Wednesday, May 07, 2014

Lit Bits: May 7, 2014

From the recent medical literature...

1. Topical Tetracaine Used for 24 Hours Is Safe and Rated Highly Effective by Patients for the Treatment of Pain Caused by Corneal Abrasions: A Double-blind RCT

Waldman N, et al. Acad Emerg Med. 2014;21:374-82.

Objectives: The objective of this study was to test the hypothesis that topical tetracaine would be safe to use for 24 hours and would not affect corneal healing, that patients would experience more pain relief, and that patients would perceive tetracaine to be more effective than saline eye drops for the treatment of pain caused by corneal abrasions.

Methods: The study was a 12-month, prospective, double-blind, randomized trial of tetracaine versus saline set in the emergency department (ED) of a regional tertiary care teaching hospital. A total of 116 patients presenting with uncomplicated corneal abrasions were included in this study. The intervention was either undiluted, preservative-free, topical tetracaine hydrochloride 1% or saline, applied up to every 30 minutes while awake for 24 hours. Main safety outcome measures were repeat ED examinations at 48 hours with fluorescein staining and slit-lamp examination, 1-week and 1-month telephone interviews with additional examinations as needed, and monitoring of charts for complications. Secondary outcome measures were 100-mm visual analogue scale (VAS) pain scores recorded every 2 hours while awake for 48 hours and patient-perceived overall effectiveness using a numeric rating scale (NRS) of 0 to 10 obtained during telephone interviews.

Results: At least one follow-up encounter was completed on each of the 116 patients. No complications specifically attributed to topical anesthetic use occurred in the 59 patients in the tetracaine group, and the binomial probability confidence interval (CI) of this occurring is 0 to 6.1. There was no significant difference in corneal healing as measured by the percentage of patients with persistent fluorescein uptake at 48 hours between the two groups (23.9% vs. 21.3%, difference = 2.6%, 95% CI = –14% to 20%, p = 0.761) or persistent symptoms at 48 hours (21.7% vs. 21.3%, difference = 0.4%, 95% CI = –16% to 17%, p = 0.957). There was no clinical difference in VAS pain scores between the groups. Patients in the tetracaine group rated the study drugs' overall effectiveness significantly higher on the NRS (7.7 vs. 3.9) compared to patients in the saline group (difference = 3.9, 95% CI = 2.4 to 5.3, p less than 0.0005).

Conclusions: Topical tetracaine used for 24 hours is safe, and while there was no significant difference in patient VAS pain ratings over time, patient surveys on overall effectiveness showed that patients perceived tetracaine to be significantly more effective than saline.

2. Predicting hematoma expansion after primary ICH

Brouwers HB, et al. JAMA Neurol. 2014 Feb;71(2):158-64.

IMPORTANCE: Many clinical trials focus on restricting hematoma expansion following acute intracerebral hemorrhage (ICH), but selecting those patients at highest risk of hematoma expansion is challenging.

OBJECTIVE: To develop a prediction score for hematoma expansion in patients with primary ICH.

DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study at 2 urban academic medical centers among patients having primary ICH with available baseline and follow-up computed tomography for volumetric analysis (817 patients in the development cohort and 195 patients in the independent validation cohort).

MAIN OUTCOMES AND MEASURES: Hematoma expansion was assessed using semiautomated software and was defined as more than 6 mL or 33% growth. Covariates were tested for association with hematoma expansion using univariate and multivariable logistic regression. A 9-point prediction score was derived based on the regression estimates and was subsequently tested in the independent validation cohort.

RESULTS: Hematoma expansion occurred in 156 patients (19.1%). In multivariable analysis, predictors of expansion were as follows: warfarin sodium use, the computed tomography angiography spot sign, and shorter time to computed tomography (≤ 6 vs beyond 6 hours) (P less than  .001 for all), as well as baseline ICH volume (below 30 [reference], 30-60 [P = .03], and over 60 [P = .005] mL). The incidence of hematoma expansion steadily increased with higher scores. In the independent validation cohort (n = 195), our prediction score performed well and showed strong association with hematoma expansion (odds ratio, 4.59; P less than  .001 for a high vs low score). The C statistics for the score were 0.72 for the development cohort and 0.77 for the independent validation cohort.

CONCLUSIONS AND RELEVANCE: A 9-point prediction score for hematoma expansion was developed and independently validated. The results open a path for individualized treatment and trial design in ICH aimed at patients at highest risk of hematoma expansion with maximum potential for therapeutic benefit.

3. Effect of Out-of-Hospital Noninvasive Positive-Pressure Support Ventilation in Adult Patients with Severe Respiratory Distress: A Systematic Review and Meta-analysis

Mal S, et al. Ann Emerg  Med. 2014;63: 600–607.e1

Study objective: Noninvasive positive-pressure ventilation (NIPPV) is increasingly being used by emergency medical services (EMS) for treatment of patients in respiratory distress. The primary objective of this systematic review is to determine whether out-of-hospital NIPPV for treatment of adults with severe respiratory distress reduces inhospital mortality compared with “standard” therapy. Secondary objectives are to examine the need for invasive ventilation, hospital and ICU length of stay, and complications.

Methods: Electronic searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature were conducted and reference lists of relevant articles hand searched. Randomized controlled trials comparing out-of-hospital NIPPV with standard therapy in adults (aged ≥16 years) with severe respiratory distress published in English were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled with random-effects models and reported as risk ratios (RRs) with 95% confidence intervals (CIs) and number needed to treat (NNT).

Results: Seven randomized controlled trials were included, with a combined total of 632 patients; 313 in the standard therapy group and 319 in the NIPPV group. In patients treated with NIPPV, the pooled estimate showed a reduction in both inhospital mortality (RR 0.58; 95% CI 0.35 to 0.95; NNT=18) and need for invasive ventilation (RR 0.37; 95% CI 0.24 to 0.58; NNT=8). There was no difference in ICU or hospital length of stay.

Conclusion: Out-of-hospital administration of NIPPV appears to be an effective therapy for adult patients with severe respiratory distress.

4. Intermediate-Risk Patients with PE Should Receive Thrombolytics Only If They Decompensate

Raja AS, Journal Watch Emergency Medicine. April 9, 2014

Primary thrombolysis did not improve mortality but did increase major hemorrhage and stroke in patients with intermediate-risk pulmonary embolism.

Administration of thrombolytic therapy for acute pulmonary embolism (PE) requires weighing the substantial risk of hemorrhage against the potential benefits, mainly improved hemodynamics and reduced mortality. For patients in shock with clear evidence of PE (high risk), the benefits seem to outweigh the risks, but for hemodynamically stable patients with evidence of right ventricular dysfunction and elevated troponin levels (intermediate risk), the evidence has been less clear. To determine the safety and efficacy of thrombolytic therapy in intermediate-risk patients, researchers in France performed a multicenter, randomized, double-blind trial comparing tenecteplase plus heparin with placebo plus heparin in 1005 hemodynamically stable patients with PE, right ventricular dysfunction on ultrasound or computed tomography, and troponin elevation.

Mortality was similar in the tenecteplase and placebo groups at 7 days (1.2% and 1.8%) and 30 days (2.4% and 3.2%). The tenecteplase group had higher rates of both intracranial bleeding (2.0% vs. 0.2%) and extracranial bleeding (6.3% vs. 1.2%). However, significantly more patients in the placebo group had hemodynamic decompensation and needed rescue thrombolysis during their admission (5.0% vs. 1.6%).

Comment: Given the risk for hemorrhage, primary thrombolysis should not be given to hemodynamically stable patients with intermediate-risk pulmonary embolism. However, intermediate-risk patients can decompensate and should be closely monitored in case they need rescue thrombolysis or mechanical embolectomy during hospitalization. These results are similar to those of earlier smaller trials and reinforce current practice.

Source: Meyer G et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014;370:1402.

5. Occult Pneumothoraces in Children with Blunt Torso Trauma: Observation Works

Lee LK, et al. Acad Emerg Med. 2014;21:440–448

Objectives: Plain chest x-ray (CXR) is often the initial screening test to identify pneumothoraces in trauma patients. Computed tomography (CT) scans can identify pneumothoraces not seen on CXR (“occult pneumothoraces”), but the clinical importance of these radiographically occult pneumothoraces in children is not well understood. The objectives of this study were to determine the proportion of occult pneumothoraces in injured children and the rate of treatment with tube thoracostomy among these children.

Methods: This was a planned substudy from a large prospective multicenter observational cohort study of children younger than 18 years old evaluated in emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network (PECARN) for blunt torso trauma from May 2007 to January 2010. Children with CXRs as part of their trauma evaluations were included for analysis. The faculty radiologist interpretations of the CXRs and any subsequent imaging studies, including CT scans, were reviewed for the absence or presence of pneumothoraces. An “occult pneumothorax” was defined as a pneumothorax that was not identified on CXR, but was subsequently demonstrated on cervical, chest, or abdominal CT scan. Rates of pneumothoraces and placement of tube thoracostomies and rate differences with 95% confidence intervals (CIs) were calculated.

Results: Of 12,044 enrolled in the parent study, 8,020 (67%) children (median age = 11.3 years, interquartile range [IQR] = 5.3 to 15.2 years) underwent CXRs in the ED, and these children make up the study population. Among these children, 4,276 had abdominal CT scans performed within 24 hours. A total of 372 of 8,020 children (4.6%; 95% CI = 4.2% to 5.1%) had pneumothoraces identified by CXR and/or CT. The CXRs visualized pneumothoraces in 148 patients (1.8%; 95% CI = 1.6% to 2.2%), including one false-positive pneumothorax, which was identified on CXR, but was not demonstrated on CT. Occult pneumothoraces were present in 224 of 372 (60.2%; 95% CI = 55.0% to 65.2%) children with pneumothoraces. Tube thoracostomies were performed in 85 of 148 (57.4%; 95% CI = 49.0% to 65.5%) children with pneumothoraces on CXR and in 35 of 224 (15.6%; 95% CI = 11.1% to 21.1%) children with occult pneumothoraces (rate difference = –41.8%; 95% CI = –50.8 to –32.3%).

Conclusions: In pediatric patients with blunt torso trauma, pneumothoraces are uncommon, and most are not identified on the ED CXR. Nearly half of pneumothoraces, and most occult pneumothoraces, are managed without tube thoracostomy. Observation, including in children requiring endotracheal intubation, should be strongly considered during the initial management of children with occult pneumothoraces.

6. Does a Prehospital ECG Improve MI Care?

Daniel J. Pallin, MD, MPH, Journal Watch Emergency Medicine. Apr 5 2013

An observational study in England and Wales correlates obtaining a prehospital ECG with better care and outcomes.

Most emergency medical services (EMS) systems can perform prehospital electrocardiograms (ECGs), and some can even bypass the emergency department to transport patients straight to the catheterization lab. However, debate continues about whether specific prehospital interventions actually improve patient care or outcomes. Investigators reviewed a national myocardial infarction (MI) registry in England and Wales to determine whether obtaining a prehospital ECG was associated with better processes of care and patient outcomes.

Of 288,990 MI patients transported to the hospital by EMS between 2005 and 2009, 50% received prehospital ECGs, and 32% did not (ECG status was unknown for 18%). Among patients with ST segment elevation myocardial infarction, those with a prehospital ECG were more likely than those without to undergo reperfusion (84% vs. 74%), have a call-to-balloon time below 90 minutes (28% vs. 21%), and have an arrival-to-fibrinolysis time below 30 minutes (91% vs. 84%). Overall, 30-day mortality was lower in patients with a prehospital ECG (7.4% vs. 8.2%).

Comment: There may be reasons why some patients received prehospital electrocardiograms and others did not: The ones who did not may have been sicker or may have had more obscure presentations. Although this study is flawed by its design, its findings are consistent with those of other studies showing that obtaining a prehospital ECG shortens time to treatment and improves care -

Source: Quinn T et al. Effects of prehospital 12-lead ECG on processes of care and mortality in acute coronary syndrome: A linked cohort study from the Myocardial Ischaemia National Audit Project. Heart 2014 Apr 14 [Epub ahead of print]

7. An ED scribe program is able to improve throughput time and patient satisfaction

Bastani A, et al. Amer J Emerg Med. 2014;32:399-402.

Introduction: At our institution, we previously described the detrimental effect of computerized physician order entry (CPOE) on throughput time and patient satisfaction (Ann of Emer Med, Vol 56, P S83-S84). To address these quality metrics, we conducted a pilot program using scribes in the emergency department (ED).

Methods: We conducted a before-and-after study of ED throughput at our 320-bed suburban community hospital with a census of 70000 annual visits. Our primary outcome measure was the effect of scribes on ED throughput as measured by the effect on (1) door-to-room time; (2) room-to-doc time; (3) door-to-doc time; (4) doc-to-dispo time; and (5) length of stay for discharged/admitted patients, between pre-CPOE and post-CPOE cohorts. Our secondary outcome measure was patient satisfaction as provided by Press Ganey surveys. Data were analyzed using descriptive statistics, and means were compared using a standard t test.

Results: Patient data from a total of 11729 patients in the before cohort were compared with data from 12609 patients in the after cohort. Despite a 7.5 % increase in volume between the post-CPOE and post-scribe cohorts, all throughput metrics improved in the post-scribe cohort. This process improved the overall door-to-doc time to 61 minutes in the after cohort from 74 minutes in the before cohort. Furthermore, patient and physician satisfaction was improved from the 58th and 62nd percentile to 75th and 92nd percentile, respectively.

8. Post-Intubation Sedation: The Tube Is In, Now What?

by Neil Singh, MD, Emerg Physicians Monthly, May 5, 2014           

How to reduce anxiety and improve comfort while not oversedating.

A 70-year-old male comes to the emergency department via EMS febrile, with worsening respiratory distress and altered mental status. You quickly diagnose him as having severe sepsis stemming from pneumonia, and initiate treatment. After setting up and preoxygenating him, you have first-pass success on your intubation, pat yourself on the back, and admit him to the ICU. But your nursing manager then informs you that the hospital is full, including the ICU. So now your severely septic patient will be boarding in the ED. He quickly starts to get hypotensive on your sedation and you can only sweat and wonder, “How am I supposed to manage him now?”

Once mechanical ventilation has been initiated, the physician’s initial goals are to relieve patient anxiety and keep them comfortable. In “The ICU Book,” Marino states “the common denominator in these conditions (anxiety and delirium) is the absence of a sense of well-being.”

Reducing anxiety on a ventilated patient is challenging. Double breathing the ventilator, pulling at lines and persistent tachycardia are all obvious signs of anxiety. In the “good old days,” trying to achieve those two goals under these conditions was often met with a slight dose of paralysis – vecuronium at times – while maintaining ventilator synchrony, mixed with a few pushes of benzodiazepines to relieve anxiety and hopefully introduce some amnesia.

Fortunately, as emergency medicine knowledge progressed, so did pharmacology, and now the idea of paralyzing an awake patient brings chills to us all. Unfortunately, while the use of opiates and benzodiazepines post-intubation may be a step forward, they come with their own unique set of complications. The normotensive patient that becomes hypotensive on sedation is markedly common, and unfortunately many respond by simply adding some wrist restraints and cutting back on drips. The other side of the coin occurs just as often — patients overmedicated with enough sedation to knock out a small elephant. These dilemmas occur often in the ED and even in many ICUs, but with new ICU guidelines on sedation, the ED can take evidence-based decisive measures to improve patient care for the most critically ill patients.1

Reference 1: Barr J, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306

9. Airflow efficacy of ballpoint pen tubes: a consideration for use in bystander cricothyrotomy

Owens  D, et al. Emerg Med J  2010;27:317-320.

OBJECTIVE To examine the suitability of commonly available ballpoint pens as a substitute emergency tracheostomy tube.

METHODS commonly available ballpoint pens were examined and compared against two standard cricothyroidotomy sets. The pens were evaluated for dimensions, speed of construction of a temporary tracheostomy tube and airway resistance with differing flow rates.

RESULTS Internal diameters of the pens varied considerably. Time taken to construct a temporary tube ranged from 3 to 170 s, and in the majority of pens the airway resistance increased dramatically as the airflow rate increased.

CONCLUSION Contrary to popular belief, the majority of ballpoint pens appear unsuitable for use as a substitute tracheostomy tube. In this study only two pens fulfilled the criteria for use: the Baron retractable ballpoint and the BIC soft feel Jumbo.

10. Give Antibiotics Quickly for Severe Sepsis and Septic Shock

Probability of death steadily increased with each hour's delay to antibiotics.

Ferrer R, et al. Empiric Antibiotic Treatment Reduces Mortality in Severe Sepsis and Septic Shock From the First Hour: Results From a Guideline-Based Performance Improvement Program. Crit Care Med. 2014 Apr 8. [Epub ahead of print]

OBJECTIVES: Compelling evidence has shown that aggressive resuscitation bundles, adequate source control, appropriate antibiotic therapy, and organ support are cornerstone for the success in the treatment of patients with sepsis. Delay in the initiation of appropriate antibiotic therapy has been recognized as a risk factor for mortality. To perform a retrospective analysis on the Surviving Sepsis Campaign database to evaluate the relationship between timing of antibiotic administration and mortality.

DESIGN: Retrospective analysis of a large dataset collected prospectively for the Surviving Sepsis Campaign.

SETTING: One hundred sixty-five ICUs in Europe, the United States, and South America.

PATIENTS: A total of 28,150 patients with severe sepsis and septic shock, from January 2005 through February 2010, were evaluated.

INTERVENTIONS: Antibiotic administration and hospital mortality.

MEASUREMENTS AND MAIN RESULTS: A total of 17,990 patients received antibiotics after sepsis identification and were included in the analysis. In-hospital mortality was 29.7% for the cohort as a whole. There was a statically significant increase in the probability of death associated with the number of hours of delay for first antibiotic administration. Hospital mortality adjusted for severity (sepsis severity score), ICU admission source (emergency department, ward, vs ICU), and geographic region increased steadily after 1 hour of time to antibiotic administration. Results were similar in patients with severe sepsis and septic shock, regardless of the number of organ failure.

CONCLUSIONS: The results of the analysis of this large population of patients with severe sepsis and septic shock demonstrate that delay in first antibiotic administration was associated with increased in-hospital mortality. In addition, there was a linear increase in the risk of mortality for each hour delay in antibiotic administration. These results underscore the importance of early identification and treatment of septic patients in the hospital setting.

11. What decides the suspicion of ACS in acute CP patients?

Kamali A, et al. BMC Emergency Medicine 2014, 14:9

BACKGROUND: Physicians assessing chest pain patients in the emergency department (ED) base the likelihood of acute coronary syndrome (ACS) mainly on ECG, symptom history and blood markers of myocardial injury. Among these, the ECG has been stated to be the most important diagnostic tool. We aimed to analyze the relative contributions of these three diagnostic modalities to the ED physicians' evaluation of ACS likelihood in clinical practice.

METHODS: 1151 consecutive ED chest pain patients were prospectively included. The ED physician's subjective assessment of the patient's likelihood of ACS (obvious ACS, strong, vague or no suspicion of ACS), the symptoms and the ECG were recorded on a special form. The ED TnT value was retrieved from the medical records. Frequency tables and logistic regression models were used to evaluate the contributions of the diagnostic tests to the level of ACS suspicion.

RESULTS: Symptoms determined whether the physician had any suspicion of ACS (odds ratio, OR 526 for symptoms typical compared to not suspicious of ACS) since neither ECG nor TnT contributed significantly (ORs not significantly different from 1) to this assessment. ACS was suspected in only one in ten patients with symptoms not suspicious of ACS. Symptoms were also more important (OR 620 for typical symptoms) than ECG (OR 31 for ischemic ECG) and TnT (OR 3.4 for a positive TnT) for the assessment of obvious ACS/strong suspicion versus vague/no suspicion. Of the patients with ST-elevation on ECG, 71% were considered to have an obvious ACS, as opposed to only 6% of those with symptoms typical of ACS and 10% of those with a positive TnT.

CONCLUSION: The ED physicians used symptoms as the most important assessment tool and applied primarily the symptoms to determine the level of ACS suspicion and to rule out ACS. The ECG was primarily used to rule in ACS. The TnT level played a minor role for the assessment of ACS likelihood. Further studies regarding ACS prediction based on symptoms may help improve decision-making in ED patients with possible ACS.

12. Images in Clinical Practice

Measles is back: But what does it look like?

Man with severe shoulder pain

Female With Lower Abdominal Pain and Bleeding

Fever and macular lesions on toes

Reversible posterior leukoencephalopathy syndrome

13. Geriatrics

A. An intro to the Geriatric ED
Christina Shenvi, Geriatric Emergency Departments: Coming to a Hospital Near You? Acad Life in Emerg Med. April 29th, 2014

We are all familiar with the concept of pediatric EDs. We see them as medical students, we train in them as residents, and we work alongside pediatric EM fellows. It is generally clear what pediatric EDs have to offer: smaller sized beds and equipment, nurses trained in pediatric triage and assessment who know how to put IVs in babies and calm crying kids, and physicians with training in pediatric Emergency Medicine. But what about the other end of the age spectrum? Over the last 10 years geriatric EDs, also called Senior EDs, have been popping up around the country. You may have been wondering why that is, and what they have to offer. Here are a few thoughts.

B. New Geri-ED Guidelines
This document is the product of two years of consensus-based work that included representatives from the American College of Emergency Physicians, The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine.

C. Impact of a New Senior Emergency Department on Emergency Department Recidivism, Rate of Hospital Admission, and Hospital Length of Stay

D. Toward Patient-Centered Care: A Systematic Review of Older Adults’ Views of Quality Emergency Care

E. Screening for Delirium in the Emergency Department: A Systematic Review

14. Door-to-Needle Times for tPA Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative

Fonarow GC, et al. JAMA. 2014;311(16):1632-1640

Importance  The benefits of intravenous tissue plasminogen activator (tPA) in patients with acute ischemic stroke (AIS) are time dependent and guidelines recommend a door-to-needle (DTN) time of 60 minutes or less. However, studies have found that less than 30% of US patients are treated within this time window. Target: Stroke was designed as a national quality improvement initiative to improve DTN times for tPA administration in patients with AIS.

Objectives  To evaluate DTN times for tPA administration and the proportion of patients with times of 60 minutes or less before and after initiation of a quality improvement initiative and to determine whether potential improvements in DTN times were associated with improvements in clinical outcomes.

Design, Setting, and Patients  The Target: Stroke initiative disseminated 10 care strategies to achieve faster DTN times for tPA administration, provided clinical decision support tools, facilitated hospital participation, and encouraged sharing of best practices. This study included 71 169 patients with AIS treated with tPA (27 319 during the preintervention period from April 2003-December 2009 and 43 850 during the postintervention period from January 2010-September 2013) from 1030 Get With The Guidelines—Stroke participating hospitals (52.8% of total).

Main Outcomes and Measures  The DTN times for tPA administration of 60 minutes or less and in-hospital risk-adjusted mortality, symptomatic intracranial hemorrhage, ambulatory status at discharge, and discharge destination.

Results  Median DTN time for tPA administration declined from 77 minutes (interquartile range [IQR], 60-98 minutes) during the preintervention period to 67 minutes (IQR, 51-87 minutes) during the postintervention period (P  less than .001). The DTN times for tPA administration of 60 minutes or less increased from 26.5% (95% CI, 26.0%-27.1%) of patients during the preintervention period to 41.3% (95% CI, 40.8%-41.7%) during the postintervention period (P  less than .001). The DTN times of 60 minutes or less increased from 29.6% (95% CI, 27.8%-31.5%) of patients in the quarter immediately before the intervention (fourth quarter of 2009) to 53.3% (95% CI, 51.5%-55.2%) in the final postintervention quarter (third quarter of 2013) (P  less than  .001). The annual rate of improvement in DTN times of 60 minutes or less increased from 1.36% (95% CI, 1.04%-1.67%) per year preintervention to 6.20% (95% CI, 5.58%-6.78%) per year postintervention (P  less than .001). In-hospital all-cause mortality improved significantly from the preintervention to the postintervention period (9.93% vs 8.25%, respectively; adjusted odds ratio [OR], 0.89 [95% CI, 0.83-0.94], P  less than .001), symptomatic intracranial hemorrhage within 36 hours was less likely to occur (5.68% vs 4.68%; adjusted OR, 0.83 [95% CI, 0.76-0.91], P  less than .001), and discharge to home was more frequent (37.6% vs 42.7%; adjusted OR, 1.14 [95% CI, 1.09-1.19], P  less than .001).

Conclusions and Relevance  Implementation of a national quality improvement initiative was associated with improved timeliness of tPA administration following AIS on a national scale, and this improvement was associated with lower in-hospital mortality and intracranial hemorrhage, along with an increase in the percentage of patients discharged home.

15. Adverse childhood experiences predict health-harming behaviors

Bellis MA, et al. BMC Medicine 2014, 12:72 

Background: Epidemiological and biomedical evidence link adverse childhood experiences (ACEs) with health-harming behaviors and the development of non-communicable disease in adults. Investment in interventions to improve early life experiences requires empirical evidence on levels of childhood adversity and the proportion of HHBs potentially avoided should such adversity be addressed.

Methods: A nationally representative survey of English residents aged 18 to 69 (n = 3,885) was undertaken during the period April to July 2013. Individuals were categorized according to the number of ACEs experienced. Modeling identified the proportions of HHBs (early sexual initiation, unintended teenage pregnancy, smoking, binge drinking, drug use, violence victimization, violence perpetration, incarceration, poor diet, low levels of physical exercise) independently associated with ACEs at national population levels.

Results: Almost half (47%) of individuals experienced at least one of the nine ACEs. Prevalence of childhood sexual, physical, and verbal abuse was 6.3%, 14.8%, and 18.2% respectively (population-adjusted). After correcting for sociodemographics, ACE counts predicted all HHBs, e.g. (0 versus 4+ ACEs, adjusted odds ratios (95% confidence intervals)): smoking 3.29 (2.54 to 4.27); violence perpetration 7.71 (4.90 to 12.14); unintended teenage pregnancy 5.86 (3.93 to 8.74). Modeling suggested that 11.9% of binge drinking, 13.6% of poor diet, 22.7% of smoking, 52.0% of violence perpetration, 58.7% of heroin/crack cocaine use, and 37.6% of unintended teenage pregnancy prevalence nationally could be attributed to ACEs.

Conclusions: Stable and protective childhoods are critical factors in the development of resilience to health-harming behaviors in England. Interventions to reduce ACEs are available and sustainable, with nurturing childhoods supporting the adoption of health-benefiting behaviors and ultimately the provision of positive childhood environments for future generations.

16. The Association between Pretest Probability of CAD and Stress Test Utilization and Outcomes in a CP Observation Unit

Napoli AM, et al. Acad Emerg Med. 2014;21:401–407

Objectives: Cardiology consensus guidelines recommend use of the Diamond and Forrester (D&F) score to augment the decision to pursue stress testing. However, recent work has reported no association between pretest probability of coronary artery disease (CAD) as measured by D&F and physician discretion in stress test utilization for inpatients. The author hypothesized that D&F pretest probability would predict the likelihood of acute coronary syndrome (ACS) and a positive stress test and that there would be limited yield to diagnostic testing of patients categorized as low pretest probability by D&F score who are admitted to a chest pain observation unit (CPU).

Methods: This was a prospective observational cohort study of consecutively admitted CPU patients in a large-volume academic urban emergency department (ED). Cardiologists rounded on all patients and stress test utilization was driven by their recommendations. Inclusion criteria were as follows: age over 18 years, American Heart Association (AHA) low/intermediate risk, nondynamic electrocardiograms (ECGs), and normal initial troponin I. Exclusion criteria were as follows: age older than 75 years with a history of CAD. A D&F score for likelihood of CAD was calculated on each patient independent of patient care. Based on the D&F score, patients were assigned a priori to low-, intermediate-, and high-risk groups (less than 10, 10 to 90, and above 90%, respectively). ACS was defined by ischemia on stress test, coronary artery occlusion of ≥70% in at least one vessel, or elevations in troponin I consistent with consensus guidelines. A true-positive stress test was defined by evidence of reversible ischemia and subsequent angiographic evidence of critical stenosis or a discharge diagnosis of ACS. An estimated 3,500 patients would be necessary to have 1% precision around a potential 0.3% event rate in low-pretest-probability patients. Categorical comparisons were made using Pearson chi-square testing.

Results: A total of 3,552 patients with index visits were enrolled over a 29-month period. The mean (± standard deviation [SD]) age was 51.3 (±9.3) years. Forty-nine percent of patients received stress testing. Pretest probability based on D&F score was associated with stress test utilization (p less than 0.01), risk of ACS (p less than 0.01), and true-positive stress tests (p = 0.03). No patients with low pretest probability were subsequently diagnosed with ACS (95% CI = 0 to 0.66%) or had a true-positive stress test (95% CI = 0 to 1.6%).

Conclusions: Physician discretionary decision-making regarding stress test use is associated with pretest probability of CAD. However, based on the D&F score, low-pretest-probability patients who meet CPU admission criteria are very unlikely to have a true-positive stress test or eventually receive a diagnosis of ACS, such that observation and stress test utilization may be obviated.

Remind me: what’s the D&F score?

17. Epinephrine May Be of No Survival Benefit in Cardiac Arrest

A meta-analysis shows similar survival to discharge and neurological outcomes in adult cardiac arrest patients irrespective of epinephrine use or dose.

Lin S, et al. Adrenaline for out-of-hospital cardiac arrest resuscitation: A systematic review and meta-analysis of randomized controlled trials. Resuscitation 2014 March 15 [Epub ahead of print]

Introduction: The evidence for adrenaline in out-of-hospital cardiac arrest (OHCA) resuscitation is inconclusive. We systematically reviewed the efficacy of adrenaline for adult OHCA.

Methods: We searched in MEDLINE, EMBASE, and Cochrane Library from inception to July 2013 for randomized controlled trials (RCTs) evaluating standard dose adrenaline (SDA) to placebo, high dose adrenaline (HDA), or vasopressin (alone or combination) in adult OHCA patients. Meta-analyses were performed using random effects modeling. Subgroup analyses were performed stratified by cardiac rhythm and by number of drug doses. The primary outcome was survival to discharge and the secondary outcomes were return of spontaneous circulation (ROSC), survival to admission, and neurological outcome.

Results: Fourteen RCTs (n = 12,246) met inclusion criteria: one compared SDA to placebo (n = 534), six compared SDA to HDA (n = 6174), six compared SDA to an adrenaline/vasopressin combination (n = 5202), and one compared SDA to vasopressin alone (n = 336). There was no survival to discharge or neurological outcome differences in any comparison group, including subgroup analyses. SDA showed improved ROSC (RR 2.80, 95%CI 1.78–4.41, p  less than 0.001) and survival to admission (RR 1.95, 95%CI 1.34–2.84, p  less than 0.001) compared to placebo. SDA showed decreased ROSC (RR 0.85, 95%CI 0.75–0.97, p = 0.02; I2 = 48%) and survival to admission (RR 0.87, 95%CI 0.76–1.00, p = 0.049; I2 = 34%) compared to HDA. There were no differences in outcomes between SDA and vasopressin alone or in combination with adrenaline.

Conclusions: There was no benefit of adrenaline in survival to discharge or neurological outcomes. There were improved rates of survival to admission and ROSC with SDA over placebo and HDA over SDA.

18. Oseltamivir for influenza in adults and children: pros and cons

Jefferson T, et al. BMJ 2014;348:g2545

Objective To describe the potential benefits and harms of oseltamivir by reviewing all clinical study reports (or similar document when no clinical study report exists) of randomised placebo controlled trials and regulatory comments (“regulatory information”).

Design Systematic review of regulatory information.

Data sources Clinical study reports, trial registries, electronic databases, regulatory archives, and correspondence with manufacturers.

Eligibility criteria for selecting studies Randomised placebo controlled trials on adults and children who had confirmed or suspected exposure to natural influenza.

Main outcome measures Time to first alleviation of symptoms, influenza outcomes, complications, admissions to hospital, and adverse events in the intention to treat population.

Results From the European Medicines Agency and Roche, we obtained clinical study reports for 83 trials. We included 23 trials in stage 1 (reliability and completeness screen) and 20 in stage 2 (formal analysis). In treatment trials on adults, oseltamivir reduced the time to first alleviation of symptoms by 16.8 hours (95% confidence interval 8.4 to 25.1 hours, P less than 0.001). There was no effect in children with asthma, but there was an effect in otherwise healthy children (mean difference 29 hours, 95% confidence interval 12 to 47 hours, P=0.001). In treatment trials there was no difference in admissions to hospital in adults (risk difference 0.15%, 95% confidence interval −0.91% to 0.78%, P=0.84) and sparse data in children and for prophylaxis. In adult treatment trials, oseltamivir reduced investigator mediated unverified pneumonia (risk difference 1.00%, 0.22% to 1.49%; number needed to treat to benefit (NNTB) 100, 95% confidence interval 67 to 451). The effect was not statistically significant in the five trials that used a more detailed diagnostic form for “pneumonia,” and no clinical study reports reported laboratory or diagnostic confirmation of “pneumonia.” The effect on unverified pneumonia in children and for prophylaxis was not significant. There was no significant reduction in risk of unverified bronchitis, otitis media, sinusitis, or any complication classified as serious or that led to study withdrawal.

14 of 20 trials prompted participants to self report all secondary illnesses to an investigator. Oseltamivir in the treatment of adults increased the risk of nausea (risk difference 3.66%, 0.90% to 7.39%; number needed to treat to harm (NNTH) 28, 95% confidence interval 14 to 112) and vomiting (4.56%, 2.39% to 7.58%; 22, 14 to 42). In treatment of children, oseltamivir induced vomiting (5.34%, 1.75% to 10.29%; 19, 10 to 57).

In prophylaxis trials, oseltamivir reduced symptomatic influenza in participants by 55% (3.05%, 1.83% to 3.88%; NNTB 33, 26 to 55) and households (13.6%, 9.52% to 15.47%; NNTB 7, 6 to 11) based on one study, but there was no significant effect on asymptomatic influenza and no evidence of a reduction in transmission. In prophylaxis studies, oseltamivir increased the risk of psychiatric adverse events during the combined “on-treatment” and “off-treatment” periods (risk difference 1.06%, 0.07% to 2.76%; NNTH 94, 36 to 1538) and there was a dose-response effect on psychiatric events in two “pivotal” treatment trials of oseltamivir, at 75 mg (standard dose) and 150 mg (high dose) twice daily (P=0.038). In prophylaxis studies, oseltamivir increased the risk of headaches on-treatment (risk difference 3.15%, 0.88% to 5.78%; NNTH 32, 18 to 115), renal events with treatment (0.67%, −0.01% to 2.93%), and nausea while receiving treatment (4.15%, 0.86% to 9.51%; NNTH 25, 11 to 116).

Conclusions In prophylactic studies oseltamivir reduces the proportion of symptomatic influenza. In treatment studies it also modestly reduces the time to first alleviation of symptoms, but it causes nausea and vomiting and increases the risk of headaches and renal and psychiatric syndromes. The evidence of clinically significant effects on complications and viral transmission is limited because of rarity of such events and problems with study design. The trade-off between benefits and harms should be borne in mind when making decisions to use oseltamivir for treatment, prophylaxis, or stockpiling.

19. Lorazepam vs Diazepam for Pediatric Status Epilepticus: A RCT

Chamberlain JM, et al. JAMA. 2014;311(16):1652-1660.

Importance  Benzodiazepines are considered first-line therapy for pediatric status epilepticus. Some studies suggest that lorazepam may be more effective or safer than diazepam, but lorazepam is not Food and Drug Administration approved for this indication.

Objective  To test the hypothesis that lorazepam has better efficacy and safety than diazepam for treating pediatric status epilepticus.

Design, Setting, and Participants  This double-blind, randomized clinical trial was conducted from March 1, 2008, to March 14, 2012. Patients aged 3 months to younger than 18 years with convulsive status epilepticus presenting to 1 of 11 US academic pediatric emergency departments were eligible. There were 273 patients; 140 randomized to diazepam and 133 to lorazepam.

Interventions  Patients received either 0.2 mg/kg of diazepam or 0.1 mg/kg of lorazepam intravenously, with half this dose repeated at 5 minutes if necessary. If status epilepticus continued at 12 minutes, fosphenytoin was administered.

Main Outcomes and Measures  The primary efficacy outcome was cessation of status epilepticus by 10 minutes without recurrence within 30 minutes. The primary safety outcome was the performance of assisted ventilation. Secondary outcomes included rates of seizure recurrence and sedation and times to cessation of status epilepticus and return to baseline mental status. Outcomes were measured 4 hours after study medication administration.

Results  Cessation of status epilepticus for 10 minutes without recurrence within 30 minutes occurred in 101 of 140 (72.1%) in the diazepam group and 97 of 133 (72.9%) in the lorazepam group, with an absolute efficacy difference of 0.8% (95% CI, −11.4% to 9.8%). Twenty-six patients in each group required assisted ventilation (16.0% given diazepam and 17.6% given lorazepam; absolute risk difference, 1.6%; 95% CI, −9.9% to 6.8%). There were no statistically significant differences in secondary outcomes except that lorazepam patients were more likely to be sedated (66.9% vs 50%, respectively; absolute risk difference, 16.9%; 95% CI, 6.1% to 27.7%).

Conclusions and Relevance  Among pediatric patients with convulsive status epilepticus, treatment with lorazepam did not result in improved efficacy or safety compared with diazepam. These findings do not support the preferential use of lorazepam for this condition.

20. Admit or Transfer? The Role of Insurance in High-Transfer-Rate Medical Conditions in the ED

Kindermann DR, et al. Ann Emerg Med. 2014;63:561–571.e8

Study objective: We study the association of payer status with odds of transfer compared with admission from the emergency department (ED) for multiple diagnoses with a high percentage of transfers.

Methods: This was a retrospective study of adult ED encounters using the Healthcare Cost and Utilization Project 2010 Nationwide Emergency Department Sample. We used the Clinical Classification Software to identify disease categories with 5% or more encounters resulting in transfer (27 categories; 3.7 million encounters based on survey weights). We sorted encounters by condition into 12 groups according to expected medical or surgical specialist needs. We used logistic regression to assess the role of payer status on odds of transfer compared with admission and report adjusted odds ratios (ORs).

Results: Among high-transfer conditions in 2010, uninsured patients had double the odds of transfer compared with privately insured patients (OR 2.12; 95% confidence interval [CI] 1.72 to 2.62). Medicaid patients were also more likely to be transferred (OR 1.2; 95% CI 1.04 to 1.38). Uninsured patients had higher odds of transfer in all specialist categories (significant in 9 of 12). The categories with the highest odds of transfer for the uninsured included nephrology (OR 2.44; 95% CI 1.07 to 5.55), psychiatry (OR 2.26; 95% CI 1.65 to 3.25), and hematology-oncology (OR 2.21; 95% CI 1.50 to 3.25); the highest for Medicaid were general surgery (OR 1.61; 95% CI 1.09 to 1.83), hematology-oncology (OR 1.55; 95% CI 1.05 to 2.30), and vascular surgery (OR 1.55; 95% CI 1.02 to 2.28).

Conclusion: Insurance status appears to play a role in ED disposition (transfer versus admission) for many high-transfer conditions.

21. An Apple a Day? Exploring Medical Myths

George Johnson. New York Times. April 21, 2014. SAN DIEGO — A trip to almost any bookstore or a cruise around the Internet might leave the impression that avoiding cancer is mostly a matter of watching what you eat. One source after another promotes the protective powers of “superfoods,” rich in antioxidants and other phytochemicals, or advises readers to emulate the diets of Chinese peasants or Paleolithic cave dwellers.

But there is a yawning divide between this nutritional folklore and science. During the last two decades the connection between the foods we eat and the cellular anarchy called cancer has been unraveling string by string.

This month at the annual meeting of the American Association for Cancer Research, a mammoth event that drew more than 18,500 researchers and other professionals here, the latest results about diet and cancer were relegated to a single poster session and a few scattered presentations. There were new hints that coffee may lower the risk of some cancers and more about the possible benefits of vitamin D. Beyond that there wasn’t much to say.

In the opening plenary session, Dr. Walter C. Willett, a Harvard epidemiologist who has spent many years studying cancer and nutrition, sounded almost rueful as he gave a status report. Whatever is true for other diseases, when it comes to cancer there was little evidence that fruits and vegetables are protective or that fatty foods are bad.

About all that can be said with any assurance is that controlling obesity is important, as it also is for heart disease, Type 2 diabetes, hypertension, stroke and other threats to life. Avoiding an excess of alcohol has clear benefits. But unless a person is seriously malnourished, the influence of specific foods is so weak that the signal is easily swamped by noise.

The situation seemed very different in 1997, when the World Cancer Research Fund and the American Institute for Cancer Research published a report, thick as a phone book, concluding that diets loaded with fruits and vegetables might reduce the overall incidence of cancer by more than 20 percent.

After reviewing more than 4,000 studies, the authors were persuaded that green vegetables helped ward off lung and stomach cancer. Colon and thyroid cancer might be avoided with broccoli, cabbage and brussels sprouts. Onions, tomatoes, garlic, carrots and citrus fruits all seemed to play important roles.

In 2007, a major follow-up all but reversed the findings. While some kinds of produce might have subtle benefits, the authors concluded, “in no case now is the evidence of protection judged to be convincing.”

The reason for the change was more thorough epidemiology. The earlier studies tended to be “retrospective,” relying on people to remember dietary details from the distant past. These results were often upended by “prospective” protocols, in which the health of large populations was followed in real time.

22. Impact of Increasing Ondansetron Use on Clinical Outcomes in Children with Gastroenteritis

Freedman SB, et al. JAMA Pediatr. 2014 Apr 1;168(4):321-9.

IMPORTANCE Ondansetron hydrochloride use in children with gastroenteritis is increasing rapidly; however, little is known about its impact on outcomes. OBJECTIVE To determine whether increasing emergency department ondansetron use has resulted in a reduction in intravenous rehydration rates.

DESIGN, SETTING, AND PARTICIPANTS Retrospective observational analysis of eligible visits included in the Pediatric Health Information System administrative database. Eligible institutions included 18 emergency departments geographically distributed across the United States, and participants included 804 000 patients aged 0 to 18 years who were diagnosed as having gastroenteritis in an emergency department at an eligible participating institution between January 1, 2002, and December 31, 2011.

INTERVENTIONS The presence or absence of oral ondansetron administration was identified for each patient through database review. Visits were categorized based on institutional ondansetron use: low (<5% administered ondansetron), medium (5%-25%), or high (>25%).

MAIN OUTCOMES AND MEASURES We conducted hospital-level analyses of the associations between ondansetron use and 3 outcomes: intravenous rehydration (primary), hospitalization, and emergency department revisits within 3 days. Time-series regression models were used, adjusting for demographic characteristics, laboratory testing, diagnostic imaging, and rotavirus infection.

RESULTS A total of 804 000 eligible patient visits were identified. Oral ondansetron use increased from a median institutional rate of 0.11% (interquartile range, 0.04%-0.44%) of patient visits in 2002 to 42.2% (interquartile range, 37.5%-49.1%) in 2011 (P < .001). Intravenous rehydration was administered to 43 413 of 232 706 children (18.7%) during the low ondansetron period compared with 59 450 of 334 264 (17.8%) during the high ondansetron period (adjusted percentage change = -0.33%; 95% CI, -1.86% to 1.20%). During the transition from low to high ondansetron use, we observed no change in the hospitalization rate (adjusted percentage change = -0.33%; 95% CI, -0.95% to 0.29%), but emergency department revisits decreased (adjusted percentage change = -0.31%; 95% CI, -0.49% to -0.13%). The change in all 3 outcomes varied widely between low and high ondansetron use categories at an institutional level. Oral ondansetron was provided to 13.5% (95% CI, 13.3% to 13.7%) of children administered intravenous rehydration.

CONCLUSIONS AND RELEVANCE Although ondansetron use increased during the study period, intravenous rehydration rates were unchanged. Most children administered intravenous fluids did not receive oral ondansetron. Our findings highlight the need to focus efforts to administer ondansetron to children at greatest risk for oral rehydration failure.

23. Informed consent for LP in the ED

Patel PB, et al. West J Emerg Med. 2014;15(3):318-324.

Introduction: Informed consent is a required process for procedures performed in the emergency department (ED), though it is not clear how often or adequately it is obtained by emergency physicians.Incomplete performance and documentation of informed consent can lead to patient complaints,medico-legal risk, and inadequate education for the patient/guardian about the procedure. Weundertook this study to quantify the incidence of informed consent documentation in the ED setting forlumbar puncture (LP) and to compare rates between pediatric (,18 years) and adult patients.

Methods: In this retrospective cohort study, we reviewed the ED electronic health records (EHR) for allpatients who underwent successful LPs in 3 EDs between April 2010 and June 2012. Specific elementsof informed consent documentation were reviewed. These elements included the presence of generalED and LP-specific consent forms, signatures of patient/guardian, witness, and physician,documentation of purpose, risks, benefits, alternatives, and explanation of the LP. We also reviewedthe use of educational material about the LP and LP-specific discharge information.

Results: Our cohort included 937 patients; 179 (19.1%) were pediatric. A signed general ED consent form was present in the EHR for 809 (86%) patients. A consent form for the LP was present for 524 (56%) patients, with signatures from 519 (99%) patients/guardians, 327 (62%) witnesses, and 349 (67%) physicians. Documentation rates in the EHR were as follows: purpose (698; 74%), risks (742; 79%), benefits (605; 65%), alternatives (635; 68%), and explanation for the LP (57; 6%). Educational material about the LP was not documented as having been given to any of the patients and LP-specific discharge information was documented as given to 21 (2%) patients. No significant differences were observed in the documentation of informed consent elements between pediatric and adult patients.

Conclusion: General ED consent was obtained in the vast majority of patients, but use of a specific LP consent form and documentation of the elements of informed consent for LP in the ED were suboptimal, though comparable between pediatric and adult patients. There is significant opportunity for improvement in many aspects of documenting informed consent for LP in the ED.

24. Tid Bits

A. Antibiotics alone may be effective for treating pediatric appendicitis

Among 30 7- to 17-year-olds who received intravenous antibiotics for treatment of appendicitis, 93% recovered successfully without undergoing appendectomy, according to a study in the Journal of the American College of Surgeons. The antibiotic group took an average of three days to recover compared with 17 days among the surgical patients.

B. Many U.S. parents still believe vaccines are linked to autism

A National Consumers League survey of 1,756 adults showed that 33% of those with children under age 18 believed that vaccines can cause autism. Half of the parents surveyed knew about the study linking vaccines to autism, but just 50% of those were aware that the research has been retracted.

C. Potential Use of Pulse Oximetry for the Diagnosis of Testicular Torsion

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D. A Consensus Parameter for the Evaluation and Management of Angioedema in the ED

Moellman JJ, et al. Acad Emerg Med. 2014;21:469–484.

Endorsed by the American College of Allergy, Asthma & Immunology (ACAAI) and the Society for Academic Emergency Medicine (SAEM).

E. Standard GlideScope Outperforms the Cobalt GlideScope in the ED

The standard GlideScope had greater intubation success and fewer image problems than its single-use cousin.

F. Diabetes on the rise among kids and teens

G. Trauma Centers: Past Performance Predicts Future Care

Patients admitted to trauma centers that were the lowest performers two years earlier had two-fold higher mortality than patients admitted to the highest-performing centers.

H. Tubular Gauze Finger Dressing: Not too tight!

I. Intra-articular Lidocaine for Reduction of Shoulder Dislocation: Review

Aronson, PL, et al. Pediatr Emerg Care 2014 May;30(5):363-5.

Intra-articular injection of lidocaine has demonstrated efficacy in reduction of pain and facilitation of shoulder reduction compared with analgesia and sedation. Intra-articular lidocaine may also reduce time to successful reduction of shoulder dislocations

J. Epidemiology of Nursemaid’s Elbow: Over 1200 cases

Vitello S, et al. West J Emerg Med. 2014 [Epub ahead of print]

Objective: To provide an epidemiological description of radial head subluxation, also known as nursemaid’s elbow, from a database of emergency department visits.

Methods: We conducted a retrospective medical record review of patients six years of age and younger, who presented to the emergency department between January 1, 2005 and December 31, 2012 and were diagnosed with nursemaid’s elbow. Inclusion criteria consisted of chart information including date, unique account number, medical record number, weight, age, sex, and arm affected. Exclusion criteria included any charts with missing or incomplete data.

Results: There were 1,228 charts that met inclusion criteria. The majority of patients were female (60%) The mean age was 28.6 months (±12.6). The left arm was affected 60% of the time. Most of the included patients were over the 75th percentile for weight and more than one quarter were over the 95th percentile in each gender.

Conclusion: The average age of children presenting with nursemaid’s elbow was 28.6 months. Females were affected more than males, and the left arm was predominately affected. Most patients were above the 75th percentile for weight and more than one quarter were over the 95th percentile for weight.

K. FDA advises against aspirin use in patients with no history of heart disease

Aspirin should not be used for stroke or heart attack prevention in people with no history of heart disease, the FDA said on Monday. Although evidence indicates that aspirin's benefits outweigh its bleeding risks for patients with a history of a cardiovascular event, the data do not support the use of the drug for the prevention of first heart attack, the agency said. The FDA released the statement in response to Bayer's request to change its aspirin product labeling.

L. CDC: 39% of premature deaths across U.S. could be prevented

Up to 39% of premature deaths each year from heart disease, cancer, chronic lower respiratory disease, stroke and unintentional injury could be averted, the CDC said Thursday. Southeastern states had the highest number of potentially preventable deaths from all of the five leading causes. "With preventive care, we can drive down heart disease and stroke, in particular, as well as [improve] cancer screening," CDC Director Tom Frieden said.

M. A Review of and Recommendations for the Management of Patients With Life-Threatening Dabigatran-Associated Hemorrhage: A Single-Center University Hospital Experience.

N. End Tidal CO2 not helpful in ED COPD Management

O. Many U.S. children in the ED are still given codeine despite safety risks

Codeine prescriptions written for 3- to 17-year-olds dropped from 644,394 in 2001 to 577,270 in 2010, according to a study published in the journal Pediatrics. Nearly 3% of emergency department visits led to a prescription of the narcotic in 2010, down from 3.7% of visits in 2001. Despite these declines, too many children are getting the medication when safer options are available, researchers said.

P. IV Ketamine Rapidly Effective in PTSD 
Patients with moderate to severe post-traumatic stress symptoms showed rapid and substantial relief with a single intravenous dose of ketamine in a pilot randomized trial, researchers said.

Q. Yield of Skeletal Survey by Age in Children Referred to Abuse Specialists

R. Oral Zinc for the Common Cold

Clinical Question  Is oral zinc associated with a shorter duration, decreased severity, and reduced incidence of the common cold compared with placebo ?

Bottom Line  When initiated within 24 hours of symptom onset, oral zinc is associated with a shorter duration of the common cold in healthy people. However, there is no association between oral zinc and symptom severity, and the prevalence of adverse effects with zinc lozenges is high. Given the high heterogeneity of data, these results should be interpreted with caution. Used prophylactically, oral zinc is associated with a reduced cold incidence in children. Prophylactic use has not been studied in adults.