A collection of assorted summaries, highlights, and abstracts from the recent medical literature.
Sunday, October 06, 2013
Lit Bits: Oct 6, 2013
From the recent medical literature...
1. Clinical Decision Rules to Rule Out SAH
for Acute HA
Perry JJ, et al. JAMA. 2013;310(12):1248-1255.
ImportanceThree clinical decision rules were previously
derived to identify patients with headache requiring investigations to rule out
ObjectiveTo assess the accuracy, reliability,
acceptability, and potential refinement (ie, to improve sensitivity or
specificity) of these rules in a new cohort of patients with headache.
Design, Setting, and PatientsMulticenter cohort study conducted at 10
university-affiliated Canadian tertiary care emergency departments from April
2006 to July 2010. Enrolled patients were 2131 adults with a headache peaking
within 1 hour and no neurologic deficits. Physicians completed data forms after
assessing eligible patients prior to investigations.
Main Outcomes and MeasuresSubarachnoid hemorrhage, defined as (1)
subarachnoid blood on computed tomography scan; (2) xanthochromia in
cerebrospinal fluid; or (3) red blood cells in the final tube of cerebrospinal
fluid, with positive angiography findings.
ResultsOf the 2131 enrolled patients, 132 (6.2%) had
subarachnoid hemorrhage. The decision rule including any of age 40 years or
older, neck pain or stiffness, witnessed loss of consciousness, or onset during
exertion had 98.5% (95% CI, 94.6%-99.6%) sensitivity and 27.5% (95% CI, 25.6%-29.5%)
specificity for subarachnoid hemorrhage. Adding “thunderclap headache” (ie,
instantly peaking pain) and “limited neck flexion on examination” resulted in
the Ottawa SAH Rule, with 100% (95% CI, 97.2%-100.0%) sensitivity and 15.3%
(95% CI, 13.8%-16.9%) specificity.
Conclusions and RelevanceAmong patients presenting to the emergency
department with acute nontraumatic headache that reached maximal intensity
within 1 hour and who had normal neurologic examination findings, the Ottawa
SAH Rule was highly sensitive for identifying subarachnoid hemorrhage. These
findings apply only to patients with these specific clinical characteristics
and require additional evaluation in implementation studies before the rule is
applied in routine clinical care.
Teasing Excerpt from the editorial
Newman-Toker DE, et al. High-Stakes Diagnostic Decision Rules
for Serious Disorders The Ottawa Subarachnoid Hemorrhage Rule. JAMA.
However, there are several
important caveats for application of this decision rule. Effective use of any
decision rule requires careful attention to clinical details affecting its
generalizability. Does the patient meet all original inclusion criteria, such
as having a headache that peaked in less than an hour? Has an examination been
performed carefully enough to verify that neurologic status is truly normal,
including no papilledema? Is subarachnoid hemorrhage the only target diagnosis being
considered, or are unstudied, rare, yet important causes of sudden-onset
headache (eg, cerebral venous sinus thrombosis, pituitary apoplexy, arterial
dissection) still part of the differential diagnosis? Are other unstudied
variables (eg, family history of brain aneurysms) present that might complicate
interpretation of the rule?
In clinical practice, “rules creep”
can lead to overly broad application of a decision rule. Such creep in the
setting of headache could be toward patients who present with severe headaches that
are more gradual in onset. This misuse could present a problem for patients,
especially if the rule were used to exclude causes other than subarachnoid
hemorrhage. Dangerous causes of headache other than subarachnoid hemorrhage were
mostly identified by the rule in the sample studied by Perry et al (n = 50/54
[93%]).12 However, this may not hold true for similar dangerous causes in
patients with new headaches that are more gradual in onset (ie, developing over
hours to days, rather than seconds to minutes).Medical emergencies such as
obstructive hydrocephalus, giant cell arteritis, bacterial brain abscess, and
fungal meningitis can present with more gradual-onset headaches without focal
neurologic or other red-flag features.15
If used in the correct patients,
will the new decision rule help reduce missed subarachnoid hemorrhages? To
reduce missed cases, the approach would need to outperform current real-world
practice and be used more often than the CT-LP rule. This seems plausible,
because the sensitivity of the rule is estimated at 100% (lower 95% confidence
limit, 97.2%), and this approach is less invasive than CT-LP. However, any reduction in missed cases
assumes that accuracy estimates are correct (the final rule still lacks full,
prospective validation) and the rule is correctly and consistently applied.
This latter point is critical—similarly simple sounding decision rules are
interpreted incorrectly for up to one-third of patients.16 Because some aspects
of the rule depend on subjective physician interpretation (eg, headache peaking
“instantly”), subtle physician biases (eg, linked to physician risk
tolerance17) might lead to underuse or overuse of imaging unrelated to true
Gestalt Estimate of Pretest Probability for ACS and PE in Patients with Chest
Pain and Dyspnea
JA, et al. Ann Emerg Med. 25 September 2013 [Epub ahead of print]
Study objective: Pretest
probability helps guide diagnostic testing for patients with suspected acute
coronary syndrome and pulmonary embolism. Pretest probability derived from the
clinician's unstructured gestalt estimate is easier and more readily available
than methods that require computation. We compare the diagnostic accuracy of
physician gestalt estimate for the pretest probability of acute coronary
syndrome and pulmonary embolism with a validated, computerized method.
Methods: This was a secondary
analysis of a prospectively collected, multicenter study. Patients (N=840) had
chest pain, dyspnea, nondiagnostic ECGs, and no obvious diagnosis. Clinician
gestalt pretest probability for both acute coronary syndrome and pulmonary
embolism was assessed by visual analog scale and from the method of attribute
matching using a Web-based computer program. Patients were followed for
outcomes at 90 days.
Results: Clinicians had
significantly higher estimates than attribute matching for both acute coronary
syndrome (17% versus 4%; P less than .001, paired t test) and pulmonary
embolism (12% versus 6%; P less than .001). The 2 methods had poor correlation
for both acute coronary syndrome (r2=0.15) and pulmonary embolism (r2=0.06).
Areas under the receiver operating characteristic curve were lower for
clinician estimate compared with the computerized method for acute coronary
syndrome: 0.64 (95% confidence interval [CI] 0.51 to 0.77) for clinician
gestalt versus 0.78 (95% CI 0.71 to 0.85) for attribute matching. For pulmonary
embolism, these values were 0.81 (95% CI 0.79 to 0.92) for clinician gestalt
and 0.84 (95% CI 0.76 to 0.93) for attribute matching.
Conclusion: Compared with a
validated machine-based method, clinicians consistently overestimated pretest
probability but on receiver operating curve analysis were as accurate for pulmonary
embolism but not acute coronary syndrome.
3. Vomiting Should Be a Prompt Predictor of
Shigematsu K, et al. Emerg Med J.
Background To predict the outcome
of stroke at an acute stage is important but still difficult. Vomiting is one
of the commonest symptoms in stroke patients. The aim of this study is
threefold: first, to examine the percentage of vomiting in each of the three
major categories of strokes; second, to investigate the association between
vomiting and other characteristics and third, to determine the correlation
between vomiting and mortality.
Methods We investigated the
existence or absence of vomiting in stroke patients in the Kyoto prefecture
cohort. We compared the characteristics of patients with and without vomiting.
We calculated the HR for death in both types of patients, adjusted for age,
sex, blood pressure, arrhythmia, tobacco and alcohol use and paresis.
Results Of the 1968 confirmed
stroke patients, 1349 (68.5%) had cerebral infarction (CI), 459 (23.3%) had
cerebral haemorrhage (CH) and 152 (7.7%) had subarachnoid haemorrhage (SAH).
Vomiting was seen in 14.5% of all stroke patients. When subdivided according to
stroke type, vomiting was observed in 8.7% of CI, 23.7% of CH and 36.8% of SAH
cases. HR for death and 95% CI were 5.06 and 3.26 to 7.84 (p less than 0.001)
when all stroke patients were considered, 5.27 and 2.56 to 10.83 (p less than 0.001)
in CI, 2.82 and 1.33 to 5.99 (p=0.007) in CH and 5.07 and 1.87 to 13.76
(p=0.001) in SAH.
Conclusions Compared with patients
without vomiting, the risk of death was significantly higher in patients with
vomiting at the onset of stroke. Vomiting should be an early predictor of the
A. Patients with Mild Head Injury and Intracranial Bleed Do
Not Need Repeat Imaging
In the face of a normal
neurological exam, repeat imaging only adds hospital days and costs.
Nayak NV, et al. J Trauma Acute
Care Surg. 2013 Aug;75(2):273-8.
BACKGROUND: Previous studies
proposed that routine repeat head computed tomography (RHCT) is of little value
in patients with a minimal head injury (MHI) and normal neurologic examination
(NE). As of 2003, routine RHCT in these MHI patients was ordered at the
discretion of the attending physician. The goal of this study was to compare
the neurologic outcomes of MHI patients with an intracranial bleed and a normal
NE who were managed with or without a routine RHCT.
METHODS: A retrospective chart
review of adult patients with MHI presenting to a Level I trauma center from
August 2003 to December 2008 was performed. Demographics, injury severity, and
HCT findings were collected for patients managed with or without a routine
RHCT. Outcome measures included delayed neurologic deterioration, neurosurgical
interventions, Glasgow Outcome Scale, and hospital length of stay (LOS).
RESULTS: A total of 321 MHI
patients with an intracranial bleed had a normal NE 24 hours after
presentation. There were no significant differences in demographics, arrival
Glasgow Coma Scale score, or injury severity between the 142 (44%) patients
managed with RHCT and the 179 (56%) managed without RHCT. No patient had a
neurologic deterioration or required a neurosurgical intervention, regardless
of initial management. There was no significant difference in the neurologic
outcomes, mortality, or discharge dispositions between both groups. Patients
managed without an RHCT had significantly shorter LOS (2.2 ± 2.3 days vs. 4.3 ±
6.0 days; p less than 0.001) compared with those with RHCT.
CONCLUSION: Our study is the first
to compare early neurologic outcomes of MHI patients with or without a routine
RHCT. Patients managed without an RHCT had similar neurologic outcomes and
shorter hospital LOS. Our data suggest that initial HCT followed by serial NEs
(not routine RHCT) should be the standard of care in this patient population.
B. A Multicenter Study of the Risk of Intra-Abdominal Injury
in Children after Normal Abdominal CT Scan Results in the ED
Kerrey BT, et al, for PECARN. Ann
Emerg Med. 2013;62:319-326.
Study objective: We determine
whether intra-abdominal injury is rarely diagnosed after a normal abdominal
computed tomography (CT) scan result in a large, generalizable sample of
children evaluated in the emergency department (ED) after blunt torso trauma.
Methods: This was a planned
analysis of data collected during a prospective study of children evaluated in
one of 20 EDs in the Pediatric Emergency Care Applied Research Network. The
study sample consisted of patients with normal results for abdominal CT scans
performed in the ED. The principal outcome measure was the negative predictive
value of CT for any intra-abdominal injury and those undergoing acute
Results: Of 12,044 enrolled
children, 5,380 (45%) underwent CT scanning in the ED; for 3,819 of these scan
the results were normal. Abdominal CT had a sensitivity of 97.8% (717/733; 95%
confidence interval [CI] 96.5% to 98.7%) and specificity of 81.8% (3,803/4,647;
95% CI 80.7% to 82.9%) for any intra-abdominal injury. Sixteen (0.4%; 95% CI
0.2% to 0.7%) of the 3,819 patients with normal CT scan results later received
a diagnosis of an intra-abdominal injury, and 6 of these underwent acute
intervention for an intra-abdominal injury (0.2% of total sample; 95% CI 0.06%
to 0.3%). The negative predictive value of CT for any intra-abdominal injury
was 99.6% (3,803/3,819; 95% CI 99.3% to 99.8%); and for injury undergoing acute
intervention, 99.8% (3,813/3,819; 95% CI 99.7% to 99.9%).
Conclusion: In a multicenter study
of children evaluated in EDs after blunt torso trauma, intra-abdominal injuries
were rarely diagnosed after a normal abdominal CT scan result, suggesting that
safe discharge is possible for the children when there are no other reasons for
C. Patients with traumatic SAH are at low risk for
deterioration or neurosurgical intervention.
Borczuk P, et al. J Trauma Acute
Care Surg. 2013;74(6):1504-9.
BACKGROUND: Current standard of
care for patients with traumatic intracranial hemorrhage (TIH) includes
neurosurgical consultation and/or transfer to a trauma center with
neurosurgical backup. We hypothesize that a set of low-risk criteria can be
applied to such patients to identify those who may not require neurosurgical
METHODS: This is a cross-sectional
study of consecutive emergency department patients in 2009 and 2010 with TIH on
computerized tomographic scan owing to blunt head trauma. Patients presented to
an urban academic Level I trauma center (volume, 92,000) were older than 15
years and had a Glasgow Coma Scale (GCS) score of 13 or greater. Charts were
abstracted using a standardized data form by two emergency physicians. Our
principal outcome was deterioration represented by a composite of neurosurgical
intervention, clinical deterioration, or worsening computerized tomographic
RESULTS: During the study period,
404 patients were seen with TIH and met our inclusion criteria, and 48 of those
patients (11.8%) deteriorated. Patients with isolated subarachnoid hemorrhage,
were less likely to deteriorate (odds ratio [OR], 0.08; 95% confidence interval
[CI], 0.011-0.58). Characteristics associated with deterioration were subdural
hematomas (OR, 2.63; 95% CI, 1.198-5.81) or presenting GCS of less than 15 (OR,
2.12; 95% CI, 1.01-4.43).The use of anticoagulant medications or antiplatelet
agents were not associated with deterioration for warfarin, aspirin, or
clopidogrel; however bleeding diatheses were corrected with vitamin K, fresh
frozen plasma, and platelets as necessary.
CONCLUSION: Patients with isolated
traumatic subarachnoid hemorrhage are at low risk for deterioration. These
individuals may not need neurosurgical consultation or transfer to a trauma
center where neurosurgical backup is available. Those patients with subdural
hematoma or a GCS of less than 15 have a higher risk of deterioration and
require neurosurgical evaluation.
D. Isolated Sternal Fractures May Not Warrant Hospital Admission
Journal Watch Emergency Medicine, September
Richard D. Zane, MD, FAAEM
reviewing Odell DD et al. J Trauma Acute Care Surg 2013 Sep.
Journal Watch 2013
Most patients can be safely
discharged after emergency department evaluation.
Sternal fractures are usually
associated with high-energy trauma. Conventional wisdom has been that patients
with sternal fractures require hospitalization because of the injury mechanism
(usually motor vehicle crash), potential for occult associated injury, and
severity of pain.
In this retrospective study of 1867
patients with sternal fracture who were admitted to Israeli trauma centers over
a 12-year period, the authors compared in-hospital events between patients with
isolated sternal fractures (26%) and those with sternal fractures associated
with other injuries (polytrauma; 73%).Patient characteristics and mechanisms of
injury (mostly motor vehicle collisions and falls from significant height) were
similar in the two groups. Compared with patients with polytrauma, those with
isolated sternal fractures less frequently exhibited tachycardia, hypotension,
tachypnea, Glasgow Coma Scale score ≤14, and Revised Trauma Score ≤11. No
patients with isolated sternal fracture required endotracheal intubation, chest
tube, thoracoscopy, or resuscitative thoracotomy; these procedures were performed
in 17% of patients with polytrauma.
Comment: Patients with isolated
sternal fracture, no evidence of associated injury, and pain that can be
controlled do not require hospital admission and can be safely discharged from
the emergency department.
Reference: Odell DD et al. Sternal
fracture: Isolated lesion versus polytrauma from associated extrasternal
injuries — Analysis of 1,867 cases. J Trauma Acute Care Surg 2013 Sep; 75:448.
5. Therapeutic Hypothermia and the Risk of
Infection: A Systematic Review and Meta-Analysis.
Geurts M, et al. Crit Care Med.
2013 Aug 28. [Epub ahead of print]
OBJECTIVE: Observational studies
suggest that infections are a common complication of therapeutic hypothermia.
We performed a systematic review and meta-analysis of randomized trials to
examine the risk of infections in patients treated with hypothermia.
DATA SOURCES: PubMed, Embase, and
the Cochrane Central Register of Controlled Trials were systematically searched
for eligible studies up to October 1, 2012.
STUDY SELECTION: We included
randomized controlled clinical trials of therapeutic hypothermia induced in
adults for any indication, which reported the prevalence of infection in each
DATA EXTRACTION: For each study, we
collected information about the baseline characteristics of patients, cooling
strategy, and infections.
DATA SYNTHESIS: Twenty-three
studies were identified, which included 2,820 patients, of whom 1,398 (49.6%)
were randomized to hypothermia. Data from another 31 randomized trials,
involving 4,004 patients, could not be included because the occurrence of
infection was not reported with sufficient detail or not at all. The risk of
bias in the included studies was high because information on the method of
randomization and definitions of infections lacked in most cases, and
assessment of infections was not blinded. In patients treated with hypothermia,
the prevalence of all infections was not increased (rate ratio, 1.21 [95% CI,
0.95-1.54]), but there was an increased risk of pneumonia and sepsis (risk
ratios, 1.44 [95% CI, 1.10-1.90]; 1.80 [95% CI, 1.04-3.10], respectively).
CONCLUSION: The available evidence,
subject to its limitations, strongly suggests an association between
therapeutic hypothermia and the risk of pneumonia and sepsis, whereas no
increase in the overall risk of infection was observed. All future randomized
trials of hypothermia should report on this important complication.
6. A Randomized Trial of IV Ketorolac vs IV
Metoclopramide Plus Diphenhydramine for Tension-Type and All Nonmigraine,
Noncluster Recurrent Headaches
Friedman BW, et al. Ann Emerg Med.
Study objective: We compare
metoclopramide 20 mg intravenously, combined with diphenhydramine 25 mg
intravenously, with ketorolac 30 mg intravenously in adults with tension-type
headache and all nonmigraine, noncluster recurrent headaches.
Methods: In this emergency department
(ED)–based randomized, double-blind study, we enrolled adults with nonmigraine,
noncluster recurrent headaches. Patients with tension-type headache were a
subgroup of special interest. Our primary outcome was a comparison of the
improvement in pain score between baseline and 1 hour later, assessed on a 0 to
10 verbal scale. We defined a between-group difference of 2.0 as the minimum
clinically significant difference. Secondary endpoints included need for rescue
medication in the ED, achieving headache freedom in the ED and sustaining it
for 24 hours, and patient's desire to receive the same medication again.
Results: We included 120 patients
in the analysis. The metoclopramide/diphenhydramine arm improved by a median of
5 (interquartile range 3, 7) scale units, whereas the ketorolac arm improved by
a median of 3 (IQR 2, 6) (95% confidence interval [CI] for difference 0 to 3).
Metoclopramide+diphenhydramine was superior to ketorolac for all 3 secondary
outcomes: the number needed to treat for not requiring ED rescue medication was
3 (95% CI 2 to 6); for sustained headache freedom, 6 (95% CI 3 to 20); and for
wish to receive the same medication again, 7 (95% CI 4 to 65). Tension-type
headache subgroup results were similar.
Conclusion: For adults who presented
to an ED with tension-type headache or with nonmigraine, noncluster recurrent
headache, intravenous metoclopramide+diphenhydramine provided more headache
relief than intravenous ketorolac.
7. Rupture of the ulnar collateral ligament of the thumb
– a review
Mahajan M, et al. Internat J Emerg Med. 2013;6:31
Skier’s thumb is a partial or
complete rupture of the ulnar collateral ligament of the metacarpophalangeal
joint of the thumb. It is an often-encountered injury and can lead to chronic
pain and instability when diagnosed incorrectly. Knowledge of the anatomy and
accurate physical examination are essential in the evaluation of a patient with
This article provides a review of the
relevant anatomy, the correct method of physical examination and the options
for additional imaging and treatment with attention to possible pitfalls.
8. Effect of smoking on comparative
efficacy of antiplatelet agents: systematic review, meta-analysis, and indirect
This analysis of the literature
suggests that the benefits of anti-platelet agents reside largely in the
population of smokers. Non-smokers had little benefit.
Gagne JJ, et al. BMJ 2013;347:f5307
Objective To evaluate whether
smoking status is associated with the efficacy of antiplatelet treatment in the
prevention of cardiovascular events.
Design Systematic review,
meta-analysis, and indirect comparisons.
Data sources Medline (1966 to
present) and Embase (1974 to present), with supplementary searches in databases
of abstracts from major cardiology conferences, the Cumulative Index to Nursing
and Allied Health (CINAHL) and the CAB Abstracts databases, and Google Scholar.
Study selection Randomized trials
of clopidogrel, prasugrel, or ticagrelor that examined clinical outcomes among
subgroups of smokers and nonsmokers.
Data extraction Two authors
independently extracted all data, including information on the patient
populations included in the trials, treatment types and doses, definitions of
clinical outcomes and duration of follow-up, definitions of smoking subgroups
and number of patients in each group, and effect estimates and 95% confidence
intervals for each smoking status subgroup.
Results Of nine eligible randomized
trials, one investigated clopidogrel compared with aspirin, four investigated
clopidogrel plus aspirin compared with aspirin alone, and one investigated
double dose compared with standard dose clopidogrel; these trials include 74 489
patients, of whom 21 717 (29%) were smokers. Among smokers, patients randomized
to clopidogrel experienced a 25% reduction in the primary composite clinical
outcome of cardiovascular death, myocardial infarction, and stroke compared
with patients in the control groups (relative risk 0.75, 95% confidence
interval 0.67 to 0.83). In nonsmokers, however, clopidogrel produced just an 8%
reduction in the composite outcome (0.92, 0.87 to 0.98). Two studies
investigated prasugrel plus aspirin compared with clopidogrel plus aspirin, and
one study investigated ticagrelor plus aspirin compared with clopidogrel plus
aspirin. In smokers, the relative risk was 0.71 (0.61 to 0.82) for prasugrel
compared with clopidogrel and 0.83 (0.68 to 1.00) for ticagrelor compared with clopidogrel.
Corresponding relative risks were 0.92 (0.83 to 1.01) and 0.89 (0.79 to 1.00)
Conclusions In randomized clinical
trials of antiplatelet drugs, the reported clinical benefit of clopidogrel in
reducing cardiovascular death, myocardial infarction, and stroke was seen
primarily in smokers, with little benefit in nonsmokers.
9. Utility of CT
and derivation and validation of a score to identify an emergent outcome in
2,315 patients with suspected urinary tract stone
Aubrey-Bassler FK, et al. CJEM 2013;15(5):261-269
Objective:Because a majority of urinary tract
stones (UTSs) pass spontaneously and clinically significant alternative
pathology is rare, we hypothesize that many computed tomographic (CT) scans to
diagnose them are likely unnecessary. We sought to measure the impact of renal
CT scans on resource use and to justify a prospective study to derive a score
that predicts an emergent diagnosis in patients with suspected UTS by doing so
in our retrospective series.
Methods:We conducted a retrospective study of
ED patients who had noncontrast CT of the abdomen for suspected UTS. A
split-sample was used to derive and validate a score to predict the presence of
an emergent diagnosis on CT.
Results:Of the 2,315 patients (50.8% female,
mean age 45 years), 49 (2.1%) had an emergent outcome observed on CT. An
additional 12 (0.5%) patients had an urgent outcome and 239 (10.6%) had a
urologic procedure within 8 weeks of the CT. Serum white blood cell count,
highest temperature, urine red blood cell count, and the presence of abdominal
pain were significant predictors of the primary outcome. A score derived using
these predictors had a potential range of −2 (0.26% predicted risk, 0.5% actual
risk of the outcome) to 6 (52% predicted risk). The score was moderately
discriminatory with c-statistics of 0.752 (derivation) and 0.668 (validation)
and accurate with Hosmer-Lemeshow statistics of 10.553 (p = 0.228,
derivation) and 9.70 (p = 0.286, validation).
Conclusions:A sensible, relevant score derived
and validated on all patients presenting with symptoms suggestive of renal
colic could be useful in reducing abdominal CT scan ordering.
11. Evaluation of the Mercy TAPE:
Performance Against the Standard for Pediatric Weight Estimation
Abdel-Rahman SM, et al. 2013;62:
Study objective: We assessed the
performance of 2 new devices (2D- and 3D-Mercy TAPE) to implement the Mercy
Method for pediatric weight estimation and contrasted their accuracy with the
Methods: We enrolled children aged
2 months through 16 years in this prospective, multicenter, observational
study. Height/length, weight, humeral length, and mid-upper arm circumference
were obtained for each child, using calibrated scales and measures. We then
made measurements with blinded versions of the 2D- and 3D-TAPEs. Using
height/length data, we calculated the weight estimated by the Broselow method.
We contrasted measures with mean error, mean percentage error, and percentage
predicted within 10% and 20% of actual.
Results: Six hundred twenty-four
participants (median 8.5 years, 27.6 kg, 17.3 kg/m2) completed the study. Mean
error was 0.3 kg (mean percentage error 1.6%), 0.2 kg (mean percentage error
1.9%), and −1.3 kg (mean percentage error −4.1%) for 2D-, 3D-, and Broselow,
respectively. Concordance between both TAPE devices and the Mercy Method was
greater than 0.99. The proportion of children predicted within 10% and 20% of
actual weight was 76% and 98% for the 2D-TAPE and 65% and 93% for the 3D-TAPE.
Excluding the 209 (33%) children who were too tall for the device, Broselow
predictions were within 10% and 20% of actual weight in 59% and 91%.
Conclusion: The 2D- and 3D-Mercy
TAPEs outperform the Broselow tape for pediatric weight estimation and can be
used in a wider range of children.
12. Happy Hearts: Positivity Plus Exercise
Linked to Lower CVD Mortality
Michael O'Riordan, Heartwire. Sep
TILBURG, THE NETHERLANDS — The
association between a positive emotional state of mind and lower mortality in
patients with ischemic heart disease is mediated by exercise, according to the
results of a new study (link below).
Patients with higher levels of
positive affect, which reflects a pleasurable response to the environment and
typically includes feelings of happiness, joy, excitement, contentment, and
enthusiasm, had a 42% lower risk of all-cause mortality at five years and were
50% more likely to participate in an exercise program than those with lower
levels of positive affect.
"When adding exercise to the
model, with exercise being significantly associated with mortality, the
relationship between positive affect and mortality became marginally
significant," according to Dr Madelein Hoogwegt (Tilburg University, the
Netherlands) and colleagues. "These results indicate that exercise might
act as a mediator in this relationship, independent of demographic and clinical
In the paper, published online
September 10, 2013 in Circulation, the researchers state that mortality rates
from ischemic heart disease have declined steadily in the past 20 years. As a
result, it is now considered a chronic disease and is frequently accompanied by
impaired psychological functioning and quality of life. Heart-disease patients
often have higher rates of depression, anxiety, and other negative affective
states, and these negative emotions have all been associated with adverse
cardiac events, including hospitalizations and mortality.
Previous studies have focused on
negative affect and its relationship to cardiovascular outcomes, but less is
known about positive psychological well-being and health outcomes. In addition,
the mechanism underlying the association between positive psychological
well-being and improved health outcomes is unknown. In 607 patients with
ischemic heart disease, Hoogwegt and colleagues sought to determine whether
positive affect predicted time to first cardiac-related hospitalization and
all-cause mortality and whether exercise mediated this relationship.
In an adjusted regression model,
there was no significant association between positive affect, as measured using
the global mood scale (GMS), and cardiac-related hospitalizations. Ischemic
heart disease patients with higher levels of positive affect on the GMS had a
significant 42% lower risk of all-cause mortality at five years. In addition,
these happier patients were also 48% more likely to exercise.
In a risk model that adjusted for
positive affect, patients who exercised were less likely to die during the
five-year follow-up. And the relationship between positive affect and mortality
became marginally significant once exercise was included in the model.
According to the investigators, this suggests that the mortality benefit among
those with positive affect is mediated by exercise.
"Because positive affect is
related to exercise, interventions aimed at positive-affect induction in
combination with exercise promotion may induce better outcomes for patients,
both in terms of increasing the likelihood of the accomplishment and
maintenance of a healthy exercise pattern and in terms of better psychological
functioning, than interventions focusing on the promotion of exercise
alone," conclude the researchers.
13. Management and Outcomes of Major
Bleeding during Treatment with Dabigatran or Warfarin
Majeed A, et al. Circ 2013
September 30 [Epub ahead of print]
Background—The aim of this study
was to compare the management and prognosis of major bleeding in patients
treated with dabigatran or warfarin.
Methods and Results—Two independent
investigators reviewed bleeding reports from 1,034 individuals with 1,121 major
bleeds enrolled in 5 phase III trials comparing dabigatran with warfarin in
27,419 patients treated for 6 to 36 months. Patients with major bleeds on
dabigatran (n=627 of 16,755) were older, had lower creatinine clearance and
more frequently used aspirin or non-steroid anti-inflammatory agents than those
on warfarin (n=407 of 10,002).
The 30-day mortality after the
first major bleed tended to be lower in the dabigatran group (9.1%) than in the
warfarin group (13.0%; pooled odds ratio [OR] 0.68, 95% confidence interval
[CI]: 0.46-1.01; p=0.057). After adjustment for sex, age, weight, renal function
and concomitant antithrombotic therapy, the pooled OR for 30-day mortality with
dabigatran versus warfarin was 0.66 (95% CI: 0.44-1.00; p=0.051). Major bleeds
in dabigatran patients were more frequently treated with blood transfusions
(423/696, 61%) than bleeds in warfarin patients (175/425, 42%; p less than 0.001)
but less frequently with plasma (dabigatran, 19.8%; warfarin, 30.2%; p less than
0.001). Patients who experienced a bleed had shorter stays in the intensive
care unit if they had previously received dabigatran (mean 1.6 nights) compared
with those who had received warfarin (mean 2.7 nights; p=0.01).
experienced major bleeding on dabigatran required more red cell transfusions
but received less plasma, required a shorter stay in intensive care and had a
trend to lower mortality compared with those who had major bleeding on
See related: Fawole A, et al.
Practical management of bleeding due to the anticoagulants dabigatran,
rivaroxaban, and apixaban. Cleve Clin J Med. 2013;80(7):443-51. Full-text
14. RCT of the 2 mg Hydromorphone Bolus
Protocol vs the “1+1” Hydromorphone Titration Protocol in Treatment of Acute,
Severe Pain in the First Hr of ED Presentation
Chang AK, et al. Ann Emerg Med.
Study objective: We compare a high
initial dose of 2 mg intravenous hydromorphone against titration of 1 mg
intravenous hydromorphone followed by an optional second dose.
Methods: Patients aged 21 to 64
years with severe pain were randomly allocated to 2 mg intravenous
hydromorphone in a single bolus or the “1+1” hydromorphone titration protocol.
1+1 Patients received 1 mg intravenous hydromorphone followed by a second 1 mg
dose 15 minutes later if they answered yes when asked, Do you want more pain
medication? The primary outcome was the between-group difference in proportion
of patients who declined additional analgesia at 60 minutes.
Results: Of the 350 enrolled patients,
334 had sufficient data for analysis. The proportion who declined additional
analgesics was 67.5% in the 2 mg bolus arm and 67.3% in the 1+1 titration arm
(difference 0.2%; 95% confidence interval −9.7% to 10.2%). The between-group
difference in numeric rating scale pain scores was 0.4 numeric rating scale
units (95% confidence interval −0.3 to 1.1). The incidence of adverse effects
was similar; 42.3% of 1+1 patients achieved satisfactory analgesia at 1 hour
with only 1 mg hydromorphone.
Conclusion: A hydromorphone 1+1
titration protocol provides similar pain relief to an initial 2 mg bolus dose,
with no apparent clinical advantage to the latter. The 1+1 titration protocol
had an opioid-sparing effect because 50% less opioid was needed to achieve satisfactory
analgesia for 42.3% of patients allocated to this protocol.
15. New Guidelines Released for Acute
The American College of
Gastroenterology has issued updated guidelines on the diagnosis, workup,
nutrition, and management for patients with acute pancreatitis (AP). The new
recommendations were published online July 30 and in the September issue of the
American Journal of Gastroenterology.
This guideline presents
recommendations for the management of patients with acute pancreatitis (AP).
During the past decade, there have been new understandings and developments in
the diagnosis, etiology, and early and late management of the disease. As the
diagnosis of AP is most often established by clinical symptoms and laboratory testing,
contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging
(MRI) of the pancreas should be reserved for patients in whom the diagnosis is
unclear or who fail to improve clinically.
Hemodynamic status should be
assessed immediately upon presentation and resuscitative measures begun as
needed. Patients with organ failure and/or the systemic inflammatory response
syndrome (SIRS) should be admitted to an intensive care unit or intermediary
care setting whenever possible. Aggressive hydration should be provided to all
patients, unless cardiovascular and/or renal comorbidites preclude it. Early
aggressive intravenous hydration is most beneficial within the first 12–24 h,
and may have little benefit beyond.
Patients with AP and concurrent
acute cholangitis should undergo endoscopic retrograde cholangiopancreatography
(ERCP) within 24 h of admission. Pancreatic duct stents and/or postprocedure
rectal nonsteroidal anti-inflammatory drug (NSAID) suppositories should be
utilized to lower the risk of severe post-ERCP pancreatitis in high-risk
Routine use of prophylactic
antibiotics in patients with severe AP and/or sterile necrosis is not
recommended. In patients with infected necrosis, antibiotics known to penetrate
pancreatic necrosis may be useful in delaying intervention, thus decreasing
morbidity and mortality. In mild AP, oral feedings can be started immediately
if there is no nausea and vomiting. In severe AP, enteral nutrition is
recommended to prevent infectious complications, whereas parenteral nutrition
should be avoided.
Asymptomatic pancreatic and/or
extrapancreatic necrosis and/or pseudocysts do not warrant intervention
regardless of size, location, and/or extension. In stable patients with
infected necrosis, surgical, radiologic, and/or endoscopic drainage should be
delayed, preferably for 4 weeks, to allow the development of a wall around the
Suspicious lacerations should be
investigated, even if the X-ray is normal. A step-by-step pictorial guide.
It is a busy Friday evening in the
emergency department when you get called to the resuscitation bay for a
14-year-old female who was the restrained back seat passenger in a rollover
motor vehicle crash. After a quick call to your significant other to ensure
that your daughter is safe in bed, you proceed to evaluate this young patient.
You are once again amazed by modern safety technology with the minimal amount
of head, torso and abdominal trauma on this patient. After a thorough initial
inspection you find that the patient has a large laceration to the lateral side
of her left ankle, and swelling that suggests either a fracture or a severe
sprain or dislocation. You do note that the laceration is directly over the
ankle, and make a note that you will need to determine if that is an “open
ankle” once you ensure there are no other life threatening emergencies. You
order a set of ankle x-rays with the rest of your trauma work up and give the
patient a dose of pain medications prior to shipping her off to get imaging.
Once the patient return from her
x-rays you are relieved to see there’s no fracture, and you wonder if this
could simply be a bad sprain with an overlying laceration. Can this laceration
just be irrigated and closed in the emergency department, or do you some other
service to weigh in?
Open ankle fractures are relatively
common in trauma centers around the country. The majority of emergency
physicians are comfortable taking care of these patients; they need IV
antibiotics, immobilization, and urgent orthopedic evaluation. On the other
hand, there is relatively little data on open ankle sprains (termed Severe Open
Ankle Sprain – SOAR), and open ankle dislocations sustained without a fracture.
The majority of these injuries continue to be case reportable, with the larger
studies numbering in the teens of patients. From the few case reports and case
control studies currently in the literature the majority of these injuries are
the result of motor vehicle accidents and occur in the setting of significant
plantar forces. Approximately two thirds of SOARs occur with the laceration on
the lateral aspect of the ankle. In order to diagnose a SOAR or open ankle
dislocation, the patient must have no fractures on x-ray, and the laceration
must be confirmed to communicate with the joint space.
In order to determine if the
laceration communicates with the joint space you need to perform a saline
challenge test or a methylene blue challenge test…
Choosing Wisely® aims to promote
conversations between physicians and patients by helping patients choose care
duplicative of other tests or procedures already received
In response to this challenge,
national organizations representing medical specialists have been asked to
“choose wisely” by identifying five tests or procedures commonly used in their
field, whose necessity should be questioned and discussed. The resulting lists
of “Five Things Physicians and Patients Should Question” will spark discussion
about the need—or lack thereof—for many frequently ordered tests or treatments.
The American College of Emergency
Physicians will be provided their list soon. Meanwhile, here are a few more
recommendations that challenge long-standing conventions.
A. Don't prescribe antibiotics for otitis media in children
aged 2-12 years with non-severe symptoms where the observation option is
reasonable. The "observation
option" refers to deferring antibacterial treatment of selected children
for 48 to 72 hours and limiting management to symptomatic relief. The decision
to observe or treat is based on the child’s age, diagnostic certainty and
illness severity. To observe a child without initial antibacterial therapy, it
is important that the parent or caregiver has a ready means of communicating
with the clinician. There also must be a system in place that permits
reevaluation of the child.
B. Don't perform voiding cystourethrogram routinely in first
febrile urinary tract infection (UTI) in children aged 2-24 months. The risks associated with radiation (plus the discomfort and expense of
the procedure) outweigh the risk of delaying the detection of the few children
with correctable genitourinary abnormalities until their second UTI.
18. Dexamethasone for bronchiolitis
benefits babies with familial atopy
By: MICHELE G. SULLIVAN, Family
Practice News Digital Network, Sept 2013
A 5-day course of dexamethasone
significantly shortened hospital stays for infants with bronchiolitis who had
eczema or close relatives with asthma.
The randomized, placebo-controlled
study suggests that a family history of atopy could identify a subset of babies
who would benefit from the addition of a corticosteroid to the usual salbutamol
therapy for acute bronchiolitis, according to Dr. Khalid Alansari and
colleagues. The report was published in the Sept. 16 issue of Pediatrics.
The researchers examined 7-day
outcomes in 200 infants with acute bronchiolitis who were at a high risk of
asthma, as determined by having at least one first-degree relative with either
asthma or eczema. All of the children (mean age 3.5 months) were admitted to a
pediatric hospital for treatment, wrote Dr. Alansari of Weill Cornell Medical
College, Doha, Qatar, and coauthors. Infants who received dexamethasone were
discharged 8 hours earlier than were those receiving standard treatment. The
mean duration of symptoms was 4.5 days (Pediatrics 2013 Sept. 13 [doi:
The study’s primary outcome was
time until discharge. Secondary outcomes included the number of patients who
needed epinephrine treatment, readmission for a shorter stay in an infirmary
site, and revisiting the emergency department or another clinic for the same
illness. A study nurse made daily calls to assess the patients after discharge.
Infants in the dexamethasone group
were discharged at a mean of 18.6 hours – significantly sooner than those in
the control group (27 hours). Epinephrine was necessary for 19 infants in the
dexamethasone group and 31 in the placebo group – again a significant
Similar numbers in each group
needed readmission and additional outpatient visits in the week after
discharge. During the follow-up week, 22% of the dexamethasone group needed
infirmary care and the mean stay was 17 hours, compared with 21% of the placebo
group with a mean stay of 18 hours.
Nineteen in the dexamethasone group
and 11 in the placebo group made a clinic visit (18.6% vs. 11%); this
difference was not significant. The chest radiograph was normal in about 37% of
infants studied. About half showed lesser infiltrates; 15% had a lobar collapse
More than 70% had a full sibling
with asthma. About 20% had a parent with the disease; in 5%, both parents had
it. About 20% of patients had both eczema and first-degree relative with
All of the infants received 2.5 mg
salbutamol nebulization at baseline and at 30, 60, and 120 minutes, and then
every 2 hours until discharge. Nebulized epinephrine (0.5 mL/kg with a maximum
dose of 5 mL) was available if needed. In addition, they were randomized to
either placebo or to a 5-day course of dexamethasone 1 mg/mL, at a rate of 1
mL/kg on day 1, reduced to 0.6 mL/kg for days 2-5.
Christine Carter, PhD, Greater Good
Science Center, Sept 2, 2013
Excerpt: When we look at people who
are at the top of their field, they all have grit: persistence and passion for
their long-term goals. But this doesn't mean that they burn the midnight oil
day-in and day-out in pursuit of achievement.
Just as elite performers are
strategic about what they practice, they are also strategic about how long they
practice for. The good news (I think) is that it doesn't work to just practice
until our fingers bleed or our mind spins or our muscles give out -- for hour
upon hour upon hour of endless, relentless, intrinsically boring practice.
Here's my favorite part of a series
I've written on elite performance: Super-high-achievers sleep significantly
more than the average American. On average, Americans get only 6.5 hours of
sleep per night. Elite performers tend to get 8.6 hours of sleep a night; elite
athletes need even more sleep. One study showed that when Stanford swimmers
increased their sleep time to 10 hours per 24 hours (sleeping longer at night
and often taking a nap), they felt happier, more energetic -- and their
performance in the pool improved dramatically.
Take Action: Are you tired? If so,
lie down. (Although it may feel like it, the world will not stop spinning just
because you have.) Take a nap. Hit the sack early tonight: your work and family
will thank you for it!
20. Immediate Open Repair vs Surveillance
in Patients with Small AAA (4.0- to 5.4-cm): Waiting Works Well
Filardo G, et al. Mayo Clin Proc. 2013;
OBJECTIVE: To assess whether
survival differences exist between patients undergoing immediate open repair vs
surveillance with selective repair for 4.0- to 5.4-cm abdominal aortic
aneurysms (AAAs) and whether these differences vary by diameter, within sexes,
PATIENTS AND METHODS: The study
cohort included 2226 patients randomized to immediate repair or surveillance
for the UK Small Aneurysm Trial (September 1, 1991, through July 31, 1998;
follow-up, 2.6-6.9 years) or the Aneurysm Detection and Management trial
(August 1, 1992, through July 31, 2000; follow-up, 3.5-8.0 years). Survival
differences were assessed with proportional hazard models, adjusted for a
comprehensive array of clinical and nonclinical risk factors. Interaction
between treatment and AAA size was added to the model to assess whether the
effect of immediate open repair vs surveillance varied by AAA size.
RESULTS: The adjusted analysis
revealed no statistically significant survival difference between immediate
open repair and surveillance patients (hazard ratio [HR], 0.99; 95% CI,
0.83-1.18; mean follow-up time, 1921 days for both study groups). This lack of
treatment effect persisted when men (HR, 1.01; 95% CI, 0.84-1.21) and women
(HR, 0.96; 95% CI, 0.49-1.86) were examined separately and did not vary by AAA
size (P=.39 for the entire cohort and P=.24 for women).
CONCLUSION: Immediate open repair
offered no significant survival benefit, even in patients with the largest AAAs
and highest risk of rupture. Because recent trials failed to find a survival
benefit of immediate endovascular repair over surveillance for small
asymptomatic AAAs, our findings suggest that the gray area of first-line
management for these patients should be resolved in favor of surveillance.
21. Stat Pregnancy Test . . .
byMichelle Lin, MD on September 13, 2013, EP Monthly
A 25-year-old woman presents to the
emergency department having syncopized in the waiting room, where she was
triaged with the chief complaint of abdominal pain. Ectopic pregnancy
immediately bubbles to the top of your differential diagnosis.
The patient is too dizzy to walk to
the bathroom to give you a urine specimen to check a urine pregnancy test.
Plus, she admits that she just urinated in the waiting room bathroom a few
minutes ago – so no urine now.
Apply several drops of whole blood (instead
of urine) into the pregnancy test cassette. In the photo, the patient was
pregnant with a serum beta-HCG level of 250 mIU/mL whose urine and whole blood
qualitative tests were both positive.
Did you know that most urine
pregnancy test kits are approved for both urine and serum samples? A quick
Google search reveals that Accutest, Cardinal Health, ICON, OSOM, and Rapid
Response all are approved for both. The question is whether this will work for
whole blood. Recall that serum is the extracellular component of whole blood.
One study in the Journal of
Emergency Medicine by Dr. Fromm from Maimonides Medical Center looked at
exactly this issue(1). Whole blood pregnancy test performed extremely well,
especially if positive:
predictive value 97.9%
predictive value 100%
In their study, very low beta-HCG
values (less than 159 mIU/mL) occasionally yielded a false negative for whole
blood pregnancy tests. The whole blood testing approach missed a total nine of
425 pregnancies. Interestingly, the urine pregnancy test was also negative in
five of those nine and not performed in the other four.
Bottom Line: Believe a positive
test. Confirm all tests with a urine qualitative test or quantitative serum
Tips: Be sure to wait at least 5
minutes when using whole blood in the kit. It sometimes takes a while.
Do not apply additional drops of
water or saline to the whole blood sample. This causes unnecessary dilution.
Just wait for the blood to osmose across the entire test strip.
1. Fromm C, Likourezos A, Haines L,
Khan AN, Williams J, Berezow J. Substitutingwhole blood for urine in a bedside pregnancy test. J Emerg Med. 2012
2. Habbousche JP, Walker G. Novel
use of a urine pregnancy test using whole blood. Am J Emerg Med. 2011
22. Decreased hydration status of ED
physicians and nurses by the end of their shift
Alomar MZ, et al. Internat J Emerg
Typical emergency department (ED)
shifts are physically demanding. The aim of this study was to assess the
hydration status of ED physicians and nurses by the end of their shifts.
A prospective cross-sectional
clinical study of ED physicians and nurses assessing fluid intake, activities,
vital signs, weight, urine specific gravity and ketones at the end of the
shift. Forty-three participants were tested over 172 shifts distributed over
48% in the morning, 20% in the evening and 32% at night. Fifty-eight percent
were females, and 51% were physicians.
Overall, participants lost 0.3% of
their body weight by the end of the shift. While physicians lost a mean of 0.57
kg (± SD 0.28; P less than 0.0001, 95% CI 0.16-0.28), nurses lost 0.12 kg (± SD 0.25; P less than 0.0001, 95% CI 0.07-1.7). While
nurses drank more fluid (P less
than 0.0001), physicians had a higher
specific gravity of 1.025 (P less
than 0.01), visited the washroom less
often (P less than 0.0001) and reported less workload and stress (P = 0.01 and 0.008,
respectively). There were no major changes in vital signs or urinary ketones
(OR.0.41, 95% CI 0.1-2.1). In a multivariate analysis, being male (OR 13.5, 95%
CI 1.6-112.5), being of younger age (OR 4.1, 95% CI 1.7-10.2), being Middle
Eastern (OR 5.3, 95% CI 1.1-26.2), working the morning shift (OR 2.7, 95% CI
0.7-10.5) and having less fluid intake (OR 5.7, 95% CI 1.2-26.6) were
significant predictors of decreased hydration.
The majority of physicians and to a
lesser extent nurses working in a tertiary care emergency department have
decreased hydration status at the end of the shift. Therefore, awareness of the
hydration status by emergency department staff is needed. A further study in a
similar setting with more subjects and a better balance among the variables is
A. For Better Social Skills, Scientists Recommend a Little
By PAM BELLUCK, New York Times,
October 3, 2013
Say you are getting ready for a
blind date or a job interview. What should you do? Besides shower and shave, of
course, it turns out you should read — but not just anything. Something by
Chekhov or Alice Munro will help you navigate new social territory better than
a potboiler by Danielle Steel.
That is the conclusion of a study
published Thursday in the journal Science. It found that after reading literary
fiction, as opposed to popular fiction or serious nonfiction, people performed
better on tests measuring empathy, social perception and emotional intelligence
— skills that come in especially handy when you are trying to read someone’s
body language or gauge what they might be thinking.
The researchers say the reason is
that literary fiction often leaves more to the imagination, encouraging readers
to make inferences about characters and be sensitive to emotional nuance and
A "diet report card"
issued by the Center for Science in the Public Interest gave Americans a C
grade for their eating habits, noting that they consume about 450 calories more
each day than they did in 1970. Americans are eating lots grains and slightly
less beef and sugar; fruit and vegetable levels are flat; use of fats and oils
has been increasing; and the average person is eating 23 pounds of cheese each
year, the report says.
Helicobacter pylori-negative ulcers
were associated with poorer outcomes regardless of use of NSAIDs. Patients with
ulcers negative for Helicobacter pylori and no history of NSAID use had the
worst outcomes and had more severe systemic disease.
When it comes to loneliness in
nursing homes, what works better -– a companion robot or a resident dog? This
New Zealand study found that Paro, modeled after a Canadian Harp seal, gained
more positive interactions among residents than the live dog. One explanation
could be the dog was able to choose who to interact with, while the robot could
not, and another could be the dog had already been at the facility for three
months prior to the introduction of the robot seal.
A sophisticated genetic analysis of
Clostridium difficile cases is challenging the conventional wisdom that
symptomatic patients are responsible for most transmission in hospitals. Most
C. diff infections acquired outside hospitals, data show. A study involving
four British hospitals showed that 35% of Clostridium difficile cases resulted
from exposure to the pathogen in a hospital, suggesting that diverse sources
such as food, animals, water or other health care settings play an important
role in transmission.
I. Exercise May Beat Drugs in Lowering Some Disease Death
Exercise may be just as effective
as many drugs in lowering risk for death in the secondary prevention of
coronary heart disease, rehabilitation after stroke, and prevention of
diabetes, according to an analysis of randomized controlled trials published online
October 1 in the British Medical Journal.
K. Clinical relevance of symptomatic superficial-vein
thrombosis extension: lessons from the CALISTO study.
Leizorovicz A, et al. Blood. 2013
The clinical relevance of
symptomatic extension of spontaneous, acute, symptomatic, lower-limb
superficial-vein thrombosis (SVT) is debated. We performed a post hoc analysis
of a double-blind trial comparing fondaparinux with placebo. The main study
outcome was SVT extension by day 77, whether to ≤3 cm or greater than 3 cm from
the sapheno-femoral junction (SFJ). All events were objectively confirmed and
validated by an adjudication committee. With placebo (n = 1500), symptomatic
SVT extension to ≤3 cm or greater than 3 cm from the SFJ occurred in 54 (3.6%)
and 56 (3.7%) patients, respectively, inducing comparable medical resource
consumption (eg, anticoagulant drugs and SFJ ligation); subsequent deep-vein
thrombosis or pulmonary embolism occurred in 9.3% (5/54) and 8.9% (5/56) of patients,
respectively. Fondaparinux was associated with lower incidences of SVT
extension to ≤3 cm (0.3%; 5/1502; P less than .001) and greater than 3 cm
(0.8%; 12/1502; P less than .001) from the SFJ and reduced related use of
medical resources; no subsequent deep-vein thrombosis or pulmonary embolism was
observed in fondaparinux patients. Thus, symptomatic extensions are common SVT
complications and, whether or not reaching the SFJ, are associated with a
significant risk of venous thromboembolic complications and medical resource consumption,
all reduced by fondaparinux.
L. Acute Rheumatic Fever: Case Report and Review for
Ilgenfritz S, et al. J Emerg Med.