From the recent medical literature...
1. The risk for ACS associated with atrial fibrillation among ED patients with chest pain syndromes
Brown AM, et al. Amer J Emerg Med. 2007;25:523-528.
Objective: We sought to determine if atrial fibrillation is associated with an increased risk for an acute coronary syndrome (ACS) among emergency department (ED) patients with chest pain syndromes.
Methods: We performed a retrospective analysis of a prospectively collected database on ED patients with chest pain by selecting patients with atrial fibrillation and frequency-matched control subjects without atrial fibrillation. Measured outcomes were acute myocardial infarction (AMI), ACS, and unstable angina (UA). The relative risks of AMI, ACS, and UA associated with atrial fibrillation were calculated.
Results: One hundred forty patients with atrial fibrillation and 683 matched control subjects were identified. The rates of AMI for the atrial fibrillation and control groups were 11.4% and 10.8%, respectively; those of ACS were 27.9% and 26.7%, respectively; and those of UA were 16.4% and 15.8%, respectively. The relative risks of AMI and ACS did not increase in patients with atrial fibrillation: AMI, 1.05 (95% confidence interval [CI] = 0.63-1.75); ACS, 1.05 (95% CI = 0.78-1.40); and UA, 1.05 (95% CI = 0.6-1.7).
Conclusion: Among patients presenting to the ED with chest pain syndromes, atrial fibrillation is not associated with an increased risk for AMI, ACS, and UA.
2. Hospitalist Model May Reduce Costs Without Adversely Affecting Outcomes
Laurie Barclay, MD. May 25, 2007 (Dallas) — For patients with common inpatient diagnoses, the hospitalist model reduces length of stay and costs without adversely affecting mortality or readmission, according to a presentation by Peter K. Lindenauer, MD, MSc, medical director of clinical and quality informatics at Baystate Health and associate professor of medicine at Tufts University School of Medicine, in Springfield, Massachusetts, at Hospital Medicine 2007, the Society for Hospital Medicine annual meeting.
The hospitalist model, or designating specified physicians as hospitalists available to admit patients, was put forth a decade ago by Robert M. Wachter, MD, now a professor and associate chairman of medicine at the University of California, San Francisco (UCSF). Dr. Wachter was not involved with Dr. Lindenauer’s study, but was asked by Medscape to provide independent comment.
"Since I first described the hospitalist model in a 1996 New England Journal of Medicine article [335(7):514-7], the field has grown from a few hundred physicians to more than 20,000 today," said Dr. Wachter, who is also chief of the medical service at UCSF Medical Center. "This makes it the fastest growing physician specialty in the history of medicine. This remarkable growth has been fueled by studies that have shown that the model markedly improves efficiency without harming (and quite possibly improving) quality and medical education." However, Dr. Wachter noted that previous studies were criticized for being relatively small, mostly involving only a few hospitalists, with short follow-up and limited generalizability.
"The study by Lindenauer and colleagues is by far the largest study to date testing the following critical hypothesis: Do hospitalists improve value or quality/cost when compared with care delivered by nonhospitalist generalists?" Dr. Wachter said. "The strongly positive result is likely to further increase the diffusion of hospitalist programs. Importantly, despite impressive cost and length-of-stay savings, there was no evidence that there was any harm in quality, [with] stable mortality and readmission rates."
Dr. Lindenauer’s group performed a retrospective cohort study of 76,296 patients 18 years and older who were hospitalized at 1 of 45 US hospitals that used an expanded set of physician specialty codes, which included an option to categorize attending physicians as hospitalists.
The investigators reviewed the hospital records of patients discharged between September 1, 2002 and June 30, 2005 who had a primary diagnosis of pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of chronic obstructive pulmonary disease, or acute myocardial infarction, and who were attended by a hospitalist, general internist, or family physician.
A series of multivariable models evaluated the independent effect of physician specialty on length of stay, cost, inpatient mortality, and readmission, after adjustment for patient age, sex, ethnicity, insurance, principal diagnosis, and comorbid conditions; hospital characteristics, including size, teaching status, location, and urban or rural setting; and physician’s annual case volume. Generalized estimating equation models accounted for a clustering of patients with physicians and a clustering of physicians within hospitals, and all models included an interaction term of physician specialty with principal diagnosis.
By specialty, the average number of patients with 1 of the 7 selected diagnoses cared for each year was 20 patients for the 971 family physicians, 30 patients for the 993 general internists, and 75 patients for the 284 hospitalists.
Compared with patients cared for by general internists, those cared for by hospitalists had a shorter length of stay (adjusted difference, -0.6 days; 95% confidence interval [CI], -0.7 to -0.5 days) and lower costs (adjusted difference, -$417; 95% CI, -$704 to -$131). However, inpatient mortality was similar in both groups (odds ratio [OR], 0.95; 95% CI, 0.85 to 1.05), as was 14-day readmission risk (OR, 0.98; 95% CI, 0.91 to 1.05).
Compared with patients cared for by family physicians, those cared for by hospitalists had a shorter length of stay (adjusted difference, -0.4 days; 95% CI, -0.6 to -0.3 days). However, both groups had similar costs (adjusted difference, $8; 95% CI, -$296 to $311), mortality (OR, 0.95; 95% CI, 0.83 to 1.07), and readmissions (OR, 0.95; 95% CI, 0.87 to 1.04).
"For 7 of the most common conditions seen on an inpatient medical service, when compared with care provided by general internists, the hospitalist model was associated with reductions in length of stay (0.6 days) and costs (~$400) without adversely affecting mortality or readmission," Dr. Lindenauer told Medscape. "When compared with care provided by family physicians, the hospitalist model was associated with reductions in length of stay (0.4 days), but similar costs, mortality, and readmission."
"The improved efficiency was observed at both teaching and nonteaching institutions," said Dr. Lindenauer. "These efficiency gains were only partially explained by the higher inpatient volumes of hospitalists compared with the 2 other physician groups. This suggests that the other aspects of the hospitalist model — such as their on-site and often 24-hour presence and the alignment of their incentives with those of the hospital — can result in greater efficiency."
According to Dr. Wachter, the major strengths of this study include size (many times larger than earlier studies), rigorous methodology, and multivariate analysis accounting for all the key variables. Limitations include lack of information concerning the way some physicians came to be coded as hospitalists, and difficulty in determining whether the source of the information was administrative data or clinical chart reviews.
"Overall, though, the methodology seems appropriate and strong, especially since the length-of-stay differences are so robust (approximately half a day) that they are unlikely to be explained by any subtle methodologic flaws," Dr. Wachter said. "Thousands of hospitals have chosen to provide financial support for hospitalists, in part because they believe that there will be a positive return on investment. This study provides the strongest evidence to date that this investment, which is more than $1.5 billion in the United States alone, is a wise one."
Recommendations for future research proposed by Dr. Wachter include determining the impact of hospitalists on process and outcome measures of quality, on patient satisfaction, and on trainee education. Factors making individual hospitalists, or groups of hospitalists, more or less effective in meeting their quality and efficiency goals should also be explored, as should outcomes associated with hospitalist comanagement of surgical patients.
"Based on these results, we believe that hospitalist programs will continue to be attractive to hospitals seeking ways of improving efficiency," Dr. Lindenauer concluded. "While our study provides valuable data on differences in costs and length of stay, future research is required to evaluate the impact of hospitalists on quality of care and patient satisfaction."
Hospital Medicine 2007: Abstract 40. Presented May 23-25, 2007.
Another abstract from the meeting: Medication Discrepancies in Sign-Outs among Hospitalists are Frequent and Potentially Harmful. See http://www.medscape.com/viewarticle/557179
3. The American Academy of Emergency Medicine Adopts an Official Position Statement on ED Boarding
On May 15, 2007, the American Academy of Emergency Medicine (AAEM) board of directors adopted an official position statement on the practice of boarding patients in the ED. In summary, AAEM urges hospitals to seek options other than ED boarding while waiting to admit patients and recommends that regulating agencies issue new rules that forbid the practice of boarding patients in the ED. Below is the position statement in its entirety.
AAEM Position Statement on ED Boarding
The practice of boarding patients in the ED is defined as holding admitted patients in the ED until a staffed, in-patient bed becomes available and this period usually lasts several hours (and sometimes days). Boarding is not in the best interest of the patient being boarded as it compromises their comfort, privacy and medical care. Boarding also delays the care of others, provokes ambulance diversion, and results in some patients leaving the waiting room before being seen by a physician. Boarding creates a significantly more stressful practice environment and contributes to professional dissatisfaction, burnout and high staff turnover. AAEM calls upon hospitals to seek options other than ED boarding to hold admitted patients. AAEM also calls upon regulating agencies to issue rules that forbid boarding.
4. Risk Factors Identified for Poor Short-Term Outcome in Acute Pediatric Asthma
News Author: Laurie Barclay, MD. May 25, 2007 — An observational cohort study of high-risk children with asthma, published in the May issue of the Annals of Allergy, Asthma & Immunology, helps identify more effective risk factors to screen and evaluate interventions at the time of emergency department (ED) treatment.
"Despite good initial treatment response, many children with acute asthma exacerbations have poor short-term outcomes," write Martha (Molly) W. Stevens, MD, MSCE, from the Medical College of Wisconsin, Children's Hospital of Wisconsin and Children's Research Institute, in Milwaukee, and colleagues. "Although many previous studies of pediatric asthma have attempted to find predictors of admission and relapse, none have specifically examined the ability to identify children at risk for these poor functional outcomes at the time of ED treatment for acute asthma. The aim of this study was to find predictors of poor outcome after ED care for acute asthma exacerbation and to develop and validate a model to identify patients at high risk for increased morbidity."
In this prospective cohort study of children treated for acute asthma at 2 pediatric EDs, poor 14-day outcome was defined as any of the following: asthma symptoms still above baseline at 14 days, child missed 5 or more days of school or daycare, caretaker missed 5 or more days of school or work, or unscheduled care or admission after the ED visit for worsening symptoms.
Of 1221 children enrolled, 852 were enrolled at the derivation site and 369 at the validation site. Five variables independently associated with poor outcome by logistic regression were used to create a simple linear score: wheezing 2 or more days before the visit, 3 or more acute outpatient asthma visits in the previous 12 months, home use of albuterol, history of severe persistent asthma, and fever at the ED visit.
Areas under the receiver operating characteristic curve were 0.66 for the derivation sample and 0.67 for the validation samples. Two or more features categorized high risk. For the derivation/validation samples, sensitivity was 0.67/0.62; specificity, 0.61/0.68; likelihood ratio, 1.7/1.9; pretest probability, 33%/47%; and posttest probability, 50%/62%, respectively.
Study limitations include lack of validated instrument to measure functional outcome; lack of data on environmental factors or psychosocial factors; and predominantly poor, minority, urban populations in the northeastern United States seen at pediatric-specific facilities, which may limit generalizability.
"Information available at the ED visit was used to develop a simple risk score that identifies patients at high risk for poor outcome," the authors write. "The score would be useful in evaluating interventions to improve outcomes by allowing interventions to be targeted to a subgroup most likely to benefit."
The Maternal and Child Health Bureau Research Program supported this study.
Ann Allergy Asthma Immunol. 2007;98:432-439.
5. Prolonged QTc Is an Early Sign of Transmural Ischemia
Kenigsberg DK, et al. J Am Coll Cardiol. 2007;49:1299-1305.
Objectives: In order to more clearly understand the electrocardiographic manifestations of early transmural ischemia, we studied electrocardiograms (ECGs) in patients undergoing balloon angioplasty.
Background: Decisions regarding reperfusion strategies in patients with acute myocardial infarction rely largely on the presence of ST-segment elevation (STE) in the ECG, consequently with significant limitations. Studies of the "ischemic cascade" show that ST-segment changes occur well after the onset of wall motion abnormalities.
Methods: We prospectively analyzed ECGs obtained at 20-s intervals in 74 patients undergoing elective balloon angioplasty. The ECGs were analyzed using 3 methodologies. In 74 patients, the ST-segment, the T-wave, and the QT-interval were analyzed using the MUSE (General Electric HC, Menomonee Falls, Wisconsin) automated system (MUSE). Fifty patients were also analyzed using the Interval Editor automated system (IE; General Electric HC). In 20 patients, measurements were made manually.
Results: Transmural ischemia prolonged the QTc interval (using the Bazett’s formula) in 100% of patients. In all 74 patients analyzed with MUSE, QTc interval prolonged from 423 ± 25 ms to 455 ± 34 ms (p less than 0.001). In the 50 patients analyzed with IE, QTc interval prolonged in 50 of 50 (100%) patients (from 424 ± 27 ms to 458 ± 33 ms [p less than 0.001]). Mean time to maximal QTc interval prolongation, changes in T-wave polarity, 1 mm STE, and ST-segment depression (STD) were 22, 24, 29, and 35 s, respectively. Although QTc interval prolonged in 100% of patients, T-wave changes, STE, and STD (1 mm) occurred in 7%, 15%, and 7%, respectively.
Conclusions: The QTc interval prolongs in 100% of patients with early transmural ischemia. When compared with clinically accepted indexes of transmural ischemia (i.e., STD and STE [1 mm]) it is the earliest ECG abnormality.
6. Antibiotic Prescriptions for Viral URIs: We’re Making Progress!
Prescriptions decreased by 20% from 1993 through 2004.
Objectives: To examine antibiotic prescribing trends for U.S. emergency department (ED) visits with upper respiratory tract infections (URIs) between 1993 and 2004.
Methods: Data were compiled from the National Hospital Ambulatory Medical Care Survey (NHAMCS). URI visits were identified by using ICD-9-CM code 465.9, whereas antibiotics were identified using the National Drug Code Directory class Antimicrobials. A multivariate logistic regression model revealed sociodemographic and geographic factors that were independently associated with receipt of an antibiotic prescription for URIs.
Results: There were approximately 23.4 million ED visits diagnosed as URIs between 1993 and 2004. Although the proportion of URI diagnoses remained relatively stable (ptrend = 0.26), a significant decrease in provision of antibiotic prescriptions for URIs occurred during this 12-year period, from a maximum of 55% in 1993, to a minimum of 35% in 2004. Patients who were prescribed antibiotics were more likely to be white than African American and to have been treated in EDs located in the southern United States.
Conclusions: Antibiotic prescribing for URIs continues to decrease, a favorable trend that suggests that national efforts to reduce inappropriate antibiotic usage are having some success. Nevertheless, the frequency of antibiotic treatment for URI in the ED remains high (35%). Future efforts to reduce inappropriate antibiotic prescribing may focus on patients and physicians in southern U.S. EDs. Additional work is needed to address continued evidence of race-related disparities in care.
Vanderweil SG, et al. Acad Emerg Med. 2007;14:366-369.
7. Pediatric Procedural Sedation in Community EDs
Emergency physicians in community hospital settings provide safe and effective pediatric procedural sedation.
Most studies of pediatric procedural sedation have been conducted in university and tertiary-care pediatric settings. Little is known about this practice in community settings, where pediatric patient volume is typically lower. Researchers used data from the Procedural Sedation in the Community Emergency Department (ProSCED) registry, a database of consecutive emergency physician–directed procedural sedation cases, to describe practice patterns and associated outcomes. Fourteen community hospitals prospectively submitted data to the registry from January 2003 to March 2006 on forms required by the Joint Commission on Accreditation of Healthcare Organizations.
Of 1028 sedations, 341 (33%) were performed in patients younger than 21. The volume of pediatric cases varied by site, from 0.3 to 4.2 per month. Most patients (94%) were categorized as ASA class 1. The most common indications for sedation were laceration repair and joint relocation. Ketamine was the preferred medication (41%), followed by midazolam (32%). Medication use varied significantly according to age; for example, 90% of etomidate use and 80% of fentanyl use were in patients older than 8, whereas 80% of ketamine use was in children younger than 8. Two complications (0.6%) were reported, both in adolescents: one case of apnea after etomidate and fentanyl sedation that resolved with administration of naloxone and one case of hypoxia that resolved with supplemental oxygen. Overall, 99% of procedures were successful.
Comment: These results from a community setting add to the literature from pediatric tertiary settings that show that EPs perform pediatric procedural sedation safely. The reliability of the findings is strengthened by the fact that clinicians could not exclude cases from the registry since data were collected as part of a JCAHO-mandated hospital performance improvement program.
— Jill M. Baren, MD, MBE, FACEP, FAAP. Published in Journal Watch Emergency Medicine May 25, 2007. Citation: Sacchetti A et al. Pediatric procedural sedation in the community emergency department: Results from the ProSCED registry. Pediatr Emerg Care 2007 Apr; 23:218-22.
8. ALS May (or May Not) Improve Survival in Respiratory Distress: High cost, small benefit
To determine whether the introduction of advanced life support (ALS) services improves survival in patients with out-of-hospital respiratory distress, researchers conducted a before-and-after controlled study. They enrolled approximately 4000 patients in 15 cities in Ontario during each of two 6-month study periods: In the first period, care was delivered by basic life support crews; in the second period, ALS services were available from "advanced care" paramedics who had 24 weeks of skills training in endotracheal intubation and intravenous administration of medications.
ALS crews responded to 57% of patients in the second period. During this period, 15% of all patients received IV medications, fewer than 3% received bag mask ventilation, and fewer than 2% underwent endotracheal intubation. Administration of medications for symptom relief (most often salbutamol) increased markedly between periods, from 16% to 59%. Mortality before hospital discharge (the primary outcome measure) decreased significantly, from 14.3% to 12.4%, but the absolute difference of 1.9% was less than the 2.0% difference that the investigators had predefined as being clinically important. Mortality in the emergency department did not change, however, and the entire mortality benefit was attributable to a reduction in inhospital death.
Comment: Given the low rate of ALS interventions (administration of medications for symptom relief was not considered an ALS intervention), that they had a significant effect on mortality is unlikely. Although the authors did not calculate cost per life year saved, it is likely to be high, considering the costs of 24 weeks of training and continuous skill maintenance. The finding that only 80 patients were intubated during a 6-month period in 15 cities suggests that intubation skills would be difficult to maintain even with training. This study did not show a clear cause-and-effect relation between the introduction of ALS and reduced mortality, and, therefore, EMS directors and public health officials might have reason to initiate further studies to determine exactly what benefits derive from complex and expensive prehospital ALS systems.
— J. Stephen Bohan, MD, MS, FACP, FACEP. Published in Journal Watch Emergency Medicine May 23, 2007. Citation: Stiell IG et al. Advanced life support for out-of-hospital respiratory distress. N Engl J Med 2007 May 24; 356:2156-64.
9. American Academy of Neurology Issues Lyme Disease Guidelines
The American Academy of Neurology last week published new evidence-based guidelines on the treatment of nervous system Lyme disease and post-Lyme syndrome. The Infectious Diseases Society of America has endorsed these guidelines, which focus on different treatments for different types of neurologic symptoms. Key recommendations include:
--Parenteral ceftriaxone, cefotaxime, or penicillin G are "probably safe and effective" options to treat meningitis or CSF pleocytosis.
--In the absence of severe (brain or spinal cord) involvement, oral doxycycline is "probably safe and effective." When doxycycline is contraindicated, alternatives are amoxicillin and cefuroxime axetil, but data to support these treatments are lacking.
--The highest level of evidence supports a recommendation against prolonged antibiotic courses for post-Lyme syndrome; symptomatic management is recommended instead.
--Two weeks of antibiotic treatment are recommended to eradicate neuroborreliosis.
--The data on the use of corticosteroids in patients with neuroborreliosis are limited and show no clear benefit or harm.
The guidelines also specify recommended doses of each antibiotic for adults and for children.
AAN guidelines published in Neurology (Free PDF): http://www.neurology.org/cgi/rapidpdf/01.wnl.0000265517.66976.28v1.pdf
10. Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care
The U.S. health system is the most expensive in the world, but comparative analyses consistently show the United States underperforms relative to other countries on most dimensions of performance. This report, which includes information from primary care physicians about their medical practices and views of their countries' health systems, confirms the patient survey findings discussed in previous editions of Mirror, Mirror. It also includes information on health care outcomes that were featured in the U.S. health system scorecard issued by the Commonwealth Fund Commission on a High Performance Health System.
Among the six nations studied—Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2006 and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last on dimensions of access, patient safety, efficiency, and equity. The 2007 edition includes data from the six countries and incorporates patients' and physicians' survey results on care experiences and ratings on various dimensions of care.
The most notable way the U.S. differs from other countries is the absence of universal health insurance coverage. Other nations ensure the accessibility of care through universal health insurance systems and through better ties between patients and the physician practices that serve as their long-term "medical home." It is not surprising, therefore, that the U.S. substantially underperforms other countries on measures of access to care and equity in health care between populations with above-average and below average incomes.
With the inclusion of physician survey data in the analysis, it is also apparent that the U.S. is lagging in adoption of information technology and national policies that promote quality improvement. The U.S. can learn from what physicians and patients have to say about practices that can lead to better management of chronic conditions and better coordination of care. Information systems in countries like Germany, New Zealand, and the U.K. enhance the ability of physicians to monitor chronic conditions and medication use.
These countries also routinely employ non-physician clinicians such as nurses to assist with managing patients with chronic diseases.
The area where the U.S. health care system performs best is preventive care, an area that has been monitored closely for over a decade by managed care plans. Nonetheless, the U.S.
scores particularly poorly on its ability to promote healthy lives, and on the provision of care that is safe and coordinated, as well as accessible, efficient, and equitable.
For all countries, responses indicate room for improvement. Yet, the other five countries spend considerably less on health care per person and as a percent of gross domestic product than does the United States. These findings indicate that, from the perspectives of both physicians and patients, the U.S. health care system could do much better in achieving better value for the nation's substantial investment in health.
Full-text: http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678
11. Outlook Poor After Resuscitation of In-Hospital Cardiac Arrest
NEW YORK (Reuters Health) May 31 - Many patients have limited long-term survival after successful resuscitation following in-hospital cardiac arrest. However, those who receive internal cardioverter-defibrillators (ICDs) have a significant advantage, researchers report in the May issue of the American Heart Journal.
"Post-in-hospital cardiac arrest patients who survive to be discharged from the hospital have abysmal subsequent survival," lead investigator Dr. Heather L. Bloom of the Atlanta VA Medical Center, told Reuter Health.
"The clinical implications," she added, "are that we need to be looking beyond survival to discharge as an end point for resuscitation trials, to truly impact survival in this patient population."
Dr. Bloom and colleagues retrospectively studied data on 732 patients her hospital who had in-hospital cardiac arrest between 1995 and2 004.
In total, 49 patients (6%) survived to discharge. The chances of survival were increase in patients using beta-blockers, angiotensin-converting enzyme inhibitors, and antiarrhythmics at the time of arrest. Conversely, older age and comorbidities were associated with reduced survival. The 1-year survival rate after discharge was 68%. At 3 years, this had fallen to 41% overall. However, in the 9 patients with ICDs, the 3-year survival rate was 77%.
"The small subgroup of patients who received ICDs did extremely well post-discharge," Dr. Bloom said. "This suggests that these patients, who have often been felt to be 'too sick' to receive ICDs, may, in fact, benefit quite."
Am J Heart 2007;153:831-836.
12. FAST Trial Shows No Benefit of Factor VII in Treatment of ICH
May 31 2007 (Glasgow) — Despite promising early results suggesting recombinant activated factor VII (rFVIIa, Novo Nordisk, Denmark) may be effective in the treatment of intracerebral hemorrhage (ICH), new research shows the drug, which is currently the only available agent for the treatment of ICH, stops bleeding but does not improve clinical outcomes.
However, even in light of these disappointing phase 3 results, experts say this may not be the end of the road for rFVIIa as a viable treatment for ICH.
Here at the 16th European Stroke Conference, researchers presented the results of the Factor Seven for Acute Hemorrhagic Stroke (FAST) study, which showed a reduction in bleeding but absolutely no difference in the study's primary end point, which was rates of poor outcomes, defined as death or severe disability at 90 days, among patients taking rFVIIa compared with placebo.
In the earlier, phase 2 study, published in 2005 (Mayer SA et al. N Engl J Med. 2005;352:777-785), researchers studied 3 doses (40, 80 and 160 µg/kg) of the drug and found a 50% relative reduction in ICH volume growth compared with placebo.
Shock and Disappointment
Furthermore, they found mortality across all 3 rFVIIa dose groups was 18%, vs 29% in the placebo group, a finding that was statistically significant. In addition to a reduction in mortality, phase 2 study results also showed a dose-related increase in the proportion of patients who survived with no disability at 90 days. "Even though the study was not powered to detect clinical end points, these results were statistically significant and led us, with great enthusiasm, to proceed with [phase 3 of] the FAST trial," said principal investigator Stephan Mayer, MD, from Columbia University, in New York.
However, the investigators' enthusiasm was soon quashed when FAST's phase 3 results came to light. "Initially, we were shocked and disappointed. We couldn't understand how the hemostatic effect that we observed in the first trial remained but the clinical effect completely disappeared," Dr. Mayer told Medscape.
The randomized, placebo-controlled, multicenter, multinational trial compared 20 µg/kg or 80 µg/kg of rFVIIa with placebo in 821 patients with ICH at 180 sites. Patients were eligible for the study if they were 18 years or older and diagnosed within 3 hours of symptom onset by CT scan. Patients were randomized to 1 of 3 study groups. Treatment was then administered within 1 hour of baseline scan. The trial's main outcome was the proportion of patients who died or had severe disability graded as 5 or 6 on the modified Rankin Scale (mRS) at 90 days.
Best Hope
However, he added, the investigators still have not defined an optimal responder group to serve as a cohort for future research. In addition, he said, the pharmaceutical company that manufacturers rFVIIa and has sponsored both trials is suspending further ICH research until further notice.
Nevertheless, Dr. Mayer said, the scientific community is "firmly in favor" of proceeding with further research into rFVIIa and ICH. "It is still our best hope of coming up with something that will help at least some of these patients, where mortality runs between 30% and 40%."
Bo Norrving, MD, PhD, from Lund University Hospital, in Sweden, agreed and said it is "highly plausible" that patient selection will be important in influencing outcomes of rFVIIa in ICH. "This is a very important question to explore. We definitely need better treatment in the acute phase of intracerebral hemorrhage, and if we can better target the patient population factor VII may offer that potential," he told Medscape.
Dr. Norrving pointed out that a much higher proportion of ICH patients come to the hospital much more rapidly than their counterparts with ischemic stroke. "If we have something effective to offer them at a very early stage, we have the opportunity to dramatically improve outcomes," he said.
16th European Stroke Conference: Large Clinical Trials 1/Abstract 1. May 29 – June 1, 2007.
13. Accelerated Diagnostic Protocol Effective for Transient Ischemic Attack
By Will Boggs, MD. NEW YORK (Reuters Health) May 30 - An emergency department (ED) accelerated diagnostic protocol for transient ischemic attack (TIA) is more efficient and less costly than traditional inpatient admission, according to a report in the May 8th Annals of Emergency Medicine.
"If a hospital is willing to commit resources to this accelerated approach, then it can be a win-win for everybody," Dr. Michael A. Ross from William Beaumont Hospital, Royal Oak, Michigan told Reuters Health. "Patients are diagnosed sooner, overcrowded hospitals keep inpatient beds open, and doctors are less likely to miss serious disease since the work up is more easily completed."
Dr. Ross and associates investigated whether treatment of TIA patients using an accelerated diagnostic protocol in the ED was associated with a decrease in the index visit length of stay and with comparable clinical outcomes relative to traditional inpatient care.
The initial ED evaluation included a history and physical, an ECG, cardiac monitoring, a panel of lab tests, and a head CT. Patients also underwent carotid Doppler imaging, 2-dimensional echocardiography, serial nursing "neurochecks," and a neurology consultation.
Most patients (85%) randomized to the accelerated diagnostic protocol were discharged from the ED, the authors report, and the median length of stay was significantly shorter for the accelerated diagnostic protocol patients (25.6 hours) than for patients admitted to hospital (61.2 hours).
Accelerated diagnostic protocol admissions were for clinical events, not for carotid stenosis, major arrhythmia, or echocardiographic findings, the results indicate. The median length of stay for these patients was 100.5 hours.
Median total direct costs for the index visit were significantly lower for the accelerated diagnostic protocol patients ($864) than for the inpatient group ($1528), the researchers note, as were the median 90-day total direct costs ($890 versus $1547, respectively). The median 90-day cost of admitted accelerated diagnostic protocol patients was $2737.
There were no deaths or adverse events during the study period attributable to the use of the accelerated diagnostic protocol, the report indicates.
"This study suggests that shorter periods of observation, coupled with appropriate patient selection and active testing, may be adequate to identify TIA patients who develop early adverse neurologic outcomes," the authors write. "TIA patients need follow-up with their primary care physician or neurologist," Dr. Ross said. "This is part of the TIA protocol. These patients are at increased risk of stroke and major cardiac events in the near future. Their risk profile must be actively managed as outpatients."
Ann Emerg Med 2007.
14. AHA Announces Mission: Lifeline, a New Initiative to Improve Systems of Care for STEMI Patients
from Heartwire — a professional news service of WebMD. May 31, 2007 (Dallas, TX) – The American Heart Association (AHA) today announced the launch of a community-based initiative aimed at activating the critical chain of events necessary for opening blocked arteries [1]. The new plan, known as Mission: Lifeline, is aimed at providing better diagnosis and appropriate transport and ensuring proper care of patients with ST-segment elevation MI (STEMI).
Announcing the initiative, Dr Alice Jacobs (Boston University School of Medicine, Boston, MA), who led the work group addressing the issue of STEMI systems of care this past year, told the media that Mission: Lifeline is grounded in the stark reality of the current treatment--thrombolytic therapy or PCI--of these patients.
"Despite the proven benefits of quickly restoring blood flow to the heart muscle during a heart attack with either therapy, 30% of STEMI patients do not receive the treatment available," said Jacobs. "In addition, approximately 20% of patients are not candidates for the clot-lysing therapy, most often due to a bleeding risk. Of these patients, 70% do not receive angioplasty, even though it is the only way to open the artery. We know that among patients who receive either therapy in the United States, less than half are treated within the recommended time frames after arriving at the hospital."
The new initiative is based on the findings of experts and stakeholders who convened last year to develop a plan for improving care for STEMI, and these findings and recommendations appear online today in Circulation.
All the stakeholders are involved
Speaking during a briefing for the media, Jacobs pointed out that primary PCI, when performed in STEMI patients in a timely manner by healthcare providers at experienced medical centers, is superior to thrombolytic therapy in reducing death and complications following MI, even when patients need to be transferred to hospitals equipped to perform PCI. Clot-busting therapy, however, is the mainstay of treatment because it is more widely available, she said. These realities, said Jacobs, fueled the work of individuals and organizations that have come together to launch the Mission: Lifeline initiative.
In March 2007, the AHA brought together patients, doctors, nurses, hospitals, emergency medical service (EMS) personnel, payers, and policy makers to review the current system of care for STEMI patients, to develop an ideal implementation system, and to identify gaps and barriers between the current and ideal system.
"For patients with STEMI, saving time saves lives," said Jacobs. "Getting STEMI patients the timely care they need involves a series of events that must flow seamlessly to be most effective."
The process, explained Jacobs, begins with educating patients to signs and symptoms of an MI, which are subtler than the public realizes, and the importance of activating EMS by calling 911 for hospital transport. More than half of STEMI patients drive themselves to the hospital or are driven by family and friends, a mistake that often results in delays in diagnosis and treatment that trained EMS personnel could provide. In addition, improving EMS diagnosis of STEMI before hospital arrival is critical to acquire, interpret, and transmit information from the 12-lead ECG. The catheterization lab could then be activated by EMS personnel from the field or by emergency physicians at the hospital who receive the ECG, said Jacobs.
For patients arriving at non-PCI hospitals, they would remain on the stretcher with EMS personnel in attendance until a decision is made about transferring them to a PCI-capable hospital. For STEMI patients who drive themselves to a non-PCI hospital, transfer to a PCI-capable hospital should take the same urgency as a 911 call, said Jacobs.
Other steps include working with payers and policy makers to ensure systems are in place for proper reimbursement and accountability protocols. A STEMI Center Certification Program with criteria for STEMI referral and receiving hospitals is also in the works. Existing regional STEMI systems of care have been implemented in Minnesota, North Carolina, and Boston, and these have served as models for Mission: Lifeline. California, Texas, and Florida are also participating in pilot programs.
Dr Tim Henry (Minneapolis Heart Institute Foundation, MN), who also spoke during the media briefing, provided information on the STEMI system of care experience in Minnesota, the largest reported experiences designed to integrate the care at non-PCI hospitals (STEMI referral) with a regional PCI-capable hospital (STEMI-receiving). A key component of their program is that emergency room physicians, or EMS personnel in some situations, can activate the system with a phone call. Using a standardized protocol, the median door-to-balloon times from the community STEMI-referral hospitals to balloon inflation in the STEMI-receiving hospital were 96 minutes in areas 60 miles from the referring hospital and 118 minutes from centers as far as 210 miles away. "If done in standardized manner, patients can be transferred and treated in a timely manner," said Henry.
The full cost of implementing the STEMI system of care, said Jacobs, has not been assessed. The writing group noted that the system is implemented and funded at the community level, although the AHA will work with various agencies to provide expertise and to support training. The continued operation of referring hospitals, they added, is critical, and the AHA hopes Mission: Lifeline can foster a system where both the referring and receiving STEMI hospitals remain viable.
Jacobs AK, et al. Development of systems of care for ST-elevation myocardial infarction patients. Circulation 2007; OI:10.1161/CIRCULATIONAHA.107.184043. Available (full-text free) at: http://circ.ahajournals.org
15. Aggressive Care Might Delay Recovery From Whiplash
News Author: Laurie Barclay, MD. May 29, 2007 — Increased intensity of care by a general practitioner or chiropractor is associated with slower recovery for patients with soft tissue injuries such as whiplash, according to the results of a study published in the May 25 Early View issue and June print issue of Arthritis & Rheumatism.
"Although there are few effective treatments for whiplash, a growing body of evidence suggests that the delivery of intensive health care shortly after the injury may lead to iatrogenic disability," write Pierre Côté, DC, PhD, from the University of Toronto and the Toronto Western Research Institute and Rehabilitations Solutions in Ontario, Canada, and colleagues. "The objective of our analysis was to test whether the association between early patterns of care and time to recovery reported by Côté et al in a cohort of patients compensated under no-fault insurance is reproducible in an independent cohort of patients with whiplash compensated under tort insurance."
The study cohort consisted of 1693 adults in Saskatchewan who sustained whiplash injuries between July 1, 1994, and December 31, 1994. The investigators studied 8 initial patterns of care that integrated type of provider (general practitioners, chiropractors, and specialists) and number of visits (low vs high utilization), using Cox models to estimate the association between patterns of care and time to recovery while controlling for injury severity and other confounders.
Even after controlling for important prognostic factors, patients in the low-utilization general practitioner group and those in the general medical group had the fastest recovery. Compared with the low-utilization general practitioner group, the high-utilization chiropractic group had a 1-year rate of recovery that was 25% slower (adjusted hazard rate ratio [HRR], 0.75; 95% confidence interval [CI], 0.54 - 1.04), the low-utilization general practitioner plus chiropractic group had a rate that was 26% slower (HRR, 0.74; 95% CI, 0.60 - 0.93), and the high-utilization general practitioner plus chiropractic combined group had a rate that was 36% slower (HRR, 0.64; 95% CI, 0.50 - 0.83).
"The observation that intensive health care utilization early after a whiplash injury is associated with slower recovery was reproduced in an independent cohort of patients," the authors write. "The results add to the body of evidence suggesting that early aggressive treatment of whiplash injuries does not promote faster recovery. In particular, the combination of chiropractic and general practitioner care significantly reduces the rate of recovery."
Study limitations include possible residual confounding by indication.
"Our research complements the findings of randomized clinical trials suggesting that early minimal care that promotes activation improves prognosis," the authors conclude. "Future research should include the design of pragmatic randomized trials to test the effectiveness of various patterns of care in the community. These trials are essential to understand the influence of health care provision in preventing or facilitating disability."
Arthritis Rheum. 2007;57:861-868.
16. Unnecessary, Inappropriate ER Visits Hard to Determine
Source: AMA Member Communications
In a news analysis, the UPI (5/19, Pierce) reported that although "health-care reformers say the U.S. can save a lot of money by reducing unnecessary emergency-room visits," two studies presented at the Society for Academic Emergency Medicine Annual Meeting "found that it is difficult to define what an 'unnecessary' or 'avoidable' ER visit is, and reducing those visits may not actually save a lot of money."
In the first study, researchers "examined Oregon emergency-room data before and after significant cuts in 2003 to the state's Medicaid program." While they found "a significant increase in emergency-room visits from uninsured patients, they were unable to easily divide them into categories of non-emergency, emergency, emergencies that could have been avoided with timely primary care and emergencies that could be treated if timely primary care were available." Another study "suggests there is little money to be saved from cracking down on unnecessary emergency-room visits. During the same time period in Oregon, only 6.8 percent of Medicaid dollars were spent on emergency care, and four out of five beneficiaries never went to the emergency room at all." Eileen Moore, director of the Health Rights Project at the Georgetown University School of Medicine, told the UPI, that the "causes of patients seeking primary care in emergency departments may also range beyond simple lack of affordability. Transportation, safety concerns and work schedules also play a role -- even for patients that are insured."
Cyrus Shahpar & Brian Potts, Managing Editors, CAL/AAEM News Service.
The CAL/AAEM Archives are available at: http://maillists.uci.edu/mailman/public/calaaem/
17. Recommendations Issued for Acute Pancreatitis
News Author: Laurie Barclay, MD. June 4, 2007 — A review in the May 15 issue of American Family Physician highlights the best practices for diagnosing and treating acute pancreatitis, defined as a reversible inflammatory process of the pancreas.
Full-text (free): http://www.aafp.org/afp/20070515/1513.html
18. Glucagon for the Relief of Esophageal Food Impaction: Does it really work?
Al-Haddad M, et al. Dig Dis Sci. 2006;51:1930-3.
We sought to evaluate our experience with glucagon used in the emergency department setting to relieve esophageal food impaction (EFI). We reviewed the records of patients with food impaction who received glucagon between January 1998 and May 2003 and recorded patient demographics, medical history, symptoms following glucagon administration, and endoscopic findings. There were 92 episodes of food impaction in 85 patients.
Thirty-three percent of the episodes resulted in resolution of symptoms following a dose of glucagon. Sixty-seven percent had symptoms of food impaction after glucagon and underwent upper endoscopy in the emergency room. Only previous solid food dysphagia was positively associated with response to glucagon. Patients who received glucagon plus a benzodiazepine were more likely to have resolution of the EFI. In our experience, glucagon appears to relieve food impaction in one third of patients treated. This result is comparable to previously published data examining glucagon and placebo. The lack of advantage over placebo questions the practice of glucagon administration for EFI.
19. Sodium Thiosulfate or Hydroxocobalamin for the Empiric Treatment of Cyanide Poisoning?
Hall AH, et al. Ann Emerg Med. 2007;49:806-813.
Cyanide poisoning must be seriously considered in victims of smoke inhalation from enclosed space fires; it is also a credible terrorism threat agent. The treatment of cyanide poisoning is empiric because laboratory confirmation can take hours or days. Empiric treatment requires a safe and effective antidote that can be rapidly administered by either out-of-hospital or emergency department personnel. Among several cyanide antidotes available, sodium thiosulfate and hydroxocobalamin have been proposed for use in these circumstances. The evidence available to assess either sodium thiosulfate or hydroxocobalamin is incomplete.
According to recent safety and efficacy studies in animals and human safety and uncontrolled efficacy studies, hydroxocobalamin seems to be an appropriate antidote for empiric treatment of smoke inhalation and other suspected cyanide poisoning victims in the out-of-hospital setting. Sodium thiosulfate can also be administered in the out-of-hospital setting. The efficacy of sodium thiosulfate is based on individual case studies, and there are contradictory conclusions about efficacy in animal models. The onset of antidotal action of sodium thiosulfate may be too slow for it to be the only cyanide antidote for emergency use. Hydroxocobalamin is being developed for potential introduction in the United States and may represent a new option for emergency personnel in cases of suspected or confirmed cyanide poisoning in the out-of-hospital setting.
Full-text pdf (free as of June 5): http://download.journals.elsevierhealth.com/pdfs/journals/0196-0644/PIIS0196064406022761.pdf
20. Boxed Warning Issued for MRI Contrast Agents
The FDA is mandating boxed warnings on gadolinium-based MRI contrast agents.
The agency says that patients with severe renal insufficiency who are exposed to the agents are at risk for developing nephrogenic systemic fibrosis, a life-threatening disease that can cause thickening and hardening of the skin, connective tissues, and other organs. Also at risk are patients with chronic liver disease, or with just-transplanted livers, who have any level of renal insufficiency. Several cases of gadolinium-associated fibrosis were reported in February in MMWR.
The FDA advises that physicians should check their patients' renal status before exposure to gadolinium-based agents.
FDA announcement (Free): http://www.fda.gov/bbs/topics/NEWS/2007/NEW01638.html
21. Prevention of awakening signs after rapid-sequence intubation: a randomized study
Morgan Jaffrelot M, et al. Amer J Emerg Med; 2007;25:529-534.
Background: This study aimed to establish the incidence of signs of inadequate sedation after rapid-sequence intubation (RSI) and to determine whether a supplementary bolus of induction agent decreases these signs.
Methods: A randomized, double-blind trial design was used. Patients were randomly assigned to 1 of 2 treatments: RSI plus etomidate bolus followed by continuous sedative infusion (ETO group) or RSI plus placebo followed by continuous sedative infusion (placebo group). The primary outcome measure was a composite sedation score measured 6 minutes after induction. The components of the score were the Ramsay sedation score, the presence of cough or pulling at endotracheal (ET) tube, jaw relaxation, motor activity, and eye opening. The total score (0-10) was the sum of the 5 components.
Results: There were 21 patients in the ETO group and 20 patients in the placebo group. The percentage of patients presenting with at least 1 sign of awareness was 43% in the ETO group and 65% in the placebo group (P = .16) 6 minutes after induction. The sedation score was significantly higher at 6 minutes in the placebo group compared with the ETO group (2.4 ± 2.9 vs 0.9 ± 1.4; P less than .05). The use of additional sedative drugs during the observation period was 43% (9/21) in the ETO group compared with 55% (11/20) in the placebo group (P = .44).
Conclusions: This study demonstrated that some patients have signs of inadequate sedation after RSI. These signs may be partially prevented by a supplementary dose of an induction agent but other supplementary sedation seems necessary.
Thursday, June 07, 2007
Thursday, May 24, 2007
Lit Bits: May 24, 2007
From the recent medical literature...
1. PCI Hospitals Associated with Survival Benefit After Myocardial Infarction
Myocardial infarction patients first admitted to hospitals that perform PCI have better survival than those who go to non-PCI hospitals, according to a French study in the Archives of Internal Medicine.
The prospective observational study compared the outcomes of about 1200 patients admitted to PCI hospitals and about 700 admitted to non-PCI hospitals during 1 month in 2000. Patients admitted to PCI hospitals had lower in-hospital mortality (7% vs. 12%) and 1-year mortality (13% vs. 20%).
Patients admitted to PCI hospitals were more likely to receive primary PCI (36% vs. 1%) or PCI within 48 hours (54% vs. 6%). They were also more likely to receive evidence-based acute and discharge medicines.
"Most of the survival benefit of admission to a PCI hospital was explained by the use of PCI and evidence-based discharge medications," the authors write.
Archives of Internal Medicine article (Free abstract; full text requires subscription): http://archinte.ama-assn.org/cgi/content/abstract/167/9/913
2. Odansetron Versus Metoclopramide for Nausea and Vomiting in the ED
Haensel C, et al. Acad Emerg Med. 2007;14, Supplement 1: S16-17 (full manuscript not yet published).
Objectives: Nausea and vomiting is a common ED complaint. Most of the literature involves post-operative and oncology patients. The objective is to compare the efficacy of usual (4 mg) and low (2 mg) dose ondansetron and 10 mg metoclopramide in relief of nausea and vomiting in ED patients.
Methods: This is a prospective, randomized, double-blind study of adult ED patients with nausea and at least 1 episode of vomiting within 12 hours of presentation. A validated 100 mm visual analog nausea scale (VAS) was used prior to medication and 30 minutes post-treatment. Patients also rated their nausea post-treatment on a subjective scale. All patients received at least 500 cc of saline IV. Endpoints were complete relief of nausea, significant reduction of initial VAS, subjective change in nausea, and adverse events. Analysis by ANOVA and Kruskal-Wallis.
Results: A total of 132 patients were enrolled over a 12 month period in 2005-2006. Initial VAS scores were similar with a mean of 66.4 mm. All 3 groups had a significant and similar reduction in VAS with a mean final VAS score of 33.6 mm, p less than 0.0001. There was no difference between the groups. A total of 55.3% obtained at least 50% relief and 18.2% obtained complete relief, with no difference between groups. More nausea was experienced by 7.6% in the post-treatment odansetron groups and none in the metoclopramide group. None of the patients had an adverse reaction, 95% CI = 0.0 to 2.2%.
Conclusions: Low and usual dose odansetron and metoclopramide are efficacious in ED patients with nausea and vomiting. No adverse events occurred with either drug. Significant cost savings with similar efficacy would occur by using low-dose odansetron or metoclopramide.
3. Expanding the use of topical anesthesia in wound management
Abstract
Topical anesthesia eliminates the need for injection of anesthetic. Most studies on the use of topical anesthesia were done on children, using 3 active ingredients (lidocaine, epinephrine, tetracaine, or tetracaine, adrenaline, cocaine) for relatively small wounds of the face and scalp.
Objectives
To demonstrate that topical anesthesia is effective and safe in adults of all ages and for larger wounds, using a preparation with 2 active ingredients, topical lidocaine and epinephrine (TLE).
Methods
One hundred patients were enrolled in a randomized controlled trial, with 50 in each group. The study group received TLE using a unique method of “sequential layered application.” The control group received 2% lidocaine infiltration anesthesia. Patients rated the pain from the application of anesthesia and from suturing, using a 0 to 10 visual analog pain scale. Follow-up interviews were conducted to assess for complications and to rate patients' wound repair experience.
Results
Patients in the study group reported significantly less pain from TLE application, with 66% reporting no pain vs 0% reporting no pain from the infiltration in the control group (P less than .001). There was no difference in pain during wound repair between the 2 groups (P = .59). On follow-up, 95% of patients contacted in the TLE group rated their experience in regard to pain as “excellent,” compared to 5% of patients in the control group (P less than .001).
Conclusion
Topical lidocaine and epinephrine “sequential layered application” is an effective, safe, and less painful method of anesthesia for a wide variety of lacerations. Patients recall their experience with this technique very favorably.
Gaufberg SV, et al. Amer J Emerg Med 2007;25: 379-384.
4. Review Finds Lower Dose Best for Prophylactic Aspirin
Aspirin doses should not exceed 75 to 81 mg/day when the drug is used to prevent cardiovascular disease, a JAMA systematic review finds.
The authors sought the balance point between aspirin's cardioprotective effects and the known complications of the drug, which they say is taken preventively by over one-third of U.S. adults. Their literature review leads them to conclude that, although multiple studies confirm the increasing incidence of adverse effects with increasing dosage, "no such dose relationship has been identified for efficacy."
"Currently, the clinical data are most supportive of a 75- or 81-mg daily dose," they write.
JAMA article (Free abstract; full text requires subscription): http://jama.ama-assn.org/cgi/content/abstract/297/18/2018
5. The Ottawa Aggressive Protocol for ED Management of Acute A Fib
Stiell IC, et al. Acad Emerg Med. 2007;14, Supplement 1: S9 (full manuscript not yet published)
Objectives: There is no consensus as to the optimal emergency department (ED) management of acute atrial fibrillation (AAF) or atrial flutter (AAFL). Our objective was to examine the efficacy and safety of the Ottawa Aggressive Protocol to convert and discharge ED patients with AAF/AAFL.
Methods: This 5-year cohort study included consecutive visits to a university hospital ED for adults presenting with acute-onset AAF/AAFL and who were managed with the Ottawa Aggressive Protocol. Patients were identified from the National Ambulatory Care Reporting System (NACRS) database. The Aggressive Protocol was overseen by the attending emergency physicians and included: (1) IV procainamide as infusion of 1 gram over 1 hour; (2) electrical cardioversion if necessary, by ED staff; (3) discharge from the ED with outpatient cardiology follow-up. Outcomes included conversion, adverse events, and relapse. The authors conducted descriptive data analyses with 95% CIs.
Results: Characteristics of the 660 eligible patient visits were mean age 64.5 years, mean heart rate 113.4, and mean duration symptoms 8.9 hours, AAF 95.2%, AAFL 4.9%. Overall, 96.8% of patients were discharged home from the ED and 90.3% were discharged in normal sinus rhythm. The respective discharge rates were 97.0% and 93.5% for those in AAF and 93.8% and 87.5% for those in AAFL. All patients received procainamide with a conversion rate of 58.3% (AAF 59.9%, AAFL 28.1%). Electrical cardioversion was attempted in 36.8% of visits with a success rate of 91.7% (AAF 91.0%, AAFL 100%). Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3%, AAF relapse within 7 days 8.6%, Torsades de Pointes 0%, cerebrovascular accident 0%, mortality 0%.
Conclusions: This is the largest reported study of AAF/AAFL in the ED and demonstrates that the Ottawa Aggressive Protocol is extremely effective for the rapid cardioversion and discharge of patients by ED physicians. This protocol is safe and could lead to a significant decrease in hospital admissions.
6. COX-2 Inhibitor plus PPI Reduces Bleeding in High-Risk Patients
Adding a proton-pump inhibitor to celecoxib treatment in patients at very high risk for ulcer bleeds greatly reduces the incidence of bleeding, according to a Lancet report.
Some 270 patients taking nonselective NSAIDS for arthritis and presenting with upper-GI bleeding underwent randomization — after their ulcers had healed — to treatment with either celecoxib (200 mg twice daily) plus esomeprazole (20 mg twice daily), or celecoxib alone, for a year. The 13-month incidence of recurrent ulcer bleeding was 0% in the combination-therapy group and 8.9% in the controls.
Commentators write that "the finding provides clear guidance for those individuals at greatest gastrointestinal risk who require an NSAID." They add that the new gastrointestinal data should not be interpreted "without careful consideration of competing risks from the cardiovascular perspective."
Lancet article (Free abstract with one-time registration; full text requires subscription): http://www.thelancet.com/journals/lancet/article/PIIS0140673607607491/abstract
7. Study Links TV Viewing with Learning Difficulties in Adolescence
Adolescents who watch a lot of television may be at increased risk for attention and learning problems and failure to go beyond high school, a study finds.
The prospective study, published in the Archives of Pediatrics & Adolescent Medicine, used a community-based sample of some 700 mothers and their children. The offspring were interviewed at mean ages of 14, 16, and 22. After controlling for family characteristics and earlier cognitive difficulties, researchers found that frequent TV viewing at age 14 was associated with indicators of subsequent attention and learning difficulties and academic failure. Youngsters who watched 3 or more hours a day were twice as likely to fail to get postsecondary education as those who watched less than an hour.
The authors said healthcare professionals should encourage youths to spend less than 3 hours a day watching TV. The American Academy of Pediatrics recommends no more than 1 to 2 hours a day of television.
AAP's "Children, Adolescents, and Television" --http://pediatrics.aappublications.org/cgi/content/full/107/2/423?ijkey=e9cf76013f70e23304b814bc410af3b2e0efea2c
8. Stroke Among Patients With Dizziness, Vertigo, and Imbalance in the ED: A Population-Based Study
Kerber KA, et al. Stroke 2006;37:2484–7
As part of the Brain Attack Surveillance in Corpus Christi (BASIC) project, this study sought to determine the percentage of stroke patients who presented to the Emergency Department (ED) with the complaints of dizziness, vertigo, or imbalance. This large population-based study examined all patients over the age of 44 years who presented to the ED or were directly admitted to the hospital between January 2000 and June 2003 with the previously mentioned isolated dizziness symptoms (DS) in Nueces County, Texas. The association of age, sex, race/ethnicity, and isolated dizziness symptoms with stroke or transient ischemic attack (TIA) was then determined using multivariable logistic regression.
A total of 1666 patients were included in the study, with 3.2% (53 of 1666) ultimately diagnosed with stroke/TIA. Of those diagnosed, 23 presented with dizziness as the chief complaint, 18 with vertigo, 11 with imbalance, and 1 with more than one of the above symptoms. Isolated DS without additional neurological findings was a strong negative predictor of stroke/TIA (odds ratio [OR] 0.05; 95% confidence interval [CI] 0.02–0.11), whereas male sex was associated with an increased association with stroke/TIA (OR 2.5; 95% CI 1.4–4.4). Patients diagnosed with stroke/TIA were also found to be significantly older (69.3 ± 11.7 vs. 65.3 ± 12.9, p = 0.02). No significant difference in race/ethnicity was found between the stroke and non-stroke groups.
When compared to dizziness, patients with imbalance were found to have an increased risk of stroke/TIA (OR 3.7; 95% CI 1.3–10.7), whereas no increased risk was found between those with vertigo versus dizziness (OR 0.9; 95% CI 0.4–2.0). The authors acknowledge several limitations to this study, including lack of evaluation of the majority of study patients in the ED by a neurologist, lack of magnetic resonance imaging on most study patients leading to possible undiagnosed strokes, and lack of comparison of symptom onset, duration, aggravating/alleviating factors, headache, and auditory symptoms between groups.
The authors conclude that dizziness and vertigo are not associated with stroke/TIA, whereas patients who present with imbalance, those with additional neurologic findings, male gender, and older age are at the highest risk for possible stroke/TIA.
9. A risk score to predict silent AMI in patients with CAD under aspirin therapy presenting with UGI hemorrhage
Background
Silent myocardial ischemia (SMI) is a relatively common complication in patients with coronary artery disease (CAD) under aspirin therapy presenting with upper gastrointestinal hemorrhage (UGIH).
Aim
This study was conducted to develop and prospectively validate a risk prediction score to identify SMI in patients undergoing aspirin therapy for CAD presenting with UGIH in the emergency department (ED).
Methods
This was a 2-phase noninterventional study. In the derivation phase, adults with CAD under aspirin therapy (100 mg once daily) presenting to the ED with UGIH were retrospectively recruited. By multiple logistic regression analysis, we derived a risk score from 224 patients that predicts the patients' risk of SMI. In the validation phase, we prospectively validated this score using receiver operating characteristic curves with data from 110 patients. We also developed a fast-track screening procedure from this score.
Results
There were 56 patients (25.0%) and 29 patients (26.4%) with SMI in the derivation and validation sets, respectively. Independent multivariate predictors of SMI were age of older than 75 years, severity of CAD, systolic blood pressure of less than 110 mm Hg, diastolic blood pressure of less than 85 mm Hg, hematocrit of less than 30%, and blood urea nitrogen–creatinine ratio of more than 30. The area under receiver operating characteristic curve for the rule was 0.93 in the derivation set and 0.96 in the validation set. At the cutoff value of 5 points or higher, the sensitivity and specificity of the fast-track screening procedure for SMI were 96.6% and 86.4%, respectively. The positive and negative predictive values were 71.8% and 98.6%, respectively.
Conclusions
This simple risk prediction score is easily calculated and is based on rapidly available clinical and laboratory data in the ED. It can be used to stratify patients undergoing aspirin therapy for CAD presenting with UGIH by risk of SMI.
Chen C, et al. Amer J Emerg Med 2007;25:406-413.
10. Albuterol Better Than Epinephrine for Emergency Treatment of Bronchiolitis
By Megan Rauscher. NEW YORK (Reuters Health) May 16 - In the emergency department treatment of infants with bronchiolitis, nebulized albuterol/salbutamol results in more successful discharges than does nebulized epinephrine, according to a double-blind randomized study reported at the annual meeting of the Society for Academic Emergency Medicine in Chicago.
"Because bronchiolitis is very common - it resulted in 149,000 hospital admissions in the U.S. in 2002 -- and racemic albuterol is cheap, the results of this study may have a big impact overall," principal investigator Dr. Paul Walsh of the University of California, Los Angeles told Reuters Health.
Prior outpatient studies that have looked at the emergency department treatment of bronchiolitis were all small and showed either no benefit or a benefit for epinephrine, Dr. Walsh noted. "Most people anticipated that a large study would answer the question and elevate epinephrine to the standard of care. But as has happened before in medicine, one large rigorous trial not only failed to replicate the results of small studies, it actually overturned them," he said.
For their study, the investigators excluded children with bronchiolitis so mild as not to require treatment or so severe as to need intubation, and those older than 18 months of age. Ultimately, the study included 703 infants that received saline mist followed by either nebulized epinephrine and two saline nebulizers (n = 351) or three albuterol nebulizers (n = 352).
"Albuterol was associated with more successful discharges than epinephrine -- an 18% difference in need for admission," Dr. Walsh said. "The benefit, although pretty clearcut, is modest."
It's worth noting, he added, that the trial was stratified on disease severity, which previous work had suggested might be important. "In this study, the benefit was seen across all severity-of-illness groups. Even in all subgroups analyzed, the results remained the same."
"I was as surprised as my collaborators at the results and I suspect many pediatric emergency physicians will be at these results. The take-home message for emergency physicians is that, when confronted with a child with bronchiolitis, try albuterol first," Dr. Walsh concluded.
11. Ultrasound Used to Confirm ETT Placement
A. The Sensitivity and Specificity of Transcricothyroid Ultrasonography to Confirm ETT Placement in a Cadaver Model
Abstract
Confirmation of endotracheal (ET) tube placement is critical when performing emergency airway management. No single confirmation strategy has emerged as ideal in all circumstances. Our objective in this study was to assess the sensitivity and specificity of a novel approach to verify endotracheal intubation using transcricothyroid ultrasonography (US). We performed a prospective, randomized double-blinded trial in a human cadaver model.
A 7.5-MHz curvilinear probe was placed longitudinally over the cricothyroid membrane as cadavers were randomly intubated in either the trachea or esophagus in two phases: 1) as the intubation was being performed (dynamic) and, 2) after intubation had been completed (static). Volunteer emergency medicine (EM) residents, blinded to tube placement, assessed for esophageal vs. tracheal ET placement using dynamic and static US views. Sensitivity, specificity, positive predictive value, and negative predictive value for detecting esophageal ET placement with 95% confidence intervals were calculated.
Seven EM residents made a total of 70 dynamic and 70 static assessments of ET position using transcricothyroid US. Dynamic assessment resulted in 97% sensitivity and 100% specificity for detecting esophageal ET placement. Static assessment resulted in only 51% sensitivity and 91% specificity. This pilot study suggests that dynamic transcricothyroid US is a potentially accurate method of confirming ET placement during the intubation process. Further investigation in live humans is warranted to validate these data.
Ma G, et al. J Emerg Med 2007;32:405-407.
B. Transtracheal 2-D Ultrasound for Identification of Esophageal Intubation
This prospective, blinded, observational, efficacy study is one of the first to evaluate ultrasound in detecting esophageal intubation, a significant source of morbidity and mortality. We utilized a convenience sample of patients undergoing elective surgery during July 2004 in an urban teaching hospital. Trained Emergency Physician sonographers performed transtracheal ultrasounds of intubations to identify esophageal intubation. In 35 of the 40 patients enrolled, there was intubation of the trachea, whereas esophageal intubation occurred in five patients. Sonographers correctly identified all five esophageal intubations, for a sensitivity of 100% (95% confidence interval [CI] 48–100). Ultrasound correctly identified 34 of 35 tracheal intubations and misidentified one resulting in a specificity of 97% (95% CI 90–100). It seems that transtracheal ultrasound may be an efficacious adjunct for detecting esophageal intubation.
Milling TJ, et al. J Emerg Med 2007;32:409-414.
12. A Multicenter Comparison of Tap Water versus Sterile Saline for Wound Irrigation
Moscati RM, et al. Acad Emerg Med 2007 14: 404-409.
Objectives: To compare wound infection rates for irrigation with tap water versus sterile saline before closure of wounds in the emergency department.
Methods: The study was a multicenter, prospective, randomized trial conducted at two Level 1 urban hospitals and a suburban community hospital. Subjects were a convenience sample of adults presenting with acute simple lacerations requiring sutures or staples. Subjects were randomized to irrigation in a sink with tap water or with normal saline using a sterile syringe. Wounds were closed in the standard fashion. Subjects were asked to return to the emergency department for suture removal. Those who did not return were contacted by telephone. Wounds were considered infected if there was early removal of sutures or staples, if there was irrigation and drainage of the wound, or if the subject needed to be placed on antibiotics. Equivalence of the groups was met if there was less than a doubling of the infection rate.
Results: A total of 715 subjects were enrolled in the study. Follow-up data were obtained on 634 (88%) of enrolled subjects. Twelve (4%) of the 300 subjects in the tap water group had wound infections, compared with 11 (3.3%) of the 334 subjects in the saline group. The relative risk was 1.21 (95% confidence interval = 0.5 to 2.7).
Conclusions: Equivalent rates of wound infection were found using either irrigant. The results of this multicenter trial evaluating tap water as an irrigant agree with those from previous single institution trials.
13. Denver study hints hearts don't keep beat with iPods
Researchers say the music devices interfered with pacemakers in nearly 30 percent of their test group. By Karen Auge, The Denver Post
DENVER — Attention, iPod users: Your music might be breaking Grandpa's heart - and not just because he doesn't care for the lyrics.
A study of 83 volunteers with pacemakers found the music devices interfered with the pacemakers nearly 30 percent of the time.
The results of the study, conducted by Michigan high school student Jay Thayer and Dr. Krit Jongnarangsin, a University of Michigan cardiologist, were presented Thursday at the Heart Rhythm Society meeting in Denver. The society is a professional group focusing on irregular heart rhythm. In most cases, the iPod interference caused pacemakers to misread the heart's pacing. In one, the pacemaker stopped altogether.
The iPod - like microwave ovens, cellphones and other electronic devices - appears to cause a problem by creating an electromagnetic field that interferes with the electric function of the pacemakers, Thayer said. "That seems to be the root," he said.
Thayer said the University of Michigan engineering department is looking into the electromagnetic effects of the iPod. In the study, Thayer and Jongnarangsin placed iPods 2 inches from the chests of 83 volunteers with pacemakers and then turned on the music.
Thayer, 17, said the average age of volunteers in his study was 77.
"We set the headphones on their shoulders so we didn't blow out their eardrums," he said, and then turned up the Frank Sinatra tunes. Most participants didn't use iPods, but "a lot of them had grandkids that use iPods," he said.
Thayer, who said he hopes to become a physician, like his mother and father, got interested in the iPod/pacemaker issue when one of his father's pacemaker-using patients raised the question.
Thayer said he and his father searched for an answer but couldn't find any research on the topic.
Apple reports that it has sold 100 million iPods since launching them in 2000. It's not clear how many iPod users have pacemakers. Cupertino, Calif.-based Apple declined to comment.
Jongnarangsin said he treats many elderly patients with pacemakers but that none have ever inquired about the compatibility of the music devices. The question the two researchers will now address is just how close is too close when it comes to iPods and pacemakers.
First, Thayer has to graduate from high school.
14. ED Management of Acute Pain Episodes in Sickle Cell Disease
Tanabe P, et al. Acad Emerg Med 2007 14: 419-425
Objectives: To characterize the initial management of patients with sickle cell disease and an acute pain episode, to compare these practices with the American Pain Society Guideline for the Management of Acute and Chronic Pain in Sickle-Cell Disease in the emergency department, and to identify factors associated with a delay in receiving an initial analgesic.
Methods: This was a multicenter retrospective design. Consecutive patients with an emergency department visit in 2004 for an acute pain episode related to sickle cell disease were included. Exclusion criteria included age younger than 18 years. A structured medical record review was used to abstract data, including the following outcome variables: analgesic agent and dose, route, and time to administration of initial analgesic. Additional variables included demographics, triage level, intravenous access, and study site. Mann–Whitney U test or Kruskal–Wallis test and multivariate regression were used to identify differences in time to receiving an initial analgesic between groups.
Results: There were 612 patient visits, with 159 unique patients. Median time to administration of an initial analgesic was 90 minutes (25th to 75th interquartile range, 54–159 minutes). During 87% of visits, patients received the recommended agent (morphine or hydromorphone); 92% received the recommended dose, and 55% received the drug by the recommended route (intravenously or subcutaneously). Longer times to administration occurred in female patients (mean difference, 21 minutes; 95% confidence interval = 7 to 36 minutes; p = 0.003) and patients assigned triage level 3, 4, or 5 versus 1 or 2 (mean difference, 45 minutes; 95% confidence interval = 29 to 61 minutes; p = 0.00). Patients from study sites 1 and 2 also experienced longer delays.
Conclusions: Patients with an acute painful episode related to sickle cell disease experienced significant delays to administration of an initial analgesic.
15. US-guided supraclavicular block for the treatment of upper extremity fractures, dislocations, and abscesses in the ED
Abstract
Emergency department (ED) patients with fractures, dislocations, or abscesses of the upper extremities often require closed reduction or incision and drainage to treat these conditions. Procedural sedation is often necessary when infiltration of local anesthetic provides insufficient analgesia. Anesthesiologists commonly perform supraclavicular brachial plexus nerve blocks to achieve analgesia for upper extremity surgery. We report a series of 5 ED patients in whom supraclavicular brachial plexus nerve blocks using real-time ultrasound guidance provided excellent analgesia and obviated the need for procedural sedation.
Stone MB, et al. Amer J Emerg Med 2007;25:472-475.
16. WHO Releases Global Health Statistics
The World Health Organization has released its 2007 compendium of health statistics.
Among the highlights:
--Life expectancy at birth in 2005 ranged from 37 in Sierra Leone to 80 in San Marino for men and from 37 in Swaziland to 86 in Japan for women. U.S. life expectancy was 75 for men and 80 for women.
--The leading causes of death in 2030 are projected to be cancers, ischemic heart disease, stroke, HIV/AIDS, and chronic obstructive pulmonary disease. Tobacco-related deaths are projected to rise from 5.4 million in 2005 to 6.4 million in 2015 and 8.3 million in 2030.
--Ten percent of the world's children under age 5 years suffer wasting as a result of malnutrition, according to 2005 data.
--In 2004, the world spent $4.1 trillion on health.
--In 2002, depression accounted for 4.5% of the total burden of disease worldwide.
WHO report (Free PDFs): http://www.who.int/whosis/whostat2007/en/index.html
17. Education Tool Entitled "tPA for Stroke - Potential Benefit, Risk, and Alternatives" Now Available
AAEM has created an Education Tool entitled ‘tPA for Stroke - Potential Benefit, Risk, and Alternatives,’ which can be viewed at http://aaem.org/education/tpaedtool-AAEM.pdf
The document is designed to help emergency physicians inform patients and family members about the pros and cons of tPA for stroke in appropriate patients.
American Academy of Emergency Medicine
18. Unanticipated Death After Discharge Home From the ED
Sklar DP, et al. Ann Emerg Med. 2007;49:735-745.
Editor’s Capsule Summary
What is already known on this topic: Death of a patient shortly after emergency department (ED) discharge is every emergency physician’s fear, but little is known about the frequency of such events or factors that might contribute to them.
What question this study addressed: The frequency of death occurring within 7 days of ED discharge, whether the death was unexpected, and, if so, whether a medical error may have been contributory.
What this study adds to our knowledge: In this review of almost 400,000 patients discharged from an academic medical center during a 10-year period, roughly 30 per 100,000 patients died within 7 days of ED discharge, 20 per 100,000 unexpectedly and 9 per 100,000 with a potentially contributory medical error. Atypical presentations, exacerbation of chronic disease, abnormal vital signs, and substance abuse were common themes.
How this might change clinical practice: These data may inform efforts to decrease medical errors and identify high-risk patients, such as developing better methods for assessing the significance of abnormal vital signs.
19. Predicting ETT Size by Length in Newborns
The objective of this study was to determine the relationship of length to endotracheal tube (ETT) size in newborns and to use this relationship to develop a tool for predicting ETT size.
The study, a prospective derivation, and validation of a predictive model, took place in the neonatal intensive care units (NICUs) in two urban teaching hospitals. Subjects included: ETT derivation set − 39 intubated neonates admitted to the NICU; Validation set − 69 intubated newborns from the same NICU. Leak percentages were measured in intubated neonates where the actual ETT size did not correlate with the tape-determined ETT size. Interventions were length, weight, and leak measurements. A prototype tape was developed using the derivation set and published anthropometric studies. The accuracy of the tape was validated on a separate set of newborns.
The average relative difference between tape-predicted weight and actual weight was 9.5% (confidence interval [CI] = 8.3–10.6%) and was evenly distributed throughout all the weight groups. The tape predicted actual ETT size in 96% of cases (CI 86.3–99.5%) and was correct within 1 tube size (1/2 mm) in 100% (CI 94.8–100%). The only error in prediction of ETT size was in underestimation. Length-based weight estimations were tested on 100 subjects and predicted actual weight within 20% in 94% of cases. We concluded that length is an accurate predictor of ETT size and weight in term and preterm newborns and may be useful in situations in which weights are unobtainable, such as emergency resuscitation.
Luten R, et al. J Emerg Med 2007;32:342-347.
20. Risk Factors for Traumatic or Unsuccessful LPs in Children
Nigrovic LE, et al. Ann Emerg Med 2007; 49:762-771.
Study objective: Traumatic and unsuccessful lumbar punctures can cause substantial diagnostic ambiguity that may lead to unnecessary antibiotic use and hospitalization, in addition to patient discomfort. Risk factors for obtaining traumatic and unsuccessful lumbar punctures have been studied in a limited fashion only. We sought to determine patient, physician, and procedural factors associated with traumatic and unsuccessful lumbar punctures in children.
Methods: The study included a prospective cohort of all children undergoing lumbar punctures in a single emergency department between July 2003 and January 2005. Our main outcome was either a traumatic lumbar puncture (cerebrospinal fluid RBC counts ≥10,000 cells/mm3) or unsuccessful lumbar puncture (failure of the procedure to yield fluid for cell counts) after the first lumbar puncture attempt. We performed multiple logistic regression analyses to identify independent predictors of traumatic or unsuccessful lumbar punctures.
Results: Of the 1,474 eligible lumbar punctures, 1,459 (99%) were included in the analysis. Of these, 513 (35%) were traumatic or unsuccessful on the first attempt. After adjustment for patient characteristics, physician and procedural factors associated with an increased risk of a traumatic or unsuccessful lumbar puncture included less physician experience (adjusted odds ratio for an ordinal decrease in experience 1.08; 95% confidence interval [CI] 1.01 to 1.15), lack of local anesthetic use (adjusted odds ratio 1.6; 95% CI 1.1 to 2.2), advancement of the spinal needle with stylet in place versus stylet removed (adjusted odds ratio 1.3; 95% CI 1.04 to 1.7), and increased patient movement (adjusted odds ratio 2.1; 95% CI 1.6 to 2.6).
Conclusion: Of the factors associated with traumatic or unsuccessful lumbar punctures in children, advancement of the spinal needle with the stylet in place and lack of local anesthetic use are the most modifiable. Modification of these procedural factors may reduce the risk of traumatic or unsuccessful lumbar punctures in children.
1. PCI Hospitals Associated with Survival Benefit After Myocardial Infarction
Myocardial infarction patients first admitted to hospitals that perform PCI have better survival than those who go to non-PCI hospitals, according to a French study in the Archives of Internal Medicine.
The prospective observational study compared the outcomes of about 1200 patients admitted to PCI hospitals and about 700 admitted to non-PCI hospitals during 1 month in 2000. Patients admitted to PCI hospitals had lower in-hospital mortality (7% vs. 12%) and 1-year mortality (13% vs. 20%).
Patients admitted to PCI hospitals were more likely to receive primary PCI (36% vs. 1%) or PCI within 48 hours (54% vs. 6%). They were also more likely to receive evidence-based acute and discharge medicines.
"Most of the survival benefit of admission to a PCI hospital was explained by the use of PCI and evidence-based discharge medications," the authors write.
Archives of Internal Medicine article (Free abstract; full text requires subscription): http://archinte.ama-assn.org/cgi/content/abstract/167/9/913
2. Odansetron Versus Metoclopramide for Nausea and Vomiting in the ED
Haensel C, et al. Acad Emerg Med. 2007;14, Supplement 1: S16-17 (full manuscript not yet published).
Objectives: Nausea and vomiting is a common ED complaint. Most of the literature involves post-operative and oncology patients. The objective is to compare the efficacy of usual (4 mg) and low (2 mg) dose ondansetron and 10 mg metoclopramide in relief of nausea and vomiting in ED patients.
Methods: This is a prospective, randomized, double-blind study of adult ED patients with nausea and at least 1 episode of vomiting within 12 hours of presentation. A validated 100 mm visual analog nausea scale (VAS) was used prior to medication and 30 minutes post-treatment. Patients also rated their nausea post-treatment on a subjective scale. All patients received at least 500 cc of saline IV. Endpoints were complete relief of nausea, significant reduction of initial VAS, subjective change in nausea, and adverse events. Analysis by ANOVA and Kruskal-Wallis.
Results: A total of 132 patients were enrolled over a 12 month period in 2005-2006. Initial VAS scores were similar with a mean of 66.4 mm. All 3 groups had a significant and similar reduction in VAS with a mean final VAS score of 33.6 mm, p less than 0.0001. There was no difference between the groups. A total of 55.3% obtained at least 50% relief and 18.2% obtained complete relief, with no difference between groups. More nausea was experienced by 7.6% in the post-treatment odansetron groups and none in the metoclopramide group. None of the patients had an adverse reaction, 95% CI = 0.0 to 2.2%.
Conclusions: Low and usual dose odansetron and metoclopramide are efficacious in ED patients with nausea and vomiting. No adverse events occurred with either drug. Significant cost savings with similar efficacy would occur by using low-dose odansetron or metoclopramide.
3. Expanding the use of topical anesthesia in wound management
Abstract
Topical anesthesia eliminates the need for injection of anesthetic. Most studies on the use of topical anesthesia were done on children, using 3 active ingredients (lidocaine, epinephrine, tetracaine, or tetracaine, adrenaline, cocaine) for relatively small wounds of the face and scalp.
Objectives
To demonstrate that topical anesthesia is effective and safe in adults of all ages and for larger wounds, using a preparation with 2 active ingredients, topical lidocaine and epinephrine (TLE).
Methods
One hundred patients were enrolled in a randomized controlled trial, with 50 in each group. The study group received TLE using a unique method of “sequential layered application.” The control group received 2% lidocaine infiltration anesthesia. Patients rated the pain from the application of anesthesia and from suturing, using a 0 to 10 visual analog pain scale. Follow-up interviews were conducted to assess for complications and to rate patients' wound repair experience.
Results
Patients in the study group reported significantly less pain from TLE application, with 66% reporting no pain vs 0% reporting no pain from the infiltration in the control group (P less than .001). There was no difference in pain during wound repair between the 2 groups (P = .59). On follow-up, 95% of patients contacted in the TLE group rated their experience in regard to pain as “excellent,” compared to 5% of patients in the control group (P less than .001).
Conclusion
Topical lidocaine and epinephrine “sequential layered application” is an effective, safe, and less painful method of anesthesia for a wide variety of lacerations. Patients recall their experience with this technique very favorably.
Gaufberg SV, et al. Amer J Emerg Med 2007;25: 379-384.
4. Review Finds Lower Dose Best for Prophylactic Aspirin
Aspirin doses should not exceed 75 to 81 mg/day when the drug is used to prevent cardiovascular disease, a JAMA systematic review finds.
The authors sought the balance point between aspirin's cardioprotective effects and the known complications of the drug, which they say is taken preventively by over one-third of U.S. adults. Their literature review leads them to conclude that, although multiple studies confirm the increasing incidence of adverse effects with increasing dosage, "no such dose relationship has been identified for efficacy."
"Currently, the clinical data are most supportive of a 75- or 81-mg daily dose," they write.
JAMA article (Free abstract; full text requires subscription): http://jama.ama-assn.org/cgi/content/abstract/297/18/2018
5. The Ottawa Aggressive Protocol for ED Management of Acute A Fib
Stiell IC, et al. Acad Emerg Med. 2007;14, Supplement 1: S9 (full manuscript not yet published)
Objectives: There is no consensus as to the optimal emergency department (ED) management of acute atrial fibrillation (AAF) or atrial flutter (AAFL). Our objective was to examine the efficacy and safety of the Ottawa Aggressive Protocol to convert and discharge ED patients with AAF/AAFL.
Methods: This 5-year cohort study included consecutive visits to a university hospital ED for adults presenting with acute-onset AAF/AAFL and who were managed with the Ottawa Aggressive Protocol. Patients were identified from the National Ambulatory Care Reporting System (NACRS) database. The Aggressive Protocol was overseen by the attending emergency physicians and included: (1) IV procainamide as infusion of 1 gram over 1 hour; (2) electrical cardioversion if necessary, by ED staff; (3) discharge from the ED with outpatient cardiology follow-up. Outcomes included conversion, adverse events, and relapse. The authors conducted descriptive data analyses with 95% CIs.
Results: Characteristics of the 660 eligible patient visits were mean age 64.5 years, mean heart rate 113.4, and mean duration symptoms 8.9 hours, AAF 95.2%, AAFL 4.9%. Overall, 96.8% of patients were discharged home from the ED and 90.3% were discharged in normal sinus rhythm. The respective discharge rates were 97.0% and 93.5% for those in AAF and 93.8% and 87.5% for those in AAFL. All patients received procainamide with a conversion rate of 58.3% (AAF 59.9%, AAFL 28.1%). Electrical cardioversion was attempted in 36.8% of visits with a success rate of 91.7% (AAF 91.0%, AAFL 100%). Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3%, AAF relapse within 7 days 8.6%, Torsades de Pointes 0%, cerebrovascular accident 0%, mortality 0%.
Conclusions: This is the largest reported study of AAF/AAFL in the ED and demonstrates that the Ottawa Aggressive Protocol is extremely effective for the rapid cardioversion and discharge of patients by ED physicians. This protocol is safe and could lead to a significant decrease in hospital admissions.
6. COX-2 Inhibitor plus PPI Reduces Bleeding in High-Risk Patients
Adding a proton-pump inhibitor to celecoxib treatment in patients at very high risk for ulcer bleeds greatly reduces the incidence of bleeding, according to a Lancet report.
Some 270 patients taking nonselective NSAIDS for arthritis and presenting with upper-GI bleeding underwent randomization — after their ulcers had healed — to treatment with either celecoxib (200 mg twice daily) plus esomeprazole (20 mg twice daily), or celecoxib alone, for a year. The 13-month incidence of recurrent ulcer bleeding was 0% in the combination-therapy group and 8.9% in the controls.
Commentators write that "the finding provides clear guidance for those individuals at greatest gastrointestinal risk who require an NSAID." They add that the new gastrointestinal data should not be interpreted "without careful consideration of competing risks from the cardiovascular perspective."
Lancet article (Free abstract with one-time registration; full text requires subscription): http://www.thelancet.com/journals/lancet/article/PIIS0140673607607491/abstract
7. Study Links TV Viewing with Learning Difficulties in Adolescence
Adolescents who watch a lot of television may be at increased risk for attention and learning problems and failure to go beyond high school, a study finds.
The prospective study, published in the Archives of Pediatrics & Adolescent Medicine, used a community-based sample of some 700 mothers and their children. The offspring were interviewed at mean ages of 14, 16, and 22. After controlling for family characteristics and earlier cognitive difficulties, researchers found that frequent TV viewing at age 14 was associated with indicators of subsequent attention and learning difficulties and academic failure. Youngsters who watched 3 or more hours a day were twice as likely to fail to get postsecondary education as those who watched less than an hour.
The authors said healthcare professionals should encourage youths to spend less than 3 hours a day watching TV. The American Academy of Pediatrics recommends no more than 1 to 2 hours a day of television.
AAP's "Children, Adolescents, and Television" --http://pediatrics.aappublications.org/cgi/content/full/107/2/423?ijkey=e9cf76013f70e23304b814bc410af3b2e0efea2c
8. Stroke Among Patients With Dizziness, Vertigo, and Imbalance in the ED: A Population-Based Study
Kerber KA, et al. Stroke 2006;37:2484–7
As part of the Brain Attack Surveillance in Corpus Christi (BASIC) project, this study sought to determine the percentage of stroke patients who presented to the Emergency Department (ED) with the complaints of dizziness, vertigo, or imbalance. This large population-based study examined all patients over the age of 44 years who presented to the ED or were directly admitted to the hospital between January 2000 and June 2003 with the previously mentioned isolated dizziness symptoms (DS) in Nueces County, Texas. The association of age, sex, race/ethnicity, and isolated dizziness symptoms with stroke or transient ischemic attack (TIA) was then determined using multivariable logistic regression.
A total of 1666 patients were included in the study, with 3.2% (53 of 1666) ultimately diagnosed with stroke/TIA. Of those diagnosed, 23 presented with dizziness as the chief complaint, 18 with vertigo, 11 with imbalance, and 1 with more than one of the above symptoms. Isolated DS without additional neurological findings was a strong negative predictor of stroke/TIA (odds ratio [OR] 0.05; 95% confidence interval [CI] 0.02–0.11), whereas male sex was associated with an increased association with stroke/TIA (OR 2.5; 95% CI 1.4–4.4). Patients diagnosed with stroke/TIA were also found to be significantly older (69.3 ± 11.7 vs. 65.3 ± 12.9, p = 0.02). No significant difference in race/ethnicity was found between the stroke and non-stroke groups.
When compared to dizziness, patients with imbalance were found to have an increased risk of stroke/TIA (OR 3.7; 95% CI 1.3–10.7), whereas no increased risk was found between those with vertigo versus dizziness (OR 0.9; 95% CI 0.4–2.0). The authors acknowledge several limitations to this study, including lack of evaluation of the majority of study patients in the ED by a neurologist, lack of magnetic resonance imaging on most study patients leading to possible undiagnosed strokes, and lack of comparison of symptom onset, duration, aggravating/alleviating factors, headache, and auditory symptoms between groups.
The authors conclude that dizziness and vertigo are not associated with stroke/TIA, whereas patients who present with imbalance, those with additional neurologic findings, male gender, and older age are at the highest risk for possible stroke/TIA.
9. A risk score to predict silent AMI in patients with CAD under aspirin therapy presenting with UGI hemorrhage
Background
Silent myocardial ischemia (SMI) is a relatively common complication in patients with coronary artery disease (CAD) under aspirin therapy presenting with upper gastrointestinal hemorrhage (UGIH).
Aim
This study was conducted to develop and prospectively validate a risk prediction score to identify SMI in patients undergoing aspirin therapy for CAD presenting with UGIH in the emergency department (ED).
Methods
This was a 2-phase noninterventional study. In the derivation phase, adults with CAD under aspirin therapy (100 mg once daily) presenting to the ED with UGIH were retrospectively recruited. By multiple logistic regression analysis, we derived a risk score from 224 patients that predicts the patients' risk of SMI. In the validation phase, we prospectively validated this score using receiver operating characteristic curves with data from 110 patients. We also developed a fast-track screening procedure from this score.
Results
There were 56 patients (25.0%) and 29 patients (26.4%) with SMI in the derivation and validation sets, respectively. Independent multivariate predictors of SMI were age of older than 75 years, severity of CAD, systolic blood pressure of less than 110 mm Hg, diastolic blood pressure of less than 85 mm Hg, hematocrit of less than 30%, and blood urea nitrogen–creatinine ratio of more than 30. The area under receiver operating characteristic curve for the rule was 0.93 in the derivation set and 0.96 in the validation set. At the cutoff value of 5 points or higher, the sensitivity and specificity of the fast-track screening procedure for SMI were 96.6% and 86.4%, respectively. The positive and negative predictive values were 71.8% and 98.6%, respectively.
Conclusions
This simple risk prediction score is easily calculated and is based on rapidly available clinical and laboratory data in the ED. It can be used to stratify patients undergoing aspirin therapy for CAD presenting with UGIH by risk of SMI.
Chen C, et al. Amer J Emerg Med 2007;25:406-413.
10. Albuterol Better Than Epinephrine for Emergency Treatment of Bronchiolitis
By Megan Rauscher. NEW YORK (Reuters Health) May 16 - In the emergency department treatment of infants with bronchiolitis, nebulized albuterol/salbutamol results in more successful discharges than does nebulized epinephrine, according to a double-blind randomized study reported at the annual meeting of the Society for Academic Emergency Medicine in Chicago.
"Because bronchiolitis is very common - it resulted in 149,000 hospital admissions in the U.S. in 2002 -- and racemic albuterol is cheap, the results of this study may have a big impact overall," principal investigator Dr. Paul Walsh of the University of California, Los Angeles told Reuters Health.
Prior outpatient studies that have looked at the emergency department treatment of bronchiolitis were all small and showed either no benefit or a benefit for epinephrine, Dr. Walsh noted. "Most people anticipated that a large study would answer the question and elevate epinephrine to the standard of care. But as has happened before in medicine, one large rigorous trial not only failed to replicate the results of small studies, it actually overturned them," he said.
For their study, the investigators excluded children with bronchiolitis so mild as not to require treatment or so severe as to need intubation, and those older than 18 months of age. Ultimately, the study included 703 infants that received saline mist followed by either nebulized epinephrine and two saline nebulizers (n = 351) or three albuterol nebulizers (n = 352).
"Albuterol was associated with more successful discharges than epinephrine -- an 18% difference in need for admission," Dr. Walsh said. "The benefit, although pretty clearcut, is modest."
It's worth noting, he added, that the trial was stratified on disease severity, which previous work had suggested might be important. "In this study, the benefit was seen across all severity-of-illness groups. Even in all subgroups analyzed, the results remained the same."
"I was as surprised as my collaborators at the results and I suspect many pediatric emergency physicians will be at these results. The take-home message for emergency physicians is that, when confronted with a child with bronchiolitis, try albuterol first," Dr. Walsh concluded.
11. Ultrasound Used to Confirm ETT Placement
A. The Sensitivity and Specificity of Transcricothyroid Ultrasonography to Confirm ETT Placement in a Cadaver Model
Abstract
Confirmation of endotracheal (ET) tube placement is critical when performing emergency airway management. No single confirmation strategy has emerged as ideal in all circumstances. Our objective in this study was to assess the sensitivity and specificity of a novel approach to verify endotracheal intubation using transcricothyroid ultrasonography (US). We performed a prospective, randomized double-blinded trial in a human cadaver model.
A 7.5-MHz curvilinear probe was placed longitudinally over the cricothyroid membrane as cadavers were randomly intubated in either the trachea or esophagus in two phases: 1) as the intubation was being performed (dynamic) and, 2) after intubation had been completed (static). Volunteer emergency medicine (EM) residents, blinded to tube placement, assessed for esophageal vs. tracheal ET placement using dynamic and static US views. Sensitivity, specificity, positive predictive value, and negative predictive value for detecting esophageal ET placement with 95% confidence intervals were calculated.
Seven EM residents made a total of 70 dynamic and 70 static assessments of ET position using transcricothyroid US. Dynamic assessment resulted in 97% sensitivity and 100% specificity for detecting esophageal ET placement. Static assessment resulted in only 51% sensitivity and 91% specificity. This pilot study suggests that dynamic transcricothyroid US is a potentially accurate method of confirming ET placement during the intubation process. Further investigation in live humans is warranted to validate these data.
Ma G, et al. J Emerg Med 2007;32:405-407.
B. Transtracheal 2-D Ultrasound for Identification of Esophageal Intubation
This prospective, blinded, observational, efficacy study is one of the first to evaluate ultrasound in detecting esophageal intubation, a significant source of morbidity and mortality. We utilized a convenience sample of patients undergoing elective surgery during July 2004 in an urban teaching hospital. Trained Emergency Physician sonographers performed transtracheal ultrasounds of intubations to identify esophageal intubation. In 35 of the 40 patients enrolled, there was intubation of the trachea, whereas esophageal intubation occurred in five patients. Sonographers correctly identified all five esophageal intubations, for a sensitivity of 100% (95% confidence interval [CI] 48–100). Ultrasound correctly identified 34 of 35 tracheal intubations and misidentified one resulting in a specificity of 97% (95% CI 90–100). It seems that transtracheal ultrasound may be an efficacious adjunct for detecting esophageal intubation.
Milling TJ, et al. J Emerg Med 2007;32:409-414.
12. A Multicenter Comparison of Tap Water versus Sterile Saline for Wound Irrigation
Moscati RM, et al. Acad Emerg Med 2007 14: 404-409.
Objectives: To compare wound infection rates for irrigation with tap water versus sterile saline before closure of wounds in the emergency department.
Methods: The study was a multicenter, prospective, randomized trial conducted at two Level 1 urban hospitals and a suburban community hospital. Subjects were a convenience sample of adults presenting with acute simple lacerations requiring sutures or staples. Subjects were randomized to irrigation in a sink with tap water or with normal saline using a sterile syringe. Wounds were closed in the standard fashion. Subjects were asked to return to the emergency department for suture removal. Those who did not return were contacted by telephone. Wounds were considered infected if there was early removal of sutures or staples, if there was irrigation and drainage of the wound, or if the subject needed to be placed on antibiotics. Equivalence of the groups was met if there was less than a doubling of the infection rate.
Results: A total of 715 subjects were enrolled in the study. Follow-up data were obtained on 634 (88%) of enrolled subjects. Twelve (4%) of the 300 subjects in the tap water group had wound infections, compared with 11 (3.3%) of the 334 subjects in the saline group. The relative risk was 1.21 (95% confidence interval = 0.5 to 2.7).
Conclusions: Equivalent rates of wound infection were found using either irrigant. The results of this multicenter trial evaluating tap water as an irrigant agree with those from previous single institution trials.
13. Denver study hints hearts don't keep beat with iPods
Researchers say the music devices interfered with pacemakers in nearly 30 percent of their test group. By Karen Auge, The Denver Post
DENVER — Attention, iPod users: Your music might be breaking Grandpa's heart - and not just because he doesn't care for the lyrics.
A study of 83 volunteers with pacemakers found the music devices interfered with the pacemakers nearly 30 percent of the time.
The results of the study, conducted by Michigan high school student Jay Thayer and Dr. Krit Jongnarangsin, a University of Michigan cardiologist, were presented Thursday at the Heart Rhythm Society meeting in Denver. The society is a professional group focusing on irregular heart rhythm. In most cases, the iPod interference caused pacemakers to misread the heart's pacing. In one, the pacemaker stopped altogether.
The iPod - like microwave ovens, cellphones and other electronic devices - appears to cause a problem by creating an electromagnetic field that interferes with the electric function of the pacemakers, Thayer said. "That seems to be the root," he said.
Thayer said the University of Michigan engineering department is looking into the electromagnetic effects of the iPod. In the study, Thayer and Jongnarangsin placed iPods 2 inches from the chests of 83 volunteers with pacemakers and then turned on the music.
Thayer, 17, said the average age of volunteers in his study was 77.
"We set the headphones on their shoulders so we didn't blow out their eardrums," he said, and then turned up the Frank Sinatra tunes. Most participants didn't use iPods, but "a lot of them had grandkids that use iPods," he said.
Thayer, who said he hopes to become a physician, like his mother and father, got interested in the iPod/pacemaker issue when one of his father's pacemaker-using patients raised the question.
Thayer said he and his father searched for an answer but couldn't find any research on the topic.
Apple reports that it has sold 100 million iPods since launching them in 2000. It's not clear how many iPod users have pacemakers. Cupertino, Calif.-based Apple declined to comment.
Jongnarangsin said he treats many elderly patients with pacemakers but that none have ever inquired about the compatibility of the music devices. The question the two researchers will now address is just how close is too close when it comes to iPods and pacemakers.
First, Thayer has to graduate from high school.
14. ED Management of Acute Pain Episodes in Sickle Cell Disease
Tanabe P, et al. Acad Emerg Med 2007 14: 419-425
Objectives: To characterize the initial management of patients with sickle cell disease and an acute pain episode, to compare these practices with the American Pain Society Guideline for the Management of Acute and Chronic Pain in Sickle-Cell Disease in the emergency department, and to identify factors associated with a delay in receiving an initial analgesic.
Methods: This was a multicenter retrospective design. Consecutive patients with an emergency department visit in 2004 for an acute pain episode related to sickle cell disease were included. Exclusion criteria included age younger than 18 years. A structured medical record review was used to abstract data, including the following outcome variables: analgesic agent and dose, route, and time to administration of initial analgesic. Additional variables included demographics, triage level, intravenous access, and study site. Mann–Whitney U test or Kruskal–Wallis test and multivariate regression were used to identify differences in time to receiving an initial analgesic between groups.
Results: There were 612 patient visits, with 159 unique patients. Median time to administration of an initial analgesic was 90 minutes (25th to 75th interquartile range, 54–159 minutes). During 87% of visits, patients received the recommended agent (morphine or hydromorphone); 92% received the recommended dose, and 55% received the drug by the recommended route (intravenously or subcutaneously). Longer times to administration occurred in female patients (mean difference, 21 minutes; 95% confidence interval = 7 to 36 minutes; p = 0.003) and patients assigned triage level 3, 4, or 5 versus 1 or 2 (mean difference, 45 minutes; 95% confidence interval = 29 to 61 minutes; p = 0.00). Patients from study sites 1 and 2 also experienced longer delays.
Conclusions: Patients with an acute painful episode related to sickle cell disease experienced significant delays to administration of an initial analgesic.
15. US-guided supraclavicular block for the treatment of upper extremity fractures, dislocations, and abscesses in the ED
Abstract
Emergency department (ED) patients with fractures, dislocations, or abscesses of the upper extremities often require closed reduction or incision and drainage to treat these conditions. Procedural sedation is often necessary when infiltration of local anesthetic provides insufficient analgesia. Anesthesiologists commonly perform supraclavicular brachial plexus nerve blocks to achieve analgesia for upper extremity surgery. We report a series of 5 ED patients in whom supraclavicular brachial plexus nerve blocks using real-time ultrasound guidance provided excellent analgesia and obviated the need for procedural sedation.
Stone MB, et al. Amer J Emerg Med 2007;25:472-475.
16. WHO Releases Global Health Statistics
The World Health Organization has released its 2007 compendium of health statistics.
Among the highlights:
--Life expectancy at birth in 2005 ranged from 37 in Sierra Leone to 80 in San Marino for men and from 37 in Swaziland to 86 in Japan for women. U.S. life expectancy was 75 for men and 80 for women.
--The leading causes of death in 2030 are projected to be cancers, ischemic heart disease, stroke, HIV/AIDS, and chronic obstructive pulmonary disease. Tobacco-related deaths are projected to rise from 5.4 million in 2005 to 6.4 million in 2015 and 8.3 million in 2030.
--Ten percent of the world's children under age 5 years suffer wasting as a result of malnutrition, according to 2005 data.
--In 2004, the world spent $4.1 trillion on health.
--In 2002, depression accounted for 4.5% of the total burden of disease worldwide.
WHO report (Free PDFs): http://www.who.int/whosis/whostat2007/en/index.html
17. Education Tool Entitled "tPA for Stroke - Potential Benefit, Risk, and Alternatives" Now Available
AAEM has created an Education Tool entitled ‘tPA for Stroke - Potential Benefit, Risk, and Alternatives,’ which can be viewed at http://aaem.org/education/tpaedtool-AAEM.pdf
The document is designed to help emergency physicians inform patients and family members about the pros and cons of tPA for stroke in appropriate patients.
American Academy of Emergency Medicine
18. Unanticipated Death After Discharge Home From the ED
Sklar DP, et al. Ann Emerg Med. 2007;49:735-745.
Editor’s Capsule Summary
What is already known on this topic: Death of a patient shortly after emergency department (ED) discharge is every emergency physician’s fear, but little is known about the frequency of such events or factors that might contribute to them.
What question this study addressed: The frequency of death occurring within 7 days of ED discharge, whether the death was unexpected, and, if so, whether a medical error may have been contributory.
What this study adds to our knowledge: In this review of almost 400,000 patients discharged from an academic medical center during a 10-year period, roughly 30 per 100,000 patients died within 7 days of ED discharge, 20 per 100,000 unexpectedly and 9 per 100,000 with a potentially contributory medical error. Atypical presentations, exacerbation of chronic disease, abnormal vital signs, and substance abuse were common themes.
How this might change clinical practice: These data may inform efforts to decrease medical errors and identify high-risk patients, such as developing better methods for assessing the significance of abnormal vital signs.
19. Predicting ETT Size by Length in Newborns
The objective of this study was to determine the relationship of length to endotracheal tube (ETT) size in newborns and to use this relationship to develop a tool for predicting ETT size.
The study, a prospective derivation, and validation of a predictive model, took place in the neonatal intensive care units (NICUs) in two urban teaching hospitals. Subjects included: ETT derivation set − 39 intubated neonates admitted to the NICU; Validation set − 69 intubated newborns from the same NICU. Leak percentages were measured in intubated neonates where the actual ETT size did not correlate with the tape-determined ETT size. Interventions were length, weight, and leak measurements. A prototype tape was developed using the derivation set and published anthropometric studies. The accuracy of the tape was validated on a separate set of newborns.
The average relative difference between tape-predicted weight and actual weight was 9.5% (confidence interval [CI] = 8.3–10.6%) and was evenly distributed throughout all the weight groups. The tape predicted actual ETT size in 96% of cases (CI 86.3–99.5%) and was correct within 1 tube size (1/2 mm) in 100% (CI 94.8–100%). The only error in prediction of ETT size was in underestimation. Length-based weight estimations were tested on 100 subjects and predicted actual weight within 20% in 94% of cases. We concluded that length is an accurate predictor of ETT size and weight in term and preterm newborns and may be useful in situations in which weights are unobtainable, such as emergency resuscitation.
Luten R, et al. J Emerg Med 2007;32:342-347.
20. Risk Factors for Traumatic or Unsuccessful LPs in Children
Nigrovic LE, et al. Ann Emerg Med 2007; 49:762-771.
Study objective: Traumatic and unsuccessful lumbar punctures can cause substantial diagnostic ambiguity that may lead to unnecessary antibiotic use and hospitalization, in addition to patient discomfort. Risk factors for obtaining traumatic and unsuccessful lumbar punctures have been studied in a limited fashion only. We sought to determine patient, physician, and procedural factors associated with traumatic and unsuccessful lumbar punctures in children.
Methods: The study included a prospective cohort of all children undergoing lumbar punctures in a single emergency department between July 2003 and January 2005. Our main outcome was either a traumatic lumbar puncture (cerebrospinal fluid RBC counts ≥10,000 cells/mm3) or unsuccessful lumbar puncture (failure of the procedure to yield fluid for cell counts) after the first lumbar puncture attempt. We performed multiple logistic regression analyses to identify independent predictors of traumatic or unsuccessful lumbar punctures.
Results: Of the 1,474 eligible lumbar punctures, 1,459 (99%) were included in the analysis. Of these, 513 (35%) were traumatic or unsuccessful on the first attempt. After adjustment for patient characteristics, physician and procedural factors associated with an increased risk of a traumatic or unsuccessful lumbar puncture included less physician experience (adjusted odds ratio for an ordinal decrease in experience 1.08; 95% confidence interval [CI] 1.01 to 1.15), lack of local anesthetic use (adjusted odds ratio 1.6; 95% CI 1.1 to 2.2), advancement of the spinal needle with stylet in place versus stylet removed (adjusted odds ratio 1.3; 95% CI 1.04 to 1.7), and increased patient movement (adjusted odds ratio 2.1; 95% CI 1.6 to 2.6).
Conclusion: Of the factors associated with traumatic or unsuccessful lumbar punctures in children, advancement of the spinal needle with the stylet in place and lack of local anesthetic use are the most modifiable. Modification of these procedural factors may reduce the risk of traumatic or unsuccessful lumbar punctures in children.
Saturday, May 05, 2007
Lit Bits: May 5, 2007
From the recent medical literature...
1. Antibiotics Not Required for Healing of Simple Cutaneous Abscesses
By Martha Kerr. NEW YORK (Reuters Health) Apr 20 - A course of antibiotics is not required following incision and drainage of simple cutaneous abscesses, a team at the University of Pennsylvania in Philadelphia report in an April 11th online release of an article in press for the Annals of Emergency Medicine.
Guidelines on the best management of abscesses are not clear, Dr. Abigail Hankin and Dr. Worth W. Everett note. Current guidelines from the Infectious Diseases Society of America and the Centers for Disease Control and Prevention state that incision and drainage alone is adequate. However, recurrent abscesses should be presumed to be infected with methicillin-resistant Staphylococcus aureus (MRSA), and should be treated with antibiotics.
The two investigators reviewed the literature and identified five studies and one abstract that directly addressed the issue of use of antibiotics in treating abscesses.
In presenting their findings in the Best Available Evidence section of the Annals, Drs. Hankin and Everett write that "each of the studies concluded that patients treated with incision and drainage alone exhibit resolution of their infection at the same rate as patients who are treated with incision and drainage plus antibiotic therapy." Both groups showed a greater than 90% resolution of symptoms without complications.
None of the studies addressed cases in which there is significant cellulitis accompanying the abbess. Reuters Health asked Dr. Everett about this: "Only one pediatric study suggested that overlying cellulitis greater than 5cm was predictive of later hospitalization," Dr. Everett explained. "But for the practicing clinician, in general, if the extent of the redness is limited to the skin overlying the abscess or only slightly beyond, simple incision and drainage would be recommended. Presence of systemic symptoms (fever, vomiting, etc.) felt to be related to the infection would warrant consideration of antibiotic therapy, but not an absolute," he advised.
Overall, Dr. Everett said, it's a matter of balancing probable benefits and risks. "No practicing physician has a crystal ball and can absolutely predict who will go on to clinical resolution or failure, so almost as important as deciding which course to take is to make sure the patient understands that the wound needs to be rechecked in 2 days and possibly again later to ensure proper healing."
Not using antibiotics means less cost and inconvenience to the patient, Dr. Everett pointed out. "At the same time we are not introducing the elements of adverse medication reactions and side effects, the possibility of drug-drug interactions for those taking other medications, and the potential for breeding antibiotic resistant organisms."
However, questions remain and a multicenter, randomized, placebo-controlled trial is "sorely needed," the U Penn team says.
Hankin A, Everett WW. Ann Emerg Med 2007; print publication pending.
2. New Guidelines for Treatment of Acute Ischemic Stroke
News Author: Susan Jeffrey. April 19, 2007 — The American Heart Association/American Stroke Association has released new guidelines for the early management of acute ischemic stroke. The guidelines continue to endorse the use of intravenous tissue-type plasminogen activator (tPA) but note that other modalities such as intra-arterial tPA show promise. For the first time, the authors have included recommendations for palliative care.
"Our goal was to focus on the first few hours after stroke onset where we think time is so critical," Harold P. Adams Jr., MD, from the University of Iowa Stroke Center in Iowa City, chair of the guidelines writing committee, told Medscape. "The audience is primarily physicians, but we've also included information for general emergency medical services, and some things for the public as well, focusing on the idea that from the first symptom, time is brain, and everything we can do to expedite the process to hopefully treat the patients and reduce the likelihood of an unfavorable outcome is crucial," he said.
The guidelines were published in the April 12 Stroke ASAP issue and will appear in the May print issue of Stroke.
"Time Is Brain"
The new guidelines were extensively revised since 2003. Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise, including imaging and interventional experts.
"Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials," the authors write. Recommendations have been made using an evidence-grading algorithm.
The panel considered aspects of care beginning in the prehospital setting, Dr. Adams said, including recommendations for more public education about the symptoms of stroke, and recommendations about how emergency medical services should interface with hospitals. For example, they recommend that patients should be taken to hospitals with facilities for emergency stroke care, even if this means bypassing closer hospitals. To this end, the authors recommend that more medical centers should consider seeking certification as primary or comprehensive stroke centers from the Joint Commission on Accreditation of Healthcare Organizations.
The "Engine for Emergency Stroke Care"
Intravenous tPA is still recommended as the key treatment of stroke, Dr. Adams noted, "and remains the engine for emergency stroke care." However, the guidelines discuss the use of intra-arterial tPA, he said, "which is becoming an important alternative for patients who cannot receive IV [intravenous] tPA."
The guidelines also discuss the use of mechanical devices such as the Mechanical Embolus Removal in Cerebral Embolism (MERCI) retriever that has been approved for clot removal in the setting of stroke. "We emphasize that this is approved by the FDA [Food and Drug Administration] but we also suggest that there needs to be more evidence to show these sorts of interventions help to improve outcomes," Dr. Adams commented. There has been some controversy that devices are held to a lower standard in this regard compared with drugs, where it must be shown that they not only recanalize a vessel but also result in an improved clinical outcome.
In terms of imaging, there is expanded discussion of magnetic resonance imaging (MRI) for the assessment of acute stroke. "While CT [computed tomography] remains the preferred diagnostic study because it can be done quickly and is more readily available, we also recognize there are advantages from MRI as well, and those are mentioned," Dr. Adams noted.
There also is discussion of general emergent treatment, including a recommendation for aggressive management of hyperglycemia, although this is, "I must admit, based on no definitive data," Dr. Adams added. Other areas of acute treatment such as blood pressure management are still "fertile areas for research," although some recommendations are made.
Finally, for the first time, the authors include discussion of palliative care for patients who have had acute stroke. "For those patients who have such horrendous brain injuries from stroke, who we may not be able to successfully treat, there are options that physicians and families may need to consider in that very difficult situation," Dr. Adams said.
Stroke. 2007;38:1655-1711.
3. Guideline Use Improves Pain Control in Emergency Department
NEW YORK (Reuters Health) Apr 18 - Implementation of pain control guidelines can improve the management of acute pain in the emergency department setting, new research indicates.
Despite being the most common presenting complaining in the emergency department, acute pain is often not managed adequately, Dr. Isabelle Decosterd, from the University of Lausanne in Switzerland, and colleagues note. The goal of the present study was to determine if the implementation of new pain control guidelines could improve analgesia in this setting.
The study, which is reported in the April 16th online issue of the Annals of Emergency Medicine, involved 249 patients who were evaluated for acute pain in the emergency department of the University Hospital Center prior to guideline implementation (Phase I) and 192 who were seen after implementation (Phase II). The guidelines were generated by a multidisciplinary team and presented in algorithm form for use by emergency room personnel.
Prior to the intervention, 40% of patients received analgesia with a 13% satisfaction rate. After the intervention, 63% of patients received analgesia and the satisfaction rate climbed to 69%.
Implementation of the guidelines was associated with greater use of morphine and at higher doses. In addition, use of NSAIDs and acetaminophen increased.
However, the intervention was not associated with more expeditious delivery of analgesia.
The door-to-analgesia "interval did not improve from Phase I to Phase II," Dr. Decosterd said in a statement. "In both phases, three-quarters of patients did not receive analgesia in the first 30 minutes after admission. This suggests that there is further opportunity to better train hospital staff to make rapid pain relief a priority and to meet patient expectations of rapid pain relief after admission to the emergency department."
Ann Emerg Med 2007; in press. Abstract: http://www.annemergmed.com/article/PIIS0196064407000790/abstract
4. Omeprazole Found Beneficial Before Endoscopy for Gastrointestinal Bleeding
The proton-pump inhibitor omeprazole hastened resolution of gastrointestinal bleeding in patients undergoing endoscopy.
In a double-blind, randomized, placebo-controlled trial, some 640 patients in Hong Kong admitted for upper gastrointestinal bleeding received either continuous intravenous infusions of high-dose omeprazole or placebo overnight before endoscopy. The omeprazole group were less likely to require endoscopic treatment (relative risk, 0.67) and were less likely to require therapy for bleeding ulcers (RR, 0.61) than the placebo group.
While acknowledging its limitations (patients on long-term aspirin were excluded), the authors say their study reaffirms that "acid suppression facilitates clot formation over arteries in bleeding peptic ulcers."
Commenting on the study, Journal Watch General Medicine Editor-in-Chief Dr. Allan Brett writes that the trial "corroborates the wisdom of what has already become the standard of care for patients with upper GI bleeding in the U.S. — initiation of a high-dose PPI while the patient awaits upper endoscopy."
NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/short/356/16/1631
5. Guidelines Discourage Routine Antibiotic Prophylaxis for Dental Procedures
New guidelines from the American Heart Association greatly reduce the number of patients for whom antibiotic prophylaxis is recommended to prevent infective endocarditis.
The guidelines, released online in Circulation, recommend prophylaxis only in patients at highest risk for an adverse outcome from endocarditis. These include patients with prosthetic cardiac valves, heart transplant recipients who develop cardiac valvulopathy, those who have previously had infective endocarditis, and some patients with congenital heart disease (unrepaired cyanotic CHD, up to 6 months after a repair with prosthetic material or device, or repaired CHD with residual defects).
In these patients, the guidelines recommend prophylaxis before dental procedures involving the gingival tissue or the periapical region of the teeth or that perforate the oral mucosa. These patients should also receive prophylaxis for procedures on the respiratory tract, infected skin, skin structures, or musculoskeletal tissue.
Antibiotic prophylaxis is not recommended for genitourinary or gastrointestinal tract procedures.
AHA Guidelines: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095v1
6. Niacin (Foolishly) Used in Attempt to Defeat Drug Tests
In a report in today’s MMWR, the CDC describes multiple calls to a poison control center by people who experienced adverse reactions after taking large doses of niacin (nicotinic acid or vitamin B3) to try to prevent positive results on urine drug screenings. The most common reactions were tachycardia, flushed skin, rash, nausea, and vomiting.
The claim that niacin can mask the presence of marijuana in urine tests appears on a large number of websites. An editorial note in MMWR states that "no scientific evidence indicates that taking niacin can alter a urine drug test result." The note goes on to warn clinicians that, "with the Internet now a common source of medical information, clinicians can expect to encounter patients with unusual ADRs resulting from nonscientific drug use."
MMWR article: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5615a2.htm
7. Migraine Increases Risk of Cardiovascular Disease in Men, Just as in Women
Kurth T, et al. Arch Intern Med. 2007;167:795-801.
Background: The vascular component of the migraine-specific physiologic profile and the observed adverse cardiovascular risk profile in migraineurs suggest an association between migraine and cardiovascular disease (CVD). In women, migraine has been associated with increased risk of CVD, including coronary events. Compatible data in men are lacking.
Methods: Prospective cohort study of 20 084 men aged 40 to 84 years participating in the Physicians' Health Study. In yearly questionnaires, men were asked for information on migraine, risk factors, and the occurrence of study end points. We classified men as having migraine if they indicated migraine during the first 5 years, after which time follow-up began. Information on aura was not available. All the men were free of CVD at the start of follow-up. During a mean of 15.7 years, we followed up participants for the occurrence of a first major CVD event (nonfatal ischemic stroke, nonfatal myocardial infarction, or death from ischemic CVD). We also evaluated the individual end points, coronary revascularization, and angina.
Results: A total of 1449 men (7.2%) reported migraine, and during follow-up, 2236 major CVD events occurred. Compared with nonmigraineurs, men who reported migraine had multivariable-adjusted hazard ratios (95% confidence intervals) of 1.24 (1.06-1.46; P = .008) for major CVD, 1.12 (0.84-1.50; P = .43) for ischemic stroke, 1.42 (1.15-1.77; P less than .001) for myocardial infarction, 1.05 (0.89-1.24; P = .54) for coronary revascularization, 1.15 (0.99-1.33; P = .068) for angina, and 1.07 (0.80-1.43; P = .65) for ischemic cardiovascular death.
Conclusion: In this large prospective cohort of apparently healthy men, migraine was associated with increased risk of major CVD, which was driven by increased risk of myocardial infarction.
8. Using Video Images of Dementia in Advance Care Planning
Volandes AE, et al. Arch Intern Med. 2007;167:828-833.
Background: Advance care planning is a process by which patients plan for future medical care under circumstances of impaired decision-making. Central to this process is the patient's understanding and ability to imagine future health states.
Methods: A before and after oral survey was used to compare the effect of a video depiction with that of a verbal description of a patient with advanced dementia for individuals selecting level of medical care at 7 primary care clinics at 2 US medical centers. The study enrolled 120 adults, half of whom were nonwhite.
Results: A total of 120 subjects completed the interview. Before watching the video, 60 (50.0%) subjects preferred comfort care, 25 (20.8%) desired life-prolonging care, 22 (18.3%) chose limited care, and 13 (10.8%) were unsure of their preferences. Subject preferences changed significantly after the video: 107 (89.2%) of the subjects chose comfort care, none desired life-prolonging care, 10 (8.3%) chose limited care, and 3 (2.5%) were unsure of their preferences (P less than .001). Unadjusted analysis revealed a statistically significant difference regarding preferences, based on race/ethnicity, before watching the video: 40% of African Americans and 43% of Latinos chose comfort care, compared with 58% of whites (P = .04). Differences were also noted for educational level (P = .03). After the video, differences in preferences based on race/ethnicity and educational level disappeared.
Conclusions: Watching the video significantly changed preferences for care, transcending apparent differences in preferences associated with race/ethnicity and educational level. This study suggests that using video in addition to improved verbal communication may lead to more informed advance care planning by enhancing the ability of patients to imagine a hypothetical health state.
9. Flu Vaccine Could Prevent Heart Disease Deaths, Study Suggests
Coronary deaths increase during influenza epidemics, a study concludes.
The study, published in the European Heart Journal, was based on about 35,000 autopsy-confirmed deaths from acute myocardial infarction and chronic ischemic heart disease in St. Petersburg, Russia over an 8-year period. During flu epidemics, the odds for MI deaths increased by 1.30 and ischemic heart disease deaths by 1.10, compared with off-season periods.
The investigators conclude that more effort should be made to vaccinate people at risk for coronary heart disease against influenza.
European Heart Journal article (Free abstract; full text requires subscription): http://eurheartj.oxfordjournals.org/cgi/content/abstract/ehm035v1
10. Very Elderly Patients With ACS Benefit From Guideline-Based Care
from Heartwire — a professional news service of WebMD. April 25, 2007 — Increasing adherence to guideline-recommended therapies is associated with reduced mortality in patients with acute coronary syndromes (ACSs) who are aged 90 years or older, according to an analysis of data from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) registry.
The study, published online in the April 13 In Press issue and in the May 1 print issue of the Journal of the American College of Cardiology, was conducted by a group led by Adam H. Skolnick, MD, from Beth Israel Deaconess Medical Center in Boston, Massachusetts.
Senior author David J. Cohen, MD, MSc, from Saint Luke's Mid America Heart Institute in Kansas City, Missouri, commented to heartwire, "There is very little data on patients over 90 years of age, but the CRUSADE database includes more than 5000 ACS patients of this age group, which is one of the largest cohorts of nonagenarians and centenarians ever studied. We showed that although these patients had a higher risk of bleeding complications from aggressive treatment, the benefit still outweighed this risk. In fact, those very elderly patients treated most aggressively had outcomes that were nearly as good as a somewhat younger group of patients. So age in itself should not be a contraindication to aggressive treatment."
In the current study, the authors conclude, "These findings reinforce the importance of optimizing care patterns for even the oldest patients with NSTE [non–ST-segment elevation]-ACS while examining novel approaches to reduce the risk of bleeding for this rapidly expanding patient population."
They note that although just 2% of the US population is older than 85 years, this group accounts for 30% of all myocardial infarction–related deaths. However, these patients often are excluded from clinical trials and are underrepresented in clinical registries, therefore it has not been known whether treatment guidelines, which have been developed on the basis of observations from predominantly younger populations, are applicable to this age group. The authors therefore analyzed data from the CRUSADE registry and compared contemporary treatment and outcomes of 5557 patients with NSTE-ACS 90 years or older with those of 46,270 patients aged 75 to 89 years.
Results showed that in-hospital outcomes for the older elderly were poor, with 1 in 4 patients suffering a major adverse outcome and 1 in 8 not surviving to discharge. Although both groups had much in common, compared with the younger elderly, the older elderly were less likely to be diabetic, smokers, or obese. Among patients without contraindications, the older elderly were less likely to receive glycoprotein IIb/IIIa inhibitors and statins during the first 24 hours and were less likely to undergo cardiac catheterization within 48 hours. The older elderly were more likely to die (12.0% vs 7.8%) and experienced more frequent adverse events (26.8% vs 21.3%) during hospitalization — differences that persisted after adjustment for baseline patient and hospital characteristics.
However, although the older elderly were less likely than their younger elderly counterparts to receive guideline-recommended acute hospital care, there was a strong, graded relationship between receipt of such therapies and lower in-hospital mortality. This relationship was observed despite a graded increase in major bleeding among the older elderly associated with receiving a greater number of antithrombotic and invasive interventions.
J Am Coll Cardiol. Published online April 13, 2007. 2007;49:1790-1797.
11. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade?
Roy CL, et al. JAMA. 2007;297:1810-1818.
Context: Cardiac tamponade is a state of hemodynamic compromise resulting from cardiac compression by fluid trapped in the pericardial space. The clinical examination may assist in the decision to perform pericardiocentesis in patients with cardiac tamponade diagnosed by echocardiography.
Objective: To systematically review the accuracy of the history, physical examination, and basic diagnostic tests for the diagnosis of cardiac tamponade.
Data Sources: MEDLINE search of English-language articles published between 1966 and 2006, reference lists of these articles, and reference lists of relevant textbooks.
Study Selection: We included articles that compared aspects of the clinical examination to a reference standard for the diagnosis of cardiac tamponade. We excluded studies with fewer than 15 patients. Of 787 studies identified by our search strategy, 8 were included in our final analysis.
Data Extraction: Two authors independently reviewed articles for study results and quality. A third reviewer resolved disagreements.
Data Synthesis: All studies evaluated patients with known tamponade or those referred for pericardiocentesis with known effusion. Five features occur in the majority of patients with tamponade: dyspnea (sensitivity range, 87%-89%), tachycardia (pooled sensitivity, 77%; 95% confidence interval [CI], 69%-85%), pulsus paradoxus (pooled sensitivity, 82%; 95% CI, 72%-92%), elevated jugular venous pressure (pooled sensitivity, 76%; 95% CI, 62%-90%), and cardiomegaly on chest radiograph (pooled sensitivity, 89%; 95% CI, 73%-100%). Based on 1 study, the presence of pulsus paradoxus greater than 10 mm Hg in a patient with a pericardial effusion increases the likelihood of tamponade (likelihood ratio, 3.3; 95% CI, 1.8-6.3), while a pulsus paradoxus of 10 mm Hg or less greatly lowers the likelihood (likelihood ratio, 0.03; 95% CI, 0.01-0.24).
Conclusions: Among patients with cardiac tamponade, a minority will not have dyspnea, tachycardia, elevated jugular venous pressure, or cardiomegaly on chest radiograph. A pulsus paradoxus greater than 10 mm Hg among patients with a pericardial effusion helps distinguish those with cardiac tamponade from those without. Diagnostic certainty of the presence of tamponade requires additional testing.
12. JCAHO Tweaks Emergency Departments’ Pneumonia Treatment Standards
Mike Mitka. JAMA. 2007;297:1758-1759.
A performance measure for emergency departments’ treatment of pneumonia is being modified in hopes of better reflecting the true quality of care administered. But will it do so?
At issue is a measure established by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) involving the timing of administration of antibiotics to patients diagnosed with community-acquired pneumonia. When originally issued in 2004, meeting the standard (known as PN-5b) required giving patients who present to an emergency department and are discharged with a diagnosis of pneumonia an antibiotic within 4 hours of presentation. The standard was developed after publication of 2 large retrospective studies showing an association between antibiotic timing and outcomes in patients with pneumonia.
Beginning this month, JCAHO is expanding the antibiotic administration window to the first 6 hours following patient presentation. The agency also will allow a new data element, “diagnostic uncertainty,” if an emergency physician documents that the diagnosis of pneumonia was not clear at the time of the patient’s arrival in the emergency department.
Cases designated as having “diagnostic uncertainty” will not be included in calculations of an emergency department’s success or failure rate regarding the timing of antibiotic administration for pneumonia. This is important not only for emergency departments fulfilling certain quality certifications but also could play a big role in the future as the Centers for Medicare and Medicaid Services introduces “pay-for-performance,” a program for disbursing Medicare funds to hospitals depending, in part, on how well they meet various quality measures, such as timely antibiotic administration for pneumonia.
The antibiotic timing element has frustrated many emergency departments since its inception. Emergency physicians and researchers have argued that this requirement does not reflect real-word experiences of facilities, even those offering high-quality care. They suggest the time limit can have unintended consequences that result in poorer emergency department care of patients without pneumonia, said Jesse M. Pines, MD, an emergency physician at the Hospital of the University of Pennsylvania in Philadelphia. “This is a huge issue in emergency departments,” Pines said. “Because of overcrowding, they are creating protocols where they prioritize pneumonia patients over others.”
INCREASING RESISTANCE?
Another concern is that the time pressure could lead to unnecessary treatment for patients with suspected pneumonia who ultimately receive a different diagnosis, potentially contributing to antibiotic resistance. A retrospective case series study of the UCSF (University of California, San Francisco) Medical Center released in March found the facility was unable to achieve a self-imposed goal of achieving a 90% success rate in giving antibiotics to patients with pneumonia within 4 hours of emergency department presentation (Fee C and Weber EJ. Ann Emerg Med, published online ahead of issue January 8, 2007). In the study of patients admitted to the emergency department during 2005 with an initial diagnosis of community-acquired pneumonia documented at or before admission, only 99 of 152 (65.1%) received antibiotics within the 4-hour time frame. The other 53 patients received antibiotics after 4 hours; and of these patients, 31 (58.5%) received a final diagnosis that was not pneumonia.
“It became clear to me that we’d never hit our 90% core measure without giving inappropriate doses of antibiotics,” said lead author Christopher Fee, MD, assistant clinical professor of medicine in the Division of Emergency Medicine at the University of California, San Francisco. The 90% core measure is the level signifying quality of care recommended by the University
Health Consortium, an alliance of 97 academic medical centers and 153 of their affiliated hospitals, Fee explained.
13. Single Fascia Iliaca Compartment Block for Post-Hip Fracture Pain Relief
Monzon DG, et al. J Emerg Med 2007;32:257-62.
Introduction
More than 500,000 hip fractures occur annually in the United States. About 80% of the fall-related fractures occur in elderly women with osteoporosis. The mechanisms underlying hip fracture in the elderly are complex and multifactorial, involving an interaction between risks for falling and an age-associated decline in bone and muscle mass (possibly related to increased intake of animal proteins), and impairment of neuromuscular function.
Hip fractures usually cause considerable pain. Untreated or under-treated pain and potent systemic analgesics can increase the risk of delirium, especially in elderly patients. The relationship of pain relief to decreased morbidity and mortality remains controversial. The benefits of the acute analgesia play an important role in patient comfort. It permits clinicians to take a more accurate history and do a better physical examination, improves systemic vital signs, and avoids the intense use of non-steroidal analgesics (with the accompanying risk of epigastric pain and coagulation abnormalities), or opioids (altering the sensorium). Therefore, the physician’s goal to relieve pain whenever possible in the most rapid and least damaging manner suggests that a safe and easily performed regional block, rather than mind-altering systemic analgesics, may be a very effective tool.
Pain control is often not a high priority and systemic analgesics can cause or complicate problems, especially in the elderly population most susceptible to hip fractures. Elderly patients (50 years or older) with hip fractures report a 50% to 70% incidence of “severe to very severe” pain in the first 24 h post-injury. Although narcotics continue to be the mainstay for pre- and post-operative pain relief, in this patient group, avoiding or using very low doses of opioids to treat pain significantly decreases the risk to them of developing delirium.
Abstract
Hip fractures can cause considerable pain when untreated or under-treated. To enhance pain relief and diminish the risk of delirium from typically administered parenteral analgesics and continued pain, we tested the efficacy of using fascia-iliaca blocks (FICB), administered by one of four attending physicians working in the emergency department (ED), with commonly available ED equipment. After informed consent, a physician administered one FICB to 63 sequential adult ED patients (43 women, 20 men; ages 37–96 years, mean 73.5 years) with radiographically diagnosed hip fractures.
Under aseptic conditions, a 21 g, 2-inch IM injection needle was inserted perpendicularly to the skin 1 cm below the juncture of the lateral and medial two-thirds of a line that joins the pubic tubercle to the anterior superior iliac spine. The needle was inserted until a loss of resistance was felt twice (fascia lata and fascia iliaca), at which point 0.3 mL/kg of 0.25 bupivacaine was infused. The physician tested the block’s efficacy by assessing sensory loss. Pain assessments were done using a 10-point Likert Visual Analog Scale (VAS) before, and at 15 min, 2 h, and 8 h post-block. Block failure was having the same level of pain as before the block. Oral analgesics were administered as needed. The IRB approved this study.
Post-procedure pain was reduced in all patients, but not completely abolished in any. Before the FICB, the pain ranged from 2 to 10 points (average 8.5) using the VAS; at 15 min post-injection, it ranged from 1 to 7 points (average 2.9); at 2 h post-injection, it ranged from 2 to 6 points (average 2.3); at 8 h post-injection, it ranged from 4 to 7 points (average 4.4). Analgesic requests in the first 24 h after admission averaged 1.2 doses (range 1 to 4 doses) of diclofenac 75 mg. There were no systemic complications and only two local hematomas. Resident physicians learned the procedure and could perform it successfully with less than 5 min instruction. Physicians rarely use the FICB in EDs, although the technique is simple to learn and use. This rapid, effective, and safe method of achieving excellent pain control in ED patients with hip fractures can be performed using standard ED equipment.
14. Role of Early Supported Discharge in Acute Stroke Patients
Stead LG, et al. Ann Emerg Med 2007;49:693-5.
Conclusions
Selected stroke patients in a hospital setting who received input from an early supported discharge service returned home earlier than those receiving conventional care. They were also less likely to be in institutional care; they had decreased risk of death or dependency, at approximately 5 to 6 per 100 in whom intervention was undertaken. Not surprisingly, the greatest benefit was noted in patients with mild to moderate disability who had the most tightly coordinated early supported discharge. The multidisciplinary and structured nature of early supported discharge also appears to increase the patient, but interestingly not caregiver, satisfaction, perhaps because the burden of care would start earlier for the caregiver. The benefits of these results are masked by the fact that patients with less initial disability were recruited and conclusions were based on a relatively small number of trials.
Commentary: Clinical Implication
Stroke is the third leading cause of death in the United States and a major cause of serious, long-term disability. Successful acute stroke intervention depends on early recognition of symptoms, prompt emergency transport, and rapid in-hospital treatment. Considering this increase in incidence, extensive research has been performed to improve patient care and functional outcome. RCTs have shown that care of stroke patients in dedicated stroke units improves outcome compared with alternative forms of care and that beneficial effects are still detectable 5 years after stroke.
This Cochrane review of early discharge after the initial stroke unit care demonstrates that home-based rehabilitation and care is beneficial for patients, especially for those with mild symptoms. Physical and psychosocial elements of the environment influence patients’ ability to perform desired activities and attain targeted levels of participation during rehabilitation. It has also been suggested that increased patient involvement in control of rehabilitation has a better outcome and that diminished control can have an adverse effect on emotional and physical health. Home-based rehabilitation is shown to increase motor and functional gain, with community reintegration and a better perception of physical health.
This systematic review is important to emergency physicians because it highlights the need for stroke care to begin as early as possible, with the emergency physicians identifying and initiating goal-directed management in the emergency department (ED) itself. According to the initial presentation and disability, potential candidates for early supported discharge can be identified. Physical support and rehabilitation units should also be contacted early to enable early supported discharge. Communication can be sent to the stroke unit and rehabilitation department on presentation to the ED. Results of this review lend themselves to the creation of a streamlined protocol whereby the appropriate services such as neurology, physical medicine and rehabilitation, social services, speech and occupational therapy, and psychology could be automatically deployed as early as ED presentation.
The most important limitations in the application of these results stem from the fact that they are based on a limited number of studies and their estimates are influenced by the admission disability. For example, an overall decrease in hospital length of stay is noted. Some of this is influenced by the local practices of individual countries; in countries in which the hospital length of stay is already shorter than “average,” the same benefit may not be possible. Furthermore, the decrease in shorter hospitalization lengths is primarily driven by the more severe strokes, and one questions whether shorter stays for the sickest patients are truly possible or beneficial. Another limitation is that patients with missing data for death outcomes were assumed to be alive and independent, which would bias the benefit of early supported discharge measures. These concerns notwithstanding, the concept of early supported discharge, which requires the formal cooperation of all those involved in the care of a stroke victim, is a proactive approach that deserves further study.
Take-Home Message
With an increase in the incidence of strokes, emergency physicians can expect to encounter more cases in the ED. According to this review, early initiation of supported discharge measures in the ED, in addition to conventional care, may reduce the total duration of hospital stay and thus reduce the overall cost of hospitalization, depending on the initial presentation and disability. Some might argue that large RCTs in this patient population are urgently needed to answer this question definitively; however, in the meantime, this is yet another example of the need for emergency physicians to link with their specialist colleagues to improve the care provided to patients from the time they present to the ED.
15. Comparison of Oral Prednisolone/Paracetamol [APAP] and Oral Indomethacin/Paracetamol Combination Therapy in the Treatment of Acute Goutlike Arthritis: A Double-Blind, RCT
Man CY, et al. Ann Emerg Med 2007;49:670-677.
Background
Acute gouty arthritis is a crystal-induced inflammation of the joint that primarily affects middle-aged and elderly adults. It is the commonest cause of inflammatory joint disease in men older than 40 years. It has been estimated that the overall prevalence in the United Kingdom is 10 per 1,000, with men affected more commonly than women. The diagnosis of acute gout is typically made clinically by the presence of rapid onset of severe pain, swelling, and erythema of an affected joint and definitively by demonstrating the presence of negatively birefringent uric acid crystals in aspirated joint fluid. The diagnosis is often made in the absence of joint aspiration because this procedure is painful, poorly tolerated by some patients, and declined by others and is sometimes difficult or inconvenient to perform in a busy emergency department (ED). The treatment of such patients is inconsistent, and evidence-based guidelines to support clinical management are lacking. Gout is an increasingly prevalent condition worldwide and creates a heavy economic burden.
Importance
Oral nonsteroidal antiinflammatory drugs (NSAIDs) administered in high doses are recommended as first-line agents in the management of gout but may be contraindicated because of gastrointestinal hemorrhage or renal failure. Oral colchicine may be as effective as NSAIDs but is limited by toxicity at higher doses. Intraarticular corticosteroids may also be administered for monoarticular disease and intramuscular corticosteroids for podagra. A few small controlled studies have compared oral NSAIDs with intraarticular or intramuscular steroids and suggest that NSAIDs are as effective as steroids in the treatment of acute gout. However, NSAIDs have a significant rate of adverse effects, including gastric irritation, gastrointestinal hemorrhage, and renal failure. Although steroids cause severe adverse events if taken at high doses for long periods, there appear to be few adverse effects if they are taken in low to moderate doses for short periods. The gastrointestinal adverse effects also appear to be less severe than those of NSAIDs. Long-term effects, such as osteoporosis and muscle wasting, are not relevant to acute gout treatment. Oral NSAIDs have not been compared to oral steroids in the management of acute gout.
Editor’s Capsule Summary
What is already known on this topic: Acute gouty arthritis is typically treated with nonsteroidal antiinflammatory agents, though prednisone has also been recommended. Their relative efficacy is unknown.
What question this study addressed: The efficacy and adverse effects of oral prednisolone and oral indomethacin in the treatment of acute goutlike arthritis in emergency department patients.
What this study adds to our knowledge: In this 90-patient randomized controlled trial, the treatments exhibited similar efficacy. Adverse effects were more common in patients given indomethacin, including gastrointestinal bleeding in 11%.
How this might change clinical practice: A short course of prednisolone is at least as effective as indomethacin and may be safer.
Study objective
We compare the analgesic efficacy and adverse effects of oral prednisolone/acetaminophen and oral indomethacin/acetaminophen combination therapy in the treatment of acute goutlike arthritis in patients presenting to an emergency department (ED).
Methods
This is a double-blind, randomized, controlled study in a university hospital emergency department (ED) in the New Territories of Hong Kong. Patients older than 17 years and presenting between February 1, 2003, and June 30, 2004, with a clinical diagnosis of goutlike arthritis were randomized to receive either oral prednisolone/acetaminophen or oral indomethacin/acetaminophen combination therapy. Primary outcome measures were pain scores, time to resolution of symptoms and signs, and adverse effects. Secondary outcome measures were the need for additional acetaminophen and relapse rate.
Results
There were 90 patients randomized: 46 patients to the indomethacin group and 44 patients to the prednisolone group. Baseline characteristics, including pain scores, were similar in the 2 groups. Both treatment groups had a similar decrease in pain score in the ED. The mean rate of decrease in pain score with activity for indomethacin was −1.7±1.6 (SD) mm per day and for prednisolone was −2.9±2.0 (SD) mm per day (mean difference 1.2 mm/day; 95% confidence interval 0.4 to 2.0 mm/day; P=.0026). Although these differences were statistically significant, at no time was the difference in mean pain score greater than 13 mm. Therefore, it is unclear whether these differences are clinically significant. The mean total dose of acetaminophen consumed by the prednisolone group was significantly more than in the indomethacin group (mean 10.3 g, range 1 to 21 g versus mean 6.4 g, range 1 to 21 g). Twenty-nine patients in the indomethacin group and 12 patients in the prednisolone group experienced adverse effects (P less than .05). The commonest adverse effects in the indomethacin group were nausea, indigestion, epigastric pain, dizziness, and gastrointestinal bleeding (N=5; 11%). None of the patients in the prednisolone group developed gastrointestinal bleeding. The relapse rate for both groups was similar.
Conclusion
In the treatment of acute goutlike arthritis, oral prednisolone/acetaminophen combination is as effective as oral indomethacin/acetaminophen combination in relieving pain but is associated with fewer adverse effects.
16. Decline in Rates of Death and Heart Failure in Acute Coronary Syndromes, 1999-2006
Fox KA, et al, for the GRACE Investigators. JAMA. 2007;297:1892-1900.
Context: Randomized trials provide robust evidence for the impact of pharmacological and interventional treatments in patients with ST-segment elevation and non–ST-segment elevation acute coronary syndromes (NSTE ACS), but whether this translates to changes in clinical practice is unknown.
Objective: To determine whether changes in hospital management of patients with ST-segment elevation myocardial infarction (STEMI) and NSTE ACS are associated with improvements in clinical outcome.
Design, Setting, and Patients: In the Global Registry of Acute Coronary Events (GRACE), a multinational cohort study, 44 372 patients with an ACS were enrolled and followed up in 113 hospitals in 14 countries between July 1, 1999, and December 31, 2006.
Main Outcome Measures: Temporal trends in the use of evidence-based pharmacological and interventional therapies; patient outcomes (death, congestive heart failure, pulmonary edema, cardiogenic shock, stroke, myocardial infarction).
Results: Use of pharmacological medications increased over the study period (beta-blockers, statins, angiotensin-converting enzyme inhibitors, thienopyridines with or without percutaneous coronary intervention [PCI], glycoprotein IIb/IIIa inhibitors, low-molecular-weight heparin; all P less than .001). Pharmacological reperfusion declined in patients with STEMI by –22 percentage points (95% confidence interval [CI], –27 to –17), whereas primary PCI increased by 37 percentage points (95% CI, 33-41). In patients with non-STEMI, rates of PCI increased markedly by 18 percentage points (95% CI, 15-20). Rates of congestive heart failure and pulmonary edema declined in both populations: STEMI, –9 percentage points (95% CI, –12 to –6) and NSTE ACS, –6.9 percentage points (95% CI, –8.4 to –4.7). In patients with STEMI, hospital deaths decreased by 18 percentage points (95% CI, –5.3 to –1.9) and cardiogenic shock by –24 percentage points (95% CI, –4.3 to –0.5). Risk-adjusted hospital deaths declined –0.7 percentage points (95% CI, –1.7 to 0.3) in NSTE ACS patients. Six-month follow-up rates declined among STEMI patients: stroke by –0.8 percentage points (95% CI, –1.7 to 0.1) and myocardial infarction by –2.8 percentage points (95% CI, –6.4 to 0.9). In NSTE ACS, 6-month death declined –1.6 percentage points (95% CI, –3.0 to –0.1) and stroke by 0.7 percentage points (95% CI, –1.4 to 0.1).
Conclusions: In this multinational observational study, improvements in the management of patients with ACS were associated with significant reductions in the rates of new heart failure and mortality and in rates of stroke and myocardial infarction at 6 months.
17. Optic Nerve Sheath Test Identifies Increased Intracranial Pressure
NEW YORK (Reuters Health) May 02 - Sonographic measurement of optic nerve sheath diameter accurately detects increased intracranial pressure in adult patients after head injury, according to a new report.
Although still investigational, measurement of optic nerve sheath diameter is an example of how ultrasound can be applied to common clinical problems, Dr. Vivek S. Tayal from Carolinas Medical Center, Charlotte, North Carolina told Reuters Health.
Dr. Tayal and colleagues investigated whether dilation of the optic nerve sheath, detected in the emergency department with a bedside ultrasonographic measurement, could accurately predict elevated intracranial pressure imaged with cranial CT in 59 adult patients after acute head trauma.
Bedside ultrasonography accurately identified all 8 patients that had CT findings of elevated intracranial pressure, the authors report, for a sensitivity of 100%, they report in the April Annals of Emergency Medicine. In contrast, clinical assessment by treating physicians identified only 2 of the patients with elevated intracranial pressure (sensitivity, 25%), the results indicate.
Both optic nerve sheath diameter and clinical assessment had similar numbers of false-positive results (their specificities for identifying elevated intracranial pressure were 63% and 75%, respectively), the researchers note. The sensitivity of mean binocular optic nerve sheath diameter of 5.00 mm or more for any traumatic intracranial injury found by CT was 84% and the specificity was 73%, the report indicates.
"The answer, so far (I would emphasize this is preliminary work), is that if the optic nerve sheath diameter is high, you need further imaging," Dr. Tayal said. "If the optic nerve sheath diameter is below 5 mm, at least by this work, there is no elevated intracranial pressure."
Ann Emerg Med 2007;49:508-514.
18. Risk Score Useful in Assessing Chest Pain With Normal Troponin Levels
NEW YORK (Reuters Health) Apr 27 - A new risk scoring system is useful in predicting the outcomes of patients with non-ST-segment elevation chest pain and normal troponin levels, according to a recent report.
Dr. Juan Sanchis of the Universitat de Valencia and colleagues in Barcelona, Spain categorized a group of 1,449 patients with chest pain related to non-ST-segment elevation into four groups. A risk score was calculated based on five variables related to death or myocardial infarction at one year:
-- Group 1 had no ST depression, normal troponin and a risk score below 3 (633 patients);
-- Group 2 had no ST depression, a normal troponin level but a risk score of 3 or higher (158 patients);
-- Group 3 had no troponin increase and no ST depression (106 patients); and
-- Group 4 had a troponin increase (552 patients).
Mean follow-up was 26 months. Adverse events at 30 days had occurred in 1.7% of the first group, 10.8% of the second group, 6.6% of the third group and 9.5% of the fourth group. Adverse events at long-term follow-up occurred in 9.4%, 26%, 30% and 25% of groups 1, 2, 3 and 4, respectively. There were no differences in long-term outcome between groups 2, 3 and 4.
Dr. Sanchis' team concludes, in the March 15th issue of the American Journal of Cardiology, that "application of a risk score to patients without troponin increase or ST deviation identified a high-risk group with prognosis similar to that of patients with troponin increase or ST depression and affords a practical classification for the full spectrum of non-ST-elevation chest pain."
Am J Cardiol 2007;99:797-801.
How do they calculate their risk score? Here’s the abstract from an earlier publication:
OBJECTIVES: The purpose of this research was to develop a risk score for patients with chest pain, non-ST-segment deviation electrocardiogram (ECG), and normal troponin levels.
BACKGROUND: Prognosis assessment in this population remains a challenge.
METHODS: A total of 646 consecutive patients were evaluated by clinical history (risk factors and chest pain score according to pain characteristics), ECG, and early exercise testing. ST-segment deviation and troponin elevation were exclusion criteria. The primary end point was mortality or myocardial infarction at one year. The secondary end point was mortality, myocardial infarction, or urgent revascularization at 14 days (similar to the Thrombolysis In Myocardial Infarction [TIMI] risk score).
RESULTS: Primary and secondary end point rates were 6.7% and 5.4%. A risk score was constructed using the variables related to the primary end point: chest pain score 10 points or greater (hazard ratio [HR] = 2.5; 1 point), 2 or more pain episodes in last 24 h (HR = 2.2; 1 point), age 67 years or greater (HR = 2.3; 1 point), insulin-dependent DM (HR = 4.2; 2 points), and prior PTCA (HR = 2.2; 1 point). Patients were classified into five categories of risk (p = 0.0001): 0 points, 0% event rate; 1 point, 3.1%; 2 points, 5.4%; 3 points, 17.6%; 4 or more points, 29.6%. The accuracy of the score was greater than that of the TIMI risk score for the primary (C index of 0.78 vs. 0.66, p = 0.0002) and secondary (C index of 0.70 vs. 0.66, p = 0.1) end points.
CONCLUSIONS: Patients presenting with chest pain despite no ST-segment deviation or troponin elevation show a non-negligible rate of events at one year. A risk score derived from this specific population allows more accurate stratification than when using the TIMI risk score.
Sanchis J, et al. New risk score for patients with acute chest pain, non-ST-segment deviation, and normal troponin concentrations: a comparison with the TIMI risk score. J Am Coll Cardiol. 2005;46:443-9. Full-text: http://content.onlinejacc.org/cgi/reprint/46/3/443
19. Guidelines Updated for Treatment of Spontaneous Intracerebral Hemorrhage in Adults
Laurie Barclay, MD. May 3, 2007 — The American Heart Association (AHA) and American Stroke Association have issued updated evidence-based guidelines for treatment of spontaneous intracerebral hemorrhage (ICH) in adults. The new recommendations, which update the first AHA guidelines for the management of spontaneous ICH published in 1999, are published in the May 3 Stroke ASAP issue and will appear in the June print issue of Stroke.
Recommendations for initial medical therapy for ICH are as follows:
-- Manage blood pressure based on the presently available incomplete evidence, pending results from ongoing clinical trials of blood pressure intervention for ICH.
-- In 1 moderate-sized phase 2 trial, treatment with recombinant activated factor VII within the first 3 to 4 hours after onset appeared to slow progression of bleeding. However, the efficacy and safety of this treatment must be confirmed in phase 3 trials before its use in ICH can be recommended outside of a clinical trial (IIb, B).
-- Use protamine sulfate to reverse heparin-associated ICH, with the dose depending on the time from cessation of heparin (I, B).
-- To reverse the effects of warfarin, treat patients who have warfarin-associated ICH with intravenous vitamin K and with treatment to replace clotting factors (I, B).
-- Prothrombin complex concentrate, factor IX complex concentrate, and recombinant activated factor VII normalize the laboratory elevation of the international normalized ratio very rapidly and with lower volumes of fluid than fresh frozen plasma. However, potential of thromboembolism is greater. Fresh frozen plasma is an option but is associated with greater volumes and much longer infusion times (II, B).
"The first scientifically proven treatments for acute ICH are likely to become a reality during the next 5 years, and possibly sooner for some, such as rFVIIa," the authors conclude. "New trials of antihypertensive therapy, surgical removal of ICH, and other adjunctive therapies are ongoing, but sustained efforts are needed to decrease the high morbidity and mortality rates associated with this deadly type of stroke."
Stroke. Published online May 3, 2007. Full-text: http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.107.183689
20. Busy Admission Days May Jeopardize Patient Safety at Overloaded Hospitals
Weissman JS, et al. Med Care. 2007;45:448-455.
NEW YORK (Reuters Health) May 04 - At hospitals already running at full or over capacity, high admission rates and low staffing levels are associated with an increased risk of adverse patient events, according to report in the May issue of Medical Care.
"While financial and political pressures to make healthcare more efficient are leading to increased hospital occupancy and greater patient turnover, patients and policymakers are quite rightly demanding that health delivery systems be made safer," lead author Dr. Joel Weissman, from Massachusetts General Hospital in Boston, said in a statement. He added, "Our study suggests that pushing efficiency efforts to their limits could be a double-edged sword that may jeopardize patient safety."
The findings stem from an analysis of outcomes for 6841 patients who were discharged between October 2000 and September 2001 from two urban and two suburban teaching hospitals in the US. The daily workload of each hospital was assessed on four parameters: volume (enhanced occupancy rate), throughput (a measure of admissions and discharges), intensity (aggregate diagnosis related group weight), and the patient-to-nurse ratio.
Adverse events were catalogued from chart reviews and included 18 types of injury secondary to medical care (not a result of a patient's underlying condition), and included items such as wound infection, operative injury, postoperative shock, pulmonary embolism, and falls. In total, 1530 adverse events were identified.
The authors found that one of the urban centers had particularly high occupancy rates. Throughout much of the 1-year study period, this hospital was operating at or beyond its designated capacity. At this high-occupancy center, admissions and the patient-to-nurse ratio were directly linked to the adverse event rate (p less than 0.05). For example, for each 10% rise in the patient-to-nurse ratio, the adverse event rate rose 28%. By contrast, these workload variables had little effect on risk at the other three hospitals with lower occupancy rates.
"These data suggest that high workload may be risky at organizations with little slack, and suggest that administrators should adopt an array of measures to try to minimize risk under these circumstances," Dr. Weissman and colleagues conclude.
21. Forced versus minimal intravenous hydration in the management of acute renal colic: a randomized trial.
Springhart WP, et al. J Endourol. 2006;20:713-6.
BACKGROUND AND PURPOSE: The management of acute renal colic is a problem commonly encountered by both urologists and emergency medicine physicians. The classic approach to managing uncomplicated acute renal colic involves hydration, along with imaging and pain control. Previous studies have suggested that hydration has a significant impact on patient comfort, as well as spontaneous stone passage. This study evaluated the effects of maintenance v forced hydration and its effect on the pain experienced from renal colic.
PATIENTS AND METHODS: Forty male and 18 female patients with a mean age of 41 years suspected to have acute renal colic were identified in the emergency department. After screening and informed consent, the patients were enrolled in the study, and 43 patients were eventually available for analysis. Patients received intravenous (IV) analgesia, imaging with a noncontrast CT scan of abdomen and pelvis, and assignment to either forced IV hydration with 2 L of normal saline over 2 hours (N = 20) or minimal IV hydration at 20 mL of normal saline per hour (N = 23). A visual analog pain scale was completed hourly for a total of 4 hours. Demographic information, laboratory and imaging results, narcotic use in morphine equivalents (ME), and pain scores were recorded and compared. Spontaneous stone passage rates were also calculated by careful patient follow-up. Results were considered statistically significant at p less than 0.05.
RESULTS: Stone size was equivalent in the two treatment groups (p greater than 0.05). There was no difference in the narcotic requirement in ME (p = 0.644) between the two groups. Similarly, there was no difference in hourly pain score or stone-passage rates between the groups (p greater than 0.05).
CONCLUSIONS: Treatment of uncomplicated renal colic has traditionally included vigorous intravenous hydration, as well as medications for the control of pain and nausea. Our data suggest that maintenance intravenous fluids are as efficacious as forced hydration with regard to patient pain perception and narcotic use. Moreover, it appears the state of hydration has little impact on stone passage.
1. Antibiotics Not Required for Healing of Simple Cutaneous Abscesses
By Martha Kerr. NEW YORK (Reuters Health) Apr 20 - A course of antibiotics is not required following incision and drainage of simple cutaneous abscesses, a team at the University of Pennsylvania in Philadelphia report in an April 11th online release of an article in press for the Annals of Emergency Medicine.
Guidelines on the best management of abscesses are not clear, Dr. Abigail Hankin and Dr. Worth W. Everett note. Current guidelines from the Infectious Diseases Society of America and the Centers for Disease Control and Prevention state that incision and drainage alone is adequate. However, recurrent abscesses should be presumed to be infected with methicillin-resistant Staphylococcus aureus (MRSA), and should be treated with antibiotics.
The two investigators reviewed the literature and identified five studies and one abstract that directly addressed the issue of use of antibiotics in treating abscesses.
In presenting their findings in the Best Available Evidence section of the Annals, Drs. Hankin and Everett write that "each of the studies concluded that patients treated with incision and drainage alone exhibit resolution of their infection at the same rate as patients who are treated with incision and drainage plus antibiotic therapy." Both groups showed a greater than 90% resolution of symptoms without complications.
None of the studies addressed cases in which there is significant cellulitis accompanying the abbess. Reuters Health asked Dr. Everett about this: "Only one pediatric study suggested that overlying cellulitis greater than 5cm was predictive of later hospitalization," Dr. Everett explained. "But for the practicing clinician, in general, if the extent of the redness is limited to the skin overlying the abscess or only slightly beyond, simple incision and drainage would be recommended. Presence of systemic symptoms (fever, vomiting, etc.) felt to be related to the infection would warrant consideration of antibiotic therapy, but not an absolute," he advised.
Overall, Dr. Everett said, it's a matter of balancing probable benefits and risks. "No practicing physician has a crystal ball and can absolutely predict who will go on to clinical resolution or failure, so almost as important as deciding which course to take is to make sure the patient understands that the wound needs to be rechecked in 2 days and possibly again later to ensure proper healing."
Not using antibiotics means less cost and inconvenience to the patient, Dr. Everett pointed out. "At the same time we are not introducing the elements of adverse medication reactions and side effects, the possibility of drug-drug interactions for those taking other medications, and the potential for breeding antibiotic resistant organisms."
However, questions remain and a multicenter, randomized, placebo-controlled trial is "sorely needed," the U Penn team says.
Hankin A, Everett WW. Ann Emerg Med 2007; print publication pending.
2. New Guidelines for Treatment of Acute Ischemic Stroke
News Author: Susan Jeffrey. April 19, 2007 — The American Heart Association/American Stroke Association has released new guidelines for the early management of acute ischemic stroke. The guidelines continue to endorse the use of intravenous tissue-type plasminogen activator (tPA) but note that other modalities such as intra-arterial tPA show promise. For the first time, the authors have included recommendations for palliative care.
"Our goal was to focus on the first few hours after stroke onset where we think time is so critical," Harold P. Adams Jr., MD, from the University of Iowa Stroke Center in Iowa City, chair of the guidelines writing committee, told Medscape. "The audience is primarily physicians, but we've also included information for general emergency medical services, and some things for the public as well, focusing on the idea that from the first symptom, time is brain, and everything we can do to expedite the process to hopefully treat the patients and reduce the likelihood of an unfavorable outcome is crucial," he said.
The guidelines were published in the April 12 Stroke ASAP issue and will appear in the May print issue of Stroke.
"Time Is Brain"
The new guidelines were extensively revised since 2003. Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise, including imaging and interventional experts.
"Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials," the authors write. Recommendations have been made using an evidence-grading algorithm.
The panel considered aspects of care beginning in the prehospital setting, Dr. Adams said, including recommendations for more public education about the symptoms of stroke, and recommendations about how emergency medical services should interface with hospitals. For example, they recommend that patients should be taken to hospitals with facilities for emergency stroke care, even if this means bypassing closer hospitals. To this end, the authors recommend that more medical centers should consider seeking certification as primary or comprehensive stroke centers from the Joint Commission on Accreditation of Healthcare Organizations.
The "Engine for Emergency Stroke Care"
Intravenous tPA is still recommended as the key treatment of stroke, Dr. Adams noted, "and remains the engine for emergency stroke care." However, the guidelines discuss the use of intra-arterial tPA, he said, "which is becoming an important alternative for patients who cannot receive IV [intravenous] tPA."
The guidelines also discuss the use of mechanical devices such as the Mechanical Embolus Removal in Cerebral Embolism (MERCI) retriever that has been approved for clot removal in the setting of stroke. "We emphasize that this is approved by the FDA [Food and Drug Administration] but we also suggest that there needs to be more evidence to show these sorts of interventions help to improve outcomes," Dr. Adams commented. There has been some controversy that devices are held to a lower standard in this regard compared with drugs, where it must be shown that they not only recanalize a vessel but also result in an improved clinical outcome.
In terms of imaging, there is expanded discussion of magnetic resonance imaging (MRI) for the assessment of acute stroke. "While CT [computed tomography] remains the preferred diagnostic study because it can be done quickly and is more readily available, we also recognize there are advantages from MRI as well, and those are mentioned," Dr. Adams noted.
There also is discussion of general emergent treatment, including a recommendation for aggressive management of hyperglycemia, although this is, "I must admit, based on no definitive data," Dr. Adams added. Other areas of acute treatment such as blood pressure management are still "fertile areas for research," although some recommendations are made.
Finally, for the first time, the authors include discussion of palliative care for patients who have had acute stroke. "For those patients who have such horrendous brain injuries from stroke, who we may not be able to successfully treat, there are options that physicians and families may need to consider in that very difficult situation," Dr. Adams said.
Stroke. 2007;38:1655-1711.
3. Guideline Use Improves Pain Control in Emergency Department
NEW YORK (Reuters Health) Apr 18 - Implementation of pain control guidelines can improve the management of acute pain in the emergency department setting, new research indicates.
Despite being the most common presenting complaining in the emergency department, acute pain is often not managed adequately, Dr. Isabelle Decosterd, from the University of Lausanne in Switzerland, and colleagues note. The goal of the present study was to determine if the implementation of new pain control guidelines could improve analgesia in this setting.
The study, which is reported in the April 16th online issue of the Annals of Emergency Medicine, involved 249 patients who were evaluated for acute pain in the emergency department of the University Hospital Center prior to guideline implementation (Phase I) and 192 who were seen after implementation (Phase II). The guidelines were generated by a multidisciplinary team and presented in algorithm form for use by emergency room personnel.
Prior to the intervention, 40% of patients received analgesia with a 13% satisfaction rate. After the intervention, 63% of patients received analgesia and the satisfaction rate climbed to 69%.
Implementation of the guidelines was associated with greater use of morphine and at higher doses. In addition, use of NSAIDs and acetaminophen increased.
However, the intervention was not associated with more expeditious delivery of analgesia.
The door-to-analgesia "interval did not improve from Phase I to Phase II," Dr. Decosterd said in a statement. "In both phases, three-quarters of patients did not receive analgesia in the first 30 minutes after admission. This suggests that there is further opportunity to better train hospital staff to make rapid pain relief a priority and to meet patient expectations of rapid pain relief after admission to the emergency department."
Ann Emerg Med 2007; in press. Abstract: http://www.annemergmed.com/article/PIIS0196064407000790/abstract
4. Omeprazole Found Beneficial Before Endoscopy for Gastrointestinal Bleeding
The proton-pump inhibitor omeprazole hastened resolution of gastrointestinal bleeding in patients undergoing endoscopy.
In a double-blind, randomized, placebo-controlled trial, some 640 patients in Hong Kong admitted for upper gastrointestinal bleeding received either continuous intravenous infusions of high-dose omeprazole or placebo overnight before endoscopy. The omeprazole group were less likely to require endoscopic treatment (relative risk, 0.67) and were less likely to require therapy for bleeding ulcers (RR, 0.61) than the placebo group.
While acknowledging its limitations (patients on long-term aspirin were excluded), the authors say their study reaffirms that "acid suppression facilitates clot formation over arteries in bleeding peptic ulcers."
Commenting on the study, Journal Watch General Medicine Editor-in-Chief Dr. Allan Brett writes that the trial "corroborates the wisdom of what has already become the standard of care for patients with upper GI bleeding in the U.S. — initiation of a high-dose PPI while the patient awaits upper endoscopy."
NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/short/356/16/1631
5. Guidelines Discourage Routine Antibiotic Prophylaxis for Dental Procedures
New guidelines from the American Heart Association greatly reduce the number of patients for whom antibiotic prophylaxis is recommended to prevent infective endocarditis.
The guidelines, released online in Circulation, recommend prophylaxis only in patients at highest risk for an adverse outcome from endocarditis. These include patients with prosthetic cardiac valves, heart transplant recipients who develop cardiac valvulopathy, those who have previously had infective endocarditis, and some patients with congenital heart disease (unrepaired cyanotic CHD, up to 6 months after a repair with prosthetic material or device, or repaired CHD with residual defects).
In these patients, the guidelines recommend prophylaxis before dental procedures involving the gingival tissue or the periapical region of the teeth or that perforate the oral mucosa. These patients should also receive prophylaxis for procedures on the respiratory tract, infected skin, skin structures, or musculoskeletal tissue.
Antibiotic prophylaxis is not recommended for genitourinary or gastrointestinal tract procedures.
AHA Guidelines: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095v1
6. Niacin (Foolishly) Used in Attempt to Defeat Drug Tests
In a report in today’s MMWR, the CDC describes multiple calls to a poison control center by people who experienced adverse reactions after taking large doses of niacin (nicotinic acid or vitamin B3) to try to prevent positive results on urine drug screenings. The most common reactions were tachycardia, flushed skin, rash, nausea, and vomiting.
The claim that niacin can mask the presence of marijuana in urine tests appears on a large number of websites. An editorial note in MMWR states that "no scientific evidence indicates that taking niacin can alter a urine drug test result." The note goes on to warn clinicians that, "with the Internet now a common source of medical information, clinicians can expect to encounter patients with unusual ADRs resulting from nonscientific drug use."
MMWR article: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5615a2.htm
7. Migraine Increases Risk of Cardiovascular Disease in Men, Just as in Women
Kurth T, et al. Arch Intern Med. 2007;167:795-801.
Background: The vascular component of the migraine-specific physiologic profile and the observed adverse cardiovascular risk profile in migraineurs suggest an association between migraine and cardiovascular disease (CVD). In women, migraine has been associated with increased risk of CVD, including coronary events. Compatible data in men are lacking.
Methods: Prospective cohort study of 20 084 men aged 40 to 84 years participating in the Physicians' Health Study. In yearly questionnaires, men were asked for information on migraine, risk factors, and the occurrence of study end points. We classified men as having migraine if they indicated migraine during the first 5 years, after which time follow-up began. Information on aura was not available. All the men were free of CVD at the start of follow-up. During a mean of 15.7 years, we followed up participants for the occurrence of a first major CVD event (nonfatal ischemic stroke, nonfatal myocardial infarction, or death from ischemic CVD). We also evaluated the individual end points, coronary revascularization, and angina.
Results: A total of 1449 men (7.2%) reported migraine, and during follow-up, 2236 major CVD events occurred. Compared with nonmigraineurs, men who reported migraine had multivariable-adjusted hazard ratios (95% confidence intervals) of 1.24 (1.06-1.46; P = .008) for major CVD, 1.12 (0.84-1.50; P = .43) for ischemic stroke, 1.42 (1.15-1.77; P less than .001) for myocardial infarction, 1.05 (0.89-1.24; P = .54) for coronary revascularization, 1.15 (0.99-1.33; P = .068) for angina, and 1.07 (0.80-1.43; P = .65) for ischemic cardiovascular death.
Conclusion: In this large prospective cohort of apparently healthy men, migraine was associated with increased risk of major CVD, which was driven by increased risk of myocardial infarction.
8. Using Video Images of Dementia in Advance Care Planning
Volandes AE, et al. Arch Intern Med. 2007;167:828-833.
Background: Advance care planning is a process by which patients plan for future medical care under circumstances of impaired decision-making. Central to this process is the patient's understanding and ability to imagine future health states.
Methods: A before and after oral survey was used to compare the effect of a video depiction with that of a verbal description of a patient with advanced dementia for individuals selecting level of medical care at 7 primary care clinics at 2 US medical centers. The study enrolled 120 adults, half of whom were nonwhite.
Results: A total of 120 subjects completed the interview. Before watching the video, 60 (50.0%) subjects preferred comfort care, 25 (20.8%) desired life-prolonging care, 22 (18.3%) chose limited care, and 13 (10.8%) were unsure of their preferences. Subject preferences changed significantly after the video: 107 (89.2%) of the subjects chose comfort care, none desired life-prolonging care, 10 (8.3%) chose limited care, and 3 (2.5%) were unsure of their preferences (P less than .001). Unadjusted analysis revealed a statistically significant difference regarding preferences, based on race/ethnicity, before watching the video: 40% of African Americans and 43% of Latinos chose comfort care, compared with 58% of whites (P = .04). Differences were also noted for educational level (P = .03). After the video, differences in preferences based on race/ethnicity and educational level disappeared.
Conclusions: Watching the video significantly changed preferences for care, transcending apparent differences in preferences associated with race/ethnicity and educational level. This study suggests that using video in addition to improved verbal communication may lead to more informed advance care planning by enhancing the ability of patients to imagine a hypothetical health state.
9. Flu Vaccine Could Prevent Heart Disease Deaths, Study Suggests
Coronary deaths increase during influenza epidemics, a study concludes.
The study, published in the European Heart Journal, was based on about 35,000 autopsy-confirmed deaths from acute myocardial infarction and chronic ischemic heart disease in St. Petersburg, Russia over an 8-year period. During flu epidemics, the odds for MI deaths increased by 1.30 and ischemic heart disease deaths by 1.10, compared with off-season periods.
The investigators conclude that more effort should be made to vaccinate people at risk for coronary heart disease against influenza.
European Heart Journal article (Free abstract; full text requires subscription): http://eurheartj.oxfordjournals.org/cgi/content/abstract/ehm035v1
10. Very Elderly Patients With ACS Benefit From Guideline-Based Care
from Heartwire — a professional news service of WebMD. April 25, 2007 — Increasing adherence to guideline-recommended therapies is associated with reduced mortality in patients with acute coronary syndromes (ACSs) who are aged 90 years or older, according to an analysis of data from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) registry.
The study, published online in the April 13 In Press issue and in the May 1 print issue of the Journal of the American College of Cardiology, was conducted by a group led by Adam H. Skolnick, MD, from Beth Israel Deaconess Medical Center in Boston, Massachusetts.
Senior author David J. Cohen, MD, MSc, from Saint Luke's Mid America Heart Institute in Kansas City, Missouri, commented to heartwire, "There is very little data on patients over 90 years of age, but the CRUSADE database includes more than 5000 ACS patients of this age group, which is one of the largest cohorts of nonagenarians and centenarians ever studied. We showed that although these patients had a higher risk of bleeding complications from aggressive treatment, the benefit still outweighed this risk. In fact, those very elderly patients treated most aggressively had outcomes that were nearly as good as a somewhat younger group of patients. So age in itself should not be a contraindication to aggressive treatment."
In the current study, the authors conclude, "These findings reinforce the importance of optimizing care patterns for even the oldest patients with NSTE [non–ST-segment elevation]-ACS while examining novel approaches to reduce the risk of bleeding for this rapidly expanding patient population."
They note that although just 2% of the US population is older than 85 years, this group accounts for 30% of all myocardial infarction–related deaths. However, these patients often are excluded from clinical trials and are underrepresented in clinical registries, therefore it has not been known whether treatment guidelines, which have been developed on the basis of observations from predominantly younger populations, are applicable to this age group. The authors therefore analyzed data from the CRUSADE registry and compared contemporary treatment and outcomes of 5557 patients with NSTE-ACS 90 years or older with those of 46,270 patients aged 75 to 89 years.
Results showed that in-hospital outcomes for the older elderly were poor, with 1 in 4 patients suffering a major adverse outcome and 1 in 8 not surviving to discharge. Although both groups had much in common, compared with the younger elderly, the older elderly were less likely to be diabetic, smokers, or obese. Among patients without contraindications, the older elderly were less likely to receive glycoprotein IIb/IIIa inhibitors and statins during the first 24 hours and were less likely to undergo cardiac catheterization within 48 hours. The older elderly were more likely to die (12.0% vs 7.8%) and experienced more frequent adverse events (26.8% vs 21.3%) during hospitalization — differences that persisted after adjustment for baseline patient and hospital characteristics.
However, although the older elderly were less likely than their younger elderly counterparts to receive guideline-recommended acute hospital care, there was a strong, graded relationship between receipt of such therapies and lower in-hospital mortality. This relationship was observed despite a graded increase in major bleeding among the older elderly associated with receiving a greater number of antithrombotic and invasive interventions.
J Am Coll Cardiol. Published online April 13, 2007. 2007;49:1790-1797.
11. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade?
Roy CL, et al. JAMA. 2007;297:1810-1818.
Context: Cardiac tamponade is a state of hemodynamic compromise resulting from cardiac compression by fluid trapped in the pericardial space. The clinical examination may assist in the decision to perform pericardiocentesis in patients with cardiac tamponade diagnosed by echocardiography.
Objective: To systematically review the accuracy of the history, physical examination, and basic diagnostic tests for the diagnosis of cardiac tamponade.
Data Sources: MEDLINE search of English-language articles published between 1966 and 2006, reference lists of these articles, and reference lists of relevant textbooks.
Study Selection: We included articles that compared aspects of the clinical examination to a reference standard for the diagnosis of cardiac tamponade. We excluded studies with fewer than 15 patients. Of 787 studies identified by our search strategy, 8 were included in our final analysis.
Data Extraction: Two authors independently reviewed articles for study results and quality. A third reviewer resolved disagreements.
Data Synthesis: All studies evaluated patients with known tamponade or those referred for pericardiocentesis with known effusion. Five features occur in the majority of patients with tamponade: dyspnea (sensitivity range, 87%-89%), tachycardia (pooled sensitivity, 77%; 95% confidence interval [CI], 69%-85%), pulsus paradoxus (pooled sensitivity, 82%; 95% CI, 72%-92%), elevated jugular venous pressure (pooled sensitivity, 76%; 95% CI, 62%-90%), and cardiomegaly on chest radiograph (pooled sensitivity, 89%; 95% CI, 73%-100%). Based on 1 study, the presence of pulsus paradoxus greater than 10 mm Hg in a patient with a pericardial effusion increases the likelihood of tamponade (likelihood ratio, 3.3; 95% CI, 1.8-6.3), while a pulsus paradoxus of 10 mm Hg or less greatly lowers the likelihood (likelihood ratio, 0.03; 95% CI, 0.01-0.24).
Conclusions: Among patients with cardiac tamponade, a minority will not have dyspnea, tachycardia, elevated jugular venous pressure, or cardiomegaly on chest radiograph. A pulsus paradoxus greater than 10 mm Hg among patients with a pericardial effusion helps distinguish those with cardiac tamponade from those without. Diagnostic certainty of the presence of tamponade requires additional testing.
12. JCAHO Tweaks Emergency Departments’ Pneumonia Treatment Standards
Mike Mitka. JAMA. 2007;297:1758-1759.
A performance measure for emergency departments’ treatment of pneumonia is being modified in hopes of better reflecting the true quality of care administered. But will it do so?
At issue is a measure established by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) involving the timing of administration of antibiotics to patients diagnosed with community-acquired pneumonia. When originally issued in 2004, meeting the standard (known as PN-5b) required giving patients who present to an emergency department and are discharged with a diagnosis of pneumonia an antibiotic within 4 hours of presentation. The standard was developed after publication of 2 large retrospective studies showing an association between antibiotic timing and outcomes in patients with pneumonia.
Beginning this month, JCAHO is expanding the antibiotic administration window to the first 6 hours following patient presentation. The agency also will allow a new data element, “diagnostic uncertainty,” if an emergency physician documents that the diagnosis of pneumonia was not clear at the time of the patient’s arrival in the emergency department.
Cases designated as having “diagnostic uncertainty” will not be included in calculations of an emergency department’s success or failure rate regarding the timing of antibiotic administration for pneumonia. This is important not only for emergency departments fulfilling certain quality certifications but also could play a big role in the future as the Centers for Medicare and Medicaid Services introduces “pay-for-performance,” a program for disbursing Medicare funds to hospitals depending, in part, on how well they meet various quality measures, such as timely antibiotic administration for pneumonia.
The antibiotic timing element has frustrated many emergency departments since its inception. Emergency physicians and researchers have argued that this requirement does not reflect real-word experiences of facilities, even those offering high-quality care. They suggest the time limit can have unintended consequences that result in poorer emergency department care of patients without pneumonia, said Jesse M. Pines, MD, an emergency physician at the Hospital of the University of Pennsylvania in Philadelphia. “This is a huge issue in emergency departments,” Pines said. “Because of overcrowding, they are creating protocols where they prioritize pneumonia patients over others.”
INCREASING RESISTANCE?
Another concern is that the time pressure could lead to unnecessary treatment for patients with suspected pneumonia who ultimately receive a different diagnosis, potentially contributing to antibiotic resistance. A retrospective case series study of the UCSF (University of California, San Francisco) Medical Center released in March found the facility was unable to achieve a self-imposed goal of achieving a 90% success rate in giving antibiotics to patients with pneumonia within 4 hours of emergency department presentation (Fee C and Weber EJ. Ann Emerg Med, published online ahead of issue January 8, 2007). In the study of patients admitted to the emergency department during 2005 with an initial diagnosis of community-acquired pneumonia documented at or before admission, only 99 of 152 (65.1%) received antibiotics within the 4-hour time frame. The other 53 patients received antibiotics after 4 hours; and of these patients, 31 (58.5%) received a final diagnosis that was not pneumonia.
“It became clear to me that we’d never hit our 90% core measure without giving inappropriate doses of antibiotics,” said lead author Christopher Fee, MD, assistant clinical professor of medicine in the Division of Emergency Medicine at the University of California, San Francisco. The 90% core measure is the level signifying quality of care recommended by the University
Health Consortium, an alliance of 97 academic medical centers and 153 of their affiliated hospitals, Fee explained.
13. Single Fascia Iliaca Compartment Block for Post-Hip Fracture Pain Relief
Monzon DG, et al. J Emerg Med 2007;32:257-62.
Introduction
More than 500,000 hip fractures occur annually in the United States. About 80% of the fall-related fractures occur in elderly women with osteoporosis. The mechanisms underlying hip fracture in the elderly are complex and multifactorial, involving an interaction between risks for falling and an age-associated decline in bone and muscle mass (possibly related to increased intake of animal proteins), and impairment of neuromuscular function.
Hip fractures usually cause considerable pain. Untreated or under-treated pain and potent systemic analgesics can increase the risk of delirium, especially in elderly patients. The relationship of pain relief to decreased morbidity and mortality remains controversial. The benefits of the acute analgesia play an important role in patient comfort. It permits clinicians to take a more accurate history and do a better physical examination, improves systemic vital signs, and avoids the intense use of non-steroidal analgesics (with the accompanying risk of epigastric pain and coagulation abnormalities), or opioids (altering the sensorium). Therefore, the physician’s goal to relieve pain whenever possible in the most rapid and least damaging manner suggests that a safe and easily performed regional block, rather than mind-altering systemic analgesics, may be a very effective tool.
Pain control is often not a high priority and systemic analgesics can cause or complicate problems, especially in the elderly population most susceptible to hip fractures. Elderly patients (50 years or older) with hip fractures report a 50% to 70% incidence of “severe to very severe” pain in the first 24 h post-injury. Although narcotics continue to be the mainstay for pre- and post-operative pain relief, in this patient group, avoiding or using very low doses of opioids to treat pain significantly decreases the risk to them of developing delirium.
Abstract
Hip fractures can cause considerable pain when untreated or under-treated. To enhance pain relief and diminish the risk of delirium from typically administered parenteral analgesics and continued pain, we tested the efficacy of using fascia-iliaca blocks (FICB), administered by one of four attending physicians working in the emergency department (ED), with commonly available ED equipment. After informed consent, a physician administered one FICB to 63 sequential adult ED patients (43 women, 20 men; ages 37–96 years, mean 73.5 years) with radiographically diagnosed hip fractures.
Under aseptic conditions, a 21 g, 2-inch IM injection needle was inserted perpendicularly to the skin 1 cm below the juncture of the lateral and medial two-thirds of a line that joins the pubic tubercle to the anterior superior iliac spine. The needle was inserted until a loss of resistance was felt twice (fascia lata and fascia iliaca), at which point 0.3 mL/kg of 0.25 bupivacaine was infused. The physician tested the block’s efficacy by assessing sensory loss. Pain assessments were done using a 10-point Likert Visual Analog Scale (VAS) before, and at 15 min, 2 h, and 8 h post-block. Block failure was having the same level of pain as before the block. Oral analgesics were administered as needed. The IRB approved this study.
Post-procedure pain was reduced in all patients, but not completely abolished in any. Before the FICB, the pain ranged from 2 to 10 points (average 8.5) using the VAS; at 15 min post-injection, it ranged from 1 to 7 points (average 2.9); at 2 h post-injection, it ranged from 2 to 6 points (average 2.3); at 8 h post-injection, it ranged from 4 to 7 points (average 4.4). Analgesic requests in the first 24 h after admission averaged 1.2 doses (range 1 to 4 doses) of diclofenac 75 mg. There were no systemic complications and only two local hematomas. Resident physicians learned the procedure and could perform it successfully with less than 5 min instruction. Physicians rarely use the FICB in EDs, although the technique is simple to learn and use. This rapid, effective, and safe method of achieving excellent pain control in ED patients with hip fractures can be performed using standard ED equipment.
14. Role of Early Supported Discharge in Acute Stroke Patients
Stead LG, et al. Ann Emerg Med 2007;49:693-5.
Conclusions
Selected stroke patients in a hospital setting who received input from an early supported discharge service returned home earlier than those receiving conventional care. They were also less likely to be in institutional care; they had decreased risk of death or dependency, at approximately 5 to 6 per 100 in whom intervention was undertaken. Not surprisingly, the greatest benefit was noted in patients with mild to moderate disability who had the most tightly coordinated early supported discharge. The multidisciplinary and structured nature of early supported discharge also appears to increase the patient, but interestingly not caregiver, satisfaction, perhaps because the burden of care would start earlier for the caregiver. The benefits of these results are masked by the fact that patients with less initial disability were recruited and conclusions were based on a relatively small number of trials.
Commentary: Clinical Implication
Stroke is the third leading cause of death in the United States and a major cause of serious, long-term disability. Successful acute stroke intervention depends on early recognition of symptoms, prompt emergency transport, and rapid in-hospital treatment. Considering this increase in incidence, extensive research has been performed to improve patient care and functional outcome. RCTs have shown that care of stroke patients in dedicated stroke units improves outcome compared with alternative forms of care and that beneficial effects are still detectable 5 years after stroke.
This Cochrane review of early discharge after the initial stroke unit care demonstrates that home-based rehabilitation and care is beneficial for patients, especially for those with mild symptoms. Physical and psychosocial elements of the environment influence patients’ ability to perform desired activities and attain targeted levels of participation during rehabilitation. It has also been suggested that increased patient involvement in control of rehabilitation has a better outcome and that diminished control can have an adverse effect on emotional and physical health. Home-based rehabilitation is shown to increase motor and functional gain, with community reintegration and a better perception of physical health.
This systematic review is important to emergency physicians because it highlights the need for stroke care to begin as early as possible, with the emergency physicians identifying and initiating goal-directed management in the emergency department (ED) itself. According to the initial presentation and disability, potential candidates for early supported discharge can be identified. Physical support and rehabilitation units should also be contacted early to enable early supported discharge. Communication can be sent to the stroke unit and rehabilitation department on presentation to the ED. Results of this review lend themselves to the creation of a streamlined protocol whereby the appropriate services such as neurology, physical medicine and rehabilitation, social services, speech and occupational therapy, and psychology could be automatically deployed as early as ED presentation.
The most important limitations in the application of these results stem from the fact that they are based on a limited number of studies and their estimates are influenced by the admission disability. For example, an overall decrease in hospital length of stay is noted. Some of this is influenced by the local practices of individual countries; in countries in which the hospital length of stay is already shorter than “average,” the same benefit may not be possible. Furthermore, the decrease in shorter hospitalization lengths is primarily driven by the more severe strokes, and one questions whether shorter stays for the sickest patients are truly possible or beneficial. Another limitation is that patients with missing data for death outcomes were assumed to be alive and independent, which would bias the benefit of early supported discharge measures. These concerns notwithstanding, the concept of early supported discharge, which requires the formal cooperation of all those involved in the care of a stroke victim, is a proactive approach that deserves further study.
Take-Home Message
With an increase in the incidence of strokes, emergency physicians can expect to encounter more cases in the ED. According to this review, early initiation of supported discharge measures in the ED, in addition to conventional care, may reduce the total duration of hospital stay and thus reduce the overall cost of hospitalization, depending on the initial presentation and disability. Some might argue that large RCTs in this patient population are urgently needed to answer this question definitively; however, in the meantime, this is yet another example of the need for emergency physicians to link with their specialist colleagues to improve the care provided to patients from the time they present to the ED.
15. Comparison of Oral Prednisolone/Paracetamol [APAP] and Oral Indomethacin/Paracetamol Combination Therapy in the Treatment of Acute Goutlike Arthritis: A Double-Blind, RCT
Man CY, et al. Ann Emerg Med 2007;49:670-677.
Background
Acute gouty arthritis is a crystal-induced inflammation of the joint that primarily affects middle-aged and elderly adults. It is the commonest cause of inflammatory joint disease in men older than 40 years. It has been estimated that the overall prevalence in the United Kingdom is 10 per 1,000, with men affected more commonly than women. The diagnosis of acute gout is typically made clinically by the presence of rapid onset of severe pain, swelling, and erythema of an affected joint and definitively by demonstrating the presence of negatively birefringent uric acid crystals in aspirated joint fluid. The diagnosis is often made in the absence of joint aspiration because this procedure is painful, poorly tolerated by some patients, and declined by others and is sometimes difficult or inconvenient to perform in a busy emergency department (ED). The treatment of such patients is inconsistent, and evidence-based guidelines to support clinical management are lacking. Gout is an increasingly prevalent condition worldwide and creates a heavy economic burden.
Importance
Oral nonsteroidal antiinflammatory drugs (NSAIDs) administered in high doses are recommended as first-line agents in the management of gout but may be contraindicated because of gastrointestinal hemorrhage or renal failure. Oral colchicine may be as effective as NSAIDs but is limited by toxicity at higher doses. Intraarticular corticosteroids may also be administered for monoarticular disease and intramuscular corticosteroids for podagra. A few small controlled studies have compared oral NSAIDs with intraarticular or intramuscular steroids and suggest that NSAIDs are as effective as steroids in the treatment of acute gout. However, NSAIDs have a significant rate of adverse effects, including gastric irritation, gastrointestinal hemorrhage, and renal failure. Although steroids cause severe adverse events if taken at high doses for long periods, there appear to be few adverse effects if they are taken in low to moderate doses for short periods. The gastrointestinal adverse effects also appear to be less severe than those of NSAIDs. Long-term effects, such as osteoporosis and muscle wasting, are not relevant to acute gout treatment. Oral NSAIDs have not been compared to oral steroids in the management of acute gout.
Editor’s Capsule Summary
What is already known on this topic: Acute gouty arthritis is typically treated with nonsteroidal antiinflammatory agents, though prednisone has also been recommended. Their relative efficacy is unknown.
What question this study addressed: The efficacy and adverse effects of oral prednisolone and oral indomethacin in the treatment of acute goutlike arthritis in emergency department patients.
What this study adds to our knowledge: In this 90-patient randomized controlled trial, the treatments exhibited similar efficacy. Adverse effects were more common in patients given indomethacin, including gastrointestinal bleeding in 11%.
How this might change clinical practice: A short course of prednisolone is at least as effective as indomethacin and may be safer.
Study objective
We compare the analgesic efficacy and adverse effects of oral prednisolone/acetaminophen and oral indomethacin/acetaminophen combination therapy in the treatment of acute goutlike arthritis in patients presenting to an emergency department (ED).
Methods
This is a double-blind, randomized, controlled study in a university hospital emergency department (ED) in the New Territories of Hong Kong. Patients older than 17 years and presenting between February 1, 2003, and June 30, 2004, with a clinical diagnosis of goutlike arthritis were randomized to receive either oral prednisolone/acetaminophen or oral indomethacin/acetaminophen combination therapy. Primary outcome measures were pain scores, time to resolution of symptoms and signs, and adverse effects. Secondary outcome measures were the need for additional acetaminophen and relapse rate.
Results
There were 90 patients randomized: 46 patients to the indomethacin group and 44 patients to the prednisolone group. Baseline characteristics, including pain scores, were similar in the 2 groups. Both treatment groups had a similar decrease in pain score in the ED. The mean rate of decrease in pain score with activity for indomethacin was −1.7±1.6 (SD) mm per day and for prednisolone was −2.9±2.0 (SD) mm per day (mean difference 1.2 mm/day; 95% confidence interval 0.4 to 2.0 mm/day; P=.0026). Although these differences were statistically significant, at no time was the difference in mean pain score greater than 13 mm. Therefore, it is unclear whether these differences are clinically significant. The mean total dose of acetaminophen consumed by the prednisolone group was significantly more than in the indomethacin group (mean 10.3 g, range 1 to 21 g versus mean 6.4 g, range 1 to 21 g). Twenty-nine patients in the indomethacin group and 12 patients in the prednisolone group experienced adverse effects (P less than .05). The commonest adverse effects in the indomethacin group were nausea, indigestion, epigastric pain, dizziness, and gastrointestinal bleeding (N=5; 11%). None of the patients in the prednisolone group developed gastrointestinal bleeding. The relapse rate for both groups was similar.
Conclusion
In the treatment of acute goutlike arthritis, oral prednisolone/acetaminophen combination is as effective as oral indomethacin/acetaminophen combination in relieving pain but is associated with fewer adverse effects.
16. Decline in Rates of Death and Heart Failure in Acute Coronary Syndromes, 1999-2006
Fox KA, et al, for the GRACE Investigators. JAMA. 2007;297:1892-1900.
Context: Randomized trials provide robust evidence for the impact of pharmacological and interventional treatments in patients with ST-segment elevation and non–ST-segment elevation acute coronary syndromes (NSTE ACS), but whether this translates to changes in clinical practice is unknown.
Objective: To determine whether changes in hospital management of patients with ST-segment elevation myocardial infarction (STEMI) and NSTE ACS are associated with improvements in clinical outcome.
Design, Setting, and Patients: In the Global Registry of Acute Coronary Events (GRACE), a multinational cohort study, 44 372 patients with an ACS were enrolled and followed up in 113 hospitals in 14 countries between July 1, 1999, and December 31, 2006.
Main Outcome Measures: Temporal trends in the use of evidence-based pharmacological and interventional therapies; patient outcomes (death, congestive heart failure, pulmonary edema, cardiogenic shock, stroke, myocardial infarction).
Results: Use of pharmacological medications increased over the study period (beta-blockers, statins, angiotensin-converting enzyme inhibitors, thienopyridines with or without percutaneous coronary intervention [PCI], glycoprotein IIb/IIIa inhibitors, low-molecular-weight heparin; all P less than .001). Pharmacological reperfusion declined in patients with STEMI by –22 percentage points (95% confidence interval [CI], –27 to –17), whereas primary PCI increased by 37 percentage points (95% CI, 33-41). In patients with non-STEMI, rates of PCI increased markedly by 18 percentage points (95% CI, 15-20). Rates of congestive heart failure and pulmonary edema declined in both populations: STEMI, –9 percentage points (95% CI, –12 to –6) and NSTE ACS, –6.9 percentage points (95% CI, –8.4 to –4.7). In patients with STEMI, hospital deaths decreased by 18 percentage points (95% CI, –5.3 to –1.9) and cardiogenic shock by –24 percentage points (95% CI, –4.3 to –0.5). Risk-adjusted hospital deaths declined –0.7 percentage points (95% CI, –1.7 to 0.3) in NSTE ACS patients. Six-month follow-up rates declined among STEMI patients: stroke by –0.8 percentage points (95% CI, –1.7 to 0.1) and myocardial infarction by –2.8 percentage points (95% CI, –6.4 to 0.9). In NSTE ACS, 6-month death declined –1.6 percentage points (95% CI, –3.0 to –0.1) and stroke by 0.7 percentage points (95% CI, –1.4 to 0.1).
Conclusions: In this multinational observational study, improvements in the management of patients with ACS were associated with significant reductions in the rates of new heart failure and mortality and in rates of stroke and myocardial infarction at 6 months.
17. Optic Nerve Sheath Test Identifies Increased Intracranial Pressure
NEW YORK (Reuters Health) May 02 - Sonographic measurement of optic nerve sheath diameter accurately detects increased intracranial pressure in adult patients after head injury, according to a new report.
Although still investigational, measurement of optic nerve sheath diameter is an example of how ultrasound can be applied to common clinical problems, Dr. Vivek S. Tayal from Carolinas Medical Center, Charlotte, North Carolina told Reuters Health.
Dr. Tayal and colleagues investigated whether dilation of the optic nerve sheath, detected in the emergency department with a bedside ultrasonographic measurement, could accurately predict elevated intracranial pressure imaged with cranial CT in 59 adult patients after acute head trauma.
Bedside ultrasonography accurately identified all 8 patients that had CT findings of elevated intracranial pressure, the authors report, for a sensitivity of 100%, they report in the April Annals of Emergency Medicine. In contrast, clinical assessment by treating physicians identified only 2 of the patients with elevated intracranial pressure (sensitivity, 25%), the results indicate.
Both optic nerve sheath diameter and clinical assessment had similar numbers of false-positive results (their specificities for identifying elevated intracranial pressure were 63% and 75%, respectively), the researchers note. The sensitivity of mean binocular optic nerve sheath diameter of 5.00 mm or more for any traumatic intracranial injury found by CT was 84% and the specificity was 73%, the report indicates.
"The answer, so far (I would emphasize this is preliminary work), is that if the optic nerve sheath diameter is high, you need further imaging," Dr. Tayal said. "If the optic nerve sheath diameter is below 5 mm, at least by this work, there is no elevated intracranial pressure."
Ann Emerg Med 2007;49:508-514.
18. Risk Score Useful in Assessing Chest Pain With Normal Troponin Levels
NEW YORK (Reuters Health) Apr 27 - A new risk scoring system is useful in predicting the outcomes of patients with non-ST-segment elevation chest pain and normal troponin levels, according to a recent report.
Dr. Juan Sanchis of the Universitat de Valencia and colleagues in Barcelona, Spain categorized a group of 1,449 patients with chest pain related to non-ST-segment elevation into four groups. A risk score was calculated based on five variables related to death or myocardial infarction at one year:
-- Group 1 had no ST depression, normal troponin and a risk score below 3 (633 patients);
-- Group 2 had no ST depression, a normal troponin level but a risk score of 3 or higher (158 patients);
-- Group 3 had no troponin increase and no ST depression (106 patients); and
-- Group 4 had a troponin increase (552 patients).
Mean follow-up was 26 months. Adverse events at 30 days had occurred in 1.7% of the first group, 10.8% of the second group, 6.6% of the third group and 9.5% of the fourth group. Adverse events at long-term follow-up occurred in 9.4%, 26%, 30% and 25% of groups 1, 2, 3 and 4, respectively. There were no differences in long-term outcome between groups 2, 3 and 4.
Dr. Sanchis' team concludes, in the March 15th issue of the American Journal of Cardiology, that "application of a risk score to patients without troponin increase or ST deviation identified a high-risk group with prognosis similar to that of patients with troponin increase or ST depression and affords a practical classification for the full spectrum of non-ST-elevation chest pain."
Am J Cardiol 2007;99:797-801.
How do they calculate their risk score? Here’s the abstract from an earlier publication:
OBJECTIVES: The purpose of this research was to develop a risk score for patients with chest pain, non-ST-segment deviation electrocardiogram (ECG), and normal troponin levels.
BACKGROUND: Prognosis assessment in this population remains a challenge.
METHODS: A total of 646 consecutive patients were evaluated by clinical history (risk factors and chest pain score according to pain characteristics), ECG, and early exercise testing. ST-segment deviation and troponin elevation were exclusion criteria. The primary end point was mortality or myocardial infarction at one year. The secondary end point was mortality, myocardial infarction, or urgent revascularization at 14 days (similar to the Thrombolysis In Myocardial Infarction [TIMI] risk score).
RESULTS: Primary and secondary end point rates were 6.7% and 5.4%. A risk score was constructed using the variables related to the primary end point: chest pain score 10 points or greater (hazard ratio [HR] = 2.5; 1 point), 2 or more pain episodes in last 24 h (HR = 2.2; 1 point), age 67 years or greater (HR = 2.3; 1 point), insulin-dependent DM (HR = 4.2; 2 points), and prior PTCA (HR = 2.2; 1 point). Patients were classified into five categories of risk (p = 0.0001): 0 points, 0% event rate; 1 point, 3.1%; 2 points, 5.4%; 3 points, 17.6%; 4 or more points, 29.6%. The accuracy of the score was greater than that of the TIMI risk score for the primary (C index of 0.78 vs. 0.66, p = 0.0002) and secondary (C index of 0.70 vs. 0.66, p = 0.1) end points.
CONCLUSIONS: Patients presenting with chest pain despite no ST-segment deviation or troponin elevation show a non-negligible rate of events at one year. A risk score derived from this specific population allows more accurate stratification than when using the TIMI risk score.
Sanchis J, et al. New risk score for patients with acute chest pain, non-ST-segment deviation, and normal troponin concentrations: a comparison with the TIMI risk score. J Am Coll Cardiol. 2005;46:443-9. Full-text: http://content.onlinejacc.org/cgi/reprint/46/3/443
19. Guidelines Updated for Treatment of Spontaneous Intracerebral Hemorrhage in Adults
Laurie Barclay, MD. May 3, 2007 — The American Heart Association (AHA) and American Stroke Association have issued updated evidence-based guidelines for treatment of spontaneous intracerebral hemorrhage (ICH) in adults. The new recommendations, which update the first AHA guidelines for the management of spontaneous ICH published in 1999, are published in the May 3 Stroke ASAP issue and will appear in the June print issue of Stroke.
Recommendations for initial medical therapy for ICH are as follows:
-- Manage blood pressure based on the presently available incomplete evidence, pending results from ongoing clinical trials of blood pressure intervention for ICH.
-- In 1 moderate-sized phase 2 trial, treatment with recombinant activated factor VII within the first 3 to 4 hours after onset appeared to slow progression of bleeding. However, the efficacy and safety of this treatment must be confirmed in phase 3 trials before its use in ICH can be recommended outside of a clinical trial (IIb, B).
-- Use protamine sulfate to reverse heparin-associated ICH, with the dose depending on the time from cessation of heparin (I, B).
-- To reverse the effects of warfarin, treat patients who have warfarin-associated ICH with intravenous vitamin K and with treatment to replace clotting factors (I, B).
-- Prothrombin complex concentrate, factor IX complex concentrate, and recombinant activated factor VII normalize the laboratory elevation of the international normalized ratio very rapidly and with lower volumes of fluid than fresh frozen plasma. However, potential of thromboembolism is greater. Fresh frozen plasma is an option but is associated with greater volumes and much longer infusion times (II, B).
"The first scientifically proven treatments for acute ICH are likely to become a reality during the next 5 years, and possibly sooner for some, such as rFVIIa," the authors conclude. "New trials of antihypertensive therapy, surgical removal of ICH, and other adjunctive therapies are ongoing, but sustained efforts are needed to decrease the high morbidity and mortality rates associated with this deadly type of stroke."
Stroke. Published online May 3, 2007. Full-text: http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.107.183689
20. Busy Admission Days May Jeopardize Patient Safety at Overloaded Hospitals
Weissman JS, et al. Med Care. 2007;45:448-455.
NEW YORK (Reuters Health) May 04 - At hospitals already running at full or over capacity, high admission rates and low staffing levels are associated with an increased risk of adverse patient events, according to report in the May issue of Medical Care.
"While financial and political pressures to make healthcare more efficient are leading to increased hospital occupancy and greater patient turnover, patients and policymakers are quite rightly demanding that health delivery systems be made safer," lead author Dr. Joel Weissman, from Massachusetts General Hospital in Boston, said in a statement. He added, "Our study suggests that pushing efficiency efforts to their limits could be a double-edged sword that may jeopardize patient safety."
The findings stem from an analysis of outcomes for 6841 patients who were discharged between October 2000 and September 2001 from two urban and two suburban teaching hospitals in the US. The daily workload of each hospital was assessed on four parameters: volume (enhanced occupancy rate), throughput (a measure of admissions and discharges), intensity (aggregate diagnosis related group weight), and the patient-to-nurse ratio.
Adverse events were catalogued from chart reviews and included 18 types of injury secondary to medical care (not a result of a patient's underlying condition), and included items such as wound infection, operative injury, postoperative shock, pulmonary embolism, and falls. In total, 1530 adverse events were identified.
The authors found that one of the urban centers had particularly high occupancy rates. Throughout much of the 1-year study period, this hospital was operating at or beyond its designated capacity. At this high-occupancy center, admissions and the patient-to-nurse ratio were directly linked to the adverse event rate (p less than 0.05). For example, for each 10% rise in the patient-to-nurse ratio, the adverse event rate rose 28%. By contrast, these workload variables had little effect on risk at the other three hospitals with lower occupancy rates.
"These data suggest that high workload may be risky at organizations with little slack, and suggest that administrators should adopt an array of measures to try to minimize risk under these circumstances," Dr. Weissman and colleagues conclude.
21. Forced versus minimal intravenous hydration in the management of acute renal colic: a randomized trial.
Springhart WP, et al. J Endourol. 2006;20:713-6.
BACKGROUND AND PURPOSE: The management of acute renal colic is a problem commonly encountered by both urologists and emergency medicine physicians. The classic approach to managing uncomplicated acute renal colic involves hydration, along with imaging and pain control. Previous studies have suggested that hydration has a significant impact on patient comfort, as well as spontaneous stone passage. This study evaluated the effects of maintenance v forced hydration and its effect on the pain experienced from renal colic.
PATIENTS AND METHODS: Forty male and 18 female patients with a mean age of 41 years suspected to have acute renal colic were identified in the emergency department. After screening and informed consent, the patients were enrolled in the study, and 43 patients were eventually available for analysis. Patients received intravenous (IV) analgesia, imaging with a noncontrast CT scan of abdomen and pelvis, and assignment to either forced IV hydration with 2 L of normal saline over 2 hours (N = 20) or minimal IV hydration at 20 mL of normal saline per hour (N = 23). A visual analog pain scale was completed hourly for a total of 4 hours. Demographic information, laboratory and imaging results, narcotic use in morphine equivalents (ME), and pain scores were recorded and compared. Spontaneous stone passage rates were also calculated by careful patient follow-up. Results were considered statistically significant at p less than 0.05.
RESULTS: Stone size was equivalent in the two treatment groups (p greater than 0.05). There was no difference in the narcotic requirement in ME (p = 0.644) between the two groups. Similarly, there was no difference in hourly pain score or stone-passage rates between the groups (p greater than 0.05).
CONCLUSIONS: Treatment of uncomplicated renal colic has traditionally included vigorous intravenous hydration, as well as medications for the control of pain and nausea. Our data suggest that maintenance intravenous fluids are as efficacious as forced hydration with regard to patient pain perception and narcotic use. Moreover, it appears the state of hydration has little impact on stone passage.
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