Lit Bits: January 31, 2009

From the recent medical literature...

1. Greater Use of Reperfusion Therapy and Faster Reperfusion Times With Prehospital ECGs

Michael O'Riordan, from Heartwire — a professional news service of WebMD. January 7, 2008 (Boston, Massachusetts) — Only one in four patients transported to the hospital by emergency medical services (EMS) is receiving a prehospital electrocardiogram (ECG), a new study has shown [1]. Those who are screened with an ECG, however, are reperfused faster and more frequently than those who do not receive a prehospital ECG with first medical contact, report investigators.

"We hope the findings drive home the message that irrespective of reperfusion strategy, whether in an academic center that can do primary PCI 24/7 or a community hospital that utilizes fibrinolysis, an EMS system that transports patients who have chest pain and performs an ECG before arriving at the hospital improves our patients' outcomes and improves time to reperfusion," lead investigator Dr Deborah Diercks (University of California Davis Medical Center, Sacramento) told heartwire.

In August 2008, the American Heart Association (AHA) issued a scientific statement on the use of prehospital ECGs to improve the quality of care delivered to STEMI patients. The AHA guidelines, as well as other consensus and scientific statements, recommend the acquisition and use of prehospital ECGs by EMS for the evaluation of patients with suspected acute coronary syndrome. The current recommendation is class 2a with a B level of evidence.

In this recent study, Diercks and colleagues evaluated patients with STEMI in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment and Intervention Outcomes Network (ACTION) over a one-year period in 2007.

In total, 7098 patients utilized the EMS, and of these patients, just 27.4% received a prehospital ECG. Within this EMS transport population, 92% of those who received a prehospital ECG underwent primary PCI compared with 86% of those who received an ECG in the hospital. Also, more patients receiving an ECG in the ambulance were treated with fibrinolytic therapy compared with those who received one in the hospital.

Reperfusion times among STEMI patients screened with an ECG by EMS personnel were also shorter compared with those who received an ECG in the hospital. Similarly, more patients who received a prehospital ECG met the AHA door-to-balloon time recommendations of less than 90 minutes for PCI and the door-to-needle time of less than 30 minutes for fibrinolysis.

"I think what really improves the quality of care with the prehospital ECG is the time it takes to activate the system," said Diercks. "The prehospital ECG allows institutions to open up the lab, get their personnel ready, so that when the patient arrives the machine is started--the patient can get to where they need to go in a more prompt fashion."

Just one in four patients receiving an ECG prior to arriving at the hospital is a surprising finding, said Diercks. She added, however, that this study comes on the heels of the latest recommendations for prehospital ECG screening, so there might be insufficient time to see changes in the system. Increasing funding, training for EMS personnel to develop skills to interpret the ECG, and improvements in data transmission will hopefully result in an increase in utilization, she said.

In addition to improvements in reperfusion, investigators observed a trend toward improved clinical outcomes among patients who received a prehospital ECG. There were trends toward lower mortality, less congestive heart failure, and less cardiogenic shock among STEMI patients screened with an ECG by the EMS personnel. Although it failed to reach statistical significance, the risk of death was reduced 20% among those who received an ECG with first medical contact.

"The findings fall in line with what we know," said Diercks. "The faster we're able to reperfuse these people, the better their outcomes are. A reduction in mortality is very much in line with the reduced time to reperfusion with the prehospital ECG."

Diercks DB, Kontos MC, Chen AY, et al. Utilization and impact of prehospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction. J Am Coll Cardiol 2009; 53:161-166. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19130984

2. Direct Paramedic Transport of Acute Myocardial Infarction Patients to Percutaneous Coronary Intervention Centers: A Decision Analysis

Wang HE, et al. Ann Emerg Med. 2009;53:233-240.e5

Study objective
One potential strategy in the emergency medical services (EMS) care of acute ST-segment elevation myocardial infarction (STEMI) is to bypass the nearest community hospital in favor of a more distant specialty center able to perform primary percutaneous coronary intervention. We seek to determine whether EMS transport of out-of-hospital STEMI patients directly to more distant specialty percutaneous coronary intervention centers will alter 30-day survival compared with transport to the nearest community hospital fibrinolytic therapy.

Methods
This decision analysis used parameter values and ranges from meta-analyses and North American clinical studies of STEMI and chest pain care published after 2001. The primary hypothetical interventions were primary percutaneous coronary intervention versus community hospital–delivered fibrinolytic therapy. We defined total STEMI treatment time as the sum of symptom duration, EMS response time, EMS scene time, EMS transport time to the nearest community hospital, additional EMS transport time to a more distant percutaneous coronary intervention center, and door-to-drug or door-to-balloon time. We related total STEMI treatment time to the primary outcome 30-day post-STEMI survival. We assumed that the closest specialty percutaneous coronary intervention centers were located farther than the nearest community hospital and that patients would receive primary percutaneous coronary intervention at specialty centers and fibrinolytic therapy at community hospitals. We assumed the use of ground transportation only and excluded situations with fibrinolytic therapy contraindications. We examined standard risk and best-case scenarios for each intervention, as well as changes in predicted risk with parameter value variations.

Results
Baseline total treatment times (chest pain onset to intervention) were percutaneous coronary intervention 188 minutes (range 41 to 447 minutes) and community hospital fibrinolytic therapy 118 minutes (range 51 to 267 minutes). Thirty-day survival was higher for standard percutaneous coronary intervention than standard community hospital fibrinolytic therapy (95.8% versus 93.8%; relative risk [RR] 1.021; number needed to treat 50) but lower when compared to best-case community hospital fibrinolytic therapy (95.8% versus 97.8%; RR 0.980; number needed to harm 50). Best-case percutaneous coronary intervention was equivalent to best-case community hospital fibrinolytic therapy (RR 1.000). In 1-way sensitivity analyses, best-case community hospital fibrinolytic therapy versus standard percutaneous coronary intervention was sensitive to treatment time parameter variations. Probabilistic sensitivity analysis favored standard percutaneous coronary intervention over standard community hospital fibrinolytic therapy (RR=1.020; 95% probability range 1.002 to 1.045) but did not indicate a favored strategy for the other scenarios.

Conclusion
In select out-of-hospital STEMI care scenarios, EMS transport of acute STEMI patients directly to percutaneous coronary intervention centers may offer small but uncertain survival benefits over nearest community hospital fibrinolytic therapy.

3. A Mysterious Link Between Sleeplessness and Heart Disease

December 24, 2008. By RONI CARYN RABIN. People who don’t get much sleep are more likely than those who do to develop calcium deposits in their coronary arteries, possibly raising their risk for heart disease, a new study has found.

The 495 participants in the study filled out sleep questionnaires and kept a log of their hours in bed. At night they also wore motion-sensing devices around their wrists that estimate the number of hours of actual sleep. At the beginning, none of the participants, who were ages 35 to 47, had evidence of coronary artery calcification.

Five years later, 27 percent of those who were sleeping less than five hours a night on average had developed coronary artery calcification for the first time, while only 6 percent of those who were sleeping seven hours or more had developed it. Among those who were sleeping between five and seven hours a night, 11 percent had developed coronary artery calcification, the study found.

After accounting for various other causes, the researchers concluded that one hour more of sleep per night was associated with a 33 percent decrease in the odds of calcification, comparable to the heart benefit gained by lowering one’s systolic blood pressure by 17 millimeters of mercury.

The study was published on Tuesday in the Journal of the American Medical Association. The data were drawn from the ongoing Coronary Artery Risk Development In Young Adults study.

Senior author Diane S. Lauderdale cautioned that the new report does not prove a cause-and-effect relationship between a lack of sleep and heart disease.

“It’s important to say that this is the first report and this does not yet prove the association is causal,” said Dr. Lauderdale, an associate professor of health studies at the University of Chicago Medical Center. “Until we know what the mechanism is -- that it’s really a direct or a causal relationship -- there is no point in making recommendations based on this.”

Although a number of studies have suggested that people who sleep less are at greater risk of heart disease and death, this is the first investigation to measure how much its subjects actually are sleeping, said Dr. Sanjay Patel, assistant professor of medicine at Case Western Reserve University and expert in sleep medicine. Patients’ own self-assessments can be very inaccurate, he added.

What isn’t clear is whether reduced sleep triggers physiological changes that increase heart disease risk, or whether a third, unrelated factor causes both changes, he said.

“It’s possible, for example, that people who are under more stress may be both sleeping less and at higher risk of heart disease,” Dr. Patel said.

If so, he added, “If we got those people to sleep more but they still were under a lot of stress, it wouldn’t change their risk of heart disease.”

Higher education levels are also associated with both a lower risk of heart disease and a tendency to get more sleep, said Dr. Lauderdale.

But it is also possible that lack of sleep leads to certain changes, like increasing blood levels of the stress hormone cortisol, which can raise the risk of coronary artery disease over time, Dr. Lauderdale said.

Another possible mechanism could be through the effect that sleep has on average blood pressure levels over a 24-hour period. Blood pressure usually dips when people are asleep, which could provide health benefits for those who get more sleep, Dr. Lauderdale suggested.

4. Full extension (nearly) rules out elbow fracture

Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children

Appelboam A, et al. BMJ 2008;337:a2428

Objective: To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury.
Design Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care.

Setting: Five emergency departments in southwest England.

Participants: 2127 adults and children presenting to the emergency department with acute elbow injury.

Intervention: Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children.

Main outcome measures: Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days.

Results: Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children.

Conclusion: The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.

Full-text: http://www.bmj.com/cgi/content/full/337/dec09_1/a2428

For similar findings, cf. Darracq MA, Vinson DR, Panacek EA. Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture. Am J Emerg Med. 2008;26:779-82. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/18774042

5. Data indicate amount of free hospital care continues to skyrocket.

Source: The Orlando Business Journal (http://orlando.bizjournals.com/orlando/)
Date: December 19, 2008

The Orlando Business Journal reports that data indicate that the "amount of free hospital care provided to needy patients locally skyrocketed by 41.6 percent in the past three years, from a combined $431.1 million in 2005 to a whopping $610.4 million in 2007." Nationally, "the amount of charity hospital care provided grew by eight percent in third-quarter 2008 when compared to the same period last year." Hospital officials "expect the situation to worsen in 2009 as the recession deepens and unemployment grows."

In fact, "every one percentage point increase in unemployment leads to a loss of employer-sponsored health coverage for an estimated 2.5 million employees and dependents," according to an American Hospital Association report. Moreover, "many people lacking health insurance turn to the emergency [department] as a last resort," and to "make matters worse, uncompensated care costs typically get shifted to the amount billed to private insurers, which drives up insurance premiums for employers and their workers." The culmination of all these events can put "the squeeze on hospitals, which are looking for a variety of ways to cut costs."

6. First Simple Febrile Seizure in Some Young Children Not Likely Bacterial Meningitis

Laurie Barclay, MD. January 14, 2009 — Lumbar puncture may not be necessary for a first simple febrile seizure at ages 6 to 18 months because the risk for bacterial meningitis is very low, according to the results of a retrospective cohort review in the January issue of Pediatrics.

"American Academy of Pediatrics consensus statement recommendations are to consider strongly for infants 6 to 12 months of age with a first simple febrile seizure and to consider for children 12 to 18 months of age with a first simple febrile seizure lumbar puncture for cerebrospinal fluid analysis," write Amir A. Kimia, MD, from Children's Hospital Boston in Massachusetts, and colleagues. "Our aims were to determine compliance with these recommendations and to assess the rate of bacterial meningitis detected among these children."

The investigators reviewed records for patients aged 6 to 18 months who were seen in a pediatric emergency department between October 1995 and October 2006 for a first simple febrile seizure. This presenting complaint accounted for 1% of all emergency department visits for children of this age during this period (704 cases of children among 71,234 eligible visits).

Of the first simple febrile seizure visits, 188 (27%) were for infants aged 6 to 12 months, and 516 (73%) were for infants aged 12 to 18 months; in total, 271 (38%) had lumbar puncture. Of 188 children aged 6 to 12 months, 131 (70%) had available samples, as did 129 (25%) of 516 children aged 12 to 18 months. In both age groups, rates of lumbar puncture decreased significantly with time.

Ten cases (3.8%) had elevated cerebrospinal fluid white blood cell count, but all results of cerebrospinal fluid cultures were negative for pathogens. Although 10 (3.8%) of cultures were positive for a contaminant, no patients were diagnosed with bacterial meningitis.

"The risk of bacterial meningitis presenting as first simple febrile seizure at ages 6 to 18 months is very low," the study authors write. "Current American Academy of Pediatrics recommendations should be reconsidered."

Limitations of the study include lack of generalizability to patients with complex febrile seizures, ill-appearing patients, or those with an underlying illness; lack of complete follow-up of patients who did not have lumbar puncture; and pretreatment of 68 patients with antibiotics before their visit to the emergency department.

"Sound clinical judgment should always prevail, and clinicians should err on the side of caution (including performing an LP [lumbar puncture]) when evaluating any febrile child for whom the presence of bacterial meningitis is being considered," the study authors conclude.

Kimia AA ,et al. Pediatrics. 2009;123:6-12.
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19117854

7. Is Subcutaneous Administration of Rapid-Acting Insulin as Effective as Intravenous Insulin for Treating Diabetic Ketoacidosis?

Mazer M, et al. Ann Emerg Med. 2009;53:259-263.

Introduction
Diabetes mellitus, second only to hypertension as the most common chronic condition of emergency department (ED) patients, can cause acute hyperglycemia and ketoacidosis, responsible for more than 1 million ED visits in 2005. Traditionally (and more recently endorsed by the American Diabetes Association), the treatment of diabetic ketoacidosis is accomplished by the administration of a low dose intravenous infusion of regular insulin that is initiated in the ED and continued in an ICU3 setting for frequent insulin/fluid adjustments, glucose monitoring, and electrolyte assessment.

Although insulin administration by any route is effective for treating diabetic ketoacidosis, intravenous insulin is preferred over subcutaneous and intramuscular insulin because it provides rapid, titratable glycemic control. For example, subcutaneous regular insulin has an onset of action within 1 hour, peaks within 1 to 5 hours, and may last for 6 to 10 hours, whereas intravenous insulin acts within minutes and has a half-life of 9 minutes. Within the past decade, rapid-acting insulin analogues (lispro [Humalog, Eli Lilly and Company, Indianapolis, IN], aspart [Novolog, Novo Nordisk Inc, Princeton, NJ], and glulisine [Apidra, Sanofi-Aventis, Bridgewater, NJ]) have been adopted preferentially for the inpatient treatment of hyperglycemia because of their more favorable pharmacokinetic profiles. When administered subcutaneously, these analogs have an onset of action within 10 to 20 minutes, peak within 30 to 90 minutes, and last approximately 3 to 4 hours.

Because intravenous insulin infusion requires ICU admission in some institutions and higher equipment (infusion pumps, additional intravenous access) and nursing costs, we searched the literature to determine whether intermittent subcutaneous use of these rapid-acting analogs might be as effective as intravenous insulin infusions in treating uncomplicated diabetic ketoacidosis.

Objective
To determine whether intermittent subcutaneous administration of rapid-acting insulin is as effective as intravenous infusion of regular insulin for treating uncomplicated diabetic ketoacidosis, we performed a MEDLINE, EMBASE, and Cochrane Library search…

The Bottom Line
According to this review of the available data (Table), subcutaneous administration of rapid-acting insulin analogues such as lispro every hour (0.3 U/kg bolus; then 0.1 U/kg) or 2 hours (0.3 U/kg bolus; then 0.2 U/kg) may be a reasonable alternative to intravenous regular insulin infusion for treating uncomplicated diabetic ketoacidosis. Insulin analogues are as effective as intravenous insulin at normalizing glucose levels and other acid-base characteristics, with similar rates of hypoglycemia. Moreover, patients receiving subcutaneous insulin may be treated on the medical floors or in step-down units, which may provide an overall cost savings and improve ED patient flow when ICU beds are scarce.

Finally, although the data provided support for our conclusions, they are based on a few small studies (with slightly different inclusion and exclusion criteria and definitions for resolution of diabetic ketoacidosis), focused on one particular analogue (lispro), and assume that intravenous insulin infusions require monitoring in intensive care settings. More important, the majority are manufacturer-sponsored studies, thereby introducing the potential for a conflict of interest. Despite these limitations, we conclude that it would be safe and effective to treat uncomplicated diabetic ketoacidosis with a subcutaneously administered rapid-acting insulin analogue.

8. Use of the Emergency Department for Severe Headache. A Population-Based Study

Friedman BF, et al. Headache 2009;49:21-30.

Background.—Although headache is a common emergency department (ED) chief complaint, the role of the ED in the management of primary headache disorders has rarely been assessed from a population perspective. We determined frequency of ED use and risk factors for use among patients suffering severe headache.

Methods.—As part of the American Migraine Prevalence and Prevention study, a validated self-administered questionnaire was mailed to 24,000 severe headache sufferers, who were randomly drawn from a larger sample constructed to be sociodemographically representative of the US population. Participants were asked a series of questions on headache management, healthcare system use, sociodemographic features, and number of ED visits for management of headache in the previous 12 months. In keeping with the work of others, "frequent" ED use was defined as a particpant's report of 4 or more visits to the ED for treatment of a headache in the previous 12 months. Headaches were categorized into specific diagnoses using a validated methodology.

Results.—Of 24,000 surveys, 18,514 were returned, and 13,451 (56%) provided complete data on ED use. Sociodemographic characteristics did not differ substantially between responders and nonresponders. Among the 13,451 responders, over the course of the previous year, 12,592 (94%) did not visit the ED at all, 415 (3%) visited the ED once, and 444 (3%) visited the ED more than once. Patients with severe episodic tension-type headache were less likely to use the ED than patients with severe episodic migraine (OR 0.4 [95% CI: 0.3, 0.6]). Frequent ED use was reported by 1% of the total sample or 19% (95% CI: 17%, 22%) of subjects who used the ED in the previous year, although frequent users accounted for 51% (95% CI: 49%, 53%) of all ED visits. Predictors of ED use included markers of disease severity, elevated depression scores, low socioeconomic status, and a predilection for ED use for conditions other than headache.

Conclusions.—Most individuals suffering severe headaches do not use the ED over the course of a single year. The majority of ED visits for severe headache are accounted for by a small subset of all ED users. Increasing disease severity and depression are the most readily addressable factors associated with ED use.

9. Images in Emergency Medicine

a. Woman With Low Back Pain
Link: http://www.annemergmed.com/article/S0196-0644(08)00837-8/fulltext

b. Limp in an 11-Year-Old Male
Link: http://www.annemergmed.com/article/S0196-0644(08)00910-4/fulltext

10. Impact of an Internet-Based Emergency Department Appointment System to Access Primary Care at Safety Net Community Clinics

Chan TC, et al. Ann Emerg Med 2009; in press.

Study objective
We evaluate the effect of an Internet-based, electronic referral system (termed IMPACT-ED for Improving Medical home and Primary care Access to the Community clinics Through the ED) on access and follow-up at primary care community clinics for safety net emergency department (ED) patients.

Methods
We conducted a nonblinded interventional trial at an urban, safety net, hospital ED with a census of 39,000 annually. IMPACT-ED identified patients who had no source of regular care and lived in a 15-ZIP-code low-income area served by 3 community clinics. Emergency physicians received an automated notification through the electronic medical record to access an imbedded software program for scheduling follow-up clinic appointments. Patients who would benefit from a follow-up clinic visit within 2 weeks as determined by the emergency physician received a computer-generated appointment time and clinic map with bus routes as part of their discharge instructions, and the clinics received an electronic notification of the appointment. We compared frequency of follow-up for a 6-month period before implementation when patients received written instructions to call the clinic on their own (pre-IMPACT) and 6 months after implementation (post-IMPACT). Statistical analysis was conducted with χ2 testing, and corresponding 95% confidence intervals are presented.

Results
There were 326 patients who received an appointment (post-IMPACT), of whom 81 followed up at the clinic as directed (24.8%), compared with 399 patients who received a referral (pre-IMPACT), of whom 4 followed up as directed (1.0%), for an absolute improvement of 23.8% (95% confidence interval 19.1% to 28.6%).

Conclusion
Although most patients still failed to follow up at the community clinics as directed, the use of an Internet-based scheduling program linking a safety net ED with local community clinics significantly improved the frequency of follow-up for patients without primary care.

11. Sleep and the Common Cold

Adults who slept fewer than 7 hours per night were almost three times more likely than longer sleepers to develop a cold after rhinovirus exposure.

Sleep deprivation can adversely affect immune function, and one study has suggested a link between poor sleep habits and increased risk for common colds (JAMA 1997; 277:1940). Researchers now report results from a prospective study of sleep habits and rhinovirus susceptibility.

Participants were interviewed daily for 14 days to assess sleep duration and "sleep efficiency" (the proportion of time in bed spent asleep). Information on several other variables (e.g., rhinoviral antibody titers, age, body-mass index, race, income, sex, smoking) was also collected to allow control for potential confounders. After this assessment, participants were placed in quarantine, exposed to an experimental rhinovirus (RV-39), and monitored for 5 days for signs and symptoms of illness. The outcome (a cold) was defined as infection (recovery of RV-39 from nasal lavage fluid or a 4-fold rise in RV-39 antibody titer) plus the presence of signs (mucus weight 10 g or nasal clearance time 35 minutes) or symptoms of a cold.

Of 153 individuals enrolled, 135 (88%) became infected, but only 54 (35%) and 66 (43%) developed a cold as determined by signs and by symptoms, respectively. Participants who averaged less than 7 hours of sleep per night had the highest risk for colds as determined by signs (odds ratio, compared with participants sleeping 8 hours/night, 2.9; 95% confidence interval, 1.2–7.3). Similarly, those with "sleep efficiency" less than 85% had the highest risk for colds after RV-39 exposure (OR, compared with the rest of the sample, 5.4; 95% CI, 1.5–19.1).

Comment: To the many benefits of good sleep we can now add protection from symptomatic rhinovirus infection. Data from this prospective investigation, combined with other study findings linking sleep duration to mortality and to heart disease morbidity, support a recommendation for 7–8 hours of sleep nightly. Further study of the link between sleep habits and disease susceptibility is warranted.

— Daniel J. Diekema, MD, MS. Published in Journal Watch Infectious Diseases January 21, 2009. Citation: Cohen S et al. Sleep habits and susceptibility to the common cold. Arch Intern Med 2009;169:62.

12. MI Reduction After Smoking Ban Is Sustained Over Long Term

from Heartwire — a professional news service of WebMD. Sue Hughes. January 7, 2009 (Pueblo, Colorado) — The reduction in MI hospitalizations observed after a smoke-free law takes effect appears to be sustained over an extended period, according to a new study from Pueblo, CO.

The study, reported in the January 2, 2009 issue of the Center for Disease Control and Prevention's (CDC's) Morbidity and Mortality Weekly Report, examined MI hospitalization rates before and after the implementation of a municipal law in the city of Pueblo making workplaces and public places smoke-free.

Results showed that MI hospitalizations for city residents decreased by 27% in the initial 18-month period (phase 1) after the smoke-free law came into effect on July 1, 2003. In addition, MI hospitalizations decreased by a further 19% during the following 18 months--through to June 30, 2006 (the phase 2 period).

No significant changes in MI hospitalizations were observed in two nearby comparison areas that did not have smoke-free laws in place before or during the study periods. "These findings suggest that smoke-free policies can result in reductions in AMI hospitalizations that are sustained over a three-year period and that these policies are important in preventing morbidity and mortality associated with heart disease," the CDC researchers write. "This effect likely is mediated through reduced second-hand-smoke exposure among nonsmokers and reduced smoking, with the former making the larger contribution," they add.

Full-text: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5751a1.htm

13. Raising the Threshold for Trauma Team Activation Decreases Workload Without Consequence

A change in criteria at a single trauma center reduced the incidence of trauma team activations, with no delays to surgery or increase in mortality.

A general tendency exists to over-triage patients to trauma centers and to activate trauma teams. Trauma team activation requires numerous personnel and the attending trauma surgeon to arrive within 20 minutes. In a retrospective observational study, researchers at a single level I trauma center determined whether changing criteria for trauma team activation from those recommended by the American College of Surgeons Committee on Trauma to more-aggressive indications affects patient outcomes. Criteria for trauma team activation were changed to decrease the systolic blood pressure cutoff (from less than 90 mm Hg to less than 80 mm Hg), decrease the respiratory rate cutoff (from less than 10 or greater than 28 to less than 8 or greater than 28 breaths per minute), eliminate the heart rate criterion, decrease the Glasgow Coma Scale score cutoff (from less than 14 to less than 9), and eliminate the following three anatomic criteria: pelvic fracture, flail chest, and 2 long bone fractures.

Researchers compared trauma registry data for 1955 patients who were admitted during an 18-month period before the criteria were changed and for 1844 patients who were admitted during an 18-month period after the change; 95% of patients had blunt injuries. After the change, the proportion of cases that led to trauma team activation was significantly lower overall (18% vs. 12%) and during nights and weekends (19% vs. 13%). The mean Injury Severity Score among cases that led to trauma team activation was significantly higher after the change (22.96 vs. 28.57), yet mortality did not change significantly. Among patients with systolic BP between 80 and 90 mm Hg, mortality decreased after the change (7 deaths among 23 patients vs. 0 deaths among 22 patients). The percentage of laparotomies that were performed more than 2 hours after arrival did not change.

Comment: As resources for trauma become increasingly limited, fewer physicians are opting to be trauma surgeons because of the high workload, the concentration of work on nights and weekends, and the risk for exposure to pathogens such as HIV (especially among victims of penetrating trauma). In this study, the changes in criteria for trauma team activation diminished the demand on resources and the workload for trauma surgeons, without compromising patient care.

— John A. Marx, MD. Published in Journal Watch Emerg Med January 30, 2009. Citation:
Shapiro MJ et al. Let the surgeon sleep: Trauma team activation for severe hypotension. J Trauma 2008;65:1245.

14. Oral Prednisolone May Not Be Helpful for Acute Virus-Induced Wheezing in Children

Laurie Barclay, MD. January 22, 2009 — Oral prednisolone is not superior to placebo in shortening hospitalization or improving other outcomes in preschool children with mild to moderate wheezing associated with a virus infection, according to the results of a randomized, double-blind, placebo-controlled trial reported in the January 22 issue of the New England Journal of Medicine.

"Attacks of wheezing induced by upper respiratory viral infections are common in preschool children between the ages of 10 months and 6 years," write Jayachandran Panickar, MD, MRCPCH, from University of Leicester, in Leicester, United Kingdom, and colleagues. "A short course of oral prednisolone is widely used to treat preschool children with wheezing who present to a hospital, but there is conflicting evidence regarding its efficacy in this age group."

In this study, 700 children aged 10 to 60 months who presented to 3 hospitals in England with an attack of wheezing associated with a virus infection were randomly assigned to a 5-day course of oral prednisolone (10 mg once a day for children aged 10 to 24 months and 20 mg once a day for older children) or placebo. Of 687 children included in the intent-to-treat analysis, 343 were in the prednisolone group and 344 in the placebo group. The main endpoint of the study was the duration of hospitalization, and secondary endpoints were the Preschool Respiratory Assessment Measure (PRAM) score, albuterol use, and a 7-day symptom score.

The placebo group and the prednisolone group were not significantly different in the duration of hospitalization (13.9 vs 11.0 hours; ratio of geometric means, 0.90; 95% confidence interval, 0.77 - 1.05), in the interval between hospital admission and signoff for discharge by a clinician, or in any of the secondary outcomes or the number of adverse events.

"In preschool children presenting to a hospital with mild-to-moderate wheezing associated with a viral infection, oral prednisolone was not superior to placebo," the study authors write. "We found no evidence that a short course of an oral corticosteroid significantly shortened the duration of hospitalization or significantly reduced markers of the severity of symptoms, as assessed by either physicians or parents," the study authors conclude. "Our results suggest that oral prednisolone should not be routinely given to preschool children presenting to the hospital with acute, mild-to-moderate virus-induced wheezing."

In an accompanying editorial, Andrew Bush, MD, from the Imperial School of Medicine at the National Heart and Lung Institute and the Royal Brompton Hospital, London, United Kingdom, notes that prednisolone should be administered to preschoolers only when they are severely ill in the hospital and that intermittent, high-dose inhaled corticosteroids should not be used.

"Also needed is follow-up of all preschool children enrolled in therapeutic trials to see who will go on to have persistent, atopic, multitrigger wheezing (true asthma)," Dr. Bush writes. "The data from the studies should be analyzed retrospectively to determine whether the response to treatment for acute episodes in preschoolers in whom true asthma develops differs from that in patients in whom symptoms subsequently regress. My suspicion is that there will be no difference."

N Engl J Med. 2009;360:329-338, 409-410.
Abstract: http://content.nejm.org/cgi/content/abstract/360/4/329

15. Standard Needle for Pneumothorax Decompression Might Not Reach the Pleural Space

Chest wall thickness was greater than the length of a standard needle in half the patients in this small study.

Objective. Tension pneumothorax can lead to cardiovascular collapse and death. In the prehospital setting, needle thoracostomy for emergent decompression may be lifesaving. Taught throughout the United States to emergency medical technicians (EMTs) and physicians, the true efficacy of this procedure is unknown. Some question the utility of this procedure in the prehospital setting, doubting that the needle actually enters the pleural space. This study was designed to determine if needle decompression of a suspected tension pneumothorax would access the pleural cavity as predicted by chest computed tomography (CT).

Methods. We retrospectively reviewed consecutive adult trauma patients admitted to a level I trauma center between January and March 2005. We measured chest wall depth at the second intercostal space, midclavicular line on CT scans. Data on chest wall thickness were compared with the standard 4.4-cm angiocatheter used for needle decompression.

Results. Data from 110 patients were analyzed. The mean age of the patients was 43.5 years. The mean chest wall depth on the right was 4.5 cm (± 1.5 cm) and on the left was 4.1 cm (± 1.4 cm). Fifty-five of 110 patients had at least one side of the chest wall measuring greater than 4.4 cm.

Conclusions. The standard 4.4-cm angiocatheter is likely to be unsuccessful in 50% (95% confidence interval = 40.7-59.3%) of trauma patients on the basis of body habitus. In light of its low predicted success, the standard method for treatment of tension pneumothorax by prehospital personnel deserves further consideration.

Stevens RL, et al. Prehospital Emerg Care. 2009;13:14-17.

16. Teens’ Ability to “Text” indicates Full Post-Syncopal Recovery

Sinclair M, et al. BMJ 2008;337:a2723

Festival Medical Services is a charitable trust that provides music festivals throughout the United Kingdom with doctors, nurses, paramedics, first aiders, and other trained medical and administrative staff. One of the authors (MS) is the coordinator for the Festival Medical Services "pit crew." This team provides a resuscitation facility for the audience at the two main stages at Glastonbury and Reading festivals as well as a triage system to sort or treat people who need medical attention. The team follows the advice of the Third Annual Rock Concert Safety Survey Report published by Crowd Management Strategies in February 1995 (www.crowdsafe.com/mosh.html).

Festival Medical Services has a small tent (3 m x 3 m) at the side of these stages, with resuscitation equipment as suggested by the Resuscitation Council UK’s recommended minimum equipment for inhospital adult resuscitation. A consultant anaesthetist, two nurses, an operating department practitioner, and at least two first aiders are present from when the first band appears on stage until the last band of the day finishes.

Three years ago we noticed that most of the patients with faint or panic attack were teenagers and as soon as they could they used their mobile phones to send an SMS (short message service) text message to their friends. SMS allows the interchange of short text messages between mobile phones. About 1.4 billion text messages are sent in the UK alone every week, according to the Mobile Data Association (www.text.it).

The ability to text, whether or not it actually makes sense, requires a Glasgow coma scale score of 15 (fully conscious), an adequately functioning "executive system" in the frontal lobes, and a high degree of manual dexterity and psychomotor coordination. It also shows a degree of common sense not always evident in teenagers.

Two years ago we decided to use this texting sign as an indication that patients had recovered from their faint or panic attack and were orientated and coordinated enough to be discharged back to the festival. At times of massive influx to the medical tent, when up to two patients a minute are triaged, this system seems to work well.

This year at the Reading festival we managed, with only one consultant anaesthetist, two accident and emergency nurses, one operating department practitioner, and two to four first aiders, to treat 142 patients in less than 60 minutes during the performance by Bloc Party and 130 patients over 90 minutes during the performance by Rage Against the Machine. The texting sign needs further investigation to determine whether it is a valid criterion for recovery after faint or panic attack at festivals as well as in busy accident and emergency departments.

17. Recurrence Common Following Emergency Treatment of Headache

NEW YORK (Reuters Health) Dec 30 - Headache patients treated at the emergency department frequently experience pain and functional impairment following discharge, regardless of type of primary headache disorder, according to a study reported in the December issue of the Annals of Emergency Medicine.

Headache is the fifth most common emergency department (ED) complaint. "Effective treatments for the acute headache exist, but patients often have a recurrence or persistence of the initial headache after ED discharge," write Dr. Benjamin W. Friedman and colleagues from Albert Einstein College of Medicine, Bronx, New York.

In a prospective cohort study, the researchers examined the frequency of moderate or severe headache during the first 24 hours after an ED visit for a primary headache disorder, and determined the burden of headache-related functional impairment during the 3 months after the ED visit.

The team enrolled 309 primary headache disorder patients during their initial ED visit over an 18-month period. The subjects were interviewed using a standardized questionnaire, and were followed by telephone 24 hours and 3 months after discharge. All headaches were classified according to the International Headache Society criteria by two emergency physicians.

The most common primary headache diagnoses were migraine, tension-type headache, and unclassifiable recurrent headache disorder. Ninety-four percent of patients were successfully followed-up at both time points.

Within 24 hours of ED discharge, 31% of migraine patients, 19% of tension-type headache patients, and 27% of the unclassifiable headache patients experienced moderate or severe headache.

Overall, 37% of migraine patients, 38% of tension-type headache patients, and 26% of the unclassifiable headache patients experienced headache-related functional impairment during the 3 months after discharge.

"Of the 2 hypothesized predictors of poor 24-hour outcome, duration of headache and discharge pain intensity, only duration of headache seemed an independent predictor of moderate or severe headache in the 24 hours after ED discharge," Dr. Friedman and colleagues report.

"Additional independent predictors of moderate or severe headache within 24 hours were severe baseline pain, presence of nausea, and a positive response to depression screening questions." The only independent predictor of poor 3-month outcomes was Medicaid insurance.

The team notes that the best treatment for postdischarge headache has not been determined. "Absent data," they advise, "it is reasonable practice to provide an oral agent with known efficacy in acute migraine or acute tension type headache, such as a triptan, a migraine-specific combination, an oral antiemetic combined with a nonsteroidal anti-inflammatory drug, or a nonspecific analgesic."

Ann Emerg Med 2008;52:696-704.

18. Preoxygenation for Emergency Intubation: Longer Is Not Better

Preoxygenation beyond 4 minutes adds no benefit.

Objective: To determine the effectiveness of increasing the preoxygenation period with 100% oxygen in the critically ill patient from 4 to 8 mins in preparation for emergency tracheal intubation.

Design: Nonrandomized, controlled trial.

Setting: Large, level one trauma center, tertiary care intensive care unit.

Patients: Critically ill patients failing noninvasive respiratory support techniques who required tracheal intubation followed by mechanical ventilation.

Interventions: A baseline arterial blood gas was obtained on noninvasive passive therapy and at 4, 6, and 8 mins of active preoxygenation efforts with 100% oxygen therapy with a noncollapsing resuscitator bag and mask. Best effort to achieve a tight fitting mask seal was pursued coupled with other mask ventilation maneuvers to optimize noninvasive oxygenation and ventilation.

Measurements and Main Results: Thirty-four patients consecutively intubated by the author during the 7-month study period were studied. The baseline Pao2 (mean ± sd) with concurrent noninvasive support was 61.9 ± 14.6 mm Hg (range: 44-109 mm Hg) and increased a mean of 22 mm Hg to 83.8 ± 51.5 mm Hg after 4 mins of preoxygenation (p less than 0.01). Continued preoxygenation efforts (6 mins) increased the Pao2 to 88.2 mm Hg ± 48.5 and after 8 mins to 92.7 mm Hg ± 55.2. At the 8-min mark, 5 of 34 patients achieved greater than 10% increase in their Pao2 and only two patients increased their 4-min Pao2 by 50 mm Hg or more after the additional 4 mins of preoxygenation. One quarter of the patients experienced a reduction in their Pao2 from the 4 to the 8-min time period. Nearly, 50% of the patients met the criteria for desaturation during the intubation procedure.

Conclusions: Extending the preoxygenation period from the customary 4 mins to either 6 or 8 min seems to be marginally effective in the majority of patient suffering from cardiopulmonary deterioration and such an extension may jeopardize oxygenation efforts in some patients.

Mort TC, et al. Critical Care Medicine 2009;37:68-71.

19. Recommendations for Prevention of Recurrent Stroke Reviewed

Laurie Barclay, MD. January 27, 2009 — Recommendations for prevention of recurrent stroke are reviewed in the January issue of Mayo Clinic Proceedings. In addition to control of modifiable risk factors, virtually all patients who have had ischemic stroke should be prescribed antiplatelet agents.

"Stroke is the leading cause of death and disability in the United States," writes Harold Adams Jr, MD, from the University of Iowa in Iowa City. "The economic consequences of stroke, including health care costs and lost economic productivity, are substantial. These are the reasons that stroke prevention, including treatment of underlying causes, are clearly of critical importance."

The leading cause of ischemic stroke is atherosclerotic vascular disease, which gives rise to occlusion or severe stenosis of major intracranial or extracranial arteries, as well as narrowing of small penetrating arteries of the brain.

Coronary artery disease, or atherosclerosis of the coronary arteries, may result in myocardial infarction, which in turn is an indirect cause of cardioembolic stroke. Atrial fibrillation and cardioembolic stroke may also complicate ischemic heart disease.
"Some risk factors associated with increased likelihood of advanced atherosclerosis and ischemic disease are not modifiable," Dr. Adams writes. "These risk factors include age, sex, ethnicity, family history and premature vascular disease. However, several conditions that augment the course of atherosclerosis can be effectively addressed across the continuum of care."

For patients with symptomatic ischemic cerebrovascular disease, a crucial aspect of treatment is prevention of recurrent stroke, myocardial infarction, and other ischemic events. This requires optimal control of modifiable risk factors that accelerate development of atherosclerosis, such as hypertension, hyperlipidemia, diabetes mellitus, and smoking.

Management of hypertension should aim to achieve a normal blood pressure for the patient, realizing that no single, specific antihypertensive regimen is ideal for all patients. When prescribing a blood pressure–lowering treatment plan, clinicians should consider a patient's history, while awaiting the results of ongoing and future studies.

Some evidence suggests that aggressive lowering of cholesterol levels may modestly increase the risk for hemorrhagic stroke. However, the benefits of statins to decrease the risk for recurrent ischemic stroke and other ischemic vascular events are thought to outweigh the risk of bleeding. In patients with diabetes mellitus, management should include aggressive control of blood pressure and lipid levels as well as of blood glucose levels.

More aggressive interventions may be required, such as carotid endarterectomy and endovascular treatment. In selected patients, carotid endarterectomy should be considered as complementary to use of antiplatelet agents and other medications. For other patients with atherosclerotic cerebrovascular disease, extracranial-intracranial bypass surgery and carotid artery stenting may be considered, pending the results of ongoing clinical trials.

The keystone of management to prevent recurrent stroke and other cardiovascular events in patients at risk continues to be administration of antiplatelet agents, which should be prescribed for virtually all patients who have had ischemic stroke. Therapeutic options include aspirin, aspirin plus extended-release dipyridamole, or clopidogrel. Specific choice among these should be guided by the patient's previous treatment and history of ischemic events as well as allergies or other potential contraindications.

Specific recommendations of the American Heart Association/American Stroke Association for antithrombotic therapy in patients with ischemic stroke of noncardioembolic origin (secondary prevention), and their accompanying levels of evidence, are as follows:

Antiplatelet agents are recommended vs oral anticoagulants (level of evidence, I, A).

Preferred options for initial treatment are aspirin (50 - 325 mg/day), a combination of aspirin and extended-release dipyridamole, or clopidogrel (level of evidence, I, A).

The combination of aspirin and extended-release dipyridamole may be preferred vs aspirin alone (level of evidence, I, B).

Instead of aspirin alone, clopidogrel may be considered (level of evidence, IIb, B).

Clopidogrel is a reasonable option for patients who are hypersensitive to aspirin (level of evidence, IIa, B).

Addition of aspirin to clopidogrel increases the risk for hemorrhage (level of evidence, III, A).

"Use of an integrated treatment approach involving risk-factor management, antiplatelet therapy and surgical procedure when indicated presents the opportunity to lower the risk of recurrent stroke and other ischemic events in patients with recent ischemic stroke," Dr. Adams concludes. "Future research may provide support for using new medications, clarify the role of currently available medications, and better define the appropriate role of surgery, particularly endovascular treatments."

In an accompanying editorial, James F. Meschia, MD, from the Mayo Clinic in Jacksonville, Florida, confirms that "after the immediate post-thrombolytic period, care needs to focus on secondary prevention."

"Patients with acute ischemic stroke are at high risk of recurrent stroke," Dr. Meschia writes. "If successful reperfusion therapy is like dodging a bullet, successful secondary prevention is like being caught in the line of fire again. [Dr. Adams'] review will be welcomed by clinicians seeking guidance beyond evidence-based guidelines."

Mayo Clin Proc. 2009;84:3-4,43-51.

20. Guidelines Issued for Field Triage of Injured Patients

Laurie Barclay, MD. January 27, 2009 — The National Expert Panel on Field Triage has issued guidelines for field triage of injured patients and has published the new recommendations in the January 23 issue of Morbidity and Mortality Weekly Report. Because not all patients require the services of a Level I trauma center (TC), those with less severe injuries may be transported to a closer emergency department (ED) capable of managing milder injuries.

"In the United States, injury is the leading cause of death for persons aged 1–44 years, and the approximately 800,000 emergency medical services (EMS) providers have a substantial impact on the care of injured persons and on public health," write Scott M. Sasser, MD, from the Division of Injury Response, National Center for Injury Prevention and Control, Atlanta, Georgia, and colleagues. "At an injury scene, EMS providers determine the severity of injury, initiate medical management, and identify the most appropriate facility to which to transport the patient through a process called 'field triage.'...Determining the appropriate facility to which an injured patient should be transported can have a profound impact on subsequent morbidity and mortality."

In addition to basic emergency services, which are generally available in all hospital EDs, designated TCs are those hospitals with additional expertise, resources, and equipment to treat severely injured patients.

Classification of TCs is based on the scope of resources and services available. Level I TCs provide the highest level of trauma care, Levels II and III are intermediate, and Level IV centers provide initial trauma care and transfer to a higher level of trauma care if needed.

Although the risk for death is 25% lower for a severely injured person treated at a Level I TC, not all patients need the level of services available at a Level I TC. The guidelines suggest that less severely injured patients might be better served by being transported to a closer ED capable of managing milder injuries and that transferring all injured patients to Level I TCs could place an unnecessary load on these centers, negatively affect patient outcomes, and reduce cost effectiveness.

The Field Triage Decision Scheme (Decision Scheme), first developed by the American College of Surgeons in 1986, serves as the basis for triage protocols for state and local EMS systems across the United States. To help determine the most appropriate destination facility within the local trauma care system, this algorithm guides EMS providers through 4 decision points: physiologic concerns, anatomic considerations, mechanism of injury, and special considerations.

The Decision Scheme has been revised 4 times since it was first published in 1986. To facilitate revision of the Decision Scheme, the US Centers for Disease Control and Prevention hosted a series of meetings of the National Expert Panel on Field Triage in 2005, with support from the National Highway Traffic Safety Administration.

The expert panel, which includes injury-care providers, public health professionals, automotive industry representatives, and officials from federal agencies, reviewed pertinent literature, presented its findings, and agreed on necessary revisions allowing publication of the revised Decision Scheme in 2006. The report published in the Morbidity and Mortality Weekly Report details the process and rationale used by the expert panel to revise the Decision Scheme.

Full-text: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5801a1.htm

Lilt Bits: Dec 22, 2008

From the recent medical literature...

1. EMS, Emergency Depts Slowly Warm Up to Therapeutic Hypothermia

December 22, 2008 — One of the hottest topics in emergency medicine is a decidedly cold one: therapeutic hypothermia to prevent brain damage in patients after cardiac arrest.

New York City has announced that as of January 1, 2009, emergency medical services (EMS) will take patients who have been resuscitated after cardiac arrest to an emergency department (ED) trained and equipped to perform therapeutic hypothermia, rather than to a closer hospital that does not offer the treatment. Several other US cities, including Boston, Seattle, and Miami, have similar policies in place.

Research Supports NYC Move

In 2002, European and Australian investigators published results of separate studies in which patients who were successfully resuscitated after cardiac arrest caused by ventricular fibrillation were randomly assigned to undergo therapeutic hypothermia to a target temperature of 32° to 34° C or to standard treatment at normal temperatures.

In the European study, 55% of 75 patients treated with mild hypothermia for whom data were available had favorable neurologic outcomes compared with 39% of 137 patients treated according to standard protocols. Six-month overall mortality rates were also lower among patients treated with hyperthermia vs standard care, at 41% vs 55%, respectively. Complication rates were similar between the 2 groups, however (N Engl J Med. 2002;346:549-556).

Similarly, the Australian investigators found that 49% of 43 patients treated with hypothermia after out-of-hospital arrest survived and had a good outcome (discharge home or to rehabilitation) compared with 26% of 34 treated with normothermia. An analysis adjusted for baseline differences in age and time from collapse to the return of spontaneous circulation showed a more than 5-fold greater likelihood for a favorable outcome with hypothermia (N Engl J Med. 2002;346:557-563).

A retrospective study published in 2007 in the journal Resuscitation reported that among 40 consecutive comatose post–cardiac arrest patients with ST-elevation myocardial infarction who received early coronary angiography/percutaneous coronary intervention (PCI) and mild therapeutic hypothermia, the in-hospital mortality rate was 25% compared with 66% for matched historical controls who underwent PCI without therapeutic hypothermia. In all, 78% of patients (21 of 27) treated with hypothermia who survived out to 6 months had a good neurologic outcome compared with only half of control patients (6 of 12 survivors).

Slow Implementation of Hypothermia Programs

Stephan Mayer, MD, chief of the neurological intensive care unit at New York–Presbyterian/Columbia Hospital in New York City and a prominent advocate for NYC's adoption of the new protocol, asks why, if the evidence strongly supports the benefits of hypothermia, aren't more hospitals using it? "What we have is this problem of implementation," Dr. Mayer told Medscape Medical News. "We've known this for 6 years, since the clinical trials, and in addition there have been multiple single-center studies showing bad results with standard care, and when they implemented hypothermia, and have doubled the rate of survival."

Dr. Mayer said that because patients who are comatose after resuscitation have historically had a poor prognosis, there is an assumption by many clinicians that such patients will not benefit from aggressive interventions.

Bret A. Nicks, MD, assistant medical director in the Department of Emergency Medicine at Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina, agrees that the technique has been accepted more slowly than many would like. "Considering that we're 6 years down the road from the clinical trials, most places have not adopted it, because of, number one, the perceived difficulties in starting it, and two, the perceived difficulties in continuing it in the intensive care unit setting," he told Medscape Medical News.

Better Coordination Needed

Dr. Nicks noted that although his center has had a protocol for therapeutic hypothermia in place for several years, "our biggest struggle is that [although] we can continue [ED-initiated hypothermia] in our cardiac intensive care unit, but not all postarrest patients go there; they may go to the medical intensive care unit depending on the nature of their illness, and maintaining that protocol and that concept to keep them cool for neuroprotective properties aren't as well established."

Better coordination of the protocol between the ED and other centers in his institution is a major goal for 2009, he said.

In several large urban centers, including Seattle, Wake County, North Carolina, and Richmond, Virginia, paramedics are trained and equipped for inducing hypothermia in the field. In Richmond, for example, paramedics can initiate cooling during resuscitation, and if the patient has return of spontaneous circulation, the cooling can be continued in transport, with rapid cooling initiated in the ED using a percutaneous catheter technique. The ambulances bypass other hospitals and take all suitable patients directly to Virginia Commonwealth University Medical Center for treatment.

In Wake County, the EMS system in 2006 began prehospital induction of hypothermia for patients with return of spontaneous circulation after cardiac arrest. In the program, all patients aged 16 years and older who are not neurologically intact after resuscitation from nontraumatic arrest are considered for induced cooling in the field, regardless of presenting rhythm. Here too, ambulances transport therapeutic hypothermia candidates directly to 1 of 2 hospitals where cooling can be induced 24 hours a day in the cardiac catheterization lab.

Cardiovascular Benefits of Hypothermia Less Clear

But while the neuroprotective benefits of therapeutic hypothermia are evident, the cardiovascular benefits are not quite as clear, according to Elliott Antman, MD, director of the Samuel A. Levine Cardiac Unit at Brigham & Women's Hospital in Boston, Massachusetts. "That hasn't been as well studied," he told Medscape Medical News. "There are theoretical benefits, but they have not been found to be as compelling as the neurologic benefits. The most important thing from a cardiovascular perspective is the door-to-balloon time."

In a consensus statement published in an advance online edition of Circulation by the International Liaison Committee on Resuscitation (ILCOR), the committee members state that the neuroprotective benefits of hypothermia are well established and that "[t]herapeutic hypothermia should be part of a standardized treatment strategy for comatose survivors of cardiac arrest."

Dr. Nicks said that instituting a therapeutic hypothermia protocol need not be overwhelming — it can be done with cooling blankets and a bear hugger air-cooling device to make a "patient sandwich," plus cool fluids to reach the goal temperatures for mild hypothermia.

"You don't have to go out and buy the expensive central line cooling kit," he said.

But Dr. Mayer noted that low-tech cooling methods are labor intensive, and the methods are less precise than dedicated cooling systems.

"The hours go by and you're not getting the temperatures down where you want them to be, or you're getting them too cold and if the body temperature goes below thirty, you can actually cause ventricular arrhythmia," he pointed out. "The newer technologies work, they're powerful, and the target temperature can be achieved in an hour or two."

Dr. Mayer reports that he is a consultant to Medivance, maker of therapeutic hypothermia equipment, and holds stock in the company. None of the other physicians interviewed have disclosed any relevant financial relationships.

2. Coordination by Hospitalists Eases Emergency Department Crowding

By David Douglas. NEW YORK (Reuters Health) Dec 09 - Active bed management by hospitalists can reduce emergency department (ED) congestion and increase throughput, Maryland-based researchers report in the December 2nd issue of the Annals of Internal Medicine.

"Our study," lead investigator Dr. Eric Howell told Reuters Health, "showed that hospitalists can be part of an effective solution for ED crowding, as well as help solve inpatient hospital capacity issues -- including ICU capacity."

Dr. Howell of Johns Hopkins University School of Medicine, Baltimore, and colleagues explain that the intervention included real-time monitoring of bed availability in ICUs, intermediate care and other units, as well as regular visits to the ED to assess congestion and flow of patients, and to facilitate transfers to appropriate units.

The researchers then compared data from the intervention period (from November 2006 to February 2007) with that from November 2005 to February 2006, prior to the intervention.

During the intervention period there was an 8.8% increase in patients (17,573 versus 16,148). However, throughput for patients who were admitted fell by 98 minutes (360 versus 458 minutes). There was no change in throughput for patients who were not admitted.

The amount of time that ambulances had to be diverted because of ED crowding fell by 6%, and there was a 27% drop in diversion time because of lack of ICU beds.

Dr. Howell concluded that "it is interesting that our study shows that hospitalists can have a dramatic impact on improving quality and efficiency in areas outside of the medical floor -- where hospitalists traditionally care for patients -- like the ED or ICU."

Ann Intern Med 2008;149:804-810. Abstract: http://www.annals.org/cgi/content/abstract/149/11/804

3. Festive Medical Myths

Vreeman RC, Carroll AE. BMJ 2008;337:a2769 [References not included.]

In the pursuit of scientific truth, even widely held medical beliefs require examination or re-examination. Both physicians and non-physicians sometimes believe things about our bodies that just are not true. As a reminder of the need to apply scientific investigation to conventional wisdom, we previously discussed the evidence disputing seven commonly held medical myths.1 The holiday season presents a further opportunity to probe medical beliefs recounted during this time of the year.

We generated a list of common medical or health beliefs related to the holidays and winter season and searched Medline for scientific evidence to support or refute these beliefs. If we couldn’t find any evidence in the medical literature, we searched the internet using Google.

Sugar causes hyperactivity in children
While sugarplums may dance in children’s heads, visions of holiday sweets terrorise parents with anticipation of hyperactive behaviour. Regardless of what parents might believe, however, sugar is not to blame for out of control little ones. At least 12 double blind randomised controlled trials have examined how children react to diets containing different levels of sugar.2 None of these studies, not even studies looking specifically at children with attention-deficit/hyperactivity disorder, could detect any differences in behaviour between the children who had sugar and those who did not.3 This includes sugar from sweets, chocolate, and natural sources. Even in studies of those who were considered "sensitive" to sugar, children did not behave differently after eating sugar full or sugar-free diets.3

Scientists have even studied how parents react to the sugar myth. When parents think their children have been given a drink containing sugar (even if it is really sugar-free), they rate their children’s behaviour as more hyperactive.4 The differences in the children’s behaviour were all in the parents’ minds.4

Suicides increase over the holidays
Holidays can bring out the worst in us. The combined stresses of family dysfunction, exacerbations in loneliness, and more depression over the cold dark winter months are commonly thought to increase the number of suicides. While the holidays might, indeed, be a difficult time for some, there is no good scientific evidence to suggest a holiday peak in suicides.5 6 7

One study from Japan that looked at suicides in 1979-94 showed that the rate of suicide was lowest in the days before a holiday and highest in the days after the holiday.8 In contrast, in a study from the United States of suicides over a 35 year period, there was no increase before, during, or after holidays.9 Indeed, people might actually experience increased emotional and social support during holidays. In the US, rates of psychiatric visits decrease before Christmas and increase again afterwards.10 A smaller study of adolescents showed a peak in suicide attempts at the end of the school year,11 possibly reflecting a decrease in social support. Data from Ireland on suicide in 1990-8 also failed to connect suicides with the holidays.12 While Irish women were no more likely to commit suicide on holidays than on any other days, Irish men were actually significantly less likely to do so.

Further debunking myths about suicide, people are not more likely to commit suicide during the dark winter months. Around the world, suicides peak in warmer months and are actually lowest in the winter. In Finland, suicides peak in autumn and are lowest in the winter.13 In a 30 year study of suicides in Hungary, researchers again found the highest rates of suicides in the summer and the lowest in the winter.14 Studies of suicide rates from India also show peaks in April and May.15 Studies from the US reflect this pattern, with lower rates in November and December than in typically warmer months.6

Of course, none of this evidence suggests that suicides do not happen over the holidays. The epidemiological evidence just does not support that the holidays are a time of increased risk.

Poinsettia toxicity
With flowers and leaves of red, green, and white, poinsettias are widely used in holiday decorations. Even though public health officials have reported that poinsettias are safe, many continue to believe this is a poisonous plant.16

In an analysis of 849 575 plant exposures reported to the American Association of Poison Control Centers,17 none of the 22 793 cases involving poinsettia resulted in considerable poisoning.17 No one died from exposure to or ingestion of poinsettia, and most (96%) did not even require medical treatment. In 92 of the cases, children ingested substantial quantities of poinsettias, but none needed medical treatment, and toxicologists concluded that poinsettia exposures and ingestions can be treated without referral to a healthcare facility.17 Another study, looking at poinsettia ingestion by rats, could not find a toxic amount of poinsettia, even at amounts that would be the equivalent of 500-600 poinsettia leaves or nearly a kilogram of sap.18

Excess heat loss in the hatless
As temperatures drop, hats and caps flourish. Even the US Army Field manual for survival recommends covering your head in cold weather because "40 to 45 percent of body heat" is lost through the head.19 If this were true, humans would be just as cold if they went without trousers as if they went without a hat. But patently this is just not the case.

This myth probably originated with an old military study in which scientists put subjects in arctic survival suits (but no hats) and measured their heat loss in extremely cold temperatures.20 Because it was the only part of the subjects’ bodies that was exposed to the cold, they lost the most heat through their heads. Experts say, however, that had this experiment been performed with subjects wearing only swimsuits, they would not have lost more than 10% of their body heat through their heads.20 A more recent study confirms that there is nothing special about the head and heat loss.21 Any uncovered part of the body loses heat and will reduce the core body temperature proportionally. So, if it is cold outside, you should protect your body. But whether you want to keep your head covered or not is up to you.

Nocturnal feasting makes you fat
Holiday feasts and festivities present us with many culinary options. A common suggestion to avoid unwanted weight gain is to avoid eating at night, and at first glance, some scientific studies seem to support this. In a study of 83 obese and 94 non-obese women in Sweden, the obese women reported eating more meals, and their meals were shifted to the afternoon, evening, or night.22 But just because obesity and eating more meals at night are associated, it does not mean that one causes the other. People gain weight because they take in more calories overall than they burn up. The obese women were not just night eaters, they were also eating more meals, and taking in more calories makes you gain weight regardless of when calories are consumed.

Other studies found no link at all between eating at night and weight gain. Swedish men did not show any evidence of gaining weight with night time meals.23 In a study of 86 obese and 61 normal weight men, there were no differences in the timing of when they ate.23 Another study of 15 obese people found that the timing of meals did not change the circadian rhythm pattern of energy expenditure.24 In a study of over 2500 patients, eating at night was not associated with weight gain, but eating more than three times a day was linked to being overweight or obese.25 Studies have connected skipping breakfast with gaining more weight, but this is not because breakfast skippers eat more at night.26 Breakfast skippers eat more during the rest of the day. Records of calorie intake suggest that those who eat breakfast maintain healthy weights because their calorie intake is more evenly distributed over the day.26 27 In other words, when you eat three regular meals, you are not as likely to overeat at any one particular meal or time.

You can cure a hangover
From aspirin and bananas to Vegemite and water, internet searches present seemingly endless options for preventing or treating alcohol hangovers.28 Even medical experts offer suggestions.29

No scientific evidence, however, supports any cure or effective prevention for alcohol hangovers. A systematic review of randomised trials evaluating medical interventions for preventing or treating hangovers found no effective interventions in either traditional or complementary medicine.28 While a few small studies using unvalidated symptom scores showed minor improvements, the conclusion of the exhaustive review was that propranolol, tropisetron, tolfenamic acid, fructose or glucose, and dietary supplements including borage, artichoke, prickly pear, and Vegemite all failed to effectively "cure hangovers." While more recent studies in rats show some potential for new products to alter mechanisms associated with hangovers,30 31 humans also face risks when using certain "hangover cures."32 A hangover is caused by excess alcohol consumption. Thus, the most effective way to avoid a hangover is to consume alcohol only in moderation or not at all.

Conclusions
Examining common medical myths reminds us to be aware of when evidence supports our advice, and when we operate based on unexamined beliefs. This was not a systematic review of either the evidence to refute these medical myths or of doctors’ beliefs. None the less, we applied rigorous search methods to compile data, and evidence of the prevalence of these medical beliefs is readily available. Only by investigation, discussion, and debate can we reveal the existence of such myths and move the field of medicine forward.

4. Women with STEMI Fare Worse Than Men

Lisa Nainggolan. From Heartwire — a professional news service of WebMD. December 10, 2008 — A contemporary look at whether there are still differences between men and women in terms of medical care and outcomes after acute myocardial infarction (AMI) has revealed that the situation appears to be improving for women but that there is still some way to go to achieve equality [1].

In their report published online December 8, 2008 in Circulation, Dr Hani Jneid (Baylor College of Medicine and Michael E De Bakey VA Medical Center, Houston, TX) and colleagues analyzed data from the American Heart Association (AHA) Get With the Guidelines program and found no differences between the sexes in terms of in-hospital mortality from AMI. However, women with ST-elevation MI (STEMI) were still more likely than men to die in the hospital.

Our work is still cut out for us
"It's disturbing that there is still a persistent gap in mortality in the highest-risk STEMI group," Jneid told heartwire. "We were able to close the gap between the sexes after adjusting for age and risk factors, but we found a disparity across the board in all treatments between women and men and a disturbing delay in treatment in women compared with men. We have room to improve on the healthcare and outcome of women when they present with this severe type of heart attack."

Dr Nieca Goldberg (Women's Heart Center, New York University, NY), an AHA spokesperson who was not involved in the research but has a special interest in women's health, told heartwire: "I'm disappointed by this research, as there have been a lot of campaigns to increase awareness about cardiovascular disease in women. It seems like we've improved our care in women with non-STEMI, but it's kind of confusing to me why women with a STEMI come in and are more likely to die." She adds that she is reassured that doctors seem to have gotten better at treating the subtler forms of heart attack, "but our work is still cut out for us."

Women less likely to receive adequate therapies

In their study, Jneid et al examined sex differences in care processes and in-hospital deaths among 78,254 patients with AMI in 420 US hospitals from 2001 to 2006. Women, in general, were older, had more comorbidities, less often presented with STEMI, and had higher unadjusted in-hospital death (8.2% vs 5.7% for men; p less than 0.0001).

But after multivariate adjustment, sex differences in in-hospital mortality were no longer apparent in the overall AMI cohort (adjusted odds ratio 1.04), although they persisted among STEMI patients (mortality rate 10.2% among women compared with 5.5% in men; p less than 0.0001; adjusted odds ratio [OR] 1.12).

This excess death seen in women with STEMI was primarily accounted for by an excess of very early deaths among women in the initial 24 hours of hospitalization, the researchers note. Women were less likely to receive early medical treatments, acute reperfusion therapies, timely pharmacological and mechanical reperfusion, and invasive procedures.

"This tells us that there are true disparities," Jneid says.

Abstract: http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.108.789800v1

5. No Benefit of TNK in Cardiac Arrest: TROICA Published

from Heartwire — a professional news service of WebMD. December 19, 2008 — The first large-scale trial to investigate the addition of the thrombolytic tenecteplase (TNK) to standard cardiopulmonary resuscitation (CPR) — which showed no increase in survival in cardiac-arrest patients given such therapy — has been published in the December 19, 2008, issue of the New England Journal of Medicine. The results were first presented at the World Congress of Cardiology in Barcelona two years ago, as reported by heartwire.

Lead author Dr Bernd Boettiger (University of Cologne, Germany), who also presented the study — called Thrombolysis in Cardiac Arrest (TROICA) — in Barcelona, told heartwire that nothing has changed between the presentation and publication, except for the fact that the survival rates reported in Barcelona were slightly higher, because asystolic patients were excluded from the analysis. "The New England Journal of Medicine recommended that we include the asystolic patients (n = 209), so we have a slightly lower survival rate in the paper by incorporating these patients with a very poor prognosis," he remarked.

Nevertheless, the overall conclusion is the same, he says. "In the setting of witnessed cardiac arrest of presumed cardiac origin, there is no additional benefit from the use of TNK without concomitant antithrombotic treatment. This was a result that was very disappointing to us, as we did expect it would help very much."

But as he stressed in Barcelona, Boettiger is not yet ready to give up on this strategy completely. "Further investigation has to focus on combining TNK treatment with anticoagulants, such as heparin, and other things. We are working on further trials because we are convinced that anticoagulation plays a role in reperfusion after cardiac arrest, and we have been discussing with industry as to how we can proceed from here."

Boettiger BW, Arntz HR, Chamberlain DA, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359:2651-2662. Abstract: http://content.nejm.org/cgi/content/abstract/359/25/2651

6. Inhaled corticosteroids don’t reduce mortality in stable COPD

JAMA 2008;300:2407-16.

Like most drug treatments for chronic obstructive pulmonary disease (COPD), inhaled corticosteroids are better at symptom control and preventing exacerbations than they are at saving lives. The latest meta-analysis to look specifically at mortality found that long term inhaled steroids made no difference to survival for people with stable disease but did increase the risk of pneumonia.

The authors found 11 randomised trials evaluating fluticasone, triamcinolone, and budesonide, alone or in combination with other inhaled drugs, usually salmeterol. The trials tested treatments that lasted at least six months and studied more than 14 000 adults between them. Relative risk of death was 0.86 (95% CI 0.68 to 1.09) in patients treated with inhaled steroids, compared with controls given placebo or other inhaled drugs. Subgroup analyses looking at the effect of duration of treatment, type of product (monotherapy or combined), severity of disease, and dose were all negative. Inhaled corticosteroids were associated with a significant 34% increase in the risk of pneumonia (1.34, 1.03 to 1.75), but no extra fractures (1.09, 0.89 to 1.33).

Because this treatment seems to have no effect on mortality, doctors must weigh up the other risks (pneumonia) and benefits (fewer exacerbations, improved quality of life) when making therapeutic decisions in patients with stable chronic pulmonary obstructive disease, say the authors. As usual, the balance will vary between different subgroups. In this analysis, risk of pneumonia was highest in patients with the poorest lung function, those given higher doses, and those treated with combined products. Doctors who decide to prescribe inhaled steroids should use the lowest effective dose, say the authors.

7. They Don’t Train ’em Like They Used to

Taylor JS, et al. BMJ 2008;337:a2895. [Tables not included.]

To check perceptions that the younger generation are lacking the etiquette of their seniors, we reviewed over 300 radiology request forms written on a single weekday in a hospital on the south coast of England. We used the presence of the word "please" on the request form as a proxy measure of courtesy (table 1).

Table 1. Use of "please" on radiology request forms

Consultants and associate specialists came out on top. Junior hospital doctors (all grades) did less well, although better than nurses. Overall, the staff in the intensive therapy unit and the accident and emergency department scored modestly.

Among consultants, those in general surgery and general medicine were the most courteous, and orthopaedic surgeons conformed to their alledged stereotype of never requesting politely. However, the results for orthopaedic juniors give faint grounds for hope.

Graduates of Birmingham, Bristol, and Nottingham medical schools seemed the most polite, although the numbers are small (table 2). Foundation year docotors’ results were variable, with notable politeness from St George’s Medical School. Senior trainees from Guy’s, King’s and St Thomas’ and from Cambridge also scored very well.

Table 2. Use of "please" on radiology request forms, by medical school

Our investigation shows that seniors still set the gold standard for chivalry, with the rest of us only hoping to emulate them.

8. The fattening truth about restaurant food

Karen McColl. BMJ 2008;337:a2229

Going out to eat is often a disaster for the waistline. Karen McColl reports on US efforts to make diners more aware of what they are eating

Customers going into restaurant chains like Burger King or Starbucks in New York can now take calories into account when they choose what to eat. Since May, chain restaurants in the city have been required to include calorie contents on menu boards, menus, and item tags. The law applies to restaurant chains with more than 15 branches nationally.

Similar menu labelling, or "calorie posting," laws came into force in September in San Francisco and Santa Clara County in California, and the requirement will soon apply to the whole state. Arnold Schwarzenegger has now approved an amended version of a menu labelling bill that he vetoed last year, making California the first state to pass a menu labelling law. Around 20 cities and states across the US are considering menu labelling legislation. But the restaurant industry is fighting all the way.

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"It’s just the most astonishing thing I’ve ever seen," says Marion Nestle from New York University. Professor Nestle is an academic nutritionist with decades of experience advising on nutrition issues. Yet, since calories have been posted on menus in New York she has been surprised. "For someone like me who thinks that they know about these things, I’m stunned by the number of calories in fast foods. I had no idea." As examples, she cites a blueberry and pomegranate smoothie that provides 1180 kcal (4.9 MJ) and a pizza for one person with more than 2000 kcal (8.3 MJ).

Professor Nestle is not the only nutrition expert to have difficulty assessing the nutritional content of fast food. The Food Commission recently asked 66 nutrition experts at an international obesity conference whether they could tell from the menu description which food was likely to contain most energy or fat. None of the experts answered all five questions correctly, and only a quarter answered more than two questions correctly.

Given that nutrition experts have difficulty choosing the healthiest options, what hope for the rest of the population? Research shows that consumers, like nutrition experts, have difficulty assessing the calorie content of fast food items and that people tend to underestimate energy content.

It is because people find it difficult to estimate calories that these laws are being introduced as part of an effort to tackle obesity, which now affects a third of US adults. Another key factor is the importance of eating out in the overall diet. Americans consume around one third of their calories outside the home, and nearly three quarters of all restaurant visits are to fast food or other chain restaurants. A survey of over 7000 fast food customers by New York’s health department found that a third (34%) of respondents purchased 1000 kilocalories or more at lunchtime.6 Research also shows that when calorie information is given people tend to choose high calorie items less often.6 7 We also know that consumers—both in the US and the UK—strongly favour having more accessible nutrition information when they eat out.

"We’re confident that this law will have two positive effects," says Tom Frieden, New York’s health commissioner. "The first is to encourage restaurants to offer healthier options, and the second will be to encourage some customers to make healthier choices." Dr Frieden estimates that the legislation could result in 150 000 fewer New Yorkers being obese and 30 000 fewer cases of diabetes in the city over the next five years.

Improved visibility
Although many fast food chains already make nutrition information available, few customers see this information. At the time of the New York survey only Subway provided information at the point of purchase. Among customers of other outlets, just 4% reported seeing calorie information. Some nutrition information is available on company websites. Calculations based on figures from McDonald’s, which now also provides nutrition information on the back of tray liners, show that its nutrition information website receives one hit for every 25 000 meals sold. Where restaurants provide nutrition information leaflets on site, public health advocates argue that this information is overly complex and is not readily accessible when consumers order their food.

The key concept behind the menu labelling rules is to provide information in places where people will see it when they are choosing what to order. That means on menu boards and menus. Fast food restaurants describe the menu board as their most important means of communicating with customers, and this is one of the reasons that they have been resisting the legislation so strongly.

Although it is still too early to evaluate the impact of the new law, newspaper and blogs have been full of reports quoting shocked customers. Dr Frieden says that preliminary feedback suggests consumers are becoming more aware of calories, and some outlets are also starting to change what is on offer. There are reports of leading chains highlighting lower calorie options on the menus and introducing healthier options.

"What you hear essentially is sticker shock about the number of [kilo]calories in some common items—whether it’s a 600 calorie cup of coffee, a 1200 calorie salad, a 1400 calorie breakfast, or a 2700 calorie appetiser," Dr Frieden says.

Professor Nestle agrees that some New Yorkers are in shock, but is concerned that the numbers mean little to people who do not know that a typical adult needs only around 2000 kilocalories a day. "It’s a good thing, but it needs to be accompanied by a very clear know your number message so that you know that you should be aiming to consume somewhere in the 2000 range every day," she said. The California legislation does require restaurants to include information explaining recommended intakes in nutrition leaflets. In October the New York Health Department launched an advertising campaign to get the message across that most adults need no more than 2000 kilocalories a day to maintain a healthy weight. Dr Frieden also points out that even if you don’t know how many calories you should be consuming in a day, you can still use the calorie information to compare items and make healthier choices.

Industry response
The restaurant industry has been vigorously opposing the menu labelling legislation. The New York State Restaurant Association has challenged the legislation in court, arguing that the regulation overlaps with federal law and violates their members’ free speech by compelling them to deliver a government message about the importance of calories. The court rejected both arguments in April. The association has appealed, and the appeal court’s decision is expected any day now. In the meantime, restaurants have to comply with the legislation.

In Seattle (King County), industry lobbying and pressure from the state legislature obtained a compromise that allows calories to be posted on signs next to menu boards or on eye level signs at the point of ordering instead of menu boards.

As well as using the legal systems to get menu labelling revoked, the restaurant industry is lobbying for legislation to ban such laws being passed in the first place. Ohio and Georgia have recently passed state measures that prohibit any local authorities from introducing menu labelling legislation. There are signs that some restaurant chains now accept that these rules are here to stay. Yum brands, which owns the Pizza Hut and KFC chains, announced on 1 October that it will introduce calorie counts on menu boards in its 20 000 US outlets by 2011.

9. GASP! Agonal Breathing Common, Predicts Survival After Out-of-Hospital Cardiac Arrest

from Heartwire — a professional news service of WebMD. Steve Stiles. November 27, 2008 (Tucson, AZ) - Someone stricken with out-of-hospital cardiac arrest might still be gasping for air, but that's no reason for witnesses to avoid jumping in with chest compressions, according to researchers who studied the phenomenon [1]. On the contrary, that initial period of distressed breathing might last only minutes but provides the best chance for resuscitation efforts to succeed and allow the patient to survive to hospital discharge, suggests a retrospective analysis published online November 24, 2008 in Circulation.

About a third of more than 1200 cases of witnessed out-of-hospital cardiac arrest attended by Arizona emergency medical services (EMS) over a recent three-year period were characterized by gasping, "often referred to as snoring, snorting, gurgling, or moaning, or as agonal, barely, labored, noisy, or heavy breathing," report the authors, led by Dr Bentley J Bobrow (Mayo Clinic College of Medicine, Phoenix, AZ, and University of Arizona Sarver Heart Center, Tucson). Gasping was most frequent in the early minutes after the patients collapsed.

The patients who gasped, compared with those who didn't, were overall three times more likely to survive to hospital discharge, but were five times more likely if they received bystander cardiopulmonary resuscitation (CPR).

Gasping is an indication that you're doing a great job and you shouldn’t stop.

The incidence and prognostic implications of gasping at cardiac arrest are underappreciated, a shortfall in public education that can delay or discourage bystander participation, according to Bobrow et al. "It is not uncommon to hear anecdotal reports that bystanders (even medical professionals) failed to initiate CPR because they concluded that the patient was still breathing and therefore did not have a cardiac arrest," they write. (Their study, however, does not show this.)

The gasping is a sign of poor but marginally adequate cerebral perfusion, and it is promising whether it starts as the patient collapses or only after the beginning of CPR, according to coauthor Dr Gordon A Ewy (University of Arizona Sarver Heart Center). Lay people who initiate CPR tend to be startled if gasping occurs, believing the patient is "waking up," and then often stop what they are doing, he said to heartwire. But, "gasping is an indication that you're doing a great job and you shouldn’t stop."

In a review of records from the Phoenix Fire Department Regional Dispatch Center, the authors observed that 44 of 113 cases (39%) of witnessed and unwitnessed out-of-hospital cardiac arrests were characterized by abnormal breathing.

They looked at the phenomenon's prevalence in relation to EMS response times for 1218 cases of witnessed out-of-hospital cardiac arrest occurring in Arizona from 2004 to 2007. Whether EMS personnel observed gasping was inversely related to how soon they arrived after the patient's collapse.

Gasping was associated with a significantly increased odds of survival to hospital discharge, the study's primary end point--whether or not, but especially if, bystander CPR was performed.

Gasping was observed by EMS personnel in 33% of cases when collapse occurred with EMS on the scene, and the rate steadily decreased with EMS arrival times: 20% for less than 7 minutes, 14% for 7 to 9 minutes, and 7.5% for more than 9 minutes. The odds ratio for gasping with EMS arrival beyond 9 minutes after collapse was 0.30, compared with less than 7 minutes (p less than 0.001) after adjustment for age, sex, whether bystander CPR was performed, location of cardiac arrest, and whether VF was documented.

Ewy is among the principal advocates of what he calls cardiocerebral resuscitation for arrest of cardiac origin, characterized most notably by an emphasis on chest compressions uninterrupted by assisted breathing. The technique, as previously reported by heartwire, was recently endorsed by the American Heart Association as being about as effective as the traditional method involving compressions plus "mouth to mouth" resuscitation.

But proponents of the chest-compression-only method say it is superior, not only in being more successful but in encouraging bystanders to attempt it in the first place. In fact, Ewy said, the current study was designed, in part, to help get the public and providers to see abnormal breathing as a reason to initiate or continue CPR rather than a reason to stop or avoid it.

Ewy has no industry-related disclosures; of his coauthors, Dr Robert A Berg (University of Arizona Sarver Heart Center) discloses grant support from Medtronic and Dr Karl B Kern (University of Arizona Sarver Heart Center) reports being on the scientific advisory committees of Zoll and PhysioControl.

Abstract: http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.108.799940v1

10. Health, Emergency Staff Get Drugs First in Pandemic

WASHINGTON (Reuters) Dec 17 - Health care and emergency services workers who might help sick people during an influenza pandemic should take antiviral drugs throughout the epidemic, the U.S. Department of Health and Human Services said in new guidance released on Tuesday.

Employers such as hospitals should be responsible for stockpiling the drugs and designating who gets them, HHS said in its latest guidance.

People with weakened immune systems, such as cancer patients, should also get so-called prophylactic antivirals, which means taking them before they ever get sick, HHS said.

Two antiviral drugs can both prevent and treat all forms of influenza A, including H5N1. They are Roche and Gilead Sciences Inc's Tamiflu and GlaxoSmithKline and Biota Holdings Ltd's Relenza.

"Planning and preparing for a pandemic influenza requires action by every part of society, including individuals and families, communities, and private sector employers as well as all levels of government," Dr. Craig Vanderwagen, HHS assistant secretary for preparedness and response, said in a statement.

"Employers will play a key role in protecting employees' health and safety, which in turn reduces the impact of a pandemic on the nation's health, the economy and society."

HHS earlier encouraged employers to stockpile the drugs, which can both treat and prevent flu.

In July, HHS said about a million essential health care workers would be immunized first if a flu pandemic broke out in the United States.

Many public health experts agree some sort of influenza pandemic is inevitable, although no one can predict when it might come and how severe it may be.

It is also impossible to predict what strain of flu might cause it, although H5N1 avian influenza is the main suspect now. It has become entrenched in birds in Asia, Europe, the Middle East and possibly Africa.

While just 390 people have been infected since 2003 and 246 have died, experts fear H5N1 could acquire the ability to spread easily from human to human, setting off a pandemic that could kill hundreds of millions of people.

11. Head and neck injury risks in heavy metal: head bangers stuck between rock and a hard bass

Patton D, et al. BMJ 2008;337:a2825

Objective: To investigate the risks of mild traumatic brain injury and neck injury associated with head banging, a popular dance form accompanying heavy metal music.
Design Observational studies, focus group, and biomechanical analysis.

Participants: Head bangers.

Main outcome measures: Head Injury Criterion and Neck Injury Criterion were derived for head banging styles and both popular heavy metal songs and easy listening music controls.

Results: An average head banging song has a tempo of about 146 beats per minute, which is predicted to cause mild head injury when the range of motion is greater than 75°. At higher tempos and greater ranges of motion there is a risk of neck injury.

Conclusion: To minimise the risk of head and neck injury, head bangers should decrease their range of head and neck motion, head bang to slower tempo songs by replacing heavy metal with adult oriented rock, only head bang to every second beat, or use personal protective equipment.

12. Safety Improvements Mandated for Emergency Dept Design, Management

Laurie Barclay, MD. December 9, 2008 — Safety improvements in emergency department (ED) design and management are needed, according to a survey of emergency department clinicians reported in the December 5 issue of the Annals of Emergency Medicine.

"This is a national problem," lead author David Magid, MD, senior scientist at the Kaiser Permanente Colorado Institute for Health Research and director for research at the Colorado Permanente Medical Group in Denver, said in a news release. "It doesn't matter if the hospital is big or small, an academic or community-based institution, or the region of the country."

The study objective was to evaluate the degree to which EDs are designed, managed, and supported in ways that promote patient safety.

"A basic tenet of quality and safety theory is that personnel involved in daily work are often best informed to identify problems that threaten quality and safety in the workplace," the study authors write. "According to previous work on the state of US EDs and the prevalence of safety problems in EDs, we hypothesized that reports of ED personnel would reveal multiple opportunities to improve ED systems in ways that might contribute to safety of care."

Clinicians working in 65 US EDs completed a validated, psychometrically tested survey evaluating their observations and opinions regarding the EDs' physical environment, staffing, equipment and supplies, nursing, teamwork, safety culture, triage and monitoring, and coordination of information flow, consultation, and flow to inpatient departments.

Response rate was 66%, with 3562 eligible respondents completing the survey. The participants often reported problems in 4 systems vital to ED safety: physical environment, staffing, inpatient coordination, and information coordination and consultation. Across all 9 domains surveyed, few respondents reported that support systems were adequate most or all of the time.

Space was reported to be inadequate for the delivery of care most (25%) or some (37%) of the time. In addition, clinicians reported that the number of patients exceeded ED capacity to ensure safe care most (32%) or some (50%) of the time.

Only 41% of respondents reported that most of the time, specialty consultation for critically ill patients arrived within 30 minutes of being contacted, and half reported that ED patients needing intensive care unit admission were rarely transferred from the ED to the intensive care unit within 1 hour.

About 40% of respondents reported that physician staffing is inadequate to handle patient loads during busy periods, two thirds reported that nursing staff is insufficient to handle patient loads during busy periods, and one third reported that patients in the ED's waiting rooms are monitored often.

"Reports by ED clinicians suggest that substantial improvements in institutional design, management, and support for emergency care are necessary to maximize patient safety in US EDs," the study authors write. "Our results suggest that conditions may be somewhat better in smaller, non–residency-affiliated EDs."

Study limitations include lack of generalizability to all US EDs, reliance on clinician report rather than direct observation of the conditions being investigated, and an inability to determine whether perceived deficiencies were actually associated with hazard or harm to patients.

Factors that may hinder provision of safe ED care may include loss of information during handoffs at change of shift and frequent interruptions of ED clinicians.

"Gaining access to a patient's medical record is often difficult, and the availability of computers in the ED is frequently inadequate," the study authors conclude. "Finally, with respect to safety culture, the blaming of individuals for safety problems remains common, and hospital administrators are frequently perceived not to be supportive of improving patient safety.

This study was supported by the Agency for Healthcare Research and Quality.

Ann Emerg Med. Published online December 5, 2008. Abstract: http://www.annemergmed.com/article/S0196-0644(08)01863-5/abstract

13. In Upper GI Bleeding, Choosing Who Gets Admitted and Who Goes Home

A scoring system based on simple clinical evaluation and without the need for endoscopy can identify low-risk patients who present with upper gastrointestinal bleeding, according to a Lancet study released online.

Researchers compared two scoring systems for predicting level of risk in patients presenting with upper GI hemorrhage to four U.K. hospitals — the widely used Rockall score and the newer Glasgow-Blatchford bleeding score (GBS). (The GBS is based on lab values — namely, blood urea and hemoglobin — along with systolic pressure, pulse, and presenting signs. Patients with normal values and no melena, syncope, or evidence of liver disease or heart failure are considered to be at low risk and thus eligible for outpatient management.)

The GBS outperformed the Rockall score at identifying low-risk patients in the emergency room, resulting in fewer hospitalizations. None of the patients with low-risk GBS required intervention for hemorrhage or had died after at least 6 months' follow-up.
The Lancet. Published online December 15, 2008.

14. Epidemic of Overdose Deaths Linked to Nonmedical Use of Prescription Opioids

December 11, 2008 — Up to 93% of unintentional overdose deaths in West Virginia, 1 of the poorest US states, are due to nonmedical use of prescription pharmaceuticals, primarily opioid analgesics, new research shows.

A population-based, observational study by investigators at the Centers for Disease Control and Prevention (CDC), in Atlanta, Georgia, shows nearly two-thirds of all drug-overdose deaths involved prescription diversion, meaning those who died did not have prescriptions for the drugs that killed them.

"We had anticipated that drug diversion would be an important contributor to these [overdose] deaths. However, the finding that nearly two-thirds of the deaths involved prescription drug diversion was particularly noteworthy," principal investigator Aron J. Hall, DVM, told Medscape Psychiatry.

Furthermore, investigators found that "doctor shopping" was a major contributor to unintentional drug-overdose mortality. "Roughly 1 in 5 of those who died had evidence of doctor shopping, which was defined as an individual who had 5 or more health providers in the previous year writing prescriptions for controlled substances," he said.

Hall AJ, et al. JAMA. 2008;300:2613-2620. Abstract: http://jama.ama-assn.org/cgi/content/abstract/300/22/2613

15. Internet-Based CME Leads to Good Evidence-Based Clinical Choices

NEW YORK (Reuters Health) Dec 10 - Physicians who participate in selected internet-based continuing medical education (CME) activities are more likely to make evidence-based clinical decisions than their counterparts who do not participate in these types of CME, according to new research.

Linda Casebeer of Outcomes, Inc., in Birmingham, Alabama, and colleagues with Medscape, LLC, of New York, Harvard Medical School in Boston, and the University of Alabama at Birmingham, conducted a controlled trial of the effectiveness of 48 internet-based CME activities.

Responses to several case vignettes reflecting the information provided in the CME activities were assessed for 2785 physicians who participated in the CME programs and 2836 nonparticipants.

There was a 45% increased likelihood that participants made clinical decisions in various vignettes based on clinical evidence, Casebeer and colleagues report in BioMed Central (BMC) Medicine, issued online December 4.

"This likelihood was higher in interactive case-based activities, 51%, than for text-based clinical updates, 40%," the team found. Effectiveness was higher among primary care physicians than specialists, the authors add.

"Internet CME activities show promise in offering a searchable, credible, available on-demand, high-impact source of CME for physicians," Casebeer and colleagues conclude.

BMC Medicine 2008;6. Abstract: http://www.biomedcentral.com/1741-7015/6/37/abstract

16. Thrombolytic Therapy: Not for Uncomplicated PE

Patients without hemodynamic compromise had higher mortality rates when they were given thrombolytic therapy.

Ibrahim SA, et al. Arch Intern Med. 2008;168:2183-2190. Abstract: http://archinte.ama-assn.org/cgi/content/abstract/168/20/2183

Editorial: Systemic thrombolysis effectively and rapidly dissolves clots in the pulmonary vasculature as well as the deep veins, but unlike thrombi in coronary or cerebral arteries, a PE usually does not result in permanent tissue necrosis. Provided that the patient survives the immediate hemodynamic effects of the initial event, therapy with antithrombotics alone (heparin products followed by warfarin) will usually keep further clotting at bay, allowing the body's natural fibrinolytic system to slowly dissolve any existing thromboses. This favorable response to standard anticoagulation in the majority of patients with PE, coupled with the known hemorrhagic risks of systemic thrombolysis, limits the target population for thrombolysis to those patients at high risk for hemodynamic collapse…

Brotman DJ, et al. Arch Intern Med. 2008;168:2191-2192.

17. Ultrasound in the ED Diagnosis of CHF

Identification of congestive heart failure via respiratory variation of inferior vena cava diameter

Blehar DJ, et al. Amer J Emerg Med. 2009;27:71-75.

Introduction
Rapid diagnosis of volume overload in patients with suspected congestive heart failure (CHF) is necessary for the timely administration of therapeutic agents. We sought to use the measurement of respiratory variation of inferior vena cava (IVC) diameter as a diagnostic tool for identification of CHF in patients presenting with acute dyspnea.

Methods
The IVC was measured sonographically during a complete respiratory cycle of 46 patients meeting study criteria. Percentage of respiratory variation of IVC diameter was compared to the diagnosis of CHF or alternative diagnosis.

Results
Respiratory variation of IVC was smaller in patients with CHF (9.6%) than without CHF (46%) and showed good diagnostic accuracy with area under the receiver operating characteristic curve of 0.96. Receiver operating characteristic curve analysis showed optimum cutoff of 15% variation or less of IVC diameter with 92% sensitivity and 84% specificity for the diagnosis of CHF.

Conclusion
Inferior vena cava ultrasound is a rapid, reliable means for identification of CHF in the acutely dyspneic patient.

18. A worrying proportion of the British medical students can’t tell their left from their right

Gormley GJ, et al. BMJ 2008;337:a2826

Right-left discrimination among medical students: questionnaire and psychometric study

Objective: To determine medical students’ self awareness and ability to discriminate right from left; to identify characteristics associated with this ability; and to identify any techniques used to aid discrimination.

Design: Questionnaire and psychometric study.

Setting: Undergraduate medical school, Northern Ireland.

Participants: 290 first year undergraduate students.

Main outcome measure: Medical students’ ability to discriminate right from left using the Bergen right-left discrimination test.

Results: Test scores ranged from 31 to 143 on a scale of 0-144 (mean 112 (standard deviation 22.2)). Male students significantly outperformed female students (117.18 (26.96) v 110.80 (28.94)). Students who wanted to be surgeons performed significantly better than those who wanted to be general practitioners or medical doctors (119.87 (25.15) v 110.55 (27.36) v 112.50 (26.88)). The interaction effect for sex and career wishes was not significant (P=0.370). Students who used learnt techniques to help them discriminate scored significantly less than those who did not (P less than 0.001). Students had greater difficulty in discriminating right from left when looking at the forward view rather than the back view (P less than 0.001).

Conclusions: Male students were better than female students at distinguishing right from left, and aspiring surgeons were better than aspiring general practitioners or medical doctors. Students had more difficulty with the forward view than the back view.

19. Use of lipid emulsion in the resuscitation of patients overdosing on lipid-soluble drugs

Sirianni AJ. Ann Emerg Med. 2008;51:412-5, 415.e1.

Animal studies show efficacy of intravenous lipid emulsion in the treatment of severe cardiotoxicity associated with local anesthetics, clomipramine, and verapamil, possibly by trapping such lipophilic drugs in an expanded plasma lipid compartment ("lipid sink"). Recent case reports describe lipid infusion for the successful treatment of refractory cardiac arrest caused by parenteral administration of local anesthetics, but clinical evidence has been lacking for lipid's antidotal efficacy on toxicity caused by ingested medications.

A 17-year-old girl developed seizure activity and cardiovascular collapse after intentional ingestion of up to 7.95 g of bupropion and 4 g of lamotrigine. Standard cardiopulmonary resuscitation for 70 minutes was unsuccessful in restoring sustained circulation. A 100-mL intravenous bolus of 20% lipid emulsion was then administered, and after 1 minute an effective sustained pulse was observed. The patient subsequently manifested significant acute lung injury but had rapid improvement in cardiovascular status and recovered, with near-normal neurologic function. Serum bupropion levels before and after lipid infusion paralleled triglyceride levels. This patient developed cardiovascular collapse because of intentional, oral overdose of bupropion and lamotrigine that was initially refractory to standard resuscitation measures. An infusion of lipid emulsion was followed rapidly by restoration of effective circulation. Toxicologic studies are consistent with the lipid sink theory of antidotal efficacy.

Followed by a letter to the editor:

Cave G, et al. Ann Emerg Med. 2008;51:449-50.

To the Editor:

We wish to congratulate Sirianni et al on their case publication “Use of Lipid Emulsion in the Resuscitation of a Patient With Prolonged Cardiovascular Collapse After Overdose of Bupropion and Lamotrigine.” This represents a major step in the evolution of lipid emulsion as antidotal therapy in lipid-soluble drug cardiotoxicity, and is the first to demonstrate effect in an enteric overdose of lipid soluble drug.

Application of lipid infusion in local anesthetic-induced cardiotoxicity follows pioneering work by Weinberg and others demonstrating efficacy in animal models, and subsequently successful case publications. Re-establishment of new plasma equibrilium favoring sequestration of lipophilic drugs into a newly created intravascular compartment is the currently proposed mechanism of action. We have additionally demonstrated efficacy for lipid infusion in animal models of clomipramine and verapamil toxicity, suggesting potential benefit in deliberate overdose from these lipid soluble agents.

Guidelines advocating lipid emulsion as therapy for local anesthetic cardiotoxocity have recently been published by The Association of Anaesthetists of Great Britain and Ireland.6 We would endeavor to contribute to the “bringing over” of lipid therapy for lipophilic drug toxidromes from the anesthetic domain to the general toxicologic domain wherein we believe the greatest benefit is likely to be manifest.

The use of lipid emulsion as antidote should, however, progress with some caution. Enthusiasm and imprudence are common bedfellows in the commendation and application of novel medical therapies. The special setting encountered by Sirianni et al, that of refractory arrest despite all conventional therapy, is one where use of lipid emulsion is rational. The only potential alteration to outcome is benefit. Indiscriminate application of this therapy at the expense of validated antidotal therapies is unwarranted at this point. We would echo the call of the anesthetic literature for the use of lipid emulsion in the setting of lipophilic drug cardiotoxicity where death is adjudged inevitable despite all available alternative therapies.

Finally, as the nature and presentation of life-threatening lipophilic drug intoxication renders systemic human study impractical, animal modelling and case publication are likely to represent the avenues by which lipid therapy may advance. It is therefore the responsibility of individual clinicians to disseminate their experience with lipid therapy, both successes and otherwise. Moreover we would implore editors to publish such case reports both positive and negative. In time a major new therapy may be available to severely intoxicated patients.

20. Screening Laboratory and Radiology Panels for Trauma Patients Have Low Utility and Are Not Cost Effective

Tasse JL, et al. J Trauma 2008;65:1114-1116.

Background: Routine laboratory and radiology panels as part of the initial evaluation of the trauma patient are prevalent practices. This is a study of utility and cost effectiveness of this practice.

Methods: During a 3-month period, trauma panels were analyzed for cost and impact on patient care in our institution.

Results: Four hundred ten consecutive patients had 3,982 studies (cost $417,839) performed of which 1,292 (cost $114,753) were abnormal and only 253 (cost $36,703) were clinically contributory.

Conclusions: Routine panels are not useful or cost effective. Negative results contribute little to management. Selective and targeted studies should be indicated by the secondary survey, and may result in substantial cost savings ($1,500,000 per year at our institution).

21. Inability to get up after falling, subsequent time on floor, and summoning help: prospective cohort study in people over 90

Fleming J, et al. BMJ 2008;337:a2227

Objectives: To describe the incidence and extent of lying on the floor for a long time after being unable to get up from a fall among people aged over 90; to explore their use of call alarm systems in these circumstances.

Design: 1 year follow-up of participants in a prospective cohort study of ageing, using fall calendars, phone calls, and visits.

Setting: Participants’ usual place of residence (own homes or care homes), mostly in Cambridge.

Participants: 90 women and 20 men aged over 90 (n=110), surviving participants of the Cambridge City over-75s Cohort, a population based sample.

Main outcome measures: Inability to get up without help, lying on floor for a long time after falling, associated factors; availability and use of call alarm systems; participants’ views on using call alarms to summon help if needed after falling.

Results: In one year’s intensive follow-up, 54% (144/265) of fall reports described the participant as being found on the floor and 82% (217/265) of falls occurred when the person was alone. Of the 60% who fell, 80% (53/66) were unable to get up after at least one fall and 30% (20/66) had lain on the floor for an hour or more. Difficulty in getting up was consistently associated with age, reported mobility, and severe cognitive impairment. Cognition was the only characteristic that predicted lying on the floor for a long time. Lying on the floor for a long time was strongly associated with serious injuries, admission to hospital, and subsequent moves into long term care. Call alarms were widely available but were not used in most cases of falls that led to lying on the floor for a long time. Comments from older people and carers showed the complexity of issues around the use of call alarms, including perceptions of irrelevance, concerns about independence, and practical difficulties.

Conclusions: Lying on the floor for a long time after falling is more common among the "oldest old" than previously thought and is associated with serious consequences. Factors indicating higher risk and comments from participants suggest practical implications. People need training in strategies to get up from the floor. Work is needed on access and activation issues for design of call alarms and information for their effective use. Care providers need better understanding of the perceptions of older people to provide acceptable support services.