Lit Bits: March 14, 2009

From the recent medical literature...

1. Care by Hospitalists in US Growing

NEW YORK (Reuters Health) Mar 11 - In the last 10 years, there has been a marked increase in the proportion of hospitalized patients being managed by hospitalist physicians, according to a report in The New England Journal of Medicine for March 12.

The findings, based on an analysis of Medicare data, indicate that from 1995 to 2006, the percentage of claims for internist services provided by hospitalists rose from 9.1% to 37.1%. At the same time, the percentage of hospitalized patients treated by any general internist, both hospitalist and non-hospital-based clinicians, climbed from 46.4% to 61.0%.

"The rapid growth of care by hospitalists exemplifies the dynamic nature of medical care in the United States in recent years," Dr. Yong-Fang Kuo, from the University of Texas Medical Branch, Galveston, and co-researchers comment.

From a 5% sample of Medicare beneficiaries, the researchers identified 120,226 internal medicine physicians who provided care to older patients at 5800 US hospitals during the study period. Hospitalists were defined as clinicians who derived at least 90% of their Medicare claims from services provided to hospitalized patients.

From 1995 to 2006, the percentage of internists who were hospitalists increased from 5.9% to 19.0%, the authors report.

On multivariate analysis, the authors found that the likelihood of receiving care from a hospitalist rose by 29.2% each year from 1997 to 2006.

An analysis of 2006 data showed that the extent of hospitalist care varied greatly by geographic region. Hospital-referral areas with the highest percentages of hospitalist care were St. Cloud, Minnesota (85.6%), Mesa, Arizona (84.0%), and Appleton, Wisconsin (81.6%).

N Engl J Med 2009;360:1102-1112.

http://content.nejm.org/cgi/content/short/360/11/1102

2. Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department

Green SW, at al. Ann Emerg Med. 2009; in press

Study objective
Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events.

Methods
We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events.

Results
In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose ≥2.5 mg/kg or total dose ≥5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class ≥3), and the choice of intravenous versus intramuscular route.

Conclusion
Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

3. Tailoring the Use of Plain Abdominal X-rays in the ED

Smith J E, et al. Emerg Med J 2009: 26:160-163.

Most useful in three circumstances:
• Acute abdominal pain: if bowel obstruction suspected
• Oesophageal foreign body suspected (depending on local protocol for metal detector)
• Sharp/poisonous foreign body suspected

Full-text (free): http://emj.bmj.com/cgi/content/full/26/3/160

4. Clopidogrel and Proton-Pump Inhibitors

Risk for adverse cardiac events was elevated in patients taking both medications.

Prior biochemical studies have suggested that proton-pump inhibitors (PPIs) reduce the inhibitory effect of clopidogrel on platelet aggregation. A recent FDA review raised concerns about this issue, but data were insufficient to make a specific recommendation. In this study, a Veterans Affairs database was used to retrospectively assess this interaction clinically in 8205 patients discharged with acute coronary syndromes (ACS); 5244 (64%) were taking both clopidogrel and a PPI, and the rest were taking clopidogrel alone. Medication use was assessed by pharmacy prescription data.

At a mean follow-up of roughly 18 months, death or rehospitalization for ACS had occurred in 1561 patients (30%) taking both medications and 615 (21%) of patients taking only clopidogrel. In analyses adjusted for about 25 demographic and clinical variables, risk for death or rehospitalization was roughly 25% higher in patients taking both medications (86% higher for recurrent ACS, 49% higher for revascularization procedures, but no difference for death alone).

Comment: As with any retrospective analysis, there are confounders for which statistical adjustment might not be fully adequate, so prospective clinical trials are needed to confirm this result. However, based on plausible biological mechanisms (e.g., inhibition by PPIs of the cytochrome P450 enzyme system responsible for the active metabolite of clopidogrel), clinicians should be more parsimonious in their use of PPIs for specific indications, rather than using them for routine prophylaxis, as is often done.

— Thomas L. Schwenk, MD. Published in Journal Watch General Medicine March 12, 2009.
Citation: Ho PM et al. JAMA 2009 Mar 4; 301:937.

5. Images in EM

Young Girl With Lump on Forehead
http://www.annemergmed.com/article/S0196-0644(08)00940-2/fulltext

Adolescent Male With Vision Loss and Headache http://www.annemergmed.com/article/S0196-0644(08)01393-0/fulltext

6. A New Drug to Cure Insomnia from Shift Work or Jet Lag?

Tasimelteon, a melatonin agonist, shows promise.

After an abrupt advance in sleep time, tasimelteon improved sleep initiation and maintenance concurrently with a shift in endogenous circadian rhythms. Tasimelteon may have therapeutic potential for transient insomnia in circadian rhythm sleep disorders.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61812-7/abstract

7. Exercise Dose and Quality of Life: A Randomized Controlled Trial

Martin CK, et al. Arch Intern Med. 2009;169(3):269-278.

Background: Improved quality of life (QOL) is a purported benefit of exercise, but few randomized controlled trials and no dose-response trials have been conducted to examine this assertion.

Methods: The effect of 50%, 100%, and 150% of the physical activity recommendation on QOL was examined in a 6-month randomized controlled trial. Participants were 430 sedentary postmenopausal women (body mass index range, 25.0-43.0 [calculated as weight in kilograms divided by height in meters squared]) with elevated systolic blood pressure randomized to a nonexercise control group (n = 92) or 1 of 3 exercise groups: exercise energy expenditure of 4 (n = 147), 8 (n = 96), or 12 (n = 95) kilocalories per kilogram of body weight per week. Eight aspects of physical and mental QOL were measured at baseline and month 6 with the use of the Medical Outcomes Study 36-Item Short Form Health Survey.

Results: Change in all mental and physical aspects of QOL, except bodily pain, was dose dependent (trend analyses were significant, and exercise dose was a significant predictor of QOL change; P less than .05). Higher doses of exercise were associated with larger improvements in mental and physical aspects of QOL. Controlling for weight change did not attenuate the exercise-QOL association.

Conclusion: Exercise-induced QOL improvements were dose dependent and independent of weight change.

8. Which Is Better for Diagnosing Vaginitis: Clinical Judgment or DNA Analysis?

DNA analysis was more accurate than clinical diagnosis, but managing patients with vaginitis remains difficult.

Lowe NK, et al. Obstetrics & Gynecology 2009;113:89-95.

Abstract
OBJECTIVE: To estimate the accuracy of the clinical diagnosis of the three most common causes of acute vulvovaginal symptoms (bacterial vaginosis, candidiasis vaginitis, and trichomoniasis vaginalis) using a traditional, standardized clinical diagnostic protocol compared with a DNA probe laboratory standard.

METHODS: This prospective clinical comparative study had a sample of 535 active-duty United States military women presenting with vulvovaginal symptoms. Clinical diagnoses were made by research staff using a standardized protocol of history, physical examination including pelvic examination, determination of vaginal pH, vaginal fluid amines test, and wet-prep microscopy. Vaginal fluid samples were obtained for DNA analysis. The research clinicians were blinded to the DNA results.

RESULTS: The participants described a presenting symptom of abnormal discharge (50%), itching/irritation (33%), malodor (10%), burning (4%), or others such as vulvar pain and vaginal discomfort. According to laboratory standard, there were 225 cases (42%) of bacterial vaginosis, 76 cases (14%) of candidiasis vaginitis, 8 cases (1.5%) of trichomoniasis vaginalis, 87 cases of mixed infections (16%), and 139 negative cases (26%). For each single infection, the clinical diagnosis had a sensitivity and specificity of 80.8% and 70.0% for bacterial vaginosis, 83.8% and 84.8% for candidiasis vaginitis, and 84.6% and 99.6% for trichomoniasis vaginalis when compared with the DNA probe standard.

CONCLUSION: Compared with a DNA probe standard, clinical diagnosis is 81-85% sensitive and 70-99% specific for bacterial vaginosis, Candida vaginitis, and trichomoniasis. Even under research conditions that provided clinicians with sufficient time and materials to conduct a thorough and standardized clinical evaluation, the diagnosis and, therefore, subsequent treatment of these common vaginal problems remains difficult.

9. Taking Multivitamins? Don’t Expect to Prevent Cancer or Cardiovascular Disease

Multivitamin supplements did not affect CVD risk, cancer risk, or overall mortality in WHI participants.

http://archinte.ama-assn.org/cgi/content/abstract/169/3/294

10. Fit and Function of the Laryngeal Mask Airway Supreme

In a study of 100 women, the mask was easy to insert, had high leak resistance, and allowed easy insertion of a nasogastric tube.

The Laryngeal Mask Airway Supreme (LMAS) is a new (2007), single-use airway device that the manufacturer claims to provide easier insertion and higher seal pressure than other laryngeal mask airways and to allow access for nasogastric tube insertion. Researchers evaluated these claims in a prospective study of 100 women without anticipated difficult airways who underwent LMAS insertion after induction of general anesthesia for elective surgery. If an air leak was heard after the cuff was inflated, the mask was repositioned (inserted more deeply or moved to one side or the other) until no leak was present. If ventilation was not possible, the mask was removed and reinserted.

Mask insertion was successful in 94 patients on the first attempt and in 5 on the second attempt. One patient was too small to accommodate the device. Median insertion time was 10 seconds. Repositioning was required and successful in 13 patients. Nasogastric tube insertion was successful in all patients on the first attempt. LMAS positioning was assessed using a fiber-optic scope and was scored as "optimal" in all patients, both immediately after insertion and at the end of surgery. Mean seal leak pressure was 28 cm H2O. Eleven patients had unexpected vocal cord narrowing, three patients had increased inspiratory pressure, and two patients developed stridor. No patient required mask removal or surgery to be stopped. After mask removal, nine patients had minor upper airway trauma (slight blood on the mask edge), and eight complained of mild sore throat.

Comment: The LMAS combines the following advantages of other LMA models: a semirigid curved shaft (like the intubating LMA Fastrach), a port for nasogastric tube insertion (like the LMA ProSeal), and single-use design (like the LMA Unique). In addition, the LMAS has a higher seal pressure than the standard LMA does (useful in cases with high inspiratory resistance, such as patients with asthma, chronic obstructive pulmonary disease, pulmonary edema, and obesity). If additional studies confirm that the LMAS is reliably easy to place, it might become the preferred LMA model for prehospital and emergency department use when the ability to intubate is not required.

— Ron M. Walls, MD, FRCPC, FAAEM. Published in Journal Watch Emergency Medicine March 6, 2009. Citation: Timmermann A, et al. Anesthesiology 2009 Feb; 110:262.

11. Long-Term Survival Benefits of Early Evidence-Based Treatment for AMI

Rates of 12-year survival among patients who survived for at least 28 days after AMI have improved in association with increased use of evidence-based treatments.

Full-text (free): http://www.bmj.com/cgi/content/full/338/jan26_2/b36

12. The Use of Penicillin Skin Testing to Assess the ED Prevalence of Penicillin Allergy

Raja AS, et al. Ann Emerg Med. 2009; in press.

Study objective
Patient-reported penicillin allergies are often unreliable and can result in unnecessary changes in antibiotic therapy. Although penicillin allergy skin testing is commonly performed in allergy clinics, it has not been used in emergency departments (EDs) to verify self-reported allergies. We hypothesize that ED-based testing is possible and that the false-positive rate of patients with self-reported penicillin allergy are greater than 90%.

Methods
This prospective observational cohort study enrolled a convenience sample of ED patients with a self-reported penicillin allergy. Patients were enrolled by one of 2 emergency physicians who performed skin prick and intracutaneous tests with penicillin major and minor determinants. The total testing time was 30 minutes. The proportion of false-positive self-reported allergies was computed with 95% confidence intervals (CIs) by using the score method.

Results
A total of 150 patients (mean age 42 years; SD 16 years; 46% men; 47% black) were enrolled. The false-positive rate for self-reported penicillin allergy was 137 of 150 (91.3%; 95% CI 85.3% to 95.1%). There were no adverse reactions associated with penicillin skin testing. Compared with patients with a false-positive penicillin allergy result (confirmed by negative penicillin skin testing result), patients reporting a true penicillin allergy confirmed by positive penicillin skin test results tended to be more frequently men (61.5% versus 44.5%; Δ 17.0%; 95% CI −13.5% to 42%), black (69.2% versus 44.5%; Δ 24.7%; 95% CI −6.9% to 46.8%), and have no family history of drug allergy (7.7% versus 17.5%; Δ9.8%; 95% CI −20.9% to 20.4%), but self-reported other drug allergies more frequently (61.5% versus 38.7%; Δ 22.9%; 95% CI −7.7% to 47.5%).

Conclusion
Penicillin skin testing is feasible in the ED setting. A substantial number of patients who self-report a penicillin allergy do not exhibit immunoglobulin E-mediated sensitization to penicillin major and minor determinants. Penicillin testing in the ED may allow the use of more appropriate antibiotics for patients presenting with a history of penicillin allergy.

13. Weekend Admission Tied to Worse Outcomes for Bleeding Peptic Ulcers

Don’t Get Sick on Saturday

NEW YORK (Reuters Health) Mar 06 - Patients who are admitted on a weekend for bleeding peptic ulcers have worse survival than their peers admitted on a weekday, according to the results of two studies appearing in Clinical Gastroenterology and Hepatology for March.

By contrast, weekend admission for hemorrhage due to bleeding varices is not associated with increased mortality, findings from one of the studies shows.

Prior research has shown that a number of medical conditions have poorer outcomes when patients are admitted on weekends. Whether the same held true for upper gastrointestinal hemorrhage was unclear, although the limited availability of urgent endoscopic intervention on weekends suggests that this may be the case.

In the first study, Dr. Ashwin N. Ananthakrishnan, from the Medical College of Wisconsin, Milwaukee, and colleagues took up this topic by analyzing data from the Nationwide Inpatient Sample 2004, which featured 28,820 discharges with acute variceal hemorrhage and 391,119 with acute nonvariceal hemorrhage.

With nonvariceal hemorrhage, weekend admission increased in-hospital morality by 21% and reduced the likelihood of early (within 1 day of admission) endoscopy by 36%.

With variceal hemorrhage, by contrast, weekend admission did not increase mortality, but it did reduce the odds of early endoscopy at nonteaching hospitals.

Early endoscopy was linked to both shorter hospital stays and to lower hospital charges, the report indicates.

In the second study, Dr. Abdel Aziz M. Shaheen, from the University of Calgary, Alberta, focused solely on bleeding from peptic ulcer disease. Their study, which incorporated data from the 1993-2005 US Nationwide Inpatient Sample, featured 237,412 admissions to 3166 hospitals for peptic ulcer-related bleeding.

Mortality was higher in weekend- versus weekday-admitted cases: 3.4% vs. 3.0%. Likewise, weekend-admitted patients were more likely to undergo surgery, had longer hospital stays, and incurred greater hospital charges.

The average time to endoscopy was 2.21 days for weekend-admitted cases versus 2.06 days for those admitted on a weekday (p less than 0.0001). Thirty percent of weekend cases underwent endoscopy the same day compared with 34% of weekday cases (p less than 0.0001).

Multivariate analysis confirmed that weekend admission was an independent predictor of increased mortality.

"Although wait times for endoscopy are prolonged in patients hospitalized on the weekend, this delay does not appear to mediate the observed weekend effect for mortality," Dr. Shaheen's team states. "Future studies," they add, "should explore alternative processes of care that might mediate this effect in patients with bleeding peptic ulcers."

Clinical Gastroenterol Hepatol 2009;7:296-310.

14. Pauses in Pre-Shock Chest Compression Reduce Likelihood of Resuscitation Success

NEW YORK (Reuters Health) Mar 05 - Pauses of a few seconds in pre-shock chest compression decrease the likelihood of return of spontaneous circulation during out-of-hospital cardiac arrest, according to a report in the February 6th issue of BMC Medicine.

"The fact that interruptions in chest compressions are detrimental has been known, but our results show that literally every second counts," Dr. Kenneth Gundersen from the University of Stravanger, Norway, told Reuters Health. "The pauses necessary to perform tasks like mouth-to-mouth and signal analysis should be kept as short as absolutely possible and all unnecessary pauses avoided."

Dr. Gundersen and colleagues investigated the effect of interruptions of chest compressions on the probability of return of spontaneous circulation calculated from the electrocardiogram (ECG) using data from 530 defibrillation attempts given to 86 patients.

The probability of return of spontaneous circulation decreased in a steady manner with increasing pauses in chest compression, the authors report, with each second without perfusion contributing negatively to the likelihood of return of spontaneous circulation.

Regardless of the baseline probability of return of spontaneous circulation, the researchers note, about 23% of the chance of return of spontaneous circulation will be lost with increasing the pre-shock pause in chest compressions from 3 to 27 seconds.

This represents about a 1% relative decrease in the chance of return of spontaneous circulation for each second of pre-shock pause in chest compressions, the investigators say.

"I believe that to reduce interruptions in chest compressions clinically requires regular training of CPR skills for relevant personnel," Dr. Gundersen said. "I further believe that our results in a convincing way show the importance of minimizing interruptions in chest compressions and that it therefore can be used to achieve an increased focus on this particular aspect of CPR quality."

"My current main research focus is on developing a new type of statistical model for the influence of CPR on the probability of return of spontaneous circulation following defibrillation during ventricular fibrillation/ventricular tachycardia," Dr. Gundersen added. "The primary objective of this research is to identify which CPR quality variables (e.g., compression depth, compression force, ventilation rate) that best reflect the effectiveness of CPR, and what values of the relevant variables maximize the effect."

BMC Med 2009;7:6. http://www.biomedcentral.com/1741-7015/7/6/abstract

15. Thrombolysis May Benefit Some Patients Who Wake With Stroke

March 5, 2009 — Results of a retrospective case series suggest that certain patients who wake with stroke symptoms may still benefit from intervention using intravenous (IV) or intra-arterial (IA) thrombolysis.

Researchers at the University of Texas–Houston report off-label use of thrombolysis in 46 patients with acute ischemic stroke appeared to be safe, with a rate of symptomatic intracerebral hemorrhage of 4.3%, and was associated with higher rates of excellent and favorable outcome, although mortality was also significantly higher than those who were not treated.

A second comparison of treated wake-up patients with those treated within the 3-hour time window after symptom onset showed no differences in safety and clinical outcomes.

"It's the first evidence that treating these patients who routinely do not get treated is potentially safe, and there's some implication that maybe they should not be excluded solely based on waking up with their symptoms," first author Andrew D. Baretto, MD, from University of Texas–Houston Health Science Center, told Medscape Neurology & Neurosurgery.

The findings are published in the March issue of Stroke. Senior author on the paper is Sean I. Savitz, MD, also from the University of Texas–Houston.

Contraindication

In general, patients who wake with stroke symptoms are not considered candidates for thrombolytic therapy, because the time of stroke onset cannot be established reliably. Tissue plasminogen activator (tPA) is approved by the Food and Drug Administration (FDA) for use in patients who present within 3 hours of a known symptom onset.

However, it is estimated that between 16% and 28% of patients who have a stroke each year wake up with their symptoms, Dr. Barreto said. "There are many patients for whom that is the only exclusion," he said. "You know everything else about these patients, all the labs are favorable, and then you find out he woke up with his symptoms," he said.

In some of these cases, when the computed tomography (CT) scan still shows radiologic features of a relatively recent ischemic event, their group has offered off-label, compassionate treatment with tPA, he said. In this study, they reviewed demographics, safety, and outcomes in these cases and compared them with wake-up stroke cases who did not receive thrombolysis, as well as outcomes in patients who met the 3-hour FDA-approved window for treatment.

The rest of the article: http://www.medscape.com/viewarticle/589161

16. MRI Helpful in Diagnosing Acute Appendicitis in Pregnant Patients

March 3, 2009 — Magnetic resonance (MR) imaging aids in the diagnosis of acute appendicitis in pregnant patients and may be able to obviate the need for computed tomography (CT) and itsundesirable radiation exposure in this situation, according to a retrospective study reported in the March 2009 issue of Radiology.

The investigators hypothesized that MR imaging has the potential to reduce the negative laparotomy rate (NLR) while maintaining an acceptable perforation rate (PR). Currently, ultrasound is the favored technique for examination of women with abdominal pain, and CT scan is reserved for patients with inconclusive ultrasound examinations. The present study is the first to examine the impact of MR imaging on surgical outcomes in a large series of pregnant women suspected of having acute appendicitis.

"[T]he aim of our study was to assess the effects of MR imaging [in this group of patients,] using the NLR and PR as objective measures of outcome and to assess the need for CT in this setting," write Ivan Pedrosa, MD, and colleagues at Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts.

In this single-center retrospective review of 148 consecutive pregnant patients with clinical symptoms suggesting acute appendicitis, mean age was 29 years (range, 15 – 42 years). Mean gestational age was 20 weeks (range, 4 – 37 weeks). All subjects underwent MR imaging between March 2002 and August 2007; 140 subjects underwent ultrasonography before MR imaging. CT was performed on 4 patients (3%).

Fourteen patients (10%) had acute appendicitis, and MR imaging correctly identified all of these patients. In contrast, ultrasound was positive for acute appendicitis in 5 (36%) of 14 patients, while ultrasound was interpreted as normal in 7 (50%) of the 14 acute appendicitis patients. Perforation — the most serious consequence of acute appendicitis — occurred in 3 of the 14 patients with acute appendicitis, for a PR rate of 21%.

Of the 134 patients without acute appendicitis, MR yielded negative results for 125 patients and false-positive results for 9 patients. There were no false-negative results for MR imaging, suggesting that it is a valid technique for ruling out acute appendicitis. In those without acute appendicitis, ultrasound was able to visualize the normal appendix in 2 (less than 2%) of 126 cases compared with 116 (87%) of 134 cases for MR imaging.

"The improved visualization of the normal appendix with MR imaging is a major attribute that assists in clinical decision making," write the authors.

Surgical exploration was performed in 27 patients (18%), and 8 had negative laparotomy results, for an NLR of 30%. The authors note that if the decision to avoid exploratory laparotomy had been based on negative MR findings, the NLR would have declined to 7%, while maintaining an acceptable PR of 21%. The authors expect further declines in NLR as surgeons and obstetricians gain confidence in the negative predictive value of a normal appendix visualized by MR imaging.

The study had several limitations, including the small number of patients with acute appendicitis, the potential for bias inherent in a retrospective review, and the inability to generalize results to centers that do not have MR imaging available at all times. Also, residents on call interpreted some of the ultrasound studies, while radiologists read the MR images, which may have led to more favorable MR results.

"In conclusion, when examining pregnant patients for clinically suspected [acute appendicitis], the use of MR imaging yields favorable combinations of the NLR and the PR compared with values previously reported in the literature," the authors write. "With use of MR imaging, the radiation exposure associated with CT examinations can be minimized and in many cases avoided."

The authors have disclosed no relevant financial relationships.

Radiology. 2009;250:749–757.

17. Physicians Increasingly Support a Single-Payer National Health Insurance System

Laurie Barclay, MD. February 13, 2009 — US physicians increasingly support a single-payer national health insurance system, according to the results of a survey reported online January 29 in the Journal of General Internal Medicine.

“Many politicians may mistakenly believe that single-payer national health insurance lacks support among key stakeholders such as doctors,” lead author Danny McCormick, from Harvard Medical School and Cambridge Health Alliance (CHA), said in a news release. “Our finding that support for single-payer national health insurance now approaches that of tax-based incremental reforms suggests that a Medicare-for-all-type plan may be more politically viable than conventional wisdom suggests.”

The goal of this US nationally representative mail survey was to evaluate physician opinion regarding financing options for expanding coverage for and access to healthcare.

Between March 2007 and October 2007, US physicians involved in direct patient care were asked to rate their support for reform options such as financial incentives to encourage people to buy health insurance and single-payer national health insurance, as well as to rate their views of several aspects of access to healthcare.

Of 3300 physicians sent the survey, 1675 (50.8%) responded; 49% prefer either tax incentives or penalties to promote the purchase of health insurance; 42% prefer a government-run, taxpayer-financed single-payer national health insurance program, which increased from 26% in a study 5 years previously; and only 9% prefer the current, employer-based financing system.

Regarding access to healthcare, 89% of physicians surveyed believe that all Americans should receive needed medical care regardless of ability to pay; 33% believe that the uninsured currently have access to needed care; and 19.3% believe that even the insured lack access to needed care. Opinions regarding access were independently associated with support for single-payer national health insurance.

"Surveys show that a majority of Americans support a single-payer system. It's not surprising that increasing numbers of doctors do,” said coauthor David Bor, MD, also from Harvard Medical School and Cambridge Health Alliance. “Single payer is the only proposal that can cover all Americans, for all needed care, without driving up healthcare costs. National health insurance would eliminate the massive administrative costs and hassles imposed by our current multiplicity of private insurers.”

Limitations of this study include modest response rate; the possibility that physicians strongly interested in health policy issues may have been more likely to respond; lack of generalizability to all physicians’ views; and possible misinterpretation of question meaning or bias related to question wording and response option content.

“Although a plurality of physicians favored incremental health care reform proposals based on the use of tax credits and penalties, a substantial proportion of physicians preferred an entirely different health care financing system — a government-run, taxpayer-financed single-payer [national health insurance] program,” the study authors write. “Physicians play a central role in the health care system and these views could be influential in reforming the financing of the American health care system.”

The Department of Medicine at the Cambridge Hospital funded this study. The authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online January 29, 2009.

18. Initial Clinical Experience With a 64-MDCT Whole-Body Scanner in an Emergency Department: Better Time Management and Diagnostic Quality?

Rieger M, et al. J Trauma. 2009;66:648-657

Background: The objective of this study was to assess time management and diagnostic quality when using a 64-multidetector-row computed tomography (MDCT) whole-body scanner to evaluate polytraumatized patients in an emergency department.

Methods: Eighty-eight consecutive polytraumatized patients with injury severity score (ISS) ≥ 18 (mean ISS = 29) were included in this study. Documented and evaluated data were crash history, trauma mechanism, number and pattern of injuries, injury severity, diagnostics, time flow, and missed diagnoses. Data were stored in our hospital information system. Seven time intervals were evaluated. In particular, attention was paid to the acquisition interval, the reformatting and evaluation time as well as the CT time (time from CT start to preliminary diagnosis). A standardized whole-body CT was performed. The acquired CT data together with automatically generated multiplanar reformatted images (direct MPR) were transferred to a 3D rendering workstation. Diagnostic quality was determined on the basis of missed diagnoses. Head-to-toe scout images were possible because volume coverage was up to 2 m. Experienced radiologists at an affiliated workstation performed radiologic evaluation of the acquired datasets immediately after acquisition.

Results: The acquisition interval was 12 minutes ± 4.9 minutes, the reformatting and evaluation interval 7.0 minutes ± 2.1 minutes, and the CT time 19 minutes ± 6.1 minutes. Altogether, 7 of 486 lesions were recognized but not communicated in the reformatting and evaluation interval, and 10 injuries were initially missed and detected during follow-up.

Conclusion: This study indicates that 64-MDCT saves time, especially in the reformatting and evaluation interval. Diagnostic quality is high, as reflected by the small number of missed diagnoses.

19. Health Care and the American Recovery and Reinvestment Act

Steinbrook R. N Engl J Med 2009;360:1057-1060.

On February 17, 2009, four weeks after his inauguration, President Barack Obama signed into law a $787 billion economic stimulus package. The economic impact of the American Recovery and Reinvestment Act of 2009, as the measure is officially known, will not be apparent for months. Nonetheless, the bill's approval — even before any new senior officials of the Department of Health and Human Services (DHHS) were in place — has jump-started the Obama administration's plans for health care…

Full-text: http://content.nejm.org/cgi/content/full/360/11/1057

20. Randomized Controlled Trial of Ultrasound-Guided Peripheral Intravenous Catheter Placement Versus Traditional Techniques in Difficult-Access Pediatric Patients

Doniger SJ, et al. Pediatr Emerg Care 2009;25:154-159.

Objectives: We hypothesized that the use of ultrasound guidance would improve the success rate of peripheral intravenous catheter placement in pediatric patients with difficult access in a pediatric emergency department (ED). Our secondary hypotheses were that ultrasound guidance would reduce the number of attempts, the number of needle redirections, and the overall time to catheter placement.

Methods: This was a prospective randomized study of pediatric ED patients younger than 10 years old requiring intravenous access, presenting between August 2006 and May 2007. Inclusion criteria were 2 unsuccessful traditional attempts at peripheral intravenous access or history of difficult access. Exclusion was critical illness or instability. Patients were randomized to undergo peripheral intravenous catheter placement using continued traditional approaches or real-time, dual-operator ultrasound-guided technique. Measured outcomes were success of cannulation, number of attempts, number of needle redirections, and overall time to catheter placement.

Results: Fifty patients were enrolled, with 25 patients randomized to each group. The overall success rates for the ultrasound-guided group were 80% and for the traditional-attempts group, 64%, with a difference in proportions of 16% (95% confidence interval, -9% to 38%, P = 0.208). The ultrasound-guided group required less overall time (6.3 vs 14.4 minutes, difference of -8.1 minutes [95% confidence interval, -12.5 to -3.6], P = 0.001), fewer attempts (median, 1 vs 3; P = 0.004), and fewer needle redirections (median, 2 vs 10; P less than 0.0001) than traditional approaches.

Conclusions: In a sample of pediatric ED patients with difficult access, ultrasound-guided intravenous cannulation required less overall time, fewer attempts, and fewer needle redirections than traditional approaches.

Lit Bits: February 19, 2009

From the recent medical literature...

1. Intl Stroke Conference (ICS) 2009: Stroke Patients Arriving Within "Golden Hour" More Likely to Get tPA

Susan Jeffrey. February 19, 2009 (San Diego, California) — A greater proportion of patients who arrive at the hospital in the first 60 minutes after symptom onset — the so-called "golden hour" — receive thrombolytic therapy than those who arrive later, new data from the Get With The Guidelines-Stroke (GWTG-S) quality-improvement program shows.

In this analysis, 12% of all ischemic stroke patients seen at 100 GWTG-S hospitals arrived within 1 hour of symptom onset, and 27.1% of these were treated with tissue plasminogen activator (tPA) vs 12.9% of those arriving between 1 and 3 hours after onset.

However, Jeffery L. Saver, MD, from the University of California, Los Angeles Stroke Center, pointed out that golden-hour patients also had door-to-needle (DTN) times that were about 20 minutes longer than those arriving later, and only about 20% were treated within 60 minutes of arrival.

"These findings support greater public-education efforts to increase the proportion of patients arriving in the first 60 minutes after symptom onset and a revamping of our hospital's performance-improvement activities to shorten the DTN times in patients who've done their part in arriving in the first 60 minutes, to make sure we do our part and get drug started for them in the next 60 minutes," Dr. Saver concluded.

He presented their findings here at the American Stroke Association International Stroke Conference 2009.

Benefit Strongly Time Dependent

The benefit of intravenous (IV) tPA in acute ischemic stroke is strongly time dependent, Dr. Saver said. Therapeutic yield of treatment is maximal in the first minutes after stroke and declines steadily during the first 3 hours. "Every minute that goes by without treatment, 2 million nerve cells die," he said. "Every 10 minutes that goes by without tPA, 1 fewer patient experiences benefit from tPA."

Patients who present within the first 60 minutes after symptom onset have the greatest opportunity for benefit from treatment, but these patients have not been well characterized. "That's why we undertook this study," Dr. Saver said.

They used the GWTG-S registry, a national database of acute strokes treated at participating hospitals in the United States. From 905 participating hospitals, a total of 517,000 stroke and transient ischemic attack patients were entered in the database between April 2003 and December 2007. After excluding those who did not arrive directly at the emergency department by ambulance or private vehicle, those having hemorrhagic strokes, and patients for whom a time of symptom onset could not be documented, they were left with 106,924 patients for this analysis.

Of these, 28.3% arrived at the hospital within 60 minutes of symptom onset; the mean onset-to-door time for these patients was 39.9 minutes.

Although most patient characteristics examined were to some extent statistically significant, 2 factors stood out; National Institutes of Health Stroke Scale (NIHSS) score, which was higher in those arriving earlier (8 for those arriving within 60 minutes vs 4 in those arriving after 3 hours), and arrival by ambulance, which was the case in 79% of those arriving in the golden hour, vs 55% of those arriving after 3 hours.

Overall, 11.8% of all ischemic stroke patients arriving directly at the hospital with a documented onset time were treated with IV tPA, vs 5% of those without a documented onset of symptoms. The mean onset-to-door time in patients who received tPA was 56 minutes, and the mean DTN time was 84 minutes.

Those arriving within the golden hour were much more likely than those arriving later to receive thrombolysis, Dr. Saver said.

The frequency of delivery of tPA was 27.1% of the golden-hour patients vs 12.9% in the 1-to-3 hour patients (P less than .0001).

However, those arriving earlier also had longer DTN times. Patients who arrived at the hospital within the first hour had a mean DTN time of 90.6 minutes, compared with 76.7 minutes for those arriving between 1 and 3 hours after symptom onset. Only 18.3% of these patients who arrived within 60 minutes of symptom onset had a DTN time under the recommended target of 60 minutes.

There was a "modest increase" of about 1.2% per year over time in the number of golden-hour patients being treated within 60 minutes, from 12.8% in 2003 to 19.5% in 2007; this improvement did not appear to be related to length of participation in the GWTG-S program, he noted.

Having More Time Should Not Mean Taking More Time

After his presentation, Dr. Saver was asked about what might explain the longer times to treatment among those who arrived earlier. Although they plan to look at this issue further in this data set, he pointed out that doctors might take the opportunity for a longer informed-consent process when they have more time.

Furthermore, during a press conference here, Dr. Saver speculated that this potential problem of using the time for deliberation may worsen over time, given the results of ECASS 3 reported last fall that showed thrombolytic therapy was safe and effective up to 4.5 hours after symptom onset.

"I think for the providers, focusing the attention on how well your health system is performing by focusing on door-to-needle time for treatment, rather than the onset-to-treatment time or the maximal permitted time, is the way to go," Dr. Saver said. "We're trying to emphasize a door-to-needle time of 60 minutes."

Arthur Pancioli, MD, professor and vice chair of emergency medicine at the University of Cincinnati, in Ohio, moderated a press conference here where this paper was presented. He pointed out that while there is a benefit to treatment, there are also serious risks associated with thrombolytic therapy, including a 6.4% risk of hemorrhage, "even if you're doing it right."

While it is still clearly the right thing to do, he said, "that would give you pause . . . but what you cannot do is pause, and that's the hard part.

"We're caught in a situation where you have to be fast, and you have to do it well."

The study was funded by the American Heart Association PRT Outcomes Research Center and the National Institutes of Health-National Institute of Neurological Disorders and Stroke. Dr. Saver reports he is an investigator in the NIH CLEAR, IMS-3, and the MR-RESCUE trials.

International Stroke Conference 2009: Abstract 31. Presented February 18, 2009.

2. Urgent Care for TIA and Minor Stroke Reduces Disability and Costs: EXPRESS

Susan Jeffrey. February 5, 2009 — A new analysis from the EXPRESS trial, which showed that urgent aggressive intervention after a transient ischemic attack (TIA) or minor stroke cut the 90-day risk for recurrent stroke by 80%, now confirms this strategy reduces fatal and nonfatal stroke as well as disability, hospital admission days, and costs by the same magnitude.

"In contrast to most medical treatments or interventions, which cost money but do some good, this intervention would actually save much more money than it costs to implement," Peter M. Rothwell, FMedSci, from John Radcliffe Hospital, in Oxford, the United Kingdom, told Medscape Neurology & Neurosurgery.

The results, from the Early Use of Existing Preventive Strategies for Stroke (EXPRESS) trial, are published online February 5 ahead of print in the March issue of Lancet Neurology.

EXPRESS Intervention After TIA

After a TIA or minor stroke, the risk for recurrent stroke within 7 days is between 8% and 10%, the authors write.

The EXPRESS trial was a prospective, population-based study looking at the effect of early assessment and treatment of TIA or minor stroke by comparing outcomes in two 30-month periods before and after implementation of a "no-appointment-necessary" clinic where patients could be seen within 24 hours of the event and preventive treatments, including antiplatelet therapy and statins, could begin immediately.

Full-text here: http://www.medscape.com/viewarticle/587884

3. Prescribe prednisolone alone for Bell’s palsy diagnosed within 72 hours of symptom onset

Madhok V, et al. BMJ 2009;338:b255.

The clinical problem
Bell’s palsy affects 11 to 40 people per 100, 000 population each year, and although most patients recover, as many as 30% are left with facial disfigurement and pain. Uncertainty surrounds the most commonly used treatments, corticosteroids and antiviral agents: two Cochrane reviews examining their effectiveness concluded that there were unsatisfactory data to determine definitive treatment.However, on the basis of a more recent randomised controlled trial of prednisolone and aciclovir for early Bell’s palsy, we now propose that prednisolone should be prescribed immediately on diagnosis and that aciclovir either alone or in combination does not confer any benefit.

The evidence for change
The treatment of Bell’s palsy has been an area of clinical uncertainty in terms of whether to treat with corticosteroid or antiviral therapy. Two separate Cochrane reviews in 2004 examined the effectiveness of corticosteroids and antiviral agents in patients with Bell’s palsy. The first Cochrane review included three randomised controlled trials with 117 patients, and the second review included two randomised control trials with 200 patients. Each review concluded that the data were unsatisfactory for determining definitive treatment. Following these two reviews, England’s National Institute for Health Research commissioned a randomised controlled trial within primary care to look at the effectiveness of prednisolone and aciclovir in treating early Bell’s palsy. This trial included twice as many patients as did the Cochrane reviews, thereby reducing the selection bias found in hospital based studies.

In this newly commissioned trial, over a two year period 752 patients with symptoms suggestive of Bell’s palsy were referred from primary care to 17 hospital based receiving centres in Scotland to be assessed within 72 hours of symptom onset. Altogether, 551 patients met the inclusion criteria and were randomised twice, resulting in four study groups. Each group received a combination of two preparations: prednisolone plus placebo; aciclovir plus placebo; prednisolone plus aciclovir; or two placebo capsules. Facial nerve function was the primary outcome and was assessed using the House-Brackmann scale, with quality of life, appearance, and pain as secondary outcomes (table).

Prednisolone provides an effective treatment for Bell’s palsy—the number needed to treat (NNT) for one additional person to experience full facial function being six and eight at three and nine months respectively.

Barriers to change
Effective dissemination of this new knowledge on how the best to treat Bell’s palsy is needed. This article and others in review publications such as the Drug and Therapeutics Bulletin (http://dtb.bmj.com/cgi/content/abstract/46/7/53), together with the incorporation of the new findings into the online resource Map of Medicine (www.nhs.uk/Conditions/Bells-palsy/Pages/Treatment.aspx?url=Pages/what-is-it.aspx), will enable these findings to be more widely known. This will make it more likely that patients receive corticosteroids within three days of the onset of symptoms.

How should we change our practice?
Prednisolone should be prescribed as first line treatment in patients diagnosed with Bell’s palsy within 72 hours of onset. Corticosteroids alone are easy for patients to take, are well tolerated, and now have clear supporting evidence. They are also more cost effective, with the daily dose of 50 mg (25 mg twice daily) of prednisolone costing £0.52 compared with £0.70 for 2 g (400 mg five times daily) of aciclovir; patients are recommended to take a 10 day course. Corticosteroids are contraindicated in patients with systemic infection. It remains to be seen if other antiviral agents, such as valaciclovir, have any benefit in the treatment of Bell’s palsy in primary care.

Methods
We searched Medline and the Cochrane Library to identify published randomised controlled trials and systematic reviews that assessed the efficacy of steroids and antivirals in the treatment of Bell’s palsy. We also consulted widely among specialists and generalists, as well as drug companies, to identify relevant published evidence. A single recent study dominates the current evidence base as the largest randomised control trial providing the best supportive evidence on management of the early stages for patients presenting in primary care

Key points

Prednisolone given within 72 hours of onset of Bell’s palsy increases the chance of complete recovery at three and nine months

Combining the antiviral aciclovir with prednisolone confers no additional benefit

Prednisolone is easy to take, well tolerated, and cheap

4. Parental Preferences for Boarding Locations When a Children's Hospital Exceeds Capacity

Guthrie BD, et al. Ann Emerg Med 2009; in press

Study objective
Our objective is to determine parental preferences for boarding locations when a children's hospital is at full capacity. We also assess parental interest in transfer to a general hospital when a children's hospital is experiencing crowding.

Methods
Eligible patients were surveyed within 24 hours of admission. Surveys were completed in emergency department (ED) and inpatient areas. Previous admission was not required; children with chronic illnesses were included. Parents were asked whether they would prefer their child to board in an ED hallway or inpatient hallway or whether they had no preference. Parents were also asked the maximum acceptable waiting time for an inpatient bed and whether they would prefer to be transferred to another hospital should the children's hospital not have a bed available. Responses were hypothetical and confidential and did not affect care.

Results
A total of 382 patients met enrollment criteria and 359 (94%) were enrolled; 58.8% (95% confidence interval [CI] 53.5% to 63.9%) preferred boarding on inpatient hallways, 11.1% (95% CI 8.2% to 15.0%) preferred ED hallways, and 30.1% (95% CI 25.4% to 35.2%) had no preference. Seventy percent (95% CI 65.2% to 74.9%) of parents preferred to wait at a children's hospital despite crowding. Most parents believed that the maximum acceptable waiting time was less than or equal to 3 hours.

Conclusion
Parents of pediatric patients prefer boarding on inpatient hallways over ED hallways. The majority of parents prefer to remain at a children's hospital despite crowded conditions, but some parents may be amenable to transfer. These results may help institutions develop strategies to improve patient satisfaction when hospital capacity is exceeded.

5. ISC 2009: Misdiagnosis of Young Stroke Patients Not Uncommon

Caroline Cassels. February 19, 2009 (San Diego, California) — It is not uncommon for young adults with stroke to be misdiagnosed during initial presentation to the emergency department, particularly if they experience an infarct in their posterior circulation.

New research presented here at the American Stroke Association International Stroke Conference 2009 shows an overall misdiagnosis rate of 14% among adults under the age of 50 years.

"In these individuals, we also found there was a strong trend among the very youngest patients — those under age 35 — to have an even greater chance of misdiagnosis," principal investigator Seemant Chaturvedi, MD, from Wayne State University, in Detroit, Michigan, told Medscape Neurology.

Dr. Chaturvedi said his own anecdotal experience and that of some of his colleagues led them to look into the issue of misdiagnosis in young stroke patients.

"I think we've all seen young patients who, even though they have presented to the emergency department early after symptom onset, do not receive the proper diagnosis. When that happens, patients are deprived of the opportunity to receive [tissue plasminogen activator] tPA or interventional stroke therapy, so we decided to look at this issue in a more systematic way," he said.

Inner-Ear Disorder Diagnosed in 50%

The researchers reviewed data on 57 patients aged 16 to 50 years enrolled since 2001 in the Young Stroke Registry at the Comprehensive Stroke Center at Wayne State University.

With an average age of 34 years, 8 patients — 4 males and 4 females — were misdiagnosed with conditions including alcohol intoxication, migraine, vertigo, and inner-ear disorder.

Of these, half were diagnosed with an inner-ear disorder, including labyrinthitis or peripheral vertigo, and subsequently ended up being diagnosed with stroke in the brain stem or cerebellum. One 18-year-old patient diagnosed with alcohol intoxication also ended up with a diagnosis of posterior cerebral artery stroke.

Of the misdiagnosed cases, 7 of the 8 presented within 3 hours to the emergency department. Of these, said Dr. Chaturvedi, 3 would have been considered good candidates for thrombolysis.

A Diagnostic Challenge

Diagnosing posterior stroke can be challenging, said Dr. Chaturvedi.

"There are a number of neural pathways in the brain stem that can affect different functions, including strength, coordination, speech, eye movements, hearing, and swallowing. So to a nonspecialist, it can be challenging to tease out which of these are serious and which are benign," he said.

Nevertheless, he added, the presenting signs and symptoms in these misdiagnosed patients were not atypical.

"It may be that physicians are just not expecting stroke [in these young patients]. A lot of the presentations were classic for stroke, but for whatever reason, they just weren't recognized as such," he said.

Dr. Chaturvedi said the study highlights the need for efforts to increase awareness among the public and clinicians that stroke can occur in young people. He estimated that in the United States there are approximately 10,000 to 15,000 strokes in individuals under the age of 45 years annually.

"I think I would recommend that doctors consider a diagnosis of stroke in patients who present with acute neurologic deficits, regardless of age. It is particularly important in patients who present with dizziness to evaluate patients' gait, speech, and eye movements before concluding their condition is benign."

Dr. Chaturvedi said his future research will examine potential differences between misdiagnosis rates in designated and undesignated stroke centers.

International Stroke Conference 2009: Abstract 33. Presented February 18, 2009.

6. Postreduction Management of First-Time Traumatic Anterior Shoulder Dislocations

McNeil NJ. Ann Emerg Med. 2009; in press.

The shoulder is the most commonly dislocated joint. The overall sex- and age-adjusted incidence of initial traumatic shoulder dislocation is 8.2 per 100,000 person-years in the United States. For the past 2,000 years, immobilization in internal rotation has been performed after reduction. In a 2004 survey of British Trauma Society members, 93% immobilize anterior shoulder dislocations postreduction in internal rotation. Despite this, the recurrence rate after an initial dislocation ranges between 20% and 50%.The rate is 50% to 64% in patients younger than 30 years. It is unclear whether the duration of immobilization has any effect on the recurrence rate. The traumatic lesion found in 94% to 97% of initial shoulder dislocations is called the Bankart lesion. It consists of a detachment of the inferior glenohumeral ligament–labrum complex from the glenoid and is the main determinant of acquired shoulder instability after shoulder dislocation. Anterior shoulder dislocations evaluated after reduction by arthroscopy and magnetic reonance imaging (MRI) showed better reduction of the labrum in external rotation than in internal rotation. There is also MRI evidence of healing in the reduced position after immobilization for 3 weeks in external rotation. We reviewed the available evidence to determine the optimal method of immobilization of a first-time traumatic anterior shoulder dislocation.

Search Strategy
An Ovid MEDLINE (1950 to present) search was performed by using “shoulder dislocation” in the title and keywords (immobilization or immobilisation or “external rotation” or recurrence), with no limits. This search yielded 230 articles. Bibliographic references found in these articles were also examined to identify pertinent literature. Articles dealing with operative treatment were excluded. Cadaveric and MRI outcome studies were also excluded as a result of their low level of evidence-based medicine. Five original research articles were identified that addressed the optimal method of immobilization after traumatic anterior shoulder dislocations.

The Bottom Line
The currently available evidence suggests that the immobilization of a first-time traumatic shoulder dislocation in external rotation for 3 weeks reduces the risk of recurrent dislocation. There is little to no evidence that immobilization in internal rotation has any effect on recurrence. Shoulder dislocations with a nondisplaced fracture of the greater tuberosity have a decreased risk of recurrence. It would be within the standard of care to immobilize first-time traumatic anterior shoulder dislocations without a fracture of the greater tuberosity in external rotation

7. New Guidelines on Management of Aneurysmal Subarachnoid Hemorrhage

January 22, 2009 — New guidelines on the management of aneurysmal subarachnoid hemorrhage (aSAH) have been released by the American Heart Association/American Stroke Association.

Mortality associated with aSAH is high, about 45% in the first 30 days after a rupture, Dr. Bederson said. Still, he notes, "The majority of aneurysms do not rupture, and as much as 1% of the population dies of old age with a small, unruptured aneurysm."
SAH is frequently misdiagnosed, in up to 12% of cases. For the initial evaluation of headache, CT scanning for suspected SAH is "strongly recommended," followed by lumbar puncture if the CT is negative. A standard management protocol for the evaluation of patients with headaches and other symptoms that may potentially relate to SAH does not currently exist and should be developed.

Early vs later treatment of the aneurysm reduces the risk for rebleeding after SAH, and so early surgery is "reasonable and probably indicated in the majority of cases," the authors write.

Medical measures to prevent rebleeding include blood-pressure monitoring and control and bed rest, although these should be part of a broader strategy with more definitive measures. A short course of antifibrinolytics may be considered prior to definitive treatment.

To reduce poor outcomes associated with vasospasm, the authors "strongly recommend" use of oral nimodipine. The value of other calcium antagonists remains uncertain, they note. Treatment begins with early management of the ruptured aneurysm, they add; "in most cases maintaining normal circulating blood volume and avoiding hypovolemia is probably indicated."

Another "reasonable" approach to symptomatic vasospasm is volume expansion with induction of hypertension and hemodilution, so-called "triple-H therapy," the authors note. "Alternatively, cerebral angioplasty and/or selective intra-arterial vasodilator therapy may also be reasonable, either following, or together with, or in the place of, triple-H therapy, depending on the clinical scenario."

The relationship between hypertension and aSAH is "uncertain," they conclude, but management of blood pressure to prevent other clinical problems is recommended. Quitting smoking is "reasonable," they note, "although the evidence for this association is indirect."

Screening for unruptured aneurysms in high-risk populations is of "uncertain value," they conclude. Noninvasive imaging may be used for such screening, "but catheter angiography remains the 'gold standard' when it is clinically imperative to know if an aneurysm exists."

Full-text: http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.108.191395v1.pdf

8. Respiratory Syncytial Virus Infection May Cause Substantial Morbidity in Young Children

Laurie Barclay, MD. February 4, 2009 — Respiratory syncytial virus (RSV) infection in young children is linked with substantial morbidity in US children in both inpatient and outpatient settings, according to results from a surveillance study reported in the February 5 issue of the New England Journal of Medicine.

"The primary role of [RSV] in causing infant hospitalizations is well recognized, but the total burden of RSV infection among young children remains poorly defined," write Caroline Breese Hall, MD, from the University of Rochester School of Medicine and Dentistry in New York, and colleagues.

"The Centers for Disease Control and Prevention (CDC) initiated the New Vaccine Surveillance Network...a prospective, population-based inpatient and outpatient surveillance for acute respiratory infections among children under 5 years of age in 2000 in Nashville and Rochester, New York, and in 2003 in Cincinnati," the authors write. "The aim of our study was to determine the population-based burden of RSV infection among hospitalized children and outpatients in emergency departments and primary care settings."

This prospective, population-based surveillance study of acute respiratory infections among children younger than 5 years took place in 3 US counties. Hospitalized children were enrolled from 2000 through 2004, and outpatients in emergency departments and pediatric offices were enrolled from 2002 through 2004. Culture and reverse-transcriptase polymerase chain reaction were used to diagnose RSV infection. Parents and medical record review provided clinical data. The investigators calculated population-based rates of hospitalization linked to RSV infection and determined approximate rates of RSV-associated outpatient visits.

RSV infections occurred in 919 (18%) of 5067 children enrolled in the study. From November through April, RSV was associated with 20% of hospitalizations, 18% of emergency department visits, and 15% of office visits for acute respiratory infections. For children younger than 6 months, average annual hospitalization rates were 17 per 1000 vs 3 per 1000 children younger than 5 years. Prematurity and young age were independent risk factors for hospitalization; most of the hospitalized children had no comorbid illnesses.

Among children younger than 5 years, estimated rates of RSV-associated office visits were 3 times those in emergency departments. Although outpatients had moderately severe RSV-associated illness, only 3% of the illnesses were diagnosed as being caused by RSV.

"RSV infection is associated with substantial morbidity in U.S. children in both inpatient and outpatient settings," the study authors write. "Most children with RSV infection were previously healthy, suggesting that control strategies targeting only high-risk children will have a limited effect on the total disease burden of RSV infection.... On the basis of our findings, we estimate that among children under the age of 5 years, RSV infection results in approximately 1 of 334 hospitalizations, 1 of 38 visits to an emergency department, and 1 of 13 visits to a primary care office each year in the United States."

This study was supported by cooperative agreements with the CDC. Some of the authors report various financial relationships with MedImmune, Astellas, GlaxoSmithKline, Merck, Pfizer, and/or Wyeth.

N Engl J Med. 2009;360:588–598.

9. New Class of Drugs for Acute Migraine

Telcagepant, a calcitonin gene-related peptide antagonist, is as effective as zolmitriptan, with fewer adverse effects.

Migraine headache is commonly treated with triptans (serotonin-receptor agonists), but, because these agents are associated with side effects (such as chest discomfort, dizziness, and throat tightness), they are poorly tolerated by some patients and contraindicated in those with cardiovascular disease. Telcagepant is a new calcitonin gene-related peptide antagonist that lacks the vasoconstrictor effects of triptans. In a randomized, controlled, double-blind, parallel-treatment trial funded by the maker of telcagepant, 1380 adult patients (mean age, 42; 85% female) with acute migraine received one of four oral treatments: telcagepant (160 mg or 300 mg), zolmitriptan (5 mg), or placebo. The study was conducted at 81 outpatient primary care and headache centers in Europe and the U.S.

Patients were excluded if they had cardiovascular disease or uncontrolled hypertension or had used selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, or propranolol within 1 month before the screening visit. Patients recorded headache pain severity (none, mild, moderate, or severe) and presence or absence of phonophobia, photophobia, and nausea at baseline; every 30 minutes for 3 hours; and at 4, 6, 8, and 24 hours.

Telcagepant 300 mg and zolmitriptan 5 mg were similarly effective, and both were superior to telcagepant 150 mg and placebo for pain relief; pain freedom; and absence of phonophobia, photophobia, and nausea. No deaths and only one serious adverse event (in a placebo recipient) were reported. Adverse events were significantly more common in the zolmitriptan group than in the other three groups.

Comment: An editorialist suggests that the proof of efficacy of telcagepant — the first of a new class of drugs — "marks a new era in migraine therapy." If approved by the FDA (the manufacturer plans to file a new drug application in 2009) and other regulatory agencies, telcagepant and its future congeners show promise as effective alternatives to triptans. This new drug might be another important step toward the goal of minimizing or eliminating emergency department visits by patients with chronic migraine syndromes.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emerg Med January 16, 2009.
Citation: Ho TW et al. Lancet 2008 Dec 20; 372:2115.

10. Etomidate Induction Does Not Increase Mortality in Septic Patients

Neither mortality nor hospital length of stay differed between septic patients who received etomidate and those who received other agents for rapid sequence intubation.

Tekwani KL, et al. Acad Emerg Med. 2009;16:11-14.
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19055676

11. Mortality Rates Vary Among Trauma Centers

NEW YORK (Reuters Health) Feb 03 - Even after controlling for injury severity, mortality rates vary significantly across similarly designated trauma centers, according to a report in the January issue of the Archives of Surgery.

"Our results imply that the quality of trauma care is not consistent across similarly designated trauma centers despite the use of the designation process," the authors say.

Dr. Shahid Shafi from the University of Texas Southwestern Medical School, Dallas, and colleagues measured mortality rates at 15 designated Level 1 and 2 trauma centers in Texas, after controlling for injury severity and other patient characteristics.

In a logistic regression analysis, age, mechanism of injury, Injury Severity Score, initial systolic blood pressure, and Glasgow Coma Scale scores measured in the emergency department and individual trauma centers independently predicted mortality, the researchers report.

Compared with the best-performing center, 8 of the other 14 trauma centers had significantly worse odds of survival, while the remaining 6 had similar odds of survival.

"The current criteria used in the designation process may not measure all of the resources needed to achieve best possible survival rates," the investigators speculate. "Alternatively, it is possible that the factors that do influence outcome are not measured by the designation process."

"Either way," they add, "it appears that the designation process could be improved if the factors associated with differences in outcome can be identified and included in the process."

Arch Surg 2009;144:64-68.

12. TRIAD II: Do Living Wills Have an Impact on Pre-Hospital Lifesaving Care?

Mirarchi FL, et al. J Emerg Med. 2009;36:105-115.

Background: Living wills accompany patients who present for emergent care. To the best of our knowledge, no studies assess pre-hospital provider interpretations of these instructions.

Objectives: Determine how a living will is interpreted and assess how interpretation impacts lifesaving care.

Design setting: Three-part survey administered at a regional emergency medical system educational symposium to 150 emergency medical technicians (EMTs) and paramedics. Part I assessed understanding of the living will and do-not-resuscitate (DNR) orders. Part II assessed the living will's impact in clinical situations of patients requiring lifesaving interventions. Part III was similar to part II except a code status designation (full code) was incorporated into the living will.

Results: There were 127 surveys completed, yielding an 87% response rate. The majority were male (55%) and EMTs (74%). The average age was 44 years and the average duration of employment was 15 years. Ninety percent of respondents determined that, after review of the living will, the patient's code status was DNR, and 92% defined their understanding of DNR as comfort care/end-of-life care. When the living will was applied to clinical situations, it resulted in a higher proportion of patients being classified as DNR as opposed to full code (Case A 78% vs. 22%, respectively; Case B 67% vs. 33%, respectively; Case C 63% vs. 37%), respectively. With the scenarios presented, this DNR classification resulted in a lack of or a delay in lifesaving interventions. Incorporating a code status into the living will produced statistically significant increases in the provision of lifesaving care. In Case A, intubation increased from 15% to 56% (p less than 0.0001); Case B, defibrillation increased from 40% to 59% (p less than 0.0001); and Case C, defibrillation increased from 36% to 65% (p less than 0.0001).

Conclusions: Significant confusion and concern for patient safety exists in the pre-hospital setting due to the understanding and implementation of living wills and DNR orders. This confusion can be corrected by implementing clearly defined code status into the living will.

13. Should the Digital Rectal Examination Be a Part of the Trauma Secondary Survey?

Hankin AD, et al. Ann Emerg Med. 2009;53:208-212.

The Bottom Line
In our review of the literature on the utility of digital rectal examination in the trauma evaluation, we found 7 studies appropriate for inclusion. Of these, 3 studies were prospective, involving data collection completed by members of the trauma team, and 4 were retrospective reviews. Limitations present in all included studies are the lack of randomization, lack of independent confirmation of digital rectal examination findings, and lack of blinding because the physician performing and recording the digital rectal examination findings was aware of the results of the rest of the trauma evaluation in all cases. However, lack of blinding would be expected to result in a bias toward a higher proportion of true positives and true negatives than would be present in a fully blinded study.

The consistency of the findings is compelling. All studies found that the digital rectal examination performed poorly as a screening test, with sensitivities ranging from 0% to 50% and with consistently high false-positive and false-negative rates. Two studies that compared the statistical characteristics of digital rectal examination with the rest of the physical examination found that inclusion of the digital rectal examination did not improve the predictive value of the other components of a typical trauma examination.

Nevertheless, there remain some situations in the setting of trauma in which the digital rectal examination may be a valuable part of the trauma evaluation (as suggested by Porter and Ursic), including in patients with evidence of penetrating trauma in the vicinity of the rectum, in cases in which the presence of neurologic injury is neither completely supported nor refuted by the clinical findings, and before pharmacologic paralysis. This selective approach to the use of digital rectal examination is supported by the strong positive likelihood ratios found in these studies, which ranged from 5.1 to 33.

Cf. Porter and Ursic: Digital rectal examination for trauma: does every patient need one?. Am Surg. 2001;67:438–441. http://www.ncbi.nlm.nih.gov/pubmed/11379644

14. Images in Emergency Medicine

a. Elderly Man With Upper Lip Swelling
Link: http://www.annemergmed.com/article/S0196-0644(08)00829-9/fulltext

b. Bilateral Knee Deformity Following a Fall
Link: http://www.annemergmed.com/article/S0196-0644(08)00835-4/fulltext

15. Below-Knee Cast Best for Rapid Recovery From Ankle Sprain

Barbara Boughton. February 13, 2009 — A 10-day period of immobilization in a below-knee cast or Aircast results in a more rapid recovery from ankle sprain compared with the current clinical practice of mobilization after a severe ankle sprain, according to a randomized controlled trial reported in the February 14 issue of The Lancet.

In a trial of 584 patients treated at 8 emergency departments across the United Kingdom, support with tubular compression bandage was compared with a below-knee cast, Aircast brace, and Bledsoe boot, and outcomes were assessed at 3 and 9 months.

Only the below-knee cast resulted in significantly better ankle function as well as improvements in pain, symptoms, and activity at 3 months. While the Aircast brace did not show any benefits in lessening pain or symptoms or patient activity, it produced a significant improvement in ankle function when compared with tubular compression bandage at 3 months.

"Contrary to popular clinical opinion, a period of immobilization was the most effective strategy for promoting rapid recovery. This was achieved best by the application of a below-knee cast," write Sarah E. Lamb, DPhil, from the Warwick Clinical Trials Unit, Medical School, University of Warwick, Coventry, United Kingdom, and colleagues. "The Aircast brace was a suitable alternative to below-knee casts. Results for the Bledsoe boot were disappointing, especially in view of the substantial additional cost of this device. Tubular compression bandage, which is currently the most commonly used of all the supports investigated, was, consistently the worst treatment."

The researchers conclude that below-knee cast is a better choice for clinicians treating severe ankle sprains than tubular compression bandage because it aids recovery, lessens symptoms, and helps patients return to normal function. These advantages are especially important in treating severe ankle sprain because the condition can result in severe incapacity and lingering symptoms for months or years, according to the study authors. They recommend a below-knee cast as the first-choice treatment for severe ankle sprain, because of the range of benefits seen in the study.

When compared with tubular compression bandage, the below-knee cast resulted in a 9% mean difference in ankle function at 3 months (95% confidence interval [CI], 2.4% – 15.0%) in the study. There was an 8% mean difference in quality of ankle function when the Aircast brace was compared with tubular compression bandage (95% CI, 1.8% – 14.2%).

The 3-month results are especially important in assessing the relative strengths of different treatments because most recovery from severe ankle sprains occurs within the first 6 months, according to the researchers.

The study found that there was little difference between any of the 4 treatments when patients were assessed at 9 months.

In an accompanying editorial, Jay Hertel, PhD, from the University of Virginia in Charlottesville, notes that the study's findings are likely to be viewed as controversial, because established clinical consensus on ankle sprains have emphasized functional treatment rather than immobilization. He also points out that the authors did not report on the incidence of recurrent ankle sprains in the 4 groups, which could have illuminated the long-term clinical benefits of below-knee casting.

Other limitations of the study were that the researchers were not able to measure long-term compliance with the supports accurately, except by patient self-report, and the presence of a 3-day delay before randomization in order to confirm injury severity and allow initial swelling to decrease before using a support.

Yet Dr. Hertel notes that the findings of the study are both provocative and compelling. "The results of the study call into question the current standard of aggressive functional treatment of patients recovering from acute ankle sprains," he writes.

Lancet. 2009;373:524-525, 575–581.

16. Does 16 Detector CT Improve Detection of Subarachnoid Hemorrhage?

A retrospective review was performed of patients presenting to the emergency department (ED) with symptoms suggestive of subarachnoid hemorrhage and in whom the final diagnosis was non-traumatic subarachnoid hemorrhage. Results of 16 Detector computed tomography (CT) scan, angiogram, and spinal fluid analysis were reviewed.

Of 61 patients entered in the study, one patient did not have subarachnoid hemorrhage identified by 16 detector CT but had a positive lumbar puncture and an aneurysm confirmed by cerebral angiography. In conclusion, 16 detector CT did not improve detection of non-traumatic subarachnoid hemorrhage compared to studies using single detector CT.

Lourenco AP, et al. J Emerg Med 2009;36:171-175.

17. Secondhand smoke raises risk of dementia

British researchers found that exposure to secondhand smoke can raise a person's risk of developing dementia by 44%. The study of more than 4,800 nonsmokers who were over age 50, published in the journal BMJ.com, also showed the risk increased with the amount of exposure

BMJ 2009;338:b462.

Abstract: http://www.bmj.com/cgi/content/abstract/338/feb12_2/b462

18. A Critical Comparison of Clinical Decision Instruments for Computed Tomographic Scanning in Mild Closed Traumatic Brain Injury in Adolescents and Adults

Stein SC, et al. Ann Emerg Med. 2009;53:180-188.

Study objective
A number of clinical decision aids have been introduced to limit unnecessary computed tomographic scans in patients with mild traumatic brain injury. These aids differ in the risk factors they use to recommend a scan. We compare the instruments according to their sensitivity and specificity and recommend ones based on incremental benefit of correctly classifying patients as having surgical, nonsurgical, or no intracranial lesions.

Methods
We performed a secondary analysis of prospectively collected database from 7,955 patients aged 10 years or older with mild traumatic brain injury to compare sensitivity and specificity of 6 common clinical decision strategies: the Canadian CT Head Rule, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies, the New Orleans, the National Emergency X-Radiography Utilization Study II (NEXUS-II), the National Institute of Clinical Excellence guideline, and the Scandinavian Neurotrauma Committee guideline. Excluded from the database were patients for whom the history of trauma was unclear, the initial Glasgow Coma Scale score was less than 14, the injury was penetrating, vital signs were unstable, or who refused diagnostic tests. Patients revisiting the emergency department within 7 days were counted only once.

Results
The percentage of scans that would have been required by applying each of the 6 aids were Canadian CT head rule (high risk only) 53%, Canadian (medium & high risk) 56%, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies 56%, New Orleans 69%, NEXUS-II 56%, National Institute of Clinical Excellence 71%, and the Scandinavian 50%. The 6 decision aids' sensitivities for surgical hematomas could not be distinguished statistically (P greater than .05). Sensitivity was 100% (95% confidence interval [CI] 96% to 100%) for NEXUS-II, 98.1% (95% CI 93% to 100%) for National Institute of Clinical Excellence, and 99.1% (95% CI 94% to 100%) for the other 4 clinical decision instruments. Sensitivity for any intracranial lesion ranged from 95.7% (95% CI 93% to 97%) (Scandinavian) to 100% (95% CI 98% to 100%) (National Institute of Clinical Excellence). In contrast, specificities varied between 30.9% (95% CI 30% to 32%) (National Institute of Clinical Excellence) and 52.9% (95% CI 52% to 54) (Scandinavian).

Conclusion
NEXUS-II and the Scandinavian clinical decision aids displayed the best combination of sensitivity and specificity in this patient population. However, we cannot demonstrate that the higher sensitivity of NEXUS-II for surgical hematomas is statistically significant. Therefore, choosing which of the 2 clinical decision instruments to use must be based on decisionmakers' attitudes toward risk.

NEXUS-II Review
The study identified eight criteria that were independently and highly associated with intracranial injuries. These include:

evidence of significant skull fracture
scalp hematoma
neurologic deficit
altered level of alertness
abnormal behavior
coagulopathy
persistent vomiting
age 65 or more

The study showed that patients who did not have any of the above criteria were unlikely to have significant injuries revealed by CT imaging and could therefore be safely discharged following a thorough evaluation without the use of CT.

Source: Mower et al. Developing a Decision Instrument to Guide Computed Tomographic Imaging of Blunt Head Injury Patients. Journal of Trauma-Injury Infection & Critical Care. 2005;59:954-959.

19. Post-Transient Ischemic Attack Early Stroke Stratification: The ABCD2 Prognostic Aid

Carpenter CR, et al. J Emerg Med. 2009;36:194-200.

Abstract
Background: In many patients, transient ischemic attack (TIA) precedes stroke. Prompt recognition of TIA patients who are at increased short-term risk for stroke may facilitate efficient resource utilization and improved patient outcomes. Three prognostic decision aids have been derived and validated to empower emergency physicians to stratify TIA patients for 2-day stroke risk based upon information readily available at the bedside.

Clinical Question: Can a TIA stratification tool predict short-term stroke risk?

Evidence Review: Two relevant tool derivation studies and one validation study were selected from an evidence search and a structured review.

Results: The three tools reveal similar prognostic capabilities, although the ABCD2 prognostic guide may be slightly superior. A proposal scoring system for TIA patients at low risk for stroke within 90 days is presented.

Conclusion: Stroke risk stratification is possible with a simple prediction rule.

Commentary: The ABCD2 rule and any subsequent improved rule will need to undergo implementation studies to ensure that such rules have an important impact on the resulting morbidity and mortality of TIA patients due to subsequent stroke, and assess the impact of using such rules in busy EDs.

ABCD2 Rule Review

Risk Factor Points
Age over 60 years 1
Blood pressure over 140/90 1
Clinical features
Unilateral weakness 2
Language disturbance w/o weakness 1
Diabetes 2
Duration more than 60 min 2
Duration 10–59 min 1
Duration less than 10 min 0

A score of 0 was associated with a 0% 90-day stroke risk, whereas a score of 1 had a 1–3% 90-day risk. The 2-day stroke risk for ABCD2 score 1 or less was 0%, but for a score of 2, the 2-day stroke risk was 1–2%. The authors advocate for an ABCD2 score of 3 or less as “low risk,” although ED patients in California had a 2–3% 2-day stroke risk with a score of 3 (10/438 suffered a stroke) and an ABCD2 score 6 or greater as high risk.

20. Imaging strategies for low-back pain: systematic review and meta-analysis

Chou R, et al. Lancet 2009;373 (9662):463-472.

Background
Some clinicians do lumbar imaging routinely or in the absence of historical or clinical features suggestive of serious low-back problems. We investigated the effects of routine, immediate lumbar imaging versus usual clinical care without immediate imaging on clinical outcomes in patients with low-back pain and no indication of serious underlying conditions.

Methods
We analysed randomised controlled trials that compared immediate lumbar imaging (radiography, MRI, or CT) versus usual clinical care without immediate imaging for low-back pain. These trials reported pain or function (primary outcomes), quality of life, mental health, overall patient-reported improvement (based on various scales), and patient satisfaction in care received. Six trials (n=1804) met inclusion criteria. Study quality was assessed by two independent reviewers with criteria adapted from the Cochrane Back Review Group. Meta-analyses were done with a random effects model.

Findings
We did not record significant differences between immediate lumbar imaging and usual care without immediate imaging for primary outcomes at either short-term (up to 3 months, standardised mean difference 0·19, 95% CI −0·01 to 0·39 for pain and 0·11, −0·29 to 0·50 for function, negative values favour routine imaging) or long-term (6—12 months, −0·04, −0·15 to 0·07 for pain and 0·01, −0·17 to 0·19 for function) follow-up. Other outcomes did not differ significantly. Trial quality, use of different imaging methods, and duration of low-back pain did not affect the results, but analyses were limited by small numbers of trials. Results are most applicable to acute or subacute low-back pain assessed in primary-care settings.

Interpretation
Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.

Funding
American Pain Society.

Lit Bits: January 31, 2009

From the recent medical literature...

1. Greater Use of Reperfusion Therapy and Faster Reperfusion Times With Prehospital ECGs

Michael O'Riordan, from Heartwire — a professional news service of WebMD. January 7, 2008 (Boston, Massachusetts) — Only one in four patients transported to the hospital by emergency medical services (EMS) is receiving a prehospital electrocardiogram (ECG), a new study has shown [1]. Those who are screened with an ECG, however, are reperfused faster and more frequently than those who do not receive a prehospital ECG with first medical contact, report investigators.

"We hope the findings drive home the message that irrespective of reperfusion strategy, whether in an academic center that can do primary PCI 24/7 or a community hospital that utilizes fibrinolysis, an EMS system that transports patients who have chest pain and performs an ECG before arriving at the hospital improves our patients' outcomes and improves time to reperfusion," lead investigator Dr Deborah Diercks (University of California Davis Medical Center, Sacramento) told heartwire.

In August 2008, the American Heart Association (AHA) issued a scientific statement on the use of prehospital ECGs to improve the quality of care delivered to STEMI patients. The AHA 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.

In this recent study, Diercks and colleagues evaluated patients with STEMI in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment and Intervention Outcomes Network (ACTION) over a one-year period in 2007.

In total, 7098 patients utilized the EMS, and of these patients, just 27.4% received a prehospital ECG. Within this EMS transport population, 92% of those who received a prehospital ECG underwent primary PCI compared with 86% of those who received an ECG in the hospital. Also, more patients receiving an ECG in the ambulance were treated with fibrinolytic therapy compared with those who received one in the hospital.

Reperfusion times among STEMI patients screened with an ECG by EMS personnel were also shorter compared with those who received an ECG in the hospital. Similarly, more patients who received a prehospital ECG met the AHA door-to-balloon time recommendations of less than 90 minutes for PCI and the door-to-needle time of less than 30 minutes for fibrinolysis.

"I think what really improves the quality of care with the prehospital ECG is the time it takes to activate the system," said Diercks. "The prehospital ECG allows institutions to open up the lab, get their personnel ready, so that when the patient arrives the machine is started--the patient can get to where they need to go in a more prompt fashion."

Just one in four patients receiving an ECG prior to arriving at the hospital is a surprising finding, said Diercks. She added, however, that this study comes on the heels of the latest recommendations for prehospital ECG screening, so there might be insufficient time to see changes in the system. Increasing funding, training for EMS personnel to develop skills to interpret the ECG, and improvements in data transmission will hopefully result in an increase in utilization, she said.

In addition to improvements in reperfusion, investigators observed a trend toward improved clinical outcomes among patients who received a prehospital ECG. There were trends toward lower mortality, less congestive heart failure, and less cardiogenic shock among STEMI patients screened with an ECG by the EMS personnel. Although it failed to reach statistical significance, the risk of death was reduced 20% among those who received an ECG with first medical contact.

"The findings fall in line with what we know," said Diercks. "The faster we're able to reperfuse these people, the better their outcomes are. A reduction in mortality is very much in line with the reduced time to reperfusion with the prehospital ECG."

Diercks DB, Kontos MC, Chen AY, et al. Utilization and impact of prehospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction. J Am Coll Cardiol 2009; 53:161-166. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19130984

2. Direct Paramedic Transport of Acute Myocardial Infarction Patients to Percutaneous Coronary Intervention Centers: A Decision Analysis

Wang HE, et al. Ann Emerg Med. 2009;53:233-240.e5

Study objective
One potential strategy in the emergency medical services (EMS) care of acute ST-segment elevation myocardial infarction (STEMI) is to bypass the nearest community hospital in favor of a more distant specialty center able to perform primary percutaneous coronary intervention. We seek to determine whether EMS transport of out-of-hospital STEMI patients directly to more distant specialty percutaneous coronary intervention centers will alter 30-day survival compared with transport to the nearest community hospital fibrinolytic therapy.

Methods
This decision analysis used parameter values and ranges from meta-analyses and North American clinical studies of STEMI and chest pain care published after 2001. The primary hypothetical interventions were primary percutaneous coronary intervention versus community hospital–delivered fibrinolytic therapy. We defined total STEMI treatment time as the sum of symptom duration, EMS response time, EMS scene time, EMS transport time to the nearest community hospital, additional EMS transport time to a more distant percutaneous coronary intervention center, and door-to-drug or door-to-balloon time. We related total STEMI treatment time to the primary outcome 30-day post-STEMI survival. We assumed that the closest specialty percutaneous coronary intervention centers were located farther than the nearest community hospital and that patients would receive primary percutaneous coronary intervention at specialty centers and fibrinolytic therapy at community hospitals. We assumed the use of ground transportation only and excluded situations with fibrinolytic therapy contraindications. We examined standard risk and best-case scenarios for each intervention, as well as changes in predicted risk with parameter value variations.

Results
Baseline total treatment times (chest pain onset to intervention) were percutaneous coronary intervention 188 minutes (range 41 to 447 minutes) and community hospital fibrinolytic therapy 118 minutes (range 51 to 267 minutes). Thirty-day survival was higher for standard percutaneous coronary intervention than standard community hospital fibrinolytic therapy (95.8% versus 93.8%; relative risk [RR] 1.021; number needed to treat 50) but lower when compared to best-case community hospital fibrinolytic therapy (95.8% versus 97.8%; RR 0.980; number needed to harm 50). Best-case percutaneous coronary intervention was equivalent to best-case community hospital fibrinolytic therapy (RR 1.000). In 1-way sensitivity analyses, best-case community hospital fibrinolytic therapy versus standard percutaneous coronary intervention was sensitive to treatment time parameter variations. Probabilistic sensitivity analysis favored standard percutaneous coronary intervention over standard community hospital fibrinolytic therapy (RR=1.020; 95% probability range 1.002 to 1.045) but did not indicate a favored strategy for the other scenarios.

Conclusion
In select out-of-hospital STEMI care scenarios, EMS transport of acute STEMI patients directly to percutaneous coronary intervention centers may offer small but uncertain survival benefits over nearest community hospital fibrinolytic therapy.

3. A Mysterious Link Between Sleeplessness and Heart Disease

December 24, 2008. By RONI CARYN RABIN. People who don’t get much sleep are more likely than those who do to develop calcium deposits in their coronary arteries, possibly raising their risk for heart disease, a new study has found.

The 495 participants in the study filled out sleep questionnaires and kept a log of their hours in bed. At night they also wore motion-sensing devices around their wrists that estimate the number of hours of actual sleep. At the beginning, none of the participants, who were ages 35 to 47, had evidence of coronary artery calcification.

Five years later, 27 percent of those who were sleeping less than five hours a night on average had developed coronary artery calcification for the first time, while only 6 percent of those who were sleeping seven hours or more had developed it. Among those who were sleeping between five and seven hours a night, 11 percent had developed coronary artery calcification, the study found.

After accounting for various other causes, the researchers concluded that one hour more of sleep per night was associated with a 33 percent decrease in the odds of calcification, comparable to the heart benefit gained by lowering one’s systolic blood pressure by 17 millimeters of mercury.

The study was published on Tuesday in the Journal of the American Medical Association. The data were drawn from the ongoing Coronary Artery Risk Development In Young Adults study.

Senior author Diane S. Lauderdale cautioned that the new report does not prove a cause-and-effect relationship between a lack of sleep and heart disease.

“It’s important to say that this is the first report and this does not yet prove the association is causal,” said Dr. Lauderdale, an associate professor of health studies at the University of Chicago Medical Center. “Until we know what the mechanism is -- that it’s really a direct or a causal relationship -- there is no point in making recommendations based on this.”

Although a number of studies have suggested that people who sleep less are at greater risk of heart disease and death, this is the first investigation to measure how much its subjects actually are sleeping, said Dr. Sanjay Patel, assistant professor of medicine at Case Western Reserve University and expert in sleep medicine. Patients’ own self-assessments can be very inaccurate, he added.

What isn’t clear is whether reduced sleep triggers physiological changes that increase heart disease risk, or whether a third, unrelated factor causes both changes, he said.

“It’s possible, for example, that people who are under more stress may be both sleeping less and at higher risk of heart disease,” Dr. Patel said.

If so, he added, “If we got those people to sleep more but they still were under a lot of stress, it wouldn’t change their risk of heart disease.”

Higher education levels are also associated with both a lower risk of heart disease and a tendency to get more sleep, said Dr. Lauderdale.

But it is also possible that lack of sleep leads to certain changes, like increasing blood levels of the stress hormone cortisol, which can raise the risk of coronary artery disease over time, Dr. Lauderdale said.

Another possible mechanism could be through the effect that sleep has on average blood pressure levels over a 24-hour period. Blood pressure usually dips when people are asleep, which could provide health benefits for those who get more sleep, Dr. Lauderdale suggested.

4. Full extension (nearly) rules out elbow fracture

Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children

Appelboam A, et al. BMJ 2008;337:a2428

Objective: To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury.
Design Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care.

Setting: Five emergency departments in southwest England.

Participants: 2127 adults and children presenting to the emergency department with acute elbow injury.

Intervention: Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children.

Main outcome measures: Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days.

Results: Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children.

Conclusion: The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.

Full-text: http://www.bmj.com/cgi/content/full/337/dec09_1/a2428

For similar findings, cf. Darracq MA, Vinson DR, Panacek EA. Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture. Am J Emerg Med. 2008;26:779-82. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/18774042

5. Data indicate amount of free hospital care continues to skyrocket.

Source: The Orlando Business Journal (http://orlando.bizjournals.com/orlando/)
Date: December 19, 2008

The Orlando Business Journal reports that data indicate that the "amount of free hospital care provided to needy patients locally skyrocketed by 41.6 percent in the past three years, from a combined $431.1 million in 2005 to a whopping $610.4 million in 2007." Nationally, "the amount of charity hospital care provided grew by eight percent in third-quarter 2008 when compared to the same period last year." Hospital officials "expect the situation to worsen in 2009 as the recession deepens and unemployment grows."

In fact, "every one percentage point increase in unemployment leads to a loss of employer-sponsored health coverage for an estimated 2.5 million employees and dependents," according to an American Hospital Association report. Moreover, "many people lacking health insurance turn to the emergency [department] as a last resort," and to "make matters worse, uncompensated care costs typically get shifted to the amount billed to private insurers, which drives up insurance premiums for employers and their workers." The culmination of all these events can put "the squeeze on hospitals, which are looking for a variety of ways to cut costs."

6. First Simple Febrile Seizure in Some Young Children Not Likely Bacterial Meningitis

Laurie Barclay, MD. January 14, 2009 — Lumbar puncture may not be necessary for a first simple febrile seizure at ages 6 to 18 months because the risk for bacterial meningitis is very low, according to the results of a retrospective cohort review in the January issue of Pediatrics.

"American Academy of Pediatrics consensus statement recommendations are to consider strongly for infants 6 to 12 months of age with a first simple febrile seizure and to consider for children 12 to 18 months of age with a first simple febrile seizure lumbar puncture for cerebrospinal fluid analysis," write Amir A. Kimia, MD, from Children's Hospital Boston in Massachusetts, and colleagues. "Our aims were to determine compliance with these recommendations and to assess the rate of bacterial meningitis detected among these children."

The investigators reviewed records for patients aged 6 to 18 months who were seen in a pediatric emergency department between October 1995 and October 2006 for a first simple febrile seizure. This presenting complaint accounted for 1% of all emergency department visits for children of this age during this period (704 cases of children among 71,234 eligible visits).

Of the first simple febrile seizure visits, 188 (27%) were for infants aged 6 to 12 months, and 516 (73%) were for infants aged 12 to 18 months; in total, 271 (38%) had lumbar puncture. Of 188 children aged 6 to 12 months, 131 (70%) had available samples, as did 129 (25%) of 516 children aged 12 to 18 months. In both age groups, rates of lumbar puncture decreased significantly with time.

Ten cases (3.8%) had elevated cerebrospinal fluid white blood cell count, but all results of cerebrospinal fluid cultures were negative for pathogens. Although 10 (3.8%) of cultures were positive for a contaminant, no patients were diagnosed with bacterial meningitis.

"The risk of bacterial meningitis presenting as first simple febrile seizure at ages 6 to 18 months is very low," the study authors write. "Current American Academy of Pediatrics recommendations should be reconsidered."

Limitations of the study include lack of generalizability to patients with complex febrile seizures, ill-appearing patients, or those with an underlying illness; lack of complete follow-up of patients who did not have lumbar puncture; and pretreatment of 68 patients with antibiotics before their visit to the emergency department.

"Sound clinical judgment should always prevail, and clinicians should err on the side of caution (including performing an LP [lumbar puncture]) when evaluating any febrile child for whom the presence of bacterial meningitis is being considered," the study authors conclude.

Kimia AA ,et al. Pediatrics. 2009;123:6-12.
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19117854

7. Is Subcutaneous Administration of Rapid-Acting Insulin as Effective as Intravenous Insulin for Treating Diabetic Ketoacidosis?

Mazer M, et al. Ann Emerg Med. 2009;53:259-263.

Introduction
Diabetes mellitus, second only to hypertension as the most common chronic condition of emergency department (ED) patients, can cause acute hyperglycemia and ketoacidosis, responsible for more than 1 million ED visits in 2005. Traditionally (and more recently endorsed by the American Diabetes Association), the treatment of diabetic ketoacidosis is accomplished by the administration of a low dose intravenous infusion of regular insulin that is initiated in the ED and continued in an ICU3 setting for frequent insulin/fluid adjustments, glucose monitoring, and electrolyte assessment.

Although insulin administration by any route is effective for treating diabetic ketoacidosis, intravenous insulin is preferred over subcutaneous and intramuscular insulin because it provides rapid, titratable glycemic control. For example, subcutaneous regular insulin has an onset of action within 1 hour, peaks within 1 to 5 hours, and may last for 6 to 10 hours, whereas intravenous insulin acts within minutes and has a half-life of 9 minutes. Within the past decade, rapid-acting insulin analogues (lispro [Humalog, Eli Lilly and Company, Indianapolis, IN], aspart [Novolog, Novo Nordisk Inc, Princeton, NJ], and glulisine [Apidra, Sanofi-Aventis, Bridgewater, NJ]) have been adopted preferentially for the inpatient treatment of hyperglycemia because of their more favorable pharmacokinetic profiles. When administered subcutaneously, these analogs have an onset of action within 10 to 20 minutes, peak within 30 to 90 minutes, and last approximately 3 to 4 hours.

Because intravenous insulin infusion requires ICU admission in some institutions and higher equipment (infusion pumps, additional intravenous access) and nursing costs, we searched the literature to determine whether intermittent subcutaneous use of these rapid-acting analogs might be as effective as intravenous insulin infusions in treating uncomplicated diabetic ketoacidosis.

Objective
To determine whether intermittent subcutaneous administration of rapid-acting insulin is as effective as intravenous infusion of regular insulin for treating uncomplicated diabetic ketoacidosis, we performed a MEDLINE, EMBASE, and Cochrane Library search…

The Bottom Line
According to this review of the available data (Table), subcutaneous administration of rapid-acting insulin analogues such as lispro every hour (0.3 U/kg bolus; then 0.1 U/kg) or 2 hours (0.3 U/kg bolus; then 0.2 U/kg) may be a reasonable alternative to intravenous regular insulin infusion for treating uncomplicated diabetic ketoacidosis. Insulin analogues are as effective as intravenous insulin at normalizing glucose levels and other acid-base characteristics, with similar rates of hypoglycemia. Moreover, patients receiving subcutaneous insulin may be treated on the medical floors or in step-down units, which may provide an overall cost savings and improve ED patient flow when ICU beds are scarce.

Finally, although the data provided support for our conclusions, they are based on a few small studies (with slightly different inclusion and exclusion criteria and definitions for resolution of diabetic ketoacidosis), focused on one particular analogue (lispro), and assume that intravenous insulin infusions require monitoring in intensive care settings. More important, the majority are manufacturer-sponsored studies, thereby introducing the potential for a conflict of interest. Despite these limitations, we conclude that it would be safe and effective to treat uncomplicated diabetic ketoacidosis with a subcutaneously administered rapid-acting insulin analogue.

8. Use of the Emergency Department for Severe Headache. A Population-Based Study

Friedman BF, et al. Headache 2009;49:21-30.

Background.—Although headache is a common emergency department (ED) chief complaint, the role of the ED in the management of primary headache disorders has rarely been assessed from a population perspective. We determined frequency of ED use and risk factors for use among patients suffering severe headache.

Methods.—As part of the American Migraine Prevalence and Prevention study, a validated self-administered questionnaire was mailed to 24,000 severe headache sufferers, who were randomly drawn from a larger sample constructed to be sociodemographically representative of the US population. Participants were asked a series of questions on headache management, healthcare system use, sociodemographic features, and number of ED visits for management of headache in the previous 12 months. In keeping with the work of others, "frequent" ED use was defined as a particpant's report of 4 or more visits to the ED for treatment of a headache in the previous 12 months. Headaches were categorized into specific diagnoses using a validated methodology.

Results.—Of 24,000 surveys, 18,514 were returned, and 13,451 (56%) provided complete data on ED use. Sociodemographic characteristics did not differ substantially between responders and nonresponders. Among the 13,451 responders, over the course of the previous year, 12,592 (94%) did not visit the ED at all, 415 (3%) visited the ED once, and 444 (3%) visited the ED more than once. Patients with severe episodic tension-type headache were less likely to use the ED than patients with severe episodic migraine (OR 0.4 [95% CI: 0.3, 0.6]). Frequent ED use was reported by 1% of the total sample or 19% (95% CI: 17%, 22%) of subjects who used the ED in the previous year, although frequent users accounted for 51% (95% CI: 49%, 53%) of all ED visits. Predictors of ED use included markers of disease severity, elevated depression scores, low socioeconomic status, and a predilection for ED use for conditions other than headache.

Conclusions.—Most individuals suffering severe headaches do not use the ED over the course of a single year. The majority of ED visits for severe headache are accounted for by a small subset of all ED users. Increasing disease severity and depression are the most readily addressable factors associated with ED use.

9. Images in Emergency Medicine

a. Woman With Low Back Pain
Link: http://www.annemergmed.com/article/S0196-0644(08)00837-8/fulltext

b. Limp in an 11-Year-Old Male
Link: http://www.annemergmed.com/article/S0196-0644(08)00910-4/fulltext

10. Impact of an Internet-Based Emergency Department Appointment System to Access Primary Care at Safety Net Community Clinics

Chan TC, et al. Ann Emerg Med 2009; in press.

Study objective
We evaluate the effect of an Internet-based, electronic referral system (termed IMPACT-ED for Improving Medical home and Primary care Access to the Community clinics Through the ED) on access and follow-up at primary care community clinics for safety net emergency department (ED) patients.

Methods
We conducted a nonblinded interventional trial at an urban, safety net, hospital ED with a census of 39,000 annually. IMPACT-ED identified patients who had no source of regular care and lived in a 15-ZIP-code low-income area served by 3 community clinics. Emergency physicians received an automated notification through the electronic medical record to access an imbedded software program for scheduling follow-up clinic appointments. Patients who would benefit from a follow-up clinic visit within 2 weeks as determined by the emergency physician received a computer-generated appointment time and clinic map with bus routes as part of their discharge instructions, and the clinics received an electronic notification of the appointment. We compared frequency of follow-up for a 6-month period before implementation when patients received written instructions to call the clinic on their own (pre-IMPACT) and 6 months after implementation (post-IMPACT). Statistical analysis was conducted with χ2 testing, and corresponding 95% confidence intervals are presented.

Results
There were 326 patients who received an appointment (post-IMPACT), of whom 81 followed up at the clinic as directed (24.8%), compared with 399 patients who received a referral (pre-IMPACT), of whom 4 followed up as directed (1.0%), for an absolute improvement of 23.8% (95% confidence interval 19.1% to 28.6%).

Conclusion
Although most patients still failed to follow up at the community clinics as directed, the use of an Internet-based scheduling program linking a safety net ED with local community clinics significantly improved the frequency of follow-up for patients without primary care.

11. Sleep and the Common Cold

Adults who slept fewer than 7 hours per night were almost three times more likely than longer sleepers to develop a cold after rhinovirus exposure.

Sleep deprivation can adversely affect immune function, and one study has suggested a link between poor sleep habits and increased risk for common colds (JAMA 1997; 277:1940). Researchers now report results from a prospective study of sleep habits and rhinovirus susceptibility.

Participants were interviewed daily for 14 days to assess sleep duration and "sleep efficiency" (the proportion of time in bed spent asleep). Information on several other variables (e.g., rhinoviral antibody titers, age, body-mass index, race, income, sex, smoking) was also collected to allow control for potential confounders. After this assessment, participants were placed in quarantine, exposed to an experimental rhinovirus (RV-39), and monitored for 5 days for signs and symptoms of illness. The outcome (a cold) was defined as infection (recovery of RV-39 from nasal lavage fluid or a 4-fold rise in RV-39 antibody titer) plus the presence of signs (mucus weight 10 g or nasal clearance time 35 minutes) or symptoms of a cold.

Of 153 individuals enrolled, 135 (88%) became infected, but only 54 (35%) and 66 (43%) developed a cold as determined by signs and by symptoms, respectively. Participants who averaged less than 7 hours of sleep per night had the highest risk for colds as determined by signs (odds ratio, compared with participants sleeping 8 hours/night, 2.9; 95% confidence interval, 1.2–7.3). Similarly, those with "sleep efficiency" less than 85% had the highest risk for colds after RV-39 exposure (OR, compared with the rest of the sample, 5.4; 95% CI, 1.5–19.1).

Comment: To the many benefits of good sleep we can now add protection from symptomatic rhinovirus infection. Data from this prospective investigation, combined with other study findings linking sleep duration to mortality and to heart disease morbidity, support a recommendation for 7–8 hours of sleep nightly. Further study of the link between sleep habits and disease susceptibility is warranted.

— Daniel J. Diekema, MD, MS. Published in Journal Watch Infectious Diseases January 21, 2009. Citation: Cohen S et al. Sleep habits and susceptibility to the common cold. Arch Intern Med 2009;169:62.

12. MI Reduction After Smoking Ban Is Sustained Over Long Term

from Heartwire — a professional news service of WebMD. Sue Hughes. January 7, 2009 (Pueblo, Colorado) — The reduction in MI hospitalizations observed after a smoke-free law takes effect appears to be sustained over an extended period, according to a new study from Pueblo, CO.

The study, reported in the January 2, 2009 issue of the Center for Disease Control and Prevention's (CDC's) Morbidity and Mortality Weekly Report, examined MI hospitalization rates before and after the implementation of a municipal law in the city of Pueblo making workplaces and public places smoke-free.

Results showed that MI hospitalizations for city residents decreased by 27% in the initial 18-month period (phase 1) after the smoke-free law came into effect on July 1, 2003. In addition, MI hospitalizations decreased by a further 19% during the following 18 months--through to June 30, 2006 (the phase 2 period).

No significant changes in MI hospitalizations were observed in two nearby comparison areas that did not have smoke-free laws in place before or during the study periods. "These findings suggest that smoke-free policies can result in reductions in AMI hospitalizations that are sustained over a three-year period and that these policies are important in preventing morbidity and mortality associated with heart disease," the CDC researchers write. "This effect likely is mediated through reduced second-hand-smoke exposure among nonsmokers and reduced smoking, with the former making the larger contribution," they add.

Full-text: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5751a1.htm

13. Raising the Threshold for Trauma Team Activation Decreases Workload Without Consequence

A change in criteria at a single trauma center reduced the incidence of trauma team activations, with no delays to surgery or increase in mortality.

A general tendency exists to over-triage patients to trauma centers and to activate trauma teams. Trauma team activation requires numerous personnel and the attending trauma surgeon to arrive within 20 minutes. In a retrospective observational study, researchers at a single level I trauma center determined whether changing criteria for trauma team activation from those recommended by the American College of Surgeons Committee on Trauma to more-aggressive indications affects patient outcomes. Criteria for trauma team activation were changed to decrease the systolic blood pressure cutoff (from less than 90 mm Hg to less than 80 mm Hg), decrease the respiratory rate cutoff (from less than 10 or greater than 28 to less than 8 or greater than 28 breaths per minute), eliminate the heart rate criterion, decrease the Glasgow Coma Scale score cutoff (from less than 14 to less than 9), and eliminate the following three anatomic criteria: pelvic fracture, flail chest, and 2 long bone fractures.

Researchers compared trauma registry data for 1955 patients who were admitted during an 18-month period before the criteria were changed and for 1844 patients who were admitted during an 18-month period after the change; 95% of patients had blunt injuries. After the change, the proportion of cases that led to trauma team activation was significantly lower overall (18% vs. 12%) and during nights and weekends (19% vs. 13%). The mean Injury Severity Score among cases that led to trauma team activation was significantly higher after the change (22.96 vs. 28.57), yet mortality did not change significantly. Among patients with systolic BP between 80 and 90 mm Hg, mortality decreased after the change (7 deaths among 23 patients vs. 0 deaths among 22 patients). The percentage of laparotomies that were performed more than 2 hours after arrival did not change.

Comment: As resources for trauma become increasingly limited, fewer physicians are opting to be trauma surgeons because of the high workload, the concentration of work on nights and weekends, and the risk for exposure to pathogens such as HIV (especially among victims of penetrating trauma). In this study, the changes in criteria for trauma team activation diminished the demand on resources and the workload for trauma surgeons, without compromising patient care.

— John A. Marx, MD. Published in Journal Watch Emerg Med January 30, 2009. Citation:
Shapiro MJ et al. Let the surgeon sleep: Trauma team activation for severe hypotension. J Trauma 2008;65:1245.

14. Oral Prednisolone May Not Be Helpful for Acute Virus-Induced Wheezing in Children

Laurie Barclay, MD. January 22, 2009 — Oral prednisolone is not superior to placebo in shortening hospitalization or improving other outcomes in preschool children with mild to moderate wheezing associated with a virus infection, according to the results of a randomized, double-blind, placebo-controlled trial reported in the January 22 issue of the New England Journal of Medicine.

"Attacks of wheezing induced by upper respiratory viral infections are common in preschool children between the ages of 10 months and 6 years," write Jayachandran Panickar, MD, MRCPCH, from University of Leicester, in Leicester, United Kingdom, and colleagues. "A short course of oral prednisolone is widely used to treat preschool children with wheezing who present to a hospital, but there is conflicting evidence regarding its efficacy in this age group."

In this study, 700 children aged 10 to 60 months who presented to 3 hospitals in England with an attack of wheezing associated with a virus infection were randomly assigned to a 5-day course of oral prednisolone (10 mg once a day for children aged 10 to 24 months and 20 mg once a day for older children) or placebo. Of 687 children included in the intent-to-treat analysis, 343 were in the prednisolone group and 344 in the placebo group. The main endpoint of the study was the duration of hospitalization, and secondary endpoints were the Preschool Respiratory Assessment Measure (PRAM) score, albuterol use, and a 7-day symptom score.

The placebo group and the prednisolone group were not significantly different in the duration of hospitalization (13.9 vs 11.0 hours; ratio of geometric means, 0.90; 95% confidence interval, 0.77 - 1.05), in the interval between hospital admission and signoff for discharge by a clinician, or in any of the secondary outcomes or the number of adverse events.

"In preschool children presenting to a hospital with mild-to-moderate wheezing associated with a viral infection, oral prednisolone was not superior to placebo," the study authors write. "We found no evidence that a short course of an oral corticosteroid significantly shortened the duration of hospitalization or significantly reduced markers of the severity of symptoms, as assessed by either physicians or parents," the study authors conclude. "Our results suggest that oral prednisolone should not be routinely given to preschool children presenting to the hospital with acute, mild-to-moderate virus-induced wheezing."

In an accompanying editorial, Andrew Bush, MD, from the Imperial School of Medicine at the National Heart and Lung Institute and the Royal Brompton Hospital, London, United Kingdom, notes that prednisolone should be administered to preschoolers only when they are severely ill in the hospital and that intermittent, high-dose inhaled corticosteroids should not be used.

"Also needed is follow-up of all preschool children enrolled in therapeutic trials to see who will go on to have persistent, atopic, multitrigger wheezing (true asthma)," Dr. Bush writes. "The data from the studies should be analyzed retrospectively to determine whether the response to treatment for acute episodes in preschoolers in whom true asthma develops differs from that in patients in whom symptoms subsequently regress. My suspicion is that there will be no difference."

N Engl J Med. 2009;360:329-338, 409-410.
Abstract: http://content.nejm.org/cgi/content/abstract/360/4/329

15. Standard Needle for Pneumothorax Decompression Might Not Reach the Pleural Space

Chest wall thickness was greater than the length of a standard needle in half the patients in this small study.

Objective. Tension pneumothorax can lead to cardiovascular collapse and death. In the prehospital setting, needle thoracostomy for emergent decompression may be lifesaving. Taught throughout the United States to emergency medical technicians (EMTs) and physicians, the true efficacy of this procedure is unknown. Some question the utility of this procedure in the prehospital setting, doubting that the needle actually enters the pleural space. This study was designed to determine if needle decompression of a suspected tension pneumothorax would access the pleural cavity as predicted by chest computed tomography (CT).

Methods. We retrospectively reviewed consecutive adult trauma patients admitted to a level I trauma center between January and March 2005. We measured chest wall depth at the second intercostal space, midclavicular line on CT scans. Data on chest wall thickness were compared with the standard 4.4-cm angiocatheter used for needle decompression.

Results. Data from 110 patients were analyzed. The mean age of the patients was 43.5 years. The mean chest wall depth on the right was 4.5 cm (± 1.5 cm) and on the left was 4.1 cm (± 1.4 cm). Fifty-five of 110 patients had at least one side of the chest wall measuring greater than 4.4 cm.

Conclusions. The standard 4.4-cm angiocatheter is likely to be unsuccessful in 50% (95% confidence interval = 40.7-59.3%) of trauma patients on the basis of body habitus. In light of its low predicted success, the standard method for treatment of tension pneumothorax by prehospital personnel deserves further consideration.

Stevens RL, et al. Prehospital Emerg Care. 2009;13:14-17.

16. Teens’ Ability to “Text” indicates Full Post-Syncopal Recovery

Sinclair M, et al. BMJ 2008;337:a2723

Festival Medical Services is a charitable trust that provides music festivals throughout the United Kingdom with doctors, nurses, paramedics, first aiders, and other trained medical and administrative staff. One of the authors (MS) is the coordinator for the Festival Medical Services "pit crew." This team provides a resuscitation facility for the audience at the two main stages at Glastonbury and Reading festivals as well as a triage system to sort or treat people who need medical attention. The team follows the advice of the Third Annual Rock Concert Safety Survey Report published by Crowd Management Strategies in February 1995 (www.crowdsafe.com/mosh.html).

Festival Medical Services has a small tent (3 m x 3 m) at the side of these stages, with resuscitation equipment as suggested by the Resuscitation Council UK’s recommended minimum equipment for inhospital adult resuscitation. A consultant anaesthetist, two nurses, an operating department practitioner, and at least two first aiders are present from when the first band appears on stage until the last band of the day finishes.

Three years ago we noticed that most of the patients with faint or panic attack were teenagers and as soon as they could they used their mobile phones to send an SMS (short message service) text message to their friends. SMS allows the interchange of short text messages between mobile phones. About 1.4 billion text messages are sent in the UK alone every week, according to the Mobile Data Association (www.text.it).

The ability to text, whether or not it actually makes sense, requires a Glasgow coma scale score of 15 (fully conscious), an adequately functioning "executive system" in the frontal lobes, and a high degree of manual dexterity and psychomotor coordination. It also shows a degree of common sense not always evident in teenagers.

Two years ago we decided to use this texting sign as an indication that patients had recovered from their faint or panic attack and were orientated and coordinated enough to be discharged back to the festival. At times of massive influx to the medical tent, when up to two patients a minute are triaged, this system seems to work well.

This year at the Reading festival we managed, with only one consultant anaesthetist, two accident and emergency nurses, one operating department practitioner, and two to four first aiders, to treat 142 patients in less than 60 minutes during the performance by Bloc Party and 130 patients over 90 minutes during the performance by Rage Against the Machine. The texting sign needs further investigation to determine whether it is a valid criterion for recovery after faint or panic attack at festivals as well as in busy accident and emergency departments.

17. Recurrence Common Following Emergency Treatment of Headache

NEW YORK (Reuters Health) Dec 30 - Headache patients treated at the emergency department frequently experience pain and functional impairment following discharge, regardless of type of primary headache disorder, according to a study reported in the December issue of the Annals of Emergency Medicine.

Headache is the fifth most common emergency department (ED) complaint. "Effective treatments for the acute headache exist, but patients often have a recurrence or persistence of the initial headache after ED discharge," write Dr. Benjamin W. Friedman and colleagues from Albert Einstein College of Medicine, Bronx, New York.

In a prospective cohort study, the researchers examined the frequency of moderate or severe headache during the first 24 hours after an ED visit for a primary headache disorder, and determined the burden of headache-related functional impairment during the 3 months after the ED visit.

The team enrolled 309 primary headache disorder patients during their initial ED visit over an 18-month period. The subjects were interviewed using a standardized questionnaire, and were followed by telephone 24 hours and 3 months after discharge. All headaches were classified according to the International Headache Society criteria by two emergency physicians.

The most common primary headache diagnoses were migraine, tension-type headache, and unclassifiable recurrent headache disorder. Ninety-four percent of patients were successfully followed-up at both time points.

Within 24 hours of ED discharge, 31% of migraine patients, 19% of tension-type headache patients, and 27% of the unclassifiable headache patients experienced moderate or severe headache.

Overall, 37% of migraine patients, 38% of tension-type headache patients, and 26% of the unclassifiable headache patients experienced headache-related functional impairment during the 3 months after discharge.

"Of the 2 hypothesized predictors of poor 24-hour outcome, duration of headache and discharge pain intensity, only duration of headache seemed an independent predictor of moderate or severe headache in the 24 hours after ED discharge," Dr. Friedman and colleagues report.

"Additional independent predictors of moderate or severe headache within 24 hours were severe baseline pain, presence of nausea, and a positive response to depression screening questions." The only independent predictor of poor 3-month outcomes was Medicaid insurance.

The team notes that the best treatment for postdischarge headache has not been determined. "Absent data," they advise, "it is reasonable practice to provide an oral agent with known efficacy in acute migraine or acute tension type headache, such as a triptan, a migraine-specific combination, an oral antiemetic combined with a nonsteroidal anti-inflammatory drug, or a nonspecific analgesic."

Ann Emerg Med 2008;52:696-704.

18. Preoxygenation for Emergency Intubation: Longer Is Not Better

Preoxygenation beyond 4 minutes adds no benefit.

Objective: To determine the effectiveness of increasing the preoxygenation period with 100% oxygen in the critically ill patient from 4 to 8 mins in preparation for emergency tracheal intubation.

Design: Nonrandomized, controlled trial.

Setting: Large, level one trauma center, tertiary care intensive care unit.

Patients: Critically ill patients failing noninvasive respiratory support techniques who required tracheal intubation followed by mechanical ventilation.

Interventions: A baseline arterial blood gas was obtained on noninvasive passive therapy and at 4, 6, and 8 mins of active preoxygenation efforts with 100% oxygen therapy with a noncollapsing resuscitator bag and mask. Best effort to achieve a tight fitting mask seal was pursued coupled with other mask ventilation maneuvers to optimize noninvasive oxygenation and ventilation.

Measurements and Main Results: Thirty-four patients consecutively intubated by the author during the 7-month study period were studied. The baseline Pao2 (mean ± sd) with concurrent noninvasive support was 61.9 ± 14.6 mm Hg (range: 44-109 mm Hg) and increased a mean of 22 mm Hg to 83.8 ± 51.5 mm Hg after 4 mins of preoxygenation (p less than 0.01). Continued preoxygenation efforts (6 mins) increased the Pao2 to 88.2 mm Hg ± 48.5 and after 8 mins to 92.7 mm Hg ± 55.2. At the 8-min mark, 5 of 34 patients achieved greater than 10% increase in their Pao2 and only two patients increased their 4-min Pao2 by 50 mm Hg or more after the additional 4 mins of preoxygenation. One quarter of the patients experienced a reduction in their Pao2 from the 4 to the 8-min time period. Nearly, 50% of the patients met the criteria for desaturation during the intubation procedure.

Conclusions: Extending the preoxygenation period from the customary 4 mins to either 6 or 8 min seems to be marginally effective in the majority of patient suffering from cardiopulmonary deterioration and such an extension may jeopardize oxygenation efforts in some patients.

Mort TC, et al. Critical Care Medicine 2009;37:68-71.

19. Recommendations for Prevention of Recurrent Stroke Reviewed

Laurie Barclay, MD. January 27, 2009 — Recommendations for prevention of recurrent stroke are reviewed in the January issue of Mayo Clinic Proceedings. In addition to control of modifiable risk factors, virtually all patients who have had ischemic stroke should be prescribed antiplatelet agents.

"Stroke is the leading cause of death and disability in the United States," writes Harold Adams Jr, MD, from the University of Iowa in Iowa City. "The economic consequences of stroke, including health care costs and lost economic productivity, are substantial. These are the reasons that stroke prevention, including treatment of underlying causes, are clearly of critical importance."

The leading cause of ischemic stroke is atherosclerotic vascular disease, which gives rise to occlusion or severe stenosis of major intracranial or extracranial arteries, as well as narrowing of small penetrating arteries of the brain.

Coronary artery disease, or atherosclerosis of the coronary arteries, may result in myocardial infarction, which in turn is an indirect cause of cardioembolic stroke. Atrial fibrillation and cardioembolic stroke may also complicate ischemic heart disease.
"Some risk factors associated with increased likelihood of advanced atherosclerosis and ischemic disease are not modifiable," Dr. Adams writes. "These risk factors include age, sex, ethnicity, family history and premature vascular disease. However, several conditions that augment the course of atherosclerosis can be effectively addressed across the continuum of care."

For patients with symptomatic ischemic cerebrovascular disease, a crucial aspect of treatment is prevention of recurrent stroke, myocardial infarction, and other ischemic events. This requires optimal control of modifiable risk factors that accelerate development of atherosclerosis, such as hypertension, hyperlipidemia, diabetes mellitus, and smoking.

Management of hypertension should aim to achieve a normal blood pressure for the patient, realizing that no single, specific antihypertensive regimen is ideal for all patients. When prescribing a blood pressure–lowering treatment plan, clinicians should consider a patient's history, while awaiting the results of ongoing and future studies.

Some evidence suggests that aggressive lowering of cholesterol levels may modestly increase the risk for hemorrhagic stroke. However, the benefits of statins to decrease the risk for recurrent ischemic stroke and other ischemic vascular events are thought to outweigh the risk of bleeding. In patients with diabetes mellitus, management should include aggressive control of blood pressure and lipid levels as well as of blood glucose levels.

More aggressive interventions may be required, such as carotid endarterectomy and endovascular treatment. In selected patients, carotid endarterectomy should be considered as complementary to use of antiplatelet agents and other medications. For other patients with atherosclerotic cerebrovascular disease, extracranial-intracranial bypass surgery and carotid artery stenting may be considered, pending the results of ongoing clinical trials.

The keystone of management to prevent recurrent stroke and other cardiovascular events in patients at risk continues to be administration of antiplatelet agents, which should be prescribed for virtually all patients who have had ischemic stroke. Therapeutic options include aspirin, aspirin plus extended-release dipyridamole, or clopidogrel. Specific choice among these should be guided by the patient's previous treatment and history of ischemic events as well as allergies or other potential contraindications.

Specific recommendations of the American Heart Association/American Stroke Association for antithrombotic therapy in patients with ischemic stroke of noncardioembolic origin (secondary prevention), and their accompanying levels of evidence, are as follows:

Antiplatelet agents are recommended vs oral anticoagulants (level of evidence, I, A).

Preferred options for initial treatment are aspirin (50 - 325 mg/day), a combination of aspirin and extended-release dipyridamole, or clopidogrel (level of evidence, I, A).

The combination of aspirin and extended-release dipyridamole may be preferred vs aspirin alone (level of evidence, I, B).

Instead of aspirin alone, clopidogrel may be considered (level of evidence, IIb, B).

Clopidogrel is a reasonable option for patients who are hypersensitive to aspirin (level of evidence, IIa, B).

Addition of aspirin to clopidogrel increases the risk for hemorrhage (level of evidence, III, A).

"Use of an integrated treatment approach involving risk-factor management, antiplatelet therapy and surgical procedure when indicated presents the opportunity to lower the risk of recurrent stroke and other ischemic events in patients with recent ischemic stroke," Dr. Adams concludes. "Future research may provide support for using new medications, clarify the role of currently available medications, and better define the appropriate role of surgery, particularly endovascular treatments."

In an accompanying editorial, James F. Meschia, MD, from the Mayo Clinic in Jacksonville, Florida, confirms that "after the immediate post-thrombolytic period, care needs to focus on secondary prevention."

"Patients with acute ischemic stroke are at high risk of recurrent stroke," Dr. Meschia writes. "If successful reperfusion therapy is like dodging a bullet, successful secondary prevention is like being caught in the line of fire again. [Dr. Adams'] review will be welcomed by clinicians seeking guidance beyond evidence-based guidelines."

Mayo Clin Proc. 2009;84:3-4,43-51.

20. Guidelines Issued for Field Triage of Injured Patients

Laurie Barclay, MD. January 27, 2009 — The National Expert Panel on Field Triage has issued guidelines for field triage of injured patients and has published the new recommendations in the January 23 issue of Morbidity and Mortality Weekly Report. Because not all patients require the services of a Level I trauma center (TC), those with less severe injuries may be transported to a closer emergency department (ED) capable of managing milder injuries.

"In the United States, injury is the leading cause of death for persons aged 1–44 years, and the approximately 800,000 emergency medical services (EMS) providers have a substantial impact on the care of injured persons and on public health," write Scott M. Sasser, MD, from the Division of Injury Response, National Center for Injury Prevention and Control, Atlanta, Georgia, and colleagues. "At an injury scene, EMS providers determine the severity of injury, initiate medical management, and identify the most appropriate facility to which to transport the patient through a process called 'field triage.'...Determining the appropriate facility to which an injured patient should be transported can have a profound impact on subsequent morbidity and mortality."

In addition to basic emergency services, which are generally available in all hospital EDs, designated TCs are those hospitals with additional expertise, resources, and equipment to treat severely injured patients.

Classification of TCs is based on the scope of resources and services available. Level I TCs provide the highest level of trauma care, Levels II and III are intermediate, and Level IV centers provide initial trauma care and transfer to a higher level of trauma care if needed.

Although the risk for death is 25% lower for a severely injured person treated at a Level I TC, not all patients need the level of services available at a Level I TC. The guidelines suggest that less severely injured patients might be better served by being transported to a closer ED capable of managing milder injuries and that transferring all injured patients to Level I TCs could place an unnecessary load on these centers, negatively affect patient outcomes, and reduce cost effectiveness.

The Field Triage Decision Scheme (Decision Scheme), first developed by the American College of Surgeons in 1986, serves as the basis for triage protocols for state and local EMS systems across the United States. To help determine the most appropriate destination facility within the local trauma care system, this algorithm guides EMS providers through 4 decision points: physiologic concerns, anatomic considerations, mechanism of injury, and special considerations.

The Decision Scheme has been revised 4 times since it was first published in 1986. To facilitate revision of the Decision Scheme, the US Centers for Disease Control and Prevention hosted a series of meetings of the National Expert Panel on Field Triage in 2005, with support from the National Highway Traffic Safety Administration.

The expert panel, which includes injury-care providers, public health professionals, automotive industry representatives, and officials from federal agencies, reviewed pertinent literature, presented its findings, and agreed on necessary revisions allowing publication of the revised Decision Scheme in 2006. The report published in the Morbidity and Mortality Weekly Report details the process and rationale used by the expert panel to revise the Decision Scheme.

Full-text: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5801a1.htm