From the recent medical literature...
1. Federal Health Officials Launch Hospital Comparisons Web Site
March 31, 2008 — Federal health officials released the latest version of a web site Friday that lets the public compare about 2,500 hospitals on some measures of quality.
The site pulls together some information that Medicare has made available to the public since 2005. Officials say the effort would force hospitals to compete more on quality and customer services while allowing patients to shop.
"I think by this afternoon there will be hospitals looking at this site and identifying the places they need to improve," says Health and Human Services Secretary Michael O. Leavitt.
Administration officials have sought to bring more transparency to the health care marketplace. Similar Medicare sites compare nursing homes in all 50 states as well as customer satisfaction with government-sponsored private managed care plans.
The site, at www.hospitalcompare.hhs.gov, compares hospitals according to how often they meet 26 performance measures, based on Medicare data. Most are process oriented, such as how often hospital personnel give aspirin to heart attack patients, a treatment shown to cut the risk of another attack.
There's also patient satisfaction measures gleaned from surveys filled out by Medicare patients.
Two measures -- admission for heart attack or for heart failure -- give a sense of death rates for patients within 30 days of hospital admission. The site doesn't give each mortality rate. Instead it displays whether death rates at the hospital are at or below the national average.
Many hospitals and other health care providers have resisted publishing detailed outcomes data. One concern is that hospitals that routinely treat sicker patients could be penalized for poorer outcomes.
"It's still in the beginning stages, we realize that," says Elizabeth Leitz, a spokeswoman for the American Hospital Association, which leads the group that chose the site's comparison measures. "It's what we have consensus built around," Leitz says of the two health outcomes metrics on the site.
The group plans in July to introduce comparisons of average pneumonia death rates for hospitals, she says.
Leavitt acknowledges that the site does compare hospitals on many measurable health outcomes, like the success of surgery or infection rates. He likened consumer health information to the development of video games over the last 40 or so years.
"We're looking at 'Pong'," he said, referring to the rudimentary 1970s video game. "We're still learning."
But he said the effort -- while supported by hospitals and other health providers -- also contends with resistance. Leavitt says there was a "tension" between health providers who want independence and employers who need to cut rising health costs.
"There's an understandable caution, but we have an imperative we have to accomplish here," Leavitt says.
2. Report looks at reasons for adult ED visits
Source: The American Hospital Association (http://www.aha.org). Date: February 27, 2008
Pneumonia was the top reason adults were admitted to the hospital from the emergency department in 2005, according to a new report from the Agency for Healthcare Research and Quality. The report presents data on adult ED visits in 23 states from the Healthcare Cost and Utilization Project. About 19% of ED visits in those states resulted in hospital admission. Other leading reasons for admission from the ED were congestive heart failure, chest pain, heart attack and chronic obstructive pulmonary disease. The poorest communities had nearly twice the rate of ED visits as the wealthiest communities. A future report will focus on pediatric ED visits.
To view this report, please visit: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb47.pdf
3. In Sinusitis, Signs and Symptoms Not Helpful in Decisions on Using Antibiotics
There is no reliable sign or symptom (such as facial pain or purulent discharge) to distinguish patients with sinusitis who would benefit from antibiotics, according to a Lancet report.
Researchers reanalyzed individual patient data from nine randomized trials. Some 2500 patients had been diagnosed on the basis of clinical signs and symptoms and not bacterial cultures or imaging. All were assigned to receive either an antibiotic or placebo. The researchers assessed the number of "cures" (resolution or mitigation of symptoms) as the outcome of interest.
Overall, the authors calculate an NNT of 15 to cure an additional patient with antibiotics. That number dropped to 8 among patients with purulent discharge, but the authors write "its prognostic value is not sufficient." However, they say that severe symptoms warrant prompt treatment, on the basis of patient safety.
They conclude that their results "should reassure physicians that only watchful waiting and symptomatic relief are warranted for almost all adult patients with acute rhinosinusitis-like complaints."
Lancet article (Free abstract; full text requires subscription): http://www.thelancet.com/journals/lancet/article/PIIS014067360860416X/abstract
4. Ketamine-Propofol Combination Sedation for Fracture Reduction in the Pediatric ED
Sharieff GQ, et al. Ped Emerg Care. 2007;23:881-884.
Objectives: To evaluate the time of onset and recovery from and the efficacy and safety of intravenous ketamine-propofol sedation for reduction of forearm fractures in the pediatric emergency department setting.
Study Design: Prospective, observational pilot study.
Methods: Children presenting to an urban pediatric emergency department requiring sedation for closed reduction of forearm fractures received ketamine 0.5 mg/kg and propofol 1 mg/kg. We measured time intervals from drug administration to reduction, recovery, and attainment of discharge criteria, and obtained ratings of depth of sedation, pain, and ease of reduction. A follow-up survey elicited patient recall, parental satisfaction, and delayed complications. Complications were recorded during the procedure and by chart review.
Results: Reduction was successful in 19 of 20 patients with one requiring open reduction. Median time intervals measured from initiation of ketamine injection were 5 minutes to reduction completion, 10 minutes to first purposeful response, and 38 minutes to suitability for discharge. Three patients recalled reduction or casting, but in no case was reduction reported to be the most painful aspect of visit. Emergency physicians and orthopedic residents rated sedation and ease of reduction favorably. Complications included mild hypoxia, vomiting, and transient ataxia. No apnea, hemodynamic compromise, dysphoria, or injection pain occurred.
Conclusions: In this pilot study, the combination of ketamine and propofol provided effective sedation with rapid recovery and no clinically significant complications for children requiring closed reduction of forearm fractures.
5. Brain Trauma Is Not the Basis for Post-Concussion Syndrome
By David Douglas. NEW YORK (Reuters Health) Mar 21 - Mild traumatic brain injury (mTBI) is often followed by acute post-concussion syndrome but does not predict the condition, according to Australian researchers.
Investigator Dr. E. Arthur Shores told Reuters Health that these results are similar to findings by other investigators who studied military personnel after combat. "Once post-traumatic stress disorder and depression was considered, the effect of mTBI was non-significant," Dr. Shores said.
He added, "Post-concussion syndrome has been a controversial diagnosis in both civilian and military populations."
In the March issue of the Journal of Neurology, Neurosurgery and Psychiatry, Dr. Shores of Macquarie University, Sydney and colleagues note that they evaluated 175 trauma patients -- 90 with mTBI and 85 without brain injury - for symptoms including poor concentration, irritability, memory problems, and mood swings. Subjects were analyzed with a modified Post-Concussion Syndrome Checklist, along with validated psychological and neuropsychological tests.
According to the report, 43.3% of mTBI patients and 43.5% of controls met the criteria for diagnosis of acute post-concussion syndrome. The strongest effect was seen in those who had had a previous affective or anxiety disorder (odds ratio 5.76). Women were at more than a 3-fold greater risk than men.
"For individuals who have mTBI," Dr. Shores, concluded, "it is important they know that symptoms they continue to experience are not due to brain injury. They can be treated with early education and psychological therapies."
In an accompanying editorial, Dr. Graham E. Powell of Powell Campbell Edelmann in London, points out the importance of taking into account the fact that some symptoms "have a high base rate of occurrence in the general population." He emphasizes that post-concussion syndrome symptoms "are rife in the general population," adding that this high base rate can lead to diagnoses which "will often be plain wrong."
J Neurol Neurosurg Psychiatry 2008;79:237,300-306.
6. Heads Up: Canadian study will derive a clinical decision rule for triage of ED patients with chest pain: “Who really can safely go home?”
Finally, Ian Stiell applies his “Ottawa Ankle Rules” methods to ED patients with chest pain!
Erik P Hess, George W Wells, Allan Jaffe and Ian G Stiell. BMC Emergency Medicine. 2008;8:3
Background
Chest pain is the second most common chief complaint in North American Emergency Departments. Data from the U.S. suggest that 2.1% of patients with acute myocardial infarction and 2.3% of patients with unstable angina are misdiagnosed, with slightly higher rates reported in a recent Canadian study (4.6% and 6.4%, respectively). Information obtained from the history, 12-lead ECG, and a single set of cardiac enzymes is unable to identify patients who are safe for early discharge with sufficient sensitivity. The 2007 ACC/AHA guidelines for UA/NSTEMI do not identify patients at low risk for adverse cardiac events who can be safely discharged without provocative testing. As a result large numbers of low risk patients are triaged to chest pain observation units and undergo provocative testing, at significant cost to the healthcare system. Clinical decision rules use clinical findings (history, physical exam, test results) to suggest a diagnostic or therapeutic course of action. Currently no methodologically robust clinical decision rule identifies patients safe for early discharge.
Methods
The goal of this study is to derive a clinical decision rule which will allow emergency physicians to accurately identify patients with chest pain who are safe for early discharge. The study will utilize a prospective cohort design. Standardized clinical variables will be collected on all patients at least 25 years of age complaining of chest pain prior to provocative testing. Variables strongly associated with the composite outcome acute myocardial infarction, revascularization, or death will be further analyzed with multivariable analysis to derive the clinical rule. Specific aims are to: i) apply standardized clinical assessments to patients with chest pain, incorporating results of early cardiac testing; ii) determine the inter-observer reliability of the clinical information; iii) determine the statistical association between the clinical findings and the composite outcome; and iv) use multivariable analysis to derive a highly sensitive clinical decision rule to guide triage decisions.
Discussion
The study will derive a highly sensitive clinical decision rule to identify low risk patients safe for early discharge. This will improve patient care, lower healthcare costs, and enhance flow in our busy and overcrowded emergency departments.
Full-text (pdf): http://www.biomedcentral.com/content/pdf/1471-227x-8-3.pdf
7. Safety and Efficacy of a Protocol Using Bougienage or Endoscopy for the Management of Coins Acutely Lodged in the Esophagus: A Large Case Series
Arms JL, et al. Ann Emerg Med. 2008;51:367-372.
Study objective
We report our experience using the bougienage procedure in the management of esophageal coins.
Methods
Observational case series of all patients presenting to our emergency departments with coins acutely lodged in the esophagus between 1994 and 2006. All patients were treated according to our protocol with either endoscopy or bougienage. Patients are eligible for bougienage if they have had a witnessed coin ingestion less than 24 hours before presentation and if esophageal coin position is confirmed by chest radiograph and there is no history of esophageal disease, surgery, or foreign body. Primary outcomes measured were complications, efficacy of procedure, hospital charges, length of stay, and return to the hospital. Length of stay and hospital charges data were gathered for patients presenting in the final 24 months of the study.
Results
Six hundred twenty patients were identified as having esophageal coins. Three hundred fifty-five patients had a successful bougienage, and 17 patients had unsuccessful bougienage. By comparison, 248 patients underwent endoscopy, and the coin was successfully removed in all but 1 of these patients. Of patients undergoing endoscopy, 89 were eligible for bougienage, but patient, parent, or physician preference was for endoscopic management. Eleven patients required reevaluation or readmission for complaints related to esophageal coin. The only complication was subglottic edema, causing respiratory distress in a single patient who had undergone endoscopy. Patients undergoing endoscopy had an average length of stay of 6.1 hours and average hospital charges were $6,087. Patients undergoing bougienage had an average length of stay of 2.2 hours and average hospital charges of $1,884.
Conclusion
In properly screened patients with coins acutely lodged in the esophagus, bougienage offers a safe and effective alternative to other methods of coin management.
Accompanying Editorial
Several years ago, a previously healthy 7-year-old boy came to my emergency department (ED), having accidentally swallowed the quarter he had been carrying in his mouth while climbing a tree at school. He could “feel it right here,” he told me, pointing to his lower sternum, but was otherwise asymptomatic. A radiograph confirmed that the coin was in the distal esophagus, just above the lower esophageal sphincter. If this patient were to present to your ED today, how would you treat him?
At many, if not most, US EDs, arrangements would be made for endoscopic coin removal under general anesthesia or deep sedation, perhaps after transfer to a regional pediatric center. At other hospitals, he might undergo a removal procedure with a Foley catheter. Knowing that being older (at age 7, this boy is older than most children with esophageal coins), a boy, and having an esophageal coin lodged in the distal part of the esophagus all make spontaneous passage likelier, other clinicians might opt for “watchful waiting” for 12 to 24 hours to allow for spontaneous passage. As Arms et al describe in this issue of Annals of Emergency Medicine, bougienage is yet another option at some hospitals. Which of these is best?
Endoscopy is widely used and is the standard by which other methods are measured. As Arms et al observe, endoscopy is safe and effective but much more expensive than the other methods. Endoscopy is the method of choice for removal of many endoscopic coins, such as multiple coins, those that have been in place for a long time, or those in high-risk patients; it is also the usual backup when another method fails. The challenge has been to find a less invasive, less expensive method for low-risk situations, which are, of course, common in the pediatric population. Until recently, most such studies focused on use of a Foley catheter; the more recent literature, however, suggests that bougienage is superior to endoscopy and Foley catheter use for low-risk patients. The article by Arms et al considerably supplements that knowledge and is a valuable addition to the literature.
The spontaneous passage of acutely swallowed esophageal coins in children has also been well described. Although it seems to occur in about 30% of all comers, several factors that make spontaneous passage more likely have been described; along with those noted above, being asymptomatic also seems predictive of spontaneous passage. Watchful waiting, giving a patient several hours to pass a recently ingested, esophageal coin, has not been widely reported but seems promising. Using drugs to enhance passage is not usually successful.
So how did I treat my 7-year-old? I gave him a big drink of water. He felt the coin pass, which I confirmed with a radiograph (I now wish I had used a metal detector instead, but that is another editorial). I was taking something of a chance because giving him a drink might have delayed endoscopy, the usual method of esophageal coin removal at my institution. However, others and I had successfully used this method before. I was also aware of the following “Editor’s Note” by the then-editor of Archives of Pediatrics and Adolescent Medicine, Dr. Catherine DeAngelis: “Back in the dark ages, when I worked in a bush hospital in West Africa, we fed kids with esophageal-lodged coins gobs of the center of fresh white bread … with great success….” Much like bougienage, having a low-risk patient swallow bread, water, or something else seems to help induce passage of an esophageal coin into the stomach, converting the passive watchful waiting process into something more active, and perhaps more successful…
Conners GP. Ann Emerg Med 2008;51:373-4.
8. What is ALTE?
Jobe AH. J Pediatrics. 2008;152:365.
Apparent life threatening events (ALTE) are a major headache for both parents and emergency rooms. Infants with these events are defined as having an episode that is frightening to the observer and characterized by some combination of apnea, color change, change in muscle tone, and choking or gagging that requires vigorous stimulation. This is a rather global and imprecise definition to use diagnostically, based on caretaker history. The concern has been that ALTE is an aborted SIDS event. The consistent result of an emergency room visit for ALTE is a complex and expensive evaluation that results in no clear answer as to what caused the ALTE in most cases.
The CHIME study (Collaborative Home Infant Monitoring Evaluation) prospectively monitored term infants, siblings of SIDS, and preterm infants to learn about what kind of cardiorespiratory events were occurring. The study also enrolled 153 ALTE cases. Esani et al report that infants with ALTE differ from the well-established epidemiology of SIDS. The ALTE infants were younger, less frequently low birth weight or growth restricted, and had fewer teenage mothers. While not clearly separating the populations of ALTE and SIDS patients, the populations do have differences suggesting different etiologies. Only one infant presenting with ALTE died of SIDS. We still do not know what causes ALTE.
CHIME study: http://www.jpeds.com/article/S0022-3476(07)00751-2/abstract
9. Ask Young Chest Pain Patients About Cocaine Use, Guidelines Urge
Younger patients being evaluated for possible acute coronary syndrome should be asked about cocaine use, according to a scientific statement from the American Heart Association. The paper also offers diagnostic and treatment strategies for cocaine-associated chest pain.
The statement, released online in Circulation, says that while establishing cocaine use should depend primarily on self-reporting, it "may be prudent" to measure cocaine urine metabolites in patients with no or few risk factors for coronary artery disease, especially if they are young or have a history of illegal drug use.
According to the statement, there were 175,000 cocaine-related emergency room visits in 2000, and chest discomfort was a symptom in 40% of those patients.
Circulation article (Free PDF): http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.188950v1
10. In-Home Automated Defibrillators Offer No Mortality Benefit
Putting automated external defibrillators (AEDs) in the homes of patients who've had myocardial infarctions does not lower mortality risk, according to a study published online in the New England Journal of Medicine.
Some 7000 patients with previous anterior-wall MIs who were not candidates for implantable defibrillators were randomized to have, or not have, AEDs in their homes. During roughly 3 years of follow-up, there were 450 deaths, with about one-third resulting from sudden cardiac arrest. The rate of death from any cause or sudden cardiac death did not differ significantly between the groups.
Home AEDs were used in 32 patients, of whom 14 received appropriate shocks. Only 4 survived beyond 48 hours.
The researchers note: "The very low event rate, the high proportion of unwitnessed events, and the underuse of AEDs in emergencies, rather than a lack of device efficacy, appear to explain these results."
NEJM article (Free): http://content.nejm.org/cgi/content/full/NEJMoa0801651
NEJM editorial (Free): http://content.nejm.org/cgi/content/full/NEJMe0801992
11. Drug treatments for dementia are better than placebo, but not much
Ann Intern Med 2008;148:379-97; 370-78
Drug treatments for dementia include the cholinesterase inhibitors donepezil, galantamine, rivastigmine, and tacrine and the neuropeptide modifying agent memantine. A systematic review of 59 trials of reasonable quality suggests that these drugs improve cognition, but probably not enough to make a real difference to patients or carers. In general, cholinesterase inhibitors and memantine produced small but statistically significant improvements in validated cognition scores and in a score of doctors’ global impressions, relative to placebo. Results for tacrine were the least convincing. The authors found only patchy and inconsistent data on behaviour and quality of life. All the drugs had side effects.
Most of the evidence applied to people with mild or moderate Alzheimer’s disease, rather than vascular or mixed dementias. Studies were generally short term so the authors couldn’t tell whether any of the five drugs helped delay the progress of dementia. They had little discernible effect on people with only mild cognitive impairment.
An updated US guideline, based on the review, urges doctors to make treatment decisions on a case by case basis, taking into consideration patients’ and carers’ preferences, tolerability, ease of use, and cost.
12. Comparison of Octreotide and Standard Therapy Versus Standard Therapy Alone for the Treatment of Sulfonylurea-Induced Hypoglycemia
Fasano CF, et al. Ann Emerg Med. 2008;51:400-6.
Study objective
This study is designed to test the hypothesis that the administration of octreotide acetate (Sandostatin; Novartis Pharmaceuticals) in addition to standard therapy will increase serum glucose level measured at serial intervals in patients presenting to the emergency department (ED) with sulfonylurea-induced hypoglycemia compared with standard therapy alone.
Methods
This study was a prospective, double-blind, placebo-controlled trial. All adult patients who presented to the ED with hypoglycemia (serum glucose level ≤60 mg/dL) and were found to be taking a sulfonylurea or a combination of insulin and sulfonylurea were screened for participation in the study. Study participants were randomized to receive standard treatment (1 ampule of 50% dextrose intravenously and carbohydrates orally) and placebo (1 mL of 0.9% normal saline solution subcutaneously) or standard treatment plus 1 dose of octreotide 75 μg subcutaneously. Subsequent treatment interventions were at the discretion of the inpatient internal medicine service.
Results
A total of 40 patients (18 placebo; 22 octreotide) were enrolled. The mean serum glucose measurement at presentation was placebo 35 mg/dL and octreotide 39 mg/dL. The mean glucose values for octreotide patients compared with placebo were consistently higher during the first 8 hours but showed no difference in subsequent hours. Mean glucose differences approached statistical significance from 1 to 3 hours and were significant from 4 to 8 hours after octreotide or placebo administration.
Conclusion
The addition of octreotide to standard therapy in hypoglycemic patients receiving treatment with a sulfonylurea increased serum glucose values for the first 8 hours after administration in our patients. Recurrent hypoglycemic episodes occurred less frequently in patients who received octreotide compared with those who received placebo.
13. People assume expensive drugs work better
JAMA 2008;299:1016-7.
People often prefer expensive branded drugs to cheaper generic alternatives, possibly because they believe expensive drugs work better. To test this hypothesis, researchers gave 82 healthy volunteers a placebo analgesic. They told half the volunteers that their pills cost $2.50 each and the other half that the pills had been discounted to just 10 cents. The volunteers thought they were testing a new fast acting opioid analgesic. They rated the pain caused by small electric shocks before and after treatment.
Volunteers given the regular priced placebo were significantly more likely to report a reduction in pain scores after treatment (85.4% v 61%, P=0.02). They also reported a significantly greater average reduction in pain scores than volunteers given the cheap placebo.
These findings suggest that when it comes to drug treatments, people equate cost with quality and quality with effectiveness, say the researchers. Which could explain why people prefer expensive cyclo-oxygenase 2 inhibitors to cheap, over-the-counter anti-inflammatory analgesics. Patients might be more willing to switch from branded to generic drugs if their doctors steered clear of loaded words such as "cheap."
14. Off-Site PCI Comparable to PCI With On-Site Backup
from Heartwire — a professional news service of WebMD. March 29, 2008 (Chicago, IL - The largest clinical analysis and comparison of PCI centers with and without surgical backup in the US has shown that off-site PCI facilities have similar outcomes to PCI centers with traditional on-site cardiac surgery. Dr Michael A Kutcher (Wake Forest University Health Sciences, Winston-Salem, NC) presented the findings from the National Cardiovascular Data Registry (NCDR) at the American College of Cardiology 57th Annual Scientific Session/i2 Summit-SCAI Annual Meeting today.
Kutcher stressed, however, that the results should not be seen as carte blanche for hospitals to go ahead and set up PCI coverage without surgical backup. "The implications of this are that off-site PCI centers can provide excellent care to patients if the program is thoughtfully developed. But we shouldn't be extrapolating from this to encourage the widespread proliferation of off-site PCI. We don't want this to be a message that every hospital should go out and develop an off-site program," he noted.
Discussant Dr Stephan Windecker (University Hospital, Bern, Switzerland) congratulated Kutcher and his team "for putting an end to a controversy that is as long as the history of angioplasty itself." The findings, said Windecker, "give impetus to update the present guidelines."
Despite limitations, off-site PCI centers perform well
Kutcher explained that the performance of PCI without backup cardiac surgery on site is controversial in the US but becoming more common. Clinical guidelines accept this practice for primary PCI in patients who are experiencing an MI but advise against it in elective PCI when the procedure is less urgent. But medical centers that offer primary PCI argue that they need to include elective PCI in the mix to survive economically and to keep staff skill levels high.
Kutcher told heartwire that there are around 300 centers in the US thought to be offering PCI without surgical backup, and only around one-third of these are participating in any kind of registry, something he believes is vital to ensure good quality control.
The NCDR is a large ongoing prospective multicenter registry "that offers a unique opportunity to provide contemporary insights into these issues," he said. For this analysis, Kutcher and colleagues assessed consecutive PCI cases reported to NCDR between January 1, 2004 and March 30, 2006 and compared 9029 patients who had PCIs performed in 61 centers without on-site cardiac surgery with 299 132 patients at 404 centers that had cardiac surgery available on site.
Off-site PCI programs had smaller bed capacities, were more likely to be in rural areas, were more likely to treat high-risk patients presenting with an MI, and had lower annual PCI volumes (70% performed fewer than the recommended 200 PCI procedures annually). Despite this, they had rates of procedural success, morbidity, emergency surgery, and risk-adjusted mortality that were comparable to on-site PCI centers.
15. Ondansetron Is as Good as Promethazine for Treating Nausea in the ED
A noninferiority trial shows that both agents are equally effective.
Ondansetron is used widely for postoperative and chemotherapy-related nausea and vomiting, but emergency department adoption has lagged somewhat, mostly because of the high cost of the drug and the effectiveness of other available agents, such as promethazine and prochlorperazine. In a randomized, double-blind, noninferiority trial, funded by the maker of ondansetron, researchers compared ondansetron with promethazine for treatment of undifferentiated nausea and vomiting in ED patients.
A convenience sample of 120 nonpregnant adults with nausea scores >40 on a validated 100-mm visual analog scale (VAS) received either promethazine (25 mg) or ondansetron (4 mg) intravenously. At 30 minutes, both groups had similar reductions in nausea scores (mean decrease, 36 mm with promethazine vs. 34 mm with ondansetron). Anxiety and sedation were measured using a self-reported nonvalidated 100-mm VAS. Promethazine and ondansetron were associated with similar reductions in anxiety scores (mean decrease, 14 mm vs. 13 mm, respectively). Sedation scores rose in both groups, but the increase was significantly greater with promethazine than with ondansetron (mean increase, 19 mm vs. 5 mm). Akathisia was reported in 3% of patients in the promethazine group only.
Comment: Ondansetron is a highly effective antiemetic agent that works as well as promethazine but with less sedation and no potential to induce akathisia, the most troubling adverse effect. Emergency physicians should consider ondansetron as a first-line, cost-effective, and clinically effective alternative to the traditional sedating anticholinergic agents.
— Diane M. Birnbaumer, MD, FACEP. Published in Journal Watch Emergency Medicine March 28, 2008. Citation: Braude D and Crandall C. Ondansetron versus promethazine to treat acute undifferentiated nausea in the emergency department: A randomized, double-blind, noninferiority trial. Acad Emerg Med 2008;15:209.
16. Responsibility for Admitted Patients
Ann Emerg Med. 2008;51:457.
The American College of Emergency Physicians (ACEP) believes that the best patient care occurs when there is no ambiguity as to which physician is responsible for each patient. Because admitted patients are sometimes held in the emergency department (ED), confusion may occur when determining which physician is responsible for an admitted patient’s care. While emergency physicians may provide care to any admitted patient during a medical emergency, emergency physicians are generally neither credentialed to provide inpatient care nor are they insured for providing inpatient care.
For these reasons, ACEP endorses the following principles:
• Regardless of the location of an admitted patient within the hospital, the ultimate responsibility for an admitted patient’s medical care rests with the admitting physician.
• Hospital policy and procedures should clearly delineate that once an admitting physician has accepted a patient, that admitting physician has assumed responsibility for the patient.
Approved by the ACEP Directors October 2007.
17. CMS Issues Updated Interpretive Guidelines on EMTALA
Date: April 03, 2007. CMS has updated its interpretive guidelines on the Emergency Medical Treatment & Labor Act (EMTALA). These guidelines are distributed to the state surveyor agencies to use during their review of potential violations. It is important for EM physicians to know what the surveyors will be looking for. The key components of the new guidance addresses the issue of on-call physician requirements; the definition of "labor"; a detailed discussion of what constitutes a medical screening examination; guidance regarding delays in service to individuals arriving via prehospital EMS (also known as the "parking" issue), and the EMTALA responsibilities of recipient hospitals with specialized capabilities or facilities. The revisions are effective immediately.
To access the full document: http://www.cms.hhs.gov/surveycertificationgeninfo/downloads/SCLetter08-15.pdf
18. The Importance of Increased Neck Circumference to Intubation Difficulties in Obese Patients
Gonzalez H, et al. Anesth Analg 2008; 106:1132-1136.
BACKGROUND: Using the intubation difficulty scale (IDS), we sought to confirm that obese patients are more difficult to intubate than lean patients. We assessed classical bedside tests and included neck circumference.
METHODS: We prospectively compared the incidence of difficult tracheal intubation in 70 obese [body mass index (BMI) 30 kg/m2] and 61 lean patients (BMI <30>5) or not (IDS 5), and the patient data, were compared between lean and obese patients. Preoperative measurements [BMI, neck circumference (at the level of the thyroid cartilage), width of mouth opening, sternomental distance, and thyromental distance], medical history of obstructive sleep apnea syndrome, and several scores (Mallampati, Wilson, El Ganzouri) were recorded. The view during direct laryngoscopy was graded, and the IDS was recorded. We then compared patients with IDS 5 and greater than 5, concerning each item.
RESULTS: The results indicate that difficult tracheal intubation is more frequent in obese than in lean patients (14.3% vs 3%; P = 0.03). In the patients with IDS greater than 5, thyromental distance, BMI, large neck circumference, and higher Mallampati score were the only predictors of potential intubation problems.
CONCLUSION: We found that problematic intubation was associated with thyromental distance, increasing neck circumference, BMI, and a Mallampati score of 3. Neck circumference should be assessed preoperatively to predict difficult intubation.
19. Just 20 Minutes of Physical Activity per Week Improves Mental Health
Being physically active just once a week for 20 minutes is enough to boost mental health, according to a cross-sectional study in the British Journal of Sports Medicine.
Researchers surveyed nearly 20,000 Scottish adults to determine their level of psychological distress and self-reported frequency of physical activity, including sports, walking, and domestic activity (e.g., heavy housework and gardening).
In adjusted analyses, at least one 20-minute session a week of any type of activity was associated with lower risk for psychological distress. For sports and all activity types combined, risk reductions increased as the frequency of activity increased.
British Journal of Sports Medicine abstract: http://bjsm.bmj.com/cgi/content/abstract/bjsm.2008.046243v1
20. ACS Patients Do Better in Clinical-Trial Hospitals
from Heartwire — a professional news service of WebMD. March 26, 2008 (Edmonton, AB, Canada) – Hospitals that participate in clinical trials appear to provide better care for ACS patients than hospitals that do not participate in clinical trials, according to a new study.
The study, published in the March 24, 2008 issue of the Archives of Internal Medicine, was conducted by a team led by Dr Sumit Majumdar (University of Alberta, Edmonton).
They explain that the quality of care for conditions such as acute coronary syndromes has improved over recent years in response to new evidence from clinical trials but that the rate of improvement has been slow and there has been marked variability between hospitals.
Noting that clinical trials demand that trial subjects receive safe, high-quality, protocol-driven care, they suggest the same elements required for hospitals to participate in clinical trials could induce beneficial changes in the hospital environment, thereby leading to better processes and outcomes of care for patients treated outside the trial setting.
To test this hypothesis, they studied 174 062 NSTEMI ACS patients treated at 494 hospitals that were part of the CRUSADE registry. Hospitals were classified into tertiles by percentage of patients concurrently enrolled in NSTEMI ACS trials. In total, 4590 patients (2.6%) were enrolled in clinical trials, with 145 hospitals having no enrollment, 226 hospitals having low enrollment (a midpoint of 1% enrollment) and 123 hospitals having high enrollment (a midpoint of 4.9% enrollment).
Results showed that adherence to clinical guidelines increased and in-hospital mortality decreased with increasing tertiles of trial participation.
21. Antibiotic use results in resistance even for individual children
Del Mar C. BMJ 2007;335:407-408
In a recent issue of BMJ, Chung and colleagues (BMJ 2007;335:429) report that community prescribing of a beta-lactam antibiotic for acute respiratory infection doubled the prevalence of antibiotic resistant bacteria in individual children. This antibiotic resistance was transferred as a gene encoding beta-lactamase from other species of bacteria to Haemophilus. What do these results mean for the future of antibiotic prescribing in general practice?
Antibiotic resistance will probably eventually appear by natural selection for every new antibiotic developed by the drug industry, and the race to produce new drugs ahead of resistance is run ever closer. Antibiotics should be thought of like oil, a non-renewable resource to be carefully husbanded. What we use now cannot be used some time in the future.
The problem is that there is no scientific solution to convincing people not to seize for their own benefit a common resource best nurtured for the good of the community. It is especially difficult for doctors treating a sick child not to provide (or, at least seem to provide) the best care, covering all possible outcomes, whatever the potential consequences for antibiotic resistance. What tools could clinicians have to balance the needs of the patient against protecting community resources?
It seemed for a while that draconian rationing would be needed to curb doctors' freedom to prescribe antibiotics—special administrative barriers to obstruct their use, rules of indications settled centrally, and so on. There are three reasons why this has not been necessary.
Firstly, one of the consequences of evidence based practice is the finding that antibiotics are minimally effective against most common childhood infections, mainly acute respiratory infections. This applies not only to infections commonly caused by viruses (colds and coughs), but even those usually caused by bacteria (especially sore throats, and acute otitis media). This message has been slow to infiltrate the community, although it is now appreciated by more people, and doctors now prescribe antibiotics less frequently—especially for sore throats and colds, if not for acute otitis media and bronchitis.
Secondly, in some countries doctors delay the access to antibiotics as a type of educational ploy. A prescription is written (to show willing), but either left to be picked up later, or given to the parents to be filled at the pharmacy only if the child does not recover. This is effective at reducing antibiotic use. However, there is a problem. It is slightly dishonest, implying that starting antibiotics later is no less effective than using them immediately, which in at least some cases is not true. In a perfect world we would educate patients in a less indirect, if more difficult and longer, way.
The third reason comes from the personalisation of resistance from a population perspective (remote and indirect) to the individual (immediate and direct). The theoretical possibility that uncontrolled antibiotic use would increase resistance was confirmed by empirical studies. Australian children prescribed antibiotics in the previous two months were twice as likely to have beta-lactam penicillin resistant respiratory streptococci than children who were not prescribed these drugs, an effect that had not worn off six months later. The study by Chung and colleagues helps us better understand the mechanisms—how resistance is transferred between species in the child.
Why does this matter? These data will be seized on by those trying to curb antibiotic prescribing to provide a more cogent argument for not using antibiotics. The argument now focuses on the risks of antibiotic resistance to the individual patient—carrying bacteria with those genes might confer a greater risk of resistance if they later have a severe infection that needs antibiotic rescue. This possibility opens an agenda for future research. Can we test whether people with a serious infection died because of a prescription of antibiotics for a more trivial infection in the recent past?
Another potential research question might come from trying different approaches entirely, thinking about that vast horde of bacteria we carry around with us. To what extent is infection the consequence of an imbalance of this population, rather than our current oversimplified model of a pathogenic bacterium entering the body? We can offset diarrhoea caused by antibiotics by populating the gastrointestinal tract with "friendly" commensal lactobacilli. Some preliminary research has shown the same can work for acute otitis media.
In the meantime, doctors have new information to help convince patients (and themselves) that prescribing antibiotics for minor upper respiratory infections should be reserved for occasions when we really need them.
Monday, April 14, 2008
Wednesday, March 12, 2008
Lit Bits: March 12, 2008
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.
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.
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/
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