Lit Bits. Sept 22, 2008

From the recent medical literature...

1. Kids with Fever: How to Calm It (and Parents!)

1a. Paracetamol [aka Acetaminophen] plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial

Hay AD, et al. BMJ 2008; 337:a1302

Objective: To investigate whether paracetamol (acetaminophen) plus ibuprofen are superior to either drug alone for increasing time without fever and the relief of fever associated discomfort in febrile children managed at home.

Design: Individually randomised, blinded, three arm trial.

Setting: Primary care and households in England.

Participants: Children aged between 6 months and 6 years with axillary temperatures of at least 37.8°C and up to 41.0°C.

Intervention: Advice on physical measures to reduce temperature and the provision of, and advice to give, paracetamol plus ibuprofen, paracetamol alone, or ibuprofen alone.

Main outcome measures: Primary outcomes were the time without fever (<37.2°c) p="0.2)." p="0.008)." p="0.025)" p="0.8)." color="#000099">1b. Editorial: Antipyretic treatment for feverish young children in primary care

Anthony Harnden. BMJ 2008;337:a1409

No persuasive evidence shows benefit of combining paracetemol and ibuprofen

Fever is one of the main concerns that parents have when their child is unwell. Many parents believe fever is potentially harmful and worry about its height and duration. It is standard practice for health professionals to give advice about administering antipyretic drugs to children. The most commonly used drugs are paracetamol (acetaminophen) and ibuprofen. Because these drugs can be given at alternating intervals some doctors tell parents to use a combination of both drugs during the course of a febrile illness.

In the linked study (doi:10.1136/bmj.a1302), Hay and colleagues report a randomised controlled trial of paracetamol, ibuprofen, and a combination of the two drugs in 156 febrile children age 6 months to 6 years in primary care. The trial has two primary outcomes—time without fever in the first four hours and fever associated discomfort after 48 hours.1 Hollinghurst and colleagues compare the costs to parents and the NHS of the three drug regimes.2

The scale of childhood fever and treatment costs is large. In the Avon longitudinal study of parents and children, parents reported fever as a symptom in more than two thirds of children under 5 years, and a third of these children had been taken to a doctor for a consultation.3 The large volume of calls and consultations for childhood fever has a substantial effect on NHS direct, out of hours services, and accident and emergency care services. In 2004 the expenditure in Europe on over the counter paracetamol and ibuprofen for children was £405m (511m; $756m).2

Yet a National Institute for Health and Clinical Excellence review of feverish illness in children found no evidence that reducing temperature shortens the duration of illness or reduces complications, such as febrile convulsions.4 In fact, reducing fever may prolong illness. In a trial of paracetamol in 50 children with Plasmodium falciparum, the clearance time of the malaria parasite was 16 hours longer in children treated with quinine and paracetamol than in those treated solely with quinine.5 Similarly, in a trial of paracetamol in 72 children with chickenpox, the time to total scabbing was significantly longer in the paracetamol group.6

Paracetemol and ibuprofen are effective at reducing temperature and ibuprofen acts for longer than paracetamol.7 The largest trial comparing paracetamol, ibuprofen, and an alternating combination was conducted in paediatric community centres in Israel.8 In total, 464 febrile children age 6-36 months were randomly allocated into three groups. The group that received an alternating combination had a significantly lower mean fever over three days, a decline in a validated checklist of children’s pain, and fewer drug doses. However, the study is difficult to interpret because the investigators used a complicated design, which loaded each of the three groups of children with either paracetamol or ibuprofen at study entry.

When advising parents to use antipyretics, professionals are trying to reduce the child’s discomfort associated with fever and manage the parents’ anxiety. Time without fever is arguably a proxy of parental concern, so the most important primary outcome examined in the trial by Hay and colleagues is discomfort associated with fever at 48 hours. Recruiting large numbers of children with acute illness in primary care into research studies is difficult, and Hay and colleagues were unable to recruit enough children to give sufficient power to detect differences for this outcome. But their data suggest no additional improvement in fever associated discomfort or activity levels in the combined drug group at 24 hours, 48 hours, and five days. A trial with greater power would be needed to confirm this.

Hollinghurst and colleagues’ economic analysis confirms that the cost associated with childhood fever is predominantly borne by parents and primary care. The authors constructed a cost consequences matrix of results at 48 hours and five days using costs to the NHS and parents, and they combined discomfort, activity, appetite, sleep, and resolution of fever to determine a variable "returned to normal for that child." Their data show no significant differences between the drug regimens.

Paracetamol and ibuprofen are safe for children when given at the recommended doses. Despite a commonly held view, no evidence exists that ibuprofen exacerbates wheeze in children.9 However, in the United Kingdom ibuprofen is not licensed for children under 3 months or for those who weigh less than 5 kg. The most worrying aspect of the study by Hay and colleagues is that even under clinical trial conditions, 31 children received a drug overdose. This suggests that parents may often inadvertently exceed the maximum recommended dose and that a more complicated alternating regimen of paracetamol and ibuprofen may be less safe than using either drug alone.

No persuasive evidence exists for recommending a combination or an alternating regimen of paracetamol and ibuprofen. Doctors should try to improve their precision of diagnosis in febrile children, and parents should be reassured that fever itself is not harmful. The importance of fluid intake and sensible clothing should be discussed. Before prescribing it may be important to weigh the child to determine the most appropriate dose of antipyretic. The longer action of ibuprofen makes it the most suitable antipyretic to use.

Footnotes: http://www.bmj.com/cgi/content/full/337/sep02_2/a1409

2. Flu Shot Does Not Reduce Risk of All-Cause Mortality in Elders

NEW YORK -- August 29, 2008 -- The widely-held perception that the influenza vaccination reduces overall mortality risk in the elderly does not withstand careful scrutiny, according to a study in the September issue of the American Journal of Respiratory and Critical Care Medicine.

The vaccine does confer protection against specific strains of influenza, but its overall benefit appears to have been exaggerated by a number of observational studies that found a very large reduction in all-cause mortality among elderly patients who had been vaccinated.

"While such a reduction in all-cause mortality would have been impressive, these mortality benefits are likely implausible. Previous studies were likely measuring a benefit not directly attributable to the vaccine itself, but something specific to the individuals who were vaccinated -- a healthy-user benefit or frailty bias," said Dean T. Eurich, PhD, School of Public Health, University of Alberta, Edmonton, Alberta.

"Over the last 2 decades in the United Sates, even while vaccination rates among the elderly have increased from 15% to 65%, there has been no commensurate decrease in hospital admissions or all-cause mortality. Further, only about 10% of winter-time deaths in the US are attributable to influenza, thus to suggest that the vaccine can reduce 50% of deaths from all causes is implausible in our opinion."

Dr. Eurich and colleagues hypothesised that if the healthy-user effect was responsible for the mortality benefit associated with influenza vaccination seen in observational studies, there should also be a significant mortality benefit present during the off-season as well.

They analysed clinical data of 704 patients aged 65 years and older from 6 hospitals in Alberta. The patients were admitted to the hospital for community-acquired pneumonia during non-flu season; half of the patients had been vaccinated, and half had not.
Each vaccinated patient was matched to a non-vaccinated patient with similar demographics, medical conditions, functional status, smoking status, and current prescription medications.

In examining in-hospital mortality, they found that 12% of the patients died overall, with a median length of stay of approximately 8 days.

While analysis with a model similar to that used in past observational studies indeed showed that patients who were vaccinated were about half as likely to die as unvaccinated patients, a finding consistent with other studies, they found a striking difference after adjusting for detailed clinical information, such as the need for an advanced directive, pneumococcal immunisations, socioeconomic status, as well as sex, smoking, functional status, and severity of disease.

Controlling for those variables reduced the relative risk of death to a statistically nonsignificant 19%.

Further analyses that included more than 3,400 patients from the same cohort did not significantly alter the relative risk. The researchers concluded that there was a difficult to capture healthy-user effect among vaccinated patients.

"The healthy-user effect is seen in … patients who are well-informed about their health, who exercise regularly, do not smoke or have quit, drink only in moderation, watch what they eat, come in regularly for health maintenance visits and disease screenings, take their medications exactly as prescribed, and quite religiously get vaccinated each year so as to stay healthy," said principal investigator Sumit Majumdar, MD, University of Alberta.

"Such attributes are almost impossible to capture in large scale studies using administrative databases." Finally, Dr. Majumder said, the findings are a reminder to researchers that "the healthy-user effect is everywhere you don't want it to be."

Abstract: http://ajrccm.atsjournals.org/cgi/content/abstract/178/5/527

3. Six Rules Doctors Need to Know

Why are patients mad at doctors? Maybe, suggests medical blogger Dr. Robert Lamberts, it’s because doctors aren’t following the rules.

Tony Cenicola, The New York Times.

Rule 1: They don’t want to be at your office.
Rule 2: They have a reason to be at your office.
Rule 3: They feel what they feel.
Rule 4: They don’t want to look stupid.
Rule 5: They pay for a plan.
Rule 6: The visit is about them.

Full-text: http://well.blogs.nytimes.com/2008/08/07/six-rules-doctors-need-to-know/

4. Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture

Darracq MA, Vinson DR, Panacek EA. Amer J Emerg Med. 2008;26:779-782. (from UC Davis and Kaiser Sacramento, Roseville, and South Sac)

Objective
Previous studies indicate that an inability to fully extend the elbow after elbow trauma is indicative of fracture. We hypothesized that maintenance of active range of motion (ROM) of the elbow in flexion, extension, pronation, and supination after elbow trauma is very specific for the absence of fracture or effusion, and limitation of ROM is sensitive for fracture or effusion.

Methods
This was a prospective observational study with convenience sampling of a carefully selected patient population. This would allow certain types of patients to be excluded from the study. Patients with elbow injury receiving radiographs and meeting enrollment criteria were enrolled between June 2006 and March 2007 at 4 emergency departments in the local region.

Demographics, active ROM, and presence of point tenderness at the olecranon, epicondyles, and radial head were recorded by enrolling clinicians. All enrolled patients received standard elbow radiographs. Radiographs were reviewed by blinded radiologists for the presence of fracture and effusion. Sensitivity, specificity, and 95% confidence intervals (CIs) of examination findings were calculated.

Results
One hundred thirteen patients were enrolled. Limitation of active ROM was 100% (95% CI, 0.93-1.00) sensitive for fracture or effusion. Preservation of active ROM was 97% (95% CI, 0.89-1.00) specific for the absence of fracture. Point tenderness was also highly sensitive but not specific.

Conclusion
Individuals with preservation of active ROM after acute elbow trauma have a very low risk of associated fracture and may not require radiographic studies.

Note: We're currently undertaking a multi-center validation study.

5. Deceptive Pharma Tactics under the Guise of Research

Seeding trials are not fictional

Ann Intern Med 2008;149:251-8.

It has long been suggested that drug companies use clinical trials to get doctors into the habit of prescribing newly approved drugs. A systematic review found only six articles that focused on the topic of such trials—four editorials and two observational studies published between 1994 and 2008. However, none of these publications could unequivocally prove that these trials—known as seeding trials—exist and that they are used by drug companies primarily for marketing purposes.

A case study of documents ordered by the court during an investigation of the ADVANTAGE (assessment of differences between Vioxx and naproxen to ascertain gastrointestinal tolerability and effectiveness) trial shows that the trial—which included 600 physician investigators and more than 5500 patients—was designed, executed, and analysed by the marketing division of Merck, the manufacturer of Vioxx. Merck’s internal documents indicate that the increased prescribing rates for Vioxx were of major interest to the company. Moreover, patients, doctors, and review boards members were not informed of the true purpose of the trial.

Institutional review boards should routinely ask—"Is this a seeding trial?"—suggests the linked editorial (p 279). The editorialists believe that companies would think twice before lying to these boards. Also, review boards, doctors, and patients alike should look for clues that a trial might be a seeding trial. Indications include posing research questions that have already been settled, open label design, lack of control group, large number of patients enrolled relative to the importance of the question, a short term study of a chronic disease, and a study of an already approved drug.

6. IV Ketamine Is Effective for Procedural Sedation in Adults

But its safety is not yet clear.

Ketamine is commonly used for procedural sedation in children, but its use in adults has not been well studied. Researchers in England conducted a prospective, observational study of adult patients who received intravenous ketamine for procedural sedation at a single emergency department during a 2-year period. Patients with contraindications to ketamine, such as ischemic heart disease, congestive heart failure, and previous psychotic illness, were excluded. Patients received an initial ketamine dose of 0.5 mg/kg, and the dose was repeated if sedation was inadequate after 5 minutes.

Adequate sedation was achieved in 91 of 92 patients and was achieved after one dose in 46 patients. The procedure was successfully completed in 98% of patients. Overall, 22% of patients had adverse events, including vomiting (4%), clonic movements (4%), and agitation (13%). Midazolam successfully treated agitation in all 7 of the 12 agitated patients who required treatment. During sedation, heart rate increased by a mean of 30.2 beats per minute, and systolic blood pressure increased by a mean of 25.4 mm Hg.

Comment: Ketamine is an attractive agent for procedural sedation because it maintains airway protective reflexes while providing both analgesic and sedative effects. However, emergence reactions and increases in BP and heart rate raise concerns about its use in adults. Emergence reactions necessitated the use of midazolam in 7% of study patients. In addition, patients in whom BP and heart rate increases could cause potential harm were excluded, so no conclusions can be drawn about ketamine’s safety in such patients.

— Diane M. Birnbaumer, MD, FACEP. Published in Journal Watch Emergency Medicine September 5, 2008. Citation: Newton A and Fitton L. Emerg Med J 2008 Aug; 25:498.

7. COPD as a Systemic Disease: Impact on Physical Functional Limitations

Eisner MD, et al. Amer J Med. 2008;121:789-796.

Purpose
Although chronic obstructive pulmonary disease (COPD) has a major impact on physical health, the specific impact of COPD on physical functional limitations has not been characterized clearly. We aimed to elucidate the physical functional limitations that are directly attributable to COPD compared to a matched referent group without the condition.

Methods
We used the Function, Living, Outcomes, and Work (FLOW) cohort study of adults with COPD (n=1202) and referent subjects matched by age, sex, and race (n=302) to study the impact of COPD on the risk of a broad array of functional limitations using validated measures: lower extremity function (Short Physical Performance Battery [SPPB]), submaximal exercise performance (Six Minute Walk Test [SMWT]), standing balance (Functional Reach Test), skeletal muscle strength (manual muscle testing with dynamometry), and self-reported functional limitation (standardized item battery). Multivariate analysis was used to control for confounding by age, sex, race, height, educational attainment, and cigarette smoking.

Results
COPD was associated with poorer lower extremity function (mean SPPB score decrement for COPD vs referent −1.0 points; 95% CI, −1.25 to −0.73 pts) and less distance walked during the SMWT (−334 feet; 95% CI, −384 to −282 ft). COPD also was associated with weaker muscle strength in every muscle group tested, including both the upper and lower extremities (P less than .0001 in all cases) and with a greater risk of self-reported functional limitation (OR 6.4; 95% CI, 3.7 to 10.9).

Conclusions
A broad array of physical functional limitations were specifically attributable to COPD. COPD affects a multitude of body systems remote from the lung.

8. Walk-In Urgent Care Clinics Becoming Popular Options for Health Care

The California Healthline. August 06, 2008. Patients seeking prompt care for injuries or illnesses increasingly are turning to walk-in urgent care clinics, the Wall Street Journal reports.

According to the Journal, such clinics require no appointment and offer extended weekend and evening hours, helping to "fill the gap" between the need for care and an increasingly limited supply of primary care physicians and crowded emergency departments.

In addition, care at urgent care clinics often costs less than what EDs charge, even for people with insurance, and many clinics offer additional discounts or payment plans for uninsured patients, according to the Journal.

Urgent care clinics are staffed by physicians and other medical personnel and in many cases have equipment, such as X-ray machines, that physicians in a traditional practice would have to refer patients to other offices or hospitals to receive.

Urgent care clinics are expanding faster than EDs, with a total of more than 8,000 clinics nationwide, allowing for more and faster patient care.

Meanwhile, the number of EDs decreased from 4,176 to 3,795 between 1995 and 2005 while the number of ED visits increased by 20% to 115.3 million during that same time period, according to CDC.

Urgent care clinics have existed for 20 years but experienced a surge in use recently as more patients encountered long waits to schedule appointments with their PCP or to receive care in an ED, the Journal reports.

Concerns About Quality, Safety

As the number of urgent care clinics increases, concerns have risen regarding their safety and quality, the Journal reports.

In addition, there also are concerns that patients may substitute treatment at urgent care clinics for an "ongoing relationship with a primary care doctor who coordinates care and follows them over time," according to the Journal.

Physicians working in urgent care clinics must be licensed but clinics often are not licensed or regulated, leading to large variances and differences between each facility. Some clinics have opted to undergo voluntary accreditation programs that evaluate their quality and safety, but there are no national standards for the facilities.

The Urgent Care Association of America recently reached an agreement with the Joint Commission to take over accreditation of these clinics and publish national quality standards by 2010.

According to UCAOA Executive Director Lou Ellen Horwitz, the goal of having the commission oversee the clinics is to avoid future regulation and to establish guidelines that can help patients and insurers evaluate the clinics. She added that patients should have a PCP and seek care in urgent care clinics when they are unable to see their regular physicians (Landro, Wall Street Journal, 8/6).

For more information, please visit:
http://www.californiahealthline.org/articles/2008/8/6/WalkIn-Urgent-Care-Clinics-Becoming-Popular-Options-for-Health-Care.aspx?topicID=37

9. Management of Acute Peptic Ulcer Bleeding Reviewed

Laurie Barclay, MD. August 27, 2008 — Recommendations for initial triage, medical therapy, and surgical considerations for the management of acute gastrointestinal tract bleeding from a peptic ulcer are reviewed in the August 27 issue of the New England Journal of Medicine.

"Acute upper gastrointestinal hemorrhage, which is defined as bleeding proximal to the ligament of Treitz, is a prevalent and clinically significant condition with important implications for health care costs worldwide," write Ian M. Gralnek, MD, MSHS, from the Rambam Health Care Campus and Rappaport Faculty of Medicine, Technion Israel Institute of Technology in Haifa, Israel, and colleagues. "Negative outcomes include rebleeding and death, and many of the deaths are associated with decompensation of coexisting medical conditions precipitated by the acute bleeding event....In most settings, the vast majority of acute episodes of upper gastrointestinal bleeding (80 to 90%) have nonvariceal causes, with gastroduodenal peptic ulcer accounting for the majority of lesions."

In the United States, there are approximately 160 hospital admissions for acute upper gastrointestinal tract hemorrhage per 100,000 population, or more than 400,000 per year, with an increasing proportion of episodes associated with use of aspirin and nonsteroidal anti-inflammatory drugs. More than two thirds of patients are older than 60 years, and more than one quarter are older than 80 years. Mortality rate is 5% to 10%.

The most frequent presenting signs of acute upper gastrointestinal tract hemorrhage are hematemesis and melena. Initial evaluation should include hemodynamic assessment with orthostatic vital signs, and the first priority in treatment is to correct fluid loss with crystalloid intravenous fluids and restore hemodynamic stability. The use of supplemental oxygen and transfusion of plasma expanders with the use of packed red blood cells should be considered, especially in frail or elderly patients, with tachycardia, hypotension, or a hemoglobin level less than 10 g/dL. Coagulopathy should be corrected.

Nasogastric tube insertion may be helpful during triage, but it is unclear how much additional information it provides. Intravenous erythromycin promotes gastric motility and significantly improves gastric mucosa visualization on initial endoscopy, but it has not been proven to improve diagnostic yield or outcome.

Clinical scores that may be useful to facilitate patient triage include the Blatchford score (see URL below) and the Rockall score; these may reduce the need for urgent endoscopy in low-risk patients. The Forrest classification uses the endoscopic appearance of a bleeding ulcer to predict the likelihood of recurrent bleeding. High-risk lesions are those with active blood spurting (grade IA) or oozing (grade IB), a nonbleeding visible vessel appearing as a pigmented protuberance (grade IIA), and an adherent clot that cannot be dislodged by suction or forceful irrigation (grade IIB). Low-risk lesions are flat, pigmented spots (grade IIC) and clean-base ulcers (grade III).

The approach to an acutely bleeding gastrointestinal tract ulcer should be multidisciplinary, with early involvement of a trained endoscopist and endoscopy assistant. Endoscopy performed within 24 hours after presentation may improve outcomes such as the number of units of blood transfused and the length of the hospital stay for selected high-risk patients. The risk of rebleeding is greatest in the first 72 hours.

High-risk patients should be hospitalized, receive endoscopic therapy, and then triaged to a monitored setting or intensive care unit for the first 24 hours, with total hospital stay usually at least 3 days. Endoscopic hemostasis has been shown to decrease rebleeding rates, the need for urgent surgery, and mortality rates. Other endoscopic treatments may include injection therapy with saline, vasoconstrictors, sclerosing agents, and/or tissue adhesives; thermal therapy with contact or noncontact methods; and mechanical therapy, usually with endoscopic clips.

Each method of endoscopic hemostasis has been proven superior to no endoscopic intervention, but adding a second hemostatic approach further decreases rebleeding rates, the need for surgery, and mortality rates. Epinephrine injection alone should be avoided.

Although a consensus statement recommends combination therapy with epinephrine injection, volume tamponade, and obtaining a clear view of the bleeding vessel, followed by targeted contact thermal therapy, this may be no better than contact thermal therapy alone. Endoscopic therapy in high-risk patients with an adherent clot remains controversial. Endoscopic clips alone may give similar outcomes to those seen with thermal therapy alone, a combination of injection and contact thermal therapy, and clips followed by injection.

Planned, second-look endoscopy within 24 hours after initial endoscopic therapy is not recommended, but a second endoscopy may be considered on a case-by-case basis for clinical signs of recurrent bleeding or uncertainty regarding the effectiveness of initial hemostasis.

After endoscopy, low-risk patients can be discharged home and treated conservatively.

For the treatment of patients with nonvariceal upper gastrointestinal tract hemorrhage, pharmacotherapy has centered on profound acid suppression with proton pump inhibitors. Increasing and maintaining the intragastric pH to 6 or more may promote clot stability, but this goal is theoretical, difficult to achieve, and may not reflect clinical efficacy. Use of histamine H2-receptor antagonists has not significantly improved outcomes.

Meta-analyses have shown that proton pump inhibitors significantly reduce the risk for ulcer rebleeding, the need for urgent surgery, and the risk for death. However, in high-risk patients, mortality rate is lower only in patients who have first undergone endoscopic therapy, suggesting that medical therapy should be an adjunct to, but not a replacement for, endoscopic hemostasis in this group.

The use of an intravenous bolus of proton pump inhibitors followed by a continuous infusion for 72 hours after endoscopic hemostasis may be recommended, but optimal dosing is still controversial. Use of high-dose intravenous proton pump inhibitors while the patient is awaiting endoscopy does not appear to affect the outcome but may be associated with downstaging of endoscopic lesions.

Somatostatin and octreotide inhibit acid and pepsin secretion while decreasing gastroduodenal mucosal blood flow, but they are not routinely recommended in patients with peptic ulcer bleeding.

Surgical rates for management of a bleeding peptic ulcer are currently approximately 5% to 7%. Various surgical approaches include vagotomy or drainage with vagotomy and resection, and alternative options include repeated endoscopic hemostasis or angiography with transcatheter embolization.

"Because of a new understanding of peptic ulcer disease, the role of surgery has changed markedly within the past two decades and now obviates the need for routine early surgical consultation in all patients presenting with acute upper gastrointestinal hemorrhage," the reviewers write. "The aim of emergency surgery is no longer to cure the disease but rather to stop the hemorrhage when endoscopic therapy is unavailable or has failed. The role of early elective surgery is less clear, as is the optimal surgical approach in patients with acute disease."

N Engl J Med. 2008;359:928-937.

Blatchford Score (Lancet 2000): http://www.aafp.org/afp/20010401/tips/3.html

10. Application of San Francisco Syncope Rule in elderly ED patients

Schladenhaufen R, et al. Amer J Emerg Med. 2008;26:773-778.

Objectives
The San Francisco Syncope Rule (SFSR) is a decision rule with the potential to identify patients at risk for serious outcomes within 7 days of the emergency department (ED) visit for syncope. The initial studies of the SFSR reported a high sensitivity and specificity for identifying patients, of all ages, with serious outcomes. Our objective was to determine if the SFSR can be safely and accurately applied to ED patients aged 65 and older with syncope or near-syncope.

Methods
A retrospective review of ED patients aged 65 years and older with syncope or near-syncope between January 2000 and August 2001 was performed. Charts were reviewed for evidence of SFSR risks for the ED visit and serious outcomes within 7 days of the ED visit.

Results
Of 773 subjects identified as having syncope or near-syncope, 517 subjects were included. There were 98 patients with serious outcomes. Twenty-three patients who were negative on SFSR had serious outcomes. The sensitivity and specificity of the SFSR were 76.5% (95% confidence interval [CI], 66.7%-84.3%) and 36.8% (95% CI, 32.2%-41.6%), respectively. The negative and positive predictive values were 87.0% (95% CI, 80.9%-91.4%) and 22.1% (95% CI, 17.8%-26.9%), respectively.

Conclusions
In our cohort of elderly ED patients, the SFSR had a lower sensitivity and specificity. The SFSR may not be applicable to the elderly ED population. Future prospective validation is necessary before application to the ED elderly population.

To review the history of the SF syncope rule and its 5 elements, go here: http://www.medscape.com/viewarticle/557901_4

11. Nuts, corn, and popcorn don’t seem to be bad for diverticular disease

Strate LS, et al. JAMA 2008;300:907-14.

Nuts may protect people from cardiovascular disease, diabetes, cancer of the colon and prostate, and cholelithiasis. But people who have diverticular disease are usually advised to avoid nuts, along with seeds, popcorn, corn, and other high residue foods because they might mechanically damage the intestinal mucosa and precipitate inflammation and bleeding. A large prospective cohort study failed to find the evidence to support this theory.

The study included more than 47 000 men, aged 40-75 years, who at baseline did not have diverticulosis, cancer, or inflammatory bowel disease. During the 18 year follow-up, these men provided information, collected by questionnaires, on their health (every two years) and on nutrition (every four years). The occurrence of diverticulosis and its complications had little to do with consuming nuts, corn, or popcorn. The researchers found that, in fact, nuts and popcorn might protect against developing diverticulitis. Compared with men who reported eating popcorn less than once a month, men who ate it at least twice a week had a lower risk of diverticulitis (hazard ratio 0.72, 95% CI 0.56 to 0.92; the corresponding numbers for nuts were 0.80, 0.63 to 1.01).

The researchers admit that, despite extensive adjustment for confounders, because of the observational nature of the study they couldn’t exclude residual confounding by a lifestyle factor or other unmeasured factor as a potential explanation for the study’s findings. Still, the results do suggest that the current advice should be reconsidered.

12. Severe Community-Associated Staphylococcus aureus Infections in California: The First Six Months of Reporting

Severe Staphylococcus aureus infection in a “previously healthy person” has been a reportable condition in California since February 13, 2008. For this surveillance, a severe infection is defined as one resulting in death or admission to an intensive care unit, and a previously healthy person is defined as one who has not been hospitalized or had surgery, dialysis, or residency in a long-term care facility in the past year, and did not have an indwelling catheter or percutaneous medical device at the onset of illness. A S. aureus infection in a person without these healthcare-associated risk factors would be considered community-associated.

Between February 13 and August 15, 2008, 92 cases of severe community-associated S. aureus were reported from 23 counties to CDPH. Included in the 92 cases were 36 deaths. The median age is toward an older adult but 13 (14%) cases and 3 (8%) deaths were less than 18 years old. There were more male than female cases and deaths. Of the types of infection, cases with pneumonia were more commonly reported than other types. Methicillin-resistant S. aureus (MRSA) represented 73% of cases, similar to the 50-75% nationwide prevalence of MRSA.
Underlying conditions (not shown) were reported in 69 (75%) cases. Of these, diabetes was most common and reported in 20 (22%) cases; 7 of these patients with diabetes had skin and soft tissue infections.

We appreciate the effort by staff of local health departments and hospitals in providing these reports. After a full year of reporting, we will provide a more detailed summary of this surveillance. Please continue to identify and report patients with severe community-associated Staphylococcus aureus infections who fit the surveillance case definition. For any questions about potential cases or this surveillance, please contact Dr. Jon Rosenberg of the Infectious Diseases Branch of CDPH at Jon.Rosenberg@cdph.ca.gov or (510) 620-3434.

13. Helical CT Is More Accurate Than Clinical Judgment for Diagnosing Appendicitis

Even in cases of clinically apparent appendicitis

The role of multidetector computed tomography (MDCT) scanning in the diagnosis of appendicitis is evolving as technology and resolution improve. Researchers in Korea compared the diagnostic accuracy of 16-detector MDCT scanning and clinical impression in 157 consecutive patients who presented to two emergency departments with signs or symptoms that raised concern for possible appendicitis.

All patients were evaluated by emergency physicians and senior residents who determined whether the clinical diagnosis was appendicitis. All patients then underwent MDCT with intravenous contrast only. MDCT scans were read by two radiologists who specialized in CT interpretation. The final diagnosis of appendicitis was based on surgical pathology or clinical follow-up. The positive predictive value of the examining physician’s clinical impression was 73%, and the negative predictive value was 56%. Corresponding values for MDCT were 97% and 97%.

Comment: These findings suggest that MDCT scanning is more accurate than clinical judgment for diagnosing appendicitis, even in cases that are considered to be "clinically apparent." However, not all radiologists who interpret CT scans are CT specialists, and CT scans are not read by two radiologists in most EDs. Patients with suspected appendicitis, especially women, should undergo abdominal CT scanning to confirm or exclude the diagnosis, with the exception of patients whose diagnosis is considered "certain" by the attending surgeon and who are taken directly to the operating room without imaging.

— Diane M. Birnbaumer, MD, FACEP. Published in Journal Watch Emergency Medicine September 5, 2008. Citation: Kim K et al. Emerg Med J 2008 Aug; 25:477.

14. Groups Tout Program Aimed at Cutting ED Use in California

August 18, 2008. Supporters of a five-year pilot program that directed frequent users of hospital emergency departments to other sources of health care are lobbying the Legislature to approve a similar effort, the Fresno Bee reports.

Six counties -- Alameda, Los Angeles, Sacramento, Santa Clara, Santa Cruz and Tulare -- participated in the pilot, which is set to end next month. It was funded by $10 million in grants from the California Endowment and the California HealthCare Foundation.

Outcomes

According to the Bee, ED visits declined by about 35% for participants in the program.

In addition, preliminary findings from the Lewin Group, a Virginia-based consulting firm, show that:

- Hospital and ED charges decreased by $9,715 for each frequent user of EDs identified in the program;
- Hospital admissions decreased by 30%; and
- Between 24% and 69% of people identified in the program were successfully enrolled in other services, including Medi-Cal.

Lobbying Efforts

Supporters of the program estimate that it would cost the state about $10 million to launch the initiative statewide but that the cost of the program would be offset by savings from preventing hospital ED visits.

Groups lobbying the Legislature for the program include the:

- California Association of Public Hospitals;
- California Medical Association;
- California State Association of Counties; and
- Western Center on Law and Poverty (Correa, Fresno Bee, 8/16).

http://www.californiahealthline.org/

15. Placebo effect may be greater in children than in adults

Rheims S, et al. PLoS Med 2008;5:e166

Children are too often prescribed drugs without evidence from paediatric trials. A systematic review compared the 50% responder rate—50% or greater reduction in seizure frequency during the treatment period compared with baseline—between active antiepileptic treatment and placebo in five trials in children and 27 trials in adults with drug resistant partial epilepsy.
The treatment effect was significantly lower in children than in adults (relative risk ratio 0.67, 95% CI 0.51 to 0.89) because children because children had a greater response to placebo (19% v 9.9%; P less than 0.001). The response to the active treatment was comparable in children and adults (37.2% v 30.4%, respectively; P=0.364).

The linked perspective (e172) stresses that children are not just small adults, and that trials are lacking in many paediatric specialties. The authors outline the methodological features that researchers should embrace in future trials. In particular, trials in children may need to be bigger than trials of the same drugs in adults to avoid false negative findings as a result of children responding better to placebo.

Full-text (free): http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0050166

16. A Little Hand Hygiene Goes a Long Way

Meta-analysis results of community-based intervention studies indicate that use of nonantibacterial soap and hand-hygiene education significantly reduce respiratory and GI illnesses.

Does hand washing really reduce the incidence of gastrointestinal (GI) and respiratory illnesses in the community, and, if so, by how much? Which is better: alcohol-based hand sanitizers, nonantibacterial (plain) soap, or antibacterial soap? To answer these questions, investigators from the University of Michigan and Columbia University identified more than 5000 relevant studies published from 1960 to 2007 and pooled results from 30 community-based intervention studies (conducted in developed and developing countries) that met criteria for review (19 of the 30 studies focused on children aged 5 years and younger).

Compared with no education, hand-hygiene education alone (7 studies) significantly reduced the risk for GI illness by 31% and for respiratory illness (4 studies) by 14%. Education plus use of nonantibacterial soap (6 studies) significantly reduced the risk for GI illness by 39% and for respiratory illness (1 study) by 51%, compared with control conditions, but had no significant effect in the two studies that combined the two outcomes. In two studies, use of antibacterial soaps did not offer an advantage over plain soap for either illness. Although alcohol-based hand sanitizer plus education did not reduce the risk for either illness alone, this strategy showed a protective effect in the three studies that combined the two outcomes (21% reduction). In two studies, benzalkonium chloride–based hand sanitizer significantly reduced the risk for GI and respiratory illnesses alone and the two outcomes combined by about 40%.

Comment: This meta-analysis provides us with solid community-based (vs. hospital-based) research to use when educating patients about the virtues of hand washing. Education is essential: The authors cite results from a U.S. study of 7800 participants indicating that only 67% (75% of women and 58% of men) washed their hands after using a public restroom. The finding that plain soap works as well as antibacterial soaps is reassuring, given concerns that use of antibacterial soaps might actually promote emergence of antibiotic-resistant bacteria. When I extolled the virtues of hand washing in my annual flu-prevention message to students, one responded that my advice seemed mundane. If parents and children discount this simple but effective prevention technique because it is not high-tech, that would be unfortunate. I’m going to keep washing my hands and telling students to do the same.

— Alain Joffe, MD, MPH, FAAP. Published in Journal Watch Pediatrics and Adolescent Medicine September 10, 2008. Citation: Aiello AE et al. Am J Public Health 2008 Aug; 98:1372.

17. Aspirin/Dipyridamole vs. Clopidogrel to Prevent Recurrent Stroke: A Toss-Up?

Sacco RL, et al. N Engl J Med. 2008; Published on-line August 27, 2008.

Background: Recurrent stroke is a frequent, disabling event after ischemic stroke. This study compared the efficacy and safety of two antiplatelet regimens — aspirin plus extended-release dipyridamole (ASA–ERDP) versus clopidogrel.

Methods: In this double-blind, 2-by-2 factorial trial, we randomly assigned patients to receive 25 mg of aspirin plus 200 mg of extended-release dipyridamole twice daily or to receive 75 mg of clopidogrel daily. The primary outcome was first recurrence of stroke. The secondary outcome was a composite of stroke, myocardial infarction, or death from vascular causes. Sequential statistical testing of noninferiority (margin of 1.075), followed by superiority testing, was planned.

Results: A total of 20,332 patients were followed for a mean of 2.5 years. Recurrent stroke occurred in 916 patients (9.0%) receiving ASA–ERDP and in 898 patients (8.8%) receiving clopidogrel (hazard ratio, 1.01; 95% confidence interval [CI], 0.92 to 1.11). The secondary outcome occurred in 1333 patients (13.1%) in each group (hazard ratio for ASA–ERDP, 0.99; 95% CI, 0.92 to 1.07). There were more major hemorrhagic events among ASA–ERDP recipients (419 [4.1%]) than among clopidogrel recipients (365 [3.6%]) (hazard ratio, 1.15; 95% CI, 1.00 to 1.32), including intracranial hemorrhage (hazard ratio, 1.42; 95% CI, 1.11 to 1.83). The net risk of recurrent stroke or major hemorrhagic event was similar in the two groups (1194 ASA–ERDP recipients [11.7%], vs. 1156 clopidogrel recipients [11.4%]; hazard ratio, 1.03; 95% CI, 0.95 to 1.11).

Conclusions: The trial did not meet the predefined criteria for noninferiority but showed similar rates of recurrent stroke with ASA–ERDP and with clopidogrel. There is no evidence that either of the two treatments was superior to the other in the prevention of recurrent stroke.

18. Thrombolysis Appears to Be Safe Up to 4.5 Hours After Stroke Onset

Susan Jeffrey. September 17, 2008 — Observational data from a large European registry suggest that thrombolysis may be safe up to 4.5 hours after stroke onset, an hour and a half longer than current recommendations of a 3-hour limit.

Results from the Safe Implementation of Treatments in Stroke International Stroke Thrombolysis Registry (SITS-ISTR), an observational audit of patients treated with intravenous alteplase, a tissue plasminogen activator (tPA), for acute ischemic stroke showed no significant difference in outcomes between patients treated between 3 and 4.5 hours after symptom onset and those treated before the recommended threshold of 3 hours.

If these findings are confirmed in the soon-to-report European Cooperative Acute Stroke Study 3 (ECASS 3) randomized trial comparing tPA treatment vs placebo in patients presenting between 3 and 4.5 hours after symptom onset, more patients with ischemic stroke may be eligible for therapy.

"Today, only a minority of stroke patients can be treated, mainly because of the restriction of the time window, and an increase of that window by 50% would make it possible to treat more patients," first author Nils Wahlgren, MD, at Karolinska University Hospital in Stockholm, Sweden, said in an interview. "We don't want to encourage a delay in treatment, but for patients who are not available before that time limit, it would be an advantage to be treated after 3 hours."

The SITS-ISTR results are published in the September 15 Online First issue of The Lancet. The ECASS 3 results are scheduled to be presented on September 25, 2008, during the World Stroke Congress in Vienna, Austria, and will be reported at that time by Medscape Neurology & Neurosurgery.

Provisional Approval

Subsequent to results of the major clinical trials of tPA during the 1990s, alteplase was approved for use in the United States in 1996 and in Canada in 1999 for patients with ischemic stroke treated within 3 hours of symptom onset. However, the European Medicines Evaluation Agency was more conservative, giving only provisional approval in 2002. One of 2 conditions for licensing was that an observational study be implemented to assess the safety of tPA in routine practice.

The results from that study, called the Safe Implementation of Thrombolysis in Stroke Monitoring Study, were reported last year and confirmed that the rates of symptomatic intracerebral hemorrhage, mortality, and independence reflecting good functional outcome were similar in clinical practice to those seen in the randomized trials, although the analysis was limited to those patients who met approved criteria for treatment (Wahlgren N et al. Lancet. 2007;369:275-282).

The second condition was the randomized trial ECASS 3. Results of a meta-analysis of pooled data from randomized trials had suggested that the proportion of patients who benefit from tPA declines with time, the authors note, but that there is still significant benefit for up to 4.5 hours after symptom onset (Hacke W. et al. Lancet 2004;363:768-774).

In this study, Dr. Wahlgren and colleagues used data from the SITS, a prospective, Internet-based audit of the ISTR. SITS represents the collaboration of more than 700 clinical centers in 35 countries documenting the use of tPA, where all treated patients are registered whether they meet approved criteria for treatment.

In this analysis, they compared outcomes in 664 patients who were given tPA between 3 and 4.5 hours after symptom onset vs those of 11,865 patients treated within the recommended 3-hour window. Except for the time window in which they were treated, all patients still met the criteria for treatment, including a computed tomography scan clear of any evidence of bleeding.

Dr. Wahlgren noted that the decision to treat with tPA after 3 hours was made in the institutions and would have been made on an individual basis. For example, if a patient has given informed consent and has been prepared for treatment, he pointed out, "it would be very difficult to say to the patient we cannot treat you any longer because you have past the time line of 3 hours."

In the 3- to 4.5-hour cohort, treatment was started at a median of 55 minutes later after symptom onset, at approximately 195 minutes vs 140 minutes in the 3-hour cohort (P less than .001). These patients were also significantly younger and had less severe strokes than those treated within 3 hours.

In the end, the investigators found no significant differences between patients treated within 3 hours and those treated between 3 and 4.5 hours in the rate of symptomatic intracerebral hemorrhage, mortality rate, or the rate of those who were independent (modified Rankin scale 0 - 2) at 3 months.

After the results of ECASS 3 are reported, discussions during the Karolinska Stroke Update Consensus Conference in November will provide some direction for any adjustments to current guidelines on the time window for treatment by the European Stroke Organization, Dr. Wahlgren said.

A Safe Option

In a commentary accompanying the publication, Georgios Tsivgoulis, MD, from the Democretus University of Thrace, University Hospital Alexandroupolis, Greece, and Andrei V. Alexandrov, MD, from the University of Alabama at Birmingham, call the results, "promising nonrandomized data which show that extension of the time frame of thrombolysis might be a safe and feasible option."

They note that after adjustment for potential confounders, there was a nonsignificant increase in the risk for symptomatic intracerebral hemorrhage and mortality in this study, amounting to absolute differences of 0.6% and 0.5% respectively, although imbalances in baseline characteristics may have accounted for this.

In addition, half of the patients in the 3- to 4.5-hour cohort were treated just 15 minutes after the 3-hour limit, they point out, with 60% treated within 180 to 200 minutes after symptom onset. Although understandable, "this skew could weaken the overall impression that reliable data are available for 3 - 4.5 hours," they note. Drs. Tsivgoulis and Alexandrov also add that symptomatic intracerebral hemorrhage was self-reported by the investigators, which means potential selection bias cannot be ruled out, and because patients older than 80 years and those with more severe strokes (NIHSS score above 25) were excluded, these results cannot be generalized to these patients.

"Whether ECASS 3 is positive or not, the SITS-ISTR findings support continuing efforts to extend the time frame for thrombolysis," Drs. Tsivgoulis and Alexandrov write. Another trial in this extended period, the International Stroke Trial 3 is also ongoing, and other trials selecting patients for treatment on the basis of imaging studies are also underway.

"We are looking forward to moving away from rigid timeframes to treatment on the basis of imaging that can assess brain pathophysiology and tissue viability," they conclude.

The SITS-ISTR is funded by an unrestricted grant from Boehringer Ingelheim and the European Union Public Health Executive Authority. Dr. Wahlgren has received expenses from Boehringer Ingelheim for this role as member of the Steering Committee in relationship to the ECASS 3 trial with alteplase and has served as a consultant to Thrombogenics as chairman of the data safety and monitoring board. He has also received lecture fees from Boehringer Ingelheim and from Ferrer. A complete list of disclosures is available in the original article.

Drs. Tsivgoulis and Alexandrov have disclosed no relevant financial relationships.

Lancet. Published online September 15, 2008.

19. Telemedicine for Stroke Patients

Telemedicine consultation with a stroke-certified neurologist might increase appropriate use of thrombolytic agents in stroke patients.

Many patients with ischemic stroke who are eligible for alteplase therapy do not receive it because the agent must be administered within 3 hours from onset of symptoms and because emergency physicians might want to involve stroke neurologists in primary decision making regarding the use of thrombolytics. Researchers evaluated whether remote consultation with a stroke neurologist could increase appropriate use of thrombolytic agents for stroke patients.

Patients with acute stroke symptoms who presented to one of four remote hospitals from 2004 to 2007 were randomized to telemedicine or telephone-only consultation by neurologists who were National Institute of Health Stroke Scale (NIHSS) certified. During the telemedicine consultation, the consultant took a medical history, performed a physical assessment, calculated the NIHSS score, and reviewed head computed tomography (CT) scans, in concert with the local EP. Telephone consultations differed in that the consultant could not speak directly with or view the patient and relied on the local radiologist’s interpretation of the CT scan. In both scenarios, the consultant made a decision about whether to administer thrombolytic agents. The correctness of the decision — the primary outcome measure — was determined by an independent committee of stroke specialists.

Of 222 patients, 104 in the telemedicine group and 103 in the telephone group completed the study. Mean NIHSS scores at presentation were significantly higher in the telemedicine group than in the telephone group (11.4 vs. 7.7). Correct decision making was significantly more likely in the telemedicine group than in the telephone group (98% vs. 82%; odds ratio, 10.9). However, no differences were noted between groups in any of the secondary outcome variables, including rate of alteplase administration (28% vs. 23%), 90-day functional outcomes, mortality, or rate of intracranial hemorrhage after alteplase administration (7% vs. 8%). The time from call to decision making was significantly longer in the telemedicine group than in the telephone group (65 vs. 55 minutes).

Comment: This study suggests that remote consultation with a stroke neurologist can obviate the need for an on-site neurologist and enable high and appropriate rates of thrombolytic administration for patients with ischemic stroke. Telemedicine, which is expensive and not routinely available, provided better decision making but no other derivative advantages.

— John A. Marx, MD, FAAEM, FACEP. Published in Journal Watch Emergency Medicine August 22, 2008. Citation: Meyer BC et al. Lancet Neurol 2008 Sep; 7:787

20. Professionalism During Residency Linked to Better Test Scores, Clinical Skills

By Anthony J. Brown, MD. NEW YORK (Reuters Health) Sept 16 - Residents regarded as highly professional by their peers score better on In-Training Examinations (ITE) and exhibit better clinical skills and more conscientious behaviors than their less-professional colleagues, according to a report in the Journal of the American Medical Association for September 17.

"Most prior studies on professionalism focus on unprofessional behaviors while this study has a very positive focus on the knowledge, skills, and behaviors demonstrated by highly professional physicians," lead author Dr. Darcy A. Reed told Reuters Health.

"The assessment of professionalism in this study," she added, "is also unique in that it incorporates observation-based assessments from multiple groups (peers, senior residents, faculty, medical students, and non-physician professionals) rather than a single measure of professionalism."

Dr. Reed and colleagues from the Mayo Clinic in Rochester, Minnesota, investigated the link between professionalism and ITE scores, clinical skills (Mini-Clinical Evaluation Exercise), conscientious behaviors, and residency warning/probation notices in 148 first-year internal medicine residents.

A professionalism score was generated for each subject based on observation ratings from peers, senior residents, medical students, faculty, and non-physician professionals over 1 year. Residents were considered to be highly professional if the total professionalism score was at the 80th percentile or higher.

Highly professional residents had significantly higher ITE scores and were more skilled clinically than less-professional residents, the report indicates. In addition, highly professional residents completed a greater percentage of required evaluations, a measure of conscientious behavior. Multivariate analysis confirmed the independent nature of all three associations.

Conversely, a low professionalism score correlated with receipt of a warning or probation from the residency program. Of the eight residents who received a warning/probation, six had professionalism scores at or below the 20th percentile.

"The results of this comparative study further the understanding of professionalism in medicine," the authors conclude. "Our findings strengthen the notion of professionalism as a multidetermined construct by contributing new information about specific knowledge, skills, and behaviors associated with professionalism during residency."

Dr. Reed added that "the relationship between professionalism and other competencies, both medical knowledge and clinical practice assessed in this study, as well as other competencies such as systems-based practice, practice-based learning and improvement require further investigation."

JAMA 2008;300:1326-1333.

21. Clinical Guidelines Released for Identifying, Treating Cerumen Impaction--STAT

ALEXANDRIA, Va -- August 29, 2008 -- The American Academy of Otolaryngology -- Head and Neck Surgery Foundation (AAO-HNSF) will issue the first comprehensive clinical guidelines to help healthcare practitioners identify patients with cerumen impaction.

The guidelines emphasise evidence-based management of cerumen impaction by clinicians and inform patients of the purpose of ear wax in hearing health.

"Approximately 12 million people a year in the United States seek medical care for impacted or excessive cerumen," said Richard Rosenfeld, MD, AAO-HNSF Guideline Development Task Force, Alexandria, Virginia.

"This leads to nearly 8 million cerumen removal procedures by healthcare professionals. Developing practical clinical guidelines for physicians to understand the harm versus benefit profile of the intervention was essential."

Recognising that patients may seek care from many different types of healthcare providers, the taskforce developed guidelines intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction.

Key features of the new guidelines include:
· Cerumen is a beneficial, self-cleaning agent, with protective, lubricating (emollient), and antibacterial properties.
· Clinicians should examine patients with hearing aids for cerumen impaction because it may cause feedback, reduce sound intensity, or damage the hearing aid.
· Cerumen may cause reversible hearing loss when it blocks 80% or more of the ear canal diameter.
· Appropriate options for cerumen impaction are (1) cerumenolytic agents, which include water, saline, and other agents of comparable efficacy; (2) irrigation or ear syringing, which is most effective when a cerumenolytic is instilled 15 to 30 minutes prior; and (3) manual removal with special instruments or a suction device, which is preferred for patients with narrow ear canals, eardrum perforation or tube, or immune deficiency.
· Inappropriate or harmful interventions are cotton-tipped swabs, oral jet irrigators, and ear candling.
· Clinicians should assess patients at the conclusion of in-office treatment for cerumen impaction and document resolution of the impaction.
· There are no proven ways to prevent cerumen impaction, but not inserting cotton-tipped swabs or other objects in the ear canal is strongly advised; individuals at high risk should consider seeing a clinician every 6 to 12 months for routine cleaning.

"The complications from cerumen impaction can be painful and ongoing, including infections and hearing loss," said Dr. Roland. "It is hoped that these guidelines will give clinicians the tools they need to spot an issue early and avoid serious outcomes."

Otolaryngology–Head and Neck Surgery (2008) 139, S1-S21. Full-text (free): http://www.entnet.org/Practice/upload/FINAL-CerumenImpaction-Journal-2008.pdf

Lit Bits: August 28, 2008

From the recent medical literature...

1. Emergency Department Visits Up Sharply From 1996 to 2006, CDC Says

Date: August 07, 2008. The number of ED visits in the U.S. increased by 36% to 119 million in 2006 from 90 million in 1996, according to a CDC report on hospital use released on Wednesday, the AP/Miami Herald reports. At the same time, the number of EDs nationwide declined from about 4,000 to about 3,800, contributing to an increase in ED treatment wait times.

The findings are based on a national survey of 362 hospital EDs.

According to the report, average ED wait time increased to about 56 minutes in 2006, compared with 38 minutes in 1997. However, the increasing ED wait time is misleading because urban EDs with waits longer than an hour boost the average, according to Catharine Burt of the National Center for Health Statistics at CDC. The report's lead author, Stephen Pitts of CDC, said that half of ED users had wait times of 31 minutes or less.

Billy Mallon, president of the California chapter of the American College of Emergency Physicians, said that California has the lowest percentage of EDs per capita, at 6.12 per one million residents.

ED Overcrowding

Several factors contribute to overcrowding in the nation's EDs. Pitts said that it is getting more difficult for U.S. residents to schedule primary care appointments, which contributes to the rise in ED use. He said this trend applies to Medicare and Medicaid beneficiaries in particular.

The report found that 82 of every 100 Medicaid beneficiaries used ED care in 2006, compared to 21 of every 100 people with private insurance.

Pitts said a limited number of inpatient beds also is contributing to ED overcrowding as patients wait in the ED to be admitted. As hospitals have reduced bed capacity, the "major solution over the past 10 years has been to allow these patients to sit in the hallways in the ER," Pitts said.

More than half of hospital admissions in 2006 were through EDs, a 38% increase since 1996, the report found.

According to the report, although the number of uninsured U.S. residents increased by more than 5 million since 1996 to about 47 million, the growing uninsured population did not account for higher ED use.

The report also found that the overall growth in population did not account for the trend. According to the report, about 40% of ED patients had private insurance; about 25% received health coverage through state programs for children; about 17% were Medicare beneficiaries; and about 17% were uninsured.

Other ED findings

The report also found that:

- ED use overall increased by 18%;
-About 13% of ED visits led to a hospital admission;
-Infants had the highest use of EDs of any age group;
-People older than 75 were the second-highest users of ED care; and
-ED or hospital outpatient department visits accounted for 38% of care used by blacks, compared with 17% for whites.

For more information, please visit:
http://www.californiahealthline.org/articles/2008/8/7/Emergency-Department-Visits-Up-Sharply-From-1996-to-2006-CDC-Says.aspx?topicID=47

The entire report can be found at this link:
http://www.cdc.gov/nchs/data/nhsr/nhsr008.pdf

2. Silver-Coated Endotracheal Tube Reduces Risk for Ventilator-Associated Pneumonia

Laurie Barclay, MD. August 19, 2008 — Use of a silver-coated endotracheal tube significantly reduces the incidence of microbiologically confirmed ventilator-associated pneumonia (VAP), according to the results of a large, randomized, multicenter study reported in the August 20 issue of the Journal of the American Medical Association.

"VAP causes substantial morbidity," write Marin H. Kollef, MD, from the Washington University School of Medicine in St. Louis, Missouri, and colleagues from the North American Silver-Coated Endotracheal Tube Investigation Group. "A silver-coated endotracheal tube has been designed to reduce VAP incidence by preventing bacterial colonization and biofilm formation."

The goal of this prospective, single-blind study conducted in 54 centers in North America was to evaluate whether use of a silver-coated endotracheal tube would reduce the incidence of microbiologically confirmed VAP.

Of 9417 adult patients aged 18 years or older who were screened between 2002 and 2006, a total of 2003 patients who were expected to need mechanical ventilation for at least 24 hours were randomly assigned to undergo intubation with 1 of 2 high-volume, low-pressure endotracheal tubes. These tubes were similar except that the experimental tube had a silver coating.

The main endpoint was incidence of VAP, diagnosed from quantitative bronchoalveolar lavage fluid culture with at least 104 colony-forming units/mL in patients intubated for at least 24 hours. Secondary endpoints were VAP incidence in all intubated patients, time to VAP onset, length of intubation and duration of intensive care unit and hospital stay, mortality rates, and adverse events.

Rates of microbiologically confirmed VAP in patients intubated for at least 24 hours were 4.8% (37/766 patients; 95% confidence interval [CI], 3.4% - 6.6%) in the group receiving the silver-coated tube and 7.5% (56/743; 95% CI, 5.7% - 9.7%; P = .03) in the group receiving the uncoated tube (relative risk reduction, 35.9%; 95% CI, 3.6% - 69.0%).

Rates of microbiologically confirmed VAP in all intubated patients were 3.8% (37/968; 95% CI, 2.7% - 5.2%) in the experimental group and 5.8% (56/964; 95% CI, 4.4% - 7.5%; P = .04) in the control group (relative risk reduction, 34.2%; 95% CI, 1.2% - 67.9%).

Use of the silver-coated endotracheal tube was associated with delayed occurrence of VAP (P = .005), but there were no statistically significant between-group differences in durations of intubation, intensive care unit stay, and hospital stay. Mortality rates and frequency and severity of adverse events were also similar in both groups.

"Patients receiving a silver-coated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube," the study authors write. "The silver-coated endotracheal tube appears to offer a unique approach because it is the first intervention that becomes user-independent after intubation, requiring no further action by the clinician."

Limitations of this study include single blinding rather than double blinding; use of a small, fixed block size stratified by center; other factors possibly contributing to between-group differences in VAP rates; study protocol not standardizing prevention strategies; and a protective effect of higher severity-of-illness scores against development of VAP.

In an accompanying editorial, Jean Chastre, MD, from Institut de Cardiologie, Groupe Hospitalier Pitié-Salpê trière in Paris, France, discusses the study limitations.

"Important uncertainties exist regarding the exact benefit of silver-coated endotracheal tubes," Dr. Chastre writes. "Consequently, silver coated tubes should not be viewed as the definitive answer for VAP prevention, and, until additional data confirm the clinical effectiveness and cost benefit of these devices, their use should be restricted to high-risk patients treated in ICUs [intensive care units] with benchmark value-based infection rates that remain above institutional goals despite implementation of a comprehensive strategy of usual preventive measures to prevent VAP."

CR Bard Inc supported this study and provided grant support to all of the study authors. Some of the study authors have disclosed various financial relationships with Kimberly Clark, Elan, Merck, Pfizer, Bayer, GlaxoSmithKline, Boehringer Ingelheim, KCI, sanofi-aventis, Johnson & Johnson, Easi, Hospira, Nomir Medical Technologies, Arpida, Cubist, Elan, Ortho-McNeil, Sanofi Pasteur, Wyeth, Bayer-Nektar, Nestle Clinical Nutrition, Lilly, Corbett Accel Healthcare, National Institutes of Health, Novartis, and/or Maquet. Dr. Chastre has received consulting and lecture fees from Pfizer, Brahms, Wyeth, Johnson & Johnson, Bayer-Nektar, and Arpida.

JAMA. 2008.300:805-813, 842-844.

3. Triage Pain Scores and the Desire for and Use of Analgesics

Singer AJ, et al. Ann Emerg Med. 2008; in press.

Study objective
Inadequate analgesia (oligoanalgesia) is a common phenomenon. In an effort to improve pain recognition and management, pain scores are mandated by The Joint Commission. When patients with pain do not receive analgesics, treatment is considered deficient. However, the mere presence of pain does not imply that all patients desire analgesics. We determine how often patients in pain desire and receive analgesics in the emergency department (ED). We hypothesize that many ED patients in pain do not desire analgesics and that most who want them receive them.

Methods
We conducted a prospective observational study of pain-related visits to an academic ED during the spring of 2007. Standardized collection of demographic and clinical data was performed, and patients rated their pain severity on a 0 to 10 numeric rating scale. The main outcome measures were the desire for and administration of analgesics during the ED visit. Univariate and multivariate logistic regression was used to identify factors associated with patient desire for and administration of analgesics.

Results
We enrolled 392 patients. Mean (SD) age was 39 years (19), 50% were female patients, 76% were white. Mean (SD) initial pain score was 7.1 (2). Of the 392 patients, 199 (51% [95% confidence interval (CI) 46% to 56%]) desired analgesics and 227 (58% [95% CI 53% to 63%]) received analgesics within 92 (SD 106) minutes. Of patients desiring analgesics, 162 (81% [95% CI 75% to 86%]) received them. Reasons for not wanting analgesics included pain tolerable (47%), analgesic taken at home (11%), and wanting to remain alert (7%). Pain scores were higher in those patients who wanted analgesics than in those patients who did not want analgesics (7.8 [95% CI 7.5 to 8.1] versus 6.4 [95% CI 6.1 to 6.7]; difference 1.4 [95% CI 0.9 to 1.8]). In multivariate analysis, pain scores (odds ratio [OR] 1.3 for every 1-point increase in pain score) and constant pain (OR 2.0) were significant factors that predicted wanting analgesics, whereas pain scores (OR 1.2) and desiring analgesics (OR 7.4) were significant predictors of receiving analgesics.

Conclusion
Nearly half of all ED patients in pain do not desire analgesics and most who desire analgesics receive them. Although the average pain score for patients not wanting analgesics was lower, it was often in the moderate to severe range. Patients should be asked whether they have pain and whether they want analgesics regardless of their pain scores.

4. Coronary Multidetector CT Cost-Effective for Triage of Acute Chest Pain Patients

NEW YORK (Reuters Health) Aug 18 - Compared with standard protocols for assessing acute chest pain in emergency department patients, the use of coronary multidetector CT (MDCT) is modestly more effective and offers cost savings in the case of women, according to a report in the August issue of the American Journal of Roentgenology.

"Coronary CT angiography may be a useful adjunct to care in the emergency department setting when patients present with acute chest pain," Dr. Joseph A. Ladapo with the Harvard Ph.D. Program in Health Policy, Cambridge, Massachusetts told Reuters Health. "I think this finding provides support for people who feel like this technology needs be studied further."

Dr. Ladapo and colleagues used a Monte Carlo microsimulation model to compare the standard of care with MDCT coronary angiography-based management in the triage of patients with low-risk chest pain who present to the emergency department.

For a 55 year-old man, coronary MDCT increased emergency department and hospital costs by $110 and raised total health care expenditures by $200, the authors report, but for a similarly aged woman, it decreased emergency department and hospital costs by $410 and decreased total health care expenditures by $380.

Small incremental improvements in unadjusted and quality-adjusted life expectancy were seen with coronary MDCT in both sexes, the report indicates.

The incremental cost-effectiveness of coronary MDCT management (compared with standard of care) was $6400 per quality-adjusted life-year in men, the researchers note. The strategy was cost-saving in women.

Most patients who were wrongfully discharged from the emergency department after being triaged with MDCT angiography faced a low risk of mortality from the missed diagnosis, the investigators say.

"Our results suggest that 64-MDCT coronary angiography may be a safe addition to the management of low-risk patients with acute chest pain and is likely to be cost-saving in women and marginally more expensive than the standard of care in men," the authors conclude.

"Because coronary CT angiography is so good at ruling out disease, women -- along with other patients with a low likelihood of disease -- are much more likely to avoid a costly admission," Dr. Ladapo explained. "I think there's a strong case for reimbursing this technology when it's used in women, but it's cost-effective and ought to be reimbursed in men, too."

He added, "I don't think emergency departments need to rush to start using the exam on their acute chest pain patients, but I do think that it's worth supporting clinical trials of its application."

Am J Roentgenol 2008;191:455-463.

5. AHA Publishes Statement on Integrating Prehospital ECGs Into Care for ACS Patients

A Scientific Statement From the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology

Michael O'Riordan. From Heartwire — a professional news service of WebMD

August 14, 2008 — The American Heart Association (AHA) has issued a scientific statement on the use of prehospital electrocardiograms (ECGs) to improve the quality of care delivered to patients with ST-segment-elevation MI (STEMI), published online August 13, 2008 in Circulation. The central challenge, say the authors, will not be in acquiring the ECG, but rather in using and integrating the diagnostic information obtained by emergency medical service (EMS) personnel into existing systems of care.

"First medical contact with a patient is usually with the EMS, and this is the next phase of coordination that we need to reach out to," said lead author Dr Henry Ting (Mayo Clinic, Rochester, MN). "We've coordinated the emergency department, the cath lab, and the cardiology group and have done well with reducing door-to-balloon times, but we've not truly engaged the prehospital phase of care. This is critically important."

The AHA national guidelines, as well as other consensus and scientific statements, recommend the acquisition and use of prehospital ECGs by EMS for the evaluation of patients with suspected acute coronary syndrome. The current recommendation is class 2a with a B level of evidence. Speaking with heartwire, Ting said that the technology is currently available, but that hospitals do not have protocols in place that allow prehospital ECGs to serve any useful purpose.

"For the past 10 years, this equipment has been available to many paramedics, but what is happening is that when they acquire the ECG it's not really utilized," said Ting. "It's acquired, then the patient is brought to the emergency department, and in hospitals without these systems of care, they're told this is a patient with chest pain, and we have an ECG, but then the patient is placed in a critical-care room and receives another ECG. Where's the value in that?"

Not a one-size-fits-all solution

In the scientific statement, the authors review the benefits of using prehospital ECGs and the barriers and challenges to routine use and recommend approaches for using the diagnostic information for improving quality of care. In terms of benefits, Ting said the Mayo Clinic has been incorporating the use of prehospital ECGs for one year, and in doing so, has reduced door-to-balloon times to consistently less than 30 minutes, with 25 minutes being the average.

Ting said there are many ways of interpreting the ECG once it has been obtained. Computer algorithms, paramedic interpretation, and wirelessly transmitting the data to a physician for interpretation are three ways to interpret the data. The diversity of the EMS providers and the differing sizes of cities they cover, as well as wireless coverage available to transmit data, are not likely to lead to a one-size-fits-all solution, he said.

A recent survey found that 90% of EMS systems serving the largest US cities have 12-lead ECG equipment, and there are prehospital ECG programs in Boston, Los Angeles County, and North Carolina, as well as in Ottawa, ON. Paramedics in Boston, for example, are allowed to bypass non–percutaneous coronary intervention (PCI) hospitals and have an emergency-department physician activate the cardiac cath lab. North Carolina, on the other hand, allows paramedics to occasionally divert some STEMI patients to PCI hospitals and activate the cath lab directly (or have it activated by an emergency-department physician). Paramedics in Ottawa can also activate the cath lab directly through a central operator. Los Angeles County paramedics use a computer algorithm to interpret the ECG, and the cath lab is activated by the emergency department based on this diagnosis.

Allowing paramedics to "do something downstream" with the information is critical, said Ting, as is changing when the paramedics perform the ECG. "If you truly want to coordinate things, you want to start the prehospital ECG as early as possible in the examination," he said. "Once you establish that the patient has stable vital signs and doesn't have a cardiac arrhythmia, you probably want to do a prehospital ECG at the scene, as early as possible. If you detect ST elevation, the next steps are very different from treating a patient who has chest pain but no ST elevation."

Implementing prehospital ECGs into existing systems of care has the potential to "change the ball game," said Ting. He noted that the focus should begin to move away from door-to-balloon times toward a measure that provides a gauge of quality and performance that is more patient centered. The national "Door to Balloon: An Alliance for Quality" campaign launched in 2006 has helped improve the timeliness of lifesaving therapy for myocardial infarction (MI) patients at all US hospitals that perform emergency angioplasty, but from a patient perspective, first medical contact to balloon is a more relevant measure of quality of care.

Ting added that too many patients still take themselves to the emergency department or are driven there by friends or family, a decision that affects the course of care because it's impossible to obtain a prehospital ECG and then activate all the necessary hospital teams.

"The public doesn't perceive EMS as transforming care," said Ting. "They view it as transportation with sirens. They think, 'If Uncle Joe can drive me there just as fast, then why do I need to call 911 and create all the hassle in the neighborhood?' But the prehospital ECG can really change the course of treatment, something that can't happen when you drive yourself or have a friend take you."

Dr. Ting has received research grants from the American College of Cardiology and the Mayo Foundation for Medical Education and Research. A complete list of disclosures is available in the original article.

Source: Ting HH, Krumholz HM, Bradley EH et al. Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome. Circulation. 2008;

Full-text (free for now): http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.108.190402v1.pdf

6. When Is it Appropriate to Use Methotrexate for Ectopic Pregnancy in the Emergency Department?

Noelle A. Rotondo, DO, Associate Professor, Penn State Hershey Medical Center, Hershey, Pennsylvania; Staff Physician, York Hospital, York, Pennsylvania

Read her reply: http://www.medscape.com/viewarticle/576935

7. I Won’t Believe You, but Tell Me the Prognosis Anyway

Physicians’ prognoses are desired and discounted at the same time.

Zier LS, et al. Critical Care Medicine. 2008;36:2341-2347.

Objectives: Although discussing a prognosis is a duty of physicians caring for critically ill patients, little is known about surrogate decision-makers' beliefs about physicians' ability to prognosticate. We sought to determine: 1) surrogates' beliefs about whether physicians can accurately prognosticate for critically ill patients; and 2) how individuals use prognostic information in their role as surrogate decision-makers.

Design, Setting, and Patients: Multicenter study in intensive care units of a public hospital, a tertiary care hospital, and a veterans' hospital. We conducted semistructured interviews with 50 surrogate decision-makers of critically ill patients. We analyzed the interview transcripts using grounded theory methods to inductively develop a framework to describe surrogates' beliefs about physicians' ability to prognosticate. Validation methods included triangulation by multidisciplinary analysis and member checking.

Measurements and Main Results: Overall, 88% (44 of 50) of surrogates expressed doubt about physicians' ability to prognosticate for critically ill patients. Four distinct themes emerged that explained surrogates' doubts about prognostic accuracy: a belief that God could alter the course of the illness, a belief that predicting the future is inherently uncertain, prior experiences where physicians' prognostications were inaccurate, and experiences with prognostication during the patient's intensive care unit stay. Participants also identified several factors that led to belief in physicians' prognostications, such as receiving similar prognostic estimates from multiple physicians and prior experiences with accurate prognostication. Surrogates' doubts about prognostic accuracy did not prevent them from wanting prognostic information. Instead, most surrogate decision-makers view physicians' prognostications as rough estimates that are valuable in informing decisions, but are not determinative. Surrogates identified the act of prognostic disclosure as a key step in preparing emotionally and practically for the possibility that a patient may not survive.

Conclusions: Although many surrogate decision-makers harbor some doubt about the accuracy of physicians' prognostications, they highly value discussions about prognosis and use the information for multiple purposes.

8. Furosemide for Emergency Management of Hypercalcemia: An Unproven yet Common Practice

LeGrand SB, et al. Ann Intern Med. 2008;149:259-263.

Although primary hyperparathyroidism is the most common cause of hypercalcemia, cancer is the most common cause requiring inpatient intervention. An estimated 10% to 20% of all patients with cancer have hypercalcemia at some point in their disease trajectory, particularly in advanced disease. Aggressive saline hydration and varying doses of furosemide continue to be the standard of care for emergency management.

However, a review of the evidence for the use of furosemide in the medical management of hypercalcemia yields only case reports published before the introduction of bisphosphonates, in contrast to multiple randomized, controlled trials supporting the use of bisphosphonates. The use of furosemide in the management of hypercalcemia should no longer be recommended.

Full-text (subscription required): http://www.annals.org/cgi/content/full/149/4/259

9. ED Patients Often Don't Understand Discharge Instructions

NEW YORK (Reuters Health) Jul 22 - Patients often fail to fully comprehend the treatment they receive during an emergency department visit or recall instructions for their care after they leave, new research suggests.

More often than not, these patients aren't even aware that they have not understood what transpired or remembered what they were told, the investigators note in the Annals of Emergency Medicine, published online July 7.

To shed light on the communication process that occurs in this setting, Dr. Kirsten G. Engel at Northwestern University in Chicago and colleagues interviewed 140 adult English-speaking patients or their primary caregivers after discharge from emergency departments at two teaching hospitals. Subjects were asked questions about four domains: their diagnosis and the cause of their symptoms, the care they received, discharge recommendations, and return instructions.

Results showed that 78% of patients or their caregivers demonstrated deficient comprehension in at least one domain, and 51% had deficits in two or more domains.

At 34%, the highest rate of mistakes involved after-care, "raising significant concerns about patients' ability to adhere to discharge instructions and recommendations after leaving the ED," the investigators note.

"Moreover," they add, "our study suggests that we cannot simply ask patients to identify their comprehension deficiencies because the majority did not report difficulties in areas in which deficits were objectively demonstrated."

Specifically, subjects were unaware of their comprehension deficits 80% of the time.

Dr. Engel's group recommends that clinicians test patients' understanding by asking them to repeat information in their own words. Improving content and organization of written discharge instructions may also be of benefit.

Engel KG, et al.Ann Emerg Med 2008. In press

10. Telemedicine for Stroke Patients

Telemedicine consultation with a stroke-certified neurologist might increase appropriate use of thrombolytic agents in stroke patients.

Many patients with ischemic stroke who are eligible for alteplase therapy do not receive it because the agent must be administered within 3 hours from onset of symptoms and because emergency physicians might want to involve stroke neurologists in primary decision making regarding the use of thrombolytics. Researchers evaluated whether remote consultation with a stroke neurologist could increase appropriate use of thrombolytic agents for stroke patients.

Patients with acute stroke symptoms who presented to one of four remote hospitals from 2004 to 2007 were randomized to telemedicine or telephone-only consultation by neurologists who were National Institute of Health Stroke Scale (NIHSS) certified. During the telemedicine consultation, the consultant took a medical history, performed a physical assessment, calculated the NIHSS score, and reviewed head computed tomography (CT) scans, in concert with the local EP. Telephone consultations differed in that the consultant could not speak directly with or view the patient and relied on the local radiologist’s interpretation of the CT scan. In both scenarios, the consultant made a decision about whether to administer thrombolytic agents. The correctness of the decision — the primary outcome measure — was determined by an independent committee of stroke specialists.

Of 222 patients, 104 in the telemedicine group and 103 in the telephone group completed the study. Mean NIHSS scores at presentation were significantly higher in the telemedicine group than in the telephone group (11.4 vs. 7.7). Correct decision making was significantly more likely in the telemedicine group than in the telephone group (98% vs. 82%; odds ratio, 10.9). However, no differences were noted between groups in any of the secondary outcome variables, including rate of alteplase administration (28% vs. 23%), 90-day functional outcomes, mortality, or rate of intracranial hemorrhage after alteplase administration (7% vs. 8%). The time from call to decision making was significantly longer in the telemedicine group than in the telephone group (65 vs. 55 minutes).

Comment: This study suggests that remote consultation with a stroke neurologist can obviate the need for an on-site neurologist and enable high and appropriate rates of thrombolytic administration for patients with ischemic stroke. Telemedicine, which is expensive and not routinely available, provided better decision making but no other derivative advantages.

— John A. Marx, MD, FAAEM, FACEP. Published in Journal Watch EM August 22, 2008.
Citation: Meyer BC et al. Lancet Neurol 2008 Sep; 7:787.

11. Staphylococcus aureus Community-Acquired Pneumonia During the 2006 to 2007 Influenza Season

Kallen AJ, et al. Ann Emerg Med. 2008; in press.

Study objective
Staphylococcus aureus is a cause of community-acquired pneumonia that can follow influenza infection. In response to a number of cases reported to public health authorities in early 2007, additional case reports were solicited nationwide to better define S aureus community-acquired pneumonia during the 2006 to 2007 influenza season.

Methods
Cases were defined as primary community-acquired pneumonia caused by S aureus occurring between November 1, 2006, and April 30, 2007. Case finding was conducted through an Emerging Infections Network survey and through contacts with state and local health departments.

Results
Overall, 51 cases were reported from 19 states; 37 (79%) of 47 with known susceptibilities involved infection with methicillin-resistant S aureus (MRSA). The median age of case patients was 16 years, and 44% had no known pertinent medical history. Twenty-two (47%) of 47 case patients with information about other illnesses were diagnosed with a concurrent or antecedent viral infection during their illness, and 11 of 33 (33%) who were tested had laboratory-confirmed influenza. Of the 37 patients with MRSA infection, 16 (43%) were empirically treated with antimicrobial agents recommended for MRSA community-acquired pneumonia. Twenty-four (51%) of 47 patients for whom final disposition was known died a median of 4 days after symptom onset.

Conclusion
S aureus continues to cause community-acquired pneumonia, with most reported cases caused by MRSA and many occurring with or after influenza. In this series, patients were often otherwise healthy young people and mortality rates were high. Further prospective investigation is warranted to clarify infection incidence, risk factors, and preventive measures.

12. In-Hospital Bed-to-Nurse Ratio Linked with Survival to Discharge After Out-of-Hospital Cardiac Arrest

Patients admitted to hospitals with a bed-to-nurse ratio less than 1 were 1.5 times more likely to survive to hospital discharge than those admitted to hospitals with higher ratios.

Background. Previous literature has identified patient and emergency medical services (EMS) system factors that are associated with survival of out-of-hospital cardiac arrest patients.

Objective. To determine variability in rates of survival to discharge of resuscitated adult out-of-hospital cardiac arrest patients and to identify hospital-related factors associated with survival.

Methods. This was a retrospective, observational study of all adult (21 years or older) out-of-hospital Utstein criteria cardiac-etiology arrests treated by Milwaukee County EMS during the period 1995-2005 and surviving to hospital intensive care unit admission. The primary outcome measure was survival to hospital discharge. Logistic regression analysis was used to compare the odds of survival between hospitals, patient factors, and hospital factors.

Results. 1,702 patients at eight receiving hospitals were included in the study analyses. Hospital survival rates ranged from 29% to 42%. Patient and case factors associated with increased survival included younger age, male gender, nonwhite race, witnessed arrest in a public location, bystander cardiopulmonary resuscitation (CPR), a modest number of defibrillations, and initial cardiac rhythm of ventricular tachycardia. The only hospital characteristic correlated with survival was the number of beds per nurse. Patients admitted to a hospital with a ratio of beds to nurse less than 1.0 were over 1.5 times more likely to survive.

Conclusions. Survival to discharge of resuscitated adult out-of-hospital cardiac arrest patients may vary by receiving hospital. A hospital's ratio of beds to nurse and several patient/case f actors are correlated with survival. Further research is warranted to investigate how this may affect resuscitation care, EMS transport policy, and research design.

Lui JM, et al. Prehospital Emerg Care. 2008;12:339–346.

13. Out-of-Hospital Continuous Positive Airway Pressure Ventilation Versus Usual Care in Acute Respiratory Failure: A Randomized Controlled Trial

Thompson J. Ann Emerg Med. 2008;52:232-241.e1

Study objective
Continuous positive airway pressure ventilation (CPAP) in appropriately selected patients with acute respiratory failure has been shown to reduce the need for tracheal intubation in hospital. Despite several case series, the effectiveness of out-of-hospital CPAP has not been rigorously studied. We performed a prospective, randomized, nonblinded, controlled trial to determine whether patients in severe respiratory distress treated with CPAP in the out-of-hospital setting have lower overall tracheal intubation rates than those treated with usual care.

Methods
Out-of-hospital patients in severe respiratory distress, with failing respiratory efforts, were eligible for the study. The study was approved under exception to informed consent guidelines. Patients were randomized to receive either usual care, including conventional medications plus oxygen by facemask, bag-valve-mask ventilation, or tracheal intubation, or conventional medications plus out-of-hospital CPAP. The primary outcome was need for tracheal intubation during the out-of-hospital/hospital episode of care. Mortality and length of stay were secondary outcomes of interest.

Results
In total, 71 patients were enrolled into the study, with 1 patient in each group lost to follow-up after refusing full consent. There were no important differences in baseline physiologic parameters, out-of-hospital scene times, or emergency department diagnosis between groups. In the usual care group, 17 of 34 (50%) patients were intubated versus 7 of 35 (20%) in the CPAP group (unadjusted odds ratio [OR] 0.25; 95% confidence interval [CI] 0.09 to 0.73; adjusted OR 0.16; 95% CI 0.04 to 0.7; number needed to treat 3; 95% CI 2 to 12). Mortality was 12 of 34 (35.3%) in the usual care versus 5 of 35 (14.3%) in the CPAP group (unadjusted OR 0.3; 95% CI 0.09 to 0.99).

Conclusion
Paramedics can be trained to use CPAP for patients in severe respiratory failure. There was an absolute reduction in tracheal intubation rate of 30% and an absolute reduction in mortality of 21% in appropriately selected out-of-hospital patients who received CPAP instead of usual care. Larger, multicenter studies are recommended to confirm this observed benefit seen in this relatively small trial.

Full-text (free): http://www.annemergmed.com/article/PIIS0196064408000322/fulltext

14. SMART-COP: A Better Pneumonia Stratification Score?

This new, simple-to-use score had high sensitivity for predicting need for intensive respiratory or vasopressor support among CAP patients.

Background. Existing severity assessment tools, such as the pneumonia severity index (PSI) and CURB-65 (tool based on confusion, urea level, respiratory rate, blood pressure, and age 65 years), predict 30-day mortality in community-acquired pneumonia (CAP) and have limited ability to predict which patients will require intensive respiratory or vasopressor support (IRVS).

Methods. The Australian CAP Study (ACAPS) was a prospective study of 882 episodes in which each patient had a detailed assessment of severity features, etiology, and treatment outcomes. Multivariate logistic regression was performed to identify features at initial assessment that were associated with receipt of IRVS. These results were converted into a simple points-based severity tool that was validated in 5 external databases, totaling 7464 patients.

Results. In ACAPS, 10.3% of patients received IRVS, and the 30-day mortality rate was 5.7%. The features statistically significantly associated with receipt of IRVS were low systolic blood pressure (2 points), multilobar chest radiography involvement (1 point), low albumin level (1 point), high respiratory rate (1 point), tachycardia (1 point), confusion (1 point), poor oxygenation (2 points), and low arterial pH (2 points): SMART-COP. A SMART-COP score of 3 points identified 92% of patients who received IRVS, including 84% of patients who did not need immediate admission to the intensive care unit. Accuracy was also high in the 5 validation databases. Sensitivities of PSI and CURB-65 for identifying the need for IRVS were 74% and 39%, respectively.

Conclusions. SMART-COP is a simple, practical clinical tool for accurately predicting the need for IRVS that is likely to assist clinicians in determining CAP severity.

Charles PGP, et al. Clinical Infectious Diseases 2008;47:375–384.

15. McCain and Obama on Emergency Care: The Candidates' Approach to Emergency Care

Berger E. Ann Emerg Med. 2008;52:265-267.

…In the turbulent arena of presidential politics, a roiling economy and unrest abroad there are no political certainties. But health care, behind only the economy, has risen to the top of domestic issues for both Senator Barack Obama, the Democratic nominee, as well as Senator John McCain, the Republican nominee. That's largely because health care has increasingly become a serious economic issue stinging the pocketbooks of voters. According to one recent study by Harvard University researchers, every 30 seconds someone files for bankruptcy in the aftermath of a serious health problem. It is fair to say, then, that at some point health care will reach the forefront of the next President's agenda…

To understand the specific views of Barack Obama and John McCain on emergency care, it is helpful to review their overall health care plans…

Full-text (free): http://www.annemergmed.com/article/S0196-0644(08)01492-3/fulltext

16. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study

Henschke N, et al. BMJ 2008;337:a171

Objective: To estimate the one year prognosis and identify prognostic factors in cases of recent onset low back pain managed in primary care.

Design: Cohort study with one year follow-up.

Setting: Primary care clinics in Sydney, Australia.

Participants: An inception cohort of 973 consecutive primary care patients (mean age 43.3, 54.8% men) with non-specific low back pain of less than two weeks’ duration recruited from the clinics of 170 general practitioners, physiotherapists, and chiropractors.

Main outcome measures: Participants completed a baseline questionnaire and were contacted six weeks, three months, and 12 months after the initial consultation. Recovery was assessed in terms of return to work, return to function, and resolution of pain. The association between potential prognostic factors and time to recovery was modelled with Cox regression.

Results: The follow-up rate over the 12 months was more than 97%. Half of those who reduced their work status at baseline had returned to previous work status within 14 days (95% confidence interval 11 to 17 days) and 83% had returned to previous work status by three months. Disability (median recovery time 31 days, 25 to 37 days) and pain (median 58 days, 52 to 63 days) took much longer to resolve. Only 72% of participants had completely recovered 12 months after the baseline consultation. Older age, compensation cases, higher pain intensity, longer duration of low back pain before consultation, more days of reduced activity because of lower back pain before consultation, feelings of depression, and a perceived risk of persistence were each associated with a longer time to recovery.

Conclusions: In this cohort of patients with acute low back pain in primary care, prognosis was not as favourable as claimed in clinical practice guidelines. Recovery was slow for most patients. Nearly a third of patients did not recover from the presenting episode within a year.

17. Antipsychotics Useful in Psychiatric Emergencies, Study Confirms

NEW YORK (Reuters Health) Aug 15 - Immediate control of aggressive and impulsive behavior in psychiatric emergencies can be achieved through administration of antipsychotic medications, findings from an observational study indicate, confirming the validity of current medication practices.

Dr. Stefan Wilhelm and two colleagues from the medical department of Lilly Deutschland GmbH, Bad Homburg, Germany evaluated the short-term effectiveness and tolerability of atypical and typical antipsychotic medications in the emergency treatment of acutely agitated adult patients.

Treatment over the first 5 days was classified according to whether olanzapine, risperidone, or haloperidol was administered, with or without benzodiazepine co-medication.

In the open-access online journal BMC Psychiatry, the investigators report that "clear improvements" in agitation and aggression scores were noted in all treatment groups within the short observation period (5 days).

Most of the 558 patients included in the study had a diagnosis of schizophrenia and large proportions had mental disorders due to psychoactive substance abuse, mood disorders, and adult personality disorders.

Dr. Wilhelm and colleagues also observed that more patients treated with olanzapine (73.8%) were fully alert and active at day 2 than patients treated with risperidone (57.1%) or haloperidol (58.0%). This may have been caused by less frequent use of concomitant benzodiazepines, "suggesting that olanzapine may achieve an effective immediate control of aggression without severe tranquilisation of the patient," they write.

Concomitant benzodiazepines were used in 68.7% of olanzapine-treated patients, versus 72.2% and 83.3% of risperidone- and haloperidol-treated patients, respectively.

Summing up, Dr. Wilhelm and colleagues say this study confirms that "current medication practices for immediate aggression control are effective with positive results present within a few days."

They conclude that "given the huge number of patients requiring emergency inpatient or outpatient treatment for aggressive or impulsive behaviour, the use of atypical antipsychotics such as olanzapine may have the potential to reduce the medical burden for patients with this psychiatric condition."

BMC Psychiatry 2008, 8:61 (22 July 2008)

Full-text (free): http://www.biomedcentral.com/1471-244X/8/61

18. Cardiac MR Can Screen for ACS in the Emergency Department

August 12, 2008 (Boston, MA) — Harvard researchers have come up with a new and improved cardiac MR protocol they say can be used in the emergency department to screen for ACS. While other MR protocols have been proposed for this setting in the past, Dr Ricardo C Cury (Harvard Medical School, Boston, MA) and colleagues says theirs has the added advantage of being able to differentiate between new and old MI, providing information over and above clinical assessment and traditional cardiac risk factors.

As Cury explained to heartwire, all imaging modalities that have been used to triage possible ACS patients in the emergency setting--MRI as well as cardiac CT and nuclear perfusion imaging--have struggled to distinguish acute from prior MI. For their study, Cury et al were interested specifically in patients with chest pain, negative cardiac biomarkers, and no ECG changes indicative of acute ischemia.

"The patients in this study were all patients who had been in the emergency department for at least 12 hours waiting for changes in cardiac enzymes and waiting for a stress test," he said. "So by doing MRI early on, we were able to detect myocardial injury before the rise of cardiac enzymes. There were some patients who had increased cardiac enzymes at a later stage, but we were able to detect both edema and necrosis before the increase in cardiac enzymes."

MR Protocol Includes Information on Edema, LV Wall Thinning

In their protocol, Cury et al used T2-weighted imaging to look for myocardial edema and assessment of left ventricular wall thickness to check for myocardial thinning, in addition to first pass perfusion, cine function, and delayed-enhancement MRI. "The beauty of this is the combination of delayed enhancement looking at myocardial necrosis and T2-weighted imaging looking at myocardial edema," Cury explained. "By combining this information, we can differentiate patients with acute vs old MI and which patients had unstable angina vs non-STEMI. Unstable angina is very difficult for different modalities to detect, and we were able to detect it in the great majority of cases," Cury said.

The entire cardiac MR protocol, on average, took just over 30 minutes per patient. A diagnosis of ACS was subsequently confirmed by chart review.

Out of 62 patients presenting with possible ACS symptoms, the new cardiac MR protocol increased the specificity, positive predictive value, and overall accuracy, as compared with the conventional cardiovascular magnetic resonance protocol (which did not include T2-weighted imaging or LV-wall assessment). Cury et al's protocol also significantly improved on information derived from clinical risk assessment alone or from clinical risk assessment combined with traditional cardiac risk factors.

"At this point, just using initial clinical risk assessment based on ECG and cardiac enzymes, we are not doing a great job, and that's why many physicians are just admitting patients for catheterization, or, in some cases, 2% to 4% of patients are discharged when they actually have ACS," he explained. "So we think this is really impressive: MRI remained a significant predictor above and beyond traditional cardiac risk factors and clinical risk assessment. Specifically, if you have a positive MRI, you have 120 times higher likelihood of having ACS as compared with patients with normal MR, after adjusting for traditional cardiac risk factors and clinical risk assessment."

How MR Might Fit In

So how would cardiac MR fit into emergency-room triage? Cury told heartwire that if a patient had a positive stress test, he or she would go directly to the cath lab. If not, the patient could undergo MRI and if this turned up myocardial edema or necrosis or a regional wall-motion abnormality, they, too, could go directly to the cath lab. But patients in whom there is no evidence of myocardial injury could likely be sent home or undergo later stress testing, although Cury emphasized that this proposed strategy would require further, prospective testing.

Cury also clarified that MR might carve out its own niche distinct from cardiac CT, which has increasingly been shown to play an important role in emergency-room triage.

"CT will, I think, be the first-line test in the acute chest pain setting for patients with low likelihood of having ACS, whereas MRI, I believe, will be used more in patients with intermediate likelihood of ACS," he said. "In the future, I can see the emergency physicians stratifying the patient as low, intermediate, or high risk based on risk factors and type of chest pain, etc, and patients with low risk would probably go to CT, whereas in patients with intermediate risk or even high risk but no diagnostic ECG and negative enzymes, MRI would be a better test."

At present, Cury acknowledged, most hospital emergency departments would not have easy access to MR, but down the road, newer acute chest pain and stroke centers might consider including dedicated MR machines.

Circulation, Aug 2008; 118: 837-844.

19. A Double-blind Randomized Clinical Trial Evaluating the Analgesic Efficacy of Ketorolac versus Butorphanol for Patients with Suspected Biliary Colic in the ED

Olsen JC, et al. Acad Emerg Med. 2008;15:718-722.

Objectives: Patients presenting to the emergency department (ED) with suspected biliary colic often require intravenous (IV) analgesia. The choice of IV analgesia typically includes opioids and ketorolac. Although ultrasound (US) is the initial diagnostic study in these patients, nondiagnostic scans and a high clinical suspicion may require the patient to undergo hepatobiliary scintigraphy (HIDA). Opioids such as morphine interfere with the HIDA scan and thus may limit its value as an analgesic in the ED for these patients. Analgesics that do not interfere with HIDA scanning include ketorolac and butorphanol, an opioid agonist–antagonist. This study evaluates the efficacy of IV ketorolac compared to butorphanol for the treatment of biliary colic pain in the ED.

Methods: Between June 2005 and February 2007, a convenience sample of patients presenting to the ED with abdominal pain suspected to be biliary colic were randomized to receive either 30 mg of IV ketorolac or 1 mg of IV butorphanol. Pain level was assessed using a 1 to 10 "faces" visual analog pain scale initially, as well as 15 and 30 minutes after medication infusion. Side effect profiles and the need for rescue analgesia were also assessed. Patients and clinicians were blinded to the study drug given.

Results: Forty-six patients were enrolled in the study. Both groups had similar demographics and baseline pain scores. The mean (±standard deviation [SD]) pain score in the butorphanol group decreased from 7.1 (±1.7) to 2.1 (±2.2) after 30 minutes. The mean (±SD) pain score in the ketorolac group decreased from 7.4 (±2.0) to 3.1 (±3.3) after 30 minutes. Both groups had similar needs for rescue analgesia. Side effects included dizziness and sedation with butorphanol and nausea with ketorolac.

Conclusions: Although limited by small sample size and convenience sample, this study demonstrates that both ketorolac and butorphanol provide pain relief in biliary colic. Both agents should be considered reasonable options in the ED treatment of biliary colic, especially in patients that may undergo HIDA.

20. Physician Clinical Impression Does Not Rule Out Spontaneous Bacterial Peritonitis in Patients Undergoing ED Paracentesis

Chinnock B, et al. Ann Emerg Med. 2008;52:268-273.

Study objective
We determine whether clinical characteristics and physician assessment are useful in the exclusion of spontaneous bacterial peritonitis in emergency department (ED) patients with ascites requiring paracentesis.

Methods
We conducted a prospective, observational study of ED patients with ascites undergoing paracentesis. Predefined clinical characteristics including historical features and ED vital signs were recorded. Each patient was assessed by 2 separate, blinded physicians for severity of abdominal tenderness and overall clinical suspicion for spontaneous bacterial peritonitis. The primary outcome measures were sensitivity, specificity, and likelihood ratios (LR) of the individual clinical characteristics and the physician assessments. Spontaneous bacterial peritonitis was defined by absolute neutrophil count greater than 250 cells/mm3 or positive fluid culture result.

Results
There were 285 separate physician assessments in 144 patients enrolled with complete data. Spontaneous bacterial peritonitis was diagnosed in 17 (11.8%) patients. Physician clinical impression had a sensitivity of 76% (95% confidence interval [CI] 62% to 91%) and specificity of 34% (95% CI 28% to 40%) for the detection of spontaneous bacterial peritonitis. The lowest negative LR was associated with the presence of any abdominal pain or tenderness (negative LR=0.4); however, the presence of pain/tenderness was also observed in 85% of patients without spontaneous bacterial peritonitis. Six patients (4.2%) with spontaneous bacterial peritonitis had at least 1 physician assessment of little to no risk for spontaneous bacterial peritonitis, and 3 of the 6 subsequently died during their hospitalization.

Conclusion
Clinical characteristics and physician assessment were insufficient in the diagnosis or exclusion of spontaneous bacterial peritonitis in the ED patient undergoing diagnostic or therapeutic paracentesis. This finding supports routine laboratory fluid analysis after ED paracentesis.