Lit Bits: Jan 17, 2010

From the recent medical literature...

1. Ranking 37th — Measuring the Performance of the U.S. Health Care System

Posted by NEJM • January 6th, 2010 •

Christopher J.L. Murray, M.D., D.Phil., and Julio Frenk, M.D., Ph.D., M.P.H.

Evidence that other countries perform better than the United States in ensuring the health of their populations is a sure prod to the reformist impulse. The World Health Report 2000, Health Systems: Improving Performance, ranked the U.S. health care system 37th in the world1 — a result that has been discussed frequently during the current debate on U.S. health care reform.

The conceptual framework underlying the rankings2 proposed that health systems should be assessed by comparing the extent to which investments in public health and medical care were contributing to critical social objectives: improving health, reducing health disparities, protecting households from impoverishment due to medical expenses, and providing responsive services that respect the dignity of patients. Despite the limitations of the available data, those who compiled the report undertook the task of applying this framework to a quantitative assessment of the performance of 191 national health care systems. These comparisons prompted extensive media coverage and political debate in many countries. In some, such as Mexico, they catalyzed the enactment of far-reaching reforms aimed at achieving universal health coverage. The comparative analysis of performance also triggered intense academic debate, which led to proposals for better performance assessment.

Despite the claim by many in the U.S. health policy community that international comparison is not useful because of the uniqueness of the United States, the rankings have figured prominently in many arenas. It is hard to ignore that in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy.3 These facts have fueled a question now being discussed in academic circles, as well as by government and the public: Why do we spend so much to get so little?

The rest of the article: http://healthcarereform.nejm.org/?p=2610

2. Cardiac Arrest: Cardiovert, Compress, Cool, ... and Cath?

Amal Mattu, MD.

In recent decades, numerous therapies have been promoted as great advances in the treatment of primary cardiac arrest: epinephrine, high-dose epinephrine, vasopressin, lidocaine, amiodarone, electrical defibrillation, biphasic defibrillation, induced hypothermia, and so on. The initial literature on these "miracle cures" has always looked promising. However, when attempts at validating these early studies were made or when meaningful outcomes (eg, hospital discharge with good neurologic function) were evaluated, most of these therapies fell short and eventually lost favor in the literature. Currently, only 3 therapies have emerged as truly beneficial in terms of meaningful outcomes: rapid defibrillation of ventricular fibrillation/pulseless ventricular tachycardia, good chest compressions (with less emphasis on early airway interventions and minimizing interruptions), and induced hypothermia.

Given that the majority of cases of primary cardiac arrest are associated with acute coronary syndromes, it seems reasonable to assume that urgent coronary angiography and percutaneous coronary intervention (PCI) would be associated with improved outcomes in patients with return of spontaneous circulation (ROSC) after cardiac arrest. Recent studies have demonstrated this to be true for patients with electrocardiogram (ECG) evidence of ST-segment elevation myocardial infarction (STEMI) either before or after resuscitation. However, it is well-known that the ECG is far from perfect at demonstrating evidence of acute MI. Therefore, use of the ECG to determine which patients should undergo urgent PCI might potentially lead to many patients missing out on beneficial therapy. Can coronary angiography and PCI improve the outcomes of resuscitated patients without definite evidence of STEMI? Reynolds and colleagues attempted to answer this question.

Reynolds JC, et al. Coronary Angiography Predicts Improved Outcome Following Cardiac Arrest: Propensity-adjusted Analysis. J Intensive Care Med. 2009;24:179-186

Summary
The authors performed a chart review of resuscitated patients in cardiac arrest between 2005 and 2007. They evaluated an assortment of parameters including acute ischemic ECG changes (new left bundle branch block or STEMI), presenting rhythm, neurologic status, and outcome. A good outcome was defined as discharge home or to an acute rehabilitation facility. Of the 241 patients they reviewed, 40% received coronary angiography. Significant disease (defined as 70% stenosis or greater in at least 1 coronary artery) was identified in 69% of patients, including 57% of patients without any ischemic changes on ECG. Of the patients who received coronary angiography and PCI, 54% experienced a good clinical outcome compared with 25% of patients not receiving coronary angiography. A propensity-adjusted analysis was used to account for the nonrandomized nature of the study. The authors determined that improved survival and good outcome were associated with coronary angiography regardless of the presence of new left bundle branch block or STEMI, and also regardless of presenting rhythm or neurologic status immediately after resuscitation.

Viewpoint
Reynolds' study further supports previously published reports encouraging urgent catheterization for survivors of cardiac arrest regardless of ECG evidence of STEMI. Recent publications also show that therapeutic hypothermia can be used safely in these patients during and after PCI without producing delays in time to balloon inflation.

The significance of this new literature cannot be overstated. If further studies confirm these findings, it would strongly argue for enormous changes in prehospital systems of care. All survivors of primary cardiac arrest would be recommended for immediate transport to hospitals that have the capability of performing urgent PCI in conjunction with therapeutic hypothermia. Based on the current literature, it certainly seems advisable that emergency healthcare practitioners who care for resuscitated victims of primary cardiac arrest should engage in conversations with cardiology consultants and urge them to take an aggressive approach to PCI in these patients.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19321536

3. Santa Claus: a public health pariah?

Grills NJ, et al. BMJ 2009;339:b5261

Santa Claus is a well known and loved character, but Nathan Grills and Brendan Halyday question whether he is a healthy role model

Santa Claus long ago displaced the Virgin Mary and baby as the most unmistakable Christmas iconography. A recent study among hospital inpatients concluded that awareness of Santa was near universal. Given Santa’s fame, he has considerable potential to influence individual and societal behaviour—and not necessarily for good. Santa is a late adopter of evidence based behaviour change and continues to sport a rotund sedentary image. But this is not the only example where Santa’s behaviour and public image are at odds with contemporary accepted public health messages.

Eric Schlosser and Morgan Spurlock have both described how McDonald’s used Ronald McDonald to target their products at children by creating an association between McDonald’s food and happy times. Spurlock showed how Ronald McDonald was more highly recognised than the American president or the Pope. Interestingly, Schlosser documents that among American schoolchildren Santa Claus was the only fictional character more highly recognised than than Ronald McDonald.

If Ronald McDonald can be so effective at selling burgers to children, we might expect Santa to be equally effective at selling other goods. After all, it was Santa’s advertising potential that reincarnated simple Saint Nicholas into the glory of a universally recognised icon. Santa’s contemporary image was cemented by the Coca-Cola advertisements that began in the 1930s. By the mid-1950s Santa had become the leading sales consultant for numerous other companies and products. Today, he is one of the biggest sellers at Christmas and appears in adverts on television, the internet, billboards, and shop fronts.

Public health needs to be aware of what giant multinational capitalists realised long ago: that Santa sells, and sometimes he sells harmful products. Several countries, like the UK, limit what can be advertised to children. Since Santa is a childhood icon should we prevent him from selling products such as alcohol and unhealthy foods?

Furthermore, Santa has a growing impact on international public health. Like Coca-Cola, Santa has become a major export item to the developing world. Countries such as India are increasing celebrating the Christmas festival. The potential for Santa’s growing acclaim to be misused may even be greater in countries where there is less regulation of advertising.

Obesity
Epidemiologically there is a correlation between countries that venerate Santa Claus and those that have high levels of childhood obesity. Although given the various confounders it is premature to conclude causality, there is a temporal pathway whereby Santa promotes a message that obesity is synonymous with cheerfulness and joviality. Rear Admiral Galson, acting US surgeon general in 2007, commented, "It is really important that the people who kids look up to as role models are in good shape, eating well and getting exercise. It is absolutely critical." He went on to explain that Santa should slim down.

To create a supportive environment for Santa’s dieting we should cease the tradition of leaving Santa cookies, mince pies, and milk, brandy, or sherry. This is bad not only for Santa’s waistline but for parental obesity. When Santa is full, Dad is a willing helper. Maybe we should encourage Santa (and his helpers) to share the carrots and celery sticks commonly left for Rudolf. Santa might also be encouraged to adopt a more active method to deliver toys—swapping his reindeer for a bike or simply walking or jogging.

The rest of the article: http://www.bmj.com/cgi/content/full/339/dec16_1/b5261

4. Geriatric Population Becoming Bigger Part of Emergency Department Mix

NEW YORK (Reuters Health) Dec 18 - Traffic in US emergency departments has increased significantly in the last decade, with geriatric patients leading the way, new research from Texas shows.

Dr. K. Tom Xu and colleagues, from Texas Tech University Health Sciences Center in Lubbock, extracted emergency department utilization data from the Medical Expenditure Panel Survey for the period 1996 to 2005.

During that period, they report in the Annals of Emergency Medicine for December, the total number of non-institutionalized individuals who used emergency department services in the US increased from 34.2 million to 40.8 million. That is, the proportion of emergency department users in the US population rose from 12.7% to 13.8%.

The authors did not report specific percentages for various age groups and subpopulations, but they "found that emergency department users had become older and (included more of) those who perceived themselves to be in poor or fair physical health, with and without population adjustment," they write in their report.

"The key observation in this study is that the composition of patients seen in emergency rooms has been changing over time," Dr. Xu told Reuters Health.

"People tend to associate ERs with traumas, injuries, accidents, poisoning, overdose and other dramatic events," Dr. Xu said. "In reality, a larger portion of patients seen in emergency rooms are those with chronic diseases and poor overall health."

The study, he added, also confirms earlier findings that the poor and the uninsured "are not the main contributing factors to emergency room crowding in recent years."

In addition to older adults and those in poor health, subpopulations that showed significantly increasing levels of emergency department use after population adjustment included blacks, people with only Medicare insurance, those with multiple types of insurance, those within 100% to 199% of the federal poverty line and those with at least one inpatient stay.

Some subpopulations that showed decreasing levels of emergency department use: women, Hispanics, uninsured individuals, people with private insurance only, and patients at greater than or equal to 200% of the federal poverty line.

"The aging population will create additional challenges in the training of future emergency physicians and in the reform of the nation's health care system," Dr. Xu said.

"This study will not change practice but will help those planning the kinds of emergency department resources that will be needed in the future."

Ann Emerg Med 2009;54:805-810.

5. Evidence based merriment

Isaacs S, et al. BMJ 2009;339:b5098

Background
Medical humour has a long history, but is short on evidence. The ancient Greeks introduced the world to bodily fluids called the four humours. You would think that a philosophy based on blood, choler, phlegm, and melancholy was no laughing matter.

What is the evidence that medical humour benefits staff or patients? We performed a systematic revue, but it was not funny. We propose a randomised controlled trial of medical humour.

Pilot study
The Royal Flying Doctor Service funded a pilot study. Hospital staff completed a standardised questionnaire about the role of humour in their department.

The department of surgery expressed an interest in side-splitting jokes.

The ophthalmology department insisted that all patients should have a slit lamp examination for aqueous and vitreous humour.

The gastroenterology department wanted to ban sick jokes and toilet humour.

The allergy department warned of the hazards of severe joke allergy. At least one child has suffered a severe allergic reaction to a shaggy dog story, while cat allergy predisposes to cataplexy. However, the most feared condition is anaphylaxis to puns, which can only be treated with outrageously expensive adrenaline syringes, called Epipuns. The State Department of Allergy and Over-reaction has recommended that all children with pun anaphylaxis carry Epipuns and that jokes are banned from nursery schools. The child must also bring to school a letter from their parents guaranteeing that they have not been told any jokes at home in the last 24 hours.

The hospital administration warned that black humour contravenes health department policy on racial discrimination and punch-lines are forbidden under department guidelines on bullying in the workplace.

Study design
Doctors will be randomised to an intervention group who will tell random jokes to children on the paediatric wards or a self control group who will be asked to save their jokes for their own long suffering children at home. Here is a random joke. "Two cannibals ate a clown doctor. One cannibal asked the other, did that taste funny to you?"

The responses of joke recipients will be screened. Their facial contours will be examined for increases in creases. Mirth will be measured in grins per milli-titter, gigglebytes, or smiles per hour. Belly laughs are expressed in units called Hertz. Laughter delayed for greater than 30 seconds is not classified as humour. He who laughs last, thinks slowest.

Statistics
The data will be massaged and tickled and subjected to a Student’s t-hee test with a funnel plot to see if the jokes come out funnelly.

Ethics approval
The proposed trial will be submitted to the Institutional Ethics and Deforestation Committee, which requires 47 double spaced, single sided copies of the trial protocol. The protocol must be on the ethics committee application form, which can be completed in less than a month by anyone with an IQ over 130 and advanced degrees in information technology and communication.

The ethics form needs to be countersigned by the Head of Department, the Head of Department’s Head of Clinical Stream, the Clinical Superintendent, the Chief Executive Officer and the Minister for Health.

Conclusion
We call for a randomised fairly controlled trial of humour. Humour is a serious matter and should not be taken lightly.

6. Is Contrast Needed for CT Diagnosis of Acute Appendicitis?

This systematic review showed that helical CT without contrast is sufficiently sensitive and specific for diagnosing acute appendicitis.

Hlibczuk V. Ann Emerg Med. 2010:55:51-59.

Study objective
We seek to determine the diagnostic test characteristics of noncontrast computed tomography (CT) for appendicitis in the adult emergency department (ED) population.

Methods
We conducted a search of MEDLINE, EMBASE, the Cochrane Library, and the bibliographies of previous systematic reviews. Included studies assessed the diagnostic accuracy of noncontrast CT for acute appendicitis in adults by using the final diagnosis at surgery or follow-up at a minimum of 2 weeks as the reference standard. Studies were included only if the CT was completed using a multislice helical scanner. Two authors independently conducted the relevance screen of titles and abstracts, selected studies for the final inclusion, extracted data, and assessed study quality. Consensus was reached by conference, and any disagreements were adjudicated by a third reviewer. Unenhanced CT test performance was assessed with summary receiver operating characteristic curve analysis, with independently pooled sensitivity and specificity values across studies.

Results
The search yielded 1,258 publications; 7 studies met the inclusion criteria and provided a sample of 1,060 patients. The included studies were of high methodological quality with respect to appropriate patient spectrum and reference standard. Our pooled estimates for sensitivity and specificity were 92.7% (95% confidence interval 89.5% to 95.0%) and 96.1% (95% confidence interval 94.2% to 97.5%), respectively; the positive likelihood ratio=24 and the negative likelihood ratio=0.08.

Conclusion
We found the diagnostic accuracy of noncontrast CT for the diagnosis of acute appendicitis in the adult population to be adequate for clinical decisionmaking in the ED setting.

Full-text: http://www.annemergmed.com/article/S0196-0644(09)01140-8/fulltext

7. Steroids May Effectively Relieve Pain of Acute Pharyngitis

Laurie Barclay, MD. January 15, 2010 — Steroids are effective as adjuvant therapy in relieving pain in acute pharyngitis, according to the results of a systematic review reported in the January/February issue of the Annals of Family Medicine.

"A major treatment goal for patients complaining of sore throat is to relieve pain and alleviate difficulties in swallowing," write Katrin Korb, MD, from the University of Goettingen in Germany, and colleagues. "The anti-inflammatory action of steroids might be effective to relieve symptoms caused by inflammation and has been studied in other upper respiratory tract infections. Steroids might, therefore, represent a useful clinical option to meet patients' needs."

The purpose of this review was to summarize evidence from randomized controlled trials (RCTs) that assessed the efficacy of adjuvant therapy with corticosteroids to relieve the pain of acute pharyngitis. After searching MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews for RCTs published between 1966 and December 2008, 2 reviewers evaluated the quality of each identified article and summarized the data.

Of 8 identified RCTs enrolling a total of 806 ambulatory patients, 5 enrolled adult patients and 3 enrolled children. Compared with placebo, steroid use (dexamethasone, betamethasone, or prednisone) was associated with statistically significant faster reduction of pain or complete pain relief in all identified RCTs. Most participants had been treated with antibiotics at least initially. Although use of acetaminophen or other analgesic medication was permitted in all studies, this factor was not always controlled. There were no serious adverse effects.

"Steroids are effective in relieving pain in acute pharyngitis," the study authors write. "Although no serious adverse effects were observed, the benefits have to be balanced with possible adverse drug effects. There are safe and effective over-the-counter medications to relieve throat pain."

Limitations of this systematic review include possible publication bias favoring studies finding steroids to be beneficial, possible recall bias, and limitations inherent in the included studies. Specific drugs used, dosing and administration, and outcome measures all varied among the included trials.

"Most patients received concomitant antibiotics; however, reducing the prescription of antibiotics for generally benign upper respiratory tract infection is a public health goal," the review authors conclude. "We therefore recommend further studies to establish both the safety of steroids without antibiotic coverage and the additional benefits of steroids when used with regular administration of over-the-counter analgesic medications."

Ann Fam Med. 2010;8:58-63. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20065280

8. For Migraine in the ED, Prochlorperazine Is Better Than Sumatriptan

NEW YORK (Reuters Health) Jan 12 - For patients in the emergency department (ED) with migraine, IV prochlorperazine with diphenhydramine is more effective than subcutaneous sumatriptan, a small prospective trial suggests.

Both prochlorperazine (Compazine) and sumatriptan (Imitrex) are effective for migraine, Dr. Mark A. Kostic, at the Medical College of Wisconsin, Milwaukee, and co-investigators note. However, little is known about how the two compare, they point out in the Annals of Emergency Medicine for January 4.

Their double-blind, placebo-controlled trial included 66 consecutive ED patients, ages 18 to 50, with "typical" migraine diagnosed on the basis of International Headache Society criteria.

Patients were randomly assigned either to subcutaneous sumatriptan 6 mg (n = 34) or to prochlorperazine 10 mg plus diphenhydramine 12.5 mg (to control akathisia) in 500 mL IV saline (n = 32). Because the trial was blinded, each patient also received a sham treatment along with the assigned therapy.

Patients were asked to assess pain and adverse effects every 20 minutes until 80 minutes or emergency department discharge, whichever came first. At baseline, there were no important differences between the groups, according to the authors.

Prochlorperazine was associated with more rapid and significantly greater reduction in pain intensity on a 100-mm visual analog scale (mean decrease in pain intensity 73 mm vs 50 mm with sumatriptan).

Both groups reported similar degrees of sedation. Prochlorperazine-treated patients had less nausea, but the difference was not statistically significant.

Dr. Kostic's team concludes, "The IV prochlorperazine with diphenhydramine route is not only more efficient and more effective but also less expensive."

Ann Emerg Med 2010; publication pending. Abstract: http://www.annemergmed.com/article/S0196-0644(09)01794-6/abstract

9. Lying obliquely—a clinical sign of cognitive impairment: cross sectional observational study

Kraft P, et al. BMJ 2009;339:b5273

Objective: To determine if failure to spontaneously orient the body along the longitudinal axis of a hospital bed when asked to lie down is associated with cognitive impairment in older patients.
Design Cross sectional observational study.

Setting: Neurology department of a university hospital in Germany.

Participants: Convenience sample of 110 older (60 years) inpatients with neurological conditions and 23 staff neurologists.

Main outcome measures: The main outcome measure was the association between the angle of the body axis and the results of three cognitive screening tests (mini-mental state examination, DemTect, and clock drawing test). Staff doctors were shown photographs of a model taken at a natural viewing able to determine their subjective perspective of what constitutes oblique.

Results: 110 neurological inpatients (mean age 70.9 (SD 6.8) years) were included after exclusions. Evidence of cognitive impairment was found in 34, with scores indicating dementia in eight, according to the mini-mental state examination, and in 11 according to the DemTect. Across all patients, the mean angular deviation of the body axis from the longitudinal axis of the bed (range 0-23 degrees) correlated linearly with the mini-mental state examination (r=–0.480), DemTect (r=–0.527), and the clock drawing test (r=–0.552) scores (P less than 0.001 for all), even after removing age as a covariate. Overall, 90% of staff neurologists considered a minimal body angle of 7 degrees to be oblique. Angular deviation of at least 7 degrees predicted cognitive impairment according to the three different tests, with specificities between 89% and 96% and sensitivities between 27% and 50%.

Conclusion: Clinicians might suspect cognitive impairment in mobile older inpatients with neurological disorders who spontaneously position themselves obliquely when asked to lie on a bed.

Full-text: http://www.bmj.com/cgi/content/full/339/dec16_3/b5273

10. Does This Patient Have Irritable Bowel Syndrome?

Rational Clinical Exam Review by Annals of Emergency Medicine

Sherbino J. Ann Emerg Med. 2010;55:117-119.

Full-text: http://www.annemergmed.com/article/S0196-0644(09)00112-7/fulltext

11. Effect of listening to Nellie the Elephant during CPR training on performance of chest compressions by lay people: randomised crossover trial

L Rawlins, et al. BMJ 2009;339:b4707

Objectives: To determine whether listening to music during cardiopulmonary resuscitation (CPR) training increases the proportion of lay people delivering chest compressions of 100 per minute.
Design Prospective randomised crossover trial.

Setting: Large UK university.

Participants: 130 volunteers (81 men) recruited on an opportunistic basis. Exclusion criteria included age under 18, trained health professionals, and cardiopulmonary resuscitation (CPR) training within the past three months.

Interventions: Volunteers performed three sequences of one minute of continuous chest compressions on a skill meter resuscitation manikin accompanied by no music, repeated choruses of Nellie the Elephant (Nellie), and That’s the Way (I like it) (TTW) according to a pre-randomised order.

Main outcome measures: Rate of chest compressions delivered (primary outcome), depth of compressions, proportion of incorrect compressions, and type of error.

Results: Median (interquartile range) compression rates were 110 (93-119) with no music, 105 (98-107) with Nellie, and 109 (103-110) with TTW. There were significant differences within groups between Nellie v no music and Nellie v TTW (P less than 0.001) but not no music v TTW (P=0.055). A compression rate of between 95 and 105 was achieved with no music, Nellie, and TTW for 15/130 (12%), 42/130 (32%), and 12/130 (9%) attempts, respectively. Differences in proportions were significant for Nellie v no music and Nellie v TTW (P less than 0.001) but not for no music v TTW (P=0.55). Relative risk for a compression rate between 95 and 105 was 2.8 (95% confidence interval 1.66 to 4.80) for Nellie v no music, 0.8 (0.40 to 1.62) for TTW v no music, and 3.5 (1.97 to 6.33) for Nellie v TTW. The number needed to treat for listening to Nellie v no music was 5 (4 to 10)—that is, the number of cardiac arrests required during which lay responders listen to Nellie to facilitate one patient receiving compressions at the correct rate (v no music) would be between four and 10. A greater proportion of compressions were too shallow when participants listened to Nellie v no music (56% v 47%, P=0.022).

Conclusions: Listening to Nellie the Elephant significantly increased the proportion of lay people delivering compression rates at close to 100 per minute. Unfortunately it also increased the proportion of compressions delivered at an inadequate depth. As current resuscitation guidelines give equal emphasis to correct rate and depth, listening to Nellie the Elephant as a learning aid during CPR training should be discontinued. Further research is required to identify music that, when played during CPR training, increases the proportion of lay responders providing chest compressions at both the correct rate and depth.

Full-text: http://www.bmj.com/cgi/content/full/339/dec11_2/b4707

For the tune, consult YouTube

12. Portrait of a Multitasking Mind: What happens when you try to do three things at once?

By Naomi Kenner and Russell Poldrack. Scientific American. Dec 2009.

Productive, or spinning wheels? Researchers are examining the psychology of quickly shifting attention

Are you a media multitasker? We know you're reading a blog, but what else are you doing right now? Take a quick inventory: Are you also listening to music? Monitoring the progress of a sports game on TV? Emailing your co-worker? Texting your friend? On hold with tech support? If your inventory has revealed a multitasking lifestyle, you are not alone. Media multitasking is increasingly common, to the extent that some have dubbed today’s teens "Generation M."
People often think of the ability to multitask as a positive attribute, to the degree that they will proudly tout their ability to multitask. Likewise it’s not uncommon to see job advertisements that place “ability to multitask” at the top of their list of required abilities. Technologies such as smartphones cater to this idea that we can (and should) maximize our efficiency by getting things done in parallel with each other. Why aren’t you paying your bills and checking traffic while you’re driving and talking on the phone with your mother? However, new research by EyalOphir, Clifford Nass, and Anthony D. Wagner at Stanford University suggests that people who multitask suffer from a problem: weaker self-control ability.

The researchers asked hundreds of college students fill out a survey on their use of 12 different types of media. Students reported not only the number of hours per week that they used each type of media, but also rated how often they used each type of media simultaneously with each other type of media. The researchers created a score for each person that reflected how much their lifestyle incorporated media-multitasking.

They then recruited people who had scores that were extremely high or low and asked them perform a series of tests designed to measure the ability to control one's attention, one's responses, and the contents of one's memory. They found that the high- and low- media-multitasking groups were equally able to control their responses, but that the heavy media-multitasking group had difficulties, compared to the low media-multitasking group, when asked to ignore information that was in the environment or in their recent memory. They also had greater trouble relative to their counterparts when asked to switch rapidly between two different tasks. This last finding was surprising, because psychologists know that multitasking involves switching rapidly between tasks rather than actually performing multiple tasks simultaneously.

It seems that chronic media-multitaskers are more susceptible to distractions. In contrast, people who do not usually engage in media-multitasking showed a greater ability to focus on important information. According to the researchers, this reflects two fundamentally different strategies of information processing. Those who engage in media-multitasking more frequently are "breadth-biased," preferring to explore any available information rather than restrict themselves. AsLin Lin at the University of North Texas puts it in a review of the article, they develop a habit of treating all information equally. On the other extreme are those who avoid breadth in favor of information that is relevant to an immediate goal.

So what does this mean for you, reading this blog while checking your stocks and playing solitaire? Are you in trouble? Should you curb your media congestion? Not necessarily. Breadth-bias may still serve a purpose in our media-heavy society. While the researchers focused on a type of control known as "top-down" attention, meaning that control is initiated by higher-level mental processes such as cognition in service of a specific goal, they suggest that heavy media-multitaskers might be better at "bottom-up" attention. In this type of control, cues from the external world drive your attention through lower-level mental processes such as perception and habit. In our fast-paced and technologically advancing society, it may be that having a single goal on which to focus our efforts is a luxury. We may often be better served by a control strategy that is cued by the demands of our surroundings. Look around yourself - do you see notes and to-do lists? Piles of objects meant to remind you about tasks and goals? These sorts of reminders are a great way to take advantage of bottom-up attentional control, and this type of control might in fact be more influential in our lives than we realize.

Abstract: http://www.pnas.org/content/106/37/15583

13. What is the Degree and Duration of Risk for DVT and PE in Post-op Patients?

Sweetland S, et al. BMJ 2009;339:b4583.

The risk of deep vein thrombosis and pulmonary embolism after surgery is substantially increased in the first 12 postoperative weeks, and varies considerably by type of surgery. An estimated 1 in 140 middle aged women undergoing inpatient surgery in the UK will be admitted with venous thromboembolism during the 12 weeks after surgery (1 in 45 after hip or knee replacement and 1 in 85 after surgery for cancer), compared with 1 in 815 after day case surgery and only 1 in 6200 women during a 12 week period without surgery.

Full-text (free): http://www.bmj.com/cgi/content/full/339/dec03_1/b4583

14. ARREST Finds Link Between Chest Compressions and VF Recurrence During CPR

January 5, 2010 (Amsterdam, Netherlands) — Results from the ongoing Amsterdam Resuscitation Study (ARREST) showing a causal relationship between CPR chest compressions and ventricular fibrillation (VF) underscore the need for defibrillators that can accurately monitor the patients' heart rhythm during chest compressions, according to researchers [1].

In their analysis published online December 30, 2009 in Circulation: Arrhythmia and Electrophysiology, in patients treated by first responders for out-of-hospital cardiac arrest, immediate resumption of chest compressions following defibrillation leads to earlier recurrence of ventricular fibrillation.

"Until this publication, the general idea was that chest compressions cannot cause refibrillation, and we have clearly shown beyond a doubt that it is not just coincidence but . . . a true relation between the moment we start chest compression and the fact that refibrillation occurs," study coauthor Dr Rudolph Koster (University of Amsterdam, the Netherlands) told heartwire .

The study included patients treated by first responders with external defibrillators in North Holland presenting with VF as their initial rhythm. The responders tracked ECG and impedance signals. Only 136 out of the initial 361 patients considered for the study met the inclusion criteria. Patients were randomized to two different resuscitation techniques. For half of the patients, following a defibrillation shock, the responders performed postshock analysis and checked the patient's pulse before resuming chest compressions, as suggested in the 2000 resuscitation guidelines. In the other half of the patients in the study, responders resumed chest compressions as soon as possible after defibrillation, as recommended in the 2005 guidelines.

In the group treated under the 2000 guidelines, rescuers resumed compressions an average of 30 seconds (range 21 to 39 seconds) after the first defibrillator shock that successfully terminated VF. In the group treated under 2005 guidelines, compressions were resumed an average of eight seconds (range seven to nine seconds) after the shock (p less than 0.001).

VF recurred, on average, after 40 seconds (range 21 to 76 seconds ) in the delayed-compressions group vs 21 seconds (range 10 to 80 seconds) in the immediate-compressions group (p=0.001). The time interval between start of the compressions and the recurrence of VF was six (range 0 to 67) and eight (range three to 61) seconds, respectively (p=0.88). The hazard ratio for VF recurrence during the first two seconds of CPR vs the hazard of VF in the period prior to resumption of compressions was 15.5, but after eight seconds of compressions, the hazard of VF recurrence was similar to the hazard of VF prior to resumption of compressions.

VF Recurrence Doesn't Diminish Value of Compressions

The link between VF recurrence and chest compressions does not diminish their value, Koster emphasized. Previous research, reported by heartwire , shows that minimizing interruptions in compressions improves the patient's chances of survival. "It was never our intention to suggest that we would not do chest compressions . . . because we are sure that chest compressions, even after defibrillation, are needed to get the patient back from cardiac arrest to a perfusing and pulsating rhythm," Koster said. "What we identified was that these chest compressions have an adverse effect. . . . You may need more and more repeated defibrillations, because the recurrence of ventricular fibrillation does occur at a high rate."

So the ideal solution, Koster explained, would be a defibrillator that can continue to accurately track a patient's heart rhythm during chest compressions so that the responder knows when VF has recurred and can deliver another shock almost immediately. However, the compressions interfere with the device's ability to monitor the heart rhythm and detect VF, so the responders have to halt compressions for about 30 seconds in order to get a "clean signal."

"Many times paramedics believe they can look at the heart rhythm while chest compressions are going on, but we think that's not true. You need an automated filtering technique to make a reliable judgment possible."

Clinical Trials of Defibrillators With Signal Filters on the Horizon

Koster expects that very soon, several external defibrillator manufacturers will be introducing devices that are able to "filter" the distortion caused by compressions and provide a clean signal within a few seconds of a chest compression. With that device, the responders could charge the defibrillator while performing the chest compressions and then, if the patient goes into VF, take their hands off the chest for about two seconds and deliver a shock from the defibrillator before immediately resuming chest compressions again, Koster said. "Then the interruption [in compressions] is so minimal compared with what is happening now many times, where interruptions are up to 20 to 30 seconds, which is really not a good thing. But only two seconds of interruption may be a very good compromise" between immediately shocking the heart, which may retrigger VF, and a long interruption in chest compressions, which could reduce the patient's chances of survival.

Koster said he knows of at least one company that may begin clinical trials of defibrillators with this type of signal filter within 2010. Unfortunately, the technology will probably not be sufficiently tested in time to be incorporated in the new resuscitation guidelines that are scheduled to be published in October 2010, according to Koster, who is one of the experts developing the new guidelines.

15. Crack Research: Good news about knuckle cracking

One man's long, noisy, asymmetrical adventure gets him a high five

By Steve Mirsky. Scientific American. Dec 2009. The latest physical anthropology research indicates that the human evolutionary line never went through a knuckle-walking phase. Be that as it may, we definitely entered, and have yet to exit, a knuckle-cracking phase. I would run out of knuckles (including those on my feet) trying to count how many musicians wouldn’t dream of playing a simple scale without throwing off a xylophone-like riff on their knuckles first. But despite the popularity of this practice, most known knuckle crackers have probably been told by some expert—whose advice very likely began, “I’m not a doctor, but ...”—that the behavior would lead to arthritis.

One M.D. convincingly put that amateur argument to rest with a study published back in 1998 in the journal Arthritis & Rheumatism entitled “Does Knuckle Cracking Lead to Arthritis of the Fingers?” The work of sole author Donald Unger was back in the news in early October when he was honored as the recipient of this year’s Ig Nobel Prize in Medicine.

The Igs, for the uninitiated, are presented annually on the eve of the real Nobel Prizes by the organization Improbable Research for “achievements that first make people laugh, and then make them think.” In Unger’s case, I thought about whether his protocol might be evidence that he is obsessive-compulsive. From his publication: “For 50 years, the author cracked the knuckles of his left hand at least twice a day, leaving those on the right as a control. Thus, the knuckles on the left were cracked at least 36,500 times, while those on the right cracked rarely and spontaneously.”

Unger undertook his self and righteous research because, as he wrote, “During the author’s childhood, various renowned authorities (his mother, several aunts and, later, his mother-in-law [personal communication]) informed him that cracking his knuckles would lead to arthritis of the fingers.” He thus used a half-century “to test the accuracy of this hypothesis,” during which he could cleverly tell any unsolicited advice givers that the results weren’t in yet.

The article continues: http://www.scientificamerican.com/article.cfm?id=crack-research&sc=WR_20091217

16. Can Comparative-Effectiveness Research Be a Physician's Best Friend?

January 9, 2010 — As healthcare reform legislation grinds its way through Congress, 2 articles published online January 6 in the New England Journal of Medicine (NEJM) advocate for one of its touchiest provisions — comparative-effectiveness research (CER).

In theory, CER sounds like a calm, academic subject: evaluate different treatment options for a given illness — drug A vs drug B, or drug A vs surgery — and determine which does a better job of reducing morbidity and mortality. You also can go a step further and compare these treatment options in terms of risks or cost-effectiveness: Does drug B outperform drug A by a 2% margin but cost 3 times as much? Experts say such research is in short supply, leading to poorer clinical outcomes and runaway costs.

However, talk of government-sponsored CER pushes hot buttons in medicine and American society alike, being called "rationing" and "government takeover of medicine." For proof, consider what happened when the US Preventive Services Task Force announced last November that, based on the scientific evidence it weighed, it no longer recommends mammograms for women aged 40 through 49 years. The task force also recommended that women aged 50 years and older no longer receive annual mammograms but, instead, get them every other year. Public outcry and pushback from several medical societies and expert groups like the American Cancer Society swayed Senate Democrats to rewrite their pending healthcare reform legislation to guarantee mammogram coverage.

If Congress enacts healthcare reform, more such medical recommendations could roil Americans. That's because reform bills passed by the House and Senate (which have yet to be reconciled) call for the creation of a CER entity that would question the value of many trusted procedures and treatments. These provisions come on top of economic stimulus legislation passed in early 2009 that pumps $1.1 billion into CER and establishes a new federal bureaucracy to manage it. The government would not conduct CER itself by and large but would instead fund the work of academic investigators.

NEJM Authors Bolster Support for CER

Individual physicians and medical societies approach CER with varying degrees of enthusiasm, cautious support, and downright fear and loathing. The 2 recent NEJM articles seek to bolster support for this controversial discipline. Two professors at Weill Cornell Medical College, New York City, write in an article titled "Health Care Reform and the Need for Comparative-Effectiveness Research" that CER is "physicians' first line of defense against blind cost containment." Furthermore, it could spur drug and medical device manufacturers "to develop products that really matter."

"I think CER is the physician's best friend," coauthor Alvin Mushlin, MD, professor and chair of the Department of Public Health at Weill Cornell, told Medscape Medical News.

Similarly, the other NEJM article, titled "Comparative Effectiveness and Health Care Spending — Implications for Reform," warns that without a shift to best-bang-for-the-buck services identified by CER, cost-cutting alone could produce worse health outcomes.

"If we can induce hospitals and health plans to improve efficiency and not just cut costs, then health costs in the United States will come down and outcomes will improve," write coauthors Milton Weinstein, PhD, a professor of health policy and management at the Harvard School of Public Health, Boston, Massachusetts, and Jonathan Skinner, PhD, a professor of economics at Dartmouth Medical School, Hanover, New Hampshire.

Give Physicians Scientific Findings, Not Recommendations

Both the ACP and the AMA agree that a government-sponsored CER body should forgo recommendations, much less mandates, on how physicians should practice medicine. For one thing, private insurers and government programs like Medicare are tempted to turn such recommendations into binding policies that may arbitrarily deny patients coverage for needed care, explained the AMA's Dr. Rohack.

"Look at vaccines," Dr. Rohack told Medscape Medical News. "The federal Advisory Committee on Immunization Practices recommends what vaccines should be administered, and insurers key off that to determine what they'll pay for."

The fracas over mammograms last year occurred at the intersection of recommendation and insurance coverage, noted health-policy analyst Dennis Smith from the Heritage Foundation, a conservative think tank. "The essential benefit package in the [original] Senate reform bill was supposed to include preventive services recommended by the US Preventive Services Task Force. So if you didn't meet the [task force] criteria, you wouldn't get your mammogram paid for."

Dr. Rohack also pointed to the problem of inflexible application of CER. A study that identifies the best way to treat a particular medical condition may have excluded patients older than 65 years, for example. A payer may then decide to cover that treatment, but not for anyone older than 65 years, he said.

It's sufficient, said Dr. Rohack, to give CER findings to physicians and patients and let them make the final decision on medical care. "Physicians by training try to use evidence-based science to do what's best for patients," he said. "If there is a gray zone, they'll rely on history, experience, and local practice styles. And there are gray zones."

Dr. Rushlin at Weill Cornell Medical College agrees with Dr. Rohack that merely publishing CER findings without adding recommendations will benefit healthcare.

"We need to get started incorporating information from CER into the public debate on healthcare. It can be a very positive step in the right direction," he said. "When you put the evidence on the table, it illuminates the discussion. It doesn't eliminate the discussion. That's healthy."

From N Engl J Med.

Selker HP, Wood AJJ: Industry Influence on Comparative-Effectiveness Research Funded through Health Care Reform. http://content.nejm.org/cgi/content/full/361/27/2595

Weinstein MC, Skinner JA. Comparative Effectiveness and Health Care Spending — Implications for Reform. http://content.nejm.org/cgi/content/extract/NEJMsb0911104

Mushlin AI, Ghomrawi H. Health Care Reform and the Need for Comparative-Effectiveness Research. http://content.nejm.org/cgi/content/extract/NEJMp0912651

17. Observed Behaviors of Subjects During Informed Consent for an Emergency Department Study

Baren J, et al. Ann Emerg Med. 2009;55:9-14.

Study objective
To determine emergency department patients' behaviors during informed consent for an intimate partner violence survey.

Methods
We conducted a cross-sectional study during administration of informed consent. Research assistants recorded whether informed consent was read, time spent reading it, whether questions were asked, and whether the patients took a copy of the form that was handed to them. Results are reported as percentage of frequency of occurrence.

Results
Of 1,609 patients approached for the intimate partner violence study, 1,312 (82%) patients participated. After verbal description of the study, 53% of patients read the informed consent but only 13% spent more than 2 minutes doing so. Only 20% of patients asked questions and less than half (49%) accepted a copy of the form when it was handed to them.

Conclusion
Patients who participated in an intimate partner violence study did not spend a lot of time reading the consent document, asked few questions, and did not take the copy of the consent form with them. Future studies of the current consent process should determine whether it provides adequate human subjects protections in a manner desired by the patient.

Full-text: http://www.annemergmed.com/article/PIIS0196064409015613/fulltext

18. A New Culprit for Pharyngitis in Adolescents

A gram-negative anaerobe that causes Lemierre syndrome has become a common cause of pharyngitis.

Guideline recommendations for the management of pharyngitis vary from doing nothing, to treating patients with positive test results (rapid or culture), to treating empirically. Current guidelines focus on infections with group A streptococcus, because, although the disease is self-limiting, it can cause substantial complications, most notably rheumatic fever (JW Pediatr Adolesc Med Apr 1 2009).

A recent surge in complicated cases of pharyngitis, particularly in adolescents, prompted more-elaborate microbiological testing. DNA analysis revealed that the gram-negative anaerobe, Fusobacterium necrophorum, is as common as group A strep in this age group. An estimated 1 in 400 cases of F. necrophorum pharyngitis progresses to complications, including abscess, septicemia with septic pulmonary emboli, and Lemierre syndrome, which is a septic thrombophlebitis of the internal jugular vein. In case series of patients with F. necrophorum pharyngitis, death — an almost unknown complication of group A strep pharyngitis — has been reported in 2% to 5% of patients, along with a substantial morbidity rate of 10%.

The organism is not sensitive to macrolides, which are recommended for suspected strep pharyngitis in penicillin-allergic patients. Penicillin or a cephalosporin remains the first treatment choice for adolescents and young adults with pharyngitis, and the addition of clindamycin is indicated for those with evidence of sepsis or neck swelling. Clindamycin should be the primary treatment in penicillin-allergic patients.

Comment: The differential diagnosis of pharyngitis in adolescents and young adults includes group A strep, mononucleosis, and acute HIV infection and should now also include F. necrophorum, both at initial presentation and in cases that have not resolved in the usual 5-day interval from onset. Any clinical indicator of bacteremia indicates the need for admission (at least to an observation unit), blood cultures, and antibiotic coverage for F. necrophorum pending culture results.

— J. Stephen Bohan, MD, MS, FACP, FACEP. Published in Journal Watch Emergency Medicine January 15, 2010. Citation: Centor RM. Expand the pharyngitis paradigm for adolescents and young adults. Ann Intern Med 2009 Dec 1; 151:812.

19. In Praise of the Physical Examination

Verghese A, et al. BMJ 2009;339:b5448

If an alien anthropologist were to visit a modern teaching hospital, "it" might conclude that, judging by where doctors spend most of their time, the business of an internal medicine service takes place around computer terminals. The alien might assume that the virtual construct of the patient, or the "iPatient", is more important than the flesh and blood human being occupying the bed.

But the alien would be wrong—patients are what medical care is all about. Yet the electronic medical record and advanced imaging technology have not only seduced doctors away from the bedside but also devalued the importance of their role there. Indeed, intensive care units exist where consultants conduct their "rounds" on the patients and adjust ventilator settings and drugs via telemetry.

These trends have left educators and trainees in internal medicine in two camps when it comes to the merits of the bedside examination. In the first camp are those who pine for the old days, bemoan the loss of clinical bedside diagnostic skills, and complain that no one knows Traube’s space or Kronig’s isthmus. In the second camp are those who say good riddance and point out that evidence based studies show that many physical signs are useless; some might even argue that examining the patient is just a waste of time.

We believe that the truth is somewhere in between....

For the remainder of the essay, cf: http://www.bmj.com/cgi/content/full/339/dec16_3/b5448

20. C-Reactive Protein Level Predicts SBI in Febrile Neonates

In well-appearing neonates with fever without a source, CRP measured more than 12 hours after fever onset was a better predictor of severe bacterial infection than ANC or WBC.

Bressan S, et al. Pediatr Infect Dis J. 2009;

OBJECTIVES: To assess the diagnostic accuracy of white blood cell count (WBC), absolute neutrophil count (ANC), and C-reactive protein (CRP) in detecting severe bacterial infections (SBI) in well-appearing neonates with early onset fever without source (FWS) and in relation to fever duration.

METHODS: An observational study was conducted on previously healthy neonates 7 to 28 days of age, consecutively hospitalized for FWS from less than 12 hours to a tertiary care Pediatric Emergency Department, over a 4-year period. Laboratory markers were obtained upon admission in all patients and repeated 6 to 12 hours from admission in those with normal values on initial determination. Sensitivity, specificity, positive and negative likelihood ratios, and receiver operating characteristic analysis were carried out for primary and repeated laboratory examinations.

RESULTS: Ninety-nine patients were finally studied. SBI was documented in 25 (25.3%) neonates. Areas under receiver operating characteristic curves were 0.78 (95% CI, 0.69-0.86) for CRP, 0.77 (95% CI, 0.67-0.85) for ANC and 0.59 (95% CI, 0.49-0.69) for WBC. Sixty-two patients presented normal laboratory markers on initial determination. Of these, 58 successfully underwent repeated blood examination more than 12 hours from fever onset. Five of them had an SBI. The area under curve calculated for repeated laboratory tests showed better values, respectively of 0.99 (95% CI, 0.92-1) for CRP, 0.85 (95% CI, 0.73-0.93) for ANC and 0.79 (95% CI, 0.66-0.88) for WBC.

CONCLUSIONS: In well-appearing neonates with early onset FWS, laboratory markers are more accurate and reliable predictors of SBI when performed more than 12 hours of fever duration. ANC and especially CRP resulted better markers than the traditionally recommended WBC.

21. Images in Emergency Medicine

Man With Right Arm Weakness

http://www.annemergmed.com/article/S0196-0644(09)00525-3/fulltext

Adult Female With Shoulder Pain

http://www.annemergmed.com/article/S0196-0644(09)01434-6/fulltext

Lit Bits: Dec 11, 2009

From the recent medical literature...

1. Hold the Epi: No Advantage Seen With IV Drugs at Out-of-Hospital Cardiac Arrest

November 25, 2009 (Oslo, Norway) — Facing off with longstanding policy and tradition, a large randomized trial found that giving IV drugs like epinephrine and atropine in the setting of out-of-hospital cardiac arrest made it more likely that patients would be admitted to the hospital but little difference in whether they survived to discharge.

That outcome was in spite of their undergoing resuscitation longer and receiving more defibrillations, and more often reattaining a spontaneous circulation, compared with another group that didn't receive IV drugs during arrest, observe the authors, led by Dr Theresa M Olasveengen (Oslo University Hospital, Norway), in this week's Journal of the American Medical Association.

The trial is only the latest of several in recent years to reappraise the efficacy of major elements of conventional cardiopulmonary resuscitation.

For now, the cornerstones of optimal cardiac resuscitation include high-quality cardiopulmonary resuscitation with minimal interruptions for anything, including any drug administration, and early defibrillation.

"These researchers present important and compelling data, which challenge the efficacy of one of the most common procedures in cardiac resuscitation: the administration of intravenous epinephrine," said Dr Bentley J Bobrow (Arizona Department of Health Services, Phoenix) in an email to heartwire. Bobrow, who wasn't involved in the study, is medical director of his state's Bureau of Emergency Medical Services & Trauma System.

"While epinephrine administration has been part of the guidelines for resuscitation for many years, there has been very little evidence supporting its benefit and some convincing evidence suggesting worse outcomes with higher doses of epinephrine," he remarked.

"The message for emergency providers is that, for now, the cornerstones of optimal cardiac resuscitation include high-quality cardiopulmonary resuscitation with minimal interruptions for anything, including any drug administration, and early defibrillation."

Olasveengen et al randomized 851 consecutive adults with nontraumatic out-of-hospital cardiac arrest to management according to advanced-cardiac-life-support guidelines with or without access to IV drug administration. In the no-IV-access group, those who achieved "return to spontaneous circulation" could receive IV drugs five minutes later, if indicated.

Those treated with access to IV drugs fared significantly better at first, but didn't outdo those managed without IV drug access for the primary end point of survival to hospital discharge.

Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest: A Randomized Trial

Olasveengen TM, et al. JAMA. 2009;302(20):2222-2229.

Context: Intravenous access and drug administration are included in advanced cardiac life support (ACLS) guidelines despite a lack of evidence for improved outcomes. Epinephrine was an independent predictor of poor outcome in a large epidemiological study, possibly due to toxicity of the drug or cardiopulmonary resuscitation (CPR) interruptions secondary to establishing an intravenous line and drug administration.

Objective: To determine whether removing intravenous drug administration from an ACLS protocol would improve survival to hospital discharge after out-of-hospital cardiac arrest.

Design, Setting, and Patients: Prospective, randomized controlled trial of consecutive adult patients with out-of-hospital nontraumatic cardiac arrest treated within the emergency medical service system in Oslo, Norway, between May 1, 2003, and April 28, 2008.

Interventions: Advanced cardiac life support with intravenous drug administration or ACLS without access to intravenous drug administration.

Main Outcome Measures: The primary outcome was survival to hospital discharge. The secondary outcomes were 1-year survival, survival with favorable neurological outcome, hospital admission with return of spontaneous circulation, and quality of CPR (chest compression rate, pauses, and ventilation rate).

Results: Of 1183 patients for whom resuscitation was attempted, 851 were included; 418 patients were in the ACLS with intravenous drug administration group and 433 were in the ACLS with no access to intravenous drug administration group. The rate of survival to hospital discharge was 10.5% for the intravenous drug administration group and 9.2% for the no intravenous drug administration group (P = .61), 32% vs 21%, respectively, (P less than .001) for hospital admission with return of spontaneous circulation, 9.8% vs 8.1% (P = .45) for survival with favorable neurological outcome, and 10% vs 8% (P = .53) for survival at 1 year. The quality of CPR was comparable and within guideline recommendations for both groups. After adjustment for ventricular fibrillation, response interval, witnessed arrest, or arrest in a public location, there was no significant difference in survival to hospital discharge for the intravenous group vs the no intravenous group (adjusted odds ratio, 1.15; 95% confidence interval, 0.69-1.91).

Conclusion: Compared with patients who received ACLS without intravenous drug administration following out-of-hospital cardiac arrest, patients with intravenous access and drug administration had higher rates of short-term survival with no statistically significant improvement in survival to hospital discharge, quality of CPR, or long-term survival.

2. Occult Abdominal Trauma Common in Children With Suspected Physical Abuse

Will Boggs, MD. NEW YORK (Reuters Health) Nov 24 - Children with suspected physical abuse should be screened for abdominal trauma, according to a report from the University of Maryland School of Medicine, Baltimore.

"Children with injuries from physical abuse can have many occult injuries, including occult abdominal trauma, and physicians should consider this possibility when deciding what medical tests should be performed," lead author Dr. Wendy Gwirtzman Lane told Reuters Health.

Dr. Lane and colleagues conducted a retrospective study to examine the rate of occult abdominal trauma among 244 children with suspected physical abuse and to identify characteristics associated with screening practice.

Fifty-one of the children had at least one screening test for occult abdominal trauma, the authors report in the December Pediatrics, but only 9 of the 21 children with positive screening results had confirmatory testing with abdominal CT and/or ultrasonography.

Overall, 5 children (10% of those screened, 2% of the total sample) had injuries identified through abdominal CT and/or ultrasonography.

Four of 5 children with elevated ALT and/or AST levels had evidence of intra-abdominal injury on CT or ultrasound scans and 3 others had evidence of liver injury, yielding positive predictive values between 60% and 80%.

Children under 18 months of age were less likely to be screened than were older children, the researchers note, and children who presented in the evening were screened significantly less often than were children who presented at other times of day.

In multivariate analysis, the likelihood of occult abdominal trauma screening was higher for children presenting with probable abusive head trauma and for children evaluated in subspecialty consultation from the child protection team.

Regarding further studies, Dr. Lane said, "Our first step is to better elucidate which children should be screened. We are doing this by conducting a prospective multi-center study, in which we plan to screen all children with abusive injuries age 0-6. We anticipate that this data will allow us to make more specific screening recommendations; e.g., what age children should be screened, and with what injuries (e.g., bruises, burns, fractures, abusive head trauma). We can then look at how to improve screening rates among children who should be screened."

Pediatrics 2009;124:1595-1602.

3. Clinical Controversies: Initiation of Therapy for Asymptomatic Hypertension in the Emergency Department

Ann Emerg Med. 2009;54:791-3.

Do it: http://www.annemergmed.com/article/S0196-0644(09)00484-3/fulltext

Don’t bother: http://www.annemergmed.com/article/S0196-0644(09)01445-0/fulltext

4. Renal Stones, Pancreatitis Receive High Cumulative Radiation Doses in the ED

December 2, 2009 (Chicago, Illinois) — A study that looked at patterns of radiation exposure from computed tomography (CT) in the emergency department of a large urban level 1 trauma center found that patients who were diagnosed with renal stone disease and pancreatitis were the most likely to receive the highest exposure to radiation from CT scans.

Cumulative effective-dose data from imaging should become part of the patient's medical record, Amita Kamath, MD, from San Francisco General Hospital and the University of California at San Francisco, said here at the Radiological Society of North America 95th Scientific Assembly and Annual Meeting.

Dr. Kamath studied cumulative exposure to radiation from CT between October 2006 and March 2007 using effective-dose estimates to determine if certain patient populations were at risk for higher levels of imaging studies and radiation.

Focusing on a retrospective review of common emergency department diagnoses — altered mental status, pancreatitis, renal stone disease, and trauma, she found that renal stone disease and pancreatitis patients had the most repeat imaging and the highest radiation exposure (50 mSv or more).

Among the 10,382 patients reviewed, 91 patients were diagnosed with renal stone disease and 61 with pancreatitis.

Overall, 28% of the cohort (2890 patients) underwent at least 1 CT scan. This ranged from 20% to 22% of patients with trauma and altered mental states, to 70% of patients with pancreatitis, to 85% of patients with renal stone disease.

A mean of 2 CT scans were performed on each patient. That number ranged from 1.8 in patients with trauma and altered mental states, to 1.4 in patients with renal stone disease, to 2.7 in patients with pancreatitis.

Overall, 4% of patients received in excess of 50 mSv. The patients most likely to receive such a high dose were those with renal stone disease and pancreatitis, Dr. Kamath said.

Patients with renal stone disease were over 60 times more likely to undergo a CT scan (odds ratio [OR], 64.6; 95% confidence interval [CI], 8.5 - 493.1) than were patients with altered mental status, and those with pancreatitis were 20 times more likely to undergo a CT scan than those diagnosed with altered mental states (OR, 21.5; CI, 7.5 - 61.7). Patients with renal stone disease were nearly 8 times more likely (OR, 7.9; CI, 1.7 - 36.0) to receive more than 50 mSv over the study period, she reported.

"I think this is often because they develop complications, such as pseudocysts or necrosis, and they end up having to get repetitive imaging," she told Medscape Radiology.

Alternative imaging modalities, such as ultrasound and magnetic resonance imaging, should be considered when such patients require a follow-up study. Limiting the number of phases within the CT itself would also limit exposure, she said.

"We have known about the risks of CT radiation exposure for a while," session moderator, Larry DeWerd, PhD, from the University of Wisconsin, Madison, told Medscape Radiology. "Now we have numbers to tell us the scope of the problem."

Heightened awareness is a good thing, he added. "The more awareness there is among radiologists, the fewer repeat exams, or at least the fewer unnecessary exams, there will be. Hopefully, this could be one of the outcomes, but of course it will take time. It won't happen overnight."

Weighing in with his opinion, J. Louis Hinshaw, MD, from the University of Wisconsin Hospital and Clinics, Madison, added: "This was very interesting work and not surprising in my experience. The use of CT in the [emergency department] has been increasing dramatically, even more so over the past 5 years or so. One of the main indications that 'needs CT in the [emergency department]' is renal stones and, if positive, there is often at least 1 follow-up examination performed, sometimes leading to large cumulative radiation doses."

He endorsed the suggestion that radiation dose should become part of the medical record.

"That is an idea that certainly has merit. There are many obstacles to overcome in order to accomplish something like that, but a national electronic medical record could make something like that possible."

Dr. Kamath, Dr. DeWerd, and Dr. Hinshaw have disclosed no relevant financial relationships.

Radiological Society of North America (RSNA) 95th Scientific Assembly and Annual Meeting: Abstract SSE22-06. Presented November 30, 2009.

5. 600 mg Clopidogrel Loading Dose Bests 300 mg in Patients with STEMI

Patients with STEMI who underwent primary PCI had better clinical outcomes — and no greater risk for bleeding — with a 600-mg loading dose compared with 300 mg.

Dangas G et al. J Am Coll Cardiol. 2009;54:1438-46.

Objectives: Our aim was to determine whether a 600-mg loading dose of clopidogrel compared with 300 mg results in improved clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Background: A 600-mg loading dose of clopidogrel compared with 300 mg provides more rapid and potent inhibition of platelet activation.

Methods: In the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial, 3,602 patients with STEMI undergoing primary PCI were randomized to bivalirudin (n = 1,800) or unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor (n = 1,802). Randomization was stratified by thienopyridine loading dose, which was determined before random assignment.

Results: Patients in the 600-mg (n = 2,158) compared with the 300-mg (n = 1,153) clopidogrel loading dose group had significantly lower 30-day unadjusted rates of mortality (1.9% vs. 3.1%, p = 0.03), reinfarction (1.3% vs. 2.3%, p = 0.02), and definite or probable stent thrombosis (1.7% vs. 2.8%, p = 0.04), without higher bleeding rates. Compared with unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor, bivalirudin monotherapy resulted in similar reductions in net adverse cardiac event rates within the 300-mg (15.2% vs. 12.3%) and 600-mg (10.4% vs. 7.3%) clopidogrel loading dose subgroups (pinteraction = 0.41). By multivariable analysis, a 600-mg clopidogrel loading dose was an independent predictor of lower rates of 30-day major adverse cardiac events (hazard ratio: 0.72 [95% confidence interval: 0.53 to 0.98], p = 0.04).

Conclusions: In patients with STEMI undergoing primary PCI with contemporary anticoagulation regimens, a 600-mg loading dose of clopidogrel may safely reduce 30-day ischemic adverse event rates compared with a 300-mg loading dose.

6. Images in Emergency Medicine

Young Man With Fishing Injury
http://www.annemergmed.com/article/S0196-0644(09)00405-3/fulltext

Man With Painful Swelling in Neck
http://www.annemergmed.com/article/S0196-0644(09)00611-8/fulltext

7. NFL to manage concussions with the help of neurologists

By ALAN SCHWARZ. NY Times. Published: November 22, 2009.

In a shift in the National Football League’s approach to handling concussions, the league will soon require teams to receive advice from independent neurologists while treating players with brain injuries, several people with knowledge of the plan confirmed Sunday.

For generations, decisions on when players who sustain concussions should return to play have been made by doctors and trainers employed by the team, raising questions of possible conflicts of interest when coaches and owners want players to return more quickly than proper care would suggest.

As scientific studies and anecdotal evidence have found a heightened risk for brain damage, dementia and cognitive decline in retired players, the league has faced barbed criticism from outside experts and, more recently, from Congress over its policies on handling players with concussions.

The league and Commissioner Roger Goodell have insisted that the N.F.L.’s policies are safe and that no third-party involvement is necessary, pointing to research by its committee on concussions as proof. But after an embarrassing hearing on the issue before the House Judiciary Committee last month in which the league was compared to the tobacco industry, the N.F.L. seems to have begun to embrace the value of outside opinion.

Full-text: http://www.nytimes.com/2009/11/23/sports/football/23concussion.html

8. Diagnostic Accuracy of Noncontrast Computed Tomography for Appendicitis in Adults: A Systematic Review

Hlibczuk V, et al. Ann Emerg Med 2009; in press

Study objective
We seek to determine the diagnostic test characteristics of noncontrast computed tomography (CT) for appendicitis in the adult emergency department (ED) population.

Methods
We conducted a search of MEDLINE, EMBASE, the Cochrane Library, and the bibliographies of previous systematic reviews. Included studies assessed the diagnostic accuracy of noncontrast CT for acute appendicitis in adults by using the final diagnosis at surgery or follow-up at a minimum of 2 weeks as the reference standard. Studies were included only if the CT was completed using a multislice helical scanner. Two authors independently conducted the relevance screen of titles and abstracts, selected studies for the final inclusion, extracted data, and assessed study quality. Consensus was reached by conference, and any disagreements were adjudicated by a third reviewer. Unenhanced CT test performance was assessed with summary receiver operating characteristic curve analysis, with independently pooled sensitivity and specificity values across studies.

Results
The search yielded 1,258 publications; 7 studies met the inclusion criteria and provided a sample of 1,060 patients. The included studies were of high methodological quality with respect to appropriate patient spectrum and reference standard. Our pooled estimates for sensitivity and specificity were 92.7% (95% confidence interval 89.5% to 95.0%) and 96.1% (95% confidence interval 94.2% to 97.5%), respectively; the positive likelihood ratio=24 and the negative likelihood ratio=0.08.

Conclusion
We found the diagnostic accuracy of noncontrast CT for the diagnosis of acute appendicitis in the adult population to be adequate for clinical decisionmaking in the ED setting.

9. Dabigatran Non-inferior to Warfarin in the Treatment of Acute Venous Thromboembolism

Much Pricier yet without the Need for Lab Monitoring

Schulman S, et al. N Engl J Med. 2009;361:2342-2352

Background: The direct oral thrombin inhibitor dabigatran has a predictable anticoagulant effect and may be an alternative therapy to warfarin for patients who have acute venous thromboembolism.

Methods: In a randomized, double-blind, noninferiority trial involving patients with acute venous thromboembolism who were initially given parenteral anticoagulation therapy for a median of 9 days (interquartile range, 8 to 11), we compared oral dabigatran, administered at a dose of 150 mg twice daily, with warfarin that was dose-adjusted to achieve an international normalized ratio of 2.0 to 3.0. The primary outcome was the 6-month incidence of recurrent symptomatic, objectively confirmed venous thromboembolism and related deaths. Safety end points included bleeding events, acute coronary syndromes, other adverse events, and results of liver-function tests.

Results: A total of 30 of the 1274 patients randomly assigned to receive dabigatran (2.4%), as compared with 27 of the 1265 patients randomly assigned to warfarin (2.1%), had recurrent venous thromboembolism; the difference in risk was 0.4 percentage points (95% confidence interval [CI], –0.8 to 1.5; P less than 0.001 for the prespecified noninferiority margin). The hazard ratio with dabigatran was 1.10 (95% CI, 0.65 to 1.84). Major bleeding episodes occurred in 20 patients assigned to dabigatran (1.6%) and in 24 patients assigned to warfarin (1.9%) (hazard ratio with dabigatran, 0.82; 95% CI, 0.45 to 1.48), and episodes of any bleeding were observed in 205 patients assigned to dabigatran (16.1%) and 277 patients assigned to warfarin (21.9%; hazard ratio with dabigatran, 0.71; 95% CI, 0.59 to 0.85). The numbers of deaths, acute coronary syndromes, and abnormal liver-function tests were similar in the two groups. Adverse events leading to discontinuation of the study drug occurred in 9.0% of patients assigned to dabigatran and in 6.8% of patients assigned to warfarin (P=0.05).

Conclusions: For the treatment of acute venous thromboembolism, a fixed dose of dabigatran is as effective as warfarin, has a safety profile that is similar to that of warfarin, and does not require laboratory monitoring.

10. What Happens When Doctors Give Patients More Power?

Dec. 03, 2009. NEW YORK (Reuters Health) - When patients are given the responsibility for medical decisions, they may be less willing to try a potentially risky treatment, a study published Monday suggests.

The study, of 216 patients with arthritis and other similar diseases, tested patients' willingness to take a hypothetical "new" drug that carried important benefits but also a small risk of serious side effects.

It turned out that patients were less willing to try the drug when they were given complete power over the decision than when a doctor advised them to take the medication.

When given a choice rather than a doctor's order, the study found, patients appeared to give greater thought to the potential side effects of the drug.

The findings, published in the journal Arthritis Care & Research, have implications for the trend toward greater patient involvement in healthcare. Studies have shown that patients who are more active in their care tend to fare better. However, there has been less research into what happens when actual decision-making is shifted over to patients.

The current results "suggest that asking some patients to assume more responsibility for decisions involving their healthcare may have unanticipated consequences," lead researcher Dr. Liana Fraenkel, of the Yale University School of Medicine, told Reuters Health in an email.

For the study, Fraenkel and colleague Dr. Ellen Peters had patients view one of two videos. Each featured a doctor describing a hypothetical new medication for which the patients were candidates -- a pain drug or a drug designed to lower heart disease risk.

Each drug was described as "very effective" and generally safe, but with a small risk of a serious side effect: either a breakdown of tissue in the jaw, or a rare but often fatal infection that causes brain inflammation. (Both of those are side effects of drugs currently on the market.)

After seeing the video, patients rated their willingness to take the drug under two circumstances: in one, their doctor said they should take the drug and wrote a prescription; in the other, the decision was left completely to the patient.

Overall, the researchers found, patients were less open to taking the drug when the decision was theirs alone. They also expressed greater worries over side effects.

"The shift of responsibility from M.D. to patient may cause some patients to pay more attention to risks," Fraenkel explained.

She and Peters note that studies in other areas have suggested that when people have a choice about whether to take a potentially risky action, they consider those risks more carefully. For example, city dwellers who can opt to drive or take the bus are more likely to see driving as a risky endeavor than do rural residents -- who have no choice but to drive.

According to Fraenkel, the current findings suggest that to make the most informed decisions about medical treatments, patients need help in weighing the potential benefits against the risks.
"I would argue that these results highlight the need to ensure that patients have the proper support to be able to participate in decision making," she said.

SOURCE: Arthritis Care & Research, online November 30, 2009.

11. Predictors of 30-Day Serious Events in Older Patients With Syncope

Sun BC, et al. Ann Emerg Med. 2009;54:769-778.e5.

Study objective
We identify predictors of 30-day serious events after syncope in older adults.

Methods
We reviewed the medical records of older adults (age ≥60 years) who presented with syncope or near syncope to one of 3 emergency departments (EDs) between 2002 and 2005. Our primary outcome was occurrence of a predefined serious event within 30 days after ED evaluation. We used multivariable logistic regression to identify predictors of 30-day serious events.

Results
Of 3,727 potentially eligible patients, 2,871 (77%) met all eligibility criteria. We excluded an additional 287 patients who received a diagnosis of a serious clinical condition while in the ED. In the final study cohort (n=2,584), we identified 173 (7%) patients who experienced a 30-day serious event. High-risk predictors included age greater than 90 years, male sex, history of an arrhythmia, triage systolic blood pressure greater than 160 mm Hg, abnormal ECG result, and abnormal troponin I level. A low-risk predictor was a complaint of near syncope rather than syncope. A risk score, generated by summing high-risk predictors and subtracting the low-risk predictor, can stratify patients into low- (event rate 2.5%; 95% confidence interval [CI] 1.4% to 3.6%), intermediate- (event rate 6.3%; 95% CI 5.1% to 7.5%), and high-risk (event rate 20%; 95% CI 15% to 25%) groups.

Conclusion
We identified predictors of 30-day serious events after syncope in adults aged 60 years and greater. A simple score was able to stratify these patients into distinct risk groups and, if externally validated, might have the potential to aid ED decisionmaking.

12. Rapid Influenza Test Helps Identify Low-Risk Febrile Infants

A positive rapid influenza test result predicted low risk for serious bacterial infection in febrile infants younger than 3 months.

Strategies for evaluating febrile infants younger than 3 months commonly use laboratory markers to identify patients at low risk for serious bacterial illness (SBI). In a prospective multicenter study, investigators in Spain evaluated whether rapid influenza tests can help identify low-risk patients. During the 2003–2008 influenza seasons, the investigators enrolled 381 infants younger than 3 months (22% aged 28 days) with fever 38°C from an unknown source who were evaluated with blood culture and rapid influenza tests. Patients who had been treated previously with antibiotics were excluded.

Overall, 3 of 113 patients (2.6%) with positive rapid influenza test results had SBI, compared with 47 of 268 patients (17.5%) with negative results. All SBIs in the positive group were from a urinary source. Blood cultures were positive in 0% of patients with positive rapid influenza test results, compared with 8 patients (3%) with negative rapid influenza test results (Streptococcus agalactiae in 4 patients, Neisseria meningitidis in 2, Streptococcus pneumoniae in 1, and Staphylococcus aureus in 1).

Comment: Historically, febrile infants younger than 1 month have been the most difficult to risk stratify. Unfortunately, these authors did not analyze the results by age, making the generalizability of these findings to that higher-risk, youngest age group unclear. However, when these results are coupled with those from previous studies that have demonstrated a low risk for bacteremia in infants with an identifiable viral source of fever, incorporating rapid influenza tests into risk stratification algorithms seems reasonable. Although rapid influenza tests have variable sensitivity, for well-appearing infants between ages 1 and 3 months with positive rapid influenza test results, urine analysis and culture are sufficient to exclude bacteremia. Caution: These investigators looked at seasonal influenza and not 2009 pandemic H1N1 influenza, which has been associated with higher rates of concomitant bacterial pneumonia.

— Katherine Bakes, MD. Published in Journal Watch Emergency Medicine November 13, 2009. Citation: Mintegi S et al. Rapid influenza test in young febrile infants for the identification of low-risk patients. Pediatr Infect Dis J 2009 Nov; 28:1026.

13. Anxieties Over Acetaminophen: FDA Panel Recommends Reducing Doses, Discarding Combination Drugs In Light of Liver Failures

Ann Emerg Med. 2009;54:A13-A16.

Full-text: http://www.annemergmed.com/article/S0196-0644(09)01642-4/fulltext

14. To Sellick or Not to Sellick?

A study of magnetic resonance images demonstrates occlusion of the hypopharynx by Sellick maneuver but does not prove that the maneuver has clinical value.

Routine use of Sellick maneuver (posterior displacement of the cricoid cartilage to occlude the alimentary tract) during rapid sequence intubation is no longer recommended because of inadequate proof of benefit and evidence that it might make intubation or ventilation more difficult (JW Emerg Med Jun 1 2000 and JW Emerg Med Jun 29 2007). To determine whether and how the maneuver occludes the alimentary tract, researchers obtained magnetic resonance images of 24 nonsedated volunteers with and without Sellick maneuver in three head and neck positions (sniffing, head extended, neutral).

Axial images showed a reduction in diameter of the postcricoid hypopharynx from an average of 7.3 mm without the maneuver to 4.7 mm with the maneuver in each position. The compressed diameter was less than the estimated wall thickness (6.1 mm) of the hypopharynx at this level, indicating complete occlusion.

Comment: An earlier study showed that the esophagus often slips left or right when Sellick maneuver is applied, thus avoiding compression by the cricoid cartilage. This study shows that the hypopharynx behind the cricoid cartilage was effectively occluded in these nonsedated patients, regardless of whether lateral displacement occurred at other levels of the esophagus. This finding's clinical meaning is not clear, nor does it help us decide whether to use Sellick maneuver. Editorialists express divergent opinions regarding the merit of the maneuver. Sellick maneuver should be considered optional until we have outcome data that support its use. However, Sellick maneuver is probably worthwhile during bag-mask ventilation, because previous research has shown that it minimizes flow of gases to the stomach.

— Ron M. Walls, MD, FRCPC, FAAEM. Published in Journal Watch Emergency Medicine December 11, 2009. Citation: Rice MJ et al. Cricoid pressure results in compression of the postcricoid hypopharynx: The esophageal position is irrelevant. Anesth Analg 2009 Nov; 109:1546.

15. Acute Metformin Overdose: Examining Serum pH, Lactate Level, and Metformin Concentrations in Survivors Versus Nonsurvivors: A Systematic Review of the Literature

Dell'Aglio DM, et al. Ann Emerg Med. 2009;54:818-823.

Study objective
Metformin is known to cause potentially fatal metabolic acidosis with an increased lactate level in both overdose and therapeutic use. No association between mortality and serum pH, lactate level, or metformin concentrations, though intuitive, has yet been described. This systematic literature review is designed to evaluate the association between mortality and serum pH, lactate level, and metformin concentrations in acute metformin overdose.

Methods
We reviewed the literature by using the MEDLINE, EMBASE, CINAHL, and TOXNET databases for cases of metformin overdose with documented mortality data and values of serum pH, lactate level, and metformin concentrations. When available, patient age, patient sex, and whether patients received intravenous sodium bicarbonate therapy or hemodialysis were also analyzed. Cases meeting inclusion criteria were analyzed to determine whether a difference in distribution of nadir serum pH, peak serum lactate level, or peak serum metformin concentrations existed between overdose survivors and nonsurvivors.

Results
We identified 10 articles that had 1 or more cases meeting our inclusion criteria. In total, there were 22 cases of metformin overdose (5/22 died) that met inclusion criteria. No intentional overdose patients died whose serum pH nadir was greater than 6.9, maximum lactate concentration less than 25 mol/L, or maximum metformin concentration less than 50 μg/mL (therapeutic range 1 to 2 μg/mL). Intentional overdose patients with a nadir serum pH less than 6.9 had 83% mortality (5/6), those with lactate concentration greater than 25 mmol/L had 83% mortality (5/6), and those with metformin concentration greater than 50 μg/mL had 38% mortality (5/12). Nadir serum pH and peak serum lactate and metformin concentration distributions in survivors and nonsurvivors revealed that survivors had a median nadir pH of 7.30, interquartile range (IQR) 7.22, 7.36; nonsurvivors, a median nadir pH of 6.71, IQR 6.71, 6.73; survivors, a median peak lactate level of 10.8 mmol/L, IQR 4.2, 12.9; nonsurvivors, a median peak lactate level of 35.0 mmol/L, IQR 33.3, 39.0; survivors, a median peak metformin level of 42 μg/mL, IQR 6.6, 67.6; and nonsurvivors, a median peak metformin level of 110 μg/mL, IQR 110, 110.

Conclusion
No cases of acute metformin overdose meeting the study's inclusion criteria were found in which patients with a nadir serum pH greater than 6.9, peak serum lactate concentrations less than 25 mmol/L, or peak serum metformin concentrations less than 50 μg/mL died. Patients with acute metformin overdose who died had much lower serum pH nadirs and much higher peak serum lactate and metformin concentrations than those who survived.

16. Downwardly Mobile: The Accidental Cost of Being Uninsured

Uninsured adults are almost twice as likely as insured adults to die after blunt or penetrating trauma.

Rosen H et al. Arch Surg. 2009;144:1006-11.

Hypothesis: Given the pervasive evidence of disparities in screening, hospital admission, treatment, and outcomes due to insurance status, a disparity in outcomes in trauma patients (in-hospital death) among the uninsured may exist, despite preventive regulations (such as the Emergency Medical Treatment and Active Labor Act).

Design: Data were collected from the National Trauma Data Bank from January 1, 2002, through December 31, 2006 (version 7.0). We used multiple logistic regression to compare mortality rates by insurance status.

Setting: The National Trauma Data Bank contains information from 2.7 million patients admitted for traumatic injury to more than 900 US trauma centers, including demographic data, medical history, injury severity, outcomes, and charges.

Patients: Data from patients (age, 18 years; n = 687 091) with similar age, race, injury severity, sex, and injury mechanism were evaluated for differences in mortality by payer status.

Main Outcome Measure: In-hospital death after blunt or penetrating traumatic injury.

Results: Crude analysis revealed a higher mortality for uninsured patients (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.36-1.42; P less than .001). Controlling for sex, race, age, Injury Severity Score, Revised Trauma Score, and injury mechanism (adjusted for clustering on hospital), uninsured patients had the highest mortality (OR, 1.80; 95% CI, 1.61-2.02; P less than .001). Subgroup analysis of young patients unlikely to have comorbidities revealed higher mortality for uninsured patients (OR, 1.89; 95% CI, 1.66-2.15; P less than .001), as did subgroup analyses of patients with head injuries (OR, 1.65; 95% CI, 1.42-1.90; P less than .001) and patients with 1 or more comorbidities (OR, 1.52; 95% CI, 1.30-1.78; P less than .001).

Conclusions: Uninsured Americans have a higher adjusted mortality rate after trauma. Treatment delay, different care (via receipt of fewer diagnostic tests), and decreased health literacy are possible mechanisms.

17. CDC: 10,000 H1N1 Flu Deaths in US by mid-Nov

from WebMD. Daniel J. DeNoon. December 10, 2009 — H1N1 influenza killed 10,000 Americans, sent 213,000 to the hospital, and sickened 50 million — a sixth of the population — by mid-November, the US Centers for Disease Control and Prevention (CDC) estimates.

The CDC's new estimates reflect a flood of new cases from mid-October to mid-November, as the current wave of the US flu pandemic was climbing to its peak. The numbers represent the middle of a range of estimates made using statistical calculations to correct for underreporting of cases, hospitalizations, and deaths.

"Sadly, there were nearly 10,000 deaths: 1,100 in children and 7,500 among young adults," CDC director Thomas R. Frieden, MD, MPH, said at a news conference. "That is much higher than we would see in a usual flu season. This is a flu that is much harder on young people and that has largely spared the elderly."

The new estimates suggest that about 15% of the population — 1 in 6 Americans — has had the H1N1 flu.

"That leaves most Americans not infected or vaccinated and still susceptible to H1N1 flu," Frieden said. "Even if there were a lot of infections without symptoms and adding in those who have been vaccinated, that still leaves a lot of people unprotected. Only time will tell what the future will hold — but the more people who get vaccinated, the lower the probability of a third wave of the pandemic."

Full-text (free) at CDC: http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm

18. Exploring Emergency Physician–Hospitalist Handoff Interactions: Development of the Handoff Communication Assessment

Apker J, et al. Ann Emerg Med. 2009; in press.

Study objective
We develop and evaluate the Handoff Communication Assessment, using actual handoffs of patient transfers from emergency department to inpatient care.

Methods
This was an observational qualitative study. We derived a Handoff Communication Assessment tool, using categories from discourse coding described in physician-patient communication, previous handoff research in medicine, health communication, and health systems engineering and pilot data from 3 physician-hospitalist handoffs. The resulting tool consists of 2 typologies, content and language form. We applied the tool to a convenience sample of 15 emergency physician-to-hospitalist handoffs occurring at a community teaching hospital. Using discourse analysis, we assigned utterances into categories and determined the frequency of utterances in each category and by physician role.

Results
The tool contains 11 content categories reflecting topics of patient presentation, assessment, and professional environment and 11 language form categories representing information-seeking, information-giving, and information-verifying behaviors. The Handoff Communication Assessment showed good interrater reliability for content (kappa=0.71) and language form (κ=0.84). We analyzed 742 utterances, which provided the following preliminary findings: emergency physicians talked more during handoffs (67.7% of all utterances) compared with hospitalists (32.3% of all utterances). Content focused on patient presentation (43.6%), professional environment (36%), and assessment (20.3%). Form was mostly information-giving (90.7%) with periodic information-seeking utterances (8.8%) and rarely information-verifying utterances (0.4%). Questions accounted for less than 10% of all utterances.

Conclusion
We were able to develop and use the Handoff Communication Assessment to analyze content and structure of handoff communication between emergency physicians and hospitalists at a single center. In this preliminary application of the tool, we found that emergency physician–to-hospitalist handoffs primarily consist of information giving and are not geared toward question-and-answer events. This critical exchange may benefit from ongoing analysis and reformulation.

19. Price of Nonadherance to Antihypertensives

Mazzaglia G, et al. Circulation. 2009;120:1598-1605.

Introduction: High blood pressure (BP) is one of the most preventable causes of cardiovascular disease morbidity and mortality. The use of antihypertensive drug therapy (AHT) has been shown to reduce the risk of stroke and coronary heart disease by an estimated 34% and 21%, respectively, in long-term randomized controlled trials (RCTs). Generally, AHT should be maintained indefinitely. However, findings in clinical practice have raised concerns about the high extent of undertreatment and nonadherence to AHT, which hampers the effectiveness of these medications. In RCTs, antihypertensive drug discontinuation rates range from 5% to 10% per year, and rates up to 50% to 60% after 6 months have been reported in actual practice.

Adherence to AHT has been associated with improved BP, decreased hospitalizations rates, and lower medical care costs. A recent cohort study has also confirmed that the long-term survival advantages associated with improved adherence to AHT after acute myocardial infarction (AMI) appear to be class specific and correlated positively in a dose-response–type fashion. This evidence suggests that the benefits associated with adherence to evidence-based therapies are mediated by drug effects rather than the adoption of healthier lifestyles that often accompanies adherent behaviors (ie, healthy adherer effect).

To the best of our knowledge, less attention has been paid to understanding how nonadherence to AHT might affect the occurrence of cardiovascular events (CVEs) among patients who had not experienced any major cardiovascular outcome. The aim of the present study was to describe adherence to AHT and its association with concurrent drug use, comorbidities, and cardiovascular risk factors. Furthermore, we assessed the impact of adherence on the incidence of CVE among newly diagnosed hypertensive patients.

Methods and Results— Using data obtained from 400 Italian primary care physicians providing information to the Health Search/Thales Database, we selected 18 806 newly diagnosed hypertensive patients 35 years of age during the years 2000 to 2001. Subjects included were newly treated for hypertension and initially free of cardiovascular diseases. Patient adherence was subdivided a priori into 3 categories—high (proportion of days covered, 80%), intermediate (proportion of days covered, 40% to 79%), and low (proportion of days covered, 40%)—and compared with the long-term occurrence of acute cardiovascular events through the use of multivariable models adjusted for demographic factors, comorbidities, and concomitant drug use. At baseline (ie, 6 months after index diagnosis), 8.1%, 40.5%, and 51.4% of patients were classified as having high, intermediate, and low adherence levels, respectively. Multiple drug treatment (odds ratio, 1.62; 95% CI, 1.43 to 1.83), dyslipidemia (odds ratio, 1.52; 95% CI, 1.24 to 1.87), diabetes mellitus (odds ratio, 1.40; 95% CI, 1.15 to 1.71), obesity (odds ratio, 1.50; 95% CI, 1.26 to 1.78), and antihypertensive combination therapy (odds ratio, 1.29; 95% CI, 1.15 to 1.45) were significantly (P less than 0.001) associated with high adherence to antihypertensive treatment. Compared with their low-adherence counterparts, only high adherers reported a significantly decreased risk of acute cardiovascular events (hazard ratio, 0.62; 95% CI, 0.40 to 0.96; P=0.032).

Conclusions— The long-term reduction of acute cardiovascular events associated with high adherence to antihypertensive treatment underscores its importance in assessments of the beneficial effects of evidence-based therapies in the population. An effort focused on early antihypertensive treatment initiation and adherence is likely to provide major benefits.

Full-text (free): http://circ.ahajournals.org/cgi/content/full/120/16/1598

20. Serious Bacterial Infection in Recently Immunized Young Febrile Infants

Wolff M, et al. Acad Emerg Med. 2009;16:1284-1298.

Objective: The objective of this study was to investigate the prevalence of serious bacterial infection (SBI) in febrile infants without a source aged 6–12 weeks who have received immunizations in the preceding 72 hours.

Methods: The authors conducted a medical record review of infants aged 6–12 weeks with a fever of 38.0°C or higher presenting to the pediatric emergency department (ED) over 88 months. Infants were classified either as having received immunizations within the 72 hours preceding the ED visit (recent immunization [RI]) or as not having received immunizations during this time period (no recent immunization [NRI]). Primary outcome of an SBI was based on culture results; only patients with a minimum of blood and urine cultures were studied.

Results: A total of 1,978 febrile infants were studied, of whom 213 (10.8%) had received RIs. The overall prevalence of definite SBI was 6.6% (95% confidence interval [CI] = 5.5 to 7.7). The prevalence of definite SBI in NRI infants was 7.0% (95% CI = 5.9 to 8.3) compared to 2.8% (95% CI = 0.6 to 5.1) in the RI infants. The prevalence of definite SBI in febrile infants vaccinated in the preceding 24 hours decreased to 0.6% (95% CI = 0 to 1.9). The prevalence of definite SBI in febrile infants vaccinated greater than 24 hours prior to presentation was 8.9% (95 CI = 1.5 to 16.4). The relative risk of SBI with RI was 0.41 (95% CI = 0.19 to 0.90). All SBIs in the RI infants were urinary tract infections (UTI).

Conclusions: Among febrile infants, the prevalence of SBI is less in the initial 24 hours following immunizations. However, there is still a substantial risk of UTI. Therefore, urine testing should be considered in febrile infants who present within 24 hours of immunization. Infants who present greater than 24 hours after immunizations with fever should be managed similarly to infants without RIs.

21. Soft Tissue Infections and ED Disposition: Fever Predicts Need for Inpatient Admission

Sabbaj A, et al. Ann Emerg Med. 2009;16:1290-1297.

Objectives: Little empiric evidence exists to guide emergency department (ED) disposition of patients presenting with soft tissue infections. This study's objective was to generate a clinical decision rule to predict the need for greater than 24-hour hospital admission for patients presenting to the ED with soft tissue infection.

Methods: This was a retrospective cohort study of consecutive patients presenting to a tertiary care hospital ED with diagnosis of nonfacial soft tissue infection. Standardized chart review was used to collect 29 clinical variables. The primary outcome was >24-hour hospital admission (either general admission or ED observation unit), regardless of initial disposition. Patients initially discharged home and later admitted for more than 24 hours were included in the outcome. Data were analyzed using classification and regression tree (CART) analysis and multivariable logistic regression.

Results: A total of 846 patients presented to the ED with nonfacial soft tissue infection. After merging duplicate records, 674 patients remained, of which 81 (12%) required longer than 24-hour admission. Using CART, the strongest predictors of >24-hour admission were patient temperature at ED presentation and mechanism of infection. In the multivariable logistic regression model, initial patient temperature (odds ratio [OR] for each degree over 37°C = 2.91, 95% confidence interval [CI] = 1.65 to 5.12) and history of fever (OR = 3.02, 95% CI = 1.41 to 6.43) remained the strongest predictors of hospital admission. Despite these findings, there was no combination of factors that reliably identified more than 90% of target patients.

Conclusions: Although we were unable to generate a high-sensitivity decision rule to identify ED patients with soft tissue infection requiring >24-hour admission, the presence of a fever (either by initial ED vital signs or by history) was the strongest predictor of need for >24-hour hospital stay. These findings may help guide disposition of patients presenting to the ED with nonfacial soft tissue infections.

Lit Bits: Nov 22, 2009

From the recent medical literature...

1. Induced Hypothermia After VF Cardiac Arrest Improves Outcomes

Hypothermia led to significantly better survival rates and neurological outcomes in patients with ventricular fibrillation but not in those with other initial rhythms.

Despite evidence that induced hypothermia therapy after cardiac arrest improves neurological outcomes and survival, cooling protocols have not been widely implemented. In a retrospective observational study, researchers compared outcomes in consecutive patients with out-of-hospital cardiac arrest who were resuscitated in the 2 years before (204 patients) and the 2 years after (287) implementation of a therapeutic hypothermia protocol at a teaching hospital in Seattle. Patients with severe infection, active bleeding, or nonintact skin from recent burns or who were in a persistent vegetative state prior to cardiac arrest were excluded.

Patients in the hypothermia group were cooled with ice packs, cooling blankets, or cooling pads and received intravenous vecuronium and diazepam. Temperature was measured with an esophageal probe; the goal of 32°C–34°C was achieved in 65% of patients. Passive rewarming commenced after 24 hours of cooling.

Rates of survival to hospital discharge were significantly higher in the hypothermia group than in the control group among patients with an initial rhythm of ventricular fibrillation (VF) (54% vs. 39%) but did not differ among patients with other rhythms. Similarly, the rate of favorable neurological outcomes was significantly higher in the hypothermia group than in the control group among patients with VF (35% vs. 15%).

Comment: Although a greater incidence of witnessed arrests in the hypothermia group (66%) than in the control group (57%) might have skewed the results, the findings suggest that cardiac arrest patients with an initial rhythm of VF might benefit from therapeutic cooling. Based on this and previous outcome studies and on other studies showing that induced hypothermia in the emergency department is feasible, it is time for EDs (and some emergency medical services systems) to implement hypothermia protocols for comatose survivors of cardiac arrest.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch EM November 6, 2009. Citation: Don CW et al. Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest: A retrospective before-and-after comparison in a single hospital. Crit Care Med 2009 Sep 16; [e-pub ahead of print]. (http://tinyurl.com/yht8qs7)

2. Capsule Endoscopy in ED Hastens Treatment of Upper GI Bleeding

By Anthony J. Brown, MD. NEW YORK (Reuters Health) Oct 26 - Use of real time capsule endoscopy in the emergency room can rapidly identify patients with upper gastrointestinal bleeding who require urgent treatment, according to study findings presented this week at the American College of Gastroenterology annual meeting in San Diego.

"A positive capsule endoscopy test, defined as visualization of a bleeding lesion, red blood or coffee grounds, (was) highly correlated with high-risk stigmata at endoscopy," senior researcher Dr. Moshe Rubin, from New York Hospital Queens, told Reuters Health. "We were surprised at the accuracy of capsule endoscopy in this small study."

Using capsule endoscopy, he added, "we may able to improve patient outcomes...by rapidly identifying those at high risk who need urgent endoscopic care."

The study featured 24 patients with a history of upper GI bleeding who were randomized to capsule endoscopy or standard clinical evaluation following admission to the emergency room.

Intravenous metoclopramide was given within 10 minutes after the capsule was swallowed. Images were evaluated in real-time at the bedside and then again later after download. Patients with positive findings received endoscopic treatment within 6 hours, whereas those without bleeding and control subjects underwent endoscopic assessment within 24 hours.

Seven of the 12 patients in the capsule endoscopy group had positive findings. In all, seven stigmata of bleeding were confirmed at endoscopy. In 6 of the 7, the actual lesion was identified either during bedside image viewing or upon download review, the researchers report.

Of the 5 patients with negative findings on capsule images, 4 had no bleeding stigmata at endoscopy and 1 had comorbidities that precluded endoscopy. Capsule endoscopy-positive patients had a significantly shorter time to endoscopy than did controls: 2.5 vs. 8.9 hours (p = 0.029).

No patient died, and blood transfusion requirements and length of stay were comparable in the two groups. A capsule was retained in one patient with a strictured esophagus, but it was retrieved with endoscopy.

"We need to validate these findings in a larger trial that we are planning," Dr. Rubin said. "In a follow up study, we will use capsule endoscopy to segregate high-risk patients who need urgent intervention from low-risk patients who can potentially be treated more conservatively, and then assess outcomes."

3. ED Waiting Times Increasing in US

Percentage of US Emergency Department Patients Seen Within the Recommended Triage Time: 1997 to 2006

Horwitz LI, et al. Arch Intern Med. 2009;169:1857-1865.

Background The wait time to see a physician in US emergency departments (EDs) is increasing and may differentially affect patients with varied insurance status and racial/ethnic backgrounds.

Methods Using a stratified random sampling of 151 999 visits, representing 539 million ED visits from 1997 to 2006, we examined trends in the percentage of patients seen within the triage target time by triage category (emergent, urgent, semiurgent, and nonurgent), payer type, and race/ethnicity.

Results The percentage of patients seen within the triage target time declined a mean of 0.8% per year, from 80.0% in 1997 to 75.9% in 2006 (P less than .001). The percentage of patients seen within the triage target time declined 2.3% per year for emergent patients (59.2% to 48.0%; P less than .001) compared with 0.7% per year for semiurgent patients (90.6% to 84.7%; P less than .001). In 2006, the adjusted odds of being seen within the triage target time were 30% lower than in 1997 (odds ratio, 0.70; 95% confidence interval, 0.55-0.89). The adjusted odds of being seen within the triage target time were 87% lower (odds ratio, 0.13; 95% confidence interval, 0.11-0.15) for emergent patients compared with semiurgent patients. Patients of each payment type experienced similar decreases in the percentage seen within the triage target over time (P for interaction = .24), as did patients of each racial/ethnic group (P = .05).

Conclusions The percentage of patients in the ED who are seen by a physician within the time recommended at triage has been steadily declining and is at its lowest point in at least 10 years. Of all patients in the ED, the most emergent are the least likely to be seen within the triage target time. Patients of all racial/ethnic backgrounds and payer types have been similarly affected.

4. Ultrasound Detects Central Line Placement and Postprocedure Pneumothorax

Chest x-ray missed 2 of 4 pneumothoraces and 1 of 25 misplaced catheter tips that were detected by bedside ultrasound.

Vezzani A et al. Crit Care Med 2009 Oct 12.

Objective: To determine the usefulness of ultrasound to evaluate central venous catheter misplacements and detection of pneumothorax, thus obviating postprocedural radiograph. After the insertion of a central venous catheter, chest radiograph is usually obtained to ensure correct positioning of the catheter tip and detect postprocedural complications.

Measurements and Main Results: A prospective study of 111 consecutive central venous catheter procedures, using a landmark technique, was conducted in an adult intensive care unit. At the end of the procedure, a B-mode ultrasonography was first performed to assess catheter position and detect pneumothorax. Then, contrast enhanced ultrasonography was used to facilitate visualization of catheter tip, avoiding unknown right atrium positioning or artifacts. A postprocedural chest radiograph was obtained for all patients and was considered as a reference technique. Right atrium positioning was detected in 19 patients by ultrasonography, and an additional six by contrast enhanced ultrasonography. Combining ultrasonography and contrast enhanced ultrasonography yielded a 96% sensitivity and 93% specificity in detecting catheter misplacement. Concordance was 95% and [kappa] value was 0.88 (p less than .001). Pneumothorax was detected in four patients by ultrasonography and in two by chest radiograph (concordance = 98%). The mean time required to perform ultrasonography plus contrast enhanced ultrasonography was 10 +/- 5 mins vs. 83 +/- 79 mins for chest radiograph (p less than .05).

Conclusions: The close concordance between ultrasonography plus contrast enhanced ultrasonography and chest radiograph justifies the use of sonography as a standard technique to ensure the correct positioning of the catheter tip and to detect pneumothorax after central venous catheter cannulation to optimize use of hospital resources and minimize time consumption and radiation. Chest radiograph will be necessary when sonographic examination is impossible to perform by technical limitations.

5. Updated Guidelines for the Care of Children in EDs

This joint policy statement provides a highly useful roadmap for standardizing emergency care of children in community EDs.

American Academy of Pediatrics et al. Pediatrics 2009;124:1233-1243.

Full-text (free): http://pediatrics.aappublications.org/cgi/content/full/124/4/1233

6. Cervical Collar, Physical Therapy, or "Wait and See" for Recent-Onset Cervical Radiculopathy?

Pain scores were significantly lower in the collar and physical therapy groups.

Kuijper B et al. BMJ 2009 Oct 7; 339:b3883.

Full-text: http://www.bmj.com/cgi/content/full/339/oct07_1/b3883

7. A Comparison of Parental and Nursing Assessments of Level of Illness or Injury in a Pediatric Emergency Department

Kestner V, et al., Pediatric Emergency Care. 2009;25:633-635.

Background: The 5-tier Emergency Severity Index (ESI) score is a well-accepted, validated triage tool with good interrater reliability. Parental perception of illness severity has not been compared to ESI score.

Objective: This study compares parental assessment of severity of illness to triage nurse acuity.

Design: Prospective and descriptive.

Setting: Large, urban pediatric emergency department (ED).

Participants: Parents/guardians of patients younger than 18 years.

Intervention: The triage nurse assigned an ESI score, and the parent/guardian assigned all patients a severity score on a scale of 1 to 5 (1, most sick and 5, least sick). Mean severity scores were compared between the groups.

Results: There were 142 participants with a mean patient age of 6.15 years. The mean participant and nurse severity scores were 3.01 and 3.35, respectively, with an intraclass correlation coefficient of 0.203 (P = 0.008). Most frequently, the parent/guardian and triage nurse assigned the same score (n = 44, 31%). Seventy-six percent of the parent/guardian scores were within 1 point of the triage nurse score.

Conclusions: Close agreement exists between parent/guardian and nurse ESI scores, illustrating objectivity in parent/guardian assessments. This study provides a springboard for future studies regarding ED use after educating families on ED triage.

8. Interobserver agreement in the interpretation of computed tomography in acute pulmonary embolism

Costantino G, Amer J Emerg Med. 2009;27:1109-1111.

Multidetector computed tomography (MDCT) is one of the best diagnostic tools for the diagnosis of pulmonary embolism (PE). However, differences in MDCT interpretation, depending on the operator personal expertise, is an important factor that could interfere with the right diagnosis and, consequently, with the more adequate and well-timed therapy.

The aim of the present study was to evaluate the interobserver agreement in the interpretation of MDCT for the diagnosis of acute PE.

On a blind basis, 4 radiologists with different expertise in CT interpretation evaluated 46 different MDCT executed for acute PE. They had to verify the presence or absence of PE and, in the positive case, localize (right-left) and quantify (massive, segmentarian or subsegmentarian) it. The interobserver concordance was expressed using the Cohen K statistic.

The mean concordance between the 4 operators was high (0.82; range, 0.68-0.95). Ruling out the massive PE cases, the mean concordance over the other cases was only moderate (0.47; range, 0.16-0.84).

We found a very good interobserver agreement in MDCT evaluation for the diagnosis of massive PE, whereas we observed a lower concordance in regard to segmentarian and subsegmentarian PE. In the case of negative or nonmassive PE diagnosis, a second evaluation of the CT performed by an expert CT radiologist would probably be effective to decrease the CT evaluation error.

9. Compress the Chest: Better CPR Improves Survival from Out-of-Hospital Cardiac Arrest

Implementation of the 2005 AHA CPR guidelines that focus on uninterrupted chest compressions nearly doubled the odds of survival among patients with out-of-hospital cardiac arrest.

In 2005, the American Heart Association (AHA) released updated evidence-based guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, but does adherence to the revised protocol improve outcomes? Investigators compared rates of survival from out-of-hospital cardiac arrest among 606 adult patients treated before and 1021 treated after implementation of the 2005 AHA guidelines in a single large emergency medical services system.

Review of a convenience sample of 69 electronic electrocardiogram recordings showed significant improvement in CPR quality after guideline implementation, including improvements in mean chest-compression rate, proportion of time that patients received chest compressions, and median preshock and postshock pause times for compressions. Unadjusted rates of survival to hospital discharge were significantly higher after implementation of the guidelines than before (9.4% vs. 6.1%). Among patients with witnessed arrest whose initial rhythm was ventricular fibrillation on EMS arrival, survival rates improved significantly from 24% (19 of 78) before implementation to 30% (34 of 112) after. Multivariate regression analysis that adjusted for initial rhythm, sex, arrest location, and witnessed arrest showed 1.8 greater odds of survival in the postintervention period.

Comment: The promising results of this large study suggest the AHA was on the right track with its renewed focus on basic CPR, including the importance of providing uninterrupted chest compressions.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine October 23, 2009. Citation: Sayre MR et al. Impact of the 2005 American Heart Association cardiopulmonary resuscitation and emergency cardiovascular care guidelines on out-of-hospital cardiac arrest survival. Prehosp Emerg Care 2009;13:469.

10. Methohexital Beats Pentobarbital for Head CT Sedation in Children

Chun TH et al. Pediatr Emerg Care 2009 Oct; 25:648.

Objectives: To determine if there are differences in the duration of sedation between pediatric emergency department (PED) patients receiving methohexital and PED patients receiving pentobarbital for the purpose of obtaining a head computed tomographic (CT) scan.

Methods: Retrospective cohort study of PED patients receiving either methohexital or pentobarbital for a sedated head CT. Data were collected on patient demographics and medical condition, indications for head CT, duration of sedation, medication dosage, and medication adverse events. Primary analyses investigated whether there were differences between the 2 groups. Secondary analysis determined whether the need for additional sedative doses contributed to observed differences between groups.

Results: The patients receiving methohexital completed their head CT more quickly and needed less total sedation monitoring than those receiving pentobarbital. The need for additional doses of medication does not appear to be responsible for the observed difference. Adverse medication events were minor and comparable between groups.

Conclusions: Methohexital may be superior to pentobarbital for the purpose of sedating PED patients for head CT.

11. Anticholinergic Drugs and Acute Urinary Retention

Risk is highest during the first several weeks of treatment.

Martín-Merino E et al. J Urol 2009 Oct; 182:1442.

Abstract: http://www.jurology.com/article/S0022-5347(09)01525-0/abstract

12. Doctors' Lack of Respect Weighs on the Obese

October 29, 2009 — Heavier patients get less respect from doctors, raising concerns about the impact on the quality of care, new research indicates.

Scientists reporting in the November issue of the Journal of General Internal Medicine say they found that the higher a patient’s body mass index (BMI), the less respect their doctors had for them.

Mary Margaret Huizinga, MD, MPH, of Johns Hopkins University School of Medicine and lead author of the study, says she came up with the idea for the research from her experiences working in a weight loss clinic.

She says that patients who'd visit would, by the time they left, “be in tears, saying 'no other physician talked with me like this before,'" and had failed to listen.

“Many patients felt like because they were overweight, they weren’t receiving the type of care other patients received,” she says in a news release.

She and colleagues looked at data on 238 patients and 40 physicians. The average BMI of the patients was 32.9.

A person with a BMI of 25 to 29.9 is considered overweight, and 30 or greater obese.

In the study, patients and physicians filled out questionnaires about a doctor’s visit. They were asked questions about their attitudes and perceptions of one another at the end of their encounter. Physicians were asked to rate the level of respect they had for each patient compared to “the average patient” on a 5-point scale.

The patients for whom doctors expressed low respect, on average, had a higher BMI than patients for whom the physicians had high respect, the researchers report. The researchers note that the findings don’t show a cause/effect relationship between BMI and physician respect. Their study also didn’t investigate patients’ health outcomes.

Huizinga writes that respect is critical because some patients may avoid the health care system altogether. In other research, physician respect has been linked to more information being provided by the physician during a patient visit. She says more research is needed “to really understand how physician attitudes toward obesity affect quality of care for those patients."

“If a doctor has a patient with obesity and has low respect for that person, is the doctor less likely to recommend certain types of weight loss programs or to send her for cancer screening?” Huizinger asks. “We need to understand these things better.”

SOURCES: News release, Johns Hopkins University School of Medicine.

Huizinga, M., Journal of General Internal Medicine, November 2009.

13. Divorce Risk Higher When Wife Gets Sick

By TARA PARKER-POPE. NY Times. Nov 12, 2009.

When Dr. Marc Chamberlain, a Seattle oncologist, was treating his brain cancer patients, he noticed an alarming pattern. His male patients were typically receiving much-needed support from their wives. But a number of his female patients were going it alone, ending up separated or divorced after receiving a brain tumor diagnosis.

Dr. Chamberlain, chief of the neuro-oncology division at the Fred Hutchinson Cancer Research Center, had heard similar stories from his colleagues. To find out if these observations were based in fact, he embarked on a study with Dr. Michael J. Glantz of the University of Utah Huntsman Cancer Institute and colleagues from three other institutions who began to collect data on 515 patients who received diagnoses of brain tumors or multiple sclerosis from 2001 through 2006.

The results were surprising. Women in the study who were told they had a serious illness were seven times as likely to become separated or divorced than men with similar health problems, according to the report published in the journal Cancer.
The remainder of the NY Times article: http://well.blogs.nytimes.com/2009/11/12/men-more-likely-to-leave-spouse-with-cancer/

The abstract of the study: http://www3.interscience.wiley.com/journal/122527377/abstract

14. Intranasal Naloxone Is Effective for Opioid Overdose

Time from patient contact to clinical response was the same with intranasal and intravenous naloxone.

Robertson TM, et al. Prehospital Emerg Care 2009;13:512-515.

Objective. To compare the prehospital time intervals from patient contact and medication administration to clinical response for intranasal (IN) versus intravenous (IV) naloxone in patients with suspected narcotic overdose.

Methods. This was a retrospective review of emergency medical services (EMS) and hospital records, before and after implementation of a protocol for administration of intranasal naloxone by the Central California EMS Agency. We included patients with suspected narcotic overdose treated in the prehospital setting over 17 months, between March 2003 and July 2004. Paramedics documented dose, route of administration, and positive response times using an electronic record. Clinical response was defined as an increase in respiratory rate (breaths/min) or Glasgow Coma Scale score of at least 6. Main outcome variables included time from medication to clinical response and time from patient contact to clinical response. Secondary variables included numbers of doses administered and rescue doses given by an alternate route. Between-group comparisons were accomplished using t-tests and chi-square tests as appropriate.

Results. One hundred fifty-four patients met the inclusion criteria, including 104 treated with IV and 50 treated with IN naloxone. Clinical response was noted in 33 (66%) and 58 (56%) of the IN and IV groups, respectively (p = 0.3). The mean time between naloxone administration and clinical response was longer for the IN group (12.9 vs. 8.1 min, p = 0.02). However, the mean times from patient contact to clinical response were not significantly different between the IN and IV groups (20.3 vs. 20.7 min, p = 0.9). More patients in the IN group received two doses of naloxone (34% vs. 18%, p = 0.05), and three patients in the IN group received a subsequent dose of IV or IM naloxone.

Conclusions. The time from dose administration to clinical response for naloxone was longer for the IN route, but the overall time from patient contact to response was the same for the IV and IN routes. Given the difficulty and potential hazards in obtaining IV access in many patients with narcotic overdose, IN naloxone appears to be a useful and potentially safer alternative.

15. Subarachnoid Hemorrhage Might Be a Common Cause of Out-of-Hospital Cardiac Arrest

In this Japanese study, 16% of survivors of out-of-hospital cardiac arrest had subarachnoid hemorrhage.

Inamasu J, et al. Resuscitation 2009;80:977-980.

Aim
Aneurysmal subarachnoid haemorrhage (SAH) is a relatively common cause of out-of-hospital cardiac arrest (OHCA). Early identification of SAH-induced OHCA with the use of brain computed tomography (CT) scan obtained immediately after resuscitation may help emergency physicians make therapeutic decision as quickly as they can.

Methods
During the 4-year observation period, brain CT scan was obtained prospectively in 142 witnessed non-traumatic OHCA survivors who remained haemodynamically stable after resuscitation. Demographics and clinical characteristics of SAH-induced OHCA survivors were compared with those with “negative” CT finding.

Results
Brain CT scan was feasible with an average door-to-CT time of 40.0min. SAH was found in 16.2% of the 142 OHCA survivors. Compared with 116 survivors who were negative for SAH, SAH-induced OHCA survivors were significantly more likely to be female, to have experienced a sudden headache, and trended to have achieved return of spontaneous circulation (ROSC) prior to arrival in the emergency department less frequently. Ventricular fibrillation (VF) was significantly less likely to be seen in SAH-induced than SAH-negative OHCA (OR, 0.06; 95% CI, 0.01–0.46). Similarly, Cardiac Trop-T assay was significantly less likely to be positive in SAH-induced OHCA (OR, 0.08; 95% CI, 0.01–0.61).

Conclusion
Aneurysmal SAH causes OHCA more frequently than had been believed. Immediate brain CT scan may particularly be useful in excluding SAH-induced OHCA from thrombolytic trial enrollment, for whom the use of thrombolytics is contraindicated. The low VF incidence suggests that VF by itself may not be a common cause of SAH-induced OHCA.

16. Combination of epinephrine and dexamethasone may reduce hospitalization in children with bronchiolitis

Frohna JG, et al. J Pediatrics 2009;155:761-762.

Commentary
Identifying effective treatments for children with bronchiolitis has proven elusive. In part, this is due to the heterogenous cause of wheezing, which can range from episodic wheezing (often caused by viral infections) to multifactorial wheezing that can be triggered by a variety of factors and often resulting in asthma. A meta-analysis showed limited short-term benefit from epinephrine, and it is well known that children with asthma respond to corticosteroids. Plint et al were surprised to find a synergistic effect between epinephrine and dexamethasone, which reduced the frequency of hospitalization for children in this study. In addition, there are likely many factors that influence the decision to hospitalize a child, such as the distance to the hospital, the ability of the parents to care for their ill child, and the availability of health care resources. While a number needed to treat of 11 to prevent 1 hospitalization might be appealing, there are several caveats to these results. First, the dose of corticosteroids used in this study is quite high, and there is still limited knowledge of potential risks associated with this treatment. Second, when the authors adjusted their results for the multiple comparisons that were made, the difference in hospitalization was no longer statistically significant. One area of future research would be to look at the subgroups of infants who respond better to corticosteroids and look for possible biomarkers that may even include virus identification techniques. Although we await follow-up studies to provide stronger evidence, it is prudent to provide supportive care and close monitoring for children with an initial episode of wheezing. Monitoring these infants in the general pediatrician's office does not require high-tech medicine—just some relatively straightforward clinical algorithims.

Full-text: http://www.jpeds.com/article/S0022-3476(09)00862-2/fulltext

17. The Oblique View: An Alternative Approach for Ultrasound-Guided Central Line Placement

Phelan M, et al. Amer J Emerg Med. 2009;37:403-408.

Background: Numerous studies have shown significant benefits of using real-time ultrasonography for central line intravenous access. Traditionally, the ultrasound probe is placed along the short axis of the vein to visualize and direct needle placement. This view has some limitations, particularly being able to visualize the needle tip. Some practitioners place the ultrasound probe in the long axis of the vessel to direct needle placement, allowing better visualization of the needle entering the vein, but this does not allow visualization of relevant anatomic structures.

Objectives: We describe an alternative means to obtain ultrasound-guided vascular access using an oblique axis rather than the traditional short-axis approach.

Discussion: This view allows better visualization of the needle shaft and tip but also offers the safety of being able to visualize all relevant anatomically significant structures at the same time and in the same plane. This orientation is halfway between the short and long axis of the vessel, allowing visualization of the needle as it enters the vessel. This capitalizes on the strengths of the long axis while optimizing short-axis visualization of important structures during intravenous line placement.

Conclusion: Ultrasound-guided vascular access can be obtained in a variety of ways. We describe a technique that is used by some experienced ultrasound users but that has never been fully described in the literature. This technique for obtaining ultrasound-guided vascular access offers another option for attempting ultrasound-guided vascular access that has the potential to improve success rates and minimize complications associated with intravenous access.

18. CT-STAT: CT Angiography Rules Out CAD Faster and Cheaper Than Standard Care

Michael O'Riordan. November 18, 2009 (Orlando, Florida) — The use of coronary computed tomography (CT) angiography in the emergency room can successfully triage at-risk chest-pain patients and can do so faster and less expensively than standard diagnostic testing, according to the results of a new study.

"I think the reassurance is that both strategies are very safe," said lead investigator Dr James Goldstein (William Beaumont Hospital, Royal Oak, MI). "We've chosen a chosen a low-risk population--we don't want anybody to go home with a heart attack. We already know that the standard of care is a very fine strategy, and we've gotten very good at evaluating chest pain, but it is cumbersome and expensive."

Although the use of CT to rule out coronary artery disease should not be used in all patients, especially those with manifest ischemia, electrocardiogram abnormalities, or elevations in enzymatic biomarkers, among low-risk patients, "wisely and prudently applied," CT angiography is a powerful addition to the armamentarium of clinicians, said Goldstein.

The results of the study, known as the Computed Tomographic Angiography for the Systematic Triage of Acute Chest Pain Patients to Treatment (CT-STAT) trial, were presented today at the American Heart Association 2009 Scientific Sessions.

The remainder of the essay: http://www.medscape.com/viewarticle/712673

19. Prophylactic Acetaminophen Blunts Immunogenicity of Childhood Vaccinations

Routine prophylactic use of acetaminophen at the time of childhood immunizations should be reconsidered.

Prymula R et al. Lancet 2009; 374:1339.

Abstract: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61208-3/abstract

20. Kubler-Ross’ Stages of Grief: Maybe Not so Cut-and-Dried

In 1969 the psychiatrist Elizabeth Kubler-Ross wrote one of the most influential books in the history of psychology, On Death and Dying. It exposed the heartless treatment of terminally-ill patients prevalent at the time. On the positive side, it altered the care and treatment of dying people. On the negative side, it postulated the now-infamous five stages of dying—Denial, Anger, Bargaining, Depression, and Acceptance (DABDA), so annealed in culture that most people can recite them by heart. The stages allegedly represent what a dying person might experience upon learning he or she had a terminal illness. “Might” is the operative word, because Kübler-Ross repeatedly stipulated that a dying person might not go through all five stages, nor would they necessarily go through them in sequence. It would be reasonable to ask: if these conditions are this arbitrary, can they truly be called stages?

Many people have contested the validity of the stages of dying, but here we are more concerned with the supposed stages of grief which derived from the stages of dying. As professional grief recovery specialists, we contend that the theory of the stages of grief has done more harm than good to grieving people. Having co-authored three books on the impact of death, divorce, and other losses, and having worked directly with over 100,000 grieving people during the past 30 years, our reasons for disputing the stages of grief theory are predicated on the horror stories we’ve heard from thousands of grieving people who’ve told us how they’d been harmed by them.
Friedman R, et al. The Myth of the Stages of Dying, Death and Grief. Skeptic. 2008;13:37-41.

Full-text: http://www.grief.net/Articles/Myth%20of%20Stages.pdf