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.  

Importance  Three clinical decision rules were previously derived to identify patients with headache requiring investigations to rule out subarachnoid hemorrhage. 

Objective  To 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 Patients  Multicenter 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 Measures  Subarachnoid 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. 

Results  Of 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 Relevance  Among 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. 2013;310(12):1237-1239. 

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 disease risk… 

2. Clinician Gestalt Estimate of Pretest Probability for ACS and PE in Patients with Chest Pain and Dyspnea

Kline 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 Stroke Outcome 

Shigematsu K, et al. Emerg Med J. 2013;30(9):728-731.  

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 outcome. 

4. Trauma Corner 

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 intervention. 

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 admission. 

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 evaluation. 

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 scan result. 

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 20, 2013
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 treatment group.

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. 2013;62:311-318.e4 

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 skier’s thumb.  

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 comparison 

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) among nonsmokers. 

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.

10. Clinical Images 

Pulsatile Chest Swelling

Child With Diarrhea and Rash

Man With Rushing Fluid From His Umbilicus

Uremic Pericarditis

Peristaltic Waves in Pyloric Stenosis 

11. Evaluation of the Mercy TAPE: Performance Against the Standard for Pediatric Weight Estimation 

Abdel-Rahman SM, et al. 2013;62: 332-339.e6. 

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 Broselow method. 

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 17, 2013 

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 risk factors." 

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).  

Conclusions—Patients who 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 warfarin. 

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 (free):  

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. 2013;62: 304-310. 

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 Pancreatitis Management 

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 patients.  

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 necrosis. 

Full-text (free): link here:  

16. How to Confirm Ankle Joint Penetration  

Johnson MA, et al. September 8, 2013, EP Monthly  

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… 

17. More from the Choosing Wisely Campaign

Choosing Wisely® aims to promote conversations between physicians and patients by helping patients choose care that is:
·         Supported by evidence
·         Not duplicative of other tests or procedures already received
·         Free from harm
·         Truly necessary 

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. 

C. Related study: We’re Still Overprescribing Abx for Adults with Sore Throat 

Among adults seeking care with sore throat, the prevalence of group A Streptococcus (GAS) infection—the only common cause of sore throat requiring antibiotics—is about 10%. 

Yet, analysis of two national ambulatory care databases suggests that doctors order antibiotics for about 60% of patients who complain of a sore throat. Whoops! 

Barnett ML, et al. JAMA Intern Med. Published online October 03, 2013. 

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: 10.1542/peds.2012-3746]).  

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 difference.  

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 or consolidation.
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 asthma.  

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.  

19. Happiness Tip: Just Lie Down for a Minute 

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; 88(9):910-9  

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, or overall.  

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 . . . Without Urine?  

by  Michelle 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. 

Quick Trick
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:
·         Sensitivity 95.8%
·         Specificity 100%
·         Negative predictive value 97.9%
·         Positive 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 beta-HCG. 

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. Substituting  whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82.
2. Habbousche JP, Walker G. Novel use of a urine pregnancy test using whole blood. Am J Emerg Med. 2011 Sep;29(7):840.e3-4.   

22. Decreased hydration status of ED physicians and nurses by the end of their shift 

Alomar MZ, et al. Internat J Emerg Med. 2013;6:27 

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 recommended. 

22. Tid Bits 

A. For Better Social Skills, Scientists Recommend a Little Chekhov 

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 complexity… 

B. C.D.C. Says Resistant Infections Kill 23,000 a Year 

By SABRINA TAVERNISE. New York Times, Sept 17, 2013 

A report also found that at least two million Americans fall ill from antibiotic-resistant infections annually. 

C. Is Helicopter Transport Cost Effective? 

Delgado MK, et al. Cost-Effectiveness of Helicopter Versus Ground Emergency Medical Services for Trauma Scene Transport in the United States. Ann Emerg Med. 2013;62:351-364.e19. 

D. Safety in Numbers: Are Major Cities the Safest Places in the United States? 

Myers SR, et al. Ann Emerg Med. 2013;62:408-418.e3. 

E. Americans get a C on "diet report card"  

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. 

F. Peptic bleeding ulcer cause affects outcome 

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. 

G. Robots vs dogs: who is the better companion? 

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. 

H. ’Facts’ of C. Diff Transmission Challenged     

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 Rates 

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. 

J. Precordial Thump Rarely of Benefit 

Only 5% of patients with out-of-hospital cardiac arrest achieved return of spontaneous circulation after precordial thump in this Australian registry study. 

K. Clinical relevance of symptomatic superficial-vein thrombosis extension: lessons from the CALISTO study. 

Leizorovicz A, et al. Blood. 2013 Sep 5;122(10):1724-9.  

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 Emergency Physicians 

Ilgenfritz S, et al. J Emerg Med. 2013;45:e103-e106