asystole for the past five minutes.
They move him onto the bed where your
EMT takes over CPR. You note good and symmetric assisted breath sounds via the
ET tube, but minimal palpable femoral pulse despite what appears to be good CPR
to the tempo of the Bee Gees hit “Staying Alive”. On the monitor there is
asystole in two leads. Pupils are fixed and dilated despite no atropine having
been received. Things are not looking promising.
You request saline wide open and a
final round of epinephrine while you take a look for cardiac motion with the
ultrasound machine. To minimize interruption of CPR you don’t have the EMT
pause until you are completely ready to look. You also have the RT hold
respirations to avoid any artifact. There is no cardiac motion. You verbalize
this to your team. The heart does not appear dilated and there is no
pericardial effusion. You ask aloud, “anyone have any other suggestions” prior
to calling the time of death.
Of course you next wonder what did
him in: MI, PE, something else… His belly looks pretty protuberant, so you
decide to take a quick look at his abdomen to check for free fluid. What you
see is shown in the two images below. What do you think killed this gentleman?
Images and the rest of the essay
(free): http://www.epmonthly.com/clinical-skills/ultrasound/dead-on-arrival-post-mortem-ultrasound/
B.
The Value of Repeat Studies
by Teresa S. Wu, MD & Brady
Pregerson, MD on June 20, 2013
It’s busy. There are twenty-eight
patients in the waiting room with the longest waiting 4 hours. The queue for CT
scans is over 2 hours and the one for ultrasounds is even longer; a staggering
4 hours, plus another hour to get results. Lots of people are frustrated. Your
next two patients are both pregnant females in their first trimester with
vaginal bleeding. As you perform your H & P, you encounter more
similarities between the two. Both have midline crampy pain like a period, with
no fever, no vomiting, and no syncope. Both recently had ultrasounds done, one
in your ED 3 days ago, and one with her obstetrician four days ago. You know
why they are here. One reason – they want to see if their baby still has a
heartbeat. You also know that repeating the ultrasound is not really medically
indicated using the strict sense of the word. Sure it’s reasonable, even
customary, but will it change management tonight? Can’t they just see their OB
tomorrow? Is it really the right way to practice medicine to clog up your
department even worse while simultaneously adding one more straw to the camel
carrying the national healthcare budget? Who are you going to listen to? Press
and Ganey? Barack Obama? Your conscience? What will the parents think and how will
they react if you tell them, “Sorry, we can’t do an ultrasound tonight. You
have to go home and make an appointment tomorrow to see your doctor.”?
Vaginal bleeding in pregnancy, like
many things in medicine, is both common and controversial. Do you really need
to do a pelvic exam? Do you need to do another ultrasound if they already had
one in this pregnancy that showed an IUP and they are not on fertility meds?
Few patients will be disappointed if the pelvic exam is skipped, especially if
is unlikely to have any important impact on their care, but if you don’t do the
ultrasound it may require some explaining if you don’t want them to feel
disappointed. But maybe there is a third option. Do a quick bedside ultrasound
and show the mom the heartbeat (hopefully). She gets what she wants, you feel
like you are doing the right thing, your ED throughput doesn’t take another
hit, and you get to improve your ultrasound skills. If sold correctly to the
patient and/or her husband, this can truly be a win-win approach.
Images and the rest of the essay
(free): http://www.epmonthly.com/clinical-skills/ultrasound/the-value-of-repeat-studies/
9.
Incidence of Rash after Amox Treatment in Children with Infectious Mono
Chovel-Sella A, et al. Pediatrics.
2013;131(5):e1424-7
BACKGROUND: “Ampicillin rash,” a
phenomenon unique to patients with Epstein-Barr virus acute infectious
mononucleosis (AIM) treated with ampicillin, was first reported in the 1960s.
The incidence was estimated as being between 80% and 100%, and the figures have
not been reviewed since those first accounts. We sought to establish the
current incidence of rash associated with antibiotic treatment among children
with AIM.
METHODS: A retrospective study of all
hospitalized children diagnosed as having AIM based upon positive Epstein-Barr
virus serology in 2 pediatric tertiary medical centers in Israel.
RESULTS: Of the 238 children who met
the study entry criteria during the study period, 173 were treated with
antibiotics. Fifty-seven (32.9%) of the subjects treated with antibiotics had a
rash during their illness compared with 15 (23.1%) in untreated patients (P =
.156; not significant). Amoxicillin was associated with the highest incidence
of antibiotic-induced rash occurrence (29.5%, 95% confidence interval:
18.52–42.57), but significantly lower than the 90% rate reported for ampicillin
in past studies. Age, gender, ethnicity, and atopic or allergic history were
not associated with the development of rash after antibiotic exposure. Among
the laboratory data, only increased white blood cell counts were more prevalent
among subjects who did not develop an antibiotic-induced rash.
CONCLUSIONS: The incidence of rash in
pediatric patients with AIM after treatment with the current oral
aminopenicillin (amoxicillin) is much lower than originally reported.
10.
Images in Clinical Medicine
Rubella Rash
Pellets in the Appendix
Uveoparotid Fever
Cutaneous Loxoscelism
Unblinded by the Lights
Quincke's Pulse
11.
Neutral versus Retracted Shoulder Position for Infraclavicular Subclavian Vein
Catheterization
R. Eleanor Anderson, MD, Ron M.
Walls, MD, FRCPC, FAAEM reviewing Kim HJ
et al. Br J Anaesth 2013 Aug.
Surprisingly, there was no benefit to
the retracted shoulder position.
Traditional patient positioning for
infraclavicular subclavian vein catheterization involves placing a rolled towel
or saline bag longitudinally between the scapulae to create a retracted
shoulder position; however, there is little scientific evidence to support this
practice.
In a noninferiority study,
researchers in Korea compared neutral shoulder and retracted shoulder positions
during anatomical-landmark–guided catheterization of the subclavian vein in 362
patients (age range, 16–82) undergoing elective surgery. Patients were
randomized to a neutral position, with head elevated on a 5-cm headrest, or a
retracted position, with a 1-L bag of normal saline placed between the scapulae
and head elevated on a 9-cm headrest. The primary endpoint was successful
catheterization (aspiration of venous blood). Two experienced anesthesiologists
were each allowed three attempts, with arterial puncture or air aspiration
counted as failures.
The patients' average body mass index
was 24.1. Catheterization success rates did not differ significantly between
groups (about 96%). Complication rates also did not differ significantly
(arterial puncture, about 2%; pneumothorax, 0.6%). Older age was an independent
risk factor for failure.
Comment: The retracted shoulder
position is unnecessary when performing blind infraclavicular subclavian venous
catheterization in patients with normal body mass index. Extra precautions, and
perhaps visualization, may be valuable adjuncts in elderly or obese patients.
Citation(s): Kim HJ et al. Comparison
of the neutral and retracted shoulder positions for infraclavicular subclavian
venous catheterization: A randomized, non-inferiority trial. Br J Anaesth 2013
Aug; 111:191.
12.
Traumatic Intracranial Injury in Intoxicated Patients with Minor Head Trauma
Easter JS, et al. Acad Emerg Med
2013;20:753-760.
Objectives
Studies focusing on minor head injury
in intoxicated patients report disparate prevalences of intracranial injury. It
is unclear if the typical factors associated with intracranial injury in
published clinical decision rules for computerized tomography (CT) acquisition
are helpful in differentiating patients with and without intracranial injuries,
as intoxication may obscure particular features of intracranial injury such as
headache and mimic other signs of head injury such as altered mental status.
This study aimed to estimate the prevalence of intracranial injury following
minor head injury (Glasgow Coma Scale [GCS] score ≥14) in intoxicated patients
and to assess the performance of established clinical decision rules in this
population.
Methods
This was a prospective cohort study
of consecutive intoxicated adults presenting to the emergency department (ED)
following minor head injury. Historical and physical examination features
included those from the Canadian CT Head Rule, National Emergency X-Radiography
Utilization Study (NEXUS), and New Orleans Criteria. All patients underwent
head CT.
Results
A total of 283 patients were
enrolled, with a median age of 40 years (interquartile range [IQR] = 28 to 48
years) and median alcohol concentration of 195 mmol/L (IQR = 154 to 256
mmol/L). A total of 238 of 283 (84%) were male, and 225 (80%) had GCS scores of
15. Clinically important injuries (injuries requiring admission to the hospital
or neurosurgical follow-up) were identified in 23 patients (8%; 95% confidence
interval [CI] = 5% to 12%); one required neurosurgical intervention (0.4%, 95%
CI = 0% to 2%). Loss of consciousness and headache were associated with
clinically important intracranial injury on CT. The Canadian CT Head Rule had a
sensitivity of 70% (95% CI = 47% to 87%) and NEXUS criteria had a sensitivity
of 83% (95% CI = 61% to 95%) for clinically important injury in intoxicated
patients.
Conclusions
In this study, the prevalence of
clinically important injury in intoxicated patients with minor head injury was
significant. While the presence of the common features associated with
intracranial injury in nonintoxicated patients should raise clinical suspicion
for intracranial injury in intoxicated patients, the Canadian CT Head Rule and
NEXUS criteria do not have adequate sensitivity to be applied in intoxicated
patients with minor head injury.
13.
Telemedicine consultations significantly improve pediatric care in rural ERs
Telemedicine consultations with
pediatric critical-care medicine physicians significantly improve the quality
of care for seriously ill and injured children treated in remote rural
emergency rooms, where pediatricians and pediatric specialists are scarce, a
study by researchers at UC Davis Children's Hospital has found.
The study also found that rural
emergency room physicians are more likely to adjust their pediatric patients'
diagnoses and course of treatment after a live, interactive videoconference
with a specialist. Parents' satisfaction and perception of the quality of their
child's care also are significantly improved when consultations are provided
using telemedicine, rather than telephone, and aid emergency room treatment,
the study found. The research is published earlier this month in Critical Care
Medicine.
"The bottom line is that this
readily available technology can and should be used to improve the quality of
care delivered to critically ill children when there are no pediatric
specialists available in their own communities," said James Marcin,
director of the UC Davis Children's Hospital Pediatric Telemedicine Program and
the study's senior author.
"People say a picture is worth a
thousand words," said Marcin, professor in the Department of Pediatrics,
"With medicine, video conferencing brings us right to the bedside,
allowing us to see what's happening and collaborate with on-site doctors to
provide the best possible care to our patients."
The use of technology to link
far-distant practitioners has been steadily increasing in American medicine,
particularly as a tool to provide rural and underserved communities with access
to specialty physicians. More recently, telemedicine has been used for
consultations to emergency rooms, and is particularly recommended for use in
the area of stroke care.
Despite the expansion of
telemedicine, studies of its effect on the quality of medical care remain
scarce, with publications mostly limited to anecdotal reports or issues of
technological feasibility and its potential to reduce health care costs. The
researchers sought to measure the impact of telemedicine consultations compared
to other modes of treatment, such as telephone consultations, or treatment
without consultations.
The study involved 320 seriously ill
or injured patients 17 years old and younger. The patients were treated at five
rural Northern California emergency departments between 2003 and 2007. The
rural hospitals' emergency departments were equipped with videoconferencing
units to facilitate telemedicine consultations. The interactive audiovisual
communications involved the rural emergency room physicians, pediatric
critical-care medicine specialists at UC Davis Children's Hospital, nurses, the
patients and their parents.
Fifty-eight consultations were
conducted using telemedicine consultations and 63 consultations were conducted
using telephone; 199 participants did not receive specialist consultations. The
researchers compared the quality of care, accuracy of diagnosis and course of
treatment, and overall satisfaction for all of the patients included in the
study. Quality of care was evaluated using medical record review by two
independent, unbiased emergency medicine physician experts.
Overall, cases involving a
telemedicine consultation received significantly higher quality-of-care scores
than did those involving a telephone consultation or no consultation. In
addition, rural emergency room physicians were far more likely to change their
diagnosis and treatment plans when consultations were provided using
telemedicine, rather than telephone. Parents' satisfaction and perception of
the quality of care also were significantly greater when telemedicine was used,
compared to telephone guidance.
Madan Dharmar, assistant research
professor in the pediatric telemedicine program and lead author of the study,
said the results underscore the important role telemedicine can play in rural
emergency departments, which often lack specialists and tools needed to treat
pediatric patients, such as specially sized pediatric ventilators, to treat
critically ill children. While 21 percent of children in the United States live
in rural areas, only 3 percent of pediatric critical-care medicine specialists
practice in such areas, Dharmar said.
"This research is
important," Dharmar said, "because it is one of the first published
studies that has evaluated the value of telemedicine against the current
standards of care from three different viewpoints—the emergency room physician;
the parents of the patients; and the actual quality of care and patient
outcome."
He noted that future research efforts
will focus on how telemedicine can affect patient safety and cut health care
costs, by reducing the numbers of children unnecessarily transported to
tertiary care hospitals in metropolitan areas.
Founded under Marcin's leadership,
the UC Davis pediatric critical-care telemedicine program is the first of its
kind in the United States. He said that, in partnership with the UC Davis
Center for Health and Technology, more than 5,500 pediatric telemedicine
consultations have been provided to rural hospitals throughout Northern California.
14.
Blood Culture Results Do Not Affect Treatment in Complicated Cellulitis
Paolo WF, et al. J Emerg Med.
2013;45:163-167.
Background
Cellulitis, a frequently encountered
complaint in the Emergency Department, is typically managed with antibiotics.
There is some debate as to whether obtaining blood cultures and knowing their
results would change the management of cellulitis, although most authors argue
that information from blood cultures does not change the empirical management
of uncomplicated cellulitis. However, for complicated cellulitis (as defined by
the presence of significant comorbidity), there is considerable disagreement and
lack of evidence as to the utility of blood cultures.
Objective
Our aim was to determine the role of
blood cultures in the management of complicated cellulitis.
Methods
This retrospective chart review
assessed the utility of obtaining blood cultures in complicated cellulitis (as
defined by active chemotherapy, dialysis, human immunodeficiency virus/acquired
immune deficiency syndrome, diabetes, or organ transplantation) vs. a cohort of
individuals without medical comorbidity.
Results
Six hundred and thirty-nine patients
were identified, 314 of which were deemed cases and 325 controls. Within the
cases, 29 of 314 returned as positive blood cultures vs. 17 of 325 positive
blood culture controls within the cases (p = 0.05; odds ratio = 1.84; 95%
confidence interval 0.99–3.43). A clinically significant change in management
(a change in the class of antibiotic) was found in 6 of 314 cases vs. 4 of 325
controls (p = 0.578; odds ratio = 1.5525; 95% confidence interval
0.434–5.5541).
Conclusions
Within this cohort of patients with
complicated cellulitis, blood cultures rarely changed management from empirical
coverage.
15.
Frequent Neurological Assessment Alone May Justify Intensive Care for ICH
Maas MB, et al. Surveillance
neuroimaging and neurologic examinations affect care for intracerebral
hemorrhage. Neurology. 2013;81(2):107-12.
OBJECTIVE: We tested the hypothesis
that surveillance neuroimaging and neurologic examinations identified changes
requiring emergent surgical interventions in patients with intracerebral
hemorrhage (ICH).
METHODS: Patients with primary ICH
were enrolled into a prospective registry between December 2006 and July 2012.
Patients were managed in a neuroscience intensive care unit with a protocol
that included serial neuroimaging at 6, 24, and 48 hours, and hourly neurologic
examinations using the Glasgow Coma Scale and NIH Stroke Scale. We evaluated
all cases of craniotomy and ventriculostomy to determine whether the procedure
was part of the initial management plan or occurred subsequently. For those
that occurred subsequently, we determined whether worsening on neurologic
examination or worsened neuroimaging findings initiated the process leading to
intervention.
RESULTS: There were 88 surgical
interventions in 84 (35%) of the 239 patients studied, including
ventriculostomy in 52 (59%), craniotomy in 21 (24%), and both in 11 (13%). Of
the 88 interventions, 24 (27%) occurred subsequently and distinctly from
initial management, a median of 15.9 hours (8.9-27.0 hours) after symptom onset.
Thirteen (54%) were instigated by findings on neurologic examination and 11
(46%) by neuroimaging. Demographics, severity of hemorrhage, and hemorrhage
location were not associated with delayed intervention.
CONCLUSIONS: More than 25% of
surgical interventions performed after ICH were prompted by delayed imaging or
clinical findings. Serial neurologic examinations and neuroimaging are
important and effective surveillance techniques for monitoring patients with
ICH.
16.
CT c IV Contrast Alone: The Role of Intra-abdominal Fat on the Ability to
Visualize the Normal Appendix in Children
Garcia M, et al. for the Pediatric
Emergency Care Applied Research Network (PECARN). Acad Emerg Med.
2013;20:795-800.
Background
Computed tomography (CT) with enteric
contrast is frequently used to evaluate children with suspected appendicitis.
The use of CT with intravenous (IV) contrast alone (CT IV) may be sufficient,
however, particularly in patients with adequate intra-abdominal fat (IAF).
Objectives
The authors aimed 1) to determine the
ability of radiologists to visualize the normal (nondiseased) appendix with CT
IV in children and to assess whether IAF adequacy affects this ability and 2)
to assess the association between IAF adequacy and patient characteristics.
Methods
This was a retrospective 16-center
study using a preexisting database of abdominal CT scans. Children 3 to 18
years who had CT IV scan and measured weights and for whom appendectomy history
was known from medical record review were included. The sample was chosen based
on age to yield a sample with and without adequate IAF. Radiologists at each
center reread their site's CT IV scans to assess appendix visualization and IAF
adequacy. IAF was categorized as “adequate” if there was any amount of fat completely
surrounding the cecum and “inadequate” if otherwise.
Results
A total of 280 patients were
included, with mean age of 10.6 years (range = 3.1 to 17.9 years). All 280 had
no history of prior appendectomy; therefore, each patient had a presumed normal
appendix. A total of 102 patients (36.4%) had adequate IAF. The proportion of
normal appendices visualized with CT IV was 72.9% (95% confidence interval [CI]
= 67.2% to 78.0%); the proportions were 89% (95% CI = 81.5% to 94.5%) and 63%
(95% CI = 56.0% to 70.6%) in those with and without adequate IAF (95% CI for
difference of proportions = 16% to 36%). Greater weight and older age were
strongly associated with IAF adequacy (p less than 0.001), with weight
appearing to be a stronger predictor, particularly in females. Although
statistically associated, there was noted overlap in the weights and ages of
those with and without adequate IAF.
Conclusions
Protocols using CT with IV contrast
alone to visualize the appendix can reasonably include weight, age, or both as
considerations for determining when this approach is appropriate. However,
although IAF will more frequently be adequate in older, heavier patients,
highly accurate prediction of IAF adequacy appears challenging solely based on
age and weight.
17.
Why is ED Holding Still an Issue?
by Richard Bukata, MD. EP Monthly,
July 30, 2013
Boarding admitted patients in the ED
is as bad for patient care as it is for the hospital’s bottom line. So why
aren’t more CEOs bringing this pervasive problem to an end?
I think if you ask most emergency
physicians who work in dysfunctional emergency departments (many) what is the
greatest source of their angst, they would say it is the holding of admitted
patients.
The literature on this subject is
very extensive (reflecting how serious a problem holding is). All manner of
solutions have been suggested yet holding continues to cripple the ED.
Holding of ED patients is a
widespread problem and is likely to get worse when the EDs are flooded by newly
insured individuals as the result of the Affordable Care Act coupled with the
graying of America and the transition of the baby boomers into large consumers
of healthcare.
Why does this problem still exist? Is holding
an insoluble problem? Hard to conceive that it is. We have solved all sorts of
more difficult problems than ED holding. How about smart phones, air travel,
robotic surgery, cars that drive themselves, solar power airplanes, man on the
moon. So what’s the big deal about ED holding?
The case to fix ED holding is
compelling. Holding patient in the ED consumes nurse and physician time and
precludes the ability to see more patients due to the blocking of an ED bed.
Decreasing the ability to see and treat patients is costly (assuming there are
patients waiting to be seen).
Conservatively, every new patient who
is discharged (representing about 80% of patients in most EDs), generates about
$600 -- $100 for the physician and $500 for the hospital. See 2.5 patients per
hour and it is $1500. Hold a patient for
six hours and it’s $9,000 in hard cash (not billings but actual collections).
Hold multiple patients and there’s a lot more patients who can’t be efficiently
treated in the ED (better hope there is no urgent care center in the area). If
you can’t see the patients someone else will be happy to. There are about 9,000
urgent care centers in the country and the number is rising rapidly.
Patients held in the ED generate
essentially no additional money after the work-up and initial treatment are
over and the patient is just tying up an ED bed – but they do take up nursing
and to a lesser extent, physician time. That is assuming the patient is stable.
If the patient being held is an ICU patient there is likely substantially more
nursing and physician work.
Lit Review with Comments (free): http://www.epmonthly.com/features/current-features/why-is-ed-holding-still-an-issue-/
18.
CT Scans Still Common in Pediatric HA Evaluation
F. Bruder Stapleton, MD. Journal Watch Emerg Med 2013
Despite current practice guidelines,
CT scans are still ordered in emergency departments and pediatric practices.
The American Academy of Pediatrics,
among other professional societies, recommends against the use of computed
tomography (CT) scans in the evaluation of childhood headache. To determine the
frequency of CT scans used to diagnose pediatric headache, investigators
retrospectively analyzed U.S. insurance claims data for 15,836 children (age
range, 3–17 years) with at least two claims for headaches in 2007 through 2008.
CT scans were performed in 25% of the
children, typically in the month following the initial evaluation. The initial
diagnostic categorization of the type of headache did not appear to influence
whether CT was ordered, and the pre- and post-CT diagnostic headache category
did not change for most patients. Among practitioners, neurologists were less
likely and family practitioners were more likely to order CT scans. Evaluation
in an emergency department (ED) increased the likelihood of CT evaluation for
headache; however, two thirds of the children who underwent CT scans in this
cohort had not been evaluated in an ED for headache
Comment
Radiation from computed tomography
increases risk for cancer in children (NEJM JW Pediatr Adolesc Med Jul 2 2013).
CT scans are seldom helpful or necessary in the evaluation of children with
headache; by limiting CT scans for evaluation of childhood headache, we can
make a large contribution to efforts to reduce radiation exposure by
eliminating unnecessary CT scans.
Citation(s): DeVries A et al. CT scan
utilization patterns in pediatric patients with recurrent headache. Pediatrics
2013 Jul; 132:e1.
19.
What is the clinical significance of chest CT when the CXR result is normal in
patients with blunt trauma?
Kea B, et al. Amer J Emerg Med.
2013;31:1268-73.
Background
Computed tomography (CT) has been
shown to detect more injuries than plain radiography in patients with blunt
trauma, but it is unclear whether these injuries are clinically significant.
Study Objectives
This study aimed to determine the
proportion of patients with normal chest x-ray (CXR) result and injury seen on
CT and abnormal initial CXR result and no injury on CT and to characterize the
clinical significance of injuries seen on CT as determined by a trauma expert
panel.
Methods
Patients with blunt trauma older than
14 years who received emergency department chest imaging as part of their
evaluation at 2 urban level I trauma centers were enrolled. An expert trauma
panel a priori classified thoracic injuries and subsequent interventions as
major, minor, or no clinical significance.
Results
Of 3639 participants, 2848 (78.3%)
had CXR alone and 791 (21.7%) had CXR and chest CT. Of 589 patients who had
chest CT after a normal CXR result, 483 (82.0% [95% confidence interval [CI],
78.7-84.9%]) had normal CT results, and 106 (18.0% [95% CI, 15.1%-21.3%]) had
CTs diagnosing injuries—primarily rib fractures, pulmonary contusion, and
incidental pneumothorax. Twelve patients had injuries classified as clinically
major (2.0% [95% CI, 1.2%-3.5%]), 78 were clinically minor (13.2% [95% CI,
10.7%-16.2%]), and 16 were clinically insignificant (2.7% (95% CI, 1.7%-4.4%]).
Of 202 patients with CXRs suggesting injury, 177 (87.6% [95% CI, 82.4%-91.5%])
had chest CTs confirming injury and 25 (12.4% [95% CI, 8.5%-17.6%]) had no
injury on CT.
Conclusion
Chest CT after a normal CXR result in
patients with blunt trauma detects injuries, but most do not lead to changes in
patient management.
20.
Heart Disease Overlooked in Women
Coronary artery disease continues to
be neglected in women, despite it killing at least as many women as men,
researchers found.
By Chris Kaiser, Cardiology Editor,
MedPage Today. Jul 28, 2013
Coronary artery disease (CAD)
continues to be neglected in women, despite it killing at least as many women
as men, a state-of-the-art review found. In addition, women are less likely to
receive preventive therapies, such as lipid-lowering therapies and lifestyle
advice compared with men at a similar risk level, according to Martha Gulati,
MD, and Kavita Sharma, MD, from The Ohio State University in Columbus.
"CAD is a leading cause of death
of women and men worldwide. Yet CAD's impact on women traditionally has been
underappreciated due to higher rates at younger ages in men," they wrote. Women
are disproportionately affected by microvascular coronary disease and they have
unique risk factors for CAD, including those related to pregnancy and
autoimmune disease, they wrote in a review in this month's edition of Global
Heart, the journal of the World Heart Federation.
In their review, the authors
summarized "the current state of knowledge about women and CAD,"
including risk assessment, unique sex-specific CAD characteristics, and
management strategies in 2013. CT scans and other imaging techniques show that
women have narrower coronary arteries than do men, and are more likely to
suffer CAD due to microvascular disease. So while appearing not to have major
coronary artery obstructions, women suffer symptoms due to blockages of these
smaller vessels.
Women without obstructive CAD suffer
repeated hospitalizations and testing due to symptoms of ischemia. In contrast,
obstructive CAD is more commonly found in men who are symptomatic and can be
treated with aggressive medical therapy or stenting. This type of CAD is less
frequently seen in women. Pooled estimates from multiple countries revealed
that women, both pre- and postmenopausal, are also 20% more likely to suffer
angina than men (pooled sex ratio of angina prevalence 1.20, 95% CI 1.14-1.28,
P less than 0.0001).
"Trial data indicate that CAD
should be managed differently in women," they said. Specifically, more
women than men die of CAD, and more women have died of CAD than of cancer,
including breast cancer, chronic lower respiratory disease, Alzheimer's's disease,
and accidents combined.
Overall, rates of CAD have declined
by 30% in the last decade, but rates have actually increased in women younger
than 55, researchers said. Despite these known facts, women are still less
likely to receive preventive recommendations, such as lipid-lowering therapy,
aspirin, and lifestyle advice, than are men at a similar risk level, Gulati and
Sharma pointed out. In terms of coronary artery bypass grafting (CABG), female
sex is an independent risk factor for morbidity and mortality, the authors also
noted. "Women have a higher risk of morbidity and mortality and they
experience less relief from angina than do men after CABG, despite comprising
less than 30% of the CABG population," they explained, adding that this
sex discrepancy seems to be reduced when an off-pump CABG is performed.
Traditional risk factors such as age,
family history of CAD, hypertension, diabetes, dyslipidemia, smoking, and
physical inactivity are important predictors of risk in women. Yet, women tend
to a dramatic increase in CAD after the age of 60, in contrast to men who tend
to have a more linear increase in CAD as they age. This difference in the
development of CAD creates a situation where the disease isn't identified until
much later in the course of the disease.
There also are risk factors that
appear to affect men and women differently. Obesity, for example, increases the
risk of CAD by 64% in women but by only 46% in men. Younger women (less than 50
years) who experience a CAD-related myocardial infarction (MI) are twice as
likely to die as men in similar circumstances, researchers noted. And as women
age, they continue to have notably different risk factors than men. Women over
the age of 65 are more likely to die within the first year after an MI compared
with men (42% versus 24%). Women are also more likely than men to suffer
autoimmune diseases, raising their risk of CAD, as well as polycystic ovary
syndrome, pre-eclampsia, and gestational diabetes, which can also ultimately
increase risk of CAD in women.
Another risk factor is breast cancer
treatment, which has improved survival for this disease in its early stages,
but "the gains are being attenuated by increasing CAD risk. Whether the
increased CAD risk is due to the breast cancer therapies or to the disease
itself -- which is associated with some of the same risk factors for CAD --
remains unknown," Gulati and Sharma wrote.
Women unable to carry out basic
physical fitness tests are three times more likely to develop CAD than fitter
women. "Increasing physical activity is a key component of the World Heart
Federation's 'Make a Healthy Heart Your Goal' campaign, running in partnership
with this month's Women's European Football Championships, researchers pointed
out.
Such awareness is greatly needed, f0r
women and healthcare providers alike, the researchers said. In 1997, only 30%
of American women surveyed were aware that the leading cause of death in women
is CAD; this increased to 54% in 2009. But in a survey performed in 2004, fewer
than one in five physicians recognized that more women than men die each year
from CAD. Furthermore, cardiac rehabilitation after heart attacks is underused,
particularly in women, as demonstrated in numerous national studies. Women are
55% less likely to participate in cardiac rehabilitation than men are.
"Increasing data demonstrate
that some treatment strategies have sex-specific effectiveness," the
investigators concluded. "Further research regarding the pathophysiology
of CAD in women, diagnosis, and treatment strategies specific to women is
required. CAD is not a 'man's only' disease, and we eagerly await future
studies that examine its unique presence in women."
21.
Doctors Tell Why They Got Sued
In this exclusive report, Medscape
gives physicians an inside look at the experience of being sued for
malpractice. Sample of key insights uncovered in this report:
·
74% of
physicians were surprised they were sued
·
93% of
physicians felt that saying 'I'm sorry' would not have helped
·
29% of
physicians treat patients differently after going through a lawsuit
Full article (free c registration): http://www.medscape.com/features/slideshow/malpractice-report/public?src=wnl_edit_specol&uac=18806EY
22.
Very Many Tib Bits
A.
New Guidelines: HIV Exposure at Work, Treat ASAP
Healthcare workers exposed to HIV at
work should immediately begin four weeks of post-exposure prophylaxis with
three antiretroviral drugs, according to new recommendations.
B.
Hard Candy Not Always So Sweet for Kids
Hard candy is a major cause of
choking for children, according to the first multiyear, nationally representative
study of food-related nonfatal choking injuries to kids.
C.
Metoclopramide Risky for Kids?
Metoclopramide should be avoided
whenever possible in children because of the drug’s neurological toxicity, the
European Medicines Agency said.
D.
Landmark medical liability cap survives court challenge
Physicians cheered a California
appeals court ruling that upholds the constitutionality of the state’s Medical
Injury Compensation Reform Act, reaffirming what physicians nationwide consider
the gold standard among tort reforms.
E.
Elevated glucose elevates risk for dementia
Our results suggest that higher
glucose levels may be a risk factor for dementia, even among persons without
diabetes.
F.
Changing Antibiotic Prescribing Practices through an Online Course
Internet training achieved important
reductions in antibiotic prescribing for respiratory-tract infections across
language and cultural boundaries.
G.
Survey: Physician satisfaction depends on cultural attributes
Data from a Physician Wellness
Services/Cejka Search Organizational Culture Survey showed cultural fit affects
physician satisfaction, recruitment and retention. Respectful and transparent
communication and a focus on patient-centered care and teamwork were among the
top cultural attributes ranked by physicians
H.
Opinions on Medical Marijuana
1. A Medscape Slide Show: http://www.medscape.com/features/slideshow/marijuana?nlid=32344_491&src=wnl_edit_medp_wir&uac=18806EY&spon=17
2. Dr Sanjay Gupta
CNN's chief medical expert Sanjay
Gupta announced [earlier this month] that he has reversed his blanket
opposition to marijuana use.
Op-ed: http://edition.cnn.com/2013/08/08/health/gupta-changed-mind-marijuana/index.html
Weed documentary: http://www.youtube.com/watch?v=WqWxys3P_nI
Weed documentary: http://www.youtube.com/watch?v=WqWxys3P_nI
I.
Predictors of severe H1N1 infection in children presenting within Pediatric
Emergency Research
Dalziel SR, et al. Networks (PERN):
retrospective case-control study. BMJ 2013;347:f4836.
J.
Probiotics Do Not Reduce Diarrhea Risk in Large Trial
Probiotic supplements did not prevent
antibiotic-associated diarrhea (AAD) or Clostridium difficile diarrhea (CDD) in
a large randomized, double-blind, placebo-controlled trial.
K.
Docs don't follow guidelines for treating back pain
Many physicians don't adhere to
treatment guidelines for patients with back pain, according to a study
published in JAMA Internal Medicine. Researchers looked at data from almost
24,000 medical visits in the U.S. from 1999 to 2010 and found that the
proportion of back pain patients given potentially addictive narcotics and
screened with CT or MRI increased during the period.
L.
One Quarter of MIs Are Type 2, by Novel Criteria
NEW YORK (Reuters Health) Jul 26 -
One fourth of all myocardial infarctions are secondary to ischemia due to
either increased oxygen demand or decreased supply (type 2), when diagnosed by
the use of novel clinical criteria developed by Danish cardiologists.
Dr. Lotte Saaby from the cardiology
department at Odense University Hospital and colleagues say common mechanisms
causing type 2 MI are anemia, respiratory failure, and tachyarrhythmias. And
roughly 50% of patients with type 2 MI [which equates to 1/8 of all AMIs] have
no significant coronary artery disease.
