A collection of assorted summaries, highlights, and abstracts from the recent medical literature.
Monday, September 16, 2013
Lit Bits: Sept 16, 2013
From the recent medical literature...
1. Severe Sepsis and Septic Shock: A Review in NEJM
DC, van der Poll T. N Engl J Med 2013; 369:840-851.
is one of the oldest and most elusive syndromes in medicine…
sepsis occurs as a result of both community-acquired and health care–associated
infections. Pneumonia is the most common cause, accounting for about half of
all cases, followed by intraabdominal and urinary tract infections. 7,8,11,12
Blood cultures are typically positive in only one third of cases, and in up to
a third of cases, cultures from all sites are negative. 7,11,13,14
Staphylococcus aureus and Streptococcus pneumoniae are the most common
gram-positive isolates, whereas Escherichia coli, klebsiella species, and
Pseudomonas aeruginosa predominate among gram-negative isolates.11,14 An
epidemiologic study of sepsis showed that during the period from 1979 to 2000,
gram-positive infections overtook gram-negative infections.15 However, in a
more recent study involving 14,000 ICU patients in 75 countries, gram-negative
bacteria were isolated in 62% of patients with severe sepsis who had positive
cultures, gram-positive bacteria in 47%, and fungi in 19%.12 …
clinical manifestations of sepsis are highly variable, depending on the initial
site of infection, the causative organism, the pattern of acute organ
dysfunction, the underlying health status of the patient, and the interval
before initiation of treatment. The signs of both infection and organ
dysfunction may be subtle, and thus the most recent international consensus
guidelines provide a long list of warning signs of incipient sepsis (Table
1Table 1Diagnostic Criteria for Sepsis, Severe Sepsis, and Septic Shock.).5
Acute organ dysfunction most commonly affects the respiratory and
cardiovascular systems. Respiratory compromise is classically manifested as the
acute respiratory distress syndrome (ARDS), which is defined as hypoxemia with
bilateral infiltrates of noncardiac origin.22 Cardiovascular compromise is
manifested primarily as hypotension or an elevated serum lactate level. After
adequate volume expansion, hypotension frequently persists, requiring the use
of vasopressors, and myocardial dysfunction may occur.23
brain and kidneys are also often affected. Central nervous system dysfunction
is typically manifested as obtundation or delirium. Imaging studies generally
show no focal lesions, and findings on electroencephalography are usually
consistent with nonfocal encephalopathy. Critical illness polyneuropathy and
myopathy are also common, especially in patients with a prolonged ICU stay.24
Acute kidney injury is manifested as decreasing urine output and an increasing
serum creatinine level and frequently requires treatment with renal-replacement
therapy. Paralytic ileus, elevated aminotransferase levels, altered glycemic
control, thrombocytopenia and disseminated intravascular coagulation, adrenal
dysfunction, and the euthyroid sick syndrome are all common in patients with
severe sepsis.5 …
Surviving Sepsis Campaign, an international consortium of professional
societies involved in critical care, treatment of infectious diseases, and
emergency medicine, recently issued the third iteration of clinical guidelines
for the management of severe sepsis and septic shock (Table 2 Guidelines
for the Treatment of Severe Sepsis and Septic Shock from the Surviving Sepsis
Campaign.).23 The most important elements of the guidelines are organized into
two “bundles” of care: an initial management bundle to be accomplished within 6
hours after the patient's presentation and a management bundle to be
accomplished in the ICU.23 Implementation of the bundles is associated with an
of the initial management bundle are to provide cardiorespiratory resuscitation
and mitigate the immediate threats of uncontrolled infection. Resuscitation
requires the use of intravenous fluids and vasopressors, with oxygen therapy
and mechanical ventilation provided as necessary. The exact components required
to optimize resuscitation, such as the choice and amount of fluids, appropriate
type and intensity of hemodynamic monitoring, and role of adjunctive vasoactive
agents, all remain the subject of ongoing debate and clinical trials; many of
these issues will be covered in this series.23 Nonetheless, some form of
resuscitation is considered essential, and a standardized approach has been
advocated to ensure prompt, effective management.23 The initial management of
infection requires forming a probable diagnosis, obtaining cultures, and
initiating appropriate and timely empirical antimicrobial therapy and source
control (i.e., draining pus, if appropriate).
choice of empirical therapy depends on the suspected site of infection, the
setting in which the infection developed (i.e., home, nursing home, or
hospital), medical history, and local microbial-susceptibility patterns.
Inappropriate or delayed antibiotic treatment is associated with increased
mortality.48,49 Thus, intravenous antibiotic therapy should be started as early
as possible and should cover all likely pathogens. It has not been determined
whether combination antimicrobial therapy produces better outcomes than
adequate single-agent antibiotic therapy in patients with severe sepsis.50-53
Current guidelines recommend combination antimicrobial therapy only for
neutropenic sepsis and sepsis caused by pseudomonas species. Empirical
antifungal therapy should be used only in patients at high risk for invasive
patient should also be moved to an appropriate setting, such as an ICU, for
ongoing care. After the first 6 hours, attention focuses on monitoring and
support of organ function, avoidance of complications, and de-escalation of
care when possible. De-escalation of initial broad-spectrum therapy may prevent
the emergence of resistant organisms, minimize the risk of drug toxicity, and
reduce costs, and evidence from observational studies indicates that such an
approach is safe.54 The only immunomodulatory therapy that is currently
advocated is a short course of hydrocortisone (200 to 300 mg per day for up to
7 days or until vasopressor support is no longer required) for patients with
refractory septic shock.23 This recommendation is supported by a
meta-analysis,55 but the two largest studies had conflicting results,56,57 and
other clinical trials are ongoing. 58,59 …
2. Door-to-Balloon Time and Mortality among Patients
Undergoing Primary PCI
S. Menees, et al. N Engl J Med 2013; 369:901-909
Current guidelines for the treatment of ST-segment elevation myocardial
infarction recommend a door-to-balloon time of 90 minutes or less for patients
undergoing primary percutaneous coronary intervention (PCI). Door-to-balloon
time has become a performance measure and is the focus of regional and national
quality-improvement initiatives. However, it is not known whether national
improvements in door-to-balloon times have been accompanied by a decline in
We analyzed annual trends in door-to-balloon times and in-hospital mortality
using data from 96,738 admissions for patients undergoing primary PCI for
ST-segment elevation myocardial infarction from July 2005 through June 2009 at
515 hospitals participating in the CathPCI Registry. In a subgroup analysis
using a linked Medicare data set, we assessed 30-day mortality.
Median door-to-balloon times declined significantly, from 83 minutes in the 12
months from July 2005 through June 2006 to 67 minutes in the 12 months from
July 2008 through June 2009 (P less than 0.001). Similarly, the percentage of
patients for whom the door-to-balloon time was 90 minutes or less increased
from 59.7% in the first year to 83.1% in the last year (P less than 0.001).
Despite improvements in door-to-balloon times, there was no significant overall
change in unadjusted in-hospital mortality (4.8% in 2005–2006 and 4.7% in
2008–2009, P=0.43 for trend) or in risk-adjusted in-hospital mortality (5.0% in
2005–2006 and 4.7% in 2008–2009, P=0.34), nor was a significant difference
observed in unadjusted 30-day mortality (P=0.64).
Although national door-to-balloon times have improved significantly for
patients undergoing primary PCI for ST-segment elevation myocardial infarction,
in-hospital mortality has remained virtually unchanged. These data suggest that
additional strategies are needed to reduce in-hospital mortality in this
3. Use of the PECARN Blunt Abdominal Injury Rules in
Cases of Suspected Abuse
to the editor
congratulate the Pediatric Emergency Care Applied Research Network (PECARN)
investigators for another important study, which, when validated, could be a
powerful tool to decrease unnecessary radiation exposure in children. However,
we caution that there is potential for harm if this rule, even when validated, is
applied to children with concern for physical abuse.
abdominal injury is the second-leading cause of death from physical abuse and
occurs predominantly in children younger than 3 years,1 who made up only a
small proportion of the cohort studied in this article. Subjects were excluded
if their injury occurred more than 24 hours before presentation, but in cases
of abuse (as distinct from peer-on-peer assaults), an accurate history is
commonly lacking, presentations may be delayed, or the true time of injury may
be unknown.2, 3 Although “physical assault involving the abdomen” was an
inclusion criterion, subjects were recruited from the emergency department and
therefore might not be enrolled if assault was recognized only after hospital
admission, because of a changing history or abnormal laboratory study or
goal of the proposed decision rule is to identify children with intra-abdominal
injury who require acute intervention, defined by the authors as laparotomy,
embolization, blood transfusion, or intravenous fluid…
thank Drs. Lindberg, Berger, and Lane for their comments about our article
titled “Identifying Children at Very Low Risk of Clinically Important Blunt
Abdominal Injuries.” They express concerns in implementing a clinical
prediction rule for the evaluation of children with blunt torso trauma when the
mechanism of injury is abuse. However, there are 2 main limitations to the
comments from this group. First, they are misinterpreting the outcome variable
of our study and are attempting to apply the clinical prediction rule to a
different outcome variable. Patients with none of the variables in the
prediction rule are at very low risk for intra-abdominal injury undergoing
acute intervention and therefore “abdominal CT [computed tomography] is generally
unwarranted.” The rule is not generated to predict an outcome of any
intra-abdominal injury, rather only those undergoing acute intervention.
needs to identify an injury that does not require a therapeutic intervention
(as in physical abuse), then it is not appropriate to use the rule…
4. Safety of US-guided thoracentesis in patients with
abnormal preprocedural coagulation parameters.
RM, et al. Chest. 2013 Aug;144(2):456-63.
Despite a low incidence of hemorrhagic complications following thoracentesis,
correction or attempted correction of abnormal preprocedural coagulation
parameters is still commonly performed. We aimed to assess hemorrhagic
complications following ultrasound-guided thoracentesis in patients with
abnormal preprocedural coagulation parameters.
We analyzed 1,009 ultrasound-guided thoracenteses performed between January
2005 and September 2011 on patients with international normalized ratio (INR)
> 1.6, serum platelet values < 50 × 109/L, or both. Procedures
were divided into two groups: those in whom abnormal preprocedural coagulation
parameters were not corrected before the thoracentesis (group 1) and a second
group in which patients received a transfusion of platelets or fresh frozen
plasma prior to thoracentesis (group 2). All procedures were evaluated for
hemorrhagic complications as defined by the National Institutes of Health
Common Terminology Criteria for Adverse Events.
A total of 1,009 ultrasound-guided thoracenteses were included in our study,
consisting of 706 procedures in 538 patients in group 1 and 303 procedures in
235 patients in group 2. There were four hemorrhagic complications out of 1,009
procedures (0.40%; 95% CI, 0.15%-1.02%): zero in group 1 (0 of 706 or 0.0%; 95%
CI, 0%-0.68%) and four in group 2 (four of 303 or 1.32%; 95% CI, 0.51%-3.36%).
Hemorrhagic complications are infrequent after ultrasound-guided thoracentesis,
and attempting to correct an abnormal INR or platelet level before the
procedure is unlikely to confer any benefit. We consider the procedure safe in
patients with abnormal preprocedural parameters when performed by expert
5. Value of helical CT in the early diagnosis of
esophageal FBs in adults
YC, et al. Amer J Emerg Med. 2013;31:1328-32.
investigate the relationship between early use of computed tomography (CT) and
complications associated with esophageal foreign body impaction in adults.
retrospective study was performed on 120 patients (63 females, 57 males, median
age 50 years) with a history of foreign bodies. All had negative findings on
clinical examination. All cases underwent unenhanced helical CT, and patients
with positive findings underwent esophagoscopy within 6 hours. All patients
were followed up postoperatively.
demonstrated 100% sensitivity, 92.6% specificity, 100% negative predictive
value, and 97.9% positive predictive value. Esophageal foreign bodies were
associated with a high incidence of complications in adults, and there was a
significant difference in the incidence of complications between different
durations of impaction (P less than .01). In total, 37 patients presented with
complications: 32 patients with grade I, 3 with grade II, 2 with grade III, and
0 with grade IV.
foreign bodies were associated with a high incidence of complications in
adults. CT could detect foreign bodies accurately in the early stages, and then
FBs could be removed as early as possible, which may reduce the incidence of
complications. Moreover, the great majority of complications were of lower
grades. Thus, CT may be a useful first-line radiological tool for the early
diagnosis of esophageal foreign bodies in adults.
6. A Risk Prediction Score for Kidney Failure or
Mortality in Rhabdomyolysis
Gm, et al. JAMA Intern Med. 2013 Sep 2. [Epub ahead of print]
ImportanceRhabdomyolysis ranges in severity from
asymptomatic elevations in creatine phosphokinase levels to a life-threatening
disorder characterized by severe acute kidney injury requiring hemodialysis or
continuous renal replacement therapy (RRT).
ObjectiveTo develop a risk prediction tool to identify
patients at greatest risk of RRT or in-hospital mortality.
Setting, and ParticipantsRetrospective
cohort study of 2371 patients admitted between January 1, 2000, and March 31,
2011, to 2 large teaching hospitals in Boston, Massachusetts, with creatine
phosphokinase levels in excess of 5000 U/L within 3 days of admission. The
derivation cohort consisted of 1397 patients from Massachusetts General
Hospital, and the validation cohort comprised 974 patients from Brigham and
Outcomes and MeasuresThe composite of
RRT or in-hospital mortality.
ResultsThe causes and outcomes of rhabdomyolysis
were similar between the derivation and validation cohorts. In total, the
composite outcome occurred in 19.0% of patients (8.0% required RRT and 14.1%
died during hospitalization). The highest rates of the composite outcome were
from compartment syndrome (41.2%), sepsis (39.3%), and following cardiac arrest
(58.5%). The lowest rates were from myositis (1.7%), exercise (3.2%), and
seizures (6.0%). The independent predictors of the composite outcome were age,
female sex, cause of rhabdomyolysis, and values of initial creatinine, creatine
phosphokinase, phosphate, calcium, and bicarbonate. We developed a
risk-prediction score from these variables in the derivation cohort and
subsequently applied it in the validation cohort. The C statistic for the
prediction model was 0.82 (95% CI, 0.80-0.85) in the derivation cohort and 0.83
(0.80-0.86) in the validation cohort. The Hosmer-Lemeshow P values were .14 and
.28, respectively. In the validation cohort, among the patients with the lowest
risk score (less than 5), 2.3% died or needed RRT. Among the patients with the
highest risk score (above 10), 61.2% died or needed RRT.
and RelevanceOutcomes from
rhabdomyolysis vary widely depending on the clinical context. The risk of RRT
or in-hospital mortality in patients with rhabdomyolysis can be estimated using
commonly available demographic, clinical, and laboratory variables on
7. A Green Light for Colchicine to Treat Acute
M. Krumholz, MD, SM reviewing Imazio M et al. for the ICAP Investigators. N
Engl J Med 2013 Sep 1.
added to anti-inflammatory agents, the drug significantly improved outcomes
after a first attack.
some experts have recommended the use of colchicine for acute pericarditis, the
recommendation has not been based on strong clinical-trial evidence. To address
this gap in knowledge, investigators conducted the randomized, double-blind,
ICAP trial at five centers in Italy. They assigned 240 patients with a first
episode of acute pericarditis to receive colchicine (0.5 mg twice/day for
patients weighing over 70 kg and 0.5 daily for those weighing ≤70 kg) or
placebo for 3 months. All patients were treated with anti-inflammatory agents,
mostly aspirin or ibuprofen.
primary endpoint, incessant or recurrent pericarditis during 18-month
follow-up, occurred significantly less frequently in the colchicine group than
in the placebo group (17% vs. 38%; relative risk, 0.56; 95% confidence
interval, 0.30–0.72). Also, fewer patients in the colchicine group had
persistent symptoms at 72 hours (19% vs. 40%; P=0.001). The remission rate at 1
week was higher in the colchicine group than in the placebo group (85% vs. 58%;
P less than 0.001). Adverse-event rates were similar in the two groups.
This study strengthens the evidence for the use of colchicine to treat acute
pericarditis. Although these results may not surprise many clinicians, having
the evidence to support this practice is reassuring.
Imazio M et al. for the ICAP Investigators. A randomized trial of colchicine
for acute pericarditis. N Engl J Med 2013 Sep 1; [e-pub ahead of print].
8. Oral and IV Acetylcysteine for Treatment of
Acetaminophen Toxicity: A Systematic Review and Meta-analysis.
JL, et al. West J Emerg Med. 2013 May;14(3):218-26.
There are few reports summarizing the effectiveness of oral and intravenous
(IV) acetylcysteine. We determined the proportion of acetaminophen poisoned
patients who develop hepatotoxicity (serum transaminase above 1000 IU/L) when
treated with oral and IV acetylcysteine.
Studies were double abstracted by trained researchers. We determined the
proportions of patients who developed hepatotoxicity for each route using a
random effects model. Studies were further stratified by early and late
We screened 4,416 abstracts; 16 articles, including 5,164 patients, were
included in the meta-analysis. The overall rate of hepatotoxicity for the oral
and IV routes were 12.6% and 13.2%, respectively. Treatment delays are
associated with a higher rate of hepatotoxicity.
Studies report similar rates of hepatotoxicity for oral and IV acetylcysteine,
but direct comparisons are lacking. While it is difficult to disentangle the
effects of dose and duration from route, our findings suggest that the rates of
hepatotoxicity are similar for oral and IV administration.
9. Overtreatment of presumed UTI in older women
presenting to the ED
LB, et al. J Am Geriatr Soc. 2013;61(5):788-92.
To determine how often older women presenting to an emergency department (ED)
are diagnosed with a urinary tract infection (UTI) without a positive urine
culture and to investigate whether collecting urine by catheterization instead
of clean catch improves the accuracy of the urinalysis (UA).
Retrospective chart review.
Academic-affiliated ED in Providence, Rhode Island.
One hundred fifty-three women aged 70 and older with diagnosis of UTI in the ED
between December 1, 2008, and March 1, 2010.
Chief complaint, review of systems, results of UA and culture, urine
procurement (clean catch, straight catheter, or newly inserted Foley catheter),
antibiotic administered or prescribed, and diagnosis. A confirmed UTI was
defined as a positive urine culture, with microbial growth of 10,000
colony-forming units (CFU)/ mL or more for clean-catch specimens and 100 CFU/mL
or more for newly inserted catheter specimens; an ED diagnosis of UTI was
defined as the designation by an ED physician.
Of 153 individuals with an ED-diagnosed UTI, only 87 (57%) had confirmed UTI
according to culture. Of the remaining 66 with negative cultures, 63 (95%) were
administered or prescribed antibiotics in the ED. The method of urine
procurement affected the ability of a UA to predict the culture result (P =
.02), with catheterization yielding a lower proportion of false-positive UA
(31%) than clean catch (48%).
Nearly half of older women diagnosed with a UTI in an ED setting did not have
confirmatory findings on urine culture and were therefore inappropriately
treated. Catheterization improved the accuracy of UA when assessing older women
for possible UTI.
11. Factors affecting pediatric isotonic fluid
resuscitation efficiency: a RCT evaluating the impact of syringe size
G, et al. BMC Emerg Med 2013, 13:14 doi:10.1186/1471-227X-13-14
therapy guidelines for pediatric septic shock resuscitation recommend fluid
delivery at speeds in excess of that possible through use of regular fluid
infusion pumps. In our experience, syringes are commonly used by health care
providers (HCPs) to achieve rapid fluid resuscitation in a pediatric fluid
resuscitation scenario. At present, it is unclear which syringe size health
care providers should use when performing fluid resuscitation to achieve
maximal fluid resuscitation efficiency. The objective of this study was
therefore to determine if an optimal syringe size exists for conducting manual
pediatric fluid resuscitation.
48-participant parallel group randomized controlled trial included 4 study arms
(10, 20, 30, 60 mL syringe size groups). Eligible participants were HCPs from
McMaster Children’s Hospital, Hamilton, Canada blinded to the purpose of the
trial. Consenting participants were randomized using a third party technique.
Following a standardization procedure, participants administered 900 mL (60
mL/kg) of isotonic saline to a simulated 15 kg child using prefilled provided
syringes of the allocated size in rapid sequence. Primary outcome was total
time to administer the 900 mL and this data was collected through video review
by two blinded outcome assessors. Sample size was predetermined based upon a
primary outcome analysis using one-way ANOVA.
participants were randomized to each group (n=48) and all completed trial
protocol to analysis. Analysis was conducted according to intention to treat
principles. A significant difference in fluid resuscitation time (in seconds)
was found between syringe size group means: 10 mL, 563s [95% CI 521; 606]; 20
mL, 506s [95% CI 64; 548]; 30 mL, 454s [95% CI 412; 596]; 60 mL, 455s [95% CI
413; 497] (p less than 0.001).
syringe size used when performing manual pediatric fluid resuscitation has a
significant impact on fluid resuscitation speed, in a setting where fluid
filled syringes are continuously available. Greatest efficiency was achieved
with 30 or 60 mL syringes.
12. A comparison of bilevel and continuous PAP
noninvasive ventilation in acute cardiogenic pulmonary edema
et al. Amer J Emerg Med 2013;31:1322-27.
bilevel positive airway pressure (BiPAP) is advantageous compared with
continuous positive airway pressure (CPAP) in acute cardiogenic pulmonary edema
(ACPO) remains uncertain. The aim of the meta-analysis was to assess potential
beneficial and adverse effects of CPAP compared with BiPAP in patients with
controlled trials comparing the treatment effects of BiPAP with CPAP were
identified from electronic databases and reference lists from January 1966 to
December 2012. Two reviewers independently assessed study quality. In trials
that fulfilled inclusion criteria, we critically evaluate the evidence for the
use of noninvasive ventilation on rates of hospital mortality, endotracheal
intubation, myocardial infarction, and the length of hospital stay. Data were
combined using Review Manager 4.3 (The Cochrane Collaboration, Oxford, UK).
Both pooled effects and 95% confidence intervals (CIs) were calculated.
randomized controlled trials with a total of 1433 patients with ACPO were
included. The hospital mortality (relative risk [RR], 0.86; 95% CI, 0.65-1.14;
P = .46; I2 = 0%) and need for requiring invasive ventilation (RR, 0.89; 95%
CI, 0.57-1.38; P = .64; I2 = 0%) were not significantly different between
patients treated with CPAP and those treated with BiPAP. The occurrence of new
cases of myocardial infarction (RR, 0.95; 95% CI, 0.77-1.17; P = .53, I2 = 0%)
and length of hospital stay (RR, 1.01; 95% CI, −0.40 to 2.41; P = .98; I2 = 0%)
were also not significantly different between the 2 groups.
are no significant differences in clinical outcomes when comparing CPAP vs
BiPAP. Based on the limited data available, our results suggest that there are
no significant differences in clinical outcomes when comparing CPAP with BiPAP.
13. Ibuprofen vs acetaminophen vs their combination in
the relief of musculoskeletal pain in the ED: a RCT
EE, et al. Amer J Emerg Med. 2013;31:1357-60.
analgesics are often administered to emergency department (ED) patients with
musculoskeletal pain but if inadequate, opioids are given with associated
potential adverse events. We tested the hypothesis that the reduction in pain
scores with the combination of ibuprofen and acetaminophen would be at least 15
mm greater than with either of the agents alone.
conducted a double-blind, randomized, controlled trial of adult ED patients with
acute musculoskeletal pain. Patients were randomized to oral ibuprofen 800 mg,
acetaminophen 1 g, or their combination. Pain scores across the groups were
compared with repeated measures analysis of variance at 20, 40, and 60 minutes.
A sample of 30 patients in each group had 80% power to detect a 15 mm
difference in pain scores across the groups (α = .05).
patients were randomized to each study group. Mean (SD) age was 36 (15), 54%
were male, 73% were white, and 13% were Hispanic. Groups were well balanced in
baseline characteristics including initial pain scores (59, 61, and 62 for
ibuprofen, acetaminophen, and their combination). Pain decreased over the one
hour study period for all groups (P less than .001) with mean (SD) scores about
20 mm lower on the Visual Analogue Scale than the mean initial score. However,
there was no significant difference among treatments (P = .59). The need for
rescue analgesics was similar across groups.
conclude that the combination of ibuprofen and acetaminophen did not reduce
pain scores or the need for rescue analgesics compared with either agent alone
in ED patients with pain secondary to acute musculoskeletal injuries.
14. Managing Bleeding in Anticoagulated Patients in the
Emergency Care Setting
CV. J Emerg Med. 2013;45:467-477.
administered anticoagulants that offer alternatives to warfarin have been
developed in recent years and are currently available for reduction of stroke
risk in patients with non-valvular atrial fibrillation, the prophylaxis of
venous thromboembolism after hip or knee replacement surgery, and the treatment
and secondary risk reduction of deep vein thrombosis and pulmonary embolism.
article will provide a brief introduction to these new oral anticoagulants and
then review the approaches that can be taken for the emergency management of
hemostasis in patients bleeding or at risk for bleeding while receiving
warfarin or one of two newer agents, the direct thrombin inhibitor dabigatran
or the factor Xa inhibitor rivaroxaban.
anticoagulant use is widespread and likely to continue to increase. Warfarin
has been the standard of care in oral anticoagulation for many years; its
bleeding risks are well known and associated emergency protocols are well
established. As newer oral anticoagulants become more widely used, similar
procedures will need to be developed. Although there are as yet no specific
reversal agents for these newer drugs, recommendations for overdose, emergency
hemostasis, and preoperative management are available. Further, while the newer
agents do not require routine coagulation monitoring, assays for use in
non-routine situations are being explored.
introduction of alternative oral anticoagulants will require emergency
procedures that differ in some respects from those currently in place for
warfarin and it will be necessary for Emergency Medicine professionals to
become familiar with these procedures. Clinical stabilization of the bleeding
or at-risk patient remains the emergency physician’s priority.
15. Implementation of an Outpatient Electronic Health
Record and ED Visits, Hospitalizations, and Office Visits among Patients with
ME, et al. JAMA. 2013;310(10):1060-1065.
The US federal government is spending billions of dollars in physician
incentives to encourage the meaningful use of electronic health records (EHRs).
Although the use of EHRs has potential to improve patient health outcomes, the
existing evidence has been limited and inconsistent.
To examine the association between implementing a commercially available
outpatient EHR and emergency department (ED) visits, hospitalizations, and
office visits for patients with diabetes mellitus.
SETTING, AND POPULATION: Staggered EHR implementation across outpatient clinics
in an integrated delivery system (Kaiser Permanente Northern California)
between 2005 and 2008 created an opportunity for studying changes associated
with EHR use. Among a population-based sample of 169,711 patients with diabetes
between 2004 and 2009, we analyzed 4,997,585 person-months before EHR
implementation and 4,648,572 person-months after an EHR was being used by
OUTCOMES AND MEASURES: We examined the association between EHR use and
unfavorable clinical events (ED visits and hospitalizations) and office visit
use among patients with diabetes, using multivariable regression with
patient-level fixed-effect analyses and adjustment for trends over time.
In multivariable analyses, use of the EHR was associated with a statistically
significantly decreased number of ED visits, 28.80 fewer visits per 1000
patients annually (95% CI, 20.28 to 37.32), from a mean of 519.12 visits per 1000
patients annually without using the EHR to 490.32 per 1000 patients when using
the EHR. The EHR was also associated with 13.10 fewer hospitalizations per 1000
patients annually (95% CI, 7.37 to 18.82), from a mean of 251.60
hospitalizations per 1000 patients annually with no EHR to 238.50 per 1000
patients annually when using the EHR. There were similar statistically
significant reductions in nonelective hospitalizations (10.92 fewer per 1000
patients annually) and hospitalizations for ambulatory care-sensitive
conditions (7.08 fewer per 1000 patients annually). There was no statistically
significant association between EHR use and office visit rates.
AND RELEVANCE: Among patients with diabetes, use of an outpatient EHR in an
integrated delivery system was associated with modest reductions in ED visits
and hospitalizations but not office visit rates. Further studies are needed to
quantify the association of EHR use with changes in costs.
16. Effect of the Low Risk Ankle Rule on the frequency of
radiography in children with ankle injuries
K, et al. CMAJ 2013 [Epub ahead of print]
The Low Risk Ankle Rule is a valid ated clinical decision rule that has the potential
to safely reduce radiography in children with acute ankle injuries. We
performed a phased implementation of the Low Risk Ankle Rule and evaluated its
effectiveness in reducing the frequency of radiography in children with ankle
Six Canadian emergency departments participated in the study from Jan. 1, 2009,
to Aug. 31, 2011. At the 3 intervention sites, there were 3 consecutive 26-week
phases. In phase 1, no interventions were implemented. In phase 2, we activated
strategies to implement the ankle rule, including physician education, reminders
and a computerized decision support system. In phase 3, we included only the
decision support system. No interventions were introduced at the 3 pair-matched
control sites. We examined the management of ankle injuries among children aged
years. The primary outcome was the proportion of children undergoing
We enrolled 2151 children with ankle injuries, 1055 at intervention and 1096 at
control hospitals. During phase 1, the baseline frequency of pediatric ankle
radiography at intervention and control sites was 96.5% and 90.2%,
respectively. During phase 2, the frequency of ankle radiography decreased
significantly at intervention sites relative to control sites (between-group
difference –21.9% [95% confidence interval [CI] –28.6% to –15.2%]), without
significant differences in patient or physician satisfaction. All effects were
sustained in phase 3. The sensitivity of the Low Risk Ankle Rule during
implementation was 100% (95% CI 85.4% to 100%), and the specificity was 53.1%
(95% CI 48.1% to 58.1%).
Implementation of the Low Risk Ankle Rule in several different emergency department
settings reduced the rate of pediatric ankle radiography significantly and safely,
without an accompanying change in physician or patient satisfaction.
17. Are US-Guided Injections Effective for Trochanteric
S. Brett, MD reviewing McEvoy JR et al. AJR Am J Roentgenol 2013 Aug.
site of injection might determine whether a patient responds. We often assume
that bursitis is the cause of pain and tenderness over the greater trochanter
of the hip. Patients with greater trochanteric pain syndrome often receive
corticosteroid injections, not necessarily guided by imaging.
the relevant anatomy is complex: Several different bursae are present, and the
anatomy varies from person to person.In this retrospective single-site study,
researchers in Wisconsin reviewed records of 65 patients who received
ultrasound-guided trochanteric corticosteroid injections and who returned pre-
and postinjection pain questionnaires. Injections were initiated at the site of
maximal tenderness in all patients, but the ultimate location of the needle tip
was the greater trochanteric bursa (i.e., deep subgluteus maximus bursa) in 41
patients and into the subgluteus medius bursa in 24 patients. Location of the
needle tip was at the discretion of injecting radiologists; no anatomic
ultrasound findings distinguished between the two groups. Among patients who
received injections into the greater trochanteric bursa, pain improved
significantly at 14 days (median improvement, 3 points on a 10-point visual
analog scale; P less than 0.01). In contrast, median improvement was 0 among
those who received injections into the subgluteus medius bursa.
This study's flaws include nonrandomized assignment of injection sites and
exclusion of an unspecified number of patients who did not return surveys.
Nevertheless, the findings might explain why response to steroid injections is
so variable in clinical practice. Although these injections are easily done in
primary care settings, I believe that we should consider referring selected
patients for ultrasound-guided injections, if a specialist who is familiar with
these landmarks is available. A nice review of greater trochanter anatomy is
available online free of charge (Anesth Analg 2009; 108:1662).
McEvoy JR et al. Ultrasound-guided corticosteroid injections for treatment of
greater trochanteric pain syndrome: Greater trochanter bursa versus subgluteus
medius bursa. AJR Am J Roentgenol 2013 Aug; 201:W313.
18. Which Patients Might Benefit from Endovascular Stroke
Kamel, MD reviewing Lemmens R et al. Neurology 2013 Aug 13.
patients whose imaging showed brain tissue at risk for infarction, successful
reperfusion was associated with better outcomes regardless of whether the
internal carotid or middle cerebral artery was occluded.
stroke therapy continues to hold out promise, but in several recent randomized
clinical trials it did not improve clinical outcomes compared with intravenous
thrombolysis alone. For endovascular therapy to prove itself in this regard
will probably require a combination of speedy intervention, technically sound
devices, and appropriate patient selection.To advance our understanding of the
patient-selection component, the DEFUSE-2 investigators now report a substudy
comparing the association between reperfusion and clinical outcomes in patients
with occluded internal carotid artery (ICA) and in those with occluded middle
cerebral artery (MCA).
multicenter DEFUSE-2 study enrolled patients anticipated to undergo
endovascular therapy within 12 hours after stroke onset, and performed magnetic
resonance imaging 90 minutes before endovascular therapy and 12 hours and 5
days afterward. The authors examined whether perfusion-diffusion mismatch
(i.e., tissue presumably at risk for infarction) and successful reperfusion
correlated with favorable clinical response (improvement by ≥8 points on the
NIH Stroke Scale or a modified Rankin Scale score of 0–1 at 30 days).
eligible patients, the 28 with ICA occlusion had more severe strokes than the
70 with MCA occlusion but had similar rates of perfusion-diffusion mismatch
(79% vs. 80%) and successful reperfusion (61% vs. 59%). In patients with MCA
occlusion and perfusion-diffusion mismatch, those with reperfusion more often
had a favorable clinical response (70%) than those without reperfusion (43%).
This effect was even more dramatic with ICA occlusion and perfusion-diffusion
mismatch: 69% favorable clinical response with reperfusion versus 0% without.
As with earlier observational studies, these findings hold out the possibility
that endovascular stroke therapy can rescue certain patients, which may be
useful particularly when intravenous thrombolysis fails. Such patients should
be transferred to stroke centers with endovascular capability for potential
treatment and enrollment in randomized clinical trials evaluating the newest
generation of endovascular devices.
Lemmens R et al. Comparison of the response to endovascular reperfusion in
relation to site of arterial occlusion. Neurology 2013 Aug 13; 81:614
19. An ED Patient with Syncope: Interactive Case from
MC, et al. N Engl J Med 2013; 369:e9
35-year-old man presented to the ED after a sudden loss of consciousness while
playing soccer with friends. He recalled the sudden onset of lightheadedness
and a tingling sensation across his forehead for a few seconds before he lost
consciousness. He had no history of head trauma, chest pain, palpitations,
dyspnea, anxiety, nausea, lightheadedness, or loss . ..
20. “Good” Patients and “Difficult”
Patients [in the ED]— Rethinking Our Definitions
Aronson, M.D. N Engl J Med 2013; 369:796-797
weeks after his quadruple bypass and valve repair, 3 weeks after the bladder
infection, pharyngeal trauma, heart failure, nightly agitated confusion, and
pacemaker and feeding-tube insertions, and 2 weeks after his return home, I was
helping my 75-year-old father off the toilet when his blood pressure dropped
out from under him. As did his legs.
him up. I shouted for my mother. As any doctor would, I kept a hand on my
father's pulse, which was regular: no pauses, no accelerations or decelerations.
mother was 71 years old and, fortunately, quite fit. She had been making dinner
and said she dropped the salad bowl when I yelled for her. She took the stairs
two at time. Something about my tone, she said.
we lowered my father to the bathroom floor. I told her to keep him talking and
to call me if he stopped, and then I dialed 911.
emergency department, after some fluids, my father felt better. My mother held
his hand. We compared this new hospital with the last one where we'd spent so
many weeks but which had been diverting ambulances elsewhere that evening. The
doctor came in and reported no ECG changes and no significant laboratory
abnormalities, except that the INR was above the target range. The doctor
guessed the trouble was a bit of dehydration. He would watch for a while, just
to be safe.
mother waited with my father. The rest of us filed in and out, not wanting to
crowd the tiny room. Then my father's blood pressure dropped again. I told the
nurse and stayed out of the way. She silenced the alarm, upped the fluids, and
rechecked the blood pressure. It was better. But less than half an hour later,
we listened as the machine scanned for a reading, dropping from triple to
double digits before it found its mark. The numbers flashed, but the silenced
alarm remained quiet. I pressed the call button, and when the nurse arrived I
asked her to call for the doctor. When no one came, I went to the nursing
station and made my case to the assembled doctors and nurses. They were polite,
but their unspoken message was that they were working hard, my father wasn't
their only patient, and they had appropriately prioritized their tasks. I
wondered how many times I had made similar assumptions and offered similar
assurances to patients or families.
weeks of illness and caregiving, it can be a relief to be a daughter and leave
the doctoring to others. But I had been holding a thought just beyond
consciousness, and not just because I hoped to remain in my assigned role as
patient's offspring. At least as important, I didn't want to be the sort of
family member that medical teams complain about. Now that I'd apparently taken
on that persona, there was no longer any point in suppressing the thought.
Although the differential diagnosis for hypotension is long, my father's heart
was working well, I had adhered to the carefully calculated regimen that we'd
received for his tube feeds and free water intake, and he did not have new
medications or signs of infection. Those facts and his overly thin blood put
internal bleeding like a neon sign at the top of the differential.
rested my hand on my father's arm to get his attention and said, “Dad, how much
would you mind if I did a rectal?”
doctors do many things that are otherwise unacceptable. We are trained not only
in how to do such things but in how to do them almost without noticing, almost
without caring, at least in the ways we might care in different circumstances
or settings. A rectal exam on one's father, of course, is exactly the same as
other rectal exams — and also completely different. Luckily for me, my father
was a doctor too. When I asked my crazy question, he smiled.
he replied, “do what you have to do.”
found gloves and lube. I had him roll onto his side. And afterward, I took my
bloody gloved finger out into the hallway to prove my point.
realize that walking to the nurses' station holding aloft one's bloody, gloved
hand is not an optimal tactic from a professionalism standpoint — but it
worked. A nurse followed me back into my father's room, saw my panicked mother
holding a bedpan overflowing with blood and clots, and called for help. Within
seconds, the room filled, and minutes later, when the ICU team showed up, I
stood back, a daughter again.
retrospect, what is most interesting is how much more comfortable I felt
performing an intimate procedure on my father than demanding the attention of
the professionals assigned to care for him. Abiding by the unspoken rules of
medical etiquette, I had quieted my internal alarms for more than 2 hours.
Instead, I had considered how doctors and nurses feel about and treat so-called
pushy or “difficult” families, and as a result, I had prioritized wanting us to
be seen as a “good patient” and “good family” over being a good
many physicians would have made different choices than I did, the impetus for
my decisions lay in a trait of our medical culture. When we call patients and
families “good,” or at least spare them the “difficult” label, we are noting
and rewarding acquiescence. Too often, this “good” means you agree with me and
you don't bother me and you let me be in charge of what happens and when. Such
a definition runs counter to what we know about truly good care as a
collaborative process. From the history that so often generates the diagnosis
to the treatment that is the basis of care or cure, active participation of
patients and families is essential to optimal outcomes.
will always be patients and families who are considered high maintenance,
challenging, or both by health care providers. Among them are a few with
evident mental illness, but most are simply trying their best to understand and
manage their own or their loved ones' illness. That we sometimes feel besieged
or irritated by these advocates speaks to opportunities for improvement in both
medical culture and the health care system. Culturally, we could benefit from a
lens shift toward seeing more-vocal patients and families as actively engaged
in their health care, presenting new, potentially important information, and
expressing unmet care needs. At the systems level, we need to both count (using
specially designated sections of the medical record) and reward (through
diagnostic and billing codes) the time that providers spend talking to patients
never know whether such changes would have altered my behavior or that of the
medical staff on the night of my father's massive intestinal bleed, and
fortunately we all acted in time. I do know that 8 years later, the most vivid
image I have of that night is not my father wobbling in the bathroom surrounded
by cold, hard tile and angular metal structures, or a mustard yellow bedpan
filling with bright red blood. The image is this, a worst-case might-have-been
scenario had I not been there, had I not had medical training, had I not spoken
up: my parents, sleepy because it was by then late at night, snuggled up
together at the top of the gurney, my mother resting her head against my
father's chest, their eyes closed, their faces relaxed. His systolic blood
pressure, usually 130, dropping to 80 and then 70. The monitors turned off or
ignored. The lights dim. A short nap and they'd feel better. A little rest and
maybe it would be time to go home.
21. Effect of the Duration of ED Observation on CT Use in
Children with Minor Blunt Head Trauma
D, et al. Ann Emerg Med. 2013 Jul 24 [Epub ahead of print]
OBJECTIVE: We determine the effect of the duration of emergency department (ED)
observation on computed tomography (CT) rate for children with minor blunt head
We performed a prospective cohort study of children with blunt head trauma and
a Glasgow Coma Scale score greater than 14. We defined time from injury as the
time from head injury to initial physician (emergency attending physician or
fellow) assessment. For children who were observed in the ED before CT
decisionmaking, we defined ED observation time as time from initial physician
assessment to the decision whether to obtain a CT. After adjusting for time
from injury, patient age, sex, physician type, and study month, we measured the
effect of ED observation time on CT rate in each of the 3 Pediatric Emergency
Care Applied Research Network Traumatic Brain Injury risk groups.
Of the 1,605 eligible patients, we enrolled 1,381 (86%). Of the enrolled
patients, 676 (49%) were observed in the ED and 272 (20%) had a CT performed.
After adjustment, every hour of ED observation time was associated with a
decrease in CT rate for children in all 3 traumatic brain injury risk groups:
high risk (adjusted odds ratio [OR] 0.11; 95% confidence interval [CI] 0.05 to
0.24), intermediate risk (adjusted OR 0.28; 95% CI 0.21 to 0.36), and low risk
(adjusted OR 0.47; 95% CI 0.31 to 0.73). All 8 children with a significant
traumatic brain injury had an immediate CT.
For children with minor blunt head trauma, ED observation time was associated
with a time-dependent reduction in cranial CT rate, with no delay in the
diagnosis of a significant traumatic brain injury.
22. Pediatric Intussusception Best Treated at Pediatric
of bowel resection and complications were lower when children with
intussusception had surgery at pediatric hospitals.
JP, et al. J Am Coll Surg. 2013 Aug;217(2):226-232.e3
Although previous studies have shown that radiologic intussusception reduction
is more likely at children's hospitals, no study to date has compared outcomes
among children advancing to surgical intervention. We hypothesized that rates
of bowel resection would differ between hospitals with and without pediatric
DESIGN: We conducted a population-based retrospective cohort study using Washington
State discharge records. All children younger than 18 years undergoing
operative intussusception reduction between 1999 and 2009 were included (n =
327). Data were collected on demographics, disease severity, comorbidities, and
concomitant gastrointestinal pathology. Multivariate logistic regression was
used to estimate odds of intestinal resection during operative intussusception
Pediatric hospitals treated a smaller proportion of children older than 4 years
of age (12.1% vs 44.4%), as well as a greater proportion of Medicaid patients
(50.9% vs 42.6%). Patients at pediatric hospitals had a lower prevalence of
underlying intestinal anomalies or identifiable mass lesions (14.3% vs 16.7%).
"Severe disease" (perforation, ischemia, acidosis) was more common at
pediatric hospitals (17.6% vs 9.3%). Overall, bowel resection was more commonly
performed at nonpediatric hospitals (59.3% vs 33.0%). On multivariate analysis,
the odds of bowel resection were significantly lower at pediatric compared with
nonpediatric hospitals (odds ratio [OR] 0.20, p less than 0.001), and this
association was strongest in younger patients. Adjusted odds of postoperative
complications were greater for bowel resection patients (OR 2.83, p less than
Bowel resection during operative intussusception reduction is more likely at
hospitals without pediatric surgeons, and is associated with increased
complications. Improved outcomes may be achieved by efforts aimed at
standardizing care and decreasing variability in the treatment of pediatric
23. A new and rapid method for epistaxis treatment using
injectable form of tranexamic acid topically: a RCT
R, et al. Amer J Emerg Med. 2013;31:1389-92.
is a common problem in the emergency department (ED). Sixty percent of people
experience it at least once in their life. There are different kinds of
treatment for epistaxis. This study intended to evaluate the topical use of
injectable form of tranexamic acid vs anterior nasal packing with pledgets
coated with tetracycline ointment.
application of injectable form of tranexamic acid (500 mg in 5 mL) was compared
with anterior nasal packing in 216 patients with anterior epistaxis presented
to an ED in a randomized clinical trial. The time needed to arrest initial
bleeding, hours needed to stay in hospital, and any rebleeding during 24 hours
and 1 week later were recorded, and finally, the patient satisfaction was rated
by a 0-10 scale.
10 minutes of treatment, bleedings were arrested in 71% of the patients in the
tranexamic acid group, compared with 31.2% in the anterior nasal packing group
(odds ratio, 2.28; 95% confidence interval, 1.68-3.09; P less than .001). In addition,
95.3% in the tranexamic acid group were discharged in 2 hours or less vs 6.4%
in the anterior nasal packing group (P less than .001). Rebleeding was reported
in 4.7% and 11% of patients during first 24 hours in the tranexamic acid and
the anterior nasal packing groups, respectively (P = .128). Satisfaction rate
was higher in the tranexamic acid compared with the anterior nasal packing
group (8.5 ± 1.7 vs 4.4 ± 1.8, P less than .001).
application of injectable form of tranexamic acid was better than anterior
nasal packing in the initial treatment of idiopathic anterior epistaxis.
24. Budweiser is most popular beer among injured ER
patients, pilot study says
Alexander, NBC News, Aug. 15, 2013
people who end their Friday or Saturday nights in a hospital emergency room
have been drinking alcohol. In fact, public health experts estimate that about
one-third of all injury-related ER visits involved alcohol consumption.
what, exactly, are people drinking? What types of alcohol and even what brands?
Is there a direct link between advertising and marketing and later injury?
now, those questions have been unanswerable, frustrating alcohol epidemiology
researchers. But if results of a pilot study conducted by researchers from
Johns Hopkins Bloomberg School of Public Health hold up, there may soon be a
way to connect the dots.
the Hopkins researchers surveyed ER patients who’d been drinking, they found
that Budweiser was the number one brand consumed, followed Steel Reserve Malt
Liquor, Colt 45 malt liquor, Bud Ice (another malt liquor), Bud Light, and a
discount-priced vodka called Barton’s.
Budweiser has 9.1 percent of the national beer market, it represented 15
percent of the of the E.R. “market.” The disparity was even more pronounced for
Steel Reserve. It has only .8 percent of the market nationally, but accounted
for 14.7 percent of the E.R. market. In all, Steel Reserve, Colt 45, Bud Ice,
and another malt liquor, King Cobra, account for only 2.4 percent of the U.S.
beer market, but accounted for 46 percent of the beer consumed by E.R.
products are marketed to certain groups of people in our society,” explained
Traci Toomey, the director of the University of Minnesota’s alcohol
epidemiology program, who was not involved in the study. Higher-alcohol malt
liquor, for example, is heavily advertised in African-American neighborhoods.
“So we might want to put some controls on certain products if we find they are
tied to greater risk. But how they are marketed and priced is critical
information and that has been very hard to study.”
Federal Trade Commission, in reports, and in personal communication with me,
said this kind of research cannot be done,” David Jernigan, a professor of
public health at Johns Hopkins and the director of the study told NBC News.
“The National Institute on Drug Abuse gave me similar pushback.”
Jernigan was quick to point out that no conclusions could be made about beer or
malt liquor advertising, pricing, or even consumption based on the study since
it was too small – 105 patient interviews -- and took place in only one
hospital in Baltimore in mostly black neighborhood, he proved such research was
using a drop down menu on a small notebook computer, the survey takers managed
to obtain information from patients, and to include about 400 brands, in less
than five minutes. At first, Jernigan, said, many patients refused to talk. But
then the survey takers, with the permission of the emergency room staff, donned
white coats. After that, patients talked freely.
malt liquor and lower alcohol beer dominated consumption but vodka, gin, brandy
and cognac were overrepresented, too.
25. Tid Bits
Study ties mindfulness among docs to patient satisfaction
who ranked in the top third of mindfulness scores had higher-quality
conversations with patients and attained better patient satisfaction ratings
than those who were in the bottom third, a study published in the Annals of
Family Medicine found. Doctors were caring for patients with HIV, and
mindfulness was defined as "purposeful and nonjudgmental attentiveness to
one's own experience, thoughts and feelings."
-- By incorporating dry, professional asthma guidelines into a music video that
went -- pardon the pun -- viral, researchers say they have dramatically
improved hospital-wide knowledge of procedures for ill patients.
Better myocardial infarction notice: More on trops
with acute chest pain, angina pectoris, or other symptoms suggestive of acute
myocardial infarction account for approximately 10% of all emergency department
consultations. Absolute changes seem to be the preferred metrics for both
hs-cTnT and hs-cTnI in the early diagnosis of acute myocardial infarction. The
combination of absolute and relative changes provides a small added value for
hs-cTnT, but not for hs-cTnI.
Doctors may be overconfident in their diagnoses, study says
Baylor College of Medicine study found physicians may be overconfident in their
diagnostic decisions, which could affect patient care, and researchers said
health care facilities need better ways of telling doctors their diagnoses are
not correct. Study data reported in JAMA Internal Medicine found physicians
expressed similar levels of confidence in diagnoses for difficult and easy
cases when they were correct only about 6% of the time in tougher calls,
compared with 55% of the time in easier situations.
study found that extended monitoring with the Zio Patch for up to 14 days is
feasible, with high patient compliance, high analyzable signal time and incremental
diagnostic yield beyond 48 hours for all arrhythmias types. These findings may
have significant implications in device selection, monitoring duration and care
pathways for arrhythmia evaluation and atrial fibrillation surveillance.
Children with ADHD manifest some autistic traits
with attention-deficit/hyperactivity disorder had a twentyfold increased risk
of showing some autism-related traits, including language delay and social and
emotional problems, compared with those without the condition, a study in the
journal Pediatrics showed. Of 242 6- to 18-year-olds with ADHD, 18% showed
autistic-type behaviors, while fewer than than 1% of 227 typically developing
peers manifested such behaviors.