1. QI Program Can Cut Unneeded Cardiac CT
By Chris Kaiser, Cardiology Editor, MedPage Today. August
09, 2012
Inappropriate coronary CT angiography (CCTA) exams can be
curtailed if physicians are educated as to when the test should be ordered,
researchers found.
Follow-up after physicians underwent a 2-year continuous
quality improvement program revealed a significant 60.3% decrease in
inappropriate orders for CCTA tests (14.5% to 5.8%, P less than 0.0001), reported
Kavitha M. Chinnaiyan, MD, from William Beaumont Hospital in Royal Oak, Mich.,
and colleagues. That decrease was accompanied by a significant 23.4% increase
in the amount of appropriate scans ordered (61.3% to 80%, P less than 0.0001),
according to the study published online in the Journal of the American College
of Cardiology.
Researchers also noted a significant 40.8% decrease in exam
scenarios classified as "uncertain" and a significant 41.7% decrease
in "unclassifiable" tests. Uncertain tests are those where the
evidence is not sufficient to definitively classify them as appropriate or not.
Unclassifiable exams are those that were not covered in the appropriate use
criteria or where was not enough information provided to classify them.
Chinnaiyan told MedPage Today that they worked to improve
the reporting of tests in order to reduce the number of unclassifiable scans.
The appropriate use criteria for CCTA are a response to the burgeoning use of
CT for cardiac imaging, which the authors said was the "fastest growing
application of CT scanners in the United States."
The appropriateness of CCTA has been questioned by a number
of stakeholders including private payers, the government, and medical specialty
groups. Researchers sought to determine whether a continuous quality
improvement intervention would make a difference in practice patterns among
those who order CCTA exams.
The study is part of the Advanced Cardiovascular Imaging
Consortium, one of 13 statewide continuous quality improvement initiatives
sponsored by Blue Cross Blue Shield of Michigan. The study cohort included
25,387 patients, with a mean age of 58. Slightly more than half (54%) of the
patients were male.
A total of 47 centers performing clinical CCTA were
enrolled; a pre-intervention period spanned from July 2007 to June 2008. During
this time, the sites received quarterly CCTA utilization reports, but there was
no emphasis on the appropriate use criteria. During an intervention period,
from July 2008 to June 2010, the sites participated in educational endeavors
that stressed appropriate use of CCTA. In addition, letters were sent to referring
physicians emphasizing appropriate use criteria and a potential loss of
insurance coverage for inappropriate scans.
Each site had the autonomy to conduct intervention in its
own way. For example, 19 sites began a program of real-time feedback to referring
physicians following prospective evaluation of patient indications.
All sites chose a clinical champion who was responsible for
keeping the team members motivated and closely monitoring the results. During
the 2-year intervention, each site received quarterly feedback regarding the
amount of appropriate and inappropriate scans relative to other participating
sites.
After the intervention period, researchers followed the
sites for another 6 months. Researchers found that the most common appropriate
indication for ordering a CCTA test was to detect coronary artery disease in
symptomatic low- and intermediate-risk patients (30%) and in patients with
prior cardiac tests (29%).
The most common inappropriate indications were to detect
coronary disease in asymptomatic patients (69%), while the most common
uncertain indication was to find coronary disease in low-risk symptomatic
patients (84%).
Compared with the pre-intervention period, physicians
ordered fewer inappropriate scans during the follow-up period. In particular,
they ordered fewer CT exams for low-risk asymptomatic patients (from 73% to
57%) and for high-risk patients with acute symptoms (from 16.7% to 13%). Both
decreases were significant at P less than 0.0001. Researchers saw similar significant
changes in ordering patterns from the intervention period through the follow-up.
Of particular importance, Chinnaiyan said, was that these changes were
significant for all specialties including cardiology, internal medicine,
emergency medicine, and others such as urgery and nephrology. Each group had a
significant decrease in inappropriate exam orders.
"One of the important take-home messages is that
physicians need to be cognizant about testing in general," Chinnaiyan
said. "There is a huge overutilization of CCTA studies and any place that
does any kind of testing should be constantly evaluating itself to ensure it is
ordering the right test for the right patient."
The study was limited by the lack of a control group, the
estimating of Framingham risk score, and limitations of the appropriate use
criteria themselves, researchers said. The study was funded by Blue Cross/Blue
Shield/Blue Care Network of Michigan.
Full-text (free at this point): http://content.onlinejacc.org/article.aspx?articleid=1309635
2. Does This Adult
Patient with Suspected Bacteremia Require Blood Cultures?
Coburn B, et al. JAMA. 2012;308(5):502-511.
Context Clinicians
order blood cultures liberally among patients in whom bacteremia is suspected,
though a small proportion of blood cultures yield true-positive results.
Ordering blood cultures inappropriately may be both wasteful and harmful.
Objective To review
the accuracy of easily obtained clinical and laboratory findings to inform the
decision to obtain blood cultures in suspected bacteremia.
Data Sources and Study Selection A MEDLINE and EMBASE search (inception to
April 2012) yielded 35 studies that met inclusion criteria for evaluating the
accuracy of clinical variables for bacteremia in adult immunocompetent
patients, representing 4566 bacteremia and 25 946 negative blood culture
episodes.
Data Extraction Data
were extracted to determine the prevalence and likelihood ratios (LRs) of
findings for bacteremia.
Data Synthesis The
pretest probability of bacteremia varies depending on the clinical context,
from low (eg, cellulitis: 2%) to high (eg, septic shock: 69%). Elevated
temperatures alone do not accurately predict bacteremia (for 38°C and above
[over 100.3°F], LR, 1.9 [95% CI, 1.4-2.4]; for 38.5°C and above [over 101.2°F], LR, 1.4
[95% CI, 1.1-2.0]), nor does isolated leukocytosis (LR, less than 1.7). The severity
of chills graded on an ordinal scale (shaking chills, LR, 4.7; 95% CI, 3.0-7.2)
may be more useful. Both the systemic inflammatory response syndrome (SIRS) and
a multivariable decision rule with major and minor criteria are sensitive (but
not specific) predictors of bacteremia (SIRS, negative LR, 0.09 [95% CI,
0.03-0.26]; decision rule, negative LR, 0.08 [95% CI, 0.04-0.17]).
Conclusions Blood
cultures should not be ordered for adult patients with isolated fever or
leukocytosis without considering the pretest probability. SIRS and the decision
rule may be helpful in identifying patients who do not need blood cultures.
These conclusions do not apply to immunocompromised patients or when
endocarditis is suspected.
3. Necrotising fasciitis:
A Review from the BMJ
Sultan HY, et al. BMJ 2012;345:e4274
Necrotising fasciitis is one of a group of highly lethal
infections that cause rapidly spreading necrosis of fascia and subcutaneous
tissues, sometimes involving muscles and skin. They were previously known by
such names as hospital gangrene, gas gangrene, and Fournier’s gangrene and are
now referred to by the generic term “necrotising soft tissue infections.” We
review the clinical features and highlight the potential pitfalls in diagnosis.
Learning points
·
Necrotising fasciitis is a lethal and rapidly
progressive soft tissue infection, which can occur in healthy young patients
·
People with diabetes, those who inject drugs,
and patients with haematological malignancy are particularly at risk
·
Diagnosis requires a high index of suspicion.
Consider necrotising fasciitis especially when the presentation is “not quite
right” or the patient is not responding to treatment
·
Early surgical exploration of the soft tissues
has little morbidity and may be the only means to reach a definitive diagnosis
and expedite treatment
·
In established necrotising fasciitis, surgery
gives a 60-80% chance of survival. The earlier the first exploration and
subsequent debridement, the less extensive the resection and postoperative
morbidity is likely to be
Full-text (subscription only): http://www.bmj.com/content/345/bmj.e4274?etoc=
4. Warning Symptoms
and Family History in Children and Young Adults with Sudden Cardiac Arrest
Drezner JA, et al. J Am Board Fam Med 2012;25:408-415.
Background: Children and young adults with undiagnosed
cardiovascular disorders at risk for sudden death may have warning symptoms or
significant family history that is detectable through screening. The objective
of this study was to determine the prevalence of warning symptoms and family
history in a cohort of children and young adults who suffered sudden cardiac
arrest (SCA).
Methods: A retrospective survey investigating warning
symptoms and family history of cardiovascular disease was completed by families
with a child or young adult who suffered SCA.
Results: Eighty-seven of 146 families (60%) returned a
completed survey. The SCA victims were an average age of 16 years (range, 5–29
years), 69% male, and 68% white. Seventy-two percent of SCA victims were
reported by their parents to have at least one cardiovascular symptom before
SCA, with fatigue (44%) and near-syncope/lightheadedness (30%) the two most
common. Twenty-four percent of SCA victims had one or more (average 2.6; range,
1 to 10) events of syncope or unexplained seizure that remained undiagnosed as
a cardiac disorder before SCA. Parents reported that cardiovascular symptoms
first occurred, on average, 30 months (range, 19 to 71 months) before SCA; a
symptom was brought to the attention of the child's physician in 41% of cases.
Twenty-seven percent of families reported a family member had suffered sudden
death before age 50 because of a heart condition.
Conclusions: Many children and young adults who suffered SCA
are reported to have cardiac symptoms or a family history of premature cardiac
death. Syncope and unexplained seizure activity are distinct events but often
go unrecognized as ominous signs of underlying cardiovascular disease.
Physician education and increased public awareness regarding cardiovascular
warning signs in the young may improve early detection of those at risk and
prevent tragedies.
Full-text (free): http://www.jabfm.org/content/25/4/408.full
5. Intensive Care
Unit Admitting Patterns in the Veterans Affairs Health Care System
Chen LM, et al. Arch Intern Med. 2012;():1-7.
doi:10.1001/archinternmed.2012.2606
Background Critical
care resource use accounts for almost 1% of US gross domestic product and
varies widely among hospitals. However, we know little about the initial
decision to admit a patient to the intensive care unit (ICU).
Methods To describe
hospital ICU admitting patterns for medical patients after accounting for
severity of illness on admission, we performed a retrospective cohort study of
the first nonsurgical admission of 289 310 patients admitted from the emergency
department or the outpatient clinic to 118 Veterans Affairs acute care
hospitals between July 1, 2009, and June 30, 2010. Severity (30-day predicted
mortality rate) was measured using a modified Veterans Affairs ICU score based
on laboratory data and comorbidities around admission. The main outcome measure
was direct admission to an ICU.
Results Of the 31 555
patients (10.9%) directly admitted to the ICU, 53.2% had 30-day predicted
mortality at admission of 2% or less. The rate of ICU admission for this
low-risk group varied from 1.2% to 38.9%. For high-risk patients (predicted
mortality above 30%), ICU admission rates also varied widely. For a 1-SD increase
in predicted mortality, the adjusted odds of ICU admission varied substantially
across hospitals (odds ratio = 0.85-2.22). As a result, 66.1% of hospitals were
in different quartiles of ICU use for low- vs high-risk patients (weighted κ =
0.50).
Conclusions The
proportion of low- and high-risk patients admitted to the ICU, variation in ICU
admitting patterns among hospitals, and the sensitivity of hospital rankings to
patient risk all likely reflect a lack of consensus about which patients most
benefit from ICU admission.
Full-text (free for now): http://archinte.jamanetwork.com/article.aspx?articleid=1221714
6. No Return of
Pulses in the Field Portends Dismal Survival
This study's findings support use of prehospital
termination-of-resuscitation protocols.
Prehospital cardiac arrest patients who do not achieve
return of spontaneous circulation (ROSC) continue to be transported to the
hospital despite the existence of prehospital termination-of-resuscitation
protocols (JW Emerg Med Oct 17 2008). To determine survival rates in such
patients, researchers analyzed data from two urban emergency medical service
systems for patients who experienced cardiac arrest presumed to be of medical
etiology from 2008 to 2010.
Among 2483 patients in whom resuscitation was attempted,
survival to hospital discharge was 6.6%. ROSC in the field occurred in 36% of
patients. Survival rates were 17.2% in patients with ROSC in the field versus
0.7% in those without ROSC. None of the 11 patients who survived without ROSC
in the field had an initial rhythm of asystole.
Comment: If termination-of-resuscitation protocols that are
based on ROSC had been followed in this study, the transport rate would have
been halved. Although the authors' recommendation for no transport of patients
without field ROSC or shockable rhythm would save critical resources and reduce
risks to prehospital providers and the public from collisions, nonmedical
indications such as family wishes sometimes mandate transport of nonviable
patients. When such patients are transported, these data are useful for
receiving-hospital emergency physicians to determine whether to continue
resuscitative efforts on arrival.
— Kristi L. Koenig, MD, FACEP. Published in Journal Watch
Emergency Medicine August 10, 2012. Citation: Wampler DA et al. Cardiac arrest
survival is rare without prehospital return of spontaneous circulation. Prehosp
Emerg Care 2012 Jul 26; [e-pub ahead of print].
(http://dx.doi.org/10.3109/10903127.2012.695435)
7. Shift work and
vascular events: systematic review and meta-analysis
Vyas MV, et al. BMJ 2012;345:e4800
Objective To synthesise the association of shift work with
major vascular events as reported in the literature.
Data sources Systematic searches of major bibliographic
databases, contact with experts in the field, and review of reference lists of
primary articles, review papers, and guidelines.
Study selection Observational studies that reported risk
ratios for vascular morbidity, vascular mortality, or all cause mortality in
relation to shift work were included; control groups could be non-shift (“day”)
workers or the general population.
Data extraction Study quality was assessed with the Downs
and Black scale for observational studies. The three primary outcomes were
myocardial infarction, ischaemic stroke, and any coronary event. Heterogeneity
was measured with the I2 statistic and computed random effects models.
Results 34 studies in 2 011 935 people were identified.
Shift work was associated with myocardial infarction (risk ratio 1.23, 95%
confidence interval 1.15 to 1.31; I2=0) and ischaemic stroke (1.05, 1.01 to
1.09; I2=0). Coronary events were also increased (risk ratio 1.24, 1.10 to
1.39), albeit with significant heterogeneity across studies (I2=85%). Pooled
risk ratios were significant for both unadjusted analyses and analyses adjusted
for risk factors. All shift work schedules with the exception of evening shifts
were associated with a statistically higher risk of coronary events. Shift work
was not associated with increased rates of mortality (whether vascular cause specific
or overall). Presence or absence of adjustment for smoking and socioeconomic
status was not a source of heterogeneity in the primary studies. 6598
myocardial infarctions, 17 359 coronary events, and 1854 ischaemic strokes
occurred. On the basis of the Canadian prevalence of shift work of 32.8%, the
population attributable risks related to shift work were 7.0% for myocardial
infarction, 7.3% for all coronary events, and 1.6% for ischaemic stroke.
Conclusions Shift work is associated with vascular events,
which may have implications for public policy and occupational medicine.
8. Are patients
willing to remove, and capable of removing, their own nonabsorbable sutures?
Macdonald P, et al. CJEM 2012;14(4):218-223
Objectives: Providing patients with instructions and
equipment regarding self-removal of nonabsorbable sutures could represent a new
efficiency in emergency department (ED) practice. The primary outcome was to
compare the proportion of patients successfully removing their own sutures when
provided with suture removal instructions and equipment versus the standard
advice and follow-up care. Secondary outcomes included complication rates,
number of physician visits, and patient comfort level.
Methods: This prospective, controlled, single-blinded,
pseudorandomized trial enrolled consecutive ED patients who met the eligibility
criteria (age above 19 years, simple lacerations, nonabsorbable sutures,
immunocompetent). The study group was provided with wound care instructions, a
suture removal kit, and instructions regarding suture self-removal. The control
group received wound care instructions alone. Outcomes were assessed by
telephone contact at least 14 days after suturing using a standardized questionnaire.
Results: Overall, 183 patients were enrolled (93 in the
intervention group; 90 in the control group). Significantly more patients
performed suture self-removal in the intervention group (91.5%; 95% CI
85.4–97.5) compared to the control group (62.8%; 95% CI 52.1–73.6) (p less than
0.001). Patients visited their physician less often in the intervention group
(9.8%; 95% CI 3.3–16.2) compared to the control group (34.6%; 95% CI
24.1–45.2%) (p less than 0.001). Complication rates were similar in both groups.
Conclusion: Most patients are willing to remove, and capable
of removing, their own sutures. Providing appropriate suture removal
instructions and equipment to patients with simple lacerations in the ED
appears to be both safe and acceptable.
9. Honey Seems to Soothe
Coughs in Toddlers
By Todd Neale, Senior Staff Writer, MedPage Today. August
06, 2012.
Parents of young children who have a cough that keeps them
up at night may want to try giving their little ones honey for some relief, a
randomized trial showed. Compared with placebo, single doses of three different
types of honey resulted in significantly greater gains on a number of
subjective outcomes, including cough frequency, in children with a median age
of 2.4 years, according to Herman Avner Cohen, MD, of Tel Aviv University in
Israel, and colleagues.
There were few adverse events, the researchers reported
online ahead of the September issue of Pediatrics.
"Honey may be a preferable treatment of cough and sleep
difficulties associated with childhood upper respiratory tract
infections," they wrote, noting that honey should not be used in infants
because of the risk of infantile botulism.
Parents have limited options when it comes to treating cough
and cold symptoms, as most over-the-counter medications sold in the U.S. state
that they should not be used in children younger than 4. In Canada, use is
restricted to children 6 and older.
Many home and herbal remedies have been used to treat a
nagging cough, including honey, which the World Health Organization lists as a
potential treatment. However, evidence supporting that use for honey is
limited. Of two studies showing a benefit for honey, one tested only buckwheat
honey and the other was not blinded.
To further explore the issue, Cohen and colleagues conducted
a double-blind, randomized, controlled trial involving 300 children, ages 1 to
5, who had upper respiratory tract infections, a nocturnal cough, and an
illness duration of less than a week. The participants were enrolled from six
general pediatric community clinics. The placebo in the study was a silan date
extract, chosen because its structure, color, and taste are similar to those of
honey. The three types of honey evaluated were eucalyptus, citrus, and
labiatae.
The patients were randomized to receive a single 10-gram
dose of placebo or one of the honey products within 30 minutes of bedtime. Parents
completed a survey the day before the intervention and the day after. It
contained five questions covering the frequency and severity of the child's cough,
how bothered the child was by the cough, and how the cough affected both the
child's and the parents' sleep. Each measure was rated on a seven-point Likert
scale.
Placebo and all three types of honey were associated with
improvements from 1 day to the next, which could be indicative of the natural
course of upper respiratory tract infections. However, the gains were larger in
the honey groups for all of the outcomes.
Cough frequency, for example, improved by 1.77 to 1.95
points in the honey groups compared with 1.00 point in the placebo group
(P less than 0.001). When all of the outcomes were combined together, the improvements
were 9.88 points with eucalyptus honey, 10.10 points for citrus honey, and 9.51
points for labiatae honey. All of those gains were significantly larger than
the 5.82-point improvement with the date extract (P less than 0.001).
Adverse events included stomach ache, nausea, and vomiting.
There were two cases in the citrus honey group and one each in the other two
honey groups and the placebo group.
The researchers noted that it is unclear what characteristic
of honey is responsible for the improvements, adding, however, that honey has
been found to have both antioxidant and antimicrobial properties. It also was
not likely that the date extract worsened cough and cold symptoms because those
patients did show some improvement. In addition, "there is also no reason
to believe silan caused allergic symptoms or bronchospasm because dates are not
a common food allergen in the Israeli population," they said.
Another possible factor to explain at least part of the
effect of honey could involve the central nervous system; there is a close
anatomic relationship between the sensory nerve fibers involved in coughing and
the gustatory nerve fibers involved in tasting sweetness.
"This theory may explain some of the observed effect in
patients treated with silan date extract because this is also a sweet
substance," the authors wrote.
They acknowledged some limitations of their study, including
the use of a single dose of honey, subjective assessments of outcomes, and the
inability to ensure compliance with honey and placebo administration. They also
pointed out that the dropout rate was higher for children receiving citrus and
eucalyptus honey, possibly because both of those substances are more aromatic,
which the children may not have liked.
The study was supported in part by a research grant from the
Israel Ambulatory Pediatric Association, Materna Infant Nutrition Research
Institute, and the Honey Board of Israel. The authors reported no conflicts of
interest.
Cohen H, et al "Effect of honey on nocturnal cough and
sleep quality: A double-blind, randomized, placebo-controlled study"
Pediatr 2012; DOI: 10.1542/peds.2011-3075. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22869830
10. Shocker: Doctors
Work When They're Sick
by Scott Hensley. NPR’s Health Blog. June 19, 2012
How do doctors work around so many ill people without
getting sick? Well, they don't.
Even if they scrub their hands like crazy, which certainly
helps, they succumb to germs every once in a while, just like the rest of us.
And also like lots of the rest of us, they'll go to work sick, a survey of
medical residents finds.
A little more than half of the 150 residents surveyed at an
Illinois medical meeting in 2010 said they'd worked while having flu-like
symptoms in the previous year. And about one-quarter said they'd done so at
least three times.
Why? They were just being responsible. More than half — 56
percent — said they felt a responsibility to take care of their patients. Fifty-seven
percent said they didn't want to make their colleagues cover for them.
The results were published in the latest Archives of
Internal Medicine. In a note about them, Dr. Deborah Grady wrote: "Working
while sick may demonstrate an admirable sense of responsibility to patients and
colleagues, but clinicians also need to worry about the real danger of
infecting vulnerable patients as well as colleagues and staff."
Now, don't you sometimes feel the same way when the cougher
in the next cube won't take a sick day? We did our own survey in 2010 and found
that almost three-quarters of people had gone to work sick in the past year.
The top reason, cited by 25 percent of people, was that they
wouldn't get paid for the absence. That was followed by people saying they
weren't sick enough to stay home and "work ethic" came in third at 19
percent.
Archives’s article (subscription required): http://archinte.jamanetwork.com/article.aspx?articleid=1188034
11. Images in
Clinical Medicine
Unexpected Swallowing of a Knife
Hernia through the Foramen of Winslow
Halitosis and Sensory Loss
Green Teeth in Neonatal Sepsis
Left Upper Quadrant Abdominal Pain
12. Distinguishing
Between Causes of Cardiac Troponin Elevations
The absolute change in troponin levels between presentation
and 1 hour can distinguish between acute myocardial infarction and nonischemic
disease states.
Haaf P et al. Circulation 2012 Jul 3; 126:31-40.
BACKGROUND: We hypothesized that high-sensitivity cardiac
troponin (hs-cTn) and its early change are useful in distinguishing acute
myocardial infarction (AMI) from acute cardiac noncoronary artery disease.
METHODS AND RESULTS: In a prospective, international
multicenter study, hs-cTn was measured with 3 assays (hs-cTnT, Roche
Diagnostics; hs-cTnI, Beckman-Coulter; hs-cTnI Siemens) in a blinded fashion at
presentation and serially thereafter in 887 unselected patients with acute
chest pain. Accuracy of the combination of presentation values with serial
changes was compared against a final diagnosis adjudicated by 2 independent
cardiologists. AMI was the adjudicated final diagnosis in 127 patients (15%);
cardiac noncoronary artery disease, in 124 (14%). Patients with AMI had higher
median presentation values of hs-cTnT (0.113 μg/L [interquartile range,
0.049-0.246 μg/L] versus 0.012 μg/L [interquartile range, 0.006-0.034 μg/L]; P less than 0.001)
and higher absolute changes in hs-cTnT in the first hour (0.019 μg/L
[interquartile range, 0.007-0.067 μg/L] versus 0.001 μg/L [interquartile range,
0-0.003 μg/L]; P less than 0.001) than patients with cardiac noncoronary artery
disease. Similar findings were obtained with the hs-cTnI assays. Adding changes
of hs-cTn in the first hour to its presentation value yielded a diagnostic
accuracy for AMI as quantified by the area under the receiver-operating
characteristics curve of 0.94 for hs-cTnT (0.92 for both hs-cTnI assays).
Algorithms using ST-elevation, presentation values, and changes in hs-cTn in
the first hour accurately separated patients with AMI and those with cardiac
noncoronary artery disease. These findings were confirmed when the final
diagnosis was readjudicated with the use of hs-cTnT values and validated in an
independent validation cohort.
CONCLUSION: The combined use of hs-cTn at presentation and
its early absolute change excellently discriminates between patients with AMI
and those with cardiac noncoronary artery disease.
13. Defining abnormal
ECG in adult ED syncope patients: the Ottawa ECG Criteria
Thiruganasambandamoorthy V, et al. CJEM 2012;14(4):248-258
Background: Previous studies have indicated that the
suboptimal performance of the San Francisco Syncope Rule (SFSR) is likely due
to the misclassification of the “abnormal electrocardiogram (ECG)” variable. We
sought to identify specific emergency department (ED) ECG and cardiac monitor
abnormalities that better predict cardiac outcomes within 30 days in adult ED
syncope patients.
Methods: This health records review included patients 16
years or older with syncope and excluded patients with ongoing altered mental
status, alcohol or illicit drug use, seizure, head injury leading to loss of consciousness,
or severe trauma requiring admission. We collected patient characteristics, 22
ECG variables, cardiac monitoring abnormalities, SFSR “abnormal ECG” criteria,
and outcome (death, myocardial infarction, arrhythmias, or cardiac procedures)
data. Recursive partitioning was used to develop the “Ottawa
Electrocardiographic Criteria.”
Results: Among 505 included patient visits, 27 (5.3%) had
serious cardiac outcomes. We found that patients were at risk for cardiac
outcomes within 30 days if any of the following were present: second-degree
Mobitz type 2 or third-degree atrioventricular (AV) block, bundle branch block
with first-degree AV block, right bundle branch with left anterior or posterior
fascicular block, new ischemic changes, nonsinus rhythm, left axis deviation,
or ED cardiac monitor abnormalities. The sensitivity and specificity of the
Ottawa Electrocardiographic Criteria were 96% (95% CI 80–100) and 76% (95% CI
75–76), respectively.
Conclusion: We successfully identified specific ED ECG and
cardiac monitor abnormalities, which we termed the Ottawa Electrocardiographic
Criteria, that predict serious cardiac outcomes in adult ED syncope patients.
Further studies are required to identify which adult ED syncope patients
require cardiac monitoring in the ED and the optimal duration of monitoring and
to confirm the accuracy of these criteria.
14. (No) Association
Between Evidence-Based Standardized Protocols in EDs with Childhood Asthma
Outcomes: A Canadian Population-Based Study
Li P, et al. Arch Pediatr Adolesc Med. 2012;():1-7.
doi:10.1001/archpediatrics.2012.1195
Objective To
determine whether children treated in emergency departments (EDs) with
evidence-based standardized protocols (EBSPs) containing evidence-based content
and format had lower risk of hospital admission or ED return visit and greater
follow-up than children treated in EDs with no standardized protocols in
Ontario, Canada.
Design Retrospective
population-based cohort study of children with asthma. We used multivariable
logistic regression to estimate risk of outcomes.
Setting All EDs in
Ontario (N = 146) treating childhood asthma from April 2006 to March 2009.
Participants
Thirty-one thousand one hundred thirty-eight children (aged 2 to 17
years) with asthma.
Main Exposure Type of
standardized protocol (EBSPs, other standardized protocols, or none).
Main Outcome Measures
Hospital admission, high-acuity 7-day return visit to the ED, and 7-day
outpatient follow-up visit.
Results The final
cohort made 46 510 ED visits in 146 EDs. From the index ED visit, 4211 (9.1%)
were admitted to the hospital. Of those discharged, 1778 (4.2%) and 7350
(17.4%) had ED return visits and outpatient follow-up visits, respectively. The
EBSPs were not associated with hospitalizations, return visits, or follow-up
(adjusted odds ratio, 1.17 [95% CI, 0.91-1.49]; adjusted odds ratio, 1.10 [95%
CI, 0.86-1.41]; and adjusted odds ratio, 1.08 [95% CI, 0.87-1.35], respectively).
Conclusions The EBSPs
were not associated with improvements in rates of hospital admissions, return
visits to the ED, or follow-up. Our findings suggest the need to address gaps
linking improved processes of asthma care with outcomes.
Full-text (free for now): http://archpedi.jamanetwork.com/article.aspx?articleid=1212372
15. Risk of Falls and
Major Bleeds in Patients on Oral Anticoagulation Therapy: No Connection
Donzé J, et al. Amer J Med 2012;125:773-778.
Background: The risk of falls is the most commonly cited
reason for not providing oral anticoagulation, although the risk of bleeding
associated with falls on oral anticoagulants is still debated. We aimed to evaluate
whether patients on oral anticoagulation with high falls risk have an increased
risk of major bleeding.
Methods: We prospectively studied consecutive adult medical
patients who were discharged on oral anticoagulants. The outcome was the time
to a first major bleed within a 12-month follow-up period adjusted for age,
sex, alcohol abuse, number of drugs, concomitant treatment with antiplatelet
agents, and history of stroke or transient ischemic attack.
Results: Among the 515 enrolled patients, 35 patients had a
first major bleed during follow-up (incidence rate: 7.5 per 100 patient-years).
Overall, 308 patients (59.8%) were at high risk of falls, and these patients
had a nonsignificantly higher crude incidence rate of major bleeding than
patients at low risk of falls (8.0 vs 6.8 per 100 patient-years, P=.64). In
multivariate analysis, a high falls risk was not statistically significantly
associated with the risk of a major bleed (hazard ratio 1.09; 95% confidence
interval, 0.54-2.21). Overall, only 3 major bleeds occurred directly after a
fall (incidence rate: 0.6 per 100 patient-years).
Conclusions: In this prospective cohort, patients on oral
anticoagulants at high risk of falls did not have a significantly increased
risk of major bleeds. These findings suggest that being at risk of falls is not
a valid reason to avoid oral anticoagulants in medical patients.
Full-text (free): http://www.amjmed.com/article/PIIS000293431200352X/fulltext
16. Ultrasound
Guidance Improves Diagnosis of Peritonsillar Abscess
Costantino TG, et al. Randomized Trial Comparing Intraoral
Ultrasound to Landmark-based Needle Aspiration in Patients with Suspected
Peritonsillar Abscess. Acad Emerg Med. 2012 Jun;19(6):626-31.
Objectives: Traditionally, emergency physicians (EPs) have
used anatomic landmark-based needle aspiration to drain peritonsillar abscesses
(PTAs). If this failed, an imaging study and/or consultation with another
service to perform the drainage is obtained. Recently, some EPs have used
ultrasound (US) to guide PTA drainage. This study seeks to determine which
initial approach leads to greater successful drainage. The primary objective of
this study was to compare the diagnostic accuracy of EPs for detecting PTA or
peritonsillar cellulitis (PTC) using either intraoral US or initial needle
aspiration after visual inspection (the landmark technique [LM]). Secondary
objectives included the successful aspiration of purulent material in those
patients with a PTA in each arm, the use of computed tomography (CT) scanning
in each arm, and the otolaryngology (ENT) consultation rate in each arm.
Methods: This was a prospective, randomized, controlled
clinical trial of a convenience sample of adult patients who presented to a
single, large, urban university hospital. Patients were enrolled if they
presented with a constellation of signs and symptoms that were judged to be a
PTA. These patients were randomized to receive intraoral US or to undergo LM
drainage. The US was performed using an 8-5 MHz intracavitary transducer
immediately prior to the procedure. The probe was then withdrawn and the
provider who did the US also performed the needle aspiration. The LM was
performed using visual landmarks in a superior to inferior approach until pus
was obtained or at least two sticks were performed. Anesthesia was
standardized. Patients returned for follow-up in 2 days where a final diagnosis
was rendered.
Results: There were 28 patients enrolled, with 14 in each arm.
US established the correct diagnosis more often than LM [(100%, 95% confidence
interval [CI] = 75% to 100% vs. 64%, 95% CI = 39% to 84%; p = 0.04)]. US also
led to more successful aspiration of purulent material by the EP than LM in patients
with PTA [(100%, 95% CI = 63% to 100% vs. 50%, 95% CI = 24% to 76%; p = 0.04)].
The ENT consult rate was 7% (95% CI = 0%
to 34%) for US versus 50% (95% CI = 27% to 73%) for LM (p = 0.03). The CT usage
rate was 0% for US versus 35% for LM (p = 0.04).
Conclusions: An initial intraoral US performed by EPs can
reliably diagnose PTC and PTA. Additionally, using intraoral US to assist in
the drainage of PTAs with needle aspiration leads to greater success compared
to the traditional method of LM relying on physical exam alone.
17. Validation and
Refinement of a Prediction Rule to Identify Children at Low Risk for Acute
Appendicitis
Kharbanda AB, et al; for the Pediatric Emergency Medicine
Collaborative Research Committee of the American Academy of Pediatrics. Arch
Pediatr Adolesc Med. 2012;166(8):738-744.
Objective To validate
and refine a clinical prediction rule to identify which children with acute
abdominal pain are at low risk for appendicitis (Low-Risk Appendicitis Rule).
Design Prospective,
multicenter, cross-sectional study.
Setting Ten pediatric
emergency departments.
Participants Children
and adolescents aged 3 to 18 years who presented with suspected appendicitis
from March 1, 2009, through April 30, 2010.
Main Outcome Measures
The test performance of the Low-Risk Appendicitis Rule.
Results Among 2625
patients enrolled, 1018 (38.8% [95% CI, 36.9%-40.7%]) had appendicitis.
Validation of the rule resulted in a sensitivity of 95.5% (95% CI, 93.9%-96.7%),
specificity of 36.3% (33.9%-38.9%), and negative predictive value of 92.7%
(90.1%-94.6%). Theoretical application would have identified 573 (24.0%) as
being at low risk, misclassifying 42 patients (4.5% [95% CI, 3.4%-6.1%]) with
appendicitis. We refined the prediction rule, resulting in a model that
identified patients at low risk with (1) an absolute neutrophil count of 6.75 ×
103/μL or less and no maximal tenderness in the right lower quadrant or (2) an
absolute neutrophil count of 6.75 × 103/μL or less with maximal tenderness in
the right lower quadrant but no abdominal pain with walking/jumping or
coughing. This refined rule had a sensitivity of 98.1% (95% CI, 97.0%-98.9%),
specificity of 23.7% (21.7%-25.9%), and negative predictive value of 95.3%
(92.3%-97.0%).
Conclusions We have
validated and refined a simple clinical prediction rule for pediatric
appendicitis. For patients identified as being at low risk, clinicians should
consider alternative strategies, such as observation or ultrasonographic
examination, rather than proceeding to immediate computed tomographic imaging.
18. Bilateral lower
cervical paraspinous bupivacaine injections for all kinds of headache (Larry
Mellick’s work was brought to my attention by EM-RAP)
Treatment of headaches in the ED with lower cervical
intramuscular bupivacaine injections: a 1-year retrospective review of 417
patients.
Mellick LB, et al. Headache. 2006 Oct;46(9):1441-9.
OBJECTIVE: The primary objective of this retrospective chart
review is to describe 1 year's experience of an academic emergency department
(ED) in treating a wide spectrum of headache classifications with intramuscular
injections of 0.5% bupivacaine bilateral to the spinous process of the lower
cervical vertebrae.
BACKGROUND: Headache is a common reason that patients
present to an ED. While there are a number of effective therapeutic
interventions available for the management of headache pain, there clearly
remains a need for other treatment options. The intramuscular injection of 1.5
mL of 0.5% bupivacaine bilateral to the sixth or seventh cervical vertebrae has
been used to treat headache pain in our facility since July 2002. The clinical
setting for the study was an academic ED with an annual volume of over 75,000
patients.
METHODS: We performed a retrospective review of over 2805 ED
patients with the discharge diagnosis of headache and over 771 patients who
were coded as having had an anesthetic injection between June 30, 2003 and July
1, 2004. All adult patients who had undergone paraspinous intramuscular
injection with bupivacaine for the treatment of their headache were gleaned
from these 2 larger databases and were included in this retrospective chart
review. A systematic review of the medical records was accomplished for these
patients.
RESULTS: Lower cervical paraspinous intramuscular injections
with bupivacaine were performed in 417 patients. Complete headache relief
occurred in 271 (65.1%) and partial headache relief in 85 patients (20.4%). No
significant relief was reported in 57 patients (13.7%) and headache worsening
was described in 4 patients (1%). Overall a therapeutic response was reported
in 356 of 417 patients (85.4%). Headache relief was typically rapid with many
patients reporting complete headache relief in 5 to 10 minutes. Associated
signs and symptoms such as nausea, vomiting, photophobia, phonophobia, and
allodynia were also commonly relieved.
CONCLUSION: Our observations suggest that the intramuscular
injection of small amounts of 0.5% bupivacaine bilateral to the sixth or
seventh cervical spinous process appears to be an effective therapeutic
intervention for the treatment of headache pain in the outpatient setting.
Also useful in kids: Mellick LB ,et al. Pediatr Emerg Care.
2010 Mar;26(3):192-6. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20179659
Wanna see how it’s done? Online video demonstrations:
19. Validation of
treatment strategies for enterohaemorrhagic E coli O104:H4 induced haemolytic
uraemic syndrome: case-control study
Menne J, et al. BMJ 2012;345:e4565
Objective To evaluate the effect of different treatment
strategies on enterohaemorrhagic Escherichia coli O104:H4 induced haemolytic
uraemic syndrome.
Design Multicentre retrospective case-control study.
Setting 23 hospitals in northern Germany.
Participants 298 adults with enterohaemorrhagic E coli
induced haemolytic uraemic syndrome.
Main outcome measures Dialysis, seizures, mechanical
ventilation, abdominal surgery owing to perforation of the bowel or bowel
necrosis, and death.
Results 160 of the 298 patients (54%) temporarily required
dialysis, with only three needing treatment long term. 37 patients (12%) had
seizures, 54 (18%) required mechanical ventilation, and 12 (4%) died. No clear
benefit was found from use of plasmapheresis or plasmapheresis with
glucocorticoids. 67 of the patients were treated with eculizumab, a monoclonal
antibody directed against the complement cascade. No short term benefit was
detected that could be attributed to this treatment. 52 patients in one centre
that used a strategy of aggressive treatment with combined antibiotics had
fewer seizures (2% v 15%, P=0.03), fewer deaths (0% v 5%, p=0.029), required no
abdominal surgery, and excreted E coli for a shorter duration.
Conclusions Enterohaemorrhagic E coli induced haemolytic
uraemic syndrome is a severe self limiting acute condition. Our findings
question the benefit of eculizumab and of plasmapheresis with or without
glucocorticoids. Patients with established haemolytic uraemic syndrome seemed
to benefit from antibiotic treatment and this should be investigated in a
controlled trial.
20. Improving Time to
Antibiotics for Pediatric Neutropenic Patients
A multidisciplinary effort decreased mean time to
antibiotics by 50 minutes.
Investigators conducted a multidisciplinary quality
improvement effort to reduce time to antibiotics for pediatric oncology
patients presenting to a pediatric emergency department (ED) with fever
(axillary temperature 38.3°C once or 38.0°C for more than 2 hours in a 24-hour
period) and either neutropenia (absolute neutrophil count 500 cells/mm3) or
possible neutropenia. Target goals were ceftazidime delivery within 60 minutes
for patients with known neutropenia and ceftriaxone within 90 minutes for
patients with possible neutropenia.
The investigators identified areas for improvement and
corresponding action plans. ED nurses and physicians teamed with ED quality
nurse leaders, hospital staff nurses, ED pharmacists, ED administrators,
security directors, oncology clinicians, and hospital quality improvement
experts. Families of children receiving chemotherapy were given bright orange
placards that acted as a visual alert for security personnel and triage staff
to expedite patients into the ED. Additional measures included clinician
reeducation on electronic ordering, pharmacist prioritization of antibiotic
preparation, nurse education on Port-a-Cath® access, real-time clinician
coaching and feedback with monthly progress reports, and monthly root cause
analyses of patients who did not reach target goals.
The study involved 137 children (mean age, 8.9 years) who
presented before implementation and 288 children (mean age, 8.4 years) who
presented after. Mean time to antibiotics decreased from 99 minutes to 49
minutes for patients with neutropenia and from 90 minutes to 81 minutes for
patients with possible neutropenia (60% were ultimately found to be
neutropenic). The proportion of patients meeting the target time increased from
50% to 89%.
Comment: This study clearly demonstrates that a structured
multidisciplinary process improvement initiative can have a significant impact
on emergency department processes and delivery of care.
— Katherine Bakes, MD. Published in Journal Watch Emergency
Medicine August 3, 2012. Citation: Volpe D et al. Improving timeliness of
antibiotic delivery for patients with fever and suspected neutropenia in a
pediatric emergency department. Pediatrics 2012 Jul; 130:e201.
21. Cunningham
Technique for Shoulder Reduction
From EM-RAP TV. This episode Rob Orman reviews the
Cunningham technique for shoulder relocation
Want other cool videos on various EM diagnostic and
management challenges from orthopedic procedures to ECG conundrums? This site’s
for you: http://www.emrap.tv/
22. Why Do We Get
Brain Freeze? Scientists Explain
Medical News Today. 2012
Harvard Medical School scientists who say they have a better
idea of what causes brain freeze, believe that their study could eventually
pave the way to more effective treatments for various types of headaches, such
as migraine-related ones, or pain caused by brain injuries.
Brain freeze, also known as an ice-cream headache, cold-stimulus
headache, or sphenopalatine ganglioneuralgia, is a kind of short-term headache
typically linked to the rapid consumption of ice-cream, ice pops, or very cold
drinks. Brain freeze occurs when something extremely cold touches the
upper-palate (roof of the mouth). It normally happens when the weather is very
hot, and the individual consumes something too fast.
Dr. Jorge Serrador, a cardiovascular electronics researcher,
who presented the team's finding at the Experimental Biology 2012 meeting, San
Diego, explained that until now, scientists have not been able to fully
understand what causes brain freeze.
Dr. Serrador and team recruited 13 healthy adult volunteers.
They were asked to sip ice-cold water through a straw, so that the liquid would
hit their upper palate. Blood flow in their brain was monitored using a
transcranial Doppler test. They found that the sensation of brain freeze
appears to be caused by a dramatic and sudden increase in blood flow through
the brain's anterior cerebral artery. As soon as the artery constricted, the
brain-freeze pain sensation wore off. The scientists were able to trigger the
artery's constriction by giving the volunteers warm water to drink.
Migraine sufferers more susceptible to brain freeze
Dr. Serrador explained that we already know that migraine
sufferers are more likely to suffer brain freeze after drinking or eating very
cold foods/drinks, compared to people who never have migraines. He suggests
that some of what occurs during brain freeze may be similar to what causes
migraines, and possibly other kinds of headaches, including those caused by
traumatic brain injuries.
Serrador and team believe that local changes in brain blood
flow may be causing other types of headaches. If this can be confirmed in
further studies, new medications that prevent or reverse vasodilation (widening
of the blood vessels) may help treat headaches.
Brain freeze can occur if you eat an ice cream too fast.
Vasodilation is probably part of a self-defense mechanism, Dr. Serrador said:
"The brain is one of the relatively important organs in the body, and it
needs to be working all the time. It's fairly sensitive to temperature, so
vasodilation might be moving warm blood inside tissue to make sure the brain
stays warm."
If dilated arteries cause a sudden rush of blood to the
brain, which raises pressure and causes pain, a drug that constricts the blood
vessel should reduce pressure and eliminate the pain. Also, constricting the
blood vessels that supply the brain could help prevent pressure building up
dangerously high.
23. Rudeness on the
Internet
Mean comments arise from a lack of eye contact more than from
anonymity.
By Melinda Wenner Moyer,
Scientific American | August 8, 2012
Read any Web forum, and you'll agree: people are meaner
online than in “real life.” Psychologists have largely blamed this
disinhibition on anonymity and invisibility: when you're online, no one knows
who you are or what you look like. A new study in Computers in Human Behavior,
however, suggests that above and beyond anything else, we're nasty on the
Internet because we don't make eye contact with our compatriots.
Researchers at the University of Haifa in Israel asked 71
pairs of college students who did not know one another to debate an issue over
Instant Messenger and try to come up with an agreeable solution. The pairs,
seated in different rooms, chatted in various conditions: some were asked to
share personal, identifying details; others could see side views of their
partner's body through webcams; and others were asked to maintain near-constant
eye contact with the aid of close-up cameras attached to the top of their computer.
Far more than anonymity or invisibility, whether or not the
subjects had to look into their partner's eyes predicted how mean they were.
When their eyes were hidden, participants were twice as likely to be hostile.
Even if the subjects were both unrecognizable (with only their eyes on screen)
and anonymous, they rarely made threats if they maintained eye contact.
Although no one knows exactly why eye contact is so crucial, lead author and
behavioral scientist Noam Lapidot-Lefler, now at the Max Stern Yezreel Valley
College in Israel, notes that seeing a partner's eyes “helps you understand the
other person's feelings, the signals that the person is trying to send you,”
which fosters empathy and communication.
