From the recent medical literature...
1. Only One-Third of Adults Know Heart Attack Signs
Only about one-third of U.S. adults are aware of the five major warning signs of heart attacks, according to a CDC survey in MMWR.
The telephone survey of 72,000 people, conducted in 2005, found that, nationally:
• 48% recognize pain or discomfort in the jaw, neck, or back as a warning sign;
• 62%, feeling weak, lightheaded, or faint;
• 85%, pain or discomfort in the arms or shoulder;
• 92%, chest pain or discomfort;
• 93%, shortness of breath.
The numbers were even lower among non-Hispanic blacks and Hispanics, men, and those with less than a high school education. In addition, 86% said they would dial 911 if they thought someone was having a heart attack or stroke.
MMWR article (Free): http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5707a3.htm
2. Patients Less Likely to Survive In-Hospital Cardiac Arrests on Nights, Weekends
Cardiac arrest during the night or on weekends places hospital patients at higher risk for death and complications, a JAMA article reports.
Using national registry data on nearly 87,000 adult cardiac arrests occurring between 2000 and 2007, researchers characterized the events by time-of-day and day-of-week. When compared with arrests that occurred during the day or evening hours, nighttime events (11 p.m. to 7 a.m.) showed significantly lower rates of survival to discharge, return of spontaneous circulation for more than 20 minutes, survival at 24 hours, and favorable neurologic outcome.
Rates on weekends were similar to those on weekday nights.
The authors write that, in searching for causes, "it is reasonable to focus on the potential for decreased physical and psychological performance on the part of the health care worker, different staffing patterns, and less patient surveillance during nights and weekends."
JAMA article (Free abstract; full text requires subscription): http://jama.ama-assn.org/cgi/content/short/299/7/785
3. Increased Blood Pressure in the ED: Pain, Anxiety, or Undiagnosed HTN?
Tanabe P, et al. Ann Emerg Med. 2008;51:221-229.
It is unclear how often increased blood pressure in emergency department (ED) patients is a marker of chronic essential hypertension and how often it is a transient finding related to stress. So this study asked ‘how frequently is an increased blood pressure in ED patients without known hypertension sustained at home?’ Of 156 ED patients prospectively followed at a single urban site, half had sustained hypertension at home. ED blood pressure increase was not associated with increased anxiety or pain. How this might change clinical practice? Patients with increased blood pressure in the ED should be advised to have serial blood pressure checks so that essential hypertension can be confirmed or excluded.
Annals abstract: http://www.annemergmed.com/article/S0196-0644(07)01670-8/abstract
Full-text: http://www.annemergmed.com/article/S0196-0644(07)01670-8/fulltext
4. Bacteria Continue to Evolve in Face of Iatrogenic Selection Pressure
A. Multidrug-Resistant E. Coli Emerging
Clinicians should be aware of the emergence of multidrug-resistant Enterobacteriaceae that produce extended-spectrum beta-lactamases (ESBLs), according to a review article in Lancet Infectious Diseases.
These bacteria are becoming important causes of urinary tract infections, and treatment failures are likely because of their broad resistance, the article says. A recent trend is community-acquired bloodstream infections caused by ESBL-producing bacteria, mostly E. coli. Though still rare, it's possible that in the near future, "clinicians will be regularly confronted with hospital types of bacteria causing infections in patients from the community," a situation similar to community-acquired MRSA.
Lancet ID abstract: http://www.thelancet.com/journals/laninf/article/PIIS1473309908700410/abstract
B. First Cases of Fluoroquinolone-Resistant N. meningitidis Reported
The first cluster of fluoroquinolone-resistant meningococcal disease in North America has been documented along the Minnesota-North Dakota border, according to a report in MMWR.
Three cases of disease resulting from resistant N. meningitidis have occurred there over the past year. The CDC says ciprofloxacin (Cipro) should not be used for chemoprophylaxis of close contacts of people with meningococcal disease in a 34-county area in the two states but can still be used elsewhere. In the affected area, the agency recommends use of rifampin, ceftriaxone, or azithromycin.
An editorial note says all cases of ciprofloxacin-resistant meningococcal disease and ciprofloxacin prophylaxis failures should be reported to the CDC as well as state and local health authorities.
MMWR article (Free): http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5707a2.htm
5. Intravenous dexamethasone vs placebo as adjunctive therapy to reduce the recurrence rate of acute migraine headaches: a multicenter, double-blinded, placebo-controlled randomized clinical trial
Donaldson D, et al. Amer J Emerg Med. 2008;26:124-130.
Objectives
Some physicians prescribe corticosteroids as adjunctive therapy for patients with migraine headaches to decrease the rate of rebound headache. The efficacy of this practice has not been tested. Our objective is to determine the efficacy of single-dose dexamethasone as adjunctive therapy for emergency medicine patients with migraine headache in preventing headache recurrence at 3 and 30 days posttreatment.
Methods
From November 2004 to November 2005, we conducted a multicenter, double-blinded, placebo-controlled randomized clinical trial of adult patients who met the International Headache Society definition of migraine headache. After informed consent, patients were randomly assigned to one of two groups: receiving either placebo or 24 mg dexamethasone intravenously. To ensure generalizability, all other aspects of patient care were left to the discretion of the emergency physician. Clinical and demographic information was obtained; and patients were subsequently contacted at both 3 and 30 days to determine headache recurrence, current functional disability, and need for return to the ED. Our primary outcome measures were the recurrence of migraine headache at 3 and 30 days. We used Fisher exact to test for statistical significance.
Results
A total of 115 patients were enrolled, with 16 patients lost to follow-up at 3 days and 3 additional patients lost at 30 days. Baseline characteristics as well as adverse event profiles were equivalent in both study groups. At 3-day follow-up, 45% (95% confidence interval [CI] 31%-60%) of the placebo group had recurrence of their migraine compared with 35% (95% CI 24%-48%) in the dexamethasone group (P = .68). At 30-day follow-up, this relative reduction in migraine recurrence decreased to a 4% difference between the 2 groups (P = .68). Limitations include small sample size and significant proportion lost to follow-up.
Conclusion
A single dose of dexamethasone as adjunctive therapy for migraine headache does not decrease the recurrence of migraines at 3 or 30 days.
6. MRSA: Deadly Super Bug or Just Another Staph?
Talan DA. Ann Emerg Med. 2008;51:299-302.
Opening paragraphs
Commenting on an article by Klevens et al in the Journal of the American Medical Association that described the incidence of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections, an editorialist estimated that more patients died with invasive MRSA than died because of HIV/AIDS in the United States in 2005. Simultaneous reports of MRSA outbreaks among high school athletes and deaths in previously healthy children set off a media frenzy calling MRSA a deadly “super bug.” Certainly the emergency department (ED) would seem to be a good place to study the epidemiology of this new disease whose impact has been confused and sensationalized. In this issue of Annals, Pallin et al attempt to answer the question of whether MRSA infection is associated with more patients being treated in EDs with skin and soft tissue infections than in the past.
We already know that the ecology of skin and soft tissue infections has changed dramatically. Our ED-based emerging infections surveillance network, EMERGEncy ID NET, reported that MRSA caused 59% of skin and soft tissue infections among 422 adults treated at 11 geographically diverse US EDs in August 2004. Almost all isolates were the newly recognized community-associated MRSA USA 300, which contained genes for Panton-Valentine leukocidin toxin and carried staphylococcal cassette chromosome (SCCmec) type IV. Before this millennium, MRSA was rarely found in community-presenting infections. For example, we found no MRSA, either community-associated MRSA or the older health care–associated strain, in a bacteriologic study of 160 cutaneous abscesses among patients presenting to the ED from 1992 to 1994; methicillin-susceptible S aureus was the most common pathogen, found in 50%.
Although community-associated MRSA now is recognized to cause more of patients’ skin and soft tissue infections, does it cause more people to have skin and soft tissue infections? In other words, has the emergence of community-associated MRSA resulted in an increased burden of disease, not just a change in the strain-specific cause? This is the question that Pallin et al attempted to answer…
Closing paragraph
Community-associated MRSA is not a deadly super bug. It is more like an aggressive type of standard honeybee than the Africanized variety; more apt to sting, usually causing a mild and sometimes uncomfortable lesion that is infrequently more serious, but only rarely fatal. Although community-associated MRSA appears to be more efficient at causing infection in healthy individuals than methicillin-susceptible S aureus, particularly among groups with frequent skin-to-skin contact, most infections are uncomplicated skin and soft tissue infections. Patients with community-associated MRSA skin and soft tissue infections should be reassured that they have a good prognosis and many antibiotic treatment options, including several inexpensive oral drugs. Continued surveillance for invasive community-associated MRSA will help determine whether the low rate of more serious community-associated MRSA infections is increasing. Despite limitations, the Pallin et al findings are compelling and suggest that community-associated MRSA has resulted in a significantly increased burden of disease and that additional attention and resources should be directed to monitor, prevent, and control this emerging problem.
For the rest of the article: http://www.annemergmed.com/article/S0196-0644(07)01856-2/fulltext
7. Meta-Analysis Shows That Statins Reduce the Incidence and Recurrence of AF
Michael O'Riordan. from Heartwire — a professional news service of WebMD. February 20, 2008 — A study published this week provides a little more evidence that the benefit of statins extends beyond their ability to lower low-density lipoprotein (LDL) cholesterol levels [1]. In a new meta-analysis, investigators showed that the use of statins was significantly associated with a decreased risk of incidence or recurrence of atrial fibrillation (AF) in patients in sinus rhythm with a history of previous AF, those undergoing cardiac surgery, or those prescribed the drugs after an acute coronary syndrome (ACS).
In a paper published in the February 18, 2008 issue of the Journal of the American College of Cardiology, a special issue focusing on AF, Dr Laurent Fauchier (Centre Hospitalier Universitaire Trousseau, Tours, France) and colleagues note that the "beneficial effect seemed more marked in the prevention of AF recurrence than in primary prevention of AF" but cautioned against making too much of this finding as there was only a trend of benefit in these patients.
The meta-analysis included six studies with approximately 3500 patients in sinus rhythm. Three studies investigated the use of statins in patients with a history of paroxysmal AF or persistent AF undergoing electrical cardioversion, while the others investigated the use of statins in primary prevention of AF in patients undergoing cardiac surgery or following ACS. The follow-up in the six trials ranged from three to 26 weeks, and in five of the six studies, atorvastatin was the statin prescribed.
Treatment with a statin reduced the incidence and recurrence of AF 61% compared with placebo. While there were trends toward significance in primary- and secondary-prevention subset analyses, none of these reductions were statistically significant. The overall results were similar when investigators excluded the Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) study, which was published only in abstract form. They note that the protective benefit of statins did not appear to be related to dose, as individual odds ratios were similar in the studies that used atorvastatin 40 mg and 80 mg to studies that used lower doses.
While the mechanisms of benefit are still unknown, Fauchier and colleagues note that statins reduce inflammation and that inflammation is involved in the "development, recurrence, and persistence of AF." They also note that some evidence suggests an association between AF and enhanced renin angiotensin system (RAS) activity. Other studies have also suggested a link between dyslipidemia and the RAS, and with statins reducing cholesterol levels, the drugs might downregulate the RAS and possibly explain the antiarrhythmic effects observed.
Still, large-scale, prospective, randomized clinical trials are needed to establish whether statins bring a similar benefit to those not part of the patient population in this meta-analysis and to explore whether the drugs might be an appropriate therapeutic option in all subgroups of patients for the management of AF, conclude the authors.
[1] Source: Fauchier L, et al. J Am Coll Cardiol. 2008;51:828-835.
8. Higher PEEP probably best for people with acute lung injury and respiratory distress syndrome
JAMA, Feb 13, 2008. Positive pressure ventilation is unphysiological and further damages the lungs of patients with acute lung injury and respiratory distress syndrome. Using a small tidal volume helps, and animal models suggest that a high positive end expiratory pressure (PEEP) can also improve outcome by stopping alveoli from collapsing at the end of each expiration. Proving it in humans is hard work, however, and two big trials recently reported no difference in mortality between groups of patients treated with higher and lower levels of PEEP.
The trials tested complex protocols that titrated PEEP according to either oxygenation or lung mechanics (pulmonary pressure and volume). In both, one group had end expiratory pressures of 15-16 cm H2O on day 1 and the other group had mean pressures of 8-10.1 cm H2O. The extra end expiratory pressure didn’t save lives, but it did seem to improve some measures of morbidity, including risk of hypoxaemia or organ failure and time on the ventilator.
At least two experts say these results are enough to support a strategy of higher PEEP for people with acute lung injury and acute respiratory distress syndrome. It is still possible that a subset of the sickest patients will survive longer, and for the rest it is fairly clear that this strategy does no harm.
JAMA 2008;299:637-45. Abstract: http://jama.ama-assn.org/cgi/content/abstract/299/6/637
JAMA 2008;299:646-55. Abstract: http://jama.ama-assn.org/cgi/content/abstract/299/6/646
9. Caution About Vasopressor Use in Hemorrhagic Shock
Use of vasopressors was associated with increased mortality 24 hours after injury.
Crystalloid resuscitation is a mainstay in the management of post-traumatic hemorrhagic shock, but excessive fluid administration might increase or aggravate coagulopathy, abdominal compartment syndrome, pulmonary and cardiac dysfunction, gastrointestinal ileus, and bowel anastomotic complications. These risks, coupled with hemorrhagic-shock research in animal models that has demonstrated a benefit of vasopressin and phenylephrine compared with crystalloid alone, have prompted increased exploration of the use of vasopressors. Investigators used data from a prospective multicenter cohort study (Inflammation and the Host Response to Injury program) to evaluate use of early vasopressor therapy and aggressive early crystalloid resuscitation in trauma patients.
Patients admitted to seven U.S. institutions between 2003 and 2007 were eligible if they were aged 16 to 90 and had a blunt mechanism of injury, systolic blood pressure less than 90 mm Hg prehospital or in the emergency department or elevated base deficit (6 mEq/L) in the ED, blood transfusion requirement within the first 12 hours of injury, and any body region other than the brain with an Abbreviated Injury Scale score 2. Mortality rates were compared between patients who did and did not receive early (within 12 hours of injury) vasopressor therapy (Levophed, phenylephrine, dopamine, or vasopressin) and between patients who did and did not receive aggressive early crystalloid resuscitation (16 L within 12 hours post-injury). Analyses were controlled for important physiologic, injury, resuscitation, and demographic parameters.
Among 921 patients, the overall mortality rate was 12% and the mean Injury Severity Scale score was 31. Use of vasopressors (any of the 4 studied) within 12 hours after injury, compared with no use of vasopressors, was associated with an increased mortality risk (hazard ratio, 1.81), as was use of vasopressors within 24 hours after injury (HR, 2.15). Aggressive early crystalloid resuscitation within 12 hours, compared with no use of crystalloid resuscitation, was associated with a reduction in mortality (HR, 0.59). In analysis by age (55 vs. those older than 55), the only significant finding was a protective effect of aggressive early crystalloid resuscitation in the younger group (HR, 0.54).
Comment: Data from this large prospective cohort demonstrate nearly doubled mortality in patients who received early vasopressor therapy compared with those who did not. However, patient management — notably the use of vasopressor therapy and the amount and rate of crystalloid resuscitation — was not controlled. A prospective, randomized, provider-blinded study is needed to definitively resolve this issue.
— John A. Marx, MD. Published in Journal Watch EM February 22, 2008. Citation: Sperry JL et al. J Trauma 2008;64:9.
10. The Claim: Stretching Can Prevent Soreness and Injury. Really??
By Anahad C’Connor. New York Times. February 26, 2008
THE FACTS
Stretching — long promoted as a way to prevent injury, to reduce soreness and to speed post-exercise recovery — may not fulfill its promise. Over the years, scientists have found that stretching before or after a workout has little effect on either risk of injury or what is commonly known as delayed onset of muscle soreness, the discomfort that comes a day or more after challenging physical activity.
Numerous studies have reached this conclusion. One of the most recent and extensive reports was published in October in The Cochrane Database of Systematic Reviews. The report reviewed 10 randomized studies, which over all looked at the impact of stretching before and after exercise, in repeated sessions and in intervals ranging from 40 seconds to 10 minutes. The authors concluded that stretching had little or no effect on post-exercise soreness.
Another systematic review, by the Centers for Disease Control and Prevention, was published in the journal Medicine and Science in Sports and Exercise in 2004. It looked at multiple studies and found that stretching “was not significantly associated with a reduction in total injuries,” but also concluded that more research was needed.
For now, many experts say that what may work is a quick warm-up, like low-impact aerobics or walking. It also helps to ease into an activity by starting off slow and then increasing speed, intensity or weight (for lifting).
THE BOTTOM LINE
Research suggests that stretching does not affect soreness or risk of injury during exercise.
11. Low Diagnostic Yield of Electrocardiogram Testing in Younger Patients With Syncope
BC Sun, JR Hoffman, WR Mower, et al. Ann Emerg Med. 2008;51:240-246.
Although a number of published guidelines recommend ECG testing in patients with syncope, the diagnostic yield is low. This prospective study examined the frequency of ECG abnormalities in emergency department (ED) patients with syncope, whether abnormalities predict subsequent cardiac events, and whether either varies as a function of age. What this study adds to our knowledge: The ECG result was abnormal in a significant proportion of the 461 patients but did not reveal a cause of syncope in any of those younger than 40 years. How this might change clinical practice: If confirmed in larger studies, immediate ECG testing may not be necessary in many younger ED patients presenting with syncope.
Annals abstract: http://www.annemergmed.com/article/S0196-0644(07)00451-9/abstract
12. Pioneering Research: Immunize (!) against Hypertension
A vaccine against angiotensin II lowers blood pressure, reports Lancet.
In a phase II (safety and efficacy) study sponsored by the developer, European researchers randomized 72 patients with mild-to-moderate hypertension to one of two doses of vaccine (100 or 300 μg) or to placebo. The vaccine consists of virus-like particles linked to angiotensin II; injections were given at weeks 0, 4, and 12.
By week 14, about 20% of vaccine recipients had experienced transient flu-like symptoms, and all had antibodies against angiotensin II. Those who received the 300-μg regimen had significant drops in mean BP compared with placebo recipients, especially early in the morning (–25 mm Hg systolic, –13 mm Hg diastolic).
Commentators wonder about the hazards of a treatment whose effects are not immediately reversible (the antibody's half-life after the third injection was 17 weeks). However, they find the exploratory trial "promising."
Lancet abstract: http://www.thelancet.com/journals/lancet/article/PIIS0140673608603815/abstract
13. New Out-of-Hospital CPR Protocol Increases Survival
A new CPR protocol, which focuses on compressions and not ventilatory support, increases the survival rate when used by emergency medical service personnel, JAMA reports.
The new protocol, called minimally interrupted cardiac resuscitation (MICR), consists of 200 compressions, followed by rhythm analysis with a single shock, another 200 compressions, a pulse check, and then rhythm reanalysis. Intubation is delayed until three rounds of compressions, and oxygenation until then is mostly passive.
Survival-to-discharge increased from 1.8% before MICR training to 5.4% afterwards. In cases of witnessed arrest and ventricular fibrillation, survival went from 4.7% to 17.6%.
An editorialist writes that although MICR "needs further scientific evaluation," such details "are likely not important factors to the numerous additional survivors who are back home with their families after the implementation of this new protocol."
JAMA article (Free abstract; full text requires subscription): http://jama.ama-assn.org/cgi/content/short/299/10/1158
JAMA editorial (Subscription required): http://jama.ama-assn.org/cgi/content/extract/299/10/1188
14. Needle Thoracostomy: Size Does Matter
The standard 14-gauge needle and catheter are too short for 10% to 35% of patients.
Zengerink I, et al. J Trauma 2008;64:111-114.
Background: A tension pneumothorax requires immediate decompression using a needle thoracostomy. According to advanced trauma life support guidelines this procedure is performed in the second intercostal space (ICS) in the midclavicular line (MCL), using a 4.5-cm (2-inch) catheter (5-cm needle). Previous studies have shown a failure rate of up to 40% using this technique. Case reports have suggested that this high failure rate could be because of insufficient length of the needle.
Objectives: To analyze the average chest wall thickness (CWT) at the second ICS in the MCL in a trauma population and to evaluate the length of the needle used in needle thoracostomy for emergency decompression of tension pneumothoraces.
Methods: Retrospective review of major trauma admissions (Injury Severity Score greater than 12) at the Foothills Medical Centre in Calgary, Canada, who underwent a computed tomography chest scan admitted in the period from October 2001 until March 2004. Subgroup analysis on men and women, less than 40 years of age and greater than 40 years of age was defined a priori. CWT was measured to the nearest 0.01 cm at the second ICS in the MCL.
Results: The mean CWT in the 604 male patients and 170 female patients studied averaged 3.50 cm at the left second ICS MCL and 3.51 cm on the right. The mean CWT was significantly higher for women than men (p less than 0.0001). About 9.9% to 19.3% of the men had a CWT greater than 4.5 cm and 24.1% to 35.4% of the women studied.
Conclusions: A catheter length of 4.5 cm may not penetrate the chest wall of a substantial amount (9.9%-35.4%) of the population, depending on age and gender. This study demonstrates the need for a variable needle length for relief of a tension pneumothorax in certain population groups to improve effectiveness of needle thoracostomy.
15. Utility of Routine Testing for Patients with Asymptomatic Severe Blood Pressure Elevation in the ED
Karras DJ, at al. Ann Emerg Med. 2008;231-239.
Study objective
Recommendations for the treatment of emergency department (ED) patients with asymptomatic severely elevated blood pressure advise assessment for occult, acute hypertensive target-organ damage. This study determines the prevalence of unanticipated, clinically meaningful test abnormalities in ED patients with asymptomatic severely elevated blood pressure.
Methods
This was a prospective observational study at 3 urban academic EDs. Consecutive patients with systolic blood pressure greater than or equal to 180 mm Hg or diastolic blood pressure greater than or equal to 110 mm Hg on 2 measurements were enrolled if they denied symptoms of hypertensive emergency. A basic metabolic panel, urinalysis, ECG, CBC count, and chest radiograph were obtained. Treating physicians were interviewed about the indication for each test and whether an abnormal result was anticipated according to clinical findings. When test results were available, physicians were asked whether abnormal findings were clinically meaningful, defined as leading to unanticipated hospitalization, medication modification, or further immediate evaluation. The primary outcome was the prevalence of unanticipated clinically meaningful test abnormalities.
Results
One hundred nine patients with asymptomatic severely elevated blood pressure were enrolled. Unanticipated abnormal test results were noted in 57 (52%) patients. Clinically meaningful unanticipated test abnormalities were found in 7 (6%) patients: basic metabolic panel in 2 (2%), CBC count in 3 (3%), urinalysis in 3 (4%), ECG in 2 (2%), and chest radiograph in 1 (1%). Five patients (5%) had abnormalities assessed as possible manifestations of acute hypertensive target-organ injury; none had abnormalities clearly related to severely elevated blood pressure.
Conclusion
Screening tests of urban ED patients with asymptomatic severely elevated blood pressure infrequently detect unanticipated hypertension-related abnormalities that alter ED management.
16. Doctors should be environmentalists too
Climate change is likely to be bad for human health. Drought, mass migration, food shortages, a surge in vector borne diseases, and deaths from extreme weather are just some of the possibilities, writes one surgeon from the US. Doctors and their institutions must do more to educate themselves about these very real threats and help to educate others. Medical schools could teach environmental science, specialist societies and research institutes could gather evidence on the likely effects of accelerating climate change on human health, hospitals could go green, and doctors could join forces with environmentalists to make plans and take action, he says.
The medical profession has a long history of responding to global challenges such as epidemics and natural disasters. It is time to step up and confront the state of the environment, along with the world’s governments, scientists, and businesses.
No one knows exactly what will happen, or how fast. But we do know that the ice caps are melting, the ozone layer is thinning, the planet is warming, and the world’s forests are being deliberately torched to grow crops to feed an exponentially increasing human population. All these events damage human health in one way or another, he says. Doctors must be part of the response.
Paul S. Auerbach, MD, MS. Physicians and the Environment. JAMA. 2008;299(8):956-958.
17. Limited Diagnostic Utility of Exam, History, and Labs in ED Patients with Vaginal Complaints
Johnson E, et al. Ann Emerg Med. 2008; print publication pending; published online 21 January 2008
This is a rational clinical examination abstract, a regular feature of the Annals' Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a rational clinical examination review from the Journal of the American Medical Association and a commentary by an emergency physician knowledgeable in the subject area.
The source for this rational clinical examination review abstract is: Anderson MR, Klink K, Cohrssen A. The rational clinical examination: evaluation of vaginal complaints JAMA. 2004;291:1368-1379. The Annals' EBEM editors assisted in the preparation of the abstract of this rational clinical examination review, as well as selection of the Evidence-Based Medicine Teaching Points.
Conclusions
It appears that the clinical evaluation is limited in determining the cause of vaginal complaints. Several patient characteristics can support the diagnosis of vaginal candidiasis and bacterial vaginosis; however, the likelihood ratios are not particularly strong. Few findings distinguish bacterial vaginosis and vaginal trichomonas from each other, making these diagnoses even more difficult. Furthermore, bedside tests and laboratory equipment are not readily available in all clinical settings, leaving it up to the clinician to make a diagnosis solely based on medical history and physical examination results. Despite many studies on this topic, the competence of the clinical examination to determine the cause of vaginal complaints remains ill defined.
18. Rapid identification of high-risk transient ischemic attacks: prospective validation of the ABCD score.
Sciolla R, et al. Stroke. 2008; 39:297-302.
BACKGROUND AND PURPOSE: A 6-point score, based on age, blood pressure, clinical features, and duration (ABCD), was shown to effectively stratify the short-term risk of stroke after a transient ischemic attack (TIA). Prospective validation in different populations of patients should precede its widespread use. Whether adding computed tomography (CT) scan findings to the score would improve its performance deserves exploring. We aimed to validate the ABCD score in a prospective cohort of patients accessing Emergency Departments within 24 hours of a TIA in an area of northern Italy and to acquire preliminary data on CT-based refinement.
METHODS: During a 6-month period, all TIA patients accessing the Emergency Departments of 13 Piemonte and Valle d'Aosta hospitals were prospectively enrolled and stratified according to the 6-point ABCD score and to a 7-point score (ABCDI, where I=imaging) incorporating CT findings.
RESULTS: Of 274 patients, stroke occurred in 10 (3.6%) within 7 days and in 15 (5.5%) within 30 days. The ABCD score was predictive of stroke risk at both 7 and 30 days (odds ratio for every point of the score=2.55 at 7 days and 2.62 at 30 days; P for linear trend across the ABCD score levels=0.018 at 7 days and 0.0017 at 30 days). CT scan findings further increased prediction (odds ratio for every point of the score=2.68 at 7 days and 2.89 at 30 days; P for linear trend across the ABCDI score levels=0.0043 at 7 days and 0.0003 at 30 days).
CONCLUSIONS: The ABCD score confirmed its prognostic value in this prospective cohort. CT results could further improve prediction.
Review from 2005: ABCD Score May Aid Stroke Risk Stratification After TIA
This study is an important step toward identifying the patients who need urgent care after a TIA.
Using three cohorts of patients from Oxford, England, these authors sought to develop rules to predict the risk for stroke in the 7 days after diagnosis of transient ischemic attack (TIA). Other studies have identified risk factors for stroke after TIA, usually assessing longer periods. In the current study, the authors evaluated these same risk factors as potential short-term predictors in a total of 190 patients with TIA identified in the 1980s. From that analysis, they derived a stroke risk score, the ABCD score:
A (age; 1 point for age over 60 years),
B (blood pressure; 1 point for hypertension at the acute evaluation),
C (clinical features; 2 points for focal weakness, 1 for speech disturbance without weakness), and
D (symptom duration; 1 point for 10–59 minutes, 2 points for more than 60 minutes).
Total scores ranged from 0 (lowest risk) to 6 (highest risk).
In a validation cohort of 378 patients with more recent TIAs, 7-day stroke risk ranged from 0% in those with scores less than 4 to 35.5% in those with scores of 6; risk was intermediate with scores of 4 or 5. The ABCD worked surprisingly well, even in a third cohort of 206 patients from the same community who were scheduled to attend a weekly TIA clinic.
Comment: This study demonstrates once again that the risk for stroke in the first few days after TIA is very high. It confirms that simple clinical factors can be used to stratify that risk further. The score should be validated in a completely independent population before it gains widespread clinical use, and fine-tuning may be required, but this work represents an important step in understanding which patients with TIA require emergent evaluation.
— S. Claiborne Johnston, MD, PhD. Published in JW Neurology, September 8, 2005. Citation:
Rothwell PM et al. Lancet 2005 Jul 2; 366:29-36.
19. Tamiflu Label Updated with Neuropsychiatric Warning
The revised label adds a warning about possible neuropsychiatric side effects.
The FDA and Roche Laboratories have revised the product label for Tamiflu (oseltamivir phosphate) to include a warning about possible neuropsychiatric events. The updated label is based on recommendations from the agency’s Pediatric Advisory Committee meeting in November 2007.
Postmarketing reports indicate that some patients with influenza who were receiving Tamiflu had delirium and abnormal behavior, leading to injury and even death. Most of the cases occurred in children and in Japan.
Although it's not clear whether Tamiflu caused these events, the label cautions clinicians to monitor their patients for abnormal behavior when taking the drug. Adverse events should be reported through the FDA’s MedWatch site.
Published in Journal Watch Pediatrics and Adolescent Medicine March 12, 2008
20. Empirical Characteristics of Litigation Involving Tissue Plasminogen Activator and Ischemic Stroke
Liang BA, et al. Ann Emerg Med. 2008; print publication pending; published online 04 March 2008
Study objective
The use of tissue plasminogen activator (tPA) in potential stroke victims by emergency physicians is controversial. One factor that may represent a barrier to use is medicolegal concerns resulting from adverse outcomes. The jury verdicts, settlements, and other adjudications associated with tPA and stroke care are assessed to determine the characteristics of these cases, including whether cases arose from adverse consequences associated with tPA or failure to provide tPA.
Methods
Using 7 primary jury verdict, settlement, and other adjudication legal databases, lawsuits involving tPA and stroke were collected for analysis of the clinical circumstances of the litigation, the causes of action against providers, the basis for liability, and the presence of emergency physicians and neurologist consultation in the litigation.
Results
Thirty-three cases were found involving tPA ischemic stroke therapy. In 29 (88%) of these cases, patient injury was claimed to have resulted from failure to treat with tPA. Emergency physicians were the most common physician defendants. Defendants prevailed in 21 (64%) cases, and among the 12 with results favorable to the plaintiff, 10 (83%) involved failure to treat and 2 (17%) claimed injury from treatment with tPA.
Conclusion
The available evidence concerning litigation involving stroke therapy with tPA indicates liability is predominantly associated with failure to provide tPA, rather than adverse events associated with its use.
21. Delayed Diagnosis of Kawasaki Disease: What Are the Risk Factors?
Minich LL, et al. Pediatrics 2007; 120:950 – 957.
OBJECTIVE. Because late diagnosis of Kawasaki disease increases the risk for coronary artery abnormalities, we explored the prevalence of and possible risk factors for delayed diagnosis by using the database of the Pediatric Heart Network trial of corticosteroid treatment for Kawasaki disease.
METHODS. We collected sociodemographic and clinical data at presentation for all patients who were treated for presumed Kawasaki disease at 8 centers (7 in the United States, 1 in Canada). Delayed diagnosis was evaluated by total number of illness days to diagnosis and by the percentage of patients who were treated after day 10 of illness. Independent predictors of delayed diagnosis were identified by using multivariate linear and logistic regression.
RESULTS. Of the 589 patients who received intravenous immunoglobulin, 27 were treated before screening for the trial and excluded; 562 patients formed the cohort for analysis. Kawasaki disease was diagnosed at 7.9 ± 3.9 days, 92 (16%) cases after day 10. Centers were similar with respect to patient age and gender. Centers differed in the patient percentage with incomplete Kawasaki disease; clinical criteria of cervical adenopathy, oral changes, and conjunctivitis; and distance of residence from the center. Independent predictors of greater number of illness days at diagnosis included center, age less than 6 months, incomplete Kawasaki disease, and greater distance from the center. Independent predictors of diagnosis after day 10 were age of less than 6 months, incomplete Kawasaki disease, and greater distance). Socioeconomic variables had no association with delayed diagnosis.
CONCLUSIONS. Even after adjustment for patient factors, illness duration at diagnosis varies by center. These findings underscore the need to maintain a high index of suspicion of Kawasaki disease in the infant who is younger than 6 months and has prolonged fever even with incomplete criteria. Outreach educational programs may be useful in promoting earlier recognition and treatment of Kawasaki disease.
Wednesday, March 12, 2008
Monday, February 18, 2008
Lit Bits: February 18, 2008
From the recent medical literature...
1. Aspirin "resistance" and risk of cardiovascular morbidity: systematic review and meta-analysis
Krasopoulos G, et al. BMJ 2008;336:195-198.
Objective: To determine if there is a relation between aspirin "resistance" and clinical outcomes in patients with cardiovascular disease.
Design: Systematic review and meta-analysis.
Data source: Electronic literature search without language restrictions of four databases and hand search of bibliographies for other relevant articles.
Review methods: Inclusion criteria included a test for platelet responsiveness and clinical outcomes. Aspirin resistance was assessed, using a variety of platelet function assays.
Results: 20 studies totalling 2930 patients with cardiovascular disease were identified. Most studies used aspirin regimens, ranging from 75-325 mg daily, and six studies included adjunct antiplatelet therapy. Compliance was confirmed directly in 14 studies and by telephone or interviews in three. Information was insufficient to assess compliance in three studies. Overall, 810 patients (28%) were classified as aspirin resistant. A cardiovascular related event occurred in 41% of patients (odds ratio 3.85, 95% confidence interval 3.08 to 4.80), death in 5.7% (5.99, 2.28 to 15.72), and an acute coronary syndrome in 39.4% (4.06, 2.96 to 5.56). Aspirin resistant patients did not benefit from other antiplatelet treatment.
Conclusion: Patients who are resistant to aspirin are at a greater risk of clinically important cardiovascular morbidity long term than patients who are sensitive to aspirin.
BMJ Abstract: http://www.bmj.com/cgi/content/abstract/336/7637/195?etoc
Editorial: Carries a worse prognosis, but may be indicative of pre-existing higher risk
Aspirin has clear benefits in cardiovascular disease. It reduces total mortality, cardiovascular mortality, and cardiovascular morbidity in people with cardiovascular disease or those at high risk of the disease; it is also cheap, relatively safe, and easy to use. So why does aspirin fail to work in some people who take it as prescribed? Research on this clinical "resistance" to aspirin has tried to assess whether the effect on the in vitro activation of platelets depends only on the dose and type of antithrombotic agent given, or whether some people respond poorly ("resist") to a specific drug, as some people do to specific antibiotics. In the accompanying systematic review, Krasopoulos and colleagues assess whether resistance to aspirin is related to cardiovascular outcomes in people with cardiovascular disease.
To date, most research has focused on whether aspirin resistance really exists, whether antiplatelet resistance is specific to certain agents or classes of drug, and whether resistance carries a worse prognosis. Firstly, no accepted gold standard test to define aspirin resistance is available. This and other epidemiological considerations have led some authors to argue that what has been dubbed resistance is just part of normal (Gaussian) variability in pharmacokinetics and pharmacodynamics. Others admit that aspirin resistance exists but are doubtful about its prognostic importance. They think that a lack of response to aspirin could just be a proxy marker for more advanced pre-existing disease or less controlled traditional risk factors.
Krasopoulos and colleagues’ review analysed data from 20 studies and 2930 patients and found resistance to aspirin in 28% of people. Resistance was significantly more common in women and those with renal failure and was associated with a statistically and clinically significant increase in the risk of death or adverse cardiovascular events, at least in univariate analysis. However, they found no association between the dose of aspirin or concomitant use of other antiplatelet agents and adverse events. The review has some limitations including use of fixed effect methods and lack of pooled multivariable adjusted estimates. A similar review recently came to the same conclusions, however, confirming the external validity of Krasopoulos and colleagues’ review.
Despite this work several questions remain. We don’t know whether aspirin resistance is a true abnormal response or whether it reflects normal variability in drug activity. We also aren’t clear whether aspirin resistance has a negative prognostic effect independent of more traditional risk factors, such as diabetes or obesity. If aspirin resistance is an abnormal response that results in worse prognosis then what can clinicians do? We suggest that when aspirin resistance is suspected patients should be screened using available tests. Management of patients with aspirin resistance should include a comprehensive appraisal of thrombotic and bleeding risks, the likelihood of non-adherence to treatment, and access to other antiplatelet agents. On the basis of this assessment, several strategies can then be proposed. These include adding another antiplatelet agent (for people at high thrombotic risk and low bleeding risk), substituting aspirin with the more effective clopidogrel (for people at intermediate thrombotic risk and low bleeding risk), increasing the dose of aspirin (for example, to 325 mg/day in people at mildly increased thrombotic risk and low to intermediate bleeding risk), or continuing with the same antiplatelet regimen (for everyone at high bleeding risk).
The problem in finding truly scientific answers to the effectiveness of these strategies lies in the lack of randomised controlled clinical trials. This will probably change, however, as results from trials such as TREND-AR (tirofiban evaluation of surrogate endpoints in prevention of ischaemic complications during percutaneous interventions in patients with coronary disease and aspirin resistance) become available. This trial will randomise patients undergoing percutaneous coronary intervention who have documented aspirin resistance to a combination of clopidogrel, aspirin, heparin, and tirofiban (a potent antiplatelet agent) or clopidogrel, aspirin, and heparin. This trial, among others, will show whether aspirin resistance is just a non-modifiable risk factor (like age or sex) or whether more aggressive antithrombotic regimens are beneficial in patients with aspirin resistance.
Conducting more clinical trials will help fill in the gaps, but another potential reason exists for the interest in aspirin resistance. Drug companies may be keen to downgrade aspirin from its leading role as an effective drug in cardiovascular disease so that they can substitute it with much more expensive but marginally more effective alternatives.
Biondi-Zoccai G. BMJ 2008;336:166-167.
2. Watching Stressful Sporting Events May More Than Double Risk for CV Emergencies
Sports fans may face more than a doubling of risk for cardiovascular events while watching stressful matches, reports the New England Journal of Medicine.
The incidence of CV emergencies among German residents during World Cup matches involving the German team in 2006 was compared with the incidence during a control period. Overall, the risk for CV emergencies was significantly increased during soccer games (incidence ratio, 2.7), with the highest incidence during the first 2 hours of a match. Risk elevations were seen for ST-segment-elevation MI, non-STEMI/unstable angina, and cardiac arrhythmia.
Risk increases were significant regardless of gender or cardiovascular history, but were highest among men and those with a history of coronary artery disease.
The authors note: "Our results do not permit identification of the exact triggers ... lack of sleep, overeating, consumption of junk food, heavy alcohol ingestion, smoking, and failure to comply with the medical regimen should all be considered."
NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/short/358/5/475
3. Impact of Abdominal Helical CT on the Negative Appendicitis Rate
Kim K, et al. J Emerg Med. 2008;34:3-6.
Introduction
Appendicitis is the most common cause of acute abdominal pain requiring surgical treatment in patients presenting to Emergency Departments (EDs), with an annual incidence of 250,000 cases in the United States. For many decades, clinical evaluation has been the mainstay for the diagnosis of appendicitis, and physicians have relied on clinical judgment to make a timely diagnosis. Diagnostic accuracies vary depending on the clinical experience of the surgeon involved, and are reported to range from 71% to 97%.
Several recent studies have identified helical computed tomography (CT) scan as the diagnostic imaging test of choice for evaluating patients with suspected appendicitis. Given the recent advances in CT technology, the abdomen and pelvis can be visualized in a relatively short period of time with thin slice multi-detector CT scanners. Accordingly, a number of authors recommend the routine use of CT for all patients with acute right lower quadrant abdominal pain, whereas others suggest that imaging may cause unnecessary delays in treatment. For such reasons, many EDs have different policies concerning the use of CT scan for the diagnosis of acute appendicitis. Some centers rely heavily on CT scan for the diagnosis of appendicitis whereas others still depend on physicians’ opinions.
Many investigations have been conducted to evaluate the utility of CT scan in single emergency centers, and have used outcome measures, such as negative appendectomy rates or frequency of complications. Therefore, we conducted a multi-center comparative study to evaluate the impact of CT utilization on negative appendectomy rates. We hypothesized that the rates of CT utilization would be inversely related to negative appendectomy rates.
This study was conducted to assess the impact of helical computed tomography (HCT) on the rate of negative appendicitis. Patients were identified from a pathology department database that included all patients taken to the operating room with a preoperative diagnosis of appendicitis, and pathologic specimens were analyzed to determine the presence of appendicitis. Two time periods were studied, Period A prior to the arrival of HCT, and Period B several years after HCT was incorporated into the evaluation of suspected appendicitis.
The results showed that during period A, no patients received HCT and the negative appendicitis rate was 15.5%. In period B, 81.5% of patients received HCT and the negative appendicitis rate was 7.9%. In conclusion, there was a 48% decline in the rate of negative appendicitis found to be associated with the common use of HCT.
Abstract: http://www.jem-journal.com/article/PIIS0736467907004763/abstract
4. Care of the Bariatric Surgery Patient in the ED
Luber SD, et al. J Emerg Med 2008;34:13-20.
Abstract: Obesity has reached epidemic proportions in the United States, with an estimated 50% of adults meeting the definition of being overweight. As this condition has become more prevalent, bariatric surgery has become an increasingly accepted form of treatment of the severely obese. Patients who have had bariatric surgery are presenting more commonly to Emergency Departments as a result. This article will review the most common bariatric surgery procedures, the complications that can arise post-operatively, and the approach to the assessment and management of the bariatric surgery patient in the Emergency Department.
Full-text (subscription required): http://www.jem-journal.com/article/PIIS0736467907002612/fulltext
5. Antiplatelet Therapy in Management of TIA: Overview and Evidence-based Rationale
Ovbiagele B. J Emerg Med 2008; in press.
Abstract: As many as 300,000 transient ischemic attacks (TIAs) occur in the United States each year, accounting for 0.3% of all Emergency Department visits. An under-recognized and under-treated problem, TIA is associated with up to a 10% risk of subsequent stroke within 7 days and a 25% risk of death at 1 year. Antiplatelet therapy can result in significant reductions in secondary stroke risk. However, nearly 50% of patients with TIA leave the Emergency Department without any medication. This article discusses recent results from major antiplatelet clinical trials in stroke prevention and highlights the need for appropriate and timely initiation of antiplatelet treatment in patients with TIA.
Full-text (subscription required): http://www.jem-journal.com/article/PIIS073646790700724X/fulltext
6. Does intraosseous equal intravenous? A pharmacokinetic study
Von Hoff DD, et al. Amer J Emerg Med. 2008;26:31-38.
Study Objective
Despite the growing popularity of intraosseous infusion for adults in emergency medicine, to date there has been little research on the pharmacokinetics of intraosseously administered medications in humans. The objective of the study was to compare the pharmacokinetics of intraosseous vs intravenous administration of morphine sulfate in adults.
Methods
The study followed a prospective, randomized, crossover design. Each subject was equipped with an indwelling intraosseous access device and an intravenous line. Subjects were randomized to receive a 5-mg bolus of morphine sulfate infused intraosseously or intravenously, followed by the alternate administration route 24 hours later.
Serial venous blood samples (5 mL) were taken at baseline and at 13 time points over 8 hours postinfusion. Blood samples were analyzed for morphine concentration by radioimmunoassay. Pharmacokinetic parameters were calculated from the data, including maximum plasma concentration (Cmax), time to maximum concentration (Tmax), and area under plasma concentration-time curve (AUC), among others. Data were analyzed by analysis of variance.
Results
No statistically significant differences were observed between intraosseous and intravenous administration of morphine sulfate for nearly all of the pharmacokinetic parameters including Cmax (235 ± 107 vs 289 ± 197 ng/mL, mean ± SD, IO vs IV, respectively), Tmax (1.3 ± 0.5 vs 1.4 ± 0.5 minutes), and AUC(0-∞) (4372 ± 1785 vs 4410 ± 1930 ng min−1 mL−1). There was, however, a statistically significant difference in the volume of distribution in the central compartment, Vd (P = .0247), which in the opinion of the investigators was thought to be due to a minor deposition effect near the intraosseous port or in the bone marrow.
Conclusion
The results support the bioequivalence of intraosseous and intravenous administration of morphine sulfate in adults.
7. Stroke After TIA
More than 15% of patients can be expected to have a stroke within 90 days of TIA presentation.
During the past five years, transient ischemic attack (TIA) has come to be regarded as angina of the brain. This new thinking arose after observational studies raised awareness of the frequency of stroke after TIA, but the actual incidence is uncertain because of varying methodology in the relevant studies.
These authors performed a meta-analysis of 11 studies that included a combined total of more than 7000 patients. To determine if a stroke occurred after the index TIA event, some of the studies relied on record review (passive ascertainment) while other studies interviewed patients at predetermined intervals after the index event (active ascertainment). The latter method is thought to be more reliable.
The overall rate of stroke after TIA was 3.5% by 2 days, 8.0% by 30 days, and 9.2% by 90 days. When only the three studies that used active outcome ascertainment were analyzed, the corresponding rates were 9.9%, 13.4%, and 17.3%.
Comment: As the U.S. population ages, cerebrovascular disease will become much more prevalent. Emergency departments can play a significant role in stroke prevention by being attentive to symptoms that may represent cerebral ischemia and by ensuring that patients are evaluated promptly. A recent study (Ross, et al. Ann Emerg Med. 2007;50:109-119) showed that the work-up can be done safely and expeditiously in an ED observation unit.
— J. Stephen Bohan, MD, MS, FACP, FACEP. Published in Journal Watch Emergency Medicine January 18, 2008. Citation: Wu CM et al. Arch Intern Med 2007;167:2417.
8. Steroids in Meningitis
Benefit was seen in patients with definite disease but not in those with probable disease.
The evidence for benefit from steroids in bacterial meningitis is conflicting. During a 9-year period at a hospital for tropical diseases in Vietnam, 435 patients with suspected bacterial meningitis were randomized in double-blind fashion to receive either dexamethasone (0.4 mg/kg) or placebo twice a day for 4 days.
At the time of hospital discharge or death, 69% of patients were classified as having definite meningitis (positive blood or cerebrospinal fluid cultures or positive Gram stain) and 29% were classified as having probable meningitis (bacteria either not detected or cultured, and no alternative diagnosis).
Thirty days after randomization, mortality rates were 10% in the dexamethasone group and 12.4% in the placebo group. The relative risk for death in the dexamethasone group was 0.79. Subgroup analysis showed a greater benefit in patients with definite meningitis (RR, 0.43) and no benefit in those with probable meningitis, possibly because some patients in the latter group had tuberculous meningitis. At 6 months, disability and hearing loss were significantly less prevalent in the dexamethasone group. The most common etiologic organism was Streptococcus suis, which is common in Asia but not in North America.
Comment: When the results of the single European trial (de Gans J, et al. NEJM 2002;347:1549-1556) are added to these data, the evidence becomes strong enough to unequivocally recommend that adults with suspected meningitis be treated with steroids. Although S. suis was the most common cause of meningitis in this study, other species of streptococcus likely would have a similar response to treatment.
— J. Stephen Bohan, MD, MS, FACP, FACEP. Published in Journal Watch Emergency Medicine January 18, 2008. Citation: Mai NTH, et al. N Engl J Med;357:2431.
9. Exercise Capacity a Strong Predictor of Mortality in Men
Exercise capacity, measured by a treadmill test, strongly predicts men's risk for death, according to a large study released online in Circulation.
Nearly 16,000 male veterans — about 40% of them black — underwent treadmill exercise testing and then were followed for about 7.5 years. After adjustment for cardiac medications, age, and other risk factors, all-cause mortality risk fell by 13% for every 1-MET increase in exercise capacity.
Exercise capacity was a stronger predictor of death than were cardiovascular risk factors, age, or BMI. The findings were similar regardless of race or presence of cardiovascular disease.
The authors conclude that "exercise capacity should be given as much attention by clinicians as other major risk factors."
Circulation article (Free abstract; full text requires subscription): http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.734764v1
10. Drinkable Tap Water is Suitable for Wound Cleansing
Laurie Barclay, MD. January 24, 2008 — Drinkable tap water applied topically is as effective as normal saline for cleansing a wound, according to a Cochrane review published in the January 23 issue of the Cochrane Database Systematic Reviews.
"Various solutions have been recommended for cleansing wounds, however normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process," write Ritin Fernandez, RN, MN, and Rhonda D. Griffiths. MSc, DrPH, from the University of Western Sydney in New South Wales, Australia. "Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective, however, there is an unresolved debate about its use."
Of 11 included trials, 7 compared rates of infection and healing in wounds cleansed with water vs normal saline, 3 trials compared cleansing vs no cleansing, and 1 trial compared procaine spirit vs water. Procaine spirit is a mixture of procaine HCl 2% with spirit 70% and is commonly prescribed for wound cleansing following surgery. Ability to pool the data was limited because there were no standard criteria across the trials for evaluating wound infection. The predominant comparisons were water vs normal saline and tap water vs no cleansing.
When chronic wounds were cleansed with tap water vs normal saline, the relative risk (RR) of developing an infection was 0.16 (95% confidence interval [CI], 0.01 - 2.96). Compared with saline, tap water was more effective in reducing the infection rate in adults with acute wounds (RR, 0.63; 95% CI, 0.40 - 0.99). In children, the use of tap water to cleanse acute wounds was not associated with a statistically significant difference in infection vs saline (RR, 1.07; 95% CI, 0.43 - 2.64).
When wounds were cleansed with tap water or not cleansed at all, there was no statistically significant difference in infection rates (RR, 1.06; 95% CI, 0.07 - 16.50). In a similar fashion, episiotomy wounds cleansed with water or with procaine spirit did not differ in infection rate. For cleansing open fractures, use of isotonic saline, distilled water, and boiled water was not statistically significantly different in the number of fractures that became infected.
"There is no evidence that using tap water to cleanse acute wounds in adults increases infection and some evidence that it reduces it," the review authors write. "However there is not strong evidence that cleansing wounds per se increases healing or reduces infection. In the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents. . . . The decision to use tap water to cleanse wounds should take into account the quality of water, nature of wounds and the patient's general condition, including the presence of comorbid conditions."
"While the findings of this review do not indicate adverse effects from the use of tap water, practitioners and health service managers should interpret the findings with caution as most of the comparisons were based on single trials, some of which do not report the methodology in sufficient detail to enable assessment of quality," the review authors conclude. "The availability and cost of resources may also determine which solution is used for cleansing wounds in different settings."
Cochrane Database Syst Rev. 2008: http://www.cochrane.org/reviews/en/ab003861.html
11. High Adverse-Event Rates Seen Within 90 Days After Stopping Clopidogrel
Adverse events may cluster in the 90 days after patients stop taking clopidogrel, JAMA reports.
The study involved some 3000 patients who, after being treated for acute coronary syndromes with medical therapy alone or percutaneous coronary intervention, were discharged from a Veterans Affairs hospital and prescribed clopidogrel. The mean duration of clopidogrel therapy was about 300 days.
In the months after clopidogrel discontinuation, all-cause mortality or acute MI occurred in 17% of medically treated patients and 8% of PCI-treated patients. After multivariable adjustment (including length of clopidogrel therapy), risk in both groups was nearly twice as high during the 90 days after stopping clopidogrel than days 91 through 180.
In Journal Watch Cardiology, JoAnne Foody notes that until these findings are confirmed, "clinicians should do their best to ensure that patients take their prescribed clopidogrel." She adds that extending clopidogrel treatment may improve outcomes in patients with high thrombosis risk and low bleeding risk.
JAMA article (Free abstract; full text requires subscription): http://jama.ama-assn.org/cgi/content/short/299/5/532
12. Acute Hypertension (over 180/110): An Undertreated Condition
from Heartwire — a professional news service of WebMD. February 11, 2008 (Honolulu, HI) – The enormous inadequacy in the management of patients with acute hypertension has been highlighted by a new registry study, which found that despite having a mortality rate similar to acute coronary syndromes or acute heart failure, many patients with this condition are not even followed up after their initial treatment.
Lead author of the study, Dr Chris Granger (Duke University Medical Center, Durham, NC), explained that acute hypertension is defined as blood pressure over 180/110 mm Hg, and the recommended treatment is IV antihypertensive drugs to get the blood pressure down to target levels. "This is a really understudied and undertreated condition--there is really very little information out there on the best way to treat it. So we conducted a registry to better understand acute hypertension. We wanted to find out who these patients are, how they are managed, what their outcomes are like, and what the causes and consequences of acute hypertension are. This is the first time this has been looked at in a multicenter study," he told heartwire.
Initial results from the STAT registry, sponsored by The Medicines Company, were presented last week at the 37th Critical Care Congress of the Society of Clinical Care Medicine (SCCM), held February 2-6, 2008 in Honolulu, HI. The study is aiming to collect data for as many as 120 consecutive patients in each of 25 US hospitals (with a target enrollment of more than 1500 patients), and to date, 982 patients have been enrolled from 21 hospitals.
A major problem
Granger noted that their most important finding was that this is a major problem, and there are major opportunities to improve care. In some areas of the southeastern US, as many as 25% of patients in some urban emergency departments have acute hypertension, he reported. He said the population involved was "more or less what we would expect"--around half were African American, the average age was 58, 90% had a history of chronic hypertension, 25% were nonadherent to prescribed medication, 30% had had a prior hospitalization for acute hypertension, and most presented to the emergency department with symptoms such as chest pain, shortness of breath, and symptoms of stroke, and one-third of them were actually having a stroke.
Many IV drugs were used for treatment, including labetalol, metoprolol, hydralazine, nitroglycerin, nicardipine, and sodium nitroprusside, and two or three different drugs were often used in the same patient. Despite this, it took a long tome to get the blood pressure down--for patients without subarachnoid hemorrhage, the median time to achieve a systolic pressure of below 160 mm Hg was four hours, and there was a high rate of overshooting, with 4% of patients developing hypotension, necessitating intervention. There was also a very high rate of recurrence, with 52% of patients having reelevation of systolic blood pressure to over 180 mm Hg after initial control.
For the 92 patients presenting with subarachnoid hemorrhage, the median time to achieve a systolic pressure below 140 mm Hg was 1.5 hours, and 6.5% developed hypotension. There was considerable variability in blood-pressure response over time, based upon the initial antihypertensive agent selected. The median duration of IV therapy was 10.5 hours, and most patients (58%) had evidence of target-organ injury associated with their hypertensive episode.
These patients had a very high rate of mortality--8% at 90 days, which Granger points out is the same as for acute coronary syndromes or acute heart failure. In addition, 40% of patients were rehospitalized within 90 days.
He added that "a very concerning finding" was that 60% of these patients either had no evidence of a follow-up appointment or did not attend the follow-up appointment. "So despite the fact these patients have a life-threatening condition, they are not being followed up well at all. There is room for a large improvement here," he commented.
13. Does This Child Have a Urinary Tract Infection?
Shaikh N, et al. JAMA. 2007;298:2895-2904.
Context: Urinary tract infection (UTI) is a frequently occurring pediatric illness that, if left untreated, can lead to permanent renal injury. Accordingly, accurate diagnosis of UTI is important.
Objective: To review the diagnostic accuracy of symptoms and signs for the diagnosis of UTI in infants and children.
Data Sources: A search of MEDLINE and EMBASE databases was conducted for articles published between 1966 and October 2007, as well as a manual review of bibliographies of all articles meeting inclusion criteria, 1 previously published systematic review, 3 clinical skills textbooks, and 2 experts in the field, yielding 6988 potentially relevant articles.
Study Selection: Studies were included if they contained data on signs or symptoms of UTI in children through age 18 years. Of 337 articles examined, 12 met all inclusion criteria.
Data Extraction: Two evaluators independently reviewed, rated, and abstracted data from each article.
Data Synthesis: In infants with fever, history of a previous UTI (likelihood ratio [LR] range, 2.3-2.9), temperature higher than 40°C (LR range, 3.2-3.3), and suprapubic tenderness (LR, 4.4; 95% confidence interval [CI], 1.6-12.4) were the findings most useful for identifying those with a UTI. Among male infants, lack of circumcision increased the likelihood of a UTI (summary LR, 2.8; 95% CI, 1.9-4.3); and the presence of circumcision was the only finding with an LR of less than 0.5 (summary LR, 0.33; 95% CI, 0.18-0.63). Combinations of findings were more useful than individual findings in identifying infants with a UTI (for temperature above 39°C for greater than 48 hours without another potential source for fever on examination, the LR for all findings present was 4.0; 95% CI, 1.2-13.0; and for temperature less than 39°C with another source for fever, the LR was 0.37; 95% CI, 0.16-0.85). In verbal children, abdominal pain (LR, 6.3; 95% CI, 2.5-16.0), back pain (LR, 3.6; 95% CI, 2.1-6.1), dysuria, frequency, or both (LR range, 2.2-2.8), and new-onset urinary incontinence (LR, 4.6; 95% CI, 2.8-7.6) increased the likelihood of a UTI.
Conclusions: Although individual signs and symptoms were helpful in the diagnosis of a UTI, they were not sufficiently accurate to definitively diagnose UTIs. Combination of findings can identify infants with a low likelihood of a UTI.
14. Hypovolemic Shock Evaluated by Sonographic Measurement of the IVC During Resuscitation in Trauma Patients
Yanagawa Y, et al. J Trauma 2007;63:1245-1248.
Background: Inferior vena cava (IVC) diameter immediately after fluid resuscitation has not yet been investigated in trauma patients with shock on arrival.
Methods: Between June 2004 and May 2005, 30 trauma patients with hemorrhagic shock were prospectively investigated. Using ultrasound, we measured maximum anterior-posterior diameter of the IVC just below the diaphragm in the hepatic segment, in the expiratory phase. This was performed on arrival and when systolic blood pressure had been raised to over 90 mm Hg by fluid resuscitation in the emergency room. Subjects were divided into two groups: a transient responder group (n = 17) in which shock recurred after leaving the emergency room and a responder group (n = 13) in which blood pressure remained stable.
Results: There were no significant differences between the two groups regarding age or gender, or regarding vital signs or IVC diameter on arrival. Average injury severity score in the transient responder group was significantly greater than that in the responder group. After fluid resuscitation, no significant intergroup differences were observed regarding vital signs. However, IVC diameter was significantly smaller in the transient responder group than in the responder group (6.5 +/- 0.5 mm; mean +/- SE vs. 10.7 +/- 0.7 mm, p less than 0.05).
Conclusion: In trauma patients, inadequate dilatation of the IVC by fluid resuscitation might indicate insufficient circulating blood volume despite normalization of blood pressure. In this small study, IVC diameter appeared a better predictor of recurrence of shock than blood pressure, heart rate, or arterial base excess. A larger prospective study is called for to clearly establish the sensitivity and specificity of this method.
15. Isolated Thoracolumbar Transverse Process Fractures Are Simply That
These fractures are markers of thoracic, intra-abdominal, and retroperitoneal visceral injuries but not of other injuries to the bony spinal column.
Isolated thoracolumbar spine transverse process fractures do not undermine the integrity of the three-column vertebral support system, but they are associated with structurally unstable thoracolumbar spine fractures in 10% to 20% of patients. Plain radiographs miss these unstable thoracolumbar bony injuries in about 10% of cases. In a retrospective study of trauma-registry data, researchers analyzed characteristics of isolated thoracolumbar transverse process fractures discovered by 16-slice computed tomography (CT) at a single level I trauma center between 2002 and 2005.
Of 314 patients with thoracolumbar transverse process fractures, 248 had isolated fractures. In the group with isolated fractures, 72% were male, 89% sustained blunt mechanisms of injury, and the mean Injury Severity Scale score was 19. Forty-four percent of patients had one thoracolumbar transverse process fracture, 21% had two, 14% had three, 12% had four, and 9% had five to nine fractures. Visceral chest injuries were present in 29% of patients, abdominal injuries in 28%, chest and abdominal injuries in 11%, and pelvic fractures in 33%. Spine consultation and follow-up did not result in the discovery of any new thoracolumbar fractures or neurological damage, and no further studies were required.
Comment: This study demonstrates that thoracolumbar transverse process fractures reflect significant torso trauma and are associated with a considerable incidence of intra-abdominal and pelvic injuries. Although the study cohort was relatively small, the findings suggest that, particularly with today’s higher-resolution 128- and 256-slice scanners, isolated thoracolumbar transverse process fractures identified by CT do not require neurosurgical or orthopedic consultation, log-roll precautions, or additional imaging.
— John A. Marx, MD. Published in Journal Watch EM February 8, 2008. Citation: Homnick A, et al. Isolated thoracolumbar transverse process fractures: Call physical therapy, not spine. J Trauma 2007 Dec; 63:1292.
16. 'Choking Game' Has Caused 82 Juvenile Deaths Since Mid-'90s
At least 82 children have died of accidental strangulation attributed to the "choking game" since 1995, according to the CDC.
A report in MMWR describes the first attempt to assess the incidence of deaths among youths playing this game — strangulation, often with a noose, to achieve brief euphoria by cerebral hypoxia. In the cases, found through newspaper articles and choking-game awareness websites, 87% of the victims were male, and the mean age was 13.
An editorial note recommends that healthcare providers watch for warning signs, including mention of the choking game, bloodshot eyes, marks on the neck, frequent severe headaches, disorientation after spending time alone, and ropes or belts tied to bedroom furniture or doorknobs.
"Although asphyxial games might have been played by youths for generations, the use of a ligature while playing alone appears to be a new practice that can be fatal," it says.
MMWR article (Free): http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5706a1.htm?s_cid=mm5706a1_x
17. Clot aspiration a promising alternative to conventional PCI
Svilaas T, et al. N Engl J Med 2008;358:557-67.
The usual way to unblock a coronary artery is to dilate it with a balloon. Balloon dilation restores blood flow but can also release thromboembolic material that clogs up vessels further downstream. An alternative approach is to suck out the clot directly. In a randomised trial comparing the two techniques, the newer one worked better in patients with myocardial infarction. Direct aspiration significantly improved downstream myocardial perfusion and led to more complete resolution of ST segment elevation on post-procedure electrocardiograms. Both groups of patients received bare metal stents after their allocated percutaneous coronary intervention (PCI).
Aspiration of the thrombus didn’t improve survival significantly during the first 30 days (11 of 529 patients died (2.1%) v 21 of 531 (4.0%); risk ratio 0.52, 95% CI 0.26 to 1.07). Instead, the authors reported a significant association between better myocardial perfusion and a lower risk of death, further infarction, or revascularisation. Further trials will need to confirm these findings.
Two thirds of the aspirated clots were made exclusively of platelets, confirming the importance of antiplatelet drugs, says an editorial (p 634). These patients had the recommended aspirin, clopidogrel, and abciximab before PCI, then aspirin and clopidogrel afterwards.
NEJM Abstract: http://content.nejm.org/cgi/content/abstract/358/6/557
18. Systematic Reviews Don’t Have all the Answers
Qayyam R, et al. Ann Intern Med 2008;148:186-96; MacLean C, et al. Ann Intern Med 2008;148:197-213; Wilt TJ, et al. Ann Intern Med 2008 Feb 4; [Epub ahead of print]
Systematic reviews and meta-analyses are most useful when they give definitive answers to clinically relevant questions, such as does this treatment work, and if so is it better or safer than other treatments? More often than not, however, researchers, doctors, and patients must make do with the far less satisfactory conclusion that we still don’t know because the research is weak and full of holes.
Three separate systematic reviews in the same journal recently ran aground trying to find the best treatments for early prostate cancer and osteoporosis, and the best strategy for treating acute coronary syndrome. In each case, the authors looked carefully for all the relevant studies, appraised their quality, extracted data, and tried to synthesise the evidence. Between them they looked at more than 600 studies that involved thousands of patients. In all three reviews, the data were simply not good enough to direct doctors to one treatment or the other, usually because there were too few head to head trials. Reviewers found none comparing different treatments for osteoporosis and just three comparing treatments for early prostate cancer. The authors of the review comparing routine percutaneous coronary intervention with a more selective strategy for acute coronary syndrome found 10 head to head trials. But they were heterogeneous and not powerful enough to be conclusive, even when combined.
19. Heavy Fast Food Consumption Can Quickly Elevate ALT Levels
A single week of overindulging in fast food can lead to pathologic levels of alanine aminotransferase (ALT), according to a small study in Gut published early online.
Swedish researchers had 18 healthy adults eat at least two fast food meals a day, thereby doubling their calorie intake, and limit their daily exercise to less than 5000 steps for 4 weeks. A matched control group continued their usual diet and exercise.
The fast food group gained an average of 14 pounds. Over half of the people in that group experienced persistently elevated ALT levels from the first week to the end of the study. To explain this, the authors speculate that an increased supply of monosaccharides to the liver could have led to induction of the enzyme in hepatocytes.
They suggest that "in the clinical evaluation of subjects with elevated ALT, physicians should include not only questions about alcohol intake, but also explore whether recent excessive food intake has occurred."
Gut article abstract: http://gut.bmj.com/cgi/gca?sendit=Get+All+Checked+Abstract%28s%29&gca=gut.2007.131797v1
20. Sugary drinks, fruit, and increased risk of gout
BMJ 2008;336:285-286
Editorials: Dietary fructose could be a contributing factor
The accompanying prospective cohort study by Choi and Curhan adds dietary fructose intake to the list of possible risk factors for gout. Laboratory evidence that dietary fructose increases serum urate already exists, and recent epidemiological studies have found an association between dietary fructose and hyperuricaemia in the United States.
The health professionals follow-up study was established in 1986 to examine the relation between nutritional factors and disease onset in later life in more than 50,000 American men. Previous analyses have looked at the association of obesity, alcohol, and diet with the onset of gout.
This new analysis looks at the role of non-alcoholic drinks and fruit on the first onset of gout. It finds a strong association between sugar sweetened soft drinks, usually containing fructose, and gout. Consuming two servings a day of a sugar sweetened soft drink increased the risk of developing gout by 85% (relative risk 1.85, 95% confidence interval 1.08 to 3.16). This compares with an increased risk of 49% from drinking 15-29.9 g/day of alcohol, 21% from eating an extra serving of meat a day, and 95% from having a body mass index of 25.0-29.9 versus 21.0-22.9; consuming 240 ml of skimmed milk a day decreased risk by 43%. A high intake of naturally occurring fructose also increased the risk of developing gout; consuming two or more glasses of fruit juice each day increased the risk by 81% (1.81, 1.12 to 2.93) and eating an apple or orange a day increased the risk by 64% (1.64, 1.05 to 2.56). These epidemiological data provide useful information for formulating appropriate dietary advice that might reduce recurrent gout.
Choi article in BMJ: http://www.bmj.com/cgi/content/abstract/336/7639/309
21. Emergency Management of Chronic Pain and Drug-Seeking Behavior: An Alternate Perspective
Hawkins SC. J Emerg Med. 2008;34:125-129.
Abstract
Pain is one of the most prevalent conditions treated by Emergency Physicians, although it remains contested how to interpret, measure, and treat this condition. In particular, there is controversy over how to identify and treat patients with chronic under-treated pain and those who are potentially malingering (drug-seeking). This article discusses currently accepted paradigms for treating potentially malingering patients, difficulties some communities may have when these paradigms are applied, and the results of implementing pain treatment guidelines that limit opioid use. Systematically limiting opioids via these guidelines was not associated with a decrease in overall patient satisfaction, patient satisfaction with pain management, overall volume, or volume of patients with potential drug-seeking diagnoses. Emergency Physicians’ perception of quality of care delivered, as well as job satisfaction, increased after implementation of the guidelines.
Link: http://www.jem-journal.com/article/S0736-4679(07)00475-1/
1. Aspirin "resistance" and risk of cardiovascular morbidity: systematic review and meta-analysis
Krasopoulos G, et al. BMJ 2008;336:195-198.
Objective: To determine if there is a relation between aspirin "resistance" and clinical outcomes in patients with cardiovascular disease.
Design: Systematic review and meta-analysis.
Data source: Electronic literature search without language restrictions of four databases and hand search of bibliographies for other relevant articles.
Review methods: Inclusion criteria included a test for platelet responsiveness and clinical outcomes. Aspirin resistance was assessed, using a variety of platelet function assays.
Results: 20 studies totalling 2930 patients with cardiovascular disease were identified. Most studies used aspirin regimens, ranging from 75-325 mg daily, and six studies included adjunct antiplatelet therapy. Compliance was confirmed directly in 14 studies and by telephone or interviews in three. Information was insufficient to assess compliance in three studies. Overall, 810 patients (28%) were classified as aspirin resistant. A cardiovascular related event occurred in 41% of patients (odds ratio 3.85, 95% confidence interval 3.08 to 4.80), death in 5.7% (5.99, 2.28 to 15.72), and an acute coronary syndrome in 39.4% (4.06, 2.96 to 5.56). Aspirin resistant patients did not benefit from other antiplatelet treatment.
Conclusion: Patients who are resistant to aspirin are at a greater risk of clinically important cardiovascular morbidity long term than patients who are sensitive to aspirin.
BMJ Abstract: http://www.bmj.com/cgi/content/abstract/336/7637/195?etoc
Editorial: Carries a worse prognosis, but may be indicative of pre-existing higher risk
Aspirin has clear benefits in cardiovascular disease. It reduces total mortality, cardiovascular mortality, and cardiovascular morbidity in people with cardiovascular disease or those at high risk of the disease; it is also cheap, relatively safe, and easy to use. So why does aspirin fail to work in some people who take it as prescribed? Research on this clinical "resistance" to aspirin has tried to assess whether the effect on the in vitro activation of platelets depends only on the dose and type of antithrombotic agent given, or whether some people respond poorly ("resist") to a specific drug, as some people do to specific antibiotics. In the accompanying systematic review, Krasopoulos and colleagues assess whether resistance to aspirin is related to cardiovascular outcomes in people with cardiovascular disease.
To date, most research has focused on whether aspirin resistance really exists, whether antiplatelet resistance is specific to certain agents or classes of drug, and whether resistance carries a worse prognosis. Firstly, no accepted gold standard test to define aspirin resistance is available. This and other epidemiological considerations have led some authors to argue that what has been dubbed resistance is just part of normal (Gaussian) variability in pharmacokinetics and pharmacodynamics. Others admit that aspirin resistance exists but are doubtful about its prognostic importance. They think that a lack of response to aspirin could just be a proxy marker for more advanced pre-existing disease or less controlled traditional risk factors.
Krasopoulos and colleagues’ review analysed data from 20 studies and 2930 patients and found resistance to aspirin in 28% of people. Resistance was significantly more common in women and those with renal failure and was associated with a statistically and clinically significant increase in the risk of death or adverse cardiovascular events, at least in univariate analysis. However, they found no association between the dose of aspirin or concomitant use of other antiplatelet agents and adverse events. The review has some limitations including use of fixed effect methods and lack of pooled multivariable adjusted estimates. A similar review recently came to the same conclusions, however, confirming the external validity of Krasopoulos and colleagues’ review.
Despite this work several questions remain. We don’t know whether aspirin resistance is a true abnormal response or whether it reflects normal variability in drug activity. We also aren’t clear whether aspirin resistance has a negative prognostic effect independent of more traditional risk factors, such as diabetes or obesity. If aspirin resistance is an abnormal response that results in worse prognosis then what can clinicians do? We suggest that when aspirin resistance is suspected patients should be screened using available tests. Management of patients with aspirin resistance should include a comprehensive appraisal of thrombotic and bleeding risks, the likelihood of non-adherence to treatment, and access to other antiplatelet agents. On the basis of this assessment, several strategies can then be proposed. These include adding another antiplatelet agent (for people at high thrombotic risk and low bleeding risk), substituting aspirin with the more effective clopidogrel (for people at intermediate thrombotic risk and low bleeding risk), increasing the dose of aspirin (for example, to 325 mg/day in people at mildly increased thrombotic risk and low to intermediate bleeding risk), or continuing with the same antiplatelet regimen (for everyone at high bleeding risk).
The problem in finding truly scientific answers to the effectiveness of these strategies lies in the lack of randomised controlled clinical trials. This will probably change, however, as results from trials such as TREND-AR (tirofiban evaluation of surrogate endpoints in prevention of ischaemic complications during percutaneous interventions in patients with coronary disease and aspirin resistance) become available. This trial will randomise patients undergoing percutaneous coronary intervention who have documented aspirin resistance to a combination of clopidogrel, aspirin, heparin, and tirofiban (a potent antiplatelet agent) or clopidogrel, aspirin, and heparin. This trial, among others, will show whether aspirin resistance is just a non-modifiable risk factor (like age or sex) or whether more aggressive antithrombotic regimens are beneficial in patients with aspirin resistance.
Conducting more clinical trials will help fill in the gaps, but another potential reason exists for the interest in aspirin resistance. Drug companies may be keen to downgrade aspirin from its leading role as an effective drug in cardiovascular disease so that they can substitute it with much more expensive but marginally more effective alternatives.
Biondi-Zoccai G. BMJ 2008;336:166-167.
2. Watching Stressful Sporting Events May More Than Double Risk for CV Emergencies
Sports fans may face more than a doubling of risk for cardiovascular events while watching stressful matches, reports the New England Journal of Medicine.
The incidence of CV emergencies among German residents during World Cup matches involving the German team in 2006 was compared with the incidence during a control period. Overall, the risk for CV emergencies was significantly increased during soccer games (incidence ratio, 2.7), with the highest incidence during the first 2 hours of a match. Risk elevations were seen for ST-segment-elevation MI, non-STEMI/unstable angina, and cardiac arrhythmia.
Risk increases were significant regardless of gender or cardiovascular history, but were highest among men and those with a history of coronary artery disease.
The authors note: "Our results do not permit identification of the exact triggers ... lack of sleep, overeating, consumption of junk food, heavy alcohol ingestion, smoking, and failure to comply with the medical regimen should all be considered."
NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/short/358/5/475
3. Impact of Abdominal Helical CT on the Negative Appendicitis Rate
Kim K, et al. J Emerg Med. 2008;34:3-6.
Introduction
Appendicitis is the most common cause of acute abdominal pain requiring surgical treatment in patients presenting to Emergency Departments (EDs), with an annual incidence of 250,000 cases in the United States. For many decades, clinical evaluation has been the mainstay for the diagnosis of appendicitis, and physicians have relied on clinical judgment to make a timely diagnosis. Diagnostic accuracies vary depending on the clinical experience of the surgeon involved, and are reported to range from 71% to 97%.
Several recent studies have identified helical computed tomography (CT) scan as the diagnostic imaging test of choice for evaluating patients with suspected appendicitis. Given the recent advances in CT technology, the abdomen and pelvis can be visualized in a relatively short period of time with thin slice multi-detector CT scanners. Accordingly, a number of authors recommend the routine use of CT for all patients with acute right lower quadrant abdominal pain, whereas others suggest that imaging may cause unnecessary delays in treatment. For such reasons, many EDs have different policies concerning the use of CT scan for the diagnosis of acute appendicitis. Some centers rely heavily on CT scan for the diagnosis of appendicitis whereas others still depend on physicians’ opinions.
Many investigations have been conducted to evaluate the utility of CT scan in single emergency centers, and have used outcome measures, such as negative appendectomy rates or frequency of complications. Therefore, we conducted a multi-center comparative study to evaluate the impact of CT utilization on negative appendectomy rates. We hypothesized that the rates of CT utilization would be inversely related to negative appendectomy rates.
This study was conducted to assess the impact of helical computed tomography (HCT) on the rate of negative appendicitis. Patients were identified from a pathology department database that included all patients taken to the operating room with a preoperative diagnosis of appendicitis, and pathologic specimens were analyzed to determine the presence of appendicitis. Two time periods were studied, Period A prior to the arrival of HCT, and Period B several years after HCT was incorporated into the evaluation of suspected appendicitis.
The results showed that during period A, no patients received HCT and the negative appendicitis rate was 15.5%. In period B, 81.5% of patients received HCT and the negative appendicitis rate was 7.9%. In conclusion, there was a 48% decline in the rate of negative appendicitis found to be associated with the common use of HCT.
Abstract: http://www.jem-journal.com/article/PIIS0736467907004763/abstract
4. Care of the Bariatric Surgery Patient in the ED
Luber SD, et al. J Emerg Med 2008;34:13-20.
Abstract: Obesity has reached epidemic proportions in the United States, with an estimated 50% of adults meeting the definition of being overweight. As this condition has become more prevalent, bariatric surgery has become an increasingly accepted form of treatment of the severely obese. Patients who have had bariatric surgery are presenting more commonly to Emergency Departments as a result. This article will review the most common bariatric surgery procedures, the complications that can arise post-operatively, and the approach to the assessment and management of the bariatric surgery patient in the Emergency Department.
Full-text (subscription required): http://www.jem-journal.com/article/PIIS0736467907002612/fulltext
5. Antiplatelet Therapy in Management of TIA: Overview and Evidence-based Rationale
Ovbiagele B. J Emerg Med 2008; in press.
Abstract: As many as 300,000 transient ischemic attacks (TIAs) occur in the United States each year, accounting for 0.3% of all Emergency Department visits. An under-recognized and under-treated problem, TIA is associated with up to a 10% risk of subsequent stroke within 7 days and a 25% risk of death at 1 year. Antiplatelet therapy can result in significant reductions in secondary stroke risk. However, nearly 50% of patients with TIA leave the Emergency Department without any medication. This article discusses recent results from major antiplatelet clinical trials in stroke prevention and highlights the need for appropriate and timely initiation of antiplatelet treatment in patients with TIA.
Full-text (subscription required): http://www.jem-journal.com/article/PIIS073646790700724X/fulltext
6. Does intraosseous equal intravenous? A pharmacokinetic study
Von Hoff DD, et al. Amer J Emerg Med. 2008;26:31-38.
Study Objective
Despite the growing popularity of intraosseous infusion for adults in emergency medicine, to date there has been little research on the pharmacokinetics of intraosseously administered medications in humans. The objective of the study was to compare the pharmacokinetics of intraosseous vs intravenous administration of morphine sulfate in adults.
Methods
The study followed a prospective, randomized, crossover design. Each subject was equipped with an indwelling intraosseous access device and an intravenous line. Subjects were randomized to receive a 5-mg bolus of morphine sulfate infused intraosseously or intravenously, followed by the alternate administration route 24 hours later.
Serial venous blood samples (5 mL) were taken at baseline and at 13 time points over 8 hours postinfusion. Blood samples were analyzed for morphine concentration by radioimmunoassay. Pharmacokinetic parameters were calculated from the data, including maximum plasma concentration (Cmax), time to maximum concentration (Tmax), and area under plasma concentration-time curve (AUC), among others. Data were analyzed by analysis of variance.
Results
No statistically significant differences were observed between intraosseous and intravenous administration of morphine sulfate for nearly all of the pharmacokinetic parameters including Cmax (235 ± 107 vs 289 ± 197 ng/mL, mean ± SD, IO vs IV, respectively), Tmax (1.3 ± 0.5 vs 1.4 ± 0.5 minutes), and AUC(0-∞) (4372 ± 1785 vs 4410 ± 1930 ng min−1 mL−1). There was, however, a statistically significant difference in the volume of distribution in the central compartment, Vd (P = .0247), which in the opinion of the investigators was thought to be due to a minor deposition effect near the intraosseous port or in the bone marrow.
Conclusion
The results support the bioequivalence of intraosseous and intravenous administration of morphine sulfate in adults.
7. Stroke After TIA
More than 15% of patients can be expected to have a stroke within 90 days of TIA presentation.
During the past five years, transient ischemic attack (TIA) has come to be regarded as angina of the brain. This new thinking arose after observational studies raised awareness of the frequency of stroke after TIA, but the actual incidence is uncertain because of varying methodology in the relevant studies.
These authors performed a meta-analysis of 11 studies that included a combined total of more than 7000 patients. To determine if a stroke occurred after the index TIA event, some of the studies relied on record review (passive ascertainment) while other studies interviewed patients at predetermined intervals after the index event (active ascertainment). The latter method is thought to be more reliable.
The overall rate of stroke after TIA was 3.5% by 2 days, 8.0% by 30 days, and 9.2% by 90 days. When only the three studies that used active outcome ascertainment were analyzed, the corresponding rates were 9.9%, 13.4%, and 17.3%.
Comment: As the U.S. population ages, cerebrovascular disease will become much more prevalent. Emergency departments can play a significant role in stroke prevention by being attentive to symptoms that may represent cerebral ischemia and by ensuring that patients are evaluated promptly. A recent study (Ross, et al. Ann Emerg Med. 2007;50:109-119) showed that the work-up can be done safely and expeditiously in an ED observation unit.
— J. Stephen Bohan, MD, MS, FACP, FACEP. Published in Journal Watch Emergency Medicine January 18, 2008. Citation: Wu CM et al. Arch Intern Med 2007;167:2417.
8. Steroids in Meningitis
Benefit was seen in patients with definite disease but not in those with probable disease.
The evidence for benefit from steroids in bacterial meningitis is conflicting. During a 9-year period at a hospital for tropical diseases in Vietnam, 435 patients with suspected bacterial meningitis were randomized in double-blind fashion to receive either dexamethasone (0.4 mg/kg) or placebo twice a day for 4 days.
At the time of hospital discharge or death, 69% of patients were classified as having definite meningitis (positive blood or cerebrospinal fluid cultures or positive Gram stain) and 29% were classified as having probable meningitis (bacteria either not detected or cultured, and no alternative diagnosis).
Thirty days after randomization, mortality rates were 10% in the dexamethasone group and 12.4% in the placebo group. The relative risk for death in the dexamethasone group was 0.79. Subgroup analysis showed a greater benefit in patients with definite meningitis (RR, 0.43) and no benefit in those with probable meningitis, possibly because some patients in the latter group had tuberculous meningitis. At 6 months, disability and hearing loss were significantly less prevalent in the dexamethasone group. The most common etiologic organism was Streptococcus suis, which is common in Asia but not in North America.
Comment: When the results of the single European trial (de Gans J, et al. NEJM 2002;347:1549-1556) are added to these data, the evidence becomes strong enough to unequivocally recommend that adults with suspected meningitis be treated with steroids. Although S. suis was the most common cause of meningitis in this study, other species of streptococcus likely would have a similar response to treatment.
— J. Stephen Bohan, MD, MS, FACP, FACEP. Published in Journal Watch Emergency Medicine January 18, 2008. Citation: Mai NTH, et al. N Engl J Med;357:2431.
9. Exercise Capacity a Strong Predictor of Mortality in Men
Exercise capacity, measured by a treadmill test, strongly predicts men's risk for death, according to a large study released online in Circulation.
Nearly 16,000 male veterans — about 40% of them black — underwent treadmill exercise testing and then were followed for about 7.5 years. After adjustment for cardiac medications, age, and other risk factors, all-cause mortality risk fell by 13% for every 1-MET increase in exercise capacity.
Exercise capacity was a stronger predictor of death than were cardiovascular risk factors, age, or BMI. The findings were similar regardless of race or presence of cardiovascular disease.
The authors conclude that "exercise capacity should be given as much attention by clinicians as other major risk factors."
Circulation article (Free abstract; full text requires subscription): http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.734764v1
10. Drinkable Tap Water is Suitable for Wound Cleansing
Laurie Barclay, MD. January 24, 2008 — Drinkable tap water applied topically is as effective as normal saline for cleansing a wound, according to a Cochrane review published in the January 23 issue of the Cochrane Database Systematic Reviews.
"Various solutions have been recommended for cleansing wounds, however normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process," write Ritin Fernandez, RN, MN, and Rhonda D. Griffiths. MSc, DrPH, from the University of Western Sydney in New South Wales, Australia. "Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective, however, there is an unresolved debate about its use."
Of 11 included trials, 7 compared rates of infection and healing in wounds cleansed with water vs normal saline, 3 trials compared cleansing vs no cleansing, and 1 trial compared procaine spirit vs water. Procaine spirit is a mixture of procaine HCl 2% with spirit 70% and is commonly prescribed for wound cleansing following surgery. Ability to pool the data was limited because there were no standard criteria across the trials for evaluating wound infection. The predominant comparisons were water vs normal saline and tap water vs no cleansing.
When chronic wounds were cleansed with tap water vs normal saline, the relative risk (RR) of developing an infection was 0.16 (95% confidence interval [CI], 0.01 - 2.96). Compared with saline, tap water was more effective in reducing the infection rate in adults with acute wounds (RR, 0.63; 95% CI, 0.40 - 0.99). In children, the use of tap water to cleanse acute wounds was not associated with a statistically significant difference in infection vs saline (RR, 1.07; 95% CI, 0.43 - 2.64).
When wounds were cleansed with tap water or not cleansed at all, there was no statistically significant difference in infection rates (RR, 1.06; 95% CI, 0.07 - 16.50). In a similar fashion, episiotomy wounds cleansed with water or with procaine spirit did not differ in infection rate. For cleansing open fractures, use of isotonic saline, distilled water, and boiled water was not statistically significantly different in the number of fractures that became infected.
"There is no evidence that using tap water to cleanse acute wounds in adults increases infection and some evidence that it reduces it," the review authors write. "However there is not strong evidence that cleansing wounds per se increases healing or reduces infection. In the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents. . . . The decision to use tap water to cleanse wounds should take into account the quality of water, nature of wounds and the patient's general condition, including the presence of comorbid conditions."
"While the findings of this review do not indicate adverse effects from the use of tap water, practitioners and health service managers should interpret the findings with caution as most of the comparisons were based on single trials, some of which do not report the methodology in sufficient detail to enable assessment of quality," the review authors conclude. "The availability and cost of resources may also determine which solution is used for cleansing wounds in different settings."
Cochrane Database Syst Rev. 2008: http://www.cochrane.org/reviews/en/ab003861.html
11. High Adverse-Event Rates Seen Within 90 Days After Stopping Clopidogrel
Adverse events may cluster in the 90 days after patients stop taking clopidogrel, JAMA reports.
The study involved some 3000 patients who, after being treated for acute coronary syndromes with medical therapy alone or percutaneous coronary intervention, were discharged from a Veterans Affairs hospital and prescribed clopidogrel. The mean duration of clopidogrel therapy was about 300 days.
In the months after clopidogrel discontinuation, all-cause mortality or acute MI occurred in 17% of medically treated patients and 8% of PCI-treated patients. After multivariable adjustment (including length of clopidogrel therapy), risk in both groups was nearly twice as high during the 90 days after stopping clopidogrel than days 91 through 180.
In Journal Watch Cardiology, JoAnne Foody notes that until these findings are confirmed, "clinicians should do their best to ensure that patients take their prescribed clopidogrel." She adds that extending clopidogrel treatment may improve outcomes in patients with high thrombosis risk and low bleeding risk.
JAMA article (Free abstract; full text requires subscription): http://jama.ama-assn.org/cgi/content/short/299/5/532
12. Acute Hypertension (over 180/110): An Undertreated Condition
from Heartwire — a professional news service of WebMD. February 11, 2008 (Honolulu, HI) – The enormous inadequacy in the management of patients with acute hypertension has been highlighted by a new registry study, which found that despite having a mortality rate similar to acute coronary syndromes or acute heart failure, many patients with this condition are not even followed up after their initial treatment.
Lead author of the study, Dr Chris Granger (Duke University Medical Center, Durham, NC), explained that acute hypertension is defined as blood pressure over 180/110 mm Hg, and the recommended treatment is IV antihypertensive drugs to get the blood pressure down to target levels. "This is a really understudied and undertreated condition--there is really very little information out there on the best way to treat it. So we conducted a registry to better understand acute hypertension. We wanted to find out who these patients are, how they are managed, what their outcomes are like, and what the causes and consequences of acute hypertension are. This is the first time this has been looked at in a multicenter study," he told heartwire.
Initial results from the STAT registry, sponsored by The Medicines Company, were presented last week at the 37th Critical Care Congress of the Society of Clinical Care Medicine (SCCM), held February 2-6, 2008 in Honolulu, HI. The study is aiming to collect data for as many as 120 consecutive patients in each of 25 US hospitals (with a target enrollment of more than 1500 patients), and to date, 982 patients have been enrolled from 21 hospitals.
A major problem
Granger noted that their most important finding was that this is a major problem, and there are major opportunities to improve care. In some areas of the southeastern US, as many as 25% of patients in some urban emergency departments have acute hypertension, he reported. He said the population involved was "more or less what we would expect"--around half were African American, the average age was 58, 90% had a history of chronic hypertension, 25% were nonadherent to prescribed medication, 30% had had a prior hospitalization for acute hypertension, and most presented to the emergency department with symptoms such as chest pain, shortness of breath, and symptoms of stroke, and one-third of them were actually having a stroke.
Many IV drugs were used for treatment, including labetalol, metoprolol, hydralazine, nitroglycerin, nicardipine, and sodium nitroprusside, and two or three different drugs were often used in the same patient. Despite this, it took a long tome to get the blood pressure down--for patients without subarachnoid hemorrhage, the median time to achieve a systolic pressure of below 160 mm Hg was four hours, and there was a high rate of overshooting, with 4% of patients developing hypotension, necessitating intervention. There was also a very high rate of recurrence, with 52% of patients having reelevation of systolic blood pressure to over 180 mm Hg after initial control.
For the 92 patients presenting with subarachnoid hemorrhage, the median time to achieve a systolic pressure below 140 mm Hg was 1.5 hours, and 6.5% developed hypotension. There was considerable variability in blood-pressure response over time, based upon the initial antihypertensive agent selected. The median duration of IV therapy was 10.5 hours, and most patients (58%) had evidence of target-organ injury associated with their hypertensive episode.
These patients had a very high rate of mortality--8% at 90 days, which Granger points out is the same as for acute coronary syndromes or acute heart failure. In addition, 40% of patients were rehospitalized within 90 days.
He added that "a very concerning finding" was that 60% of these patients either had no evidence of a follow-up appointment or did not attend the follow-up appointment. "So despite the fact these patients have a life-threatening condition, they are not being followed up well at all. There is room for a large improvement here," he commented.
13. Does This Child Have a Urinary Tract Infection?
Shaikh N, et al. JAMA. 2007;298:2895-2904.
Context: Urinary tract infection (UTI) is a frequently occurring pediatric illness that, if left untreated, can lead to permanent renal injury. Accordingly, accurate diagnosis of UTI is important.
Objective: To review the diagnostic accuracy of symptoms and signs for the diagnosis of UTI in infants and children.
Data Sources: A search of MEDLINE and EMBASE databases was conducted for articles published between 1966 and October 2007, as well as a manual review of bibliographies of all articles meeting inclusion criteria, 1 previously published systematic review, 3 clinical skills textbooks, and 2 experts in the field, yielding 6988 potentially relevant articles.
Study Selection: Studies were included if they contained data on signs or symptoms of UTI in children through age 18 years. Of 337 articles examined, 12 met all inclusion criteria.
Data Extraction: Two evaluators independently reviewed, rated, and abstracted data from each article.
Data Synthesis: In infants with fever, history of a previous UTI (likelihood ratio [LR] range, 2.3-2.9), temperature higher than 40°C (LR range, 3.2-3.3), and suprapubic tenderness (LR, 4.4; 95% confidence interval [CI], 1.6-12.4) were the findings most useful for identifying those with a UTI. Among male infants, lack of circumcision increased the likelihood of a UTI (summary LR, 2.8; 95% CI, 1.9-4.3); and the presence of circumcision was the only finding with an LR of less than 0.5 (summary LR, 0.33; 95% CI, 0.18-0.63). Combinations of findings were more useful than individual findings in identifying infants with a UTI (for temperature above 39°C for greater than 48 hours without another potential source for fever on examination, the LR for all findings present was 4.0; 95% CI, 1.2-13.0; and for temperature less than 39°C with another source for fever, the LR was 0.37; 95% CI, 0.16-0.85). In verbal children, abdominal pain (LR, 6.3; 95% CI, 2.5-16.0), back pain (LR, 3.6; 95% CI, 2.1-6.1), dysuria, frequency, or both (LR range, 2.2-2.8), and new-onset urinary incontinence (LR, 4.6; 95% CI, 2.8-7.6) increased the likelihood of a UTI.
Conclusions: Although individual signs and symptoms were helpful in the diagnosis of a UTI, they were not sufficiently accurate to definitively diagnose UTIs. Combination of findings can identify infants with a low likelihood of a UTI.
14. Hypovolemic Shock Evaluated by Sonographic Measurement of the IVC During Resuscitation in Trauma Patients
Yanagawa Y, et al. J Trauma 2007;63:1245-1248.
Background: Inferior vena cava (IVC) diameter immediately after fluid resuscitation has not yet been investigated in trauma patients with shock on arrival.
Methods: Between June 2004 and May 2005, 30 trauma patients with hemorrhagic shock were prospectively investigated. Using ultrasound, we measured maximum anterior-posterior diameter of the IVC just below the diaphragm in the hepatic segment, in the expiratory phase. This was performed on arrival and when systolic blood pressure had been raised to over 90 mm Hg by fluid resuscitation in the emergency room. Subjects were divided into two groups: a transient responder group (n = 17) in which shock recurred after leaving the emergency room and a responder group (n = 13) in which blood pressure remained stable.
Results: There were no significant differences between the two groups regarding age or gender, or regarding vital signs or IVC diameter on arrival. Average injury severity score in the transient responder group was significantly greater than that in the responder group. After fluid resuscitation, no significant intergroup differences were observed regarding vital signs. However, IVC diameter was significantly smaller in the transient responder group than in the responder group (6.5 +/- 0.5 mm; mean +/- SE vs. 10.7 +/- 0.7 mm, p less than 0.05).
Conclusion: In trauma patients, inadequate dilatation of the IVC by fluid resuscitation might indicate insufficient circulating blood volume despite normalization of blood pressure. In this small study, IVC diameter appeared a better predictor of recurrence of shock than blood pressure, heart rate, or arterial base excess. A larger prospective study is called for to clearly establish the sensitivity and specificity of this method.
15. Isolated Thoracolumbar Transverse Process Fractures Are Simply That
These fractures are markers of thoracic, intra-abdominal, and retroperitoneal visceral injuries but not of other injuries to the bony spinal column.
Isolated thoracolumbar spine transverse process fractures do not undermine the integrity of the three-column vertebral support system, but they are associated with structurally unstable thoracolumbar spine fractures in 10% to 20% of patients. Plain radiographs miss these unstable thoracolumbar bony injuries in about 10% of cases. In a retrospective study of trauma-registry data, researchers analyzed characteristics of isolated thoracolumbar transverse process fractures discovered by 16-slice computed tomography (CT) at a single level I trauma center between 2002 and 2005.
Of 314 patients with thoracolumbar transverse process fractures, 248 had isolated fractures. In the group with isolated fractures, 72% were male, 89% sustained blunt mechanisms of injury, and the mean Injury Severity Scale score was 19. Forty-four percent of patients had one thoracolumbar transverse process fracture, 21% had two, 14% had three, 12% had four, and 9% had five to nine fractures. Visceral chest injuries were present in 29% of patients, abdominal injuries in 28%, chest and abdominal injuries in 11%, and pelvic fractures in 33%. Spine consultation and follow-up did not result in the discovery of any new thoracolumbar fractures or neurological damage, and no further studies were required.
Comment: This study demonstrates that thoracolumbar transverse process fractures reflect significant torso trauma and are associated with a considerable incidence of intra-abdominal and pelvic injuries. Although the study cohort was relatively small, the findings suggest that, particularly with today’s higher-resolution 128- and 256-slice scanners, isolated thoracolumbar transverse process fractures identified by CT do not require neurosurgical or orthopedic consultation, log-roll precautions, or additional imaging.
— John A. Marx, MD. Published in Journal Watch EM February 8, 2008. Citation: Homnick A, et al. Isolated thoracolumbar transverse process fractures: Call physical therapy, not spine. J Trauma 2007 Dec; 63:1292.
16. 'Choking Game' Has Caused 82 Juvenile Deaths Since Mid-'90s
At least 82 children have died of accidental strangulation attributed to the "choking game" since 1995, according to the CDC.
A report in MMWR describes the first attempt to assess the incidence of deaths among youths playing this game — strangulation, often with a noose, to achieve brief euphoria by cerebral hypoxia. In the cases, found through newspaper articles and choking-game awareness websites, 87% of the victims were male, and the mean age was 13.
An editorial note recommends that healthcare providers watch for warning signs, including mention of the choking game, bloodshot eyes, marks on the neck, frequent severe headaches, disorientation after spending time alone, and ropes or belts tied to bedroom furniture or doorknobs.
"Although asphyxial games might have been played by youths for generations, the use of a ligature while playing alone appears to be a new practice that can be fatal," it says.
MMWR article (Free): http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5706a1.htm?s_cid=mm5706a1_x
17. Clot aspiration a promising alternative to conventional PCI
Svilaas T, et al. N Engl J Med 2008;358:557-67.
The usual way to unblock a coronary artery is to dilate it with a balloon. Balloon dilation restores blood flow but can also release thromboembolic material that clogs up vessels further downstream. An alternative approach is to suck out the clot directly. In a randomised trial comparing the two techniques, the newer one worked better in patients with myocardial infarction. Direct aspiration significantly improved downstream myocardial perfusion and led to more complete resolution of ST segment elevation on post-procedure electrocardiograms. Both groups of patients received bare metal stents after their allocated percutaneous coronary intervention (PCI).
Aspiration of the thrombus didn’t improve survival significantly during the first 30 days (11 of 529 patients died (2.1%) v 21 of 531 (4.0%); risk ratio 0.52, 95% CI 0.26 to 1.07). Instead, the authors reported a significant association between better myocardial perfusion and a lower risk of death, further infarction, or revascularisation. Further trials will need to confirm these findings.
Two thirds of the aspirated clots were made exclusively of platelets, confirming the importance of antiplatelet drugs, says an editorial (p 634). These patients had the recommended aspirin, clopidogrel, and abciximab before PCI, then aspirin and clopidogrel afterwards.
NEJM Abstract: http://content.nejm.org/cgi/content/abstract/358/6/557
18. Systematic Reviews Don’t Have all the Answers
Qayyam R, et al. Ann Intern Med 2008;148:186-96; MacLean C, et al. Ann Intern Med 2008;148:197-213; Wilt TJ, et al. Ann Intern Med 2008 Feb 4; [Epub ahead of print]
Systematic reviews and meta-analyses are most useful when they give definitive answers to clinically relevant questions, such as does this treatment work, and if so is it better or safer than other treatments? More often than not, however, researchers, doctors, and patients must make do with the far less satisfactory conclusion that we still don’t know because the research is weak and full of holes.
Three separate systematic reviews in the same journal recently ran aground trying to find the best treatments for early prostate cancer and osteoporosis, and the best strategy for treating acute coronary syndrome. In each case, the authors looked carefully for all the relevant studies, appraised their quality, extracted data, and tried to synthesise the evidence. Between them they looked at more than 600 studies that involved thousands of patients. In all three reviews, the data were simply not good enough to direct doctors to one treatment or the other, usually because there were too few head to head trials. Reviewers found none comparing different treatments for osteoporosis and just three comparing treatments for early prostate cancer. The authors of the review comparing routine percutaneous coronary intervention with a more selective strategy for acute coronary syndrome found 10 head to head trials. But they were heterogeneous and not powerful enough to be conclusive, even when combined.
19. Heavy Fast Food Consumption Can Quickly Elevate ALT Levels
A single week of overindulging in fast food can lead to pathologic levels of alanine aminotransferase (ALT), according to a small study in Gut published early online.
Swedish researchers had 18 healthy adults eat at least two fast food meals a day, thereby doubling their calorie intake, and limit their daily exercise to less than 5000 steps for 4 weeks. A matched control group continued their usual diet and exercise.
The fast food group gained an average of 14 pounds. Over half of the people in that group experienced persistently elevated ALT levels from the first week to the end of the study. To explain this, the authors speculate that an increased supply of monosaccharides to the liver could have led to induction of the enzyme in hepatocytes.
They suggest that "in the clinical evaluation of subjects with elevated ALT, physicians should include not only questions about alcohol intake, but also explore whether recent excessive food intake has occurred."
Gut article abstract: http://gut.bmj.com/cgi/gca?sendit=Get+All+Checked+Abstract%28s%29&gca=gut.2007.131797v1
20. Sugary drinks, fruit, and increased risk of gout
BMJ 2008;336:285-286
Editorials: Dietary fructose could be a contributing factor
The accompanying prospective cohort study by Choi and Curhan adds dietary fructose intake to the list of possible risk factors for gout. Laboratory evidence that dietary fructose increases serum urate already exists, and recent epidemiological studies have found an association between dietary fructose and hyperuricaemia in the United States.
The health professionals follow-up study was established in 1986 to examine the relation between nutritional factors and disease onset in later life in more than 50,000 American men. Previous analyses have looked at the association of obesity, alcohol, and diet with the onset of gout.
This new analysis looks at the role of non-alcoholic drinks and fruit on the first onset of gout. It finds a strong association between sugar sweetened soft drinks, usually containing fructose, and gout. Consuming two servings a day of a sugar sweetened soft drink increased the risk of developing gout by 85% (relative risk 1.85, 95% confidence interval 1.08 to 3.16). This compares with an increased risk of 49% from drinking 15-29.9 g/day of alcohol, 21% from eating an extra serving of meat a day, and 95% from having a body mass index of 25.0-29.9 versus 21.0-22.9; consuming 240 ml of skimmed milk a day decreased risk by 43%. A high intake of naturally occurring fructose also increased the risk of developing gout; consuming two or more glasses of fruit juice each day increased the risk by 81% (1.81, 1.12 to 2.93) and eating an apple or orange a day increased the risk by 64% (1.64, 1.05 to 2.56). These epidemiological data provide useful information for formulating appropriate dietary advice that might reduce recurrent gout.
Choi article in BMJ: http://www.bmj.com/cgi/content/abstract/336/7639/309
21. Emergency Management of Chronic Pain and Drug-Seeking Behavior: An Alternate Perspective
Hawkins SC. J Emerg Med. 2008;34:125-129.
Abstract
Pain is one of the most prevalent conditions treated by Emergency Physicians, although it remains contested how to interpret, measure, and treat this condition. In particular, there is controversy over how to identify and treat patients with chronic under-treated pain and those who are potentially malingering (drug-seeking). This article discusses currently accepted paradigms for treating potentially malingering patients, difficulties some communities may have when these paradigms are applied, and the results of implementing pain treatment guidelines that limit opioid use. Systematically limiting opioids via these guidelines was not associated with a decrease in overall patient satisfaction, patient satisfaction with pain management, overall volume, or volume of patients with potential drug-seeking diagnoses. Emergency Physicians’ perception of quality of care delivered, as well as job satisfaction, increased after implementation of the guidelines.
Link: http://www.jem-journal.com/article/S0736-4679(07)00475-1/
Wednesday, January 23, 2008
Lit Bits: January 23, 2008
From the recent medical literature...
1. ED Patient Preferences for Boarding Locations When Hospitals Are at Full Capacity
Garson C, et al. Ann Emerg Med 2008;51:9-12.e3.
Intro: Emergency department (ED) crowding is a major public health crisis in the United States. A central cause for ED crowding is hospital crowding, which occurs when demand for inpatient beds outstrips supply. The practical question when hospitals are at full capacity is where admitted ED patients should wait until inpatient beds become available. The predominant strategy is to leave patients being admitted through the ED in the ED. High levels of ED boarding reduce the effective capacity of an ED to treat new patients and increase ED workload, especially for nurses who are required to provide inpatient care. Hospitals that have longer ED boarding times for admitted patients have been associated with poorer quality of care. One alternative to ED boarding is transferring admitted patients to inpatient hallways. One institution adopting this strategy reported increased revenue and decreased ambulance diversion. Boarding in inpatient hallways has been deemed acceptable by the New York Department of Health. We aimed to determine patient preferences for boarding location. Secondarily, we assessed patient expectations about what they consider a reasonable time to wait for an inpatient bed in the ED. We hypothesized that patients would prefer to board in inpatient hallways rather than ED hallways.
Methods: We surveyed adult ED patients during a 4-week period on preferences for boarding location. Patients were eligible if they were currently being admitted through the ED and had experienced at least 1 previous hospital admission to ensure knowledge of both the ED and inpatient locations. Patients were asked to choose whether they would rather board in an ED hallway or an inpatient hallway or whether they had no preference. Survey responses were hypothetical and did not affect care or bed placement. We tested whether patient demographics, survey location (ED room or ED hallway), admission service, timing to room placement, time to admission request, and time to survey administration were associated with survey responses.
Results: A total of 565 patients were approached; 87% consented to be interviewed. Of those consented, 88% of patients had been previously admitted, leaving 431 patients in the study group. A total of 64% (95% confidence interval [CI] 59% to 69%) had a preference for boarding location: 59% (95% CI 52% to 65%) preferred inpatient hallways and 41% (95% CI 35% to 48%) preferred ED hallways. Survey location, admission service, time to room placement, admission request, and survey administration were not associated with survey responses.
Conclusion: When hospitals are at full capacity, patients would rather board in inpatient hallways than ED hallways.
Associated editorial: Viccellio P. Customer Satisfaction Versus Patient Safety: Have We Lost Our Way? Ann Emerg Med. 2008;51:13-14. Full text (free):
http://www.annemergmed.com/article/PIIS0196064407014370/fulltext
2. White people get better pain relief in US emergency departments
Pletcher MJ, et al. JAMA 2008;299:70-8.
Total opioid prescribing is on the rise, from 23% of pain related visits in 1993 to 37% in 2005. This is in tune with the national standards and recommendations put forward in the 1990s, but the gap between ethnic groups has persisted. In 2005, for example, opioid prescribing rates were 40% for white people and 32% for all other people. Differences persisted after adjustment for pain severity and other confounders, and they were more pronounced in children and as the severity of pain increased.
The linked commentary (p 89) takes a global stand and says that adequate access to drugs for pain is unevenly distributed between rich and poor nations and between their rich and poor populations. Reasons include doctors' and patients' attitudes and misconceptions, supply and access barriers, legislation and regulation, and costs. In developed countries, for example, a typical monthly supply of morphine sulphate costs no more than $5.5 (£2.8; 3.7), but prices in developing countries can be as high as $180. The commentary ends by arguing that interventions to improve the treatment of pain should be a key public health priority worldwide.
JAMA Abstract: http://jama.ama-assn.org/cgi/content/abstract/299/1/70
3. Millions of Young People Abuse Cough and Cold Medicines
About 3.1 million teens and young adults (or 5% of U.S. youth) have used over-the-counter cough and cold medicines to get high, according to data from the 2006 National Survey on Drug Use and Health.
The study, released online, was conducted on people aged 12 to 25. Among other results:
# The most commonly misused products were NyQuil, Coricidin, and Robitussin.
# Among those who had abused cough and cold medicines, 82% had also used marijuana, 49% had used inhalants, and 44% had used hallucinogens, such as LSD, PCP, or Ecstasy.
# Whites were about three times as likely as blacks to misuse cough and cold medicines.
# Misuse was more common among girls than boys under age 18, and more common among boys than girls at older ages.
Substance Abuse & Mental Health Services Administration report (Free): http://oas.samhsa.gov/2k8/cough/cough.htm
4. ED Use of IV Procainamide for Patients with Acute A Fib or Flutter
Stiell IG, et al. Acad Emerg Med. 2007;14:1158-1164.
Objectives: Acute atrial fibrillation and flutter are very common arrhythmias seen in emergency department (ED) patients, but there is no consensus for their optimal management. The objective of this study was to examine the efficacy and safety of intravenous (IV) procainamide for acute atrial fibrillation or flutter.
Methods: This health records review included a consecutive cohort of ED patients with acute-onset atrial fibrillation or atrial flutter who received IV procainamide at one university hospital ED during a five-year period. The standard clinical protocol involved IV infusion of 1 g of procainamide over 60 minutes, followed by electrical cardioversion if necessary. A trained observer extracted data from the original clinical records. Outcome measurements included conversion to sinus rhythm, adverse events, and relapse up to seven days.
Results: The 341 study patients had a mean age of 63.9 years (SD ± 15.5 years), and 56.6% were male. The conversion rates were 52.2% (95% confidence interval = 47% to 58%) for 316 atrial fibrillation cases and 28.0% (95% confidence interval = 13% to 46%) for 25 atrial flutter cases. Mean dose given was 860.7 mg (SD ± 231.2 mg), and median time to conversion was 55 minutes. Adverse events occurred in 34 cases (10.0%): hypotension, 8.5%; bradycardia, 0.6%; atrioventricular block, 0.6%; and ventricular tachycardia, 0.3%. There were no cases of torsades de pointes, cerebrovascular accident, or death. Most patients (94.4%) were discharged home, but 2.9% of patients returned with a recurrence of atrial fibrillation within seven days.
Conclusions: This study of acute atrial fibrillation or flutter patients treated in the ED with IV procainamide suggests that this treatment is safe and effective in this setting. Procainamide should be prospectively compared with other ED strategies.
5. Studies in Septic Shock
A. Corticosteroids of No Apparent Benefit in Septic Shock
Corticosteroids do not improve survival in septic shock, regardless of the patient's responsiveness to corticotropin testing, according to an international study in the New England Journal of Medicine.
Using a randomized, double-blind, placebo-controlled design, researchers studied some 500 patients, half of whom received intravenous corticosteroids every 6 hours for 5 days, followed by 6 days of tapering; the others received placebo. At entry, about half the patients did not have a response to corticotropin challenge.
At the 28-day mark, neither the patients' treatment group nor their response to corticotropin testing made any difference in survival.
An editorialist calls the study "inadequately powered to detect a clinically important treatment effect," but comments that "it seems clear" that the corticotropin stimulation test is not useful in identifying patients who might benefit from corticosteroid therapy — views shared by the study's authors.
NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/short/358/2/111
B. Intensive Insulin Therapy, Pentastarch Resuscitation Linked to Adverse Events in Septic Shock
Patients with severe sepsis are at higher risk for adverse events when given intensive insulin therapy or pentastarch fluid resuscitation, according to a New England Journal of Medicine study.
Researchers studied some 540 patients, randomized to receive either intensive or conventional insulin therapy, along with either 10% pentastarch or modified Ringer's lactate for fluid resuscitation.
The study's safety monitoring board stopped the study early, "owing to an increased number of hypoglycemic events" among patients on intensive insulin therapy. The mortality rate at 28 days did not differ between the insulin groups.
In addition, there was a "significantly greater incidence of renal failure and a trend toward higher 90-day mortality" among those receiving pentastarch. The authors say that use of pentastarch and other low-molecular-weight hydroxyethyl starch solutions "should be avoided."
NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/abstract/358/2/125
6. Bronchodilator Therapy in Acute Decompensated Heart Failure Patients Without a History of COPD
Singer AJ, et al. Ann Emerg Med 2008;51:25-34.
Intro: Dyspnea is a common complaint among patients presenting to the emergency department (ED). Data from the National Hospital Ambulatory Medical Care survey indicate that shortness of breath was the sixth most common principal reason for ED visits. In 2003, 2.9 million ED visits for shortness of breath were reported.
The symptom of dyspnea is associated with a wide range of differential diagnoses. Chronic obstructive pulmonary disease and acute decompensated heart failure are among the most common and potentially serious causes of dyspnea. At patients’ initial presentation to the clinic, hospital, or ED, it is often difficult to determine whether their symptoms are the result of an acute exacerbation of chronic obstructive pulmonary disease or acute decompensated heart failure. Because these patients are often in clear distress, physicians may respond by treating for both conditions with a “shotgun” approach.
Inhaled bronchodilator agents are frequently used in the treatment of acute dyspnea. The actual use of bronchodilators in acute decompensated heart failure patients with or without pulmonary disease has not been well described in the literature. Some data suggest that bronchodilators may be harmful in patients with heart failure or ischemic heart disease. A better understanding of the association between inhaled bronchodilator use and clinical outcomes is needed among acute decompensated heart failure patients without chronic obstructive pulmonary disease.
Our objective was to evaluate the association between bronchodilator use and outcomes in acute decompensated heart failure patients without a history of chronic obstructive pulmonary disease, after adjusting for differences in baseline characteristics, severity of illness, and prognostic markers.
Methods: We conducted an analysis of the Acute Decompensated Heart Failure National Registry Emergency Module registry of patients with a principal discharge diagnosis of acute decompensated heart failure enrolled at 76 academic or community EDs. Dichotomous outcomes (mortality, ED discharges, ICU admission, ED IV vasodilator use, new dialysis, ED or in patient endotracheal intubation, ED BiPAP, and asymptomatic at discharge) in patients without a history of chronic obstructive pulmonary disease who were given bronchodilators were compared to those who were not given bronchodilators using logistic regression; odds ratios (ORs) and 95% confidence intervals (CIs) were calculated; and propensity score adjustments were made.
Results: Of the 10,978 patients enrolled, 7299 (66.5%) did not have a history of chronic obstructive pulmonary disease. Bronchodilators were administered by the EMS or in the ED to 2317 (21%) patients. Patients without chronic obstructive pulmonary disease given bronchodilators were more likely to receive ED IV vasodilators (28.4% vs. 16.9%; propensity adjusted OR 1.40 [95% CI 1.18-1.67]) and in-patient mechanical ventilation (6.0% vs. 2.4%; propensity adjusted OR 1.69 [95% CI 1.21-2.37]) than patients without chronic obstructive pulmonary disease who were not given bronchodilators. Hospital mortality in patients without chronic obstructive pulmonary disease was similar regardless of bronchodilator treatment (3.4% vs. 2.6%, propensity adjusted OR 1.02 [95% CI 0.67, 1.56]).
Conclusion: Many acute decompensated heart failure patients without a history of chronic obstructive pulmonary disease receive inhaled bronchodilators. Bronchodilator use was associated with a greater need for aggressive interventions and monitoring, and this may reflect an adverse effect of bronchodilators or it may be a marker for patients with more severe disease.
7. Delayed In-Hospital Defib Times Common
Almost a third of hospitalized patients requiring defibrillation receive it beyond the recommended 2-minute limit, according to a New England Journal of Medicine study. Researchers examined the outcomes of delayed defib in nearly 7000 patients included in a national database of resuscitative efforts. All patients had suffered arrest from ventricular arrhythmia. The median time to defib was 1 minute, but it took longer than 2 minutes for 30% of patients.
Black race, a noncardiac admitting diagnosis, small hospital size (under 250 beds), and occurrence after-hours or in unmonitored areas were all significantly associated with delayed defib. After adjustment for those factors, delayed defib was associated with a lower likelihood of survival to discharge and, among survivors, greater likelihood of major neurologic or functional disability.
An editorialist, urging the development of better monitoring technology and the installation of automated external defibrillators in each hospital room, concludes: "What are we waiting for?"
NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/short/358/1/9
8. Champagne: the safer choice for celebrations
Douglas RJ. BMJ 2007;335:1281
A 24 year old Australian rules football player presented to the emergency department complaining of a sensation of a foreign body stuck in his throat. The sensation was associated "with an inability to breathe properly." Earlier that day, when celebrating his team’s victory in the premiership, he had downed the remaining beer in the premiership cup, inadvertently swallowing a beer bottle cap.
Physical examination, radiography, and fibreoptic examination of the neck and throat were unremarkable. An anteroposterior chest radiogram showed a round metallic foreign body with scalloped edges at the level of the aortic arch (figure). Blood ethanol level was 0.109 g/100 ml. A beer bottle cap was retrieved via endoscopy later that evening, without complications.
Excessive alcohol consumption as a celebratory consequence of high profile sporting victories is well known. Oesophageal obstruction from a bottle cap, however, is rarely seen in emergency departments. In suspected cases, airways obstruction and injury should be rapidly excluded.
A comprehensive Medline search failed to elicit an example of oesophageal obstruction secondary to the ingestion of a champagne (or wine) cork. Since the 18th century, champagne has been the beverage of choice for celebrations and on current evidence should remain so.
9. Emergency Waits Get Dangerously Long in U.S. Study
WASHINGTON (Reuters) Jan 15 - Patients seeking urgent care in U.S. emergency rooms are waiting longer than in the 1990s, U.S. researchers reported on Tuesday.
They found a quarter of MI patients waited 50 minutes or more before seeing a doctor in 2004. Waits for all types of emergency department visits became 36% longer between 1997 and 2004, the team at Harvard Medical School reported.
Especially unsettling, people who had seen a triage nurse and been designated as needing immediate attention waited 40% longer -- from an average of 10 minutes in 1997 to an average 14 minutes in 2004, the researchers report in the journal Health Affairs.
Heart attack patients waited eight minutes in 1997 but 20 minutes in 2004, Dr. Andrew Wilper and colleagues found.
Dr. Wilper's team used U.S. Census survey and National Center for Health Statistics data for their study, which covered more than 92,000 emergency department visits. They used other surveys to calculate that the number of emergency room visits rose from 93.4 million in 1994 to 110.2 million in 2004. During the same time, 12% fewer hospitals operated emergency rooms, according to the American Hospital Association.
"EDs close because, in our current payment system, emergency patients are money-losers for hospitals," Dr. Wilper said in a statement.
Harvard's Dr. David Himmelstein, who worked on the study, also lobbies for some kind of national health care system. "One contributor to ED crowding is Americans' poor access to primary and preventive care, which could address medical issues before they become emergencies," Dr. Himmelstein said in a statement.
The American College of Emergency Physicians said the findings were not surprising.
"Emergency physicians have said for years that crowding and long wait times are hurting our patients -- insured and uninsured equally," ACEP president Dr. Linda Lawrence said in a statement. "Ever-lengthening waits are a frightening trend because any delays in care can make the difference between life and death for some patients. The number of emergency patients is increasing while the number of hospital beds continues to drop. It is a recipe for disaster."
10. Minor Leg Injuries Linked to Venous Thrombosis
January 14, 2008 — Minor injuries in the leg are associated with greater risk for venous thrombosis, according to the results of a large, population-based, case-control study reported in the January 14 issue of the Archives of Internal Medicine.
"Injuries increase the risk of venous thrombosis," write Karlijn J. van Stralen, MSc, from the Leiden University Medical Center in Leiden, the Netherlands, and colleagues. "So far, most research has focused on major injuries that are accompanied by other risk factors for venous thrombosis, such as plaster casts and surgery. We studied the association of venous thrombosis with common minor injuries, such as minor sural muscle ruptures and ankle sprains."
The Multiple Environmental and Genetic Assessment (MEGA) study of risk factors for venous thrombosis included 2471 consecutive patients with a first deep venous thrombosis (DVT) of the leg or pulmonary embolism (PE) and 3534 control subjects. Exclusion criteria were malignant neoplasms, surgery, and plaster cast or extended bed rest.
A minor injury in the 3 months preceding the venous thrombosis (patients) or completion of the questionnaire (controls) occurred in 289 patients (11.7%) and in 154 controls (4.4%). After adjustment for sex and age, venous thrombosis was associated with previous minor injury (adjusted odds ratio [aOR], 3.1; 95% confidence interval [CI], 2.5 - 3.8). The association was strongest for injuries during the 4-week period preceding thrombosis, and no association was evident before 10 weeks.
Minor injuries in the leg were more strongly associated with thrombosis (aOR, 5.1; 95% CI, 3.9 - 6.7), whereas minor injuries affecting other body parts were not associated with thrombosis. Factor V Leiden carriers with a leg injury had a 50-fold increased risk compared with noncarriers without injury (aOR, 49.7; 95% CI, 6.8 - 362.7).
"Minor injuries in the leg are associated with greater risk of venous thrombosis," the study authors write. "Because minor injuries are common, they could be major contributors to the occurrence of venous thrombosis."
Study limitations may include recall bias or referral bias.
"Many individuals with minor injuries will have contacted the general practitioner first," the authors conclude. "Therefore, there may be an important task for general practitioners to identify subjects who are at a high risk of developing venous thrombosis and subsequently to provide prophylactic measures."
The Netherlands Heart Foundation, the Dutch Cancer Foundation, and the Netherlands Organisation for Scientific Research supported this study. The authors have disclosed no relevant financial relationships.
Arch Intern Med. 2008;168:21-26.
11. A RCT of Prochlorperazine Versus Metoclopramide for Treatment of Acute Migraine
Friedman BW, et al. Ann Emerg Med 2008; in press.
Intro
A mounting body of evidence has demonstrated the efficacy of the antiemetic dopamine antagonists as primary parenteral treatment for acute migraine. These agents are at least as efficacious as parenteral triptans, dihyrdroergotamine, and nonsteroidals and are well tolerated. There is no consensus as to the optimal choice among the members of this class. However, metoclopramide and prochlorperazine are often used because, unlike other medications in their class, they do not cause significant orthostatic changes or require cardiac monitoring. Although previous trials have concluded that prochlorperazine is superior to metoclopramide for the treatment of acute migraine, the 10-mg dose of metoclopramide used in those studies may have been insufficient. The optimal dose of metoclopramide for the acute treatment of migraine is unknown because dose-finding studies have not been conducted. However, 20 mg of intravenous metoclopramide is efficacious and well tolerated.
There is substantial practice variation in the ED–based treatment of acute migraine. Two dozen parenteral agents, alone or in combination, are commonly used in US EDs. Yet, ED migraine care remains suboptimal. Incomplete pain relief, need for rescue medication, adverse medication effects, functional disability, and recurrence of headache after ED discharge continue to plague individuals with migraine, independent of the primary treatment. This study addressed the efficacy and tolerability of a 20-mg dose of metoclopramide versus a 10-mg dose of prochlorperazine, with the intent of helping emergency physicians decide whether one of these 2 dopamine antagonists is superior as a primary treatment for acute migraine.
Study objective
We compare prochlorperazine 10 mg intravenously versus metoclopramide 20 mg intravenously, both accompanied by 25 mg of intravenous diphenhydramine.
Methods
This was a randomized, double-blind, clinical trial comparing 2 parenteral dopamine antagonists. Both drugs were administered during 15 minutes with 25 mg intravenous diphenhydramine. Pain scores on a numeric rating scale were assessed at baseline, every 30 minutes for 2 hours, and by telephone 24 hours after discharge. The primary endpoint was the between-group difference in change in numeric rating scale from baseline to 1 hour postbaseline. Secondary endpoints included mean differences in change in numeric rating scale at 2 and 24 hours, headache relief, adverse effects, and desire to receive the same treatment for future migraines.
Results
Of 152 patients screened, 97 were eligible and 77 were randomized. The mean change in numeric rating scale scores at 1 hour was 5.5 and 5.2 in subjects receiving prochlorperazine and metoclopramide, respectively (difference=0.3; 95% confidence interval [CI] –1.0 to 1.6). Findings were similar at 2 hours and 24 hours. Forty-six percent (18/39) of prochlorperazine and 32% (12/38) of metoclopramide subjects reported adverse events (difference=15%; 95% CI –6% to 36%). Seventy-seven percent (26/34) of prochlorperazine and 73% (27/37) of metoclopramide subjects wanted to receive the same medication in future ED visits (difference=4%; 95% CI –16% to 24%).
Conclusion
Either prochlorperazine 10 mg intravenously or metoclopramide 20 mg intravenously, combined with diphenhydramine 25 mg intravenously, is an efficacious treatment for ED patients with acute migraine. Three quarters of subjects in both arms would want the same medication for their next migraine.
12. The Role of Oral Ondansetron in Children With Vomiting as a Result of Acute Gastritis/Gastroenteritis Who Have Failed Oral Rehydration Therapy: A RCT
Roslund G, et al. Ann Emerg Med. 2008; in press.
Study objective
We hypothesize that ondansetron will facilitate oral rehydration therapy in children with acute gastritis or acute gastroenteritis and mild to moderate dehydration who fail initial oral rehydration therapy. We hypothesize that subjects receiving ondansetron will tolerate oral rehydration and that a lower proportion will require intravenous hydration than subjects receiving placebo, with a clinically important difference of at least 30% when comparing 2 groups of patients presenting to the ED with acute gastritis/acute gastroenteritis. Secondarily, we hypothesize that subjects receiving ondansetron will have a lower proportion requiring admission, fewer episodes of vomiting and diarrhea, and fewer revisits.
Methods
This double-blind, placebo-controlled, prospective, randomized trial enrolled a convenience sample of subjects 1 to 10 years old, with acute gastritis or acute gastroenteritis, who failed oral rehydration therapy in the emergency department (ED). Subjects received a weight-based dose of ondansetron (0.15 mg/kg of the orally dissolving tablet) or placebo, and oral rehydration therapy was reattempted 30 minutes later. If a subject vomited or refused to drink, he or she was considered a failed oral rehydration therapy and received acute gastroenteritis. If a subject tolerated adequate oral rehydration therapy, he or she was discharged. Parents completed symptom diaries and were contacted by telephone for follow-up. We used the chi-square test to compare the proportions of subjects requiring acute gastroenteritis in each group.
Results
We enrolled 106 subjects: 51 received ondansetron and 55 received placebo. Eleven of 51 (21.6%; 95% confidence interval [CI] 11.3% to 35.3%) of subjects who received ondansetron required intravenous hydration and 30 of 55 (54.5%; 95% CI 40.6% to 68%) of placebo subjects required intravenous hydration (p less than 0.001) for a difference of 32.9% (95% CI 14.54% to 48.37%). Admission rates were 5.9% (3/51) with ondansetron and 12.7% (7/55) with placebo.
Conclusion
In subjects with acute gastritis/acute gastroenteritis and mild to moderate dehydration who failed initial oral rehydration therapy, the proportion of children who received intravenous hydration was smaller in the ondansetron group than in the placebo group.
13. ED Crowding Is Associated With Poor Care for Patients With Severe Pain
Pines JM, Hollander JE. Ann Emerg Med. 2008;51:1-5.
Study objective
We study the impact of emergency department (ED) crowding on delays in treatment and nontreatment for patients with severe pain.
Methods
We performed a retrospective cohort study of all patients presenting with severe pain to an inner-city, teaching ED during 17 months. Poor care was defined by 3 outcomes: not receiving treatment with pain medication while in the ED, a delay (more than 1 hour) from triage to first pain medication, and a delay (more than 1 hour) from room placement to first pain medication. Three validated crowding measures were assigned to each patient at triage. Logistic regression was used to test the association between crowding and outcomes.
Results
In 13,758 patients with severe pain, the mean age was 39 years (SD 16 years), 73% were black, and 64% were female patients. Half (49%) of the patients received pain medication. Of those treated, 3,965 (59%) experienced delays in treatment from triage and 1,319 (20%) experienced delays from time of room placement. After controlling for factors associated with the ED treatment of pain (race, sex, severity, and older age), nontreatment was independently associated with waiting room number (odds ratio [OR] 1.03 for each additional waiting patient; 95% confidence interval [CI] 1.02 to 1.03) and occupancy rate (OR 1.01 for each 10% increase in occupancy; 95% CI 0.99 to 1.04). Increasing waiting room number and occupancy rate also independently predicted delays in pain medication from triage (OR 1.05 for each waiting patient, 95% CI 1.04 to 1.06; OR 1.18 for each 10% increase in occupancy; 95% CI 1.15 to 1.21) and delay in pain medication from room placement (OR 1.02 for each waiting patient, 95% CI 1.01 to 1.03; OR 1.06 for each 10% increase in occupancy, 95% CI 1.04 to 1.08).
Conclusion
ED crowding is associated with poor quality of care in patients with severe pain, with respect to total lack of treatment and delay until treatment.
Full text (free): http://www.annemergmed.com/article/PIIS0196064407012978/fulltext
14. Medical myths: Sometimes even doctors are duped
Vreeman RC, et al. BMJ 2007;335:1288-1289.
Physicians understand that practicing good medicine requires the constant acquisition of new knowledge, though they often assume their existing medical beliefs do not need re-examination. These medical myths are a light hearted reminder that we can be wrong and need to question what other falsehoods we unwittingly propagate as we practice medicine. We generated a list of common medical or medicine related beliefs espoused by physicians and the general public, based on statements we had heard endorsed on multiple occasions and thought were true or might be true. We selected seven for critical review:
# People should drink at least eight glasses of water a day
# We use only 10% of our brains
# Hair and fingernails continue to grow after death
# Shaving hair causes it to grow back faster, darker, or coarser
# Reading in dim light ruins your eyesight
# Eating turkey makes people especially drowsy
# Mobile phones create considerable electromagnetic interference in hospitals.
We used Medline and Google to search for evidence to support or refute each of these claims. Because "proving a negative" can be challenging, we noted instances in which there was no evidence to support the claim.
Full-text: http://www.bmj.com/cgi/content/full/335/7633/1288?etoc
15. Beta-blockers Are Associated With Reduced Risk of AMI After Cocaine Use
Dattilo PB, et al. Ann Emerg Med 2008;51:117-125.
Background
Cocaine has many deleterious effects on the heart. The pharmacologic effects of cocaine include both alpha and beta receptor stimulation, as well as acute myocardial depression, which is not related to reduced coronary blood flow. Cocaine has also been associated with coronary artery spasm. This effect appears to be mediated by both alpha stimulation and a direct effect of cocaine on vascular smooth muscle. Because beta-adrenergic stimulation leads to vasodilatation of the coronary arteries, the safety of using beta-adrenergic blockers in patients with history of cocaine use has been questioned repeatedly. Lange et al presented evidence that beta-adrenergic blockade increases vasoconstriction when given after cocaine exposure, as measured physiologically by reduced coronary blood flow and increased coronary vascular resistance. Labetalol, which is a combined alpha-beta receptor-blocker, does not reduce cocaine-induced coronary vasoconstriction, whereas both nitroglycerin and verapamil are effective agents for this purpose. Case reports have also documented evidence for spasm of large coronary arteries in the genesis of myocardial infarction associated with cocaine use. These considerations have led to the recommendation that beta-adrenergic blocking agents not be used in patients with acute exposure to cocaine.
Study objective
Beta-blocker use is associated with coronary artery spasm after cocaine administration but also decreases mortality in patients with myocardial infarction or systolic dysfunction. We conduct a retrospective cohort study to analyze the safety of beta-blockers in patients with positive urine toxicology results for cocaine.
Methods
The cohort consisted of 363 consecutive telemetry and ICU patients who were admitted to a municipal hospital and had positive urine toxicology results for cocaine during a 5-year period (307 patients). Fifteen patients with uncertain history of beta-blocker use before admission were excluded. The primary outcome measure was myocardial infarction; secondary outcome measure was inhospital mortality. Logistic regression analysis using generalized estimating equations models and propensity scores compared outcomes.
Results
Beta-blockers were given in 60 of 348 admissions. The incidence of myocardial infarction after administration of beta-blocker was significantly lower than without treatment (6.1% versus 26.0%; difference in proportion 19.9%; 95% confidence interval [CI] 10.3% to 30.0%). One of 14 deaths occurred in patients who received beta-blockade (incidence 1.7% versus 4.5% without beta-blockade; difference in proportion 2.8%; 95% CI –1.2% to 6.7%). Multivariate analysis showed that use of beta-blockers significantly reduced the risk of myocardial infarction (odds ratio 0.06; 95% CI 0.01 to 0.61).
Conclusion
In our cohort, administration of beta-blockers was associated with reduction in incidence of myocardial infarction after cocaine use. The benefit of beta-blockers on myocardial function may offset the risk of coronary artery spasm.
16. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the ED with Acute Carbon Monoxide Poisoning
Wolf SJ, et al. Ann Emerg Med 2008;51:138-152.
This clinical policy focuses on critical issues concerning the management of adult patients presenting to the emergency department (ED) with acute symptomatic carbon monoxide (CO) poisoning. The subcommittee reviewed the medical literature relevant to the questions posed. The critical questions are:
Should hyperbaric oxygen (HBO2) therapy be used for the treatment of patients with acute CO poisoning; and
Can clinical or laboratory criteria identify CO-poisoned patients who are most or least likely to benefit from this therapy?
Recommendations are provided on the basis of the strength of evidence of the literature.
Full-text (free!): http://www.annemergmed.com/article/PIIS0196064407016691/fulltext
17. Validation of the Acute Heart Failure Index
Hsieh M, et al. Ann Emerg Med. 2008;51:37-44.
Introduction: Heart failure affects more than 5 million Americans, with more than 550,000 new cases diagnosed in the United States each year1 and 1 million admissions in 2004. Care of heart failure patients in the United States costs approximately $33.2 billion a year, with hospitalization accounting for $17.8 billion of that expense. Emergency department (ED) visits for evaluation of heart failure, the source for the majority of the hospital admissions for heart failure, increased 19% between 1992 and 2001.
Hospital admission rates for heart failure vary widely and in a manner not fully explained by disease severity. Acute care and emergency physicians often overestimate the probability of short-term death or severe complications for heart failure patients, with the higher estimates of risk translating into patient treatment in more intense care settings. An evidence-based clinical prediction rule could improve physician risk assessment and the appropriateness of initial site of treatment decisions. Additionally, such a rule could aid investigators studying heart failure populations, allowing accurate assessment of initial illness severity (particularly useful in observational or nonrandom assignment designs).
A rule to aid in assessing short-term risk was derived and is based on data readily available in the ED to identify heart failure patients who are at low risk of inpatient death or serious medical complications (less than 2% inpatient death or complications and 1% inpatient death). This could aid initial decision-making in the ED by limiting variation and inaccuracy in judging illness burden and risk of death or morbidity.
We sought to examine the performance of this clinical prediction rule, now called the Acute Heart Failure Index, in an independent group of patients with respect to inpatient death, serious medical complication before hospital discharge, and 30-day death.
Methods: We retrospectively studied a random cohort of 8,384 adult patients admitted to Pennsylvania hospitals in 2003 and 2004 with a diagnosis of heart failure as defined by primary discharge diagnosis codes. We reported the proportions of inpatient death, serious medical complications before discharge, and 30-day death in the patients identified as low risk by the prediction rule.
Results: The prediction rule classified 1,609 (19.2%) of the patients as low risk. Within this subgroup, there were 12 (0.7%; 95% confidence interval [CI] 0.3% to 1.2%) inpatient deaths, 28 (1.7%; 95% CI 1.1% to 2.4%) patients survived to hospital discharge after a serious complication, and 47 (2.9%; 95% CI 2.1% to 3.7%) patients died within 30 days of the index hospitalization.
Conclusion: This prediction rule identifies a group of admitted heart failure patients at low risk of inpatient mortal and nonmortal complications. Our validation findings suggest the rule could assist physicians in making site-of-care decisions for this patient population and aid in analyzing presenting illness burden in study populations.
The rules can be viewed here: http://www.pitt.edu/~hfpr/HF_tree_final_web.mht
An algorithm is also available: http://www.pitt.edu/~hfpr/
18. To Sit or Not to Sit?
Johnson RL, et al. Ann Emerg Med. 2008;51:188-193.e2.
Study objective
We prospectively examine whether provider posture (seated versus standing) influences patient and provider estimates of time spent at the bedside relative to actual time and patient perceptions of the provider-patient interaction.
Methods
A convenience sample of consenting adult patients presenting to an academic tertiary care emergency department between September 7, 2005, and September 25, 2005, were eligible for inclusion in this randomized, controlled trial. Providers (emergency medicine attending physicians, residents, physician assistants, and medical students) were randomly assigned to sit or stand during the initial encounter, after which, participants completed questionnaires about their perceptions of provider-patient interactions and time spent therein. Actual encounter length was measured. Data were analyzed to determine whether patient and provider perception differences existed, using a multilevel regression model that was adjusted for patient-level and provider-level covariates.
Results
Two hundred twenty-four consenting patients met inclusion criteria (239 approached; 15 excluded). Data from 36 providers were collected. The mean length of encounters in both study arms was 8.6 minutes (SD 4.8; range 1.5 to 34.1). Patients involved in seated interactions overestimated time providers spent performing initial encounters by an average of 1.3 minutes (SD 4.3 minutes), whereas patients involved in the standing interactions underestimated time by an average of 0.6 minutes (SD 4.3 minutes) (P=.001). Conversely, providers overestimated time spent with patients in both study arms (P=.85; mean [SD] 0.5 [3.6] versus 0.3 [3.2] minutes). Patient perceptions of the quality of patient-provider interactions were not affected by provider posture.
Conclusion
Although provider posture during the initial interaction affects patient perceptions of time spent at the bedside, it does not influence patient perception of the provider’s bedside manner, sense of caring, or understanding of the patient’s problem.
19. Assessment of hyperglycemia after calcium channel blocker overdoses involving diltiazem or verapamil
Levine M, et al. Crit Care Med. 2007;35:2071-5.
BACKGROUND: Overdoses of calcium channel blocker agents result in hyperglycemia, primarily due to the blockade of pancreatic L-type calcium channels and insulin resistance on the cellular level. The clinical significance of the hyperglycemia in this setting has not previously been described.
METHODS: This study is a retrospective review of all adult (age, 15 yrs or greater) patients with a discharge diagnosis of acute verapamil or diltiazem overdose at five university-affiliated teaching hospitals. The severity of overdose was assessed by determining whether a patient met the composite end points of in-hospital mortality, the necessity for a temporary pacemaker, or the need for vasopressors. We compared the initial and peak serum glucose concentrations with hemodynamic variables between patients who did and did not meet the composite end points.
RESULTS: A total of 40 patients met inclusion criteria, with verapamil and diltiazem accounting for 27 of 40 (67.5%) and 13 of 40 (32.5%) of the ingestions, respectively. For those patients who did and did not meet the composite end points, the median initial serum glucose concentrations were 188 (interquartile range, 143.5-270.5) mg/dL and 129 (98.5-156.5) mg/dL, respectively (p = .0058). The median peak serum glucose concentrations for these two groups were 364 (267.5-408.5) mg/dL and 145 (107.5-160.5) mg/dL, respectively (p = .0001). The median increase in blood glucose was 71.2% for those who met composite end points vs. 0% for those who did not meet composite end points (p = .0067). Neither the change in the median heart rate nor the change in systolic blood pressure was significantly different in any group.
CONCLUSION: Serum glucose concentrations correlate directly with the severity of the calcium channel blocker intoxication. The percentage increase of the peak glucose concentration is a better predictor of severity of illness than hemodynamic derangements. If validated prospectively, serum glucose concentration alone might be an indicator to begin hyperinsulinemia-euglycemia therapy.
20. Management of ED Patients With Primary Spontaneous Pneumothorax: Needle Aspiration or Tube Thoracostomy?
Zehtabchi S, et al. Ann Emerg Med. 2008;51:91-100.e1
Study objective: The emergency management of primary spontaneous pneumothorax is controversial. This evidence-based emergency medicine review evaluates the existing evidence about the efficacy and safety of needle aspiration in comparison to tube thoracostomy for management of primary spontaneous pneumothorax.
Methods: We searched MEDLINE, EMBASE, the Cochrane Library, and other databases. We selected studies for inclusion in the review if the authors stated that they had randomly assigned hemodynamically stable patients with no underlying lung disease to needle aspiration or tube thoracostomy. The outcome measures of interest included admission rate, length of hospital stay, recurrence rate, failure rate of the procedure, dyspnea score during or after the procedure, pain score during or after the procedure, and complications.
Results: Three randomized trials with acceptable quality standards met the inclusion criteria. There was no significant difference between needle aspiration and tube thoracostomy when outcomes of immediate failure, 1-week failure, risk of complication, and 1-year recurrence rate were measured. Only 2 trials reported the rate of hospitalization; needle aspiration was associated with lower rates of hospitalization in both trials: relative risks of 0.26 (95% confidence interval [CI] 0.17 to 0.39) and 0.51 (95% CI 0.36 to 0.74). Length of hospital stay was lower in the needle aspiration groups in all 3 trials, with mean differences of −2.15 days (95% CI −0.99 to −3.30), −2.10 days (95% CI −0.57 to −3.63), and −1.10 days (95% CI −2.28 to 0.08), respectively. Needle aspiration was associated with less analgesia requirement in one trial and lower pain scores in another.
Conclusion: The existing evidence indicates that needle aspiration is at least as safe and effective as tube thoracostomy for management of primary spontaneous pneumothorax. Additionally, needle aspiration carries the benefit of fewer hospital admissions and shorter length of hospital stay.
21. Educational Videos Drain Baby Brains
By Matt Kaplan. ScienceNOW Daily News.
Buyer beware: Videos aimed at improving infant and toddler language skills are not as beneficial for language learning as they claim to be, according to a new study. Rather than helping youngsters, such products may actually hurt their vocabularies.
Videos like Brainy Baby and Baby Einstein have been marketed to parents since 1997. They feature simple lessons in music, math, and vocabulary, and their makers tout them as important educational tools that will help young children build skills in each of these areas. But none of these claims has ever been verified, says Frederick Zimmerman, who studies the relationship between child development and the economy at the University of Washington, Seattle. "In many cases, the corporations making the educational videos are not even testing their own products," he says.
So Zimmerman and colleagues decided to test the videos themselves. The researchers interviewed the parents of more than 1000 U.S. children between the ages of 8 and 16 months, gathering information on the children's vocabulary and how frequently they watched videos like Baby Einstein. When the team controlled for factors such as socioeconomic status, race, and parental education, it found that Baby Einstein and his ilk are not the geniuses they're cracked up to be. For every hour per day spent watching the videos, children understood an average of six to eight fewer words than did those of the same age who did not watch them--a 17-percentile drop in vocabulary, the team reports online tomorrow in the Journal of Pediatrics. "There is no clear evidence of a benefit coming from these videos, and there is some suggestion of harm," says Zimmerman.
As for why the videos hurt vocabulary when they're supposed to help it, Zimmerman can only speculate. One possibility, he says, is that the videos simply pacify children without teaching them anything. "It's like empty calories for the mind," Zimmerman says. Meanwhile, children not watching the videos are reading, interacting with their parents, or building with blocks.
"The negative effect is a real surprise," says Rebecca Collins, a behavioral scientist at the RAND Corp. in Santa Monica, California. "There is so much consumption of these videos, and nobody has any idea how effective they are."
1. ED Patient Preferences for Boarding Locations When Hospitals Are at Full Capacity
Garson C, et al. Ann Emerg Med 2008;51:9-12.e3.
Intro: Emergency department (ED) crowding is a major public health crisis in the United States. A central cause for ED crowding is hospital crowding, which occurs when demand for inpatient beds outstrips supply. The practical question when hospitals are at full capacity is where admitted ED patients should wait until inpatient beds become available. The predominant strategy is to leave patients being admitted through the ED in the ED. High levels of ED boarding reduce the effective capacity of an ED to treat new patients and increase ED workload, especially for nurses who are required to provide inpatient care. Hospitals that have longer ED boarding times for admitted patients have been associated with poorer quality of care. One alternative to ED boarding is transferring admitted patients to inpatient hallways. One institution adopting this strategy reported increased revenue and decreased ambulance diversion. Boarding in inpatient hallways has been deemed acceptable by the New York Department of Health. We aimed to determine patient preferences for boarding location. Secondarily, we assessed patient expectations about what they consider a reasonable time to wait for an inpatient bed in the ED. We hypothesized that patients would prefer to board in inpatient hallways rather than ED hallways.
Methods: We surveyed adult ED patients during a 4-week period on preferences for boarding location. Patients were eligible if they were currently being admitted through the ED and had experienced at least 1 previous hospital admission to ensure knowledge of both the ED and inpatient locations. Patients were asked to choose whether they would rather board in an ED hallway or an inpatient hallway or whether they had no preference. Survey responses were hypothetical and did not affect care or bed placement. We tested whether patient demographics, survey location (ED room or ED hallway), admission service, timing to room placement, time to admission request, and time to survey administration were associated with survey responses.
Results: A total of 565 patients were approached; 87% consented to be interviewed. Of those consented, 88% of patients had been previously admitted, leaving 431 patients in the study group. A total of 64% (95% confidence interval [CI] 59% to 69%) had a preference for boarding location: 59% (95% CI 52% to 65%) preferred inpatient hallways and 41% (95% CI 35% to 48%) preferred ED hallways. Survey location, admission service, time to room placement, admission request, and survey administration were not associated with survey responses.
Conclusion: When hospitals are at full capacity, patients would rather board in inpatient hallways than ED hallways.
Associated editorial: Viccellio P. Customer Satisfaction Versus Patient Safety: Have We Lost Our Way? Ann Emerg Med. 2008;51:13-14. Full text (free):
http://www.annemergmed.com/article/PIIS0196064407014370/fulltext
2. White people get better pain relief in US emergency departments
Pletcher MJ, et al. JAMA 2008;299:70-8.
Total opioid prescribing is on the rise, from 23% of pain related visits in 1993 to 37% in 2005. This is in tune with the national standards and recommendations put forward in the 1990s, but the gap between ethnic groups has persisted. In 2005, for example, opioid prescribing rates were 40% for white people and 32% for all other people. Differences persisted after adjustment for pain severity and other confounders, and they were more pronounced in children and as the severity of pain increased.
The linked commentary (p 89) takes a global stand and says that adequate access to drugs for pain is unevenly distributed between rich and poor nations and between their rich and poor populations. Reasons include doctors' and patients' attitudes and misconceptions, supply and access barriers, legislation and regulation, and costs. In developed countries, for example, a typical monthly supply of morphine sulphate costs no more than $5.5 (£2.8; 3.7), but prices in developing countries can be as high as $180. The commentary ends by arguing that interventions to improve the treatment of pain should be a key public health priority worldwide.
JAMA Abstract: http://jama.ama-assn.org/cgi/content/abstract/299/1/70
3. Millions of Young People Abuse Cough and Cold Medicines
About 3.1 million teens and young adults (or 5% of U.S. youth) have used over-the-counter cough and cold medicines to get high, according to data from the 2006 National Survey on Drug Use and Health.
The study, released online, was conducted on people aged 12 to 25. Among other results:
# The most commonly misused products were NyQuil, Coricidin, and Robitussin.
# Among those who had abused cough and cold medicines, 82% had also used marijuana, 49% had used inhalants, and 44% had used hallucinogens, such as LSD, PCP, or Ecstasy.
# Whites were about three times as likely as blacks to misuse cough and cold medicines.
# Misuse was more common among girls than boys under age 18, and more common among boys than girls at older ages.
Substance Abuse & Mental Health Services Administration report (Free): http://oas.samhsa.gov/2k8/cough/cough.htm
4. ED Use of IV Procainamide for Patients with Acute A Fib or Flutter
Stiell IG, et al. Acad Emerg Med. 2007;14:1158-1164.
Objectives: Acute atrial fibrillation and flutter are very common arrhythmias seen in emergency department (ED) patients, but there is no consensus for their optimal management. The objective of this study was to examine the efficacy and safety of intravenous (IV) procainamide for acute atrial fibrillation or flutter.
Methods: This health records review included a consecutive cohort of ED patients with acute-onset atrial fibrillation or atrial flutter who received IV procainamide at one university hospital ED during a five-year period. The standard clinical protocol involved IV infusion of 1 g of procainamide over 60 minutes, followed by electrical cardioversion if necessary. A trained observer extracted data from the original clinical records. Outcome measurements included conversion to sinus rhythm, adverse events, and relapse up to seven days.
Results: The 341 study patients had a mean age of 63.9 years (SD ± 15.5 years), and 56.6% were male. The conversion rates were 52.2% (95% confidence interval = 47% to 58%) for 316 atrial fibrillation cases and 28.0% (95% confidence interval = 13% to 46%) for 25 atrial flutter cases. Mean dose given was 860.7 mg (SD ± 231.2 mg), and median time to conversion was 55 minutes. Adverse events occurred in 34 cases (10.0%): hypotension, 8.5%; bradycardia, 0.6%; atrioventricular block, 0.6%; and ventricular tachycardia, 0.3%. There were no cases of torsades de pointes, cerebrovascular accident, or death. Most patients (94.4%) were discharged home, but 2.9% of patients returned with a recurrence of atrial fibrillation within seven days.
Conclusions: This study of acute atrial fibrillation or flutter patients treated in the ED with IV procainamide suggests that this treatment is safe and effective in this setting. Procainamide should be prospectively compared with other ED strategies.
5. Studies in Septic Shock
A. Corticosteroids of No Apparent Benefit in Septic Shock
Corticosteroids do not improve survival in septic shock, regardless of the patient's responsiveness to corticotropin testing, according to an international study in the New England Journal of Medicine.
Using a randomized, double-blind, placebo-controlled design, researchers studied some 500 patients, half of whom received intravenous corticosteroids every 6 hours for 5 days, followed by 6 days of tapering; the others received placebo. At entry, about half the patients did not have a response to corticotropin challenge.
At the 28-day mark, neither the patients' treatment group nor their response to corticotropin testing made any difference in survival.
An editorialist calls the study "inadequately powered to detect a clinically important treatment effect," but comments that "it seems clear" that the corticotropin stimulation test is not useful in identifying patients who might benefit from corticosteroid therapy — views shared by the study's authors.
NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/short/358/2/111
B. Intensive Insulin Therapy, Pentastarch Resuscitation Linked to Adverse Events in Septic Shock
Patients with severe sepsis are at higher risk for adverse events when given intensive insulin therapy or pentastarch fluid resuscitation, according to a New England Journal of Medicine study.
Researchers studied some 540 patients, randomized to receive either intensive or conventional insulin therapy, along with either 10% pentastarch or modified Ringer's lactate for fluid resuscitation.
The study's safety monitoring board stopped the study early, "owing to an increased number of hypoglycemic events" among patients on intensive insulin therapy. The mortality rate at 28 days did not differ between the insulin groups.
In addition, there was a "significantly greater incidence of renal failure and a trend toward higher 90-day mortality" among those receiving pentastarch. The authors say that use of pentastarch and other low-molecular-weight hydroxyethyl starch solutions "should be avoided."
NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/abstract/358/2/125
6. Bronchodilator Therapy in Acute Decompensated Heart Failure Patients Without a History of COPD
Singer AJ, et al. Ann Emerg Med 2008;51:25-34.
Intro: Dyspnea is a common complaint among patients presenting to the emergency department (ED). Data from the National Hospital Ambulatory Medical Care survey indicate that shortness of breath was the sixth most common principal reason for ED visits. In 2003, 2.9 million ED visits for shortness of breath were reported.
The symptom of dyspnea is associated with a wide range of differential diagnoses. Chronic obstructive pulmonary disease and acute decompensated heart failure are among the most common and potentially serious causes of dyspnea. At patients’ initial presentation to the clinic, hospital, or ED, it is often difficult to determine whether their symptoms are the result of an acute exacerbation of chronic obstructive pulmonary disease or acute decompensated heart failure. Because these patients are often in clear distress, physicians may respond by treating for both conditions with a “shotgun” approach.
Inhaled bronchodilator agents are frequently used in the treatment of acute dyspnea. The actual use of bronchodilators in acute decompensated heart failure patients with or without pulmonary disease has not been well described in the literature. Some data suggest that bronchodilators may be harmful in patients with heart failure or ischemic heart disease. A better understanding of the association between inhaled bronchodilator use and clinical outcomes is needed among acute decompensated heart failure patients without chronic obstructive pulmonary disease.
Our objective was to evaluate the association between bronchodilator use and outcomes in acute decompensated heart failure patients without a history of chronic obstructive pulmonary disease, after adjusting for differences in baseline characteristics, severity of illness, and prognostic markers.
Methods: We conducted an analysis of the Acute Decompensated Heart Failure National Registry Emergency Module registry of patients with a principal discharge diagnosis of acute decompensated heart failure enrolled at 76 academic or community EDs. Dichotomous outcomes (mortality, ED discharges, ICU admission, ED IV vasodilator use, new dialysis, ED or in patient endotracheal intubation, ED BiPAP, and asymptomatic at discharge) in patients without a history of chronic obstructive pulmonary disease who were given bronchodilators were compared to those who were not given bronchodilators using logistic regression; odds ratios (ORs) and 95% confidence intervals (CIs) were calculated; and propensity score adjustments were made.
Results: Of the 10,978 patients enrolled, 7299 (66.5%) did not have a history of chronic obstructive pulmonary disease. Bronchodilators were administered by the EMS or in the ED to 2317 (21%) patients. Patients without chronic obstructive pulmonary disease given bronchodilators were more likely to receive ED IV vasodilators (28.4% vs. 16.9%; propensity adjusted OR 1.40 [95% CI 1.18-1.67]) and in-patient mechanical ventilation (6.0% vs. 2.4%; propensity adjusted OR 1.69 [95% CI 1.21-2.37]) than patients without chronic obstructive pulmonary disease who were not given bronchodilators. Hospital mortality in patients without chronic obstructive pulmonary disease was similar regardless of bronchodilator treatment (3.4% vs. 2.6%, propensity adjusted OR 1.02 [95% CI 0.67, 1.56]).
Conclusion: Many acute decompensated heart failure patients without a history of chronic obstructive pulmonary disease receive inhaled bronchodilators. Bronchodilator use was associated with a greater need for aggressive interventions and monitoring, and this may reflect an adverse effect of bronchodilators or it may be a marker for patients with more severe disease.
7. Delayed In-Hospital Defib Times Common
Almost a third of hospitalized patients requiring defibrillation receive it beyond the recommended 2-minute limit, according to a New England Journal of Medicine study. Researchers examined the outcomes of delayed defib in nearly 7000 patients included in a national database of resuscitative efforts. All patients had suffered arrest from ventricular arrhythmia. The median time to defib was 1 minute, but it took longer than 2 minutes for 30% of patients.
Black race, a noncardiac admitting diagnosis, small hospital size (under 250 beds), and occurrence after-hours or in unmonitored areas were all significantly associated with delayed defib. After adjustment for those factors, delayed defib was associated with a lower likelihood of survival to discharge and, among survivors, greater likelihood of major neurologic or functional disability.
An editorialist, urging the development of better monitoring technology and the installation of automated external defibrillators in each hospital room, concludes: "What are we waiting for?"
NEJM article (Free abstract; full text requires subscription): http://content.nejm.org/cgi/content/short/358/1/9
8. Champagne: the safer choice for celebrations
Douglas RJ. BMJ 2007;335:1281
A 24 year old Australian rules football player presented to the emergency department complaining of a sensation of a foreign body stuck in his throat. The sensation was associated "with an inability to breathe properly." Earlier that day, when celebrating his team’s victory in the premiership, he had downed the remaining beer in the premiership cup, inadvertently swallowing a beer bottle cap.
Physical examination, radiography, and fibreoptic examination of the neck and throat were unremarkable. An anteroposterior chest radiogram showed a round metallic foreign body with scalloped edges at the level of the aortic arch (figure). Blood ethanol level was 0.109 g/100 ml. A beer bottle cap was retrieved via endoscopy later that evening, without complications.
Excessive alcohol consumption as a celebratory consequence of high profile sporting victories is well known. Oesophageal obstruction from a bottle cap, however, is rarely seen in emergency departments. In suspected cases, airways obstruction and injury should be rapidly excluded.
A comprehensive Medline search failed to elicit an example of oesophageal obstruction secondary to the ingestion of a champagne (or wine) cork. Since the 18th century, champagne has been the beverage of choice for celebrations and on current evidence should remain so.
9. Emergency Waits Get Dangerously Long in U.S. Study
WASHINGTON (Reuters) Jan 15 - Patients seeking urgent care in U.S. emergency rooms are waiting longer than in the 1990s, U.S. researchers reported on Tuesday.
They found a quarter of MI patients waited 50 minutes or more before seeing a doctor in 2004. Waits for all types of emergency department visits became 36% longer between 1997 and 2004, the team at Harvard Medical School reported.
Especially unsettling, people who had seen a triage nurse and been designated as needing immediate attention waited 40% longer -- from an average of 10 minutes in 1997 to an average 14 minutes in 2004, the researchers report in the journal Health Affairs.
Heart attack patients waited eight minutes in 1997 but 20 minutes in 2004, Dr. Andrew Wilper and colleagues found.
Dr. Wilper's team used U.S. Census survey and National Center for Health Statistics data for their study, which covered more than 92,000 emergency department visits. They used other surveys to calculate that the number of emergency room visits rose from 93.4 million in 1994 to 110.2 million in 2004. During the same time, 12% fewer hospitals operated emergency rooms, according to the American Hospital Association.
"EDs close because, in our current payment system, emergency patients are money-losers for hospitals," Dr. Wilper said in a statement.
Harvard's Dr. David Himmelstein, who worked on the study, also lobbies for some kind of national health care system. "One contributor to ED crowding is Americans' poor access to primary and preventive care, which could address medical issues before they become emergencies," Dr. Himmelstein said in a statement.
The American College of Emergency Physicians said the findings were not surprising.
"Emergency physicians have said for years that crowding and long wait times are hurting our patients -- insured and uninsured equally," ACEP president Dr. Linda Lawrence said in a statement. "Ever-lengthening waits are a frightening trend because any delays in care can make the difference between life and death for some patients. The number of emergency patients is increasing while the number of hospital beds continues to drop. It is a recipe for disaster."
10. Minor Leg Injuries Linked to Venous Thrombosis
January 14, 2008 — Minor injuries in the leg are associated with greater risk for venous thrombosis, according to the results of a large, population-based, case-control study reported in the January 14 issue of the Archives of Internal Medicine.
"Injuries increase the risk of venous thrombosis," write Karlijn J. van Stralen, MSc, from the Leiden University Medical Center in Leiden, the Netherlands, and colleagues. "So far, most research has focused on major injuries that are accompanied by other risk factors for venous thrombosis, such as plaster casts and surgery. We studied the association of venous thrombosis with common minor injuries, such as minor sural muscle ruptures and ankle sprains."
The Multiple Environmental and Genetic Assessment (MEGA) study of risk factors for venous thrombosis included 2471 consecutive patients with a first deep venous thrombosis (DVT) of the leg or pulmonary embolism (PE) and 3534 control subjects. Exclusion criteria were malignant neoplasms, surgery, and plaster cast or extended bed rest.
A minor injury in the 3 months preceding the venous thrombosis (patients) or completion of the questionnaire (controls) occurred in 289 patients (11.7%) and in 154 controls (4.4%). After adjustment for sex and age, venous thrombosis was associated with previous minor injury (adjusted odds ratio [aOR], 3.1; 95% confidence interval [CI], 2.5 - 3.8). The association was strongest for injuries during the 4-week period preceding thrombosis, and no association was evident before 10 weeks.
Minor injuries in the leg were more strongly associated with thrombosis (aOR, 5.1; 95% CI, 3.9 - 6.7), whereas minor injuries affecting other body parts were not associated with thrombosis. Factor V Leiden carriers with a leg injury had a 50-fold increased risk compared with noncarriers without injury (aOR, 49.7; 95% CI, 6.8 - 362.7).
"Minor injuries in the leg are associated with greater risk of venous thrombosis," the study authors write. "Because minor injuries are common, they could be major contributors to the occurrence of venous thrombosis."
Study limitations may include recall bias or referral bias.
"Many individuals with minor injuries will have contacted the general practitioner first," the authors conclude. "Therefore, there may be an important task for general practitioners to identify subjects who are at a high risk of developing venous thrombosis and subsequently to provide prophylactic measures."
The Netherlands Heart Foundation, the Dutch Cancer Foundation, and the Netherlands Organisation for Scientific Research supported this study. The authors have disclosed no relevant financial relationships.
Arch Intern Med. 2008;168:21-26.
11. A RCT of Prochlorperazine Versus Metoclopramide for Treatment of Acute Migraine
Friedman BW, et al. Ann Emerg Med 2008; in press.
Intro
A mounting body of evidence has demonstrated the efficacy of the antiemetic dopamine antagonists as primary parenteral treatment for acute migraine. These agents are at least as efficacious as parenteral triptans, dihyrdroergotamine, and nonsteroidals and are well tolerated. There is no consensus as to the optimal choice among the members of this class. However, metoclopramide and prochlorperazine are often used because, unlike other medications in their class, they do not cause significant orthostatic changes or require cardiac monitoring. Although previous trials have concluded that prochlorperazine is superior to metoclopramide for the treatment of acute migraine, the 10-mg dose of metoclopramide used in those studies may have been insufficient. The optimal dose of metoclopramide for the acute treatment of migraine is unknown because dose-finding studies have not been conducted. However, 20 mg of intravenous metoclopramide is efficacious and well tolerated.
There is substantial practice variation in the ED–based treatment of acute migraine. Two dozen parenteral agents, alone or in combination, are commonly used in US EDs. Yet, ED migraine care remains suboptimal. Incomplete pain relief, need for rescue medication, adverse medication effects, functional disability, and recurrence of headache after ED discharge continue to plague individuals with migraine, independent of the primary treatment. This study addressed the efficacy and tolerability of a 20-mg dose of metoclopramide versus a 10-mg dose of prochlorperazine, with the intent of helping emergency physicians decide whether one of these 2 dopamine antagonists is superior as a primary treatment for acute migraine.
Study objective
We compare prochlorperazine 10 mg intravenously versus metoclopramide 20 mg intravenously, both accompanied by 25 mg of intravenous diphenhydramine.
Methods
This was a randomized, double-blind, clinical trial comparing 2 parenteral dopamine antagonists. Both drugs were administered during 15 minutes with 25 mg intravenous diphenhydramine. Pain scores on a numeric rating scale were assessed at baseline, every 30 minutes for 2 hours, and by telephone 24 hours after discharge. The primary endpoint was the between-group difference in change in numeric rating scale from baseline to 1 hour postbaseline. Secondary endpoints included mean differences in change in numeric rating scale at 2 and 24 hours, headache relief, adverse effects, and desire to receive the same treatment for future migraines.
Results
Of 152 patients screened, 97 were eligible and 77 were randomized. The mean change in numeric rating scale scores at 1 hour was 5.5 and 5.2 in subjects receiving prochlorperazine and metoclopramide, respectively (difference=0.3; 95% confidence interval [CI] –1.0 to 1.6). Findings were similar at 2 hours and 24 hours. Forty-six percent (18/39) of prochlorperazine and 32% (12/38) of metoclopramide subjects reported adverse events (difference=15%; 95% CI –6% to 36%). Seventy-seven percent (26/34) of prochlorperazine and 73% (27/37) of metoclopramide subjects wanted to receive the same medication in future ED visits (difference=4%; 95% CI –16% to 24%).
Conclusion
Either prochlorperazine 10 mg intravenously or metoclopramide 20 mg intravenously, combined with diphenhydramine 25 mg intravenously, is an efficacious treatment for ED patients with acute migraine. Three quarters of subjects in both arms would want the same medication for their next migraine.
12. The Role of Oral Ondansetron in Children With Vomiting as a Result of Acute Gastritis/Gastroenteritis Who Have Failed Oral Rehydration Therapy: A RCT
Roslund G, et al. Ann Emerg Med. 2008; in press.
Study objective
We hypothesize that ondansetron will facilitate oral rehydration therapy in children with acute gastritis or acute gastroenteritis and mild to moderate dehydration who fail initial oral rehydration therapy. We hypothesize that subjects receiving ondansetron will tolerate oral rehydration and that a lower proportion will require intravenous hydration than subjects receiving placebo, with a clinically important difference of at least 30% when comparing 2 groups of patients presenting to the ED with acute gastritis/acute gastroenteritis. Secondarily, we hypothesize that subjects receiving ondansetron will have a lower proportion requiring admission, fewer episodes of vomiting and diarrhea, and fewer revisits.
Methods
This double-blind, placebo-controlled, prospective, randomized trial enrolled a convenience sample of subjects 1 to 10 years old, with acute gastritis or acute gastroenteritis, who failed oral rehydration therapy in the emergency department (ED). Subjects received a weight-based dose of ondansetron (0.15 mg/kg of the orally dissolving tablet) or placebo, and oral rehydration therapy was reattempted 30 minutes later. If a subject vomited or refused to drink, he or she was considered a failed oral rehydration therapy and received acute gastroenteritis. If a subject tolerated adequate oral rehydration therapy, he or she was discharged. Parents completed symptom diaries and were contacted by telephone for follow-up. We used the chi-square test to compare the proportions of subjects requiring acute gastroenteritis in each group.
Results
We enrolled 106 subjects: 51 received ondansetron and 55 received placebo. Eleven of 51 (21.6%; 95% confidence interval [CI] 11.3% to 35.3%) of subjects who received ondansetron required intravenous hydration and 30 of 55 (54.5%; 95% CI 40.6% to 68%) of placebo subjects required intravenous hydration (p less than 0.001) for a difference of 32.9% (95% CI 14.54% to 48.37%). Admission rates were 5.9% (3/51) with ondansetron and 12.7% (7/55) with placebo.
Conclusion
In subjects with acute gastritis/acute gastroenteritis and mild to moderate dehydration who failed initial oral rehydration therapy, the proportion of children who received intravenous hydration was smaller in the ondansetron group than in the placebo group.
13. ED Crowding Is Associated With Poor Care for Patients With Severe Pain
Pines JM, Hollander JE. Ann Emerg Med. 2008;51:1-5.
Study objective
We study the impact of emergency department (ED) crowding on delays in treatment and nontreatment for patients with severe pain.
Methods
We performed a retrospective cohort study of all patients presenting with severe pain to an inner-city, teaching ED during 17 months. Poor care was defined by 3 outcomes: not receiving treatment with pain medication while in the ED, a delay (more than 1 hour) from triage to first pain medication, and a delay (more than 1 hour) from room placement to first pain medication. Three validated crowding measures were assigned to each patient at triage. Logistic regression was used to test the association between crowding and outcomes.
Results
In 13,758 patients with severe pain, the mean age was 39 years (SD 16 years), 73% were black, and 64% were female patients. Half (49%) of the patients received pain medication. Of those treated, 3,965 (59%) experienced delays in treatment from triage and 1,319 (20%) experienced delays from time of room placement. After controlling for factors associated with the ED treatment of pain (race, sex, severity, and older age), nontreatment was independently associated with waiting room number (odds ratio [OR] 1.03 for each additional waiting patient; 95% confidence interval [CI] 1.02 to 1.03) and occupancy rate (OR 1.01 for each 10% increase in occupancy; 95% CI 0.99 to 1.04). Increasing waiting room number and occupancy rate also independently predicted delays in pain medication from triage (OR 1.05 for each waiting patient, 95% CI 1.04 to 1.06; OR 1.18 for each 10% increase in occupancy; 95% CI 1.15 to 1.21) and delay in pain medication from room placement (OR 1.02 for each waiting patient, 95% CI 1.01 to 1.03; OR 1.06 for each 10% increase in occupancy, 95% CI 1.04 to 1.08).
Conclusion
ED crowding is associated with poor quality of care in patients with severe pain, with respect to total lack of treatment and delay until treatment.
Full text (free): http://www.annemergmed.com/article/PIIS0196064407012978/fulltext
14. Medical myths: Sometimes even doctors are duped
Vreeman RC, et al. BMJ 2007;335:1288-1289.
Physicians understand that practicing good medicine requires the constant acquisition of new knowledge, though they often assume their existing medical beliefs do not need re-examination. These medical myths are a light hearted reminder that we can be wrong and need to question what other falsehoods we unwittingly propagate as we practice medicine. We generated a list of common medical or medicine related beliefs espoused by physicians and the general public, based on statements we had heard endorsed on multiple occasions and thought were true or might be true. We selected seven for critical review:
# People should drink at least eight glasses of water a day
# We use only 10% of our brains
# Hair and fingernails continue to grow after death
# Shaving hair causes it to grow back faster, darker, or coarser
# Reading in dim light ruins your eyesight
# Eating turkey makes people especially drowsy
# Mobile phones create considerable electromagnetic interference in hospitals.
We used Medline and Google to search for evidence to support or refute each of these claims. Because "proving a negative" can be challenging, we noted instances in which there was no evidence to support the claim.
Full-text: http://www.bmj.com/cgi/content/full/335/7633/1288?etoc
15. Beta-blockers Are Associated With Reduced Risk of AMI After Cocaine Use
Dattilo PB, et al. Ann Emerg Med 2008;51:117-125.
Background
Cocaine has many deleterious effects on the heart. The pharmacologic effects of cocaine include both alpha and beta receptor stimulation, as well as acute myocardial depression, which is not related to reduced coronary blood flow. Cocaine has also been associated with coronary artery spasm. This effect appears to be mediated by both alpha stimulation and a direct effect of cocaine on vascular smooth muscle. Because beta-adrenergic stimulation leads to vasodilatation of the coronary arteries, the safety of using beta-adrenergic blockers in patients with history of cocaine use has been questioned repeatedly. Lange et al presented evidence that beta-adrenergic blockade increases vasoconstriction when given after cocaine exposure, as measured physiologically by reduced coronary blood flow and increased coronary vascular resistance. Labetalol, which is a combined alpha-beta receptor-blocker, does not reduce cocaine-induced coronary vasoconstriction, whereas both nitroglycerin and verapamil are effective agents for this purpose. Case reports have also documented evidence for spasm of large coronary arteries in the genesis of myocardial infarction associated with cocaine use. These considerations have led to the recommendation that beta-adrenergic blocking agents not be used in patients with acute exposure to cocaine.
Study objective
Beta-blocker use is associated with coronary artery spasm after cocaine administration but also decreases mortality in patients with myocardial infarction or systolic dysfunction. We conduct a retrospective cohort study to analyze the safety of beta-blockers in patients with positive urine toxicology results for cocaine.
Methods
The cohort consisted of 363 consecutive telemetry and ICU patients who were admitted to a municipal hospital and had positive urine toxicology results for cocaine during a 5-year period (307 patients). Fifteen patients with uncertain history of beta-blocker use before admission were excluded. The primary outcome measure was myocardial infarction; secondary outcome measure was inhospital mortality. Logistic regression analysis using generalized estimating equations models and propensity scores compared outcomes.
Results
Beta-blockers were given in 60 of 348 admissions. The incidence of myocardial infarction after administration of beta-blocker was significantly lower than without treatment (6.1% versus 26.0%; difference in proportion 19.9%; 95% confidence interval [CI] 10.3% to 30.0%). One of 14 deaths occurred in patients who received beta-blockade (incidence 1.7% versus 4.5% without beta-blockade; difference in proportion 2.8%; 95% CI –1.2% to 6.7%). Multivariate analysis showed that use of beta-blockers significantly reduced the risk of myocardial infarction (odds ratio 0.06; 95% CI 0.01 to 0.61).
Conclusion
In our cohort, administration of beta-blockers was associated with reduction in incidence of myocardial infarction after cocaine use. The benefit of beta-blockers on myocardial function may offset the risk of coronary artery spasm.
16. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the ED with Acute Carbon Monoxide Poisoning
Wolf SJ, et al. Ann Emerg Med 2008;51:138-152.
This clinical policy focuses on critical issues concerning the management of adult patients presenting to the emergency department (ED) with acute symptomatic carbon monoxide (CO) poisoning. The subcommittee reviewed the medical literature relevant to the questions posed. The critical questions are:
Should hyperbaric oxygen (HBO2) therapy be used for the treatment of patients with acute CO poisoning; and
Can clinical or laboratory criteria identify CO-poisoned patients who are most or least likely to benefit from this therapy?
Recommendations are provided on the basis of the strength of evidence of the literature.
Full-text (free!): http://www.annemergmed.com/article/PIIS0196064407016691/fulltext
17. Validation of the Acute Heart Failure Index
Hsieh M, et al. Ann Emerg Med. 2008;51:37-44.
Introduction: Heart failure affects more than 5 million Americans, with more than 550,000 new cases diagnosed in the United States each year1 and 1 million admissions in 2004. Care of heart failure patients in the United States costs approximately $33.2 billion a year, with hospitalization accounting for $17.8 billion of that expense. Emergency department (ED) visits for evaluation of heart failure, the source for the majority of the hospital admissions for heart failure, increased 19% between 1992 and 2001.
Hospital admission rates for heart failure vary widely and in a manner not fully explained by disease severity. Acute care and emergency physicians often overestimate the probability of short-term death or severe complications for heart failure patients, with the higher estimates of risk translating into patient treatment in more intense care settings. An evidence-based clinical prediction rule could improve physician risk assessment and the appropriateness of initial site of treatment decisions. Additionally, such a rule could aid investigators studying heart failure populations, allowing accurate assessment of initial illness severity (particularly useful in observational or nonrandom assignment designs).
A rule to aid in assessing short-term risk was derived and is based on data readily available in the ED to identify heart failure patients who are at low risk of inpatient death or serious medical complications (less than 2% inpatient death or complications and 1% inpatient death). This could aid initial decision-making in the ED by limiting variation and inaccuracy in judging illness burden and risk of death or morbidity.
We sought to examine the performance of this clinical prediction rule, now called the Acute Heart Failure Index, in an independent group of patients with respect to inpatient death, serious medical complication before hospital discharge, and 30-day death.
Methods: We retrospectively studied a random cohort of 8,384 adult patients admitted to Pennsylvania hospitals in 2003 and 2004 with a diagnosis of heart failure as defined by primary discharge diagnosis codes. We reported the proportions of inpatient death, serious medical complications before discharge, and 30-day death in the patients identified as low risk by the prediction rule.
Results: The prediction rule classified 1,609 (19.2%) of the patients as low risk. Within this subgroup, there were 12 (0.7%; 95% confidence interval [CI] 0.3% to 1.2%) inpatient deaths, 28 (1.7%; 95% CI 1.1% to 2.4%) patients survived to hospital discharge after a serious complication, and 47 (2.9%; 95% CI 2.1% to 3.7%) patients died within 30 days of the index hospitalization.
Conclusion: This prediction rule identifies a group of admitted heart failure patients at low risk of inpatient mortal and nonmortal complications. Our validation findings suggest the rule could assist physicians in making site-of-care decisions for this patient population and aid in analyzing presenting illness burden in study populations.
The rules can be viewed here: http://www.pitt.edu/~hfpr/HF_tree_final_web.mht
An algorithm is also available: http://www.pitt.edu/~hfpr/
18. To Sit or Not to Sit?
Johnson RL, et al. Ann Emerg Med. 2008;51:188-193.e2.
Study objective
We prospectively examine whether provider posture (seated versus standing) influences patient and provider estimates of time spent at the bedside relative to actual time and patient perceptions of the provider-patient interaction.
Methods
A convenience sample of consenting adult patients presenting to an academic tertiary care emergency department between September 7, 2005, and September 25, 2005, were eligible for inclusion in this randomized, controlled trial. Providers (emergency medicine attending physicians, residents, physician assistants, and medical students) were randomly assigned to sit or stand during the initial encounter, after which, participants completed questionnaires about their perceptions of provider-patient interactions and time spent therein. Actual encounter length was measured. Data were analyzed to determine whether patient and provider perception differences existed, using a multilevel regression model that was adjusted for patient-level and provider-level covariates.
Results
Two hundred twenty-four consenting patients met inclusion criteria (239 approached; 15 excluded). Data from 36 providers were collected. The mean length of encounters in both study arms was 8.6 minutes (SD 4.8; range 1.5 to 34.1). Patients involved in seated interactions overestimated time providers spent performing initial encounters by an average of 1.3 minutes (SD 4.3 minutes), whereas patients involved in the standing interactions underestimated time by an average of 0.6 minutes (SD 4.3 minutes) (P=.001). Conversely, providers overestimated time spent with patients in both study arms (P=.85; mean [SD] 0.5 [3.6] versus 0.3 [3.2] minutes). Patient perceptions of the quality of patient-provider interactions were not affected by provider posture.
Conclusion
Although provider posture during the initial interaction affects patient perceptions of time spent at the bedside, it does not influence patient perception of the provider’s bedside manner, sense of caring, or understanding of the patient’s problem.
19. Assessment of hyperglycemia after calcium channel blocker overdoses involving diltiazem or verapamil
Levine M, et al. Crit Care Med. 2007;35:2071-5.
BACKGROUND: Overdoses of calcium channel blocker agents result in hyperglycemia, primarily due to the blockade of pancreatic L-type calcium channels and insulin resistance on the cellular level. The clinical significance of the hyperglycemia in this setting has not previously been described.
METHODS: This study is a retrospective review of all adult (age, 15 yrs or greater) patients with a discharge diagnosis of acute verapamil or diltiazem overdose at five university-affiliated teaching hospitals. The severity of overdose was assessed by determining whether a patient met the composite end points of in-hospital mortality, the necessity for a temporary pacemaker, or the need for vasopressors. We compared the initial and peak serum glucose concentrations with hemodynamic variables between patients who did and did not meet the composite end points.
RESULTS: A total of 40 patients met inclusion criteria, with verapamil and diltiazem accounting for 27 of 40 (67.5%) and 13 of 40 (32.5%) of the ingestions, respectively. For those patients who did and did not meet the composite end points, the median initial serum glucose concentrations were 188 (interquartile range, 143.5-270.5) mg/dL and 129 (98.5-156.5) mg/dL, respectively (p = .0058). The median peak serum glucose concentrations for these two groups were 364 (267.5-408.5) mg/dL and 145 (107.5-160.5) mg/dL, respectively (p = .0001). The median increase in blood glucose was 71.2% for those who met composite end points vs. 0% for those who did not meet composite end points (p = .0067). Neither the change in the median heart rate nor the change in systolic blood pressure was significantly different in any group.
CONCLUSION: Serum glucose concentrations correlate directly with the severity of the calcium channel blocker intoxication. The percentage increase of the peak glucose concentration is a better predictor of severity of illness than hemodynamic derangements. If validated prospectively, serum glucose concentration alone might be an indicator to begin hyperinsulinemia-euglycemia therapy.
20. Management of ED Patients With Primary Spontaneous Pneumothorax: Needle Aspiration or Tube Thoracostomy?
Zehtabchi S, et al. Ann Emerg Med. 2008;51:91-100.e1
Study objective: The emergency management of primary spontaneous pneumothorax is controversial. This evidence-based emergency medicine review evaluates the existing evidence about the efficacy and safety of needle aspiration in comparison to tube thoracostomy for management of primary spontaneous pneumothorax.
Methods: We searched MEDLINE, EMBASE, the Cochrane Library, and other databases. We selected studies for inclusion in the review if the authors stated that they had randomly assigned hemodynamically stable patients with no underlying lung disease to needle aspiration or tube thoracostomy. The outcome measures of interest included admission rate, length of hospital stay, recurrence rate, failure rate of the procedure, dyspnea score during or after the procedure, pain score during or after the procedure, and complications.
Results: Three randomized trials with acceptable quality standards met the inclusion criteria. There was no significant difference between needle aspiration and tube thoracostomy when outcomes of immediate failure, 1-week failure, risk of complication, and 1-year recurrence rate were measured. Only 2 trials reported the rate of hospitalization; needle aspiration was associated with lower rates of hospitalization in both trials: relative risks of 0.26 (95% confidence interval [CI] 0.17 to 0.39) and 0.51 (95% CI 0.36 to 0.74). Length of hospital stay was lower in the needle aspiration groups in all 3 trials, with mean differences of −2.15 days (95% CI −0.99 to −3.30), −2.10 days (95% CI −0.57 to −3.63), and −1.10 days (95% CI −2.28 to 0.08), respectively. Needle aspiration was associated with less analgesia requirement in one trial and lower pain scores in another.
Conclusion: The existing evidence indicates that needle aspiration is at least as safe and effective as tube thoracostomy for management of primary spontaneous pneumothorax. Additionally, needle aspiration carries the benefit of fewer hospital admissions and shorter length of hospital stay.
21. Educational Videos Drain Baby Brains
By Matt Kaplan. ScienceNOW Daily News.
Buyer beware: Videos aimed at improving infant and toddler language skills are not as beneficial for language learning as they claim to be, according to a new study. Rather than helping youngsters, such products may actually hurt their vocabularies.
Videos like Brainy Baby and Baby Einstein have been marketed to parents since 1997. They feature simple lessons in music, math, and vocabulary, and their makers tout them as important educational tools that will help young children build skills in each of these areas. But none of these claims has ever been verified, says Frederick Zimmerman, who studies the relationship between child development and the economy at the University of Washington, Seattle. "In many cases, the corporations making the educational videos are not even testing their own products," he says.
So Zimmerman and colleagues decided to test the videos themselves. The researchers interviewed the parents of more than 1000 U.S. children between the ages of 8 and 16 months, gathering information on the children's vocabulary and how frequently they watched videos like Baby Einstein. When the team controlled for factors such as socioeconomic status, race, and parental education, it found that Baby Einstein and his ilk are not the geniuses they're cracked up to be. For every hour per day spent watching the videos, children understood an average of six to eight fewer words than did those of the same age who did not watch them--a 17-percentile drop in vocabulary, the team reports online tomorrow in the Journal of Pediatrics. "There is no clear evidence of a benefit coming from these videos, and there is some suggestion of harm," says Zimmerman.
As for why the videos hurt vocabulary when they're supposed to help it, Zimmerman can only speculate. One possibility, he says, is that the videos simply pacify children without teaching them anything. "It's like empty calories for the mind," Zimmerman says. Meanwhile, children not watching the videos are reading, interacting with their parents, or building with blocks.
"The negative effect is a real surprise," says Rebecca Collins, a behavioral scientist at the RAND Corp. in Santa Monica, California. "There is so much consumption of these videos, and nobody has any idea how effective they are."
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