Lit Bits. June 23, 2009

From the recent medical literature...

1. ED crowding mainly due to lack of inpatient beds

The American Hospital Association

Lack of access to inpatient beds is the main reason for continued hospital emergency department crowding, according to a report released yesterday by the Government Accountability Office. The GAO found that the average wait time to see a physician in the ED – one measure of crowding – increased from 46 minutes in 2003 to 56 minutes in 2006, while the percentage of visits in which wait time exceeded recommended time frames for patients with immediate (less than 1 minute) and emergent (within 1 to 14 minutes) acuity levels increased from 37.5% in 2003 for both to 73.9% and 50.4% respectively in 2006. “Emergency rooms are a critical component of our nation’s health care safety net,” said Sen. Max Baucus (D-MT), who requested the report. He called the findings “unacceptable” and reiterated the need for comprehensive health care reform.

To view the report: http://www.gao.gov/new.items/d09347.pdf

2. Stroke After TIA: How Likely and How Soon?

Risk for stroke within 24 hours after TIA was 5% in this large population-based study.

Urgent intervention after transient ischemic attack (TIA) is highly effective for preventing recurrent stroke. Most guidelines recommend neurological evaluation within 24 hours after symptom onset, yet some patients with TIA have strokes within that 24-hour period. As part of a prospective study of all strokes and TIAs in a population of 91,106 individuals in Oxfordshire, U.K. (the Oxford Vascular Study), researchers assessed the risk for stroke within 24 hours after a first TIA and the predictive value of the ABCD2 risk scoring system.

Among 488 patients with first TIAs from 2002 to 2007, the risk for stroke was 1.2% within 6 hours, 2.0% within 12 hours, and 5.1% within 24 hours. Of the 59 strokes that occurred within 30 days after TIA, 25 (42%) occurred within the first 24 hours. Nineteen of the 25 patients who had strokes within 24 hours had ABCD2 scores 5. Risk for stroke within 24 hours after TIA was 2.0% in patients with ABCD2 scores 4, 6.5% with scores of 5, 11.8% with scores of 6, and 33.0% with scores of 7. Similarly, patients with scores 5 had greater risk for stroke than those with lower scores within 6 hours (2.6% vs. 0.3%) and within 12 hours (4.7% vs. 0.3%).

Comment: The finding of a substantial rate of stroke within 24 hours after presentation with TIA underscores the need for healthcare workers to educate patients to seek emergency care if they have symptoms of stroke, even if they are minor or resolved, and for primary care physicians to quickly refer patients for emergent evaluation. Although stroke risk correlates with the ABCD2 score, even patients in the lowest risk ABCD2 group have a 2% risk for stroke within 24 hours, which is sufficient to warrant emergent evaluation.

— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine June 1, 2009
Citation: Chandratheva A et al. Population-based study of risk and predictors of stroke in the first few hours after a TIA. Neurology 2009 Jun 2; 72:1941.

3. Body of lies: Patients aren't 100% honest with doctors

Karen Ravn, the Los Angeles Times, June 8, 2009

When patients aren't truthful, misled doctors may give a wrong diagnosis or treatment.

Bill Moore of Pacific Grove was barely in his 20s when he found out he had cholesterol trouble.

This was bad news for Moore because his father had died of a heart attack at 45 and because, as he told his doctor, Moore was eating all the right stuff.

The doctor prescribed cholesterol-lowering medication, and a subsequent test showed the drug was working very well. Too well.

His doctor was very surprised, Moore says. "I told him I must be unique. I must have a unique body composition." But the truth was Moore had fed his doctor a false written record of his eating habits before beginning the drug -- reporting vegetables and salads that had never been on his menu, and not reporting all the hamburgers and pizzas that had.

Only when he started on the cholesterol drug did he finally begin eating the way he'd been claiming to eat all along. It was that change combined with the drug that made his cholesterol levels plunge.

Inaccurate information can do more than confuse a doctor. It can lead to misinterpreted symptoms, overlooked warning signs, flawed diagnoses and treatments -- potentially endangering a patient's health, even life.

Still, doctors know that at least some of the time, at least some of their patients overstate, understate, embellish, omit, or otherwise stray from a straight and thorough reporting.

"Everybody lies at some point," says Dr. Sharon Parish, a professor of clinical medicine at Albert Einstein College of Medicine in New York City who practices at Montefiore Medical Center. They do it out of embarrassment, to please the doctor, to avoid a lecture.

But doctors and patient advocates agree that in most cases, when patients lie, they're pretty much asking for trouble. Even when telling the truth is unappealing, "getting into a lying relationship with your physician is really far more perilous," says Peter Clarke, director of the Center for Health and Medical Communication at USC and co-author of the 1998 book "Surviving Modern Medicine."

An early lesson

That patients lie is one of the basics doctors learn in medical school. Of 1,500 responders to a 2004 online survey by WebMD, 45% admitted they hadn't always told it exactly like it was -- with 13% saying they had "lied," and 32% saying they had "stretched the truth."

Not included in those figures would be patients who "lie" without knowing they do so by withholding information because it slips their mind or they have no idea it could be useful. (Maybe Aunt Agnes would gladly tell about the time she snored so loud she woke the neighbors if she knew that a diagnosis of sleep apnea could depend on it.)

In the WebMD survey, 38% of respondents said they lied about following doctors' orders and 32% about diet or exercise. Doctor reports bear this out.

"Patients are strongly motivated to have their doctors think they're good patients," says Dr. Steven Hahn, professor of clinical medicine at Albert Einstein College and an internist at Jacobi Medical Center in New York City.

It's hard to make a good impression when you're on an examining table in a flimsy, open-backed gown -- a fact that might make lying that much more tempting. But even fully clothed, talking face to face across a desk, a patient cedes authority to the doctor. And people generally like to please those in authority, says Emanuel Maidenberg, clinical professor of psychiatry at UCLA.

Patients also are prone to lying about the fact that they engage in social taboos, things their doctor might not approve of. In the WebMD survey, 22% lied about smoking, 17% about sex, 16% about drinking and 12% about recreational drug use.

"When you're studying psychiatry, you're taught that if a patient says, 'I use cocaine once a month,' you figure it's twice a month," says Dr. Robert Klitzman, professor of clinical psychiatry at Columbia University. "We were taught to double."

Patients lie because they don't want to be judged, embarrassed or misunderstood. They lie about pursuing alternative health remedies because they disagree with their doctor or because they think an item is none of their doctor's business.

The rest of the article: http://www.latimes.com/features/health/la-he-lying8-2009jun08,0,2605423.story

4. The Incremental Benefit of a Shortness-of-breath Biomarker Panel in Emergency Department Patients with Dyspnea

Singer AJ, et al. Acad Emerg Med. 2009;16:488–494.

Objectives: The objective was to determine the incremental benefit of a shortness-of-breath (SOB) point-of-care biomarker panel on the diagnostic accuracy of emergency department (ED) patients presenting with dyspnea.

Methods: Adult ED patients at 10 U.S. EDs with SOB were included. The physician's estimates of the pretest clinical probability of heart failure (HF), acute myocardial infarction (MI), and pulmonary embolism (PE) were recorded using deciles (0%–100%). Blood samples were analyzed using a SOB point-of-care biomarker panel (troponin I, myoglobin, creatinine kinase-myocardial band isoenzyme [CK-MB], D-dimer, and B-type natriuretic peptide [BNP]). Thirty-day follow-up for MI, HF, and PE was performed. Data were analyzed using logistic regression and receiver operating characteristics (ROC) curve analysis.

Results: Of 301 patients, the mean (±standard deviation [SD]) age was 61 (±18) years; 56% were female, 58% were white, and 38% were African American. Diagnoses included MI (n = 54), HF (n = 91), and PE (n = 16) in a total of 129 (43%) of the patients. High pretest clinical certainty (80% and up) identified 60 of these 129 (46.5%) cases. The SOB point-of-care biomarker panel identified 66 additional cases of MI (n = 24), HF (n = 31), and PE (n = 11). The overall adjusted sensitivity for any diagnosis was increased from 65% to 70% with the addition of the SOB point-of-care biomarker panel (difference = 5%, 95% CI = −1.1% to 11%) while specificity was increased from 82% to 83% (difference = 1%, 95% CI = −4% to 7%). The model containing pretest probability and the results of the SOB panel had an area under the curve (AUC) of 83.4% (95% CI = 78.4% to 88.5%), which was not significantly better than the AUC of 80.4% (95% CI = 75.1% to 85.7%) for clinical probability alone.

Conclusions: The addition of the SOB panel of markers did not improve the AUC for diagnosing the combined set of clinical conditions. Using the disease-specific SOB biomarkers increased the sensitivity on a disease-by-disease basis; however, specificity was reduced.

5. New Guidelines on Young Athletes’ Concussions Stir Controversy

By ALAN SCHWARZ. New York Times: June 7, 2009. New guidelines for the care of youth athletes who sustain concussions are causing controversy among brain-injury experts, reigniting the debate over whether strict rules regarding concussions can actually leave athletes at greater risk for injury.

An international panel of neurologists, updating their recommendations on concussion care in the May issue of The British Journal of Sports Medicine, said that any athlete 18 or younger who was believed to have sustained a concussion during a game or practice should never be allowed to return to the playing field the same day. The group had previously said that such athletes could return if cleared by a doctor or certified athletic trainer, but now contend that such determinations are too difficult and dangerous for same-day return to be considered safe.

Other doctors, many of whom work the sidelines of high school athletic events, said they feared the effects of such strictness. They predicted that athletes would respond by hiding their injuries from coaches and trainers even more than they are already known to do, leaving them at risk for a second and more dangerous concussion.

The panel’s recommendation to remove all players suspected of concussion has no direct influence on rules governing United States youth sports, which are generally made at the state and local levels. But it does spotlight how some attempts to improve concussion-related safety can instead compromise it, a paradox encountered at levels as high as the N.F.L.

“So many bad decisions are made when trying to assess whether a player is symptomatic or not,” said Dr. Robert Cantu, an author of the guidelines who is also a director of the Neurological Sports Injury Center at Brigham & Women’s Hospital in Boston. “We know that an unacceptable number of kids are being sent back while symptomatic, and sometimes with devastating effects. The majority believe that the bullet should be bitten, and not let a kid go back into the same contest.”

But Dr. Bob Sallis, a past president of the American College of Sports Medicine and a longtime sideline doctor in Southern California, said he saw the recommendation as a step backward.

“More kids will be hurt seriously because of this, either by players not admitting they might have gotten a concussion or coaches encouraging them not to be up front about their symptoms, whether subtly or overtly,” Sallis said.

Asked how the guidelines could have any influence on league rules throughout the country — in Iowa, for example — Sallis said: “It does put the people in Iowa in scrutiny. When a kid gets hurt, they’ll get sued and be told, why didn’t you follow those guidelines?”

High school athletes in nine primary sports sustained an estimated 137,000 concussions in the 2007-8 school year, according to a study conducted by the Center for Injury Research and Policy at Nationwide Children’s Hospital in Columbus, Ohio. Football had the most, with more than 70,000, followed by girls soccer (24,000), boys soccer (17,000) and girls basketball (7,000). These were only reported concussions; more were almost certainly sustained but went unrecognized or ignored.

“Sometimes, postconcussion symptoms can be delayed for hours or even days, like difficulty sleeping or concentrating,” Cantu said. “It’s a clinical decision that’s difficult or sometimes damn near impossible to be made on the sideline, and we aren’t doing a very good job at it. Athletes, even when assessed by qualified people, seem to be returning to contests prematurely or when symptomatic — an unacceptable number of cases.”

The panel also emphasized the importance of not just physical rest for players found to have a concussion, but cognitive rest as well. It said that teenagers should be kept from activities ranging from schoolwork to video games and text messaging while recovering from a concussion.
“That is the No. 1 management issue in our clinic — how do we manage the cognitive activity that stresses that brain’s abnormal metabolism?” said Gerry Gioia, the chief of pediatric neuropsychology at Children’s National Medical Center in Washington. “Studying for an algebra exam, reading a lengthy text, sitting in a classroom for an hour and a half trying to keep notes and keep up — it extends recovery, it feels miserable to the kid, and it’s misunderstood by the school and public.”

6. AHA/ASA Science Advisory Recommends Use of tPA Between 3 and 4.5 Hours After Stroke

Susan Jeffrey. May 28, 2009 — A new science advisory from the American Heart Association (AHA)/American Stroke Association (ASA) has given the green light to the use of tissue plasminogen activator (tPA) to treat acute ischemic stroke between 3 and 4.5 hours after symptom onset.

However, the advisory, published online May 28 in Stroke, still emphasizes that time is of the essence when it comes to treatment of stroke.

"Although a longer time window for treatment has been tested formally, delays in evaluation and initiation of therapy should be avoided," the authors stress. The writing group is chaired by Gregory J. del Zoppo, MD, from the University of Washington, in Seattle.

ECASS 3

The advisory updates the current guidelines mainly on the basis of findings from the European Cooperative Acute Stroke Study 3 (ECASS 3), which showed a benefit from thrombolytic therapy in patients treated between 3 and 4.5 hours after symptom onset. Exclusion criteria for that trial — which followed exclusions mandated by European regulatory authorities for the approval of tPA there — now become exclusion criteria for these new recommendations.

"The eligibility criteria for treatment in this time period are similar to those treated at earlier time periods, with any 1 of the following additional exclusion criteria: patients older than 80 years, those taking oral anticoagulants with an international normalized ratio [INR] of ≤ 1.7, those with a baseline National Institutes of Health Stroke Scale score greater than 25, or those with both a history of stroke and diabetes," the authors write. For this later time period, all patients receiving oral anticoagulants are excluded, regardless of their INR, they note.

"The efficacy of intravenous treatment with [recombinant tissue plasminogen activator] rtPA within 3 to 4.5 hours after stroke in patients with these exclusion criteria is not well established and requires further study," the document states. In addition, the relative utility of rtPA in this time window to other methods of recanalization such as thrombus dissolution or approval is considered "not well established."

Ancillary care for patients receiving tPA In this expanded window should be similar to what has been established in the current 2007 American Heart Association Stroke Council Guidelines, the authors note.

"These recommendations, which are based on peer-reviewed publications, should be reevaluated after the results of regulatory agency review of detailed, non–publicly available data are known," they conclude.

Do Not Hesitate to Treat

Asked for comment on the new advisory, Ralph Sacco, MD, from the Miller School of Medicine at the University of Miami, in Florida, and president-elect of the AHA, pointed out that on the basis of ECASS 3, the guidelines in Europe have already changed.

"The European Stroke Organization was quick to change the guidelines," Dr. Sacco said. "I think the American Heart Association has been more cautious about widening the window. One of our concerns is that we don't want people to hesitate, and if you all of a sudden widen the window, some people may feel they have a little more time, both patients waiting to call or healthcare professionals waiting to give tPA," he said.

"First and foremost to us is, the earlier you treat, the better; the earlier you recognize the symptoms, the better; and that's the only concern — that if we widen the window, will we lose some patients giving it later rather than earlier?"

This may allow many physicians to be more comfortable at least in treating those who arrive late in the already-approved 3-hour time window, he added.

Phillip B. Gorelick, MD, from the University of Illinois College of Medicine at Chicago, was a reviewer on the new science advisory. "There are several key factors to keep in mind when contemplating administration of intravenous tPA, given the AHA/ASA advisory," he told Medscape Neurology & Neurosurgery. "One, treatment should not be delayed if it can be given sooner than the 3- to 4.5-hour time window."

In addition, the exclusions outlined above will also apply, he noted. "The advisory does not address the role of intra-arterial rtPA administration or the use of mechanical or other clot-extraction devices in the 3- to 4.5-hour time window," Dr. Gorelick said. "The role of these latter treatments in light of the expanded time-window advisory will need to be addressed in subsequent AHA/ASA guidelines on acute stroke therapy and in subsequent research."

The American Heart Association/American Stroke Association statement notes that the association receives funding "primarily from individuals and foundations, and corporations (including pharmaceutical, device manufacturers, and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing science content. Revenues from pharmaceutical and device corporations are disclosed at www.americanheart.org/corporatefunding ."

Dr. Del Zoppo reports no disclosures. Disclosure information for other members of the writing group and reviewers are included in the advisory.

Stroke. Published online May 28, 2009.

7. Obama Open to Reining in Medical Suits

By SHERYL GAY STOLBERG and ROBERT PEAR. New York Times, June 15, 2009

WASHINGTON — The American Medical Association has long battled Democrats who oppose protecting doctors from malpractice lawsuits. But during a private meeting at the White House last month, association officials said, they found one Democrat willing to entertain the idea: President Obama.

In closed-door talks, Mr. Obama has been making the case that reducing malpractice lawsuits — a goal of many doctors and Republicans — can help drive down health care costs, and should be considered as part of any health care overhaul, according to lawmakers of both parties, as well as A.M.A. officials.

It is a position that could hurt Mr. Obama with the left wing of his party and with trial lawyers who are major donors to Democratic campaigns. But one Democrat close to the president said Mr. Obama, who wants health legislation to have broad support, views addressing medical liability issues as a “credibility builder” — in effect, a bargaining chip that might keep doctors and, more important, Republicans, at the negotiating table.

The rest of the article: http://www.nytimes.com/2009/06/15/health/policy/15health.html

8. Slower infusion of metoclopramide decreases the rate of akathisia

Regan LA, et al. Amer J Emerg Med. 2009;27:475-480.

Objective
We investigated the difference in incidence of acute akathisia related to the rate of infusion in patients receiving metoclopramide for acute nausea, vomiting, or migraine headache in the emergency department (ED).

Methods
Randomized, prospective, double-blind clinical trial of patients aged 18 years and older who were to receive intravenous metoclopramide for the treatment of nausea, vomiting, or headache were eligible. Patients were excluded if they were taking medications that might mimic or mask akathisia, had a movement disorder, renal insufficiency, or were unable or unwilling to consent. Pregnant women and prisoners were also excluded. Subjects were randomized to receive 1 of 2 accepted metoclopramide administration regimens. The regimens included 10 mg of metoclopramide administered either as a 2-minute bolus (BG) or as a slow infusion for 15 minutes (IG). All patients received a normal saline placebo at the opposite rate to maintain blinding. The main outcome was development of akathisia noted at 60 minutes after drug administration as measured either with The Prince Henry Hospital akathisia rating scale or by sudden unexplained departure from the ED during treatment.

Results
One hundred twenty-seven patients were eligible for the study. Fifty-nine patients met exclusion criteria. Of the remaining 68 patients, 36 were randomized to the BG and 32 were randomized to the IG. In the BG, 11.1% of patients developed akathisia compared with 0% in the IG (P = .026). Four patients developed akathisia based on the scale and 2 departed suddenly from the ED.

Conclusions
Slower infusion of metoclopramide reduces the incidence of akathisia.

9. Your Body Is a Wonderland ... of Bacteria

By Stephanie Pappas. ScienceNOW Daily News, 28 May 2009.

Where can you find your skin's most diverse community of bacteria? Not in a sweaty armpit or linty belly button. According to a new survey of the bacterial ecosystem that covers us, the diversity hot spot of the body's exterior is the forearm. And the surprises don't end there.
Microbes that live in and on our bodies outnumber our own cells 10 to one, but researchers have only recently begun to catalog the residents on our skin. Traditionally, scientists identified human skin bacteria by swabbing volunteers and culturing the samples, but those results skewed toward microbes that grow well in the lab. Thanks to ever-evolving gene-sequencing technology, scientists can now use microbial RNA to identify organisms. With these techniques, researchers have found an unexpectedly wide variety of bacteria on human skin (Science, 23 May 2008, p. 1001). But no one had ever systematically compared bacterial colonies from different areas on the human body.

To do so, scientists from the National Human Genome Research Institute in Bethesda, Maryland, recruited 10 volunteers and asked them to wash with mild soap for 1 week. Then, after 24 hours without bathing, the volunteers arrived at the lab, where researchers swabbed and scraped their skin in 20 places--everywhere from the nostril to the navel to that bane of low-rise jeans aficionados, the gluteal crease. The team analyzed ribosomal RNA from the samples and classified the microbes based on their genomes.

The researchers found about 1000 species total, which were fairly consistent from person to person; it turns out we all have similar tenants in our noses and on our backs. The number suggests that our skin is as variegated as our guts, which house anywhere from 500 to 1000 bacterial species. The team also found vast differences across the skin, according to the study published in tomorrow's issue of Science. Contrary to what acne-prone teenagers might expect, oily areas such as the forehead and scalp are actually less diverse than dry areas such as the forearm (though one is enough for grief: Propionibacterium acnes thrives in oily spots). The most barren region was behind the ear, with a median diversity of 15 species. In comparison, the forearm teemed with a median 44 species. A follow-up with five of the volunteers months later found that bacterial makeup changed little over time.

Why some neighborhoods are more varied than others is unknown. It could be because of skin properties such as hair or oil, exposure to bacteria, or some combination. As for the forearm, geneticist and co-author Julia Segre speculates that exposed arms make a good landing pad for bacteria. Contrasted with how we clean our hands, we rarely lather up our forearms. Whatever the reason, the research shows that location matters. "This paper really highlights that the skin is an ecosystem and that the bacteria that live on our skin are not homogenous," says Segre.

The research "could contribute to explaining why certain skin diseases appear at certain sites of the body and not others," says dermatologist Richard Gallo of the University of California, San Diego. "It's a straightforward description of something that needed to be described." The next step, Segre says, is to investigate the relationship between microbial ecosystems and diseases such as eczema and psoriasis.

10. Frequency of Acute Coronary Syndrome in Patients with Normal Electrocardiogram Performed during Presence or Absence of Chest Pain

Turnipseed SD, et al. Acad Emerg Med. 2009;16:495–499.

Objectives: The authors hypothesized that patients with active chest pain at the time of a normal electrocardiogram (ECG) have a lower frequency of acute coronary syndrome (ACS) than patients being evaluated for chest pain but with no active chest pain at the time of a normal ECG. The study objective was to describe the association between chest pain in patients with a normal ECG and the diagnosis of ACS.

Methods: This was a prospective observational study of emergency department (ED) patients with a chief complaint of chest pain and an initial normal ECG admitted to the hospital for chest pain evaluation over a 1-year period. Two groups were identified: patients with chest pain during the ECG and patients without chest pain during the ECG. Normal ECG criteria were as follow: 1) normal sinus rhythm with heart rate of 55–105 beats/min, 2) normal QRS interval and ST segment, and 3) normal T-wave morphology or T-wave flattening. "Normal" excludes pathologic Q waves, left ventricular hypertrophy, nonspecific ST-T wave abnormalities, any ST depression, and discrepancies in the axis between the T wave and the QRS. Patients' initial ED ECGs were interpreted as normal or abnormal by two emergency physicians (EPs); differences in interpretation were resolved by a cardiologist. ACS was defined as follows: 1) elevation and characteristic evolution of troponin I level, 2) coronary angiography demonstrating more than 70% stenosis in a major coronary artery, or 3) positive noninvasive cardiac stress test. Chi-square analysis was performed and odds ratios (ORs) are presented.

Results: A total of 1,741 patients were admitted with cardiopulmonary symptoms; 387 met study criteria. The study group comprised 199 males (51%) and 188 females (49%), mean age was 56 years (range, 25–90 years), and 106 (27%) had known coronary artery disease (CAD). A total of 261 (67%) patients experienced chest pain during ECG; 126 (33%) patients experienced no chest pain during ECG. There was no difference between the two groups in age, sex, cardiac risk factors, or known CAD. The frequency of ACS for the total study group was 17% (67/387). There was no difference in prevalence of ACS based on the presence or absence of chest pain (16% or 42/261 vs. 20% or 25/126; OR = 0.77, 95% confidence interval = 0.45 to 1.33, p = 0.4).

Conclusions: Contrary to our hypothesis concerning patients who presented to the ED with a chief complaint of chest pain, our study demonstrated no difference in the frequency of acute coronary syndrome between patients with chest pain at the time of acquisition of a normal electrocardiogram and those without chest pain during acquisition of a normal electrocardiogram.

11. Images in Emergency Medicine

Spider Bite
http://www.annemergmed.com/article/S0196-0644(08)02059-3/fulltext

Male With Left Neck Pain
http://www.annemergmed.com/article/S0196-0644(08)02193-8/fulltext

12. ED Pulmonary Embolism D-Dimer Screening Not Following Guidelines

By David Douglas. NEW YORK (Reuters Health) Jun 17 - Despite established clinical guidelines that suggest how D-dimer testing results should guide CT evaluation of patients with suspected pulmonary emboli (PE), emergency department (ED) use of such testing is not well-standardized, according to researchers.

"Any time a patient gets a CT scan there is a radiation dose," lead investigator Dr. Michael T. Corwin said in a statement. "The evaluation of patients with suspected PE should include D-dimer and CT testing in a more standardized fashion so that we can save patients from having unnecessary CT scans."

Dr. Corwin and his colleagues at the Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, note in the May issue of the American Journal of Roentgenology that in current accepted clinical practice, in patients with low clinical probability for PE, a D-dimer test is performed; if it is negative, the patient has no further workup. If it is positive, patients have a CT.

The researchers retrospectively reviewed data on more than 5300 patients who underwent either a D-dimer test or a multidetector CT (MDCT) examination.

"42% of patients had a positive D-dimer exam and did not have a CT scan," Dr. Corwin stated. "Current protocols suggest that those patients should have had a scan."

"MDCT was performed in 7% of patients with negative D-dimer results," he added, "and the same protocols suggest that those patients should not have undergone a scan."

"Our study shows that the evaluation of ER patients for the diagnosis of pulmonary embolism does not follow established clinical guidelines," Dr. Corwin told Reuters Health.

He added: "We hope that our results bring awareness to this and lead to stricter adherence to these guidelines. This is turn, may reduce the number of unnecessary CT examinations, thereby reducing the radiation exposure to these patients."

Am J Roentgenol 2009;192:1295-1323.

13. Adherence to Healthy Lifestyle Habits in US Adults, 1988-2006

King DE, et al. Amer J Med 2009;122:528-534.

Background
Lifestyle choices are associated with cardiovascular disease and mortality. The purpose of this study was to compare adherence to healthy lifestyle habits in adults between 1988 and 2006.

Methods
Analysis of adherence to 5 healthy lifestyle trends (5 or more fruits and vegetables/day, regular exercise more than 12 times/month, maintaining healthy weight [body mass index 18.5-29.9 kg/m2], moderate alcohol consumption [up to 1 drink/day for women, 2/day for men] and not smoking) in the National Health and Nutrition Examination Survey 1988-1994 were compared with results from the National Health and Nutrition Examination Survey 2001-2006 among adults aged 40-74 years.

Results
Over the last 18 years, the percent of adults aged 40-74 years with a body mass index 30 kg/m2 or more has increased from 28% to 36% (P less than .05); physical activity 12 times a month or more has decreased from 53% to 43% (P less than .05); smoking rates have not changed (26.9% to 26.1%); eating 5 or more fruits and vegetables a day has decreased from 42% to 26% (P less than .05), and moderate alcohol use has increased from 40% to 51% (P less than .05). Adherence to all 5 healthy habits has gone from 15% to 8% (P less than .05). Although adherence to a healthy lifestyle was lower among minorities, adherence decreased more among non-Hispanic Whites over the period. Individuals with a history of hypertension/diabetes/cardiovascular disease were no more likely to be adherent to a healthy lifestyle than people without these conditions.

Conclusions
Generally, adherence to a healthy lifestyle pattern has decreased during the last 18 years, with decreases documented in 3 of 5 healthy lifestyle habits. These findings have broad implications for the future risk of cardiovascular disease in adults.

14. The association between physician risk tolerance and imaging use in abdominal pain

Pines JM, et al. Amer J Emerg Med. 2009;27:552-557.

Objective
We sought to determine the impact of 3 validated scales of physician risk behavior on imaging use in emergency department (ED) patients with abdominal pain.

Methods
We performed a prospective cohort study of nonpregnant ED patients with acute, nontraumatic abdominal pain and then administered 3 instruments (a risk-taking subscale of the Jackson Personality Index, the stress from uncertainty scale, and a malpractice fear scale) to attending physicians who had evaluated these patients and made decisions regarding abdominal imaging. Outcomes were the use of abdominal pelvic computed tomography (CT) and any imaging use (CT, ultrasound, or abdominal plain film). Hierarchical logistic regression was used to determine the effect of risk scales on abdominal imaging use.

Results
Of 838 patients with acute abdominal pain, 487 (58%) received imaging studies; 395 (47%) received an CT, 111 (13%) ultrasound, and 122 (15%) an abdominal plain film. Both CT and any imaging use were lower among the physicians who were least risk-averse as measured by the risk-taking subscale (highest quartiles vs 3 lower quartiles). In adjusted analysis, probability of CT in the least risk-averse group was 35% (95% confidence interval [CI], 28%-44%) compared to 50% (95% CI, 45%-54%) among more risk-averse physicians, and the probability of any imaging was 53% (95% CI, 44%-61%) compared to 64% (95% CI, 61%-68%). Malpractice fear and stress due to uncertainty were not predictive of imaging use.

Conclusion
Self-reported physician risk-taking behavior predicts the use of imaging in ED patients with abdominal pain, whereas malpractice fear and stress due to uncertainty do not.

15. Outpatient Management of Primary Spontaneous Pneumothorax in the Emergency Department of a Community Hospital Using a Small-bore Catheter and a Heimlich Valve

Hassani B, et al. Acad Emerg Med. 2009;16:513–518.

Objectives: The objective was to assess the effectiveness of a small-bore catheter (8F) connected to a one-way Heimlich valve in the emergency department (ED)-based outpatient management of primary spontaneous pneumothorax (PSP).

Methods: The authors conducted a structured chart audit in a retrospective case series of patients with PSP who were treated with a small-bore (8F) catheter and a Heimlich valve who were seen in the ED of a community hospital between April 2000 and March 2005. To be eligible, patients had to be available for a telephone interview. Main outcomes were success of treatment (sustained, complete lung reexpansion), admission, and surgical intervention rates. Secondary outcomes included number of chest x-rays (CXRs), number of visits to the ED, treatment duration, complications, and recurrence rates.

Results: The authors identified 62 discrete episodes of PSP in 50 patients, with a mean (±standard deviation [SD]) age of 25.5 ± 10.5 years (range = 14–53 years). In 50 of 62 episodes (81%, 95% confidence interval [CI] = 70.8% to 90.5%), patients were discharged directly from the ED. Patients were admitted to the hospital at some point for treatment in 27/62 episodes (43.5%, 95% CI = 31.2% to 55.9%). Surgery was performed for acute treatment failure in 17 episodes. Ultimately, 19 patients, who accounted for 21 of 62 episodes (33.9%, 95% CI = 22.1% to 45.6%), had surgery at some point in the study. Mean (±SD) time to admission for those patients initially discharged from the ED was 2.9 (±2.01) days (95% CI = 1.9 to 3.8 days). There were no serious complications from treatment; the minor complication rate (misplacement or dislodging of the chest tube) was 22.6% (95% CI = 12.2% to 33.0%). No association was found between the size of pneumothorax and treatment failure.

Conclusions: This study suggests that the initial management of PSP with a small-bore catheter and Heimlich valve can easily be performed by emergency physicians in the community hospital setting and appears safe. A larger study systematically comparing this approach with alternative therapies is needed.

16. Asthma Education Intervention Reduces Emergency Department Visits

NEW YORK (Reuters Health) Jun 18 - Asthma education aimed at asthmatic children and their caretakers who present to the emergency department for acute asthma exacerbations may help lower the risk of future visits and hospitalizations, according to findings published in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration.

"Asthma management for children results in substantial costs," lead author Dr. Michelle Boyd, of Royal Children's Hospital, Herston, Australia, and colleagues write. "There is evidence to suggest that hospital admissions could be reduced with effective education for parents and children about asthma and its management."

To further investigate, the researchers conducted a systematic review of the literature using the Cochrane Airways Group Trials Register, which includes data from MEDLINE, EMBASE and other databases. Included in the analysis were randomized controlled trials of asthma education for children who had attended the emergency department for asthma, with or without hospitalization, within the previous 12 months.

Educational interventions included teaching patients how to monitor their breathing flow; showing patients the importance of early response to symptoms before they escalate into an asthma emergency; and teaching the caretakers the importance of making environmental changes in the home, such as removing allergens and asthma triggers.

A total of 38 studies involving 7843 children were included in the analysis. Significantly reduced risks of subsequent emergency department visits (RR 0.73) and hospitalizations (RR 0.79) were observed in the educational intervention groups compared with the control groups. Educational interventions also lowered the risk of unscheduled doctor visits (RR 0.68).

"We could not find evidence of statistically significant effects on measures of FEV1, PEF, rescue medication use, quality of life or symptoms; very few studies contributed data to these outcomes and interpreting this apparent lack of finding is difficult," Dr. Boyd's team explains.

Withdrawal rates from the educational intervention did not differ significantly between the intervention and control groups, "indicating that education following an acute exacerbation of asthma is no more or less acceptable for children and their carers compared with usual follow-up."

The authors suggest that an educational intervention may be especially useful for young asthma patients with a history of emergency department visits; these patients may have more severe disease and may not have the skills to effectively manage it.

Cochrane Database Syst Rev 2009.

17. Outcomes After Intravenous Opioids in Emergency Patients: A Prospective Cohort Analysis

O'Connor AB, et al. Acad Emerg Med. 2009;16:477–487.

Objectives: Pain management continues to be suboptimal in emergency departments (EDs). Several studies have documented failures in the processes of care, such as whether opioid analgesics were given. The objectives of this study were to measure the outcomes following administration of intravenous (IV) opioids and to identify clinical factors that may predict poor analgesic outcomes in these patients.

Methods: In this prospective cohort study, emergency patients were enrolled if they were prescribed IV morphine or hydromorphone (the most commonly used IV opioids in the study hospital) as their initial analgesic. Patients were surveyed at the time of opioid administration and 1 to 2 hours after the initial opioid dosage. They scored their pain using a verbal 0–10 pain scale. The following binary analgesic variables were primarily used to identify patients with poor analgesic outcomes: 1) a pain score reduction of less than 50%, 2) a postanalgesic pain score of 7 or greater (using the 0–10 numeric rating scale), and 3) the development of opioid-related side effects. Logistic regression analyses were used to study the effects of demographic, clinical, and treatment covariates on the outcome variables.

Results: A total of 2,414 were approached for enrollment, of whom 1,312 were ineligible (658 were identified more than 2 hours after IV opioid was administered and 341 received another analgesic before or with the IV opioid) and 369 declined to consent. A total of 691 patients with a median baseline pain score of 9 were included in the final analyses. Following treatment, 57% of the cohort failed to achieve a 50% pain score reduction, 36% had a pain score of 7 or greater, 48% wanted additional analgesics, and 23% developed opioid-related side effects. In the logistic regression analyses, the factors associated with poor analgesia (both less than 50% pain score reduction and postanalgesic pain score of ≥7) were the use of long-acting opioids at home, administration of additional analgesics, provider concern for drug-seeking behavior, and older age. An initial pain score of 10 was also strongly associated with a postanalgesic pain score of 7 or greater. African American patients who were not taking opioids at home were less likely to achieve a 50% pain score reduction than other patients, despite receiving similar initial and total equianalgesic dosages. None of the variables we assessed were significantly associated with the development of opioid-related side effects.

Conclusions: Poor analgesic outcomes were common in this cohort of ED patients prescribed IV opioids. Patients taking long-acting opioids, those thought to be drug-seeking, older patients, those with an initial pain score of 10, and possibly African American patients are at especially high risk of poor analgesia following IV opioid administration.

18. Cephalosporins in Patients with Penicillin Allergy: Use Them . . . but Be Careful

Patients with penicillin allergy are not necessarily allergic to cephalosporins.

Use of cephalosporins for treatment of pediatric infections is limited because of concern about cross-reactivity in patients with penicillin allergy. In an industry-supported review, researchers examined the evidence from 44 studies on cephalosporin cross-reactivity in patients allergic to penicillin (J Am Pharm Assoc 2008; 48:530).

About 10% of patients in the general population report allergic responses to penicillin and the reported risk for anaphylactic reaction to cephalosporins ranges from 1:1000 to 1:1,000,000, but this risk is increased fourfold in patients with penicillin allergy. Characteristics of adverse drug reactions (immunologic, nonimmunologic, duration, severity) are key to distinguishing allergic from nonallergic adverse reactions. The reported frequency of cross-reactivity between cephalosporins and penicillin is 7% to 18%, but the authors cite recent data that suggest that the incidence of true allergic reactions is lower because much of the evidence was based on nonallergic adverse reactions or in vitro studies, rather than on clinically relevant immune-mediated reactions. Further, improved manufacturing processes have removed contaminants from penicillins and cephalosporins that might have caused cross-reactivity reactions. First-generation cephalosporins are associated with higher risk for cross-reactivity than later-generation agents due to changes in the chemical structure.

Clear contraindications to use of cephalosporins include history of penicillin-associated type I anaphylaxis reactions associated with the presence of IgE antibodies, Stevens-Johnson syndrome, toxic epidermal necrolysis, angioedema, interstitial nephritis, vasculitis, serum sickness, hemolytic anemia, neutropenia, and thrombocytopenia.

Comment: The good news is that patients with penicillin allergy are not necessarily allergic to cephalosporins. The bad news is that some cross-reactivity exists. Clinicians need to evaluate risk based on history and diagnostic testing. The most important factors to assess when considering the use of cephalosporins in penicillin-allergic patients is the nature and extent of previous allergic reactions and the type of cephalosporin to be used. When cephalosporin use is necessary in life-threatening situations, skin testing and drug-challenge desensitization might be appropriate. Fortunately, the risk for cross-reactivity with third- and fourth-generation cephalosporins is very low, and reasonable treatment alternatives exist.

— William P. Kanto, Jr., MD. Published in Journal Watch Pediatrics and Adolescent Medicine May 27, 2009

19. The Limited Utility of Routine Cardiac Stress Testing in Emergency Department Chest Pain Patients Younger Than 40 Years

Hermann LK, et al. Ann Emerg Med. 2009;54:12-16.

Study objective
This is a study designed to evaluate the utility of routine provocative cardiac testing in low-risk young adult (younger than 40 years) patients evaluated for an acute coronary syndrome in an emergency department (ED) setting.

Methods
This was a retrospective observational study of patients aged 23 to 40 years who were evaluated for acute coronary syndrome in an ED-based chest pain unit from March 2004 to September 2007. All patients had serial cardiac biomarker testing to rule out myocardial infarction and then underwent provocative cardiac testing to identify the presence of myocardial ischemia. Patients were excluded from the study if they had known coronary artery disease, had ECG findings diagnostic of myocardial infarction or ischemia, or self-admitted, or tested positive for cocaine use.

Results
Of the 220 patients who met inclusion criteria, 6 patients (2.7%; 95% confidence interval 1% to 5.8%) had positive stress test results. Among these 6 patients, 4 underwent subsequent coronary angiography that demonstrated no obstructive coronary disease, suggesting the initial provocative study was falsely positive. For the remaining 2 patients, no diagnostic angiography was performed. Discounting the patients who had negative angiography results, only 2 of 220 study patients (0.9%; 95% confidence interval 0.1% to 3.2%) had a provocative test result that was positive for myocardial ischemia.

Conclusion
In our study, a combination of age younger than 40 years, nondiagnostic ECG result, and 2 sets of negative cardiac biomarker results at least 6 hours apart identified a patient group with a very low rate of true-positive provocative testing. Routine stress testing added little to the diagnostic evaluation of this patient group and was falsely positive in all patients who consented to diagnostic coronary angiography (4 of 6 cases).

20. Nebulized Lidocaine Before Nasogastric Tube Insertion in Children Causes Distress

This treatment is not a viable option in young children.

Nasogastric tubes often are inserted in children without analgesia or local anesthesia. In a randomized, double-blind, placebo-controlled trial, investigators in Australia assessed the efficacy of nebulized lidocaine for reducing pain and distress during this procedure in children aged 1 to 5 years. In adults, nebulized lidocaine has been shown to have less systemic absorption and a potentially better safety profile than topical lidocaine.

Thirty-eight children received 2% lidocaine (4 mg/kg) or saline administered via nebulizer for 5 minutes. The procedures were filmed, and each of six phases was scored independently by an emergency department attending physician and a nurse practitioner using the Face, Legs, Activity, Cry, and Consolability (FLACC) procedural pain scale (the primary outcome measure). A FLACC score of 10 indicates maximal distress; a difference of 2 points was considered clinically significant.

Eighteen patients in each group completed the study; more boys were in the lidocaine group, but otherwise the groups were similar at baseline. The range of FLACC scores varied widely during the different phases in both groups. Median scores in the lidocaine and placebo groups were highest during nebulization (6.3 and 6.0, respectively) and nasogastric tube insertion (9.8 and 9.5, respectively). Scores did not differ significantly between groups during any phase. Immediately after the procedure, ED nurses rated the overall pain of insertion on a visual analog scale as being lower in the lidocaine group. Adverse events included one endotracheal insertion in each group and one failed insertion in each group; none of these events resulted in harm.

Comment: The study was terminated early, before the intended 52 subjects were enrolled, because of concern about the level of patient distress during nebulization. Although adults may tolerate topical anesthetic administered via nebulizer, clearly young children do not. Therefore, nebulized lidocaine is not a viable treatment option for young children. This study highlights the importance of evaluating therapies in children and not simply extrapolating safety and efficacy from studies in adults.

— Jill M. Baren, MD, MBE, FACEP, FAAP. Published in Journal Watch Emergency Medicine June 19, 2009. Citation: Babl FE et al. Does nebulized lidocaine reduce the pain and distress of nasogastric tube insertion in young children? A randomized, double-blind, placebo-controlled trial. Pediatrics 2009 Jun; 123:1548.

21. Ultrasound Helps Confirm Pediatric Intubation, but Should Not Be Used Alone

By David Douglas. NEW YORK (Reuters Health) Jun 16 - Diaphragmatic ultrasound is showing promise in determining endotracheal tube positioning in pediatric emergency department patients, but more study is needed before it is considered equivalent to chest radiography, Ohio-based researchers report in the June issue of Pediatrics

"The general clinical implication of our study is for the feasibility of ultrasound as a diagnostic tool in pediatric emergency medicine," lead investigator Dr. Benjamin T. Kerrey told Reuters Health. "There is a growing body of literature to support several different applications of ultrasound for our patients. Our study adds to that literature in a generally positive way."

Dr. Kerrey and colleagues at Cincinnati Children's Hospital Medical Center observe that estimates of misplacement of endotracheal tubes in such patients range as high as 40%.

To compare ultrasound and chest radiography as placement aids, the team studied 127 pediatric emergency department inpatients evaluated by both techniques. There were no esophageal intubations, but in 24 patients (19%) chest radiography showed that the tube was in the mainstem bronchus.

Radiography and ultrasound agreed on placement in 94 patients with tracheal placement and 12 with mainstem bronchial placement, thus giving an overall agreement of 0.83. Ultrasound had a sensitivity for tracheal placement of 0.91 and a specificity for mainstem intubation of 0.50.

The ultrasound approach provided rapid results, taking a median of 8 minutes less than radiography. The results were also highly reproducible. In 33 of 34 re-evaluated sonograms, a separate blinded sonographer came to the same conclusions as the original sonographer.

"Although I cannot recommend diaphragmatic ultrasound be used 'as is' to confirm an intubation," concluded Dr. Kerrey, "I feel our findings are promising and warrant further investigation."

Pediatrics 2009;123:e1039-e1044.

Lit Bits. May 25, 2009

From the recent medical literature...

0. Friendships and Health

In the quest for better health, many people turn to doctors, self-help books or herbal supplements. But they overlook a powerful weapon that could help them fight illness and depression, speed recovery, slow aging and prolong life: their friends.

Researchers are only now starting to pay attention to the importance of friendship and social networks in overall health. A 10-year Australian study found that older people with a large circle of friends were 22 percent less likely to die during the study period than those with fewer friends. A large 2007 study showed an increase of nearly 60 percent in the risk for obesity among people whose friends gained weight. And last year, Harvard researchers reported that strong social ties could promote brain health as we age.

“In general, the role of friendship in our lives isn’t terribly well appreciated,” said Rebecca G. Adams, a professor of sociology at the University of North Carolina, Greensboro. “There is just scads of stuff on families and marriage, but very little on friendship. It baffles me. Friendship has a bigger impact on our psychological well-being than family relationships.”

The rest of the article: http://www.nytimes.com/2009/04/21/health/21well.html

1. Dropping the Baton: A Qualitative Analysis of Failures During the Transition From Emergency Department to Inpatient Care

Horwitz LI, et al. Ann Emerg Med. 2009;53:701-710.e4

Study objective
We identify, describe, and categorize vulnerabilities in emergency department (ED) to internal medicine patient transfers.

Methods
We surveyed all emergency medicine house staff, emergency physician assistants, internal medicine house staff and hospitalists at an urban, academic medical center. Respondents were asked to describe any adverse events occurring because of inadequate communication between emergency medicine and the admitting physician. We analyzed the open-ended responses with standard qualitative analysis techniques.

Results
Of 139 of 264 survey respondents (53%), 40 (29%) reported that a patient of theirs had experienced an adverse event or near miss after ED to inpatient transfer. These 40 respondents described 36 specific incidents of errors in diagnosis (N=13), treatment (N=14), and disposition (N=13), after which patients experienced harm or a near miss event. Six patients required an upgrade in care from the floor to the ICU. Although we asked respondents to describe communication failures, analysis of responses identified numerous contributors to error: inaccurate or incomplete information, particularly of vital signs; cultural and professional conflicts; crowding; high workload; difficulty in accessing key information such as vital signs, pending data, ED notes, ED orders, and identity of responsible physician; nonlinear patient flow; “boarding” in the ED; and ambiguous responsibility for sign-out or follow-up.

Conclusion
The transfer of a patient from the ED to internal medicine can be associated with adverse events. Specific vulnerable areas include communication, environment, workload, information technology, patient flow, and assignment of responsibility. Systems-based interventions could ameliorate many of these and potentially improve patient safety.

Free full-text: http://www.annemergmed.com/article/S0196-0644(08)00795-6/fulltext

2. An aspirin a day…?

Aspirin is enormously useful as a secondary prophylactic for cardiovascular events including myocardial infarction and ischaemic stroke in patients with known arteriosclerotic disease. There has been concern, however, that aspirin can also increase haemorrhagic strokes and cause gastrointestinal bleeding. Whether the regular use of aspirin is effective in protecting against vascular disease in healthy individuals (primary prevention) is unclear. This study involving 95,000 individuals investigated the balance of positive and negative effects, and the results indicate no overwhelming difference. For individual patients, therefore, it depends on whether it is better to risk an MI or a gastrointestinal bleed.

The Lancet. 2009;373:1849–1860.

Abstract: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60503-1/abstract

3. New AHA/ASA Guidelines on TIA Management Released

May 8, 2009 — The American Heart Association (AHA)/American Stroke Association (ASA) has released new guideline documents for transient ischemic attacks (TIA).

The TIA document waspublished online May 7 and will appear in the June issue of Stroke.

New Definition of TIA

In the scientific statement examining the definition and evaluation of TIAs, the writing group points out that large cohort and population-based studies reported in the past 5 years have shown that the risk for stroke after a TIA is higher than previously thought. "Ten percent to 15% of patients have a stroke within 3 months, with half occurring within 48 hours," the group, chaired by J. Donald Easton, MD, professor and chair of the department of clinical neurosciences at Alpert Medical School of Brown University and the Rhode Island Hospital, in Providence, writes.

Accordingly, the authors recommend that TIAs be subject to the same urgent assessment and care given to acute strokes and, to that end, have changed the clinical definition of TIA. "We think a TIA should be treated as an emergency, just like a major stroke," Dr. Easton said in a news release from the AHA/ASA. "Because we know the high risk for a future stroke, this is a golden opportunity to prevent a catastrophic event."

The traditional clinical definition, dating to the mid-1960s, is "a sudden neurological deficit of presumed vascular origin lasting less than 24 hours." The new statement changes this definition to "a transient episode of neurological dysfunction caused by focal brain, spinal-cord, or retinal ischemia, without acute infarction."

The presence of infarction has been the main distinction between stroke and TIA, but the advent of more sensitive imaging of tissue damage using magnetic resonance imaging (MRI) has suggested that infarction with presumed TIAs may occur often.

"Research around the globe has shown that the arbitrary threshold based on duration of symptoms was too broad, because up to half of TIAs defined this way actually caused sustained brain injury according to an MRI," Dr. Easton noted.

4. D-Dimer Measurement to Determine Pneumonia Severity?

An admission D-dimer level less than 500 ng/mL was associated with low risk for death and major morbidity.

Chalmers JD, et al. Ann Emerg Med. 2009;53:633-38.

Study objective
Severity assessment is an important component of the management of community-acquired pneumonia. Clinicians are increasingly searching for biomarkers to aid in clinical decisions. Coagulation disorders can accompany severe pneumonia. We seek to investigate the association of D-dimer, a fibrinolysis biomarker, and 30-day mortality or the need for mechanical ventilation or vasopressor support in emergency department (ED) patients with community-acquired pneumonia.

Methods
We prospectively enrolled ED patients with community-acquired pneumonia between December 2005 and January 2008 in a convenience manner. We measured D-dimer level with the Vitek ImmunoDiagnostic Assay System. To assess clinical illness severity, both CURB65 and the Pneumonia Severity Index (Pneumonia Severity Index class) were calculated. Our primary outcomes were 30-day mortality and need for mechanical ventilation or vasopressor support.

Results
Of the 314 enrolled patients, 23.9% of patients had a D-dimer level less than 500 ng/mL on initial ED measurement, and 81.3% of these patients were in Pneumonia Severity Index class I to III. A D-dimer level of less than 500 ng/mL had a negative likelihood ratio of 0 (95% confidence interval 0 to 1.37) for 30-day mortality and 0.33 (95% confidence interval 0.09 to 1.27) for need for mechanical ventilation or vasopressor support. For 30-day mortality, the area under the receiver operator characteristic curve for D-dimer was similar to both CURB65 and Pneumonia Severity Index class. For mechanical ventilation or vasopressor support, the area under the receiver operator characteristic curve for D-dimer was lower than that for CURB65 but did not differ from that for Pneumonia Severity Index.

Conclusion
An admission D-dimer level less than 500 ng/mL is associated with low risk of short-term death and major morbidity in patients with community-acquired pneumonia.

5. Time to PCI: Is 90 Minutes Fast Enough?

Reduction in door-to-balloon time below 90 minutes translates to decreased mortality.

Current clinical guidelines set a door-to-balloon time goal of within 90 minutes for patients with ST-segment-elevation myocardial infarction (STEMI), but do further reductions in time improve outcomes? Researchers analyzed prospectively collected data from the American College of Cardiology National Cardiovascular Data Registry for 43,801 adult patients who presented with STEMI within 12 hours of symptom onset and underwent percutaneous coronary intervention (PCI) at more than 600 U.S. centers.

Median door-to-balloon time was 83 minutes (interquartile range, 62–109 minutes); nearly 60% of patients received intervention within 90 minutes of hospital arrival. Patients who had longer door-to-balloon times were older and had more comorbidities, including cardiogenic shock, than those who had shorter door-to-balloon times and were more likely to be women, not white, and to present after hours and on weekends.

The overall mortality rate was 4.6%. In logistic regression analysis, increasing times to PCI were associated with increasingly higher adjusted mortality rates as follows: 30 minutes, 3.0%; 60 minutes, 3.5%; 90 minutes, 4.3%; 120 minutes, 5.6%; 150 minutes, 7.0%. The researchers conclude that any delay in PCI portends higher mortality. They recommend that the standard for door-to-balloon time should be "as soon as possible," rather than within 90 minutes.

Comment: These results sound a clear warning that simply meeting the 90-minute standard isn’t good enough. Hospitals and emergency medical services systems should work together to deploy prehospital electrocardiography, activate the cath lab before arrival of patients with a prehospital electrocardiogram indicating STEMI, and establish prompt access to PCI 24/7 (JW Cardiol Oct 17 2007). Shaving even a few minutes off door-to-balloon time is likely to save lives!

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine May 20, 2009. Citation: Rathore SS et al. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: National cohort study. BMJ 2009 May 19; 338:b1807. (http://dx.doi.org/10.1136/bmj.b1807)

6. Randomized, Controlled Trial of Antibiotics in the Management of Community-Acquired Skin Abscesses in the Pediatric Patient

Study objective
Emergency department visits for skin and soft tissue infections are increasing with the discovery of community-acquired methicillin-resistant Staphylococcus aureus. Whether abscesses treated surgically also require antibiotics is controversial. There are no published pediatric randomized controlled trials evaluating the need for antibiotics in skin abscess management. We determine the benefits of antibiotics in surgically managed pediatric skin abscesses.

Methods
This was a double-blind, randomized, controlled trial. Pediatric patients were randomized to receive 10 days of placebo or trimethoprim-sulfamethoxazole after incision and draining. Follow-up consisted of a visit/call at 10 to 14 days and a call at 90 days. Primary outcome was treatment failure at the 10-day follow-up. Secondary outcome was new lesion development at the 10- and 90-day follow-ups. Noninferiority of placebo relative to trimethoprim-sulfamethoxazole for primary and secondary outcomes was assessed.

Results
One hundred sixty-one patients were enrolled, with 12 lost to follow-up. The failure rates were 5.26% (n=4/76) and 4.11% (n=3/73) in the placebo and antibiotic groups, respectively, yielding a difference of 1.15, with a 1-sided 95% confidence interval (CI) (1.15% to 6.8%). Noninferiority was established with an equivalence threshold of 7%. New lesions occurred at the 10-day follow-up: 19 on placebo (26.4%) and 9 on antibiotics (12.9%), yielding a difference of 13.5, with 95% 1-sided CI (13.5% to 24.3%). At the 3-month follow-up, 15 of 52 (28.8%) in the placebo group and 13 of 46 (28.3%) in the antibiotic group developed new lesions. The difference was 0.58, with 95% 1-sided CI (0.5% to 15.6%).

Conclusion
Antibiotics are not required for pediatric skin abscess resolution. Antibiotics may help prevent new lesions in the short term, but further studies are required.

Duong M, et al. Ann Emerg Med 2009; in press

7. Epinephrine Plus Dexamethasone May Reduce Hospitalizations for Children With Bronchiolitis

Laurie Barclay, MD. May 13, 2009 — Combined epinephrine plus dexamethasone treatment may significantly reduce hospital admissions in children with bronchiolitis seen in the emergency department, according to the results of a multicenter, double-blind, placebo-controlled trial reported in the May 14 issue of the New England Journal of Medicine.

"Although numerous studies have explored the benefit of using nebulized epinephrine or corticosteroids alone to treat infants with bronchiolitis, the effectiveness of combining these medications is not well established," write Amy C. Plint, MD, MSc, from Children's Hospital of Eastern Ontario in Ottawa, Canada, and colleagues. "The current study was undertaken in response to the continued controversy concerning the use of nebulized epinephrine and systemic corticosteroids in the treatment of bronchiolitis in infants and in recognition of the substantial burden that the care of infants with this disease adds to the health care system."

In this study, 800 infants aged 6 weeks to 12 months who were seen in the pediatric emergency department for bronchiolitis were randomly assigned to 1 of 4 groups. The epinephrine-dexamethasone group received 2 treatments of nebulized epinephrine (3 mL of epinephrine in a 1:1000 solution per treatment) and a total of 6 oral doses of dexamethasone (1.0 mg/kg of body weight in the emergency department and 0.6 mg/kg for an additional 5 days). The epinephrine-alone group received nebulized epinephrine and oral placebo, the dexamethasone-alone group received nebulized placebo and oral dexamethasone, and the placebo group received nebulized placebo and oral placebo. The main endpoint of the study was hospitalization within 7 days from the day when the child was first seen in the emergency department and enrolled.

All 4 groups were well balanced in baseline clinical characteristics. Hospitalization occurred by day 7 in 34 infants (17.1%) in the epinephrine-dexamethasone group, 47 (23.7%) in the epinephrine group, 51 (25.6%) in the dexamethasone group, and 53 (26.4%) in the placebo group. Compared with the placebo group, only the infants in the epinephrine-dexamethasone group were significantly less likely to be admitted by day 7 (relative risk, 0.65; 95% confidence interval, 0.45 - 0.95; P = .02), based on the unadjusted analysis. This result was no longer significant after adjustment for multiple comparisons (P = .07). No serious adverse events were observed.

"Among infants with bronchiolitis treated in the emergency department, combined therapy with dexamethasone and epinephrine may significantly reduce hospital admissions," the study authors write. "These results were not modified by RSV [respiratory syncytial virus] status, presence or absence of a history of atopy, or the severity or the duration of illness."

Limitations of this study include enrollment restricted to infants who had wheezing for the first time, limiting generalizability; infants enrolled at academic centers; failure of the study design to anticipate the synergism between epinephrine and dexamethasone; and multiple comparisons present in the factorial study design.

"Given the unexpected synergy we found between epinephrine and dexamethasone and the lack of any apparent benefit when either drug is used alone, our results should be considered exploratory," the study authors conclude. "Although some clinicians consider a trial of a bronchodilator to be standard therapy, published data show, at most, mild transient clinical benefits and no effect on the admission rate. Therefore, confirmation of our findings by a study powered specifically to compare combined epinephrine and dexamethasone therapy with placebo is needed."

In an accompanying editorial, Urs Frey, MD, PhD, from University Hospital of Bern in Bern, Switzerland, and Erika von Mutius, MD, MSc, from University Children's Hospital in Munich, Germany, note the small effect size of the study (11 infants would have to be treated to prevent 1 hospital admission).

"It does not seem practical to apply the treatment, especially considering the potential effects of high-dose corticosteroids on brain and lung development in such young children," Drs. Frey and von Mutius write. "We need to assess risk factors and symptom history and make sure that we identify and treat children with unremitting wheezing. In these children, particularly those presenting with signs of atopy, maintenance treatment can be initiated with inhaled corticosteroids, administered through an appropriate spacer, or with leukotriene-receptor antagonists."

N Engl J Med. 2009;360:2079-2089; 2130-2133.

8. CTA Safe and Effective to Rule Out ACS in Emergency Room for Low- to Moderate-Risk Patients--Cheaper Too

May 4, 2009 (Washington, DC and Boston, Massachusetts) - Another study looking at the use of coronary computed tomography angiography (CTA) in the emergency room has found that the imaging tool can rule out coronary artery disease (CAD) and acute coronary syndromes (ACS) in 50% of patients with a low to intermediate risk of disease [1]. While other studies have also supported a role for CTA in the ER, authors of this latest study, known as ROMICAT, say their series represents one of the largest studies to date and also extends the findings to a low- to intermediate-risk patient. Most emergency-room series have focused to date on low-risk patients only.

In all, 31 of 368 patients (8%) were found to have ACS on the basis of further testing, the authors, led by Dr Udo Hoffmann (Harvard Medical School, Boston, MA), note. "CT is not a good option in a group with a high prevalence of CAD/ACS, and we do not need to do CT in people who have too low a risk," Hoffman told heartwire . "But most people would agree that in a group like the one we have here, with an 8% event rate--this is exactly the segment in whom imaging should be performed."

The ROMICAT study is published in the May 5, 2009 issue of the Journal of the American College of Cardiology.

Hoffman et al used an observational cohort study design, enrolling only patients with normal initial troponin and a nonischemic electrocardiogram. A 64-slice CT angiogram was done before hospital admission, but patients and physicians were blinded to the CTA results, and any treatment decisions were made on the basis of positive troponin or unstable angina pectoris during hospitalization and/or a positive stress test. Patients were also followed for six months for major adverse cardiac events.

As Hoffman et al report, CTA found that 50% of patients had no CAD, 31% had nonobstructive disease, and 19% had inconclusive results or significant stenosis. When these findings were assessed according to ACS diagnosis by other tests postadmission, sensitivity and negative predictive value for ACS were both 100%--none of the patients without plaque on CTA had ACS. By contrast, specificity and positive predictive value were lower, at 17% and 54%, since some of the patients had plaque but no ACS. However, patients with ACS typically had more plaque than patients without, the authors note.

Average hospital stay for patients was 40 hours, the authors report--a cost and inconvenience to patients that could have been avoided had CT been used to determine patient care, Hoffman said. "If you look at it from the emergency-department point of view, it's important to identify as quickly as possible those whom you can send home. That will save a day in the hospital, as well as the troponin test and nuclear-perfusion imaging. If doctors can clear out those patients, they can spend more time with the people who need it."

Hoffman added that he and his colleagues are currently reviewing the CT angiograms of patients who were found to have CAD, to see whether there is anything CT can detect in terms of plaque morphology that could help determine which patients have ACS vs those who don't. "That's taking these findings from a patient level to a lesion level," he said.

In an accompanying editorial [2], Dr Mark A Hlatky (Stanford University School of Medicine, CA) calls ROMICAT a "promising development" for the use of coronary CTA in the emergency department. "A finding of normal coronary arteries will likely obviate additional tests and speed patient discharge to home and appears to be associated with a good short-term prognosis. A finding of some degree of coronary atherosclerosis might not, however, 'clear the air,' as further investigations are likely with either stress testing or invasive coronary angiography (or both)."

The question of whether hard clinical outcomes are actually changed by the use of CTA will require studies in which CT is actually used to direct the course of care in patients, Hlatky points out. In this study, he points out, 8% of patients were lost to follow-up, potentially because patients who had a poor clinical outcome were more difficult to contact. "Although the low rate of adverse cardiac events in the ROMICAT study is reassuring, larger studies with more complete follow-up will be needed to assess more fully the prognostic implication of a coronary CTA in the emergency department," he concludes.

Cost Savings With CTA?

In other recent CT news, researchers presented a similar, smaller study during the American Roentgen Ray Society 2009 Annual Meeting, in Boston, MA, but also factored in the costs of using CTA to rule out ACS in chest-pain patients vs the costs of standard care--typically cardiac enzyme tests and serial ECGs [3].

In their analysis, 50 out of 53 low-risk patients initially admitted with chest pain were negative on CTA (defined as less than 30% stenosis in any one coronary segment). These 50 were also found, subsequently, to have negative cardiac enzymes and negative ECGs. Standard-care charges were a mean of $7567 per patient. By comparison, the charges for CTA followed by observation in the hospital were calculated to be $6153, while CTA without observation was calculated at $4251. They also calculated differences in patient length of hospital stay based on diagnostic workup and found that CTA without and with observation would be significantly less than standard care (five hours, 14.3 hours, and 25.4 hours, respectively).

Lead author for the study, Dr Janet May (University of Washington, Seattle), explained that cardiac CT was added to the standard patient "workup," and patients continued through the regular pathway of patient care. As such, she says, "We were able to see the actual savings in both time and charges that would have occurred had we used cardiac CT instead of the standard of care. I do think the savings in length of stay are just as important as the dollars saved. The two go hand in hand."

No patients reported adverse events over six months' postdischarge, researchers noted, although May emphasized to heartwire that safety of using cardiac CT in low-risk emergency-department chest pain requires further documentation.

"We are working on publishing some one-year follow-up data from chest-pain patients who had CT in the emergency department that will show early, rapid discharge is a very safe practice when the CT showed no coronary artery disease," May noted.

[1] Hoffman U, Bamberg F, Chae CU, et al. Coronary computed tomography angiography for early triage of patients with acute chest pain. The ROMICAT (Rule Out Myocardial Infarction Using Computer-Assisted Tomography) trial. J Am Coll Cardiol 2009; 53:1642–50.

[2] Hlatky MA. Evaluating use of coronary computed tomography angiography in the emergency department. J Am Coll Cardiol 2009; 53:1651-1653.

[3] May JM, Shuman WP, Strote N, et al. Low-risk chest pain patients in the emergency department: negative 6- channel cardiac CT may reduce length of stay and hospital charges. American Roentgen Ray Society 2009 Annual Meeting; April 27, 2009; Boston, MA. Abstract 1, page 55.

9. NY Times Joins Us in Educating the Public about the Risk of Taking Antibiotics

“Stomach Bug Crystallizes an Antibiotic Threat” by Stuart Bradford, April 13, 2009

Earlier this year, Harold and Freda Mitchell of Como, Miss., both came down with a serious stomach bug. At first, doctors did not know what was wrong, but the gastrointestinal symptoms became so severe that Mrs. Mitchell, 66, was hospitalized for two weeks. Her husband, a manufacturing supervisor, missed 20 days of work.

A local doctor who had worked in a Veterans Affairs hospital recognized the signs of Clostridium difficile, a contagious and potentially deadly bacterium. Although the illness is difficult to track, health officials estimate that in the United States the bacteria cause 350,000 infections each year in hospitals alone, with tens of thousands more occurring in nursing homes. While the majority of cases are found in health care settings, 20 percent or more may occur in the community. The illness kills an estimated 15,000 to 20,000 people annually.

“It’s been the worst thing I’ve ever tried to get through in my life,” said Mrs. Mitchell, who remains weakened by the ordeal. “I really did think I was going to die.”

What is so frightening about C. difficile is that it is often spurred by antibiotics. The drugs wipe out the targeted illness, like a urinary tract or upper respiratory infection, but they also kill off large portions of the healthy bacteria that normally live in the digestive tract. If a person comes into contact with C. difficile, or already has it, the disruption to the beneficial bacteria creates an opportunity for the harmful bacteria to flourish.

The public health community has been sounding the alarm for years about the overuse of antibiotics and the emergence of “superbugs” — bacteria that have developed immunity to a wide number of antibiotics. But the C. difficile problem shows that the threat is not generalized or hypothetical, but immediate and personal.

“One of the things that we counsel consumers about is to make sure that an antibiotic is really necessary,” said Dr. Dale N. Gerding, an infectious disease specialist at the Stritch School of Medicine at Loyola University in Chicago. “There are many good reasons for taking an antibiotic, but an illness like sinusitis or bronchitis winds up being treated with antibiotics even though it will go away by itself anyway.”

Full-text: http://www.nytimes.com/2009/04/14/health/14well.html

10. New Antivenom Rapidly Resolves Neurotoxic Effects of Scorpion Sting in Children

May 15, 2009 — Results of a new randomized trial show that a scorpion-specific F(ab')2 antivenom rapidly resolved the clinical neuromotor syndrome and respiratory insufficiency associated with envenomation by the Centruroides scorpion among critically ill children.

Treatment also reduced the need for sedation with midazolam in these children and reduced circulating serum venom levels.

Completion of this trial was a challenge from a variety of standpoints, said lead author Leslie V. Boyer, MD, from the University of Arizona Health Sciences Center, in Tucson. The condition is relatively rare and the presentation emergent, the subjects are children, and the antivenom used in this trial, while commercially available in Mexico, where scorpion stings are a huge problem, had never been subjected to clinical trials.

Using a simple binary end point of resolution of the clinical neuromotor syndrome within 4 hours or not, Dr. Boyer and colleagues were able to answer the question after enrolling only 15 children. "There were people who thought it wouldn't work, but they were people who hadn't treated scorpion sting and didn't know what a vivid syndrome it is," Dr. Boyer told Medscape Neurology & Neurosurgery.

Their report appears in the May 14 issue of the New England Journal of Medicine (NEJM).

Sting of the Scorpion

Scorpions are carnivores, eating mostly insects but also small vertebrates, Dr. Boyer said. Various species have developed a "small arsenal" of different toxins, most of which are channel toxins. "The sodium-channel toxins are the most infamous for human envenomation, but there are chloride-, potassium-, and calcium-channel toxins that have been identified as well," she said.

The sting of the Centruroides sculpturatus contains a toxin that affects sodium channels in peripheral nerves, she said. The clinical presentation of the sting in a child who has received a large-per-kilogram dose includes violent neuromotor hyperactivity with stereotypical eye movements.

"It's often mistaken for a seizure, although it's not symmetric and not rhythmic," Dr. Boyer noted. "Physicians will see it and assume that the child is unconscious, but they're actually wide awake and just can't control themselves."

In addition to motor nerves, nerves that innervate the muscarinic system are also clearly involved, so the children sweat and drool, although the most dangerous effect is respiratory failure from the combination of aberrant movement in the muscles associated with respiration and the inability to clear the airway of excessive salivation. "When you put all these together, these kids can be critically ill, and without medical care, it can be fatal," she said.

The Centruroides scorpion is a big issue in Mexico, where there are about 250,000 reported stings each year. About 8000 stings are reported annually in Arizona, as well as some in New Mexico, Nevada, and, rarely, California.

There are no currently approved therapies for the treatment of scorpion envenomation, she said. Until 1999, Arizona used antivenom that was manufactured locally by Marilyn Bloom at Arizona State University, who had produced a goat-derived whole IgG preparation that predated the modern Food and Drug Administration, Dr. Boyer said. "When she retired, nobody would take the goats, and nobody would make the antivenom."

Because these stings are such a problem in Mexico, they began a collaboration with researchers there to study a different type of antivenom that is already used commercially. It is an F(ab')2 antivenom, in which the immunoglobulin molecule has been altered to remove the Fc portion of the molecule responsible for most allergic reactions.

In this randomized, double-blind study, 15 children between the ages of 6 months and 18 years admitted to the pediatric intensive care unit (ICU) received either the F(ab')2 antivenom or placebo. The primary end point was the resolution of the clinical syndrome within 4 hours of administration of study drug.

They found complete resolution of symptoms within 4 hours in all 8 treated patients, vs 1 of the 7 children who received placebo.

Children receiving the antivenom required less sedation with midazolam, which might facilitate earlier discharge from the ICU, and all had undetectable levels of circulating unbound venom, vs 1 patient in the placebo group.

There were no serum reactions in this study, but they point out that the small size of the study precludes an assessment of the safety, and larger trials will still be needed.

N Engl J Med. 2009;360:2090-2098.

11. Images in Emergency Medicine (Full-text Free)

Woman With Neck Pain

http://www.annemergmed.com/article/S0196-0644(08)01724-1/fulltext

Infant With Retained Urinary Catheter

http://www.annemergmed.com/article/S0196-0644(08)01725-3/fulltext

Blurry Vision and Abnormal Sweating

http://www.annemergmed.com/article/S0196-0644(08)01905-7/fulltext

Adult Male With Right Shoulder Pain

http://www.annemergmed.com/article/S0196-0644(08)01908-2/fulltext

Elderly Woman With Shortness of Breath

http://www.annemergmed.com/article/S0196-0644(08)02024-6/fulltext

A Man With Black Urine

http://www.annemergmed.com/article/S0196-0644(08)01976-8/fulltext

12. A Graphic Reanalysis of the NINDS Trial

Hoffman JR, Schriger DL. Ann Emerg Med. 2009; in press

Study objective
Reports of clinical trials typically present only a fraction of the available data, at times hampering interpretation of their meaning. The initial report of the National Institute of Neurologic Diseases and Stroke (NINDS) trials of tissue plasminogen activator in acute ischemic stroke is an example of this phenomenon.

Methods
We used the original data from the NINDS trials to create graphs showing the effect of treatment on neurologic function in all 624 individual patients in the trial. Our goal was to show detailed graphics of the 90-day outcomes, stratified on relevant confounders and effect modifiers.

Results
Final outcomes were highly dependent on stroke severity. In many graphs, the small difference between groups favored tissue plasminogen activator, particularly when baseline NIHSS score was between roughly 5 and 22. These differences diminish or disappear when 90-day change in NIHSS is graphed. Our graphs fail to support the time-is-brain hypothesis.

Conclusion
Our graphical method of presenting the NINDS trial results provides more detail than was conveyed in the original report and empowers readers to reach their own conclusions about the trial's meaning. Outcomes for placebo and treatment limbs are sufficiently similar that larger trials, conducted under the same conditions as the NINDS trial, are needed to determine which patients benefit from this therapy.

13. Women Less Likely to Receive Proper Out-Of-Hospital Treatment for Chest Pain

By Anthony J. Brown, MD. NEW YORK (Reuters Health) May 18 - Women with chest pain are less likely than their male counterparts to receive aspirin and other recommended therapies by emergency medical service (EMS) personnel, according to study findings presented Friday at the Society for Academic Emergency Medicine's annual conference in New Orleans.

"We expected to find no differences in treatments (by gender) because so much of ambulance care is subject to protocol," lead researcher Dr. Zachary Mesiel told Reuters Health. "In general, there is not as much discretion in how to treat patients in the prehospital arena compared to hospital or outpatient care." However, the findings showed that there was, in fact, a gender difference.

The good news is that no racial disparities in out-of-hospital care were seen, noted Dr. Mesiel, who is with the University of Pennsylvania School of Medicine. Prior studies have suggested that there might be.

The results stem from a study of 683 patients with chest pain who were brought by EMS to one of three Philadelphia hospitals in 2006 and 2007. The main outcome measures were how often the subjects received four recommended EMS interventions: aspirin, nitroglycerin, heart rhythm monitoring, and an intravenous line.

Women were less likely than men to receive aspirin (24% vs. 32%), nitroglycerin (26% vs. 33%), and an intravenous line (61% vs. 70%).

Among women, those with a confirmed MI in the ER were significantly less likely than those without an MI to have received the recommended EMS interventions. In fact, none of the women with MI had received aspirin in the field.

"We still don't know why men and women get different care for chest pain," Dr. Mesiel noted. "Some of the differences may be due to the way patients describe their symptoms or their preferences in how they want to be treated. On the other hand, some of the differences may be due to biases of the providers."

As for future research, Dr. Mesiel said that it remains to be determined whether the differences in pre-hospital care between men and women translate into different outcomes.

14. Is the Ordering of Imaging for Suspected Venous Thromboembolism Consistent With D-dimer Result?

Teismann NA, et al. Ann Emerg Med 2009; in press

Study objective
We assessed whether the ordering of imaging studies in patients with suspected venous thromboembolism was consistent with the results of D-dimer testing.

Methods
We performed a retrospective chart review of consecutive cases in which a D-dimer assay was performed at an urban academic emergency department during a 13-month period. Measurements included D-dimer result and results of imaging for venous thromboembolism. The primary outcome measure was the percentage of patients in each D-dimer category (positive or negative result with a cutoff value of 500 ng fibrinogen equivalent units/dL) who underwent subsequent imaging within 48 hours. We also report the results of the imaging studies obtained.

Results
A total of 553 D-dimer tests were ordered, with 266 (48.1%) negative and 287 (51.9%) positive results. Of patients with a negative D-dimer result, 37 (14%; 95% confidence interval [CI] 10% to 19%) underwent at least 1 imaging study. Of patients with a positive D-dimer result, 137 (48%; 95% CI 42% to 54%) did not undergo imaging.

Conclusion
Evaluation for venous thromboembolism occasionally proceeded despite a negative D-dimer result, whereas frequently no further evaluation occurred despite a positive result. These findings suggest that actual clinical practice differs from what is recommended by published algorithms that guide evaluation of patients with suspected venous thromboembolism.

15. The Safety of Emergency Care Systems: Results of a Survey of Clinicians in 65 US Emergency Departments (includes Kaiser Sacramento)

Magid DJ, et al. Ann Emerg Med. 2009;53:715-723.e1

Study objective
Well-functioning systems are critical to safe patient care, but little is known about the status of such systems in US health care facilities, including high-risk settings such as the emergency department (ED). The purpose of this study is to assess the degree to which EDs are designed, managed, and supported in ways that ensure patient safety.

Methods
This was a validated, psychometrically tested survey of clinicians working in 65 US EDs that assessed clinician perceptions about the EDs' physical environment, staffing, equipment and supplies, nursing, teamwork, safety culture, triage and monitoring, information coordination and consultation, and inpatient coordination.

Results
Overall 3,562 eligible respondents completed the survey (response rate=66%). Survey respondents commonly reported problems in 4 systems critical to ED safety: physical environment, staffing, inpatient coordination, and information coordination and consultation. ED clinicians reported that there was insufficient space for the delivery of care most (25%) or some (37%) of the time. Respondents indicated that the number of patients exceeded ED capacity to provide safe care most (32%) or some of the time (50%). Only 41% of clinicians indicated that most of the time specialty consultation for critically ill patients arrived within 30 minutes of being contacted. Finally, half of respondents reported that ED patients requiring admission to the ICU were rarely transferred from the ED to the ICU within 1 hour.

Conclusion
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.

16. NHLBI Ends Enrollment in Trial of Hypertonic Saline for Traumatic Brain Injury

Laurie Barclay, MD. May 14, 2009 — The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) has stopped enrollment of patients with severe traumatic brain injury (TBI) into a Resuscitation Outcomes Consortium (ROC) trial testing the effects of hypertonic saline solutions given before arrival at the emergency department.

"The [ROC] is the largest research network to study real-world, prehospital interventions for cardiopulmonary arrest and traumatic injury leading to arrest," noted George Sopko, MD, program director in the NHLBI Division of Cardiovascular Science. "By conducting these studies through such a robust network, we can compare clinical interventions in meaningful ways and disseminate the results as quickly as possible, thus saving resources and providing information of immediate benefit to patients."

An independent data and safety monitoring board (DSMB) recommended stopping enrollment on the basis of an analysis of data from 1073 patients with TBI (about half of the total planned enrollment) who had been followed up for 6 months. This planned interim analysis suggested that hypertonic saline solutions offered no benefit over the standard treatment of normal saline, nor was there any difference in risks with the 2 treatments. Despite the absence of safety concerns, the board and the investigators decided that continuing to enroll new patients was unlikely to change the study outcome.

"Although hypertonic saline solutions showed promise for improving outcomes when used as quickly as possible after trauma, our findings do not support any significant benefit of hypertonic saline over standard saline in patients with either [TBI] or shock from excessive bleeding," coprincipal investigator and ROC Vice Chair for Trauma David Hoyt, MD, from the University of California, Irvine, said in a news release. "Although these findings are disappointing, they nonetheless provide major contributions to our understanding of emergency medical care."

According to the original trial design, previously enrolled patients will continue to be monitored through their 6-month follow-up visits.

In March, the NHLBI stopped a parallel study of hypertonic saline in trauma patients with hemorrhagic shock, also because interim analysis showed that hypertonic saline (with or without dextran) vs normal saline was not associated with improved survival.

The rationale for testing hypertonic saline in these trials was that compared with normal saline, it was thought to better compensate for blood loss, to reduce harmful inflammatory responses, and to prevent cerebral edema. Previous animal studies and smaller clinical trials suggested better outcomes in patients with TBI after use of hypertonic saline solution, which is currently approved and used in 14 European countries. The safety profile to date has been good, and some evidence suggests a potential survival benefit when hypertonic saline is given as early as possible after TBI.

Surprisingly, however, in the ROC hypertonic saline for hemorrhagic shock trial, 28-day mortality was no different with hypertonic saline alone or with dextran vs normal saline. The DSMB recommended early termination of the trial based on analyses of the interim data showing that deaths occurred earlier in the hypertonic saline groups, despite similar cumulative 28-day mortality between the hypertonic and normal saline groups.

In the hypertonic saline for TBI trial, analyses of 6-month follow-up data do not suggest a similar trend toward earlier deaths in the hypertonic saline vs normal saline group. Further analyses are underway, with publication anticipated in a peer-reviewed scientific journal.

"Improving treatment and survival of traumatic injury are critical public health problems," said NHLBI Director Elizabeth G. Nabel, MD. "While these study results did not show the expected benefit of one type of treatment, other findings by the resuscitation consortium researchers — and the hundreds of emergency and fire services teams they are working with — may lead to new life-saving intervention strategies."

17. Crowding Delays Treatment and Lengthens Emergency Department Length of Stay, Even Among High-Acuity Patients

McCarthy ML, et al. Ann Emerg Med. 2009; in press

Study objective: We determine the effect of crowding on emergency department (ED) waiting room, treatment, and boarding times across multiple sites and acuity groups.

Methods: This was a retrospective cohort study that included ED visit and inpatient medicine occupancy data for a 1-year period at 4 EDs. We measured crowding at 30-minute intervals throughout each patient’s ED stay. We estimated the effect of crowding on waiting room time, treatment time, and boarding time separately, using discrete-time survival analysis with time-dependent crowding measures (ie, number waiting, number being treated, number boarding, and inpatient medicine occupancy rate), controlling for patient demographic and clinical characteristics.

Results: Crowding substantially delayed patients’ waiting room and boarding times but not treatment time. During the day shift, when the number boarding increased from the 50th to the 90th percentile, the adjusted median waiting room time (range 26 to 70 minutes) increased by 6% to 78% (range 33 to 82 minutes), and the adjusted median boarding time (range 250 to 626 minutes) increased by 15% to 47% (range 288 to 921 minutes), depending on the site. Crowding delayed the care of high-acuity level 2 patients at all sites. During crowded periods (ie, 90%), the adjusted median waiting room times of high-acuity level 2 patients were 3% to 35% higher than during normal periods, depending on the site and crowding measure.

Conclusion: Using discrete-time survival analysis, we were able to dynamically measure crowding throughout each patient’s ED visit and demonstrate its deleterious

18. Evidence-Based Emergency Medicine Reviews (Full-text Free)

Clinical Prediction Rules to Stratify Short-Term Risk of Stroke Among Patients Diagnosed in the Emergency Department With a Transient Ischemic Attack

http://www.annemergmed.com/article/PIIS0196064408015886/fulltext

Is This Patient Clinically Depressed?

http://www.annemergmed.com/article/S0196-0644(08)00793-2/fulltext

Does This Patient With Diabetes Have Osteomyelitis of the Lower Extremity?

http://www.annemergmed.com/article/S0196-0644(08)00836-6/fulltext

Does This Child Have a Urinary Tract Infection?

http://www.annemergmed.com/article/S0196-0644(08)00846-9/fulltext

Continuing Education Meetings and Workshops: Effects on Professional Practice and Health Care Outcomes

http://www.annemergmed.com/article/S0196-0644(08)00849-4/fulltext

19. Neurocognitive Function of ED Patients With Mild Traumatic Brain Injury

Peterson SE, et al. Ann Emerg Med. 2009;53:796-803.e1

Study objective
We characterize the neurocognitive function of patients presenting to the emergency department (ED) with mild traumatic brain injury.

Methods
This prospective study took place at an urban, academic ED and Level I trauma center. Case patients consisted of a convenience sample of ED patients aged 18 to 59 years, presenting to the ED with mild traumatic brain injury and having a head computed tomography scan without traumatic abnormalities. Controls consisted of patients aged 18 to 59 years, presenting to the ED with an isolated, nondominant hand extremity injury. We excluded patients with multiple injuries and recent alcohol consumption. Subjects completed a computerized neurocognitive test battery (Immediate Post-concussion Assessment and Cognitive Testing). The primary measures were verbal memory, visual memory, and visual motor and reaction speed. We compared raw and age-normalized neurocognitive performance between case patients and controls by using nonparametric statistics.

Results
We included a total of 23 head-injured case patients and 31 non–head-injured controls. Case patients and controls exhibited similar raw (median 80.1 versus 85.0 points; difference in medians –4.9; P=.26) and age-normalized (31.9 versus 57.4 percentile; difference in medians –25.5; P=.12) verbal memory. Case patients and controls exhibited similar raw (64.6 versus 63.5; difference 1.1; P=.79) and age-normalized (20.8 versus 25.8 percentile; difference –5.0; P=.44) visual memory. Compared with controls, mild traumatic brain injury case patients demonstrated slower raw (31.6 versus 37.0 points; difference –5.4; P=.002) and age-normalized (17.1 versus 57.6 percentile; difference –40.5; P=.001) visual motor speed. Mild traumatic brain injury case patients exhibited slower raw (median 0.66 versus 0.60 seconds; difference 0.06; P=.01) and age-normalized (29.3 versus 42.8 percentile; difference –13.5; P=.009) reaction times.

Conclusion
In conclusion, compared with the non–head-injured patients, ED mild traumatic brain injury patients demonstrated subtle but discernible neurocognitive deficits.

20. The Association Between Transfer of Emergency Department Boarders to Inpatient Hallways and Mortality: A 4-Year Experience

Viccellio A, et al. Ann Emerg Med. 2009; in press

Study objective
We developed and implemented an institutional protocol aimed at reducing crowding by admitting boarded patients to hospital inpatient hallways. We hypothesized that transfer of admitted patients from the emergency department (ED) to inpatient hallways would be feasible and not create patient harm.

Methods
This was a retrospective cohort study in a suburban, academic ED with an annual census of 70,000. We studied consecutive patients admitted from our ED between January 2004 and January 2008. In 2001, a multidisciplinary team developed and implemented an institutional protocol in which admitted adult patients boarded in the ED were transferred to hospital inpatient hallways under select conditions. We extracted data from the electronic medical record system, measuring patient demographics, ED disposition (discharge, admit to floor, admit to hallway), ED length of stay, and inhospital mortality. We report ED length of stay, subsequent transfer to an ICU, and hospital mortality of patients admitted to standard and hallway inpatient beds.

Results
Of 55,062 ED patients admitted, there were 1,798 deaths. Of all admissions, 2,042 (4%) went to a hallway; 53,020 went to a standard bed. Patients admitted to standard and hallway beds were similar in age (median [interquartile range] 55 years [37 to 72 years] and 54 years [41 to 70 years], respectively) and sex (48.2% and 50% female patients, respectively). The median (interquartile range) times from ED triage to actual admission in patients admitted to standard and hallway beds were 426 minutes (306 to 600 minutes) and 624 (439 to 895 minutes) minutes, respectively (P less than .001). Median ED census at triage was lower for standard bed admissions than for hallway patients (44 [33 to 53] versus 50 [38 to 61], respectively, P less than .001). Inhospital mortality rates were higher among patients admitted to standard beds (2.6%; 95% confidence interval [CI] 2.5% to 2.7%) than among patients admitted to hallway beds (1.1%; 95% CI 0.7% to 1.7%). ICU transfers were also higher in the standard bed admissions (6.7% [95% CI 6.5% to 6.9%] versus 2.5% [95% CI 1.9% to 3.3%]).

Conclusion
Transfer of ED-boarded admitted patients to an inpatient hallway occurs during high ED census and waiting times for admission but does not appears to result in patient harm.

21. Randomized Trial of Computerized Quantitative Pretest Probability in Low-Risk Chest Pain Patients: Effect on Safety and Resource Use

Kline JA, et al. Ann Emerg Med. 2009;53:727-735.e1

Study objective
We hypothesize that the presentation of a quantitative pretest probability of acute coronary syndrome would safely reduce unnecessary resource use in low-risk emergency department (ED) chest pain patients.

Methods
Randomized controlled trial of adult patients with chest pain paired with their clinicians. Patients had neither obvious evidence of acute coronary syndrome nor obvious other reason for admission. Clinicans provided their unstructured point estimate for pretest probability before randomization. Clinicans and patients in the intervention group received a printout of pretest probability of acute coronary syndrome result displayed numerically and graphically. Controls received no printout. Patients were followed for 45 days for predefined criteria of acute coronary syndrome and efficacy endpoints. Endpoints were compared between groups, with 95% confidence intervals (CIs) for differences.

Results
Four hundred were enrolled, and 31 were excluded for cocaine use or elopement from care. The mean pretest probability estimates of acute coronary syndrome were 4 (SD 5%) from clinicians and 4 (SD 6%) from the computer. Safety and efficacy endpoints for controls (n=185) versus intervention patients (n=184) were as follows: (1) delayed or missed diagnosis of acute coronary syndrome: 1 of 185 versus 0 of 184 (95% CI for difference −2.8% to 15.0%); (2) hospital admission with no significant cardiovascular diagnosis, 11% versus 5% (−0.2% to 11%); (3) thoracic imaging imparting greater than 5 mSv radiation with a negative result, 20% versus 9% (95% CI for difference = 3.8% to 18.0%); (4) median length of stay, 11.4 hours versus 9.2 hours (95% CI for difference = −2.9 to 7.6 hours); (5) reported feeling “very satisfied” with clinician explanation of problem on follow-up survey, 38% versus 49% (95% CI for difference = 0.9% to 21.0%); (6) readmitted within 7 days, 11% versus 4% (95% CI for difference = 2.5% to 13.2%).

Conclusion
Presentation of a quantitative estimate of the pretest probability of acute coronary syndrome to clinicians and low-risk ED chest pain patients was associated with reduced resource use, without evidence of increased rate of premature discharge of patients with acute coronary syndrome.

22. Clinical Prediction Rules for Identifying Adults at Very Low Risk for Intra-abdominal Injuries After Blunt Trauma

Holmes JF, et al. Ann Emerg Med. 2009; in press

Study objective
We derive and validate clinical prediction rules to identify adult patients at very low risk for intra-abdominal injuries after blunt torso trauma.

Methods
We prospectively enrolled adult patients (≥18 years old) after blunt torso trauma for whom diagnostic testing for intra-abdominal injury was performed. In the derivation phase, we used binary recursive partitioning to create a rule to identify patients with intra-abdominal injury who were undergoing acute intervention (including therapeutic laparotomy or angiographic embolization) and a separate rule for identifying patients with any intra-abdominal injury present. We considered only clinical variables readily available with acceptable interrater reliability. The prediction rules were then prospectively validated in a separate cohort of patients.

Results
In the derivation phase, we enrolled 3,435 patients, including 311 (9.1%; 95% confidence interval [CI] 8.1% to 10.1%) with intra-abdominal injury and 109 (35.0%; 95% CI 29.7% to 40.6%) with intra-abdominal injury requiring acute intervention. In the validation study, we enrolled 1,595 patients, including 143 (9.0%; 95% CI 7.6% to 10.5%) with intra-abdominal injury. The derived rule for patients with intra-abdominal injuries who were undergoing acute intervention consisted of hypotension, Glasgow Coma Scale (GCS) score less than 14, costal margin tenderness, abdominal tenderness, hematuria level greater than or equal to 25 red blood cells/high powered field, and hematocrit level less than 30% and identified all 44 patients in the validation phase with intra-abdominal injury who were undergoing acute intervention (sensitivity 44/44, 100%; 95% CI 93.4% to 100%). The derived rule for the presence of any intra-abdominal injury consisted of GCS score less than 14, costal margin tenderness, abdominal tenderness, femur fracture, hematuria level greater than or equal to 25 red blood cells/high powered field, hematocrit level less than 30%, and abnormal chest radiograph result (pneumothorax or rib fracture). In the validation phase, the rule for any intra-abdominal injury present had the following test performance: sensitivity 137 of 143 (95.8%; 95% CI 91.1% to 98.4%), specificity 434 of 1,452 (29.9%; 95% CI 27.5% to 32.3%), and negative predictive value 434 of 440 (98.6%; 95% CI 97.1% to 99.5%).

Conclusion
These derived and validated clinical prediction rules can aid physicians in the evaluation of adult patients after blunt torso trauma. Patients without any of these variables are at very low risk for having intra-abdominal injury, particularly intra-abdominal injury requiring acute intervention, and are unlikely to benefit from abdominal computed tomography scanning.