Lit Bits: January 1, 2007

From the latest medical literature...

1. Guidelines Issued for Adult Tetanus-Diphtheria-Pertussis (Tdap) Vaccination

The CDC's Advisory Committee on Immunization Practices has issued recommendations for adult use of Adacel -- Sanofi Pasteur's tetanus, diphtheria, and acellular pertussis (Tdap) vaccine, licensed last year.

The guidelines, published in MMWR, suggest the Tdap vaccine be given:

-- to adults aged 19 to 64 to replace the tetanus and diphtheria toxoids vaccine (Td) for booster immunization if they got their last dose of the older vaccine at least 10 years earlier

-- at intervals of less than 10 years for those at increased risk for pertussis

-- to child-care providers and other adults having close contact with infants (ideally before pregnancy for mothers)

-- to health care workers with direct patient contact

For the last three groups, the CDC recommends an interval as short as 2 years from the last dose of Td, and says shorter intervals may be used.

MMWR report: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm

Also, the CDC issued its latest immunization guidelines Dec first: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5515a1.htm

2. PCI in Octogenarians Becoming Safer but Risk Still Substantial

By Martha Kerr. NEW YORK (Reuters Health) Dec 18 - Elective percutaneous coronary intervention (PCI) in patients who are in their eighties has an "acceptable outcome" in the stent era, with "acceptable short-term mortality." However, emergency PCI in this age group still carries substantial risk, New York investigators report in the current issue of the American Journal of Cardiology.

At New York Presbyterian Hospital-Weill Cornell Medical Center in New York City, Dr. Dmitriy N. Feldman and colleagues used the New York State Angioplasty Registry of 2000-2001 to compare in-hospital mortality and major adverse events (death, stroke or coronary artery bypass grafting) in three age groups: patients younger than 60 years of age, patients between 60 and 80 and patients older than 80 years of age.

There were 10,964 patients undergoing emergency PCI and 71,176 patients undergoing elective PCI.

Elderly patients were, in general, more unstable upon presentation and had more co-morbidities, including extensive coronary artery disease and other cardiovascular diseases.

For patients undergoing emergency PCI, the in-hospital mortality rates were 1.0%, 4.1% and 11.5% for patients in the youngest, middle and oldest age groups, respectively. Among patients undergoing elective PCI, mortality rates were 0.1%, 0.4% and 1.1%, respectively.

"Therefore, in the very elderly patients, a thorough discussion about risks and benefits of percutaneous revascularization is needed, particularly if emergency PCI is being considered, Dr. Feldman commented in correspondence with Reuters Health. However, a surgical revascularization option in this age group may carry an even higher rate of postprocedural complications compared with PCI."

"Our overall mortality in the 60-80 group was 0.8% and in the older than 80 group it was 2.2%, which is lower than previously reported in patients undergoing PCI in late 1990's. This suggests that PCI outcomes have improved in the era of widespread use of stenting and greater use of glycoprotein IIb/IIIa inhibitors," he pointed out.

Dr. Feldman concluded that "elective PCI procedures in the elderly are safe and have an acceptable short-term mortality when performed at experienced institutions." However, elderly patients undergoing emergency PCI continue to have a substantially higher risk of adverse events.

Am J Cardiol 2006;98:1334-11339.

3. Expedited Code Stroke Protocol Safely Fosters Earlier Thrombolysis

By Will Boggs, MD. NEW YORK (Reuters Health) Dec 22 - An expedited code stroke protocol can safely allow earlier administration of thrombolytic agents, according to a report in the December issue of Stroke.

"It is safe to do thrombolysis on acute stroke patients without waiting for routine tests such as platelet count or chest x-ray," Dr. Patrick D. Lyden from University of California, San Diego School of Medicine, told Reuters Health.

Dr. Lyden and colleagues implemented an expedited code stroke protocol to meet their benchmark onset-to-treatment time of 2 hours and investigated the safety and feasibility of the protocol.

Key features of the protocol included in-person triage of all code stroke calls, unmixed rt-PA at the bedside, proceeding without coagulation test results or chest x-ray unless specifically indicated, no delay for formal CT interpretation, and no delay for written consent.

The overall risk of symptomatic intracerebral hemorrhage was only 3.9%, the authors report, and this risk did not differ significantly between patients treated before 2 hours and patients treated 2 to 3 hours after symptom onset.

Patients treated 2 to 3 hours after symptom onset had arrived at the hospital a median 15 minutes later than those treated within 2 hours of symptom onset, the results indicate, but most steps in the process of care occurred at about the same time in the 2 groups (except the treatment decision, which took an additional 21 minutes in the 2- to 3-hour group).

"More experience will be necessary to confirm whether occasional mistakes, made in haste, lead to measurable increases in adverse events," the researchers conclude. "Our ongoing registry will continue to amass patient experience to address [outcomes] while maintaining considerable attention to safety."

"Too many patients miss out on an opportunity for thrombolysis due to physician ignorance of the protocol," Dr. Lyden added.

Stroke 2006;37:2935-2939.

4. U.S. Clears Cyanokit (hydroxocobalamin) to Treat Cyanide Poisoning

WASHINGTON (Reuters) Dec 18 - A drug made by Germany's Merck KGaA to treat cyanide poisoning was approved this month by U.S. regulators, who said it could be a useful weapon in the event of a terror attack.

Cyanokit has been used in France for 10 years in pre-hospital and hospital settings to treat cyanide poisoning resulting from smoke inhalation, ingestion and other causes. Although recognized in Europe for many years, only recently has the risk of cyanide exposure in fire smoke gained recognition in the U.S. The U.S. maintains one of the highest fire-related death rates of industrialized countries even though the number of fires has steadily decreased over the past two decades. Smoke inhalation is responsible for up to 80 percent of U.S. fire-related injuries and deaths. According to the United States Fire Administration (USFA), in 2004, the most recent year for which statistics are available:

3,900 civilians and 117 firefighters lost their lives in fires, with an additional 17,785 civilians injured as the result of fire. Of all civilian fire-related deaths, 83 percent of them occurred in residences.

An estimated 20,800 residential structure fires are attributed to mattresses, pillows, and bedding materials, all of which are highly likely to contain synthetic materials that release hydrogen cyanide when they smolder.

The active ingredient in Cyanokit, hydroxocobalamin, is a precursor of vitamin B12. Hydroxocobalamin works by binding directly to the cyanide, creating cyanocobalamin, a natural form of vitamin B12, which is excreted in the urine. The advantage of this approach is that methemoglobin is not produced and the oxygen-carrying capacity of the victim's blood is not lowered. Therefore, it is suitable for use in smoke inhalation victims. The most common side effect seen in clinical trials of hydroxocobalamin is injection site redness and temporary pink discoloration of the skin, urine and mucous membranes.

5. First and Only Chewable Birth Control Pill Now Available in U.S.

New Spearmint-Flavored Femcon(TM) Fe Offers Convenient New Option for More Than 11 Million Women Using Oral Contraceptives

ROCKAWAY, NJ -- December 7, 2006 -- Warner Chilcott announced today the availability of the first birth control pill that offers women the option of chewing their daily tablet, called Femcon(TM) Fe.

As the first and only FDA-approved chewable birth control pill, Femcon Fe* is indicated for the prevention of pregnancy. The chewable version is also designed to provide a convenient, new option for women "on-the-go" taking oral contraceptives. Additionally, the active ingredients and doses in Femcon Fe provide effective cycle control and may be a good choice for women who are experiencing breakthrough bleeding with their current oral contraceptive.

"Research has shown that compliance still impacts oral contraceptive failure rates, and anything we can do to make it easier for our patients to maintain a daily regimen is a notable advancement," said Laurent Delli-Bovi, MD, Medical Director, Women's Health Services at Chestnut Hill Family Planning Facility in Boston, Massachusetts. "We're excited to be able to offer a chewable formulation to patients looking for convenience or to those who may be experiencing problems on other pills, such as breakthrough bleeding."

When taken correctly, oral contraceptives have a failure rate of less than one% per year. However, studies show that 47% of women miss one or more pills per month and missing pills can increase the risk of pregnancy.

"Women who rely on the birth control pill tend to lead busy lives and have less time," said Roger Boissonneault, Chief Executive Officer of Warner Chilcott, the company that markets Femcon Fe in the United States. "We wanted to offer women a convenient, easy-to-use option for those "on-the-go" with the same reliability as the traditional swallowed pill."

Femcon Fe contains the same active ingredients as found in other combination oral contraceptives -- a progestin, norethindrone 0.4 mg, and an estrogen, ethinyl estradiol 35 mcg. Available in a 28-day regimen, each blister-package of Femcon Fe contains 21 round white tablets with norethindrone and ethinyl estradiol, followed by seven "reminder" brown (inactive) tablets to complete a four-week-cycle. The reminder tablets also contain 75 mg of ferrous fumarate (iron). The pill may be chewed, followed by a full glass of liquid, or swallowed whole.

6. Impact of a negative prior stress test on emergency physician disposition decision in ED patients with CP syndromes

Nerenberg RH, Hollander JE, et al. Amer J Emerg Med 2007;25:39-44.

Objective
Many emergency department (ED) patients with potential acute coronary syndromes (ACS) have prior visits and prior cardiac testing; however, the effect of knowledge of prior testing on the emergency physician disposition decision making is not known. We studied the impact of prior noninvasive testing (ie, stress testing) for myocardial ischemia on disposition decision making in ED patients with potential ACS.

Methods
We performed a prospective cohort study of ED patients with chest pain who received an electrocardiogram for potential ACS. Data included demographics, medical history, stress test history, and TIMI risk score. Patients were followed in-house; 30-day telephone interviews were performed for follow-up. Main outcomes were ED disposition (admit/discharge) and a composite of 30-day death, acute myocardial infarction, and revascularization stratified on the basis of prior stress testing known at the time of presentation. Standard statistical techniques were used with 95% confidence intervals (CI).

Results
There were 1853 patients enrolled and 97% had follow-up. Patients had a mean age of 53 ± 14 years; 60% were women, 67% were black. There were 1491 (79%) patients without a prior stress test, 291 (16%) had a normal prior stress test result, and 89 (5%) had an abnormal prior stress test result. Admission rates were 92% (95% CI, 87%-98%) for patients with a prior abnormal stress test, 73% (95% CI, 67%-78%) for patients with a normal prior stress test, and 70% (95% CI, 67%-72%) for patients without a prior stress test. Adverse outcomes were the highest among patients with prior abnormal stress test but did not differ significantly between patients with no prior stress test and patients with prior normal stress test (10.1% [95% CI, 3.6-16.7%] vs 5.2% [95% CI, 4.1-6.4%] vs 4.8% [95% CI, 2.4-7.3%]).

Conclusion
Patients without prior stress tests and patients with prior normal stress tests were admitted for potential ACS at the same rate and had the same 30-day cardiovascular event rates. This suggests that prior stress testing does not affect subsequent disposition decisions. Perhaps cardiac catheterization or computed tomography coronary angiograms would have more of an impact on subsequent visits, making them potentially more cost-effective in the low-risk patient.

7. Sumatriptan for the treatment of undifferentiated primary headaches in the ED?

Miner JR, Biros M, et al. Amer J Emerg Med 2007;25:60-64.

Objective
In this study, we determine the effectiveness and adverse effects of sumatriptan when used in the emergency department (ED) as a first-line treatment for benign undifferentiated headaches, and determine if the International Headache Society (IHS) classification of migraine, probable migraine, or tension-type headache has any effect on the effectiveness of the treatment. We hypothesize that there is no difference in the effectiveness of pain relief or frequency and severity of adverse effects between patients with migraine, probable migraine, or tension-type headaches when treated with sumatriptan.

Methods
This was a prospective observational study of adult ED patients undergoing treatment for primary headaches (ie, patients in whom head trauma, vascular disorders, infection, or disorders of facial or cranial structures have been clinically excluded). Other exclusions were renal impairment, hepatic impairment, and risk factors for coronary artery disease. Consenting patients then were asked to complete a 100-mm visual analog scale (VAS) representing their perceived pain, after which they were interviewed by a research assistant who completed a headache diagnosis worksheet, which differentiates the headache by IHS criteria. The patient repeated the VAS score at 30 and 60 minutes. Data were analyzed using descriptive statistics and ?2 tests.

Results
One hundred forty-seven patients were enrolled: 84 (57.1%) patients with migraine headache, 45 (30.7%) with a probable migraine headache, and 18 (12.2%) with a tension headache. A 50% reduction in VAS scores 60 minutes postdose was seen in 87 (59%) of 147 patients; 50 (60%) of 84 of migraine patients, 25 (56%) of 45 of probable migraine patients, and 12 (67%) of 18 tension patients (P = .72). There were no serious adverse events reported. Forty-seven patients (32%) received rescue medications after the 60-minute VAS score: 29 (34.5%) patients in the migraine group, 15 (33.3%) patients in the probable migraine group, and 3 (15.8%) patients in the tension-type headache group (P = .26).

Conclusions
Most of the patients presenting with primary headaches had migraine or probable migraine headaches. There was no difference in sumatriptan's effectiveness based on the classification of the headache using IHS criteria.

8. ED Physicians Can Help Implement Asthma Guidelines

NEW YORK (Reuters Health) Dec 19 – ED physicians can foster implementation of national asthma guidelines by initiating maintenance anti-inflammatory medication in children treated for acute asthma attacks, according to a report in the December issue of Pediatrics.

"Children with uncontrolled asthma are a difficult population to study, and there continues to be a need to study new and innovative interventions to increase their use of appropriate maintenance medications," Dr. Heather K. Lehman from the University at Buffalo School of Medicine and Biomedical Sciences, New York told Reuters Health.

Dr. Lehman and colleagues evaluated a pediatric emergency department-based intervention designed to create a new role for the ED physician in asthma management. With the primary care physician's approval, 40 children with persistent asthma were provided sample anti-inflammatory medications, and a letter outlining the treatment plan was faxed to the patient's primary care physician the next day. It was up to the primary care physician to prescribe ongoing anti-inflammatory medication.

Twenty-eight of the patients followed up with their primary care physicians, the authors report, and the anti-inflammatory medication was continued in 21 of those who followed up. One patient was lost to follow-up and 20 of the remaining patients had a prescription written and dispensed, the results indicate. However, seven of these patients had the prescription filled.

Overall, one third continued on a long-term anti-inflammatory controller after their initial intervention in the pediatric emergency department. Children with severe persistent asthma were more likely to follow up with their primary physician and to continue the intervention, the researchers note.

"We were pleased with our results, since all these patients prior to the study were not on anti-inflammatory therapy," Dr. Lehman said. "So even a small change in controller medication use could translate into large gains in patient care, outcomes, and economics."

"Primary care physicians need to see their asthmatic patients (especially those with moderate to severe asthma)...on a more frequent basis, rather than episodic care, to more closely monitor their use of, and response to, maintenance medications, and to stress to the family the seriousness of their child's asthma," Dr. Lehman said.

"While the emergency department can successfully function as a checkpoint to make sure children are receiving appropriate maintenance anti-inflammatory medications, primary physicians should be encouraged to always assess the severity of their patients' asthma using current guideline measures, and place them on controller medications, where appropriate," Dr. Lehman advised.

Pediatrics 2006;118:2394-2401.

9. Cognitive Training May Aid Functioning of Older Adults

Cognitive training not only can delay cognitive decline in older adults, it may also help them function independently longer. So suggests a 5-year study in a December issue of JAMA.

Researchers randomized 2832 people age 65 or older without dementia to receive either 10 weekly sessions of training in one of three domains (memory, reasoning, or processing speed) or no training.

All trained groups had less subsequent decline in the domain trained than did the other groups. Those with reasoning training also retained more of their abilities in instrumental activities of daily living.

Editorialists write that "cognitive training programs, once standardized and developed for mass market application, might be made available to seniors through [both] nonhealth care facilities ... and health care facilities." Such programs "may give individuals a greater sense of control over the disturbing prospect of cognitive decline and have a beneficial effect on their quality of life," they add.

JAMA article (free): http://jama.ama-assn.org/cgi/content/full/296/23/2805

10. Biomarkers Add Little to Standard Cardiovascular Risk Factors

Certain biomarkers predict risks of death and first major cardiovascular events, but add little to conventional risk factors, a study finds in the Dec 21st issue of the New England Journal of Medicine.

Using data from some 3200 participants in the Framingham Offspring Study, researchers assessed the predictive value of 10 biomarkers: C-reactive protein (CRP), B-type natriuretic peptide (BNP), N-terminal pro-atrial natriuretic peptide, aldosterone, renin, fibrinogen, plasminogen-activator inhibitor type 1, D-dimer, homocysteine, and urinary albumin/creatinine ratio. Participants were followed up for a median of 7.4 years.

After adjustment for traditional cardiovascular risk factors, five biomarkers -- BNP, CRP, albumin/creatinine ratio, homocysteine, and renin -- were associated with higher risk of death from any cause, and two -- BNP and albumin/creatinine ratio -- with risk of first major cardiovascular events. However, statistically, these biomarkers added only moderately to the predictive ability of conventional risk factors.

NEJM abstract: http://content.nejm.org/cgi/content/short/355/25/2631

11. Methamphetamine use increases risk of carotid artery dissection and stroke

December 27, 2006 (Irvine, CA) - Methamphetamine use may be linked to increased risk of carotid artery dissection and stroke, according to an article published in the December 26, 2006 issue of Neurology.

"It appears methamphetamine use is toxic to large blood vessels,” said Dr Wengui Yu (University of California, Irvine). "While methamphetamine use has been associated with aortic dissection . . . this is the first time there's been a possible link between methamphetamine use and carotid artery dissection."

The article reported the cases of two women, ages 36 and 29, who suffered sudden onset of speech difficulty and weakness following recent use of methamphetamine. The 29 year-old had a ten-year history of methamphetamine use. Yu acknowledged that cocaine has similar effects. "It’s therefore likely that the tears in the arteries may be due to a drug class effect rather than a specific drug, like methamphetamine."

MRI confirmed both women had severe strokes due to carotid artery dissection. The 36 year-old woman had a National Institute of Health Stroke Scale (NIHSS) of 21 (a stroke scale over 16 predicts a high probability of death or severe disability). She was treated quickly with IV tissue plasminogen activator (tPA) and improved significantly, returning to work within four months with only mild expressive aphasia. The 29 year-old woman had an NIHSS score of 17. She was treated with stent-assisted angioplasty and had moderate expressive aphasia at four months. Follow-up angiography at seven months showed no restenosis.

Yu credited timely evaluation and treatment by a multidisciplinary stroke team with the almost complete recovery of the subjects, and not the youth of the subjects themselves. "Without effective acute treatment, patients would be less likely to have good recovery."

A prospective multi-center study of young adults with stroke is warranted to further investigate the association between methamphetamine/cocaine use and neck artery dissection, the authors write. "The results of such study will not only address the drug class effect but also help physicians to better diagnose, treat, and prevent stroke in young adults," said Yu.

Yu W, McIntosh A, Hungs M, et al. Carotid artery dissection and middle cerebral artery stroke following methamphetamine use. Neurology 2006; 67:2259-2260.

12. Ondansetron Available in Generic Form

The FDA this month announced the availability of ondansetron, an antiemetic, in generic form.

According to the announcement, ondansetron, marketed by GlaxoSmithKline as Zofran, was the 20th highest-selling brand-name drug in the U.S. in 2005, with sales totaling nearly $840 million that year.

FDA announcement: http://www.fda.gov/bbs/topics/NEWS/2006/NEW01539.html

13. Hospital Ratings May Not Be True Quality Measure

Source: Washington Post. Date: December 13, 2006

Conventional wisdom holds that one sure way to improve health-care quality is to measure it. A study being published today in the Journal of the American Medical Association comes to the unconventional conclusion that it's not necessarily so.

The study by researchers at the University of Pennsylvania's School of Medicine found that going to a hospital that scored well on Medicare-mandated quality measures did not significantly reduce a patient's risk of dying.

The study examined 2004 data from 3,657 hospitals, comparing their performance on quality-of-care measures for treating heart attacks, heart failure and pneumonia with the death rates for the same patients. The quality measures charted such matters as whether patients who had a heart attack received aspirin within 24 hours of being admitted and how soon patients with bacterial pneumonia were given antibiotics.

Patients at hospitals that scored near the top on the quality-of-care measures did do better than those at hospitals near the bottom -- but not dramatically so. For every 1,000 heart attack patients, there were about five fewer deaths at the better-performing hospitals than at the lower-performing ones, the study found. The figures were similar for patients with heart failure and pneumonia.

Rachel M. Werner, an assistant professor of medicine and the study's lead author, said the results point up the need for more meaningful quality measures. "Measuring quality is clearly a good idea," Werner said. "It's a great first step. But at the same time . . . there are other things that are making outcomes different at different hospitals, and we are not capturing those differences using these measures. There is a fallacy in assuming that just taking these measures and applying them to hospitals is going to reveal important things about the differences in quality across hospitals."

14. IV Dex to prevent the recurrence of benign headache after discharge from the ED: a randomized, double-blind, placebo-controlled clinical trial

Baden EY, Hunter CJ. Can J Emerg Med 2006;8:393-400.

From the Brooke Army Medical Center and Wilford Hall Medical Center, San Antonio, Texas

Intro: Headaches are a common cause of emergency department (ED) visits. Up to 85% of the US adult population complains of headaches occasionally, and it is the chief complaint in 2%-5% of all ED visits. The vast majority of headaches in patients presenting to the ED are benign, with tension headaches representing 50%, migraine headaches 10% and mixed-type 30%.

In clinical practice, the distinction between migraine and tension-type headaches is often blurred. The International Headache Society classification for benign idiopathic headache acknowledges that some patients may simultaneously satisfy diagnostic criteria for migraine and tension-type headaches. Both are characterized by similar abnormal vascular flow and inflammatory responses, suggesting that they may represent variations of the same disease process. For purposes of ED headache treatment, there is usually little need to differentiate between these benign headache etiologies.

Although the acute symptoms can generally be relieved, 8%-66% of patients will suffer a recurrence within 48 hours, and inflammation appears to play a critical role in these recurrences. Therefore, prolonged suppression of this inflammatory process may be an important component of acute headache management. Dexamethasone, a corticosteroid with 25 times the anti-inflammatory potency of hydrocortisone, has been tested as a treatment for migraines, with generally positive results. By suppressing the sterile inflammatory response, dexamethasone may also prevent the recurrence of benign headaches after successful ED treatment.

The purpose of this study was to determine whether patients discharged from the ED after treatment for a benign headache have a lower incidence of recurrence when treated with intravenous (IV) dexamethasone before discharge. Our secondary aim was to determine whether such administration of dexamethasone could improve patients' quality of life by reducing the number of return ED or primary care clinic visits for "rescue" therapy, thus allowing them to return to normal daily activities.

Objective: To evaluate whether the addition of intravenous (IV) dexamethasone to standard emergency department (ED) benign headache therapy would reduce the incidence of headache recurrence at 48-72 hours.

Methods: This randomized, double-blind, placebo-controlled clinical trial of adult patients presenting with the chief complaint of headache was conducted in the ED of 2 academic, urban Level 1 hospitals. Headache evaluation and therapy were determined by the treating physician, and, before discharge, patients were administered either 10 mg of IV dexamethasone or placebo. The treatment groups had similar baseline characteristics, abortive therapy, IV fluids and degree of pain relief achieved before discharge. Patients were contacted 48-72 hours following discharge and asked whether their headache was "better," "worse" or "remained unchanged" when compared with their symptoms at discharge. Those whose headaches were "worse" or "unchanged," and those who reported a return of headache after being pain free at discharge were considered to be treatment failures and classified as having had a recurrence. The patient's headache at follow-up was further categorized as severe (i.e., provoking another physician visit or interfering with daily activity) or mild (i.e., requiring self-medication or no treatment).

Results: Fifty-seven patients met the inclusion criteria and 2 were lost to follow-up, leaving 55 for analysis. At follow-up, 9.7% (3/31) of those receiving dexamethasone had headache recurrence, versus 58.3% (14/24) of those receiving placebo (p less than 0.001). Four dexamethasone recipients (12.9%) had severe headaches at follow-up compared with 8 (33.3%) in the placebo group (p = 0.14).

Conclusions: In this study, IV dexamethasone reduced headache recurrence at 48-72-hour follow-up. Given its excellent safety profile and likely benefit, IV dexamethasone should be considered for ED headache patients after standard evaluation and therapy.

15. Rapid Influenza Testing in the ED Spares Febrile Infants Needless Tests

By Will Boggs, MD. NEW YORK (Reuters Health) Dec 20 - Rapid viral testing for influenza A and B in febrile infants spares them additional testing in the emergency room, according to a report in the December issue of The Pediatric Infectious Disease Journal.

"The use of rapid testing for influenza in children younger than 36 months during influenza seasons in the emergency department setting reduces the number of ancillary tests ordered and decreases antibiotic use and unnecessary hospitalization," lead investigator Dr. Javier Benito-Fernandez told Reuters Health. "Rapid viral tests are easy to perform and you can get the result in only 10 to15 minutes."

Dr. Benito-Fernandez and colleagues at the Hospital de Cruces, Bizkaia, Spain, and colleagues assessed the impact of introducing rapid viral testing for influenza into the routine protocol for the management of febrile infants with no signs of focal infection during influenza season.

Influenza tests were positive in 40.7% of 206 febrile infants, the authors report.

Infants who tested positive were less likely to undergo blood tests, urinalysis, chest X-rays, and lumbar puncture, the results indicate, and they had shorter stays in the pediatric emergency department, compared with febrile infants whose rapid influenza tests were negative.

None of the infants who tested positive for influenza received empiric antibiotic treatment, the researchers note, compared with 38.5% of infants who tested negative. Only two influenza-positive infants (2.3%) required hospital admission for observation, the report indicates, whereas 20 influenza-negative infants (16.4%) were admitted to the hospital. All influenza-positive infants had a favorable clinical course, the investigators report.

There are advantages to using rapid viral testing for influenza as part of the standard guidelines for managing fever of unknown origin in infants in good general condition during flu season, the authors conclude.

"We have introduced rapid test for influenza in our current practice when we attend a febrile infant during epidemic season," Dr. Benito-Fernandez said. "We are now studying rapid testing for respiratory syncytial virus (RSV) in very young (less than 3 months old) febrile infants."

Pediatr Infect Dis J 2006;25:1153-1157.

16. Catheterization Facilities May Not Improve AMI Outcomes

By Will Boggs, MD. NEW YORK (Reuters Health) Dec 21 - Myocardial infarction (MI) outcomes are no better at hospitals with catheterization facilities than at hospitals without such facilities, according to a report in the November European Heart Journal.

Recent trial results favor primary percutaneous coronary intervention (PCI) over thrombolysis for the emergency treatment of acute MI, the authors explain, but trial results may not be so easily obtained in the day-to-day practice of busy hospitals.

Dr. Hans Van Brabandt and colleagues from Belgian Health Care Knowledge Centre, Brussels, Belgium evaluated the costs and effects of treatment at three levels of hospitals to which acute MI patients were initially referred-hospitals with PCI capabilities, hospitals with coronary angiography but not PCI capabilities, and hospitals having only thrombolysis as a means of reperfusion. The percentage of patients reperfused was similar across the three levels of care of initial admission, the authors report.

The probability of having had a PCI or coronary artery bypass grafting at the end of the episode of care was significantly higher in patients initially admitted to the highest level of care hospitals, the results indicate, and this difference persisted after 3 years. "This suggests that supply induces demand independent of patient needs," the investigators write.

The cardiac care level of the initial admission had no significant influence on the 5-year survival of patients, the researchers note, and rates of readmissions and reinterventions were similar between the care levels.

The cost of treating a patient during the initial admission was 4072 at hospitals with thrombolysis only, the report indicates, compared with 5083 at hospitals with coronary angiography and 7741 at hospitals with PCI capabilities.

"For an infarction patient in Belgium, the nearest hospital is the best," Dr. Van Brabandt concluded. "We have shown that cardiac emergency teams working in secondary hospitals are keen enough to decide which patients should be referred to a higher level center."

"Moreover, being admitted to a lower level hospital means for a patient having an absolute 20% lower risk of being revascularized without any difference in outcome (i.e., short and long term mortality, re-infarction, re-admission, re-angiography within the next five years)," he continued.

"Additional studies are needed to better define those subgroups of acute MI patients who present at the secondary level, for whom immediate transfer to the tertiary level is beneficial," the investigators write.

"Improving compliance to guidelines and shortening the time interval between onset of symptoms and starting thrombolytic treatment when appropriate will likely result in a more efficient use of resources than the multiplication of expensive tertiary services for primary invasive treatment of acute MI patients."

Eur Heart J 2006;27:2649-2654.

17. Delays in the treatment of cauda equina syndrome due to its variable clinical features in ED patients

Ibrahim Jalloh and Pawan Minhas. Emerg Med J 2007;24:33-34.

Patients with cauda equina syndrome (CES) characteristically present with a history of lower back pain, bilateral sciatica, motor and sensory disturbance including sacral and perianal anaesthesia, and sphincter disturbance. It may progress to permanent sensory loss, motor loss and incontinence. Emergent decompression of CES is important in improving the outcome. A meta-analysis involving 322 patients from 104 studies showed that considerable improvements in sensory, motor and sphincter deficits were possible if surgery was performed within 48 h.

Many patients presenting with CES do not receive an urgent referral to a specialist. Difficulties in diagnosis may arise because of the variability of the clinical features that are present on attendance to the emergency department, and also because of the association of urinary retention and constipation with pain and opioid analgesia.

The purpose of this study was to identify reasons for delay in management and to see which features of this syndrome patients present with.

Delays in the treatment of CES were most often due to delay in making the diagnosis. Predictably, this was more likely when fewer features of CES were established at the time of presentation.

Only 19% of patients presented with the characteristic combination of bilateral sciatica, lower limb weakness, saddle anaesthesia and sphincter disturbance. The strongest presenting features of CES are lower back pain, sacral sensory loss and urinary symptoms.

Patients may not clearly manifest all the characteristic features of CES. Diagnosis is also complicated by sphincter disturbance due to pain and opioid-based analgesia. By highlighting the importance of examining for sacral sensory loss as a sensitive and relatively specific sign that is quick and easy to examine for, clinicians will be quicker in recognising it and thus improve outcomes in patients with CES.

18. Is CT effective in cases of upper oesophageal fish bone ingestion?

Das D, et al. Emerg Med J 2007;24:48-49.

Clinical scenario: A 60-year-old man attends the ED complaining that a fish bone has got stuck in his throat. Clinical examination rules out impaction within the pharynx so you are concerned that the bone has become impacted within the oesophagus. Prior experience tells you that oesophageal abrasions secondary to ingested bones can often mimic impaction, that rigid oesophgoscopy (the definitive investigation) carries a significant mortality and morbidity rate, and that the most readily available non-invasive investigations, lateral neck and chest x rays, are often unreliable. You wonder whether a computed tomography (CT) scan of the neck would be a more accurate non-invasive tool?

Question: In [patients who are suspected to have fish or chicken bones impacted in the oesophagus] is [computerised tomography better than plain radiography] at [identifying and localising a foreign body]?

Comments: The studies reviewed clearly show that CT of the neck is an extremely accurate, non-invasive diagnostic tool with a high positive predictive value. However, of the 58 patients in the four series with positive x-ray findings, there were only 3 false-positives. Positive results on plain films, which include soft tissue changes, warrant oesophagoscopy, while negative results should lead to a CT scan of the neck. Bearing in mind that there was 100% sensitivity amongst the 144 patients undergoing CT, and that there was just one false positive amongst the 80 patients with positive results, only visualisation of an actual fish or chicken bone should result in an oesophagoscopy at this point. Similarly, a negative CT scan should confidently exclude fish and chicken bones.

CLINICAL BOTTOM LINE: CT is more effective than plain radiography at identifying and excluding impacted oesophageal fish and chicken bones. However, plain radiography is also specific enough for positive results to warrant oesophagoscopy without any further imaging, and should thus continue being utilised as the first line radiological investigation.

19. Sword swallowing and its side effects

Witcombe B. BMJ 2006; 333:1285-1287.

Intro: Sword swallowers know their occupation is dangerous. The Sword Swallowers' Association International (SSAI, http://www.swordswallow.org/) recognises those who can swallow a non-retractable, solid steel blade at least two centimetres wide and 38 centimetres long. As we found only two English language case reports of injury resulting from sword swallowing, we explored the technique and side effects of this unusual practice.

Objective: To evaluate information on the practice and associated ill effects of sword swallowing.

Design: Letters sent to sword swallowers requesting information on technique and complications.

Setting: Membership lists of the Sword Swallowers' Association International.

Participants: 110 sword swallowers from 16 countries.

Results: We had information from 46 sword swallowers. Major complications are more likely when the swallower is distracted or swallows multiple or unusual swords or when previous injury is present. Perforations mainly involve the oesophagus and usually have a good prognosis. Sore throats are common, particularly while the skill is being learnt or when performances are too frequent. Major gastrointestinal bleeding sometimes occurs, and occasional chest pains tend to be treated without medical advice. Sword swallowers without healthcare coverage expose themselves to financial as well as physical risk.

Conclusions: Sword swallowers run a higher risk of injury when they are distracted or adding embellishments to their performance, but injured performers have a better prognosis than patients who suffer iatrogenic perforation.

20. Phenotypic differences between male physicians, surgeons, and film stars: comparative study

Trilla A, et al. BMJ 2006; 333:1291-1293.

Intro: We finished our medical training at the University of Barcelona more than 25 years ago, and have enjoyed our work ever since. At medical school we noted certain differences between male trainees who selected either surgery or medicine as their specialty. The tallest and most handsome male students were more likely to go for surgery, and the shortest (and perhaps not so good looking) ones were more likely to become physicians (including doctors of internal medicine and its subspecialties). Now, after all these years we hypothesise that, on average, surgeons are taller and better looking than physicians. We conducted a comparative study to test this hypothesis.

Objectives: To test the hypothesis that, on average, male surgeons are taller and better looking than male physicians, and to compare both sets of doctors with film stars who play doctors on screen.

Design: Comparative study.

Setting: Typical university hospital in Spain, located in Barcelona and not in a sleepy backwater.

Methods: We selected a random sample of senior staff surgeons and physicians working at the University of Barcelona Hospital Clinic (a 700 bed public hospital), matched by age (52 ±7 years) and sex (all men), from the staff payroll of the surgical and medical departments. We contacted all eligible participants by email. If they agreed to participate, their height (in cm) was recorded and they were asked to submit a digital picture. Age (in years) was registered and checked against that recorded in the payroll database. The external controls were four well known film stars, mostly in their 50s—Harrison Ford as Dr Richard Kimble (a neurosurgeon in the film The Fugitive), George Clooney as Dr Doug Ross (a paediatrician in the television series ER), Patrick Dempsey as Dr Derek Shepherd (a surgeon in the television series Grey's Anatomy), and Hugh Laurie as Dr Gregory House (a nephrologist and infectious disease specialist in the television series House).

We randomly organised the pictures of all surgeons, physicians, and external controls and showed them to an independent group of eight female observers—three doctors and five nurses from our hospital. All observers were in the same age group as the participants (no further checking of this information was attempted). We decided to avoid (for the time being) male observers, because of potential bias. Observers used the "good looking score" to classify each participant. This score measures the degree of handsomeness on a seven point Likert scale (1, ugly; 7, very good looking).

We discarded the highest and lowest score (outliers) for each participant and used the six remaining scores for our study. Mean scores, differences in means with 95% confidence intervals, and standard deviations were used to compare the three groups. We used the standard t test to compare age and the non-parametric (Mann-Whitney U) test to compare height and mean good looking scores.

Results: Surgeons were significantly taller than physicians (mean height 179.4 v 172.6 cm; P=0.01). Controls had significantly higher good looking scores than surgeons (mean score 5.96 v 4.39; difference between means 1.57, 95% confidence interval 0.69 to 2.45; P=0.013) and physicians (5.96 v 3.65; 2.31, 1.58 to 3.04; P=0.003). Surgeons had significantly higher good looking scores than physicians (4.39 v 3.65; 0.74; 0.25 to 1.23; P=0.010).

We did not make individual results public. However, widespread rumours, discussions, polls, and illegal bets arose throughout the institution as a by-product of our study. If they requested, participants were privately told about their personal score compared with the average score of the relevant group.

Discussion: Our study shows that, on average, senior male surgeons are significantly taller and better looking than senior male physicians. It also shows that film stars who play doctors are significantly better looking than real surgeons and physicians.

Differences between surgeons and physicians: Perhaps because of their training, surgeons have a different attitude and approach to the practice of medicine compared with physicians. The surgeon's image is that of competence, trust, expertise, and compassion. Surgeons are the only doctors who practise what has been called "confidence based medicine," which is based on boldness. They are often practical and fast acting, and they exert tight control on their natural turf—the operating theatre. Being taller and better looking has several evolutionary advantages for surgeons. Their extra height makes them more likely to be masters and commanders, and gives them a better view of the operating room, including the patient lying on the table. Also, as the senior male surgeon is normally surrounded by junior surgical staff, training fellows, nurses, anaesthetists, and the like, his height and appearance make him easily identifiable as their leader.

How do surgeons become taller and better looking than physicians? There are several potential explanations for the phenotypic changes between surgeons and physicians. Firstly, surgeons spend a lot of time in operating rooms, which are cleaner, cooler, and have a higher oxygen content than the average medical ward, where physicians spend most of their time. Furthermore, surgeons protect (but not always properly) their faces with surgical masks, a barrier to facial microtrauma, and perhaps an effective anti-ageing device (which deserves further testing). They often wear clog-type shoes, a confounding factor that adds 2-3 cm to their perceived height. The incidental finding that fewer surgeons are bald might be related to these environmental conditions and to the use of surgical caps.

In contrast, senior physicians are surrounded by fewer people in their habitat (the patient's bedside and the office), and they therefore have less need to be easily identified or spotted by families and nurses in the middle of a swarm. Physicians tend to hang heavy stethoscopes around their necks, which bows their heads forward and reduces their perceived height. They also complain of a (clearly abnormal) need to endlessly update their knowledge in accordance with the current evidence based approach to medicine by reading and studying heaps of medical journals; this overload of information further grinds them down. Although a prospective study found that doctor's white coats decrease in weight with increasing seniority, no significant difference was found between the mean weight of physicians' coats and surgeons' coats (1.4 v 1.5 kg).

Lit Bits: December 14, 2006

From the recent medical literature...

1. Strategies for Reducing the Door-to-Balloon Time in AMI

Bradley ED, Magid DJ, et al. New Engl J Med 2006; 355:2308-2320

INTRO
Prompt treatment increases the likelihood of survival for patients who have myocardial infarction with ST-segment elevation. Hospitals can therefore influence the outcomes for such patients by developing and implementing systems and processes that minimize the interval between arrival at the hospital and the administration of reperfusion therapy. Since percutaneous coronary intervention (PCI) has become the preferred approach for treating myocardial infarction with ST-segment elevation, hospitals are seeking ways to reduce the door-to-balloon time, defined as the time between arrival at the hospital and the first balloon inflation during PCI.

The importance of the door-to-balloon time is highlighted by its inclusion as one of the core quality measures collected and reported by the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations. Concomitant with national efforts to improve the care of patients with acute myocardial infarction have been substantial improvements in performance on many core measures (such as the use of aspirin and beta-blockers). However, performance with respect to the door-to-balloon time continues to lag behind national standards, which recommend an interval of 90 minutes or less. A minority of hospitals treat patients who present with myocardial infarction with ST-segment elevation within 90 minutes after their arrival, and hospital performance has not improved substantially in recent years.

Previous qualitative work has identified some common approaches among hospitals that have achieved a rapid door-to-balloon time. However, it is not clear which strategies are most effective or how great their effect might be. We sought to identify operational and clinical processes for treating patients who have myocardial infarction with ST-segment elevation and to quantify the association of these measures with hospital door-to-balloon times.

ABSTRACT
Background: Prompt reperfusion treatment is essential for patients who have AMI with ST-segment elevation. Guidelines recommend that the interval between arrival at the hospital and intracoronary balloon inflation (door-to-balloon time) during primary percutaneous coronary intervention should be 90 minutes or less. However, few hospitals meet this objective. We sought to identify hospital strategies that were significantly associated with a faster door-to-balloon time.

Methods: We surveyed 365 hospitals to determine whether each of 28 specific strategies was in use. We used hierarchical generalized linear models and data on patients from the Centers for Medicare and Medicaid Services to determine the association between hospital strategies and the door-to-balloon time.

Results: In multivariate analysis, six strategies were significantly associated with a faster door-to-balloon time. These strategies included having EM physicians activate the catheterization laboratory (mean reduction in door-to-balloon time, 8.2 minutes), having a single call to a central page operator activate the laboratory (13.8 minutes), having the ED activate the catheterization laboratory while the patient is en route to the hospital (15.4 minutes), expecting staff to arrive in the catheterization laboratory within 20 minutes after being paged (vs. >30 minutes) (19.3 minutes), having an attending cardiologist always on site (14.6 minutes), and having staff in the ED and the catheterization laboratory use real-time data feedback (8.6 minutes). Despite the effectiveness of these strategies, only a minority of hospitals surveyed were using them.

Conclusions: Several specific hospital strategies are associated with a significant reduction in the door-to-balloon time in the management of AMI with ST-segment elevation.

DISCUSSION
In a cross-sectional study of 365 acute care hospitals in the United States, we identified several hospital strategies that were strongly associated with the door-to-balloon time in the performance of PCI for patients with acute myocardial infarction with ST-segment elevation. In some cases, specific practices were associated with time savings of 10 to 15 minutes, a clinically important advantage in a group of institutions with a mean value of 100 minutes for median door-to-balloon times. Many of the strategies are not commonly used in hospitals in the United States, which may account in part for the relatively poor performance of such hospitals in meeting guidelines for the door-to-balloon time.

Although implementation of some of the advantageous strategies would require investment in new resources, other strategies that are currently used by only a minority of hospitals could be implemented with existing resources. For instance, having emergency medicine physicians determine whether a myocardial infarction with ST-segment elevation is present and activate the catheterization team without involvement of a cardiologist was strongly associated with a reduced door-to-balloon time but was used in only about 23% of hospitals during weekdays and in 27% of hospitals at night or on weekends. Furthermore, having the catheterization laboratory activated by a single call from the emergency department to a central page operator, who then paged both the interventional cardiologist and the catheterization laboratory staff, was strongly associated with a faster door-to-balloon time, but the single-call process was used in only about 14% of hospitals in this study. Research on the time to fibrinolytic therapy20 and small, single-hospital studies of the door-to-balloon time have also indicated that treatment is more rapid if emergency medicine physicians make the treatment decision without the involvement of a cardiologist. Nonetheless, most hospitals still involve a cardiologist in the decision to activate the catheterization laboratory.

In addition to the strategies that focus on processes within the hospital, the hospital's coordination with emergency medical services was strongly associated with the door-to-balloon time. Previous studies have shown that performing electrocardiography en route to the hospital can reduce the door-to-balloon time, and the National Heart Attack Alert Program Coordinating Committee has recommended increased use of such electrocardiographic services. In our study, the percentage of patients with acute coronary syndrome who underwent electrocardiography en route was not associated with the door-to-balloon time. Instead, it was the way that such electrocardiograms were used by hospitals that was important. Hospitals that activated the catheterization laboratory on the basis of electrocardiography performed while the patient was en route and those that had varied strategies to respond to electrocardiographic data transmitted from emergency medical services had an advantage. Determining the optimal approach for incorporating such electrocardiographic data into hospital processes to expedite the door-to-balloon time is an important area for future research.

False alarms were reported to be infrequent in our study, even at hospitals where emergency medicine physicians were responsible for activation of the catheterization laboratory on the basis of electrocardiography performed en route to the hospital. We were not able to obtain independent confirmation of the accuracy of the hospitals' estimates of false alarms. However, we have no evidence to suggest that these data are inaccurate, and we believe that perceptions about the number of false alarms are probably as important as is the true number of false alarms in determining whether noncardiologists are permitted to activate the catheterization laboratory. This issue may be clarified by further study….
______________________

The research, which was led by Elizabeth Bradley and a team of researchers that included David Magid, MD, MPH, Kaiser Permanente emergency medicine physician and researcher. Dr. Magid practices at Exempla Saint Joseph Hospital and as part of this study partnered with the hospital to adopt the life-saving strategies. Saint Joseph Hospital is one of the first hospitals in the country to make these important improvements. "The great point about these strategies is that most involve little or no cost to implement," said Magid. "The study offers a terrific guide for hospitals to follow as they push to improve door-to-balloon times and the quality of care for patients."

Full-text (requires subscription): http://content.nejm.org/cgi/content/full/355/22/2308

2. Arrival in the ED by Ambulance for Headache: A Marker of High Risk for SAH

Perry JJ, Ian G. Stiell, et al. Acad Emerg Med 2006;13(5, suppl 1):138-9.

ABSTRACT

Objective: There is currently little emphasis on the mode of arrival of emergency department (ED) headache patients with regard to risk of nontraumatic subarachnoid hemorrhage (SAH). This study assessed the use of ambulance for acute headache patients for the outcome of SAH.

Methods: This prospective cohort study was a substudy of a large multicenter study to derive a clinical decision rule for SAH. Six university tertiary care EDs in 5 medium to large cities participated in this study. Consecutive adult patients with an acute headache, without neurologic deficit, were enrolled. Analysis included descriptive statistics with appropriate univariate analysis and odds ratios (ORs) with 95% confidence intervals (95% CIs) for arrival by ambulance and referral from rural ED for the outcome of SAH.

Results: There were 3,051 enrolled patients with mean age 43.5 years (standard deviation [SD] 17.4), 60.2% female, and 157 (5.2%) SAH cases. Overall, 629 (20.6%) of the patients arrived by ambulance and 8.8% were referrals. Of patients who arrived by ambulance, 91 (14.5%) had SAH. Univariate chi-squared analysis found that arriving by ambulance was highly significant for SAH (p less than 0.001), OR 6.0 (95% CI: 4.3-8.4). This compares with the OR of 2.5 (95% CI: 1.7-3.9) for patients referred from other EDs. Excluding patients referred from other EDs did not alter the OR for arrival by ambulance (OR = 6.3, 95% CI: 4.4-9.1).

Conclusions: To the best of the authors' knowledge, this was the first prospective study to determine the relationship between arrival by ambulance and subarachnoid hemorrhage in neurologically intact headache patients. This study demonstrates that patients or their relatives are more likely to request an ambulance based on the seriousness of the condition. Physicians should consider mode of arrival as part of the diagnostic assessment of acute headache patients.

3. Heavy Smokers Who Cut Back Fail to Reduce Mortality

Heavy smokers who cut down but fail to quit do not appear to significantly reduce their risk for death, according to a study published in the December issue of Tobacco Control.

The prospective cohort study, conducted in Norway, involved 51,000 adults who were first screened for cardiovascular risk factors in the mid-1970s, screened again after 3 to 13 years, and then followed through 2003. It compared those who smoked at least 15 cigarettes a day at the start but then cut consumption by at least half with those who continued to smoke heavily.

It found that those who reduced smoking did not significantly lower their risk for dying from all causes, cardiovascular disease, ischemic heart disease, smoking-related cancer, or lung cancer.

The authors conclude that we need to reassess the practice of advising patients to cut down on smoking if they can't quit as a permanent solution -- a practice that may offer false expectations, as "a reduction in consumption does not seem to bring about harm reduction."

Full article: http://tc.bmj.com/cgi/content/full/15/6/472

4. Early Administration of Adenosine Improves MI Outcomes

By Will Boggs, MD. NEW YORK (Reuters Health) Nov 28 - Adjunctive administration of adenosine along with early reperfusion therapy improves outcomes after acute myocardial infarction (MI), according to a report in the October issue of the European Heart Journal.

"There is hope for the concept of cardio-protection," Dr. Robert A. Kloner from Good Samaritan Hospital, Los Angeles, California told Reuters Health. "That is, pharmacologic agents can be given at the time of acute heart attack and further reduce the size of the heart attack and improve outcome above and beyond opening the infarct artery by thrombolysis or percutaneous coronary intervention." Dr. Kloner and colleagues investigated the efficacy of high-dose intravenous adenosine in relation to reperfusion time and modality in patients presenting with ST-segment elevation anterior acute MI.

Compared with those who received placebo, patients who started reperfusion therapy within 3.17 hours of symptom onset and who received adenosine had significantly lower mortality at both 1 month (9.2% vs 5.2%) and 6 months (11.2% vs 7.3%), the investigators report. In contrast, the results indicate, adenosine did not improve clinical outcomes in patients reperfused later than 3.17 hours after onset.

Patients benefited from adenosine therapy regardless of whether they were treated with primary percutaneous coronary intervention (PCI) or with thrombolytic therapy, the researchers note, although those treated with PCI had lower rates of death at 1 and 6 months and less in-hospital congestive heart failure.

"There have been many attempts to try to improve outcome of myocardial infarction by giving adjunctive therapy acutely along with reperfusion for myocardial infarction," Dr. Kloner said. "Unfortunately most of these efforts have failed in large clinical trials. Adenosine appears to be one exception." He added: "My opinion is that a larger outcomes study that targets only patients who are reperfused early and have anterior infarcts is needed before adenosine can become a standard therapy."

However, Dr. Kloner noted that "some interventional cardiologists use adenosine in the setting of 'no reflow' when it appears that there is sluggish distal flow in a coronary artery that has received an intervention such as angioplasty or stenting. Thus, it is already being used in the catheterization laboratory in some settings."

Eur Heart J 2006;27:2400-2405.

5. Multislice CT Should Be Initiated Before Resuscitation in Blunt Major Trauma Patients

November 28, 2006 (Chicago) — Despite having a broad armamentarium of diagnostic protocols, emergency medicine physicians are often unable to provide an accurate diagnosis of patients who have suffered blunt major trauma, especially if they are unconscious. A study reported here at the 92nd scientific assembly and annual meeting of the Radiological Society of North America suggests that diagnoses should begin with multislice computed tomography (MSCT) protocols, even before resuscitation.

Common methods of assessing injury include conventional radiography, focused assessment with sonography for trauma (FAST), computed tomography (CT), and the invasive diagnostic peritoneal lavage (DPL). All have limitations, according to the study authors.

This was a retrospective cohort study of 370 patients (77.6% men, 22.4% women) with a mean age of 42.1 ± 17.7 years. "Demographic data were comparable in both cohorts," according to the authors.

Inclusion criteria were survival to admission to the intensive care unit (ICU), and 1 or more life-threatening injuries to the head, thorax, or abdomen. The injury must have received an injury severity score (ISS) of at least 17, with an abbreviated injury score (AIS) of at least 4. According to the abstract, the mean ISS of the study population (n = 370) was 27.1 ± 10.9 points.

Patients were divided into 2 cohorts (n = 185 each), the "resuscitation first" cohort and the "CT scan first" (MSCT) cohort. The former received resuscitation followed by a diagnostic procedure of either conventional radiography, FAST, or CT. The "CT-scan first" cohort underwent MSCT prior to resuscitation.

TRISS analysis was performed and SAPS II score was calculated. In addition, time in the emergency department, surgery length, ICU stay, total in-hospital stay, and survival were statistically analyzed, according to the study abstract.

In the "CT-scan first" cohort, a definitive diagnosis of injuries was achieved after 12 ± 9 minutes in 92.4% of patients compared with 41 ± 27 minutes in 76.2% of patients in the "resuscitation first" cohort. Several subsequent parameters were also shorter in the "CT-scan first" population vs the "resuscitation-first" population, including total time in the emergency department (70 vs 104 min), surgical procedure length (159 vs 186 min), ICU stay (13.6 vs 16.8 days), and total length of hospital stay (29.0 vs 32.5 days).

The authors conclude that performing MSCT in patients with blunt major trauma was safe and effective, and it led to faster and more accurate diagnoses as well as shorter stays in the emergency department, on the operating table, and in the ICU. They point out that if the MSCT is followed by adequate fluid resuscitation, the administration of contrast medium to patients in traumatic shock would have no negative effects on renal function.

"What this protocol says is doing major trauma by algorithm rather than individual patient assessment," Donald Bachman, MD, told Medscape. He is a radiologist in private practice at Metro West Medical Center in Wayland, Massachusetts. Dr. Bachman was not affiliated with this study.

"It's a technique that major trauma centers use," Dr. Bachman said. "In somebody with major life-threatening injury it may have overall benefits, but as far as I'm concerned, there are significant downsides to that approach as well."

He continued, "In young people, you are exposing people to a very large amount of radiation, which may or may not be necessary. It [also] tends to encourage doing things by a cookbook. For people who are mediocre or less than mediocre, that's probably good, but not for highly trained medical personnel who are accustomed to making assessments.

"[Emergency department] doctors tend to order studies first, and think about what to do with them afterwards. I think that runs up the cost of healthcare and results in many instances in sloppy thinking. However, it may be warranted in situations of overwhelming threatening trauma," Dr. Bachman concluded.

RSNA 92nd Annual Scientific Assembly and Annual Meeting: Abstract SSE14-06. Scheduled for presentation November 27, 2006.

6. A clinical tool for assessing risk after self-harm.

Cooper J, et al. Ann Emerg Med. 2006; 48(4):459-66

Editor’s Capsule Summary
What is already known on this topic: Decisions about the disposition of patients who harm themselves can be difficult, especially in emergency departments (EDs) with limited access to providers with expertise in the assessment of such patients.

What question this study addressed: The authors of this study of 9,086 patients who harmed themselves attempted to develop a rule for identifying those at low risk for attempting suicide during the subsequent 6 months.

What this study adds to our knowledge: The Manchester Self-Harm rule suggests that patients who (1) have no history of self-harm, (2) have never had psychiatric treatment [in the past or currently], and (3) did not use benzodiazepines in the current attempt are at low risk for repeated attempt of suicide. The rule successfully identified all 22 suicides within the 6-month period after ED presentation and had high sensitivity (94%) for subsequent self-harm. Twenty-five percent of patients met the low-risk criteria.

How this might change clinical practice: This English study suggests that patients who met the low-risk criteria could be safely sent home with outpatient referral. Unfortunately, most patients will not meet these criteria, leaving EDs with limited psychiatric evaluation resources in a dilemma about how to evaluate and treat these patients.

STUDY OBJECTIVE: Our aim is to develop a risk-stratification model for use by emergency department (ED) clinical staff in the assessment of patients attending with self-harm.

METHODS: Participants were patients who attended 5 EDs in Manchester and Salford, England, after self-harm between September 1, 1997, and February 28, 2001. Social, demographic, and clinical information was collected for each patient at each attendance. With data from the Manchester and Salford Self-Harm Project, a clinical decision rule was derived by using recursive partitioning to discriminate between patients at higher and lower risk of repetition or subsequent suicide occurring within 6 months. Data from 3 EDs were used for the derivation set. The model was validated with data from the remaining 2 EDs.

RESULTS: Data for 9,086 patients who presented with self-harm were collected during this study period, including 17% that reattended within 6 months and 22 patients who died by suicide within 6 months. A 4-question rule, with a sensitivity of 94% (92.1-95.0% [95% confidence interval]) and specificity of 25% (24.2-26.5% [95% confidence interval]), was derived to identify patients at higher risk of repetition or suicide.

CONCLUSION: Application of this simple, highly sensitive rule may facilitate assessment in the ED and help to focus psychiatric resources on patients at higher risk.

7. Even Under Optimal Conditions, CPR Quality May Fail to Meet Guidelines

NEW YORK (Reuters Health) Nov 30 - Highly trained physicians in a modern emergency department frequently meet international guidelines for cardiopulmonary resuscitation (CPR), according to a prospective observational study conducted at the Medical University of Vienna in Austria. However, "there is room for improvement," the authors say, especially with regard to hyperventilation and failure to identify ventricular fibrillation.

Recent reports exposed shortcomings often encountered when in-hospital CPR is administered, Dr. Fritz Sterz and associates note in the Archives of Internal Medicine for November 27.

In general, chest compression rates tend to be too low and ventilation rates too high, the authors note. International standards require a compression rate of 100 per minute, compression depth of 40-50 mm, and ventilation rate of 12 per minute.

Dr. Sterz's group conducted their study between 2002 and 2006, under conditions that they consider optimal. The emergency department was "fully equipped with monitors, ventilators, and complete nursing facilities." At least four physicians and six nurses were on duty around the clock.

They note that the 30 physicians were well versed in CPR and had more than 10 years of acute care clinical experience. The duration of cardiac arrest among the 80 patients in the study averaged 11.2 minutes.

The primary outcome was the hands-off ratio, defined as the hands-off time divided by the cardiac arrest time. The investigators observed that hands-off ratio (mean 12.7%) was linearly associated with duration of CPR (p <> 6 months, and six survived with a good neurological outcome.

The authors express concern that correct ventilation rates were achieved only 18% of the time during CPR. "An excessive ventilation rate during CPR will result in increased positive intrathoracic pressures, decreased coronary perfusions, and decreased survival rate." Also at issue was the delay in detecting ventricular fibrillation for up to 7 minutes.

Dr. Sterz and his team recommend greater attention to ventilation rates, and that no-flow time be reduced by keeping pulse checks and other examinations to a minimum.

Arch Intern Med 2006;166:2375-2380.

8. Lower Cervical Bupivacaine Injection Treats Headache in the ED

NEW YORK (Reuters Health) Nov 24 - For the treatment of headache pain in the emergency department, intramuscular injections of small amounts of 0.5% bupivacaine bilateral to the sixth or seventh cervical vertebrae provides safe and effective headache relief.

These are the findings of a retrospective study that included all 417 headache patients, 18 years of age or older, who received this treatment over a 1-year period at a single emergency department.

Complete headache relief occurred in 271 patients (65.1%) and partial headache occurred in 85 patients (20.4%). Fifty-seven patients (13.7%) reported no significant headache relief and 4 (1%) reported a worsening of headache pain.

Overall, bupivacaine injections yielded a therapeutic response in 356 of 417 patients (85.4%), report Dr. Larry B. Mellick of the Medical College of Georgia in Augusta and colleagues in the October issue of the journal Headache.

"Headache relief was typically rapid with many patients reporting complete headache relief in 5 to 10 minutes," the authors note. Headache relief was often accompanied by resolution of associated signs and symptoms such as allodynia, nausea, vomiting, and sensitivity to sound and light.

The mechanism of headache relief following lower cervical intramuscular bupivacaine injections is unknown, the authors note, but may involve calming of sensitized trigeminocervical complex.

Dr. Mellick and colleagues note that headache is a "common chief complaint" of patients who present to the emergency department. Many come to the ED as a last resort after other interventions have failed to provide headache relief.

Based on their experience, the authors say lower cervical injections of 0.5% bupivacaine "appears to be a safe and effective therapeutic intervention for the treatment of headache pain caused by a spectrum of etiologies presenting to the ED setting."

Headache 2006;46:1441-1449.

9. Highlights From MMWR: CDC Advises Routine Screening for HIV; and info on RSV

December 1, 2006 — The US Centers for Disease Control and Prevention (CDC) has reported in the December 1 issue of the Morbidity and Mortality Weekly Report on (1) the high rate of individuals who test positive for HIV late in the course of disease, underscoring the importance of routine screening for all adolescents and adults; and (2) recommendations to include respiratory syncytial virus in the differential diagnosis of respiratory tract infections and administer immune prophylaxis to eligible children.

(1) High Proportion of "Late Testers" for HIV: Routine Screening Advised

A CDC study has revealed that 41.3% of individuals testing HIV-positive in South Carolina over the last 5 years were diagnosed with AIDS less than 1 year later ("late testers"), including 16.5% who were diagnosed within 30 days of testing. Late testers were more likely to black (81.2% vs white, 16.4%), male (68.2%), and aged 20 to 49 years (80.1%).

Despite awareness campaigns aimed at testing high-risk individuals for HIV during healthcare visits, the majority of late testers (73%) had at least 1 documented visit to a healthcare facility during 1997 to 2005 at a mean of 2.5 years prior to HIV diagnosis and a substantial proportion of these (33.9%) were identified as injection drug users or men who have sex with men.

Whereas these practices should have prompted HIV screening if risk histories had been elicited by healthcare professionals, most of the diagnoses reported during these visits (78.6%) were not likely to prompt an HIV test and many (78.9%) occurred in an emergency department setting.

The CDC notes that South Carolina ranked 10th in the number of reported AIDS cases in the United States during 2004 (18.1 cases per 100,000 population). Moreover, approximately 50% of patients newly diagnosed with HIV during 2004-2005 had CD4+ T-cell counts less than 350 cells/mm3 (and nearly 33% had less than 200 cells/mm3), suggesting a high prevalence and long duration of undiagnosed HIV infections in this state.

The findings underscore the importance of routine HIV screening for all patients aged 13 to 64 years in all healthcare settings (unless they decline testing), as advocated by the CDC in September 2006

(2) RSV Should Be Included in Differential Diagnosis of Lower RTIs, Immune Prophylaxis Advised for At-Risk Children

From July 8 to November 18, 2006, respiratory syncytial virus (RSV) was detected in 62 laboratories from 37 states that participate in the National Respiratory and Enteric Virus Surveillance System (NREVSS). In the last season (July 2005 - June 2006), widespread RSV activity began during the third week of November and continued for 21 weeks until early April. Regionally, the highest levels of RSV activity occurred first in the South (December), later in the Northeast and Midwest (January), and latest in the West (February).

Whereas 91% of RSV detections occurred prior to mid-April, sporadic cases occurred until September 2006 and occurred at a high rate in Florida (48%). Preliminary data suggest that the annual peak for the current season began in Florida during the last week of June, followed by the rest of the south in mid-October, and the Northeast in the second week of November.

The CDC notes that RSV is a major cause of lower respiratory tract infections (LRTIs) among young children and can also cause severe disease and death among the elderly and individuals with compromised respiratory, cardiac, or immune systems.

Healthcare providers are advised to consider RSV in the differential diagnosis for patients of all ages with LRTIs during the annual seasonal peak. Although several tests can be used to diagnose RSV in young children, only reverse transcription–polymerase chain reaction (RT-PCR) assays are a reliable diagnostic tool for older children and adults.

Because no vaccine is currently available, infants and children at risk for serious RSV infection should receive immune prophylaxis with monthly doses of humanized murine anti-RSV monoclonal antibody product during the season.

Those considered at risk include infants aged less than 2 years with chronic lung disease who have required medical therapy within 6 months of RSV season onset; infants and children with hemodynamically significant heart disease; and preterm infants born at less than 32 weeks' gestation or born at 32 to 35 weeks' gestation and having at least 2 additional risk factors during their first RSV season. Risk factors include day care attendance, exposure to environmental pollutants, school-aged siblings, congenital airway abnormalities, and neuromuscular disease.

The CDC notes that RSV activity can vary among regions and communities. Local clinical laboratories should be consulted for information on the latest trends. Alternatively, additional information may be obtained online at http://www.cdc.gov/ncidod/dvrd/revb/nrevss/index.htm

MMWR. 2006;55:1269-1292.

10. Scoring System Reduces Unnecessary Antibiotic Use in Children with Pharyngitis

Use of a simple clinical decision rule in assessing children with pharyngitis reduced unnecessary antibiotic prescriptions, according to a study from Brazil published in the current issue of Pediatrics.

The study included 220 children with pharyngitis, about three quarters of whom tested culture-negative for group A streptococcus. The researchers developed a scoring system based on three criteria: age, viral signs, and bacterial signs. The specificity of the scoring system was 84%. Use of the system would reduce unnecessary antibiotic use by about 55% in clinics where bacteriologic diagnosis is of limited availability and by about 40% in clinics where it is completely unavailable, the researchers estimated.

Smeesters PR, et al. PEDIATRICS Vol. 118 No. 6 December 2006, pp. e1607-e1611

Article in Pediatrics: http://pediatrics.aappublications.org/cgi/content/full/118/6/e1607
Scoring System: http://pediatrics.aappublications.org/cgi/content-nw/full/118/6/e1607/T1
Treatment decision Rule: http://pediatrics.aappublications.org/cgi/content-nw/full/118/6/e1607/T2

11. Revisiting Swallowed Troubles: Intestinal Complications Caused by Two Magnets

A Case Report, Review and Proposed Revision to the Algorithm for the Management of Foreign Body Ingestion. Vijaysadan J. Am Board Fam Med 2006;19:511-516.

Here’s a nice review: Free full-text: http://www.jabfm.org/cgi/content/full/19/5/511

12. Low Literacy Leads to Prescription-Label Misunderstandings

Patients, particularly those with low literacy, frequently misunderstand the instructions on labels for common prescription drugs, finds a study released early online by the Annals of Internal Medicine.

Researchers asked nearly 400 English-speaking patients (recruited in clinics serving indigent populations) to read instructions from the bottles of five common prescription drugs. Participants were then asked to repeat the instruction information for each medication, and, for one of the medications, to demonstrate how many pills they would take in a day.

Findings included:

-- Almost half of patients misstated at least one label instruction; the majority of errors concerned dosage.

-- About 70% of low-literacy patients could restate the directions "take 2 tablets…twice daily," but only 35% could demonstrate the daily dose.

-- Most participants ignored auxiliary labels, such as "do not chew."

-- Taking a greater number of prescriptions was independently associated with increased risk for misunderstanding directions.

The authors caution that asking patients to repeat label instructions -- a method currently recommended for confirming patient understanding -- may not be adequate.

Editorial: http://www.annals.org/cgi/content/full/0000605-200612190-00145v1

13. Are Sore Throat Patients Who Hope for Antibiotics Actually Asking for Pain Relief?

Annals of Family Medicine 2006;4:494-499.

PURPOSE Antibiotics are still overprescribed for self-limiting upper respiratory tract infections such as acute sore throat, and physicians mention patient’s desire for antibiotics as a driving force. We studied patients’ concerns when visiting their family physician for acute sore throat, more specifically the importance they attach to antibiotic treatment and pain relief.

METHODS Family physicians in 6 peer groups in Belgium participated in an observational postvisit questionnaire survey. Patients aged 12 years and older making an office visit for acute sore throat were invited to indicate the importance of different reasons for the visit.

RESULTS Sixty-eight family physicians provided data from 298 patients. The 3 most frequently endorsed reasons for visiting the physician were examination to establish the cause of the symptoms, pain relief, and information on the course of the disease. Hopes for an antibiotic ranked 11th of 13 items. Patients who considered antibiotics very/rather important valued pain relief significantly more than patients who considered them little/not important (P less than .001). Patients who hoped for antibiotics felt more unwell (P less than .001), had more faith in antibiotics to speed recovery (P less than .001), and were less convinced that sore throat was a self-limiting disease (P less than .012). A multivariate model, adjusted for age, sex, and educational status, showed that the desire for pain relief is a strong predictor of the hope to receive a prescription for antibiotics.

CONCLUSION Our study suggests that patients with acute sore throat and who hope for antibiotics may in fact want treatment for pain. Trials are needed to test whether exploring patients’ expectations about pain management and offering adequate analgesia can assist physicians in managing sore throats without prescribing antibiotics.

Free full-text: http://www.annfammed.org/cgi/content/full/4/6/494

14. New Oral Anticoagulants Raise Hopes for Warfarin Replacement

from Heartwire — a professional news service of WebMD. December 8, 2006 (Gothenburg, Sweden) - A host of potential new oral anticoagulant agents, which could become much-needed replacements for warfarin and could also be used as an alternative to heparins or other antithrombin agents, are making good progress in development, with at least two agents now in phase 3 trials.

But experts are cautious following the fall from glory of the first such agent to be developed--ximelagatran--which actually reached the market in Europe but was swiftly withdrawn because of liver toxicity. Nevertheless, as there are so many new compounds in development, researchers are optimistic that this time at least one or two will succeed and provide the millions of patients who are--or should be--taking warfarin with a much more user-friendly treatment.

The two agents furthest on in development are the factor IIa inhibitor dabigatran (Boehringer Ingelheim) and the factor Xa inhibitor rivaroxaban (Bayer and Ortho-McNeil). Several other companies also have orally available factor Xa inhibitors in earlier clinical development, including Bristol-Myers Squibb, Lilly, Yamanouchi, and DuPont, and there are also other agents with different mechanisms in the pipeline, including a factor IXa inhibitor, TTP889 (TransTech Pharma), and an orally active glycosaminoglycan enhancer, odiparcil (SmithKline Beecham).

These agents are initially being developed for the prevention of thrombosis in orthopedic-surgery patients, but both dabigatran and rivaroxaban are also now starting late-stage trials for the prevention of stroke in atrial-fibrillation patients (as a replacement for warfarin) and in the treatment of acute coronary syndromes. Researchers in the field are optimistic that these agents will become easier-to-use alternatives to warfarin.

One of the leaders in this field, orthopedic surgeon Dr Bengt Eriksson (Sahlgrenska University Hospital, Gothenburg, Sweden), told heartwire: “I am hopeful that at least one of these new agents will reach the market within the next two to three years for the prevention of venous thromboembolism after major orthopedic surgery, and then these agents will gradually replace current anticoagulants.”

15. Oral Steroids May Trigger Some Cases of Diabetes

By David Douglas. NEW YORK (Reuters Health) Dec 08 - Use of oral glucocorticoids could be a precipitating factor in some cases of new-onset diabetes, UK researchers report in the December issue of Diabetes Care.

Lead investigator Dr. Martin C. Gulliford told Reuters Health the study results "suggest that use of orally administered glucocorticoids may be associated with up to 2% of all new cases of diabetes in primary care." Dr. Gulliford and colleagues at King's College London School of Medicine note that frequency of atopic disease is increasing, as is the burden of diabetes.

To examine whether there might be a relationship between steroid therapy for atopic conditions and new-onset diabetes, the researchers used a family practice database to conduct a case-control study. In all, 2647 patients with newly diagnosed diabetes were identified and compared with 5294 matched controls.

The researchers found that the adjusted odds ratio for diabetes associated with 3 or more prescriptions for oral glucorticoids was 1.36. Such patients appeared to account for about 2% of incident cases of diabetes.

However, "there appears to be either minimal or no association of new diabetes with prescribing of glucocorticoid-containing inhalers, topical preparations, eye drops, or infrequent glucocorticoid injections for joint problems," Dr. Gulliford concluded.

Diabetes Care 2006;29:2728-2729.

16. Risk for Thrombosis Persists After Discontinuation of Heparin Therapy

December 11, 2006 — The US Food and Drug Administration (FDA) and Baxter Healthcare Corp have warned healthcare professionals regarding the risk for delayed-onset heparin-induced thrombocytopenia (HIT) in patients receiving heparin sodium injection. HIT is a serious antibody-mediated reaction that results from irreversible platelet aggregation and can lead to the development of heparin-induced thrombocytopenia and thrombosis (HITT).

Patients presenting with thrombocytopenia or thrombosis within several weeks of discontinuing heparin therapy should be evaluated for HIT and HITT, according to an alert sent Friday from MedWatch, the FDA's safety information and adverse event reporting program.

HITT can present as thromboembolic events, including deep vein thrombosis (DVT), pulmonary embolism (PE), cerebral vein thrombosis, limb ischemia, stroke, myocardial infarction, mesenteric thrombosis, renal arterial thrombosis, skin necrosis, gangrene of the extremities that can lead to amputation, and possibly death.

Heparin sodium injection is indicated for the prophylaxis and treatment of venous thrombosis, PE, and peripheral arterial embolism; treatment of atrial fibrillation with embolization; diagnosis and treatment of acute and chronic consumptive coagulopathies; and for the prevention of clotting in arterial and cardiac surgery.

Heparin is also indicated for use as an anticoagulant in blood transfusions, extracorporeal circulation, dialysis procedures, and blood samples for laboratory purposes. A low-dose regimen may be used to prevent postoperative DVT and PE in patients undergoing major abdominothoracic surgery and those at risk for developing thromboembolic disease due to other reasons.

During treatment, thrombocytopenia of any degree should be closely monitored; if platelet counts decrease to less than 100,000/mm3, heparin should be promptly discontinued and alternative anticoagulant therapy considered if needed.

17. Patterns of Errors Contributing to Trauma Mortality: Lessons Learned From 2594 Deaths

Gruen RL, et al. Annals of Surgery 2006;244:371-80.

Objective: To identify patterns of errors contributing to inpatient trauma deaths.

Methods: All inpatient trauma deaths at a high-volume level I trauma center from 1996 to 2004 inclusive were audited. Data were collected with daily trauma registry chart abstraction, weekly morbidity and mortality reports, hospital quality assurance reports, and annual trauma registry analyses of risk of death using TRISS and HARM methodology. Deaths that met criteria for low to medium probability of mortality or those with quality of care concerns were analyzed for errors and then subjected to 3-stage peer review at weekly departmental, monthly hospital, and annual regional forums. Patterns of errors were constructed from the compiled longitudinal data.

Results: In 9 years, there were 44,401 trauma patient admissions and 2594 deaths (5.8%), of which 601 met low to medium mortality risks. Sixty-four patients (0.14% admissions, 2.47% deaths) had recognized errors in care that contributed to their death. Important error patterns included: failure to successfully intubate, secure or protect an airway (16%), delayed operative or angiographic control of acute abdominal/pelvic hemorrhage (16%), delayed intervention for ongoing intrathoracic hemorrhage (9%), inadequate DVT or gastrointestinal prophylaxis (9%), lengthy initial operative procedures rather than damage control surgery in unstable patients (8%), over-resuscitation with fluids (5%), and complications of feeding tubes (5%). Resulting data-directed institutional and regional trauma system policy changes have demonstrably reduced the incidence of associated error-related deaths.

Conclusions: Preventable deaths will occur even in mature trauma systems. This review has identified error patterns that are likely common in all trauma systems, and for which policy interventions can be effectively targeted.

18. A model for troponin I as a quantitative predictor of in-hospital mortality

Waxman DA, et al. J Am Coll Cardiol. 2006; 48(9):1755-62

OBJECTIVES: We evaluated log-transformed troponin I as a predictor of mortality in 2 independent populations.

BACKGROUND: The troponin I result is typically dichotomized by a single diagnostic cutoff. Its performance as a continuous prognostic variable has not previously been well-characterized.

METHODS: We studied the first troponin I sent from the emergency department (ED) as a predictor of all-cause inpatient mortality, with retrospectively gathered data. We performed our study in 2 stages, deriving our model with data from a single medical center and validating it with data from another. Subjects included every patient who had a troponin I sent from the ED during the period from November 2002 to January 2005. We assessed prognostic independence by including other potential confounders in nested logistic regression models. The troponin assay was identical at both sites (Ortho-Clinical Diagnostics, Rochester, New York).

RESULTS: There were a total of 34,227 patients (12,135 derivation and 22,092 validation). Odds ratio for mortality as a function of log10-troponin was 2.08 (95% confidence interval [CI] 1.85 to 2.32) in the derivation set and 2.07 (95% CI 1.92 to 2.24) for the validation set. Troponin I remained a strong predictor after inclusion of age, electrocardiogram normality, renal insufficiency, arrival mode, chief complaint, admission diagnosis, and abnormal vital signs into bivariate and nested multivariate models.

CONCLUSIONS: The presence of any detectible troponin I at ED presentation is associated with increased inpatient mortality. In 2 distinct clinical populations, the odds of death approximately doubled with any 10-fold increase in troponin result. This held true at levels below current diagnostic cutoffs. The placement and utility of dichotomous cutoffs might merit reconsideration.

19. Algorithm Could Aid in Management of Abnormal Uterine Bleeding

Researchers have designed a comprehensive, evidence-based algorithm to help primary care physicians manage abnormal uterine bleeding in women between menarche and menopause.

The algorithm, described in the November/December issue of the Journal of the American Board of Family Medicine, was drafted based on a review of the published literature, then revised and validated based on the actual care given to 300 patients at a gynecology clinic.

The algorithm advises clinicians first to rule out pregnancy, then to identify one of four bleeding patterns; for each of the patterns it offers extensive guidance about tests and treatments. Though the authors concede that the algorithm is lengthy, they write that they "wanted a practical tool that could stand alone at the point of care." The article includes a handheld-computer version of the algorithm.

Full-text (free): http://www.jabfm.org/cgi/content/full/19/6/590