From the recent medical literature...
1. TIA Work-Up as Outpatient Assessment of Clinical Evaluation and Safety
Olivot J, et al. Stroke. 2011;42:1839-1843.
Background and Purpose—To evaluate a novel emergency department-based TIA triage system.
Methods—We developed an approach to TIA triage and management based on risk assessment using the ABCD2 score in combination with early cervical and intracranial vessel imaging. It was anticipated that this triage system would avoid hospitalization for the majority of TIA patients and result in a low rate of recurrent stroke. We hypothesized that the subsequent stroke rate among consecutively encountered patients managed with this approach would be lower than predicted based on their ABCD2 scores.
Results—From June 2007 to December 2009, 224 consecutive patients evaluated in the Stanford emergency department for a possible TIA were enrolled in the study. One hundred fifty-seven were discharged to complete their evaluation at the outpatient TIA clinic; 67 patients were hospitalized. One hundred sixteen patients had a final diagnosis of TIA/minor stroke or possible TIA. The stroke rates at 7, 30, and 90 days were 0.6% (0.1%–3.5%) for patients referred to the TIA clinic and 1.5% (0.3%–8.0%) for the hospitalized patients. Combining both groups, the overall stroke rate was 0.9% (0.3%–3.2%), which is significantly less than expected based on ABCD2 scores (P=0.034 at 7 days and P=0.001 at 90 days).
Conclusions—This emergency department-based inpatient versus outpatient TIA triage system led to a low rate of hospitalization (30%). Recurrent stroke rates were low for both the hospitalized and outpatient subgroups.
2. Does Epinephrine Help Cardiac Arrest Victims Survive?
By Kerry Grens. NEW YORK (Reuters Health) Jul 14 - Epinephrine is a standard component of resuscitation for cardiac arrest, but in a controversial study from Australia it did little to increase patients' survival.
Researchers did find, however, that patients who received epinephrine were more likely to have pre-hospital return of spontaneous circulation, a result the researchers say supports the use of adrenaline.
"My guess is (the study) probably is not going to change how we practice currently, but it may stimulate a larger study on the role of epinephrine in out-of-hospital cardiac arrests," said Dr. Gordon Tomaselli, the president of the American Heart Association and the director of the Division of Cardiology at Johns Hopkins University School of Medicine, who was not involved in this new work.
In the randomized trial, reported online July 2nd in Resuscitation, more than 500 patients in Western Australia received either epinephrine or saline from emergency teams.
On the primary outcome of the study - survival to hospital discharge - the difference was not statistically significant: 1.9% in the saline group vs 4.0% in the adrenaline group.
However, the epinephrine-treated patients were more likely to have had a return of spontaneous circulation by the time they arrived at the hospital (23.5% vs 8.4%; odds ratio, 3.4).
"Although the results were statistically negative on the important outcomes, the trend was in the right direction," Dr. Tomaselli told Reuters Health.
Dr. Ian Jacobs, the lead author of the study and a professor at the University of Western Australia, told Reuters Health in an email that epinephrine should still be part of routine care.
"This is particularly so as we further identify and understand those post (return-to-circulation) factors which contribute to survival," Dr. Jacobs said.
He believes that if he had been able to include more patients in the study, he might have found an actual improvement in survival with epinephrine. But he had difficulty getting ambulance crews to participate.
"In short, the fact that adrenaline was considered standard of care -- albeit unproven -- some paramedics felt that this trial was unethical and went to the media," Dr. Jacobs said. Ultimately, those paramedics did not participate.
He said that the Human Research Ethics Committee under the Australian National Health and Medical Research Council, which funded the study, provided the researchers with a waiver for consent from the patients to participate.
The study was approved by "numerous Human Research Ethics Committees, Guardianship Boards and Departments of Crown Law," Dr. Jacobs added.
Consent from patients in an emergency setting is very difficult, Dr. Tomaselli said, which explains why there have been no studies like this to date.
"If we say, 'because you can't get consent, you can't do any studies,' then we should give up on any studies in cardiac arrest at all. I don't think that's the way we should go," Dr. Tomaselli said.
Resuscitation. 2011 Jul 2. [Epub ahead of print]
PubMed Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21745533
3. Loading Dose of Clopidogrel Safe in Elderly MI Patients
NEW YORK (Reuters Health) Jul 12 - Giving elderly patients with acute MI a clopidogrel loading dose of 300 mg or more rather than a lower conventional dose doesn't increase the risk of serious bleeding -- but it doesn't increase survival, either.
Those findings are reported in the American Journal of Cardiology online July 4 by Dr. Etienne Puymirat, with Hopital Europeen Georges Pompidou, Paris, and L'Universite Paris Descartes, and colleagues.
The authors examined data from a nationwide registry on more than 3,000 MI patients admitted to the ICU within 48 hours of symptom onset, including 791 patients at least 75 years old (mean age 81 years) given a known dose of clopidogrel.
Within this cohort, 466 patients (59%) received a loading dose of at least 300 mg (ranging from 300 mg in the majority up to 900 mg in one patient). The other 325 patients (41%) received a conventional dose (75 mg in most cases but up to 225 mg in some patients).
The rate of major bleeding was not significantly different in patients who received a higher loading dose than in those given a conventional dose (3.2% vs. 3.7%). Similarly, there was no significant difference in proportions of patients needing blood transfusions (5.4% vs. 6.2%, respectively).
On logistic regression analysis, giving a loading dose rather than a conventional dose of clopidogrel did not affect mortality at 30 days (odds ratio 1.15) or at 12 months (hazard ratio 1.00). Survival free of stroke or repeat MI was also not significantly different (HR 0.92)
"The present data, gathered from a nationwide 'real-world' registry of patients admitted for acute MI, indicate that in an elderly population the use of a clopidogrel loading dose at the acute stage of MI is not associated with an increase in major bleeding or a significant independent effect on mortality or hard events at one year," Dr. Puymirat and colleagues conclude.
That said, they add, "Large-scale randomized trials are still needed to identify the optimal loading dose of clopidogrel for elderly patients admitted for acute MI."
Am J Cardiol. 2011 Jul 2. [Epub ahead of print]
PubMed abstract: http://www.ncbi.nlm.nih.gov/pubmed/21726837
4. When the Snake Bites ... Try Ointment
by Mitch Leslie, Science Now, 26 June 2011.
Don't tread on me. An ointment might help people bitten by the eastern brown snake of Australia or other snakes.
Time is the foe for people who have been bitten by a poisonous snake, but a new study may give them a bit more of it. Researchers have identified an ointment that slows the spread of some kinds of snake venom through the body, potentially giving snakebite victims longer to reach a hospital or clinic.
Although poisonous snakes kill only a handful of people in the United States each year, the World Health Organization puts the global toll at about 100,000 people. When some snakes strike, the bulky proteins in their venom don't infiltrate the bloodstream immediately but wend through the lymphatic system to the heart. In Australia, a country slithering with noxious snakes, the recommended first aid for a bite includes tightly wrapping the bitten limb to shut the lymphatic vessels—a method called pressure bandage with immobilization (PBI). The idea is to hamper the venom's spread until the victim can receive antivenom medicine, essentially antibodies that lock onto and neutralize the poison. But PBI is not practical if the bite is on the torso or face, and one study found that even people trained to perform the technique do it right only about half the time. As a result, some people don't get antivenom in time.
So physiologist Dirk van Helden of the University of Newcastle in Australia and colleagues went looking for a chemical method to detain the venom. They settled on an ointment that contains glyceryl trinitrate, the compound better known as nitroglycerin that doctors have used to treat everything from tennis elbow to angina. The ointment, prescribed for a painful condition called anal fissures, releases nitric oxide, causing the lymphatic vessels to clench. The researchers first injected volunteers in the foot with a harmless radioactive mixture that, like some snake toxins, moves through the lymphatic vessels. In control subjects that didn't receive the ointment, the mixture took 13 minutes to climb to the top of the leg. But it required 54 minutes if the researchers immediately smeared the ointment around the injection site, the team reports online today in Nature Medicine.
To determine whether the ointment improved survival, the researchers injected the feet of anesthetized rats with venom from the eastern brown snake, a cobra relative that is one of Australia's deadliest, and measured how much time elapsed before the rodents stopped breathing. Rats lived about 50% longer if the researchers slathered the rodents' hind limbs with the cream.
Although the team can't specify how many minutes or hours the treatment might buy, the findings suggest that "it gives you time and a half to get help," says van Helden. "I'd prefer that to just time." He says that hikers and people who work in rural areas might consider carrying the cream in case they get bitten when they are far from medical facilities.
The method is "very exciting," says Steven Seifert, medical director of the New Mexico Poison and Drug Information Center in Albuquerque. "It makes sense to try to slow the passage of the venom into the circulation." Medical toxicologist Eric Lavonas, associate director of the Rocky Mountain Poison and Drug Center in Denver, Colorado, is also impressed. "This is really promising," he says. The authors "did the right studies to evaluate this approach."
Still, Seifert and Lavonas question whether such a treatment would do much good in the United States. Australian snakes largely inject neurotoxic venom that spreads through the body and attacks the nervous system, triggering paralysis. The perpetrators of most U.S. snakebites are rattlesnakes, copperheads, and cottonmouths, which inject a different type of venom that mainly destroys the tissue near the bite. But the researchers note that the ointment could prove valuable in many other countries inhabited by dangerous snakes, such as cobras, mambas, and kraits, that produce neurotoxic venom. "If this treatment pans out, it may revolutionize first aid for snakebite in parts of the world where venom causes paralysis," Lavonas says.
Nat Med. 2011 Jun 26;17(7):809-11.
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21706027
5. What reverses overanticoagulation in the elderly?
Reversal of Overanticoagulation in Very Elderly Hospitalized Patients with an INR above 5.0: 24-Hour INR Response after Vitamin K Administration
Pautas E, et al. Amer J Med, 2011;124:527-533.
In elderly inpatients with INR above or equal to 5.0, both vitamin K antagonist dose omission and vitamin K1 administration according to recommendations were effective in reversing overanticoagulation, allowing most INRs to return to the 1.8-3.2 range without excessive overcorrection. These authors conclude that the American College of Chest Physicians recommendations may be applied to elderly inpatients.
PubMed abstract: http://www.ncbi.nlm.nih.gov/pubmed/21605730
To see how UCLA has adapted the ACCP guidelines, cf http://medres.med.ucla.edu/Practices/Guidelines_anticoagulation.pdf
6. Believe It or Not: Painless Reduction of Dislocated Shoulders
Shaw, Gina. EM News. June 2011.
There are literally dozens of methods emergency physicians can use to reduce a dislocated shoulder, but they all have one thing in common: they hurt. Some are less painful than others, but in most emergency departments, the majority of patients undergoing closed shoulder reduction need at least some level of sedation to help them manage their pain during the procedure.
That's why Graham Walker, MD, was so skeptical when he saw an online video in which Australian physician Neil Cunningham, MBBS, reduced a dislocated shoulder in less than two minutes, using only massage.
“I didn't believe it,” said Dr. Walker, the chief resident in emergency medicine at St. Luke's-Roosevelt Hospital in New York City. “A painless shoulder reduction with no pulling and no sedation?”
Impossible — or so he thought until early March, when he got the chance to try the technique for himself. The pediatric emergency room at St. Luke's-Roosevelt was swamped, and when a 16-year-old boy came in after having been pushed and fallen onto his shoulder, Dr. Walker decided to give the Cunningham technique a try to avoid tying up a nurse with a procedural sedation.
Within three minutes, the patient's shoulder was back in place. “I was amazed,” he said.
Dr. Cunningham's technique works like this: Seat the patient comfortably, as upright as possible, with shoulders relaxed. Supporting the affected arm, slowly and gently move the humerus into full adduction. Gently massage the trapezius and deltoids; this helps to relax the patient and reassures them that the doctor is not going to do anything painful.
Then, move on to gently massaging the biceps at the mid-humeral level. Ask the patient to shrug her shoulders, continuing the biceps massage. Wait for the patient to relax fully, and the humeral head will slip back into place. (Warn the patient that it may feel strange as this happens and not to fight against the movement.)
Dr. Cunningham, now a staff specialist in the emergency department at St. Vincent's Hospital in Melbourne, Australia, developed the technique while working in a busy ED that was often so full that he would see patients on gurneys in the ambulance bay and sitting in corridors. “While holding patients' arms waiting for analgesia to be drawn up, I found that I could relieve their pain with positioning and by encouraging them to relax the spasming muscles with a combination of talking and massaging the muscles,” he explains. “After shoulders started reducing faster than the analgesia could be drawn up, I returned to the anatomy books to work out both the different positions of structures, and the different forces resulting from overstretched ligaments, joint capsules, and spasming muscles.”
As Dr. Walker found, the technique is not difficult to learn. “The combination of humerus and scapular positioning and specific muscle massage is fairly straightforward to grasp,” Dr. Cunningham said. “I have seen emergency physicians surprise themselves with this technique when they find the correct position and reduce a shoulder in less than five minutes on a patient twice their size.”
Because the technique is so simple, painless, and requires no sedation, should it be used for all shoulder dislocations? Absolutely not, Dr. Cunningham said. He doesn't even always use it himself (although he starts with it in about 70% of cases). If the patient can't relax enough to cooperate, or the arm can't be adducted, for example, the approach won't work. “The technique should match the patient, not the other way round,” Dr. Cunningham said.
To maximize the chance of success, Dr. Cunningham takes time to prepare the patient before laying a hand on him. “Explaining to a patient what you are going to do and that you are not going to pull their arm at any point is really important to reduce anxiety,” he says.
Instead of supporting underneath the affected limb, he grips the forearm or elbow with gentle but steady pressure, which moves the humeral head back slightly toward its usual position, which reduces the patient's pain. ”Encouraging the patient to relax verbally and with massage, followed by slow, gentle movements will allow you to get to your starting position,” he said.
With some patients, you'll never get to this point — they're simply too agitated to attempt a technique like this. For them, analgesia and sedation is a must. “Using drugs in these patients is a recognition that muscle relaxation is going to be impossible otherwise, meaning that either your chosen technique will not work, or you will hurt your patient as they fight any movement you attempt,” Dr. Cunningham said. “Once you have sedated your patient, it is then important to use a technique suitable for your patient, not just pulling hard.”
In Dr. Walker's ED, the other residents and attendings are now looking for shoulder dislocations, eager to try the Cunningham technique for themselves. “I've had a patient for whom it didn't work,” he said. “She was obese and very tense, and just not a good candidate. But with the right patient, it's so simple and a great alternative to techniques that require sedation.”
The hardest part of the technique, Dr. Cunningham said, has been convincing others that it works. “There has been such a reliance on drugs and traction techniques that it can be difficult to persuade some people to change their thinking. But anyone who has reduced a shoulder within a couple of minutes with no drugs and no pain will certainly see the benefits of a non-traction technique.”
To view videos of the technique in action and read detailed instructions, visit Dr. Cunningham's website at www.shoulderdislocation.net
7. Unimpressive Effect of Nesiritide in Patients with Acute Decompensated Heart Failure
O'Connor CM, et al. N Engl J Med 2011; 365:32-43.
Background: Nesiritide is approved in the United States for early relief of dyspnea in patients with acute heart failure. Previous meta-analyses have raised questions regarding renal toxicity and the mortality associated with this agent.
Methods: We randomly assigned 7141 patients who were hospitalized with acute heart failure to receive either nesiritide or placebo for 24 to 168 hours in addition to standard care. Coprimary end points were the change in dyspnea at 6 and 24 hours, as measured on a 7-point Likert scale, and the composite end point of rehospitalization for heart failure or death within 30 days.
Results: Patients randomly assigned to nesiritide, as compared with those assigned to placebo, more frequently reported markedly or moderately improved dyspnea at 6 hours (44.5% vs. 42.1%, P=0.03) and 24 hours (68.2% vs. 66.1%, P=0.007), but the prespecified level for significance (P≤0.005 for both assessments or P≤0.0025 for either) was not met. The rate of rehospitalization for heart failure or death from any cause within 30 days was 9.4% in the nesiritide group versus 10.1% in the placebo group (absolute difference, −0.7 percentage points; 95% confidence interval [CI], −2.1 to 0.7; P=0.31). There were no significant differences in rates of death from any cause at 30 days (3.6% with nesiritide vs. 4.0% with placebo; absolute difference, −0.4 percentage points; 95% CI, −1.3 to 0.5) or rates of worsening renal function, defined by more than a 25% decrease in the estimated glomerular filtration rate (31.4% vs. 29.5%; odds ratio, 1.09; 95% CI, 0.98 to 1.21; P=0.11).
Conclusions: Nesiritide was not associated with an increase or a decrease in the rate of death and rehospitalization and had a small, nonsignificant effect on dyspnea when used in combination with other therapies. It was not associated with a worsening of renal function, but it was associated with an increase in rates of hypotension. On the basis of these results, nesiritide cannot be recommended for routine use in the broad population of patients with acute heart failure.
8. Doctors often struggle to show compassion while dealing with patients
Manoj Jain, Washington Post. May 16, 2011
I was standing at my patient’s bedside. Mike Venata was having chills with a temperature of 103. Sweat covered his balding scalp like dew, then coalesced and rolled down past his staring eyes.
Just 20 minutes earlier, a specialist had informed him that he had metastatic pancreatic cancer and could expect to live less than six months. He was alone. I’d seen him once before; as an infectious-disease specialist, I’d been called in because his fever might be due to an underlying infection.
I wondered: How do I show him compassion?
Many say our health-care system lacks compassion. I too at times feel that pills and surgeries, CT scans and radiation therapies, biopsies and blood tests have become a priority in medicine and that compassion — the “touchy-feely” part of medicine — has become an afterthought in patient care.
After a few days in the hospital, Mr. Venata’s fever subsided, and I asked if I could talk with him about his experience. He was a retired major who earned a Bronze Star in Vietnam, then became an executive for a multinational company, from which he had recently retired. He had never been married. I wanted to talk to him about how doctors should handle end-of-life situations.
I asked, “When you were told your diagnosis of the cancer, what went through your mind?” Sitting by his bedside, I expected to hear the usual description of shock or denial. But his case was different.
“Well, the first thing I wanted to do was — I wish I was 10 years younger, I would have reached across and slapped the [expletive] out of the doctor.” Despite his words, he didn’t look angry, just deeply saddened.
Startled, I asked why.
He told me that the specialist had pulled out a piece of paper with his biopsy results and said, “ ‘Well, this isn’t very good. This is terminal.’ . . . He didn’t talk to me, he talked to a piece of paper. I got a guy sitting here reading the piece of paper telling me I am going to die [then] walking out the door. That was not well executed.”
To him, the heartlessness of the doctor’s presentation was as painful as the news.
For the rest of the Post essay, cf http://tinyurl.com/3apk7y4
9. Diagnostic performance of multidetector CT for suspected acute appendicitis
Pickhardt PJ, et al. Ann Intern Med. 2011 Jun 21;154(12):789-96.
Background: Use of preoperative computed tomography for suspected acute appendicitis has dramatically increased since the introduction of multidetector CT (MDCT) scanners. Objective: To evaluate the diagnostic performance of MDCT for suspected acute appendicitis in adults. Design: Analysis of MDCT findings and clinical outcomes of consecutive adults referred for MDCT for suspected appendicitis from January 2000 to December 2009.
Setting: Single academic medical center in the United States. Patients: 2871 adults.
Measurements: Interpretation of nonfocused abdominopelvic MDCT scans by radiologists who were aware of the study indication. Posttest assessment of diagnostic performance of MDCT for acute appendicitis, according to the reference standard of final combined clinical, surgical, and pathology findings.
Results: 675 of 2871 patients (23.5%) had confirmed acute appendicitis. The sensitivity, specificity, and negative and positive predictive values of MDCT were 98.5% (95% CI, 97.3% to 99.2%) (665 of 675 patients), 98.0% (CI, 97.4% to 98.6%) (2153 of 2196 patients), 99.5% (CI, 99.2% to 99.8%) (2153 of 2163 patients), and 93.9% (CI, 91.9% to 95.5%) (665 of 708 patients), respectively. Positive and negative likelihood ratios were 51.3 (CI, 38.1 to 69.0) and 0.015 (CI, 0.008 to 0.028), respectively. The overall rate of negative findings at appendectomy was 7.5% (CI, 5.8% to 9.7%) (54 of 716 patients), but would have decreased to 4.1% (28 of 690 patients) had surgery been avoided in 26 cases with true-negative findings on MDCT. The overall perforation rate was 17.8% (120 of 675 patients) but progressively decreased from 28.9% in 2000 to 11.5% in 2009. Multidetector computed tomography provided or suggested an alternative diagnosis in 893 of 2122 patients (42.1%) without appendicitis or appendectomy.
Limitation: Possible referral bias, because some patients whose appendicitis was difficult to diagnose on clinical grounds may not have been referred for MDCT for evaluation of suspected appendicitis.
Conclusion: Multidetector computed tomography is a useful test for routine evaluation of suspected appendicitis in adults
10. Rebound Toxicity Rare After Discharge-On-Scene for Opioid Overdose
By Dave Levitan. NEW YORK (Reuters Health) Jul 14 - Ten years of experience with a discharge-on-scene policy for opioid overdose patients in Denmark suggests that there's a low risk of death due to rebound toxicity.
Under the policy, patients are released before hospital admission if "a substantial and lasting improvement of vital signs is obtained as assessed by the treating physician," according to a paper published online ahead of print July 4 in Resuscitation.
Lead author Dr. Soren Rudolph, of Copenhagen University Hospital, told Reuters Health by email that there may be significant advantages to this practice.
"We think that the discharge-on-scene policy leads to a positive attitude towards the MECU [medical emergency care unit] and we think that it may improve the long-term outcome for the entire patient group," he said. "Also, emergency admittances are lowered with more optimal use of resources."
In this study, the authors reported 4,762 cases of acute opioid overdose between 1994 and 2003; a positive identification was obtained in 3,245 of those cases. Patients were treated with naloxone. Among the 3,245 total patients studied, 2,241 were released on-scene, and 18 of those died within 48 hours of release (0.80%). In three of those cases, rebound opioid toxicity was the likely cause of death. (0.13%).
The authors noted that though the risk in the positively identified cohort was very low, the unidentified subjects may have been more likely to have poor social support or other problems that could put them at higher risk of complications.
"Safety is a difficult issue to address as it is difficult to define a specific upper number of deaths that is acceptable," Dr. Rudolph told Reuters Health. "The ideal would of course be not to find any deaths after treatment, but we are dealing with a very non-compliant patient population with a high mortality rate compared to the normal population. We think that it is important to establish a good relationship with these patients and we consider the discharge-on-scene policy as a compromise in that respect."
He added that it would be useful to further study this patient population to determine specific risk factors for rebound overdose, but given the very small number of patients suffering from rebound toxicity in this study, this may be a difficult or impossible task.
Resuscitation. 2011 Jul 2. [Epub ahead of print]
PubMed Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21745532
11. The Brady Bunch, Episode III: Dig Overdose
by Stuart P. Swadron, MD, on June 3, 2011
Overdoses that cause bradycardia and hypotension. Part III: Digitalis glycosides demystified
This is the third installment in a series focusing on the common overdoses that cause bradycardia, hypotension and altered mental status. Over the past several months during interviews with toxicologist Dr. Sean Nordt, we have discussed calcium channel blockers, beta blockers, clonidine and digitalis glycosides. All four classes of drugs can be fatal in overdose and all of them appear on the list of single tablets that can kill a child.
Digoxin is the most commonly encountered digitalis glycoside in the United States but, as Dr. Nordt reminded us, other prescribed forms exist such as digitoxin and ouabain. Digitalis glycosides are also found in the extracts of plants (foxglove, oleander and lily-of-the-valley among many others) and even on the skin of some toads!
Digoxin is somewhat perplexing for many EPs – it’s one of the cardioactive drugs to grasp. At the center of its clinical effect is its direct inhibition of membrane-bound sodium-and potassium-activated adenosine triphosphatase (Na+/K+ ATPase), which leads to an increase in the intracellular concentration of calcium and hence an increase in cardiac contractility. Digoxin is unique among cardiac drugs in that it is both a positive inotrope and a atrioventricular nodal blocker. In addition, digoxin has an pro-arrhythmogenic effect on both the atria and the ventricles. This gives rise to the classic electrocardiographic findings of regularized, slow atrial fibrillation and paroxysmal atrial flutter with a high grade block. Unfortunately, these rhythms are seen only in some cases, with ventricular arrhythmias such as premature ventricular contractions and sustained ventricular tachycardia being more common, and more life-threatening in chronic overdoses.
Digoxin differs from the other three of the “brady bunch” in that it has measurable serum levels. However, serum levels in chronic toxicity may actually be within the normal range of standard reference laboratory values. Moreover, laboratory values may be spurious or erratic in cases involving the more exotic sources of cardiac glycosides, like plant extract ingestion. Therefore, it is the patient’s clinical presentation that is paramount in determining toxicity and the need for therapy.
Acute toxicities are less of a diagnostic challenge. Typically these are younger patients who overdose intentionally. Serum levels will be markedly elevated but because it may take up to six hours for the drug to distribute and levels to stabilize, it is generally recommended that treatment decisions be based on clinical features rather than levels during this initial period. Hyperkalemia, an acute accumulation of extracellular potassium that results from sodium-potassium pump failure, is one of the most important indicators of a life-threatening overdose. Thus, a potassium above 5.0 or 5.5 meq/L is a key trigger for administration of expensive (yet effective) immunotherapy with intravenous digoxin-specific Fab fragments.
Other indications for Fab fragments include hemodynamic instability and ventricular dysrhythmias. In patients with marked bradycardia due to nodal blockade, a trial of atropine may also be effective. While it is acceptable to lower elevated potassium levels with traditional “shifting” agents such as intravenous insulin and bicarbonate boluses, the use of calcium as a membrane stabilizer remains controversial because of historical case reports of cardiac arrest following its use in this setting. Electrical cardioversion is acceptable in patients with sustained ventricular arrhythmias, but much lower energy levels (e.g. 10-50 J) are recommended than in non-poisoned patients. Lastly, gastrointestinal decontamination with activated charcoal can be used to decrease further absorption of digoxin after oral ingestion provided that the patient is alert and not otherwise at risk for aspiration.
In chronic overdoses, the extra-cardiac manifestations of digoxin toxicity may predominate. These include non-specific gastrointestinal symptoms, visual disturbances and altered mental status. Thus, it is not difficult to see why these cases are often missed; the presentation can easily be confused with other conditions such as myocardial ischemia, hypothyroidism and uremia, which by itself often precipitates digoxin toxicity due to decreasing clearance. Potassium values are often low, reflecting the chronic wasting that occurs when potassium is unable to move into cells and over time is eliminated in the urine – a process that is facilitated by concomitant diuretic therapy. Because digoxin toxicity is exacerbated in a low potassium state, repletion of potassium is a critical step in the management of these patients. As in other low potassium states, co-administration of magnesium is also often necessary.
Dr. Swadron is the Vice-Chair for Education in the Dept of EM at the LA County/USC Medical Center. He is an Assoc. Prof. of Clinical EM at USC’s Keck School of Medicine
12. For CO Measurement, Skip the Lab Test; Clip on a Special Pulse Ox
Accuracy of Noninvasive Multiwave Pulse Oximetry Compared with Carboxyhemoglobin From Blood Gas Analysis in Unselected ED Patients
Roth D, et al. Ann Emerg Med. 2011;58:74-79.
Study objective: Accurate and timely diagnosis of carbon monoxide (CO) poisoning is difficult because of nonspecific symptoms. Multiwave pulse oximetry might facilitate the screening for occult poisoning by noninvasive measurement of carboxyhemoglobin (COHb), but its reliability is still unknown. We assess bias and precision of COHb oximetry compared with the criterion standard blood gas analysis.
Methods: This was a prospective diagnostic accuracy study according to STARD (Standards for the Reporting of Diagnostic accuracy studies) criteria, performed at a tertiary care hospital emergency department. We included all patients for whom both invasive and noninvasive measurement within 60 minutes was available, regardless of their complaints, during a 1-year period.
Results: One thousand five hundred seventy-eight subjects were studied, of whom 17 (1.1%) received a diagnosis of CO poisoning. In accordance with this limited patient cohort, we found a bias of 2.99% COHb (1.50% for smokers, 4.33% for nonsmokers) and a precision of 3.27% COHb (2.90% for smokers, 2.98% for nonsmokers), limits of agreement from −3.55% to 9.53% COHb (−4.30% to 7.30% for smokers, −1.63% to 10.29% for nonsmokers). Upper limit of normal cutoff of 6.6% COHb had the highest sensitivity in screening for CO poisoning. Smoking status and COHb level had the most influence on the deviation between measurements.
Conclusion: Multiwave pulse oximetry was found to measure COHb with an acceptable bias and precision. These results suggest it can be used to screen large numbers of patients for occult CO poisoning.
ALSO: Victim of Carbon Monoxide Poisoning Identified by Carbon Monoxide Oximetry
Roth D. J Emerg Med 2011;40:640-642.
Background: Carbon monoxide (CO) is known as a leading cause of unintentional poisoning death in many countries. Diagnosis is usually made by measuring carboxyhemoglobin (COHb), but due to the non-specific symptoms, the crucial step is considering CO poisoning. A possible solution might be screening emergency department (ED) patients. A cutaneous sensor that measures oxygen and CO saturation simultaneously could accomplish that.
Objectives: We report a case in which CO-oximetry screening helped to identify CO poisoning in a patient with otherwise non-specific complaints presenting to a busy university hospital ED.
Case Report: A 53-year-old woman presented to our ED, reporting non-specific but common symptoms including emesis and diarrhea, one-sided headache, paresthesia, and palpitations. Whereas conventional pulse oximetry showed normal results, a COHb level of 28% was measured using a CO-oximeter. This allowed a diagnosis of CO poisoning to be made at admission. The patient was treated with 100% oxygen continuous positive airway pressure ventilation, and CO washout was monitored continuously and non-invasively. In the meantime, the local fire department was alerted and found a malfunctioning water heater as the source of CO in the patient's residence. As COHb fell to normal levels and the patient reported feeling well, she was discharged the next day.
Conclusion: CO-oximetry served as a powerful tool in both identifying and monitoring a CO-poisoned patient in a busy ED. Future studies should address possible sources of error using this method on a long-term basis and its level of acceptance by ED staff.
Related studies: http://www.ncbi.nlm.nih.gov/pubmed/18226877
http://www.ncbi.nlm.nih.gov/pubmed/18568803
13. Anticholinergic Effect Boosts Elderly Death Risk
By Kate Kelland. LONDON (Reuters) Jun 24 - Anticholinergic activity, a side effect of many commonly used drugs including antihistamines and antidepressants, appears to increase the risk of reduced brain function and early death in older people, according to a study published on Friday.
Scientists from Britain's University of East Anglia who led the work said the findings showed it was vital for doctors to regularly review drugs taken by elderly patients to ensure the cumulative risks of side-effects did not outweigh the benefits.
"Our results show a potentially serious effect on mortality," Chris Fox, of UEA's Norwich Medical School, told reporters at a briefing in London.
The study, published online June 24 in the Journal of the American Geriatrics Society, is the first systematic investigation into the long-term impact of anticholinergic activity, which affects the brain by blocking the key neurotransmitter acetylcholine.
"One of the issues is that as we age, we tend to be prescribed more medicines which have an anticholinergic effect, increasing the overall burden," said Ian Maidment, a mental health pharmacist in Britain's National Health Service (NHS).
The researchers devised a ranking system which they called the AntiCholinergic Burden (ACB) score for the anticholinergic effects of more than 80 common prescription and over-the- counter drugs. They assigned scores of 0 for no effect, 1 for mild effect, 2 for moderate effect and 3 for severe effect.
Then they studied more than 13,000 British men and women aged 65 and over for a two-year period.
They found that 20% of participants taking drugs with a total ACB of four or more had died by the end of the two-year study, compared with only 7% of those taking no anticholinergic drugs. For every extra ACB point, the odds of dying increased by 26%, they found.
Those taking drugs with a combined ACB of five or more scored more than 4% lower in a cognitive function tests than those taking no anticholinergic drugs -- a finding that confirmed evidence from previous smaller studies of a link between anticholinergics and mental decline.
And the increased risks from taking anticholinergic drugs were cumulative, based on the number of medicines taken and the strength of each drug's anticholinergic effect.
"It's important to scrutinize medications given to older people very carefully to try to minimize harm as well as gain the desired benefit," said Carol Brayne of the University of Cambridge, who also worked on the study.
The researchers said medications with the ACB impact include nifedipine , codeine, beclometasone, and carbamazepine, and certain tranquilizers.
Fox said that, wherever possible, doctors should "avoid prescribing multiple drugs with anticholinergic effects."
Susanne Sorensen, head of research at the Alzheimer's Society, who was not involved in the study, said its findings must be taken seriously, particularly since loss of cognitive function can be a precursor to the mind-robbing Alzheimer's disease and other forms of dementia.
J Am Geriatr Soc 2011. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21707557
14. Pretest probability estimation in the evaluation of patients with possible DVT
Vinson DR, et al. Am J Emerg Med. 2011 Jul;29(6):594-600.
INTRODUCTION: Most patients who undergo compression ultrasonography in the evaluation of possible deep vein thrombosis have a negative result. Does such a result fully exclude thrombosis from consideration? Not always. An estimation of pretest probability is essential to guide the diagnostic evaluation of such patients. Though compression ultrasonography is the current diagnostic method of choice in the evaluation of patients with possible deep vein thrombosis, a single negative thigh compression ultrasound requires the context of the patient’s pretest probability in order to be properly interpreted. If the probability estimation is low, then a negative compression ultrasound may terminate the diagnostic assessment. However, if the pretest probability is moderate-to-high, then further evaluation is necessary before the posttest incidence of venous thromboembolic disease drops safely below 1% [1].
Pretest probability estimations can be performed using serologic tools such as quantitative D-dimer levels, structured clinical decision tools including the Wells criteria, or the clinician’s unstructured empirical clinical impression of risk [2-6]. Though risk stratification is universally recommended [3-4, 7], implementation outside the regulated confines of clinical trials has been suboptimal [8-9]. Perhaps clinicians are unaware of the indispensible role of a pretest probability determination in the interpretation of ultrasound results. Little is known about the proportion of outpatients with negative compression ultrasound who receive pretest probability assessments and what factors predict risk estimations.
This retrospective health-records study was undertaken in a community hospital to describe the rate and methods of risk stratification performed in outpatients, from the emergency department and the clinics, with a negative compression ultrasound in the assessment of possible lower-extremity deep vein thrombosis. We also sought to determine predictors of pretest probability estimations. Short-term follow-up plans and three-month outcomes were also measured.
METHODS: This cross-sectional study of outpatients was conducted in a suburban community hospital in 2006. Estimation of pretest probability was done by enzyme-linked immunosorbent assay d-dimer, Wells criteria, and unstructured clinical impression. Using logistic regression analysis, we measured predictors of documented risk assessment. A cohort analysis was undertaken to compare 3-month thromboembolic outcomes between risk groups.
RESULTS: Among 524 cases, 289 (55.2%) underwent pretest probability estimation using the following methods: enzyme-linked immunosorbent assay d-dimer (228; 43.5%), clinical impression (106; 20.2%), and Wells criteria (24; 4.6%), with 69 (13.2%) patients undergoing a combination of at least two methods. Patient factors were not predictive of pretest probability estimation, but the specialty of the clinician was predictive; emergency physicians (P less than .0001) and specialty clinicians (P = .001) were less likely than primary care clinicians to perform risk assessment. Thromboembolic events within 3 months were experienced by 0 of 52 patients in the explicitly low-risk group, 4 (1.8%) of 219 in the explicitly moderate- to high-risk group, and 1 (0.4%) of 226 in the group that did not undergo explicit risk assessment.
CONCLUSIONS: Negative ultrasounds in the workup of deep vein thrombosis are commonly interpreted in isolation apart from pretest probability estimations. Risk assessments varied by physician specialties. Opportunities exist for improvement in the diagnostic evaluation of these patients.
Full-text available from me (DRV) upon request.
15. July Mortality Effect in Hospitals Is Real
Jim Kling. July 11, 2011 (UPDATED July 12, 2011) — During year-end changeovers in hospital trainees, mortality increases and efficiency decreases, according to a systematic review of studies published online July 12 in the Annals of Internal Medicine.
There is a common perception that healthcare quality suffers during trainee academic year-end changeovers, when the average healthcare worker experience abruptly declines and established teams are broken up. The researchers conducted a systematic review of studies that investigated the effects of changeover on patient outcomes.
They searched PubMed, the Educational Research Information Center, EMBASE, and the Cochrane Library for English-language studies conducted between 1989 and July 2010 that used a control group or period of comparison.
John Q. Young, MD, MPP, from the Department of Psychiatry, University of California–San Francisco, School of Medicine, and colleagues categorized studies by methodologic quality, sample size, and reported outcomes. Thirty-nine studies were included, most conducted in the United States and all focused on inpatient settings. Measured outcomes included mortality (27 studies, 69%), efficiency (length of stay, duration of procedure, hospital charges,19 studies, 49%), morbidity (23 studies, 59%), and medical errors (6 studies, 15%).
The studies varied widely in quality. For example, 16 studies (41%) did not adjust for risk, and thus were considered to be poor quality. In contrast, 8 (21%) used a concurrent control and adjusted for patient factors and time trends; these studies were considered to be very good quality. Overall, 13 studies (33%) were judged to be of higher quality, and these studies were more likely to report higher mortality and lower efficiency during changeovers.
Studies that focused on morbidity and medical error outcomes were more likely to be judged to be of lower quality, and their findings were inconsistent.
The study was limited by several factors, including a focus on English-language reports and the fact that none of the studies considered the effect of changeovers in ambulatory care settings. There were also inconsistencies in the definition of changeover, resident role in patient care, and supervision structure. In addition, few studies controlled for time trends or level of supervision, and few employed methods appropriate for hierarchical data.
Although the studies point to increased risks during changeovers, because of the heterogeneity among the studies, it is not possible to know the magnitude of the risk.
The researchers suggest that the "July effect" could be addressed by introducing changeover systems that incorporate human factor principles. They could also be designed to avoid cognitive overload and fatigue. Alternatively, system disruption could be reduced by staggering trainee start dates.
The review backs up long-held suspicions that standards of care suffer at the beginning of academic years, according to Paul Barach, MD, MPH, from the University Medical Center Utrecht, the Netherlands, and Ingrid Philibert, PhD, MBA, from the Accreditation Council for Graduate Medical Education, Chicago, Illinois, the authors of an accompanying editorial.
"Reliable-quality and safe patient care throughout the academic year will require a multipronged approach, one that recognizes the need to immerse trainees in a new clinical environment but with seasoned mentorship, close supervision, and graduated clinical responsibilities.... We need to better understand how best to protect patients and providers during cohort turnovers while developing a culture where trainees feel psychologically safe to speak up, admit error, challenge poor practices, and learn to be accountable for their actions," the editorialists write.
The senior author, Andrew D. Auerbach, MD, was supported by a grant from the National Heart, Blood, and Lung Institute. The other authors have disclosed no relevant financial relationships.
Ann Intern Med. Published online July 11, 2011.
16. ACEP Policies
A. Physician Reporting of Potentially Impaired Drivers
Ann Emerg Med. 2011;58:110.
The American College of Emergency Physicians (ACEP) believes:
• reporting of potentially impaired drivers should be individualized to the patient's clinical condition and the clear risk posed to the patient and public by continued driving; and
• physicians exercising good faith clinical judgments should have protection from liability for their reporting actions.
ACEP opposes mandatory reporting of entire classes of patients or diagnoses (eg, epilepsy) unless compelling evidence exists for a public health benefit for such reporting.
B. Boarding of Admitted and Intensive Care Patients in the Emergency Department
Ann Emerg Med. 2011;58:110.
Optimal utilization of the emergency department (ED) includes the timely evaluation, management, and stabilization of all patients. Boarding of admitted patients in the ED contributes to lower quality of care, reduced timeliness of care, and reduced patient satisfaction. The ED should not be utilized as an extension of the ICU and other inpatient units for admitted patients because this practice adversely affects patient safety, quality, and access to care. ED leadership, hospital administrators, emergency medical services (EMS) directors, community leaders, state and federal officials, hospital regulators, and accrediting bodies should work together to resolve this problem. ED boarding is a hospital-wide problem, and the most effective care of admitted patients is provided in an inpatient unit. ED crowding is a direct result of diminished bed and resource capacity created by boarding. For the ED to continue to provide quality patient care and access to that care, the American College of Emergency Physicians (ACEP) believes that:
• Hospitals have the responsibility to provide quality patient care and optimize patient safety by ensuring the prompt transfer of patients admitted to inpatient units as soon as the treating emergency physician makes such a decision. If such a transfer cannot be promptly effected for whatever reason, the hospital must provide the supplemental nursing staff necessary to care for these inpatients boarded in the ED.
• In the event that the number of patients needing evaluation or treatment in an ED is equal to or exceeds the ED's treatment space capacity, admitted patients should be promptly distributed to inpatient units regardless of inpatient bed availability.
• Hospitals should have staffing plans in place that can mobilize sufficient health care and support personnel to meet increased patient needs.
• Hospitals should develop appropriate mechanisms to facilitate availability of inpatient beds.
• Emergency physicians should work with their hospital administration and medical staff to monitor and improve the use of inpatient resources.
• Staffing patterns applicable to other specialized areas/units of the hospital should apply equally to the ED to ensure that patients receive a consistent standard of care, appropriate for the acuity of their condition, within the organization.
• Mutual aid agreements should be in place to assist any hospital that is unable to meet the emergency and intensive care needs of its community.
• Hospital diversion should be instituted only when internal resources have been exhausted and other community facilities have resources available to meet the needs of patients presenting to their facilities. EMS systems should develop mechanisms to address patient diversion by health care facilities, using the ACEP policy on ambulance diversion.
• Hospital regulatory and accrediting bodies should mandate standards for prompt transfer of admitted patients from the ED to inpatient units. When prompt transfer does not occur, established overcapacity contingency plans should be implemented.
17. Surgical Treatment of Ruptured Intracranial Aneurysms within 24 Hours Improve Clinical Outcome
Phillips TJ, et al. Stroke 2011;42:1936-1945.
Background and Purpose—The purpose of this study was to analyze whether treating ruptured intracranial aneurysms within 24 hours of subarachnoid hemorrhage improves clinical outcome.
Methods—An 11-year database of consecutive ruptured intracranial aneurysms treated with endovascular coiling or craniotomy and clipping was analyzed. Outcome was measured by the modified Rankin Scale at 6 months. Our policy is to treat all cases within 24 hours of subarachnoid hemorrhage. Treatment delays are due to nonclinical logistical factors.
Results—Two hundred thirty cases were coiled or clipped within 24 hours of subarachnoid hemorrhage and 229 beyond 24 hours. No difference in age, gender, smoking, family history of subarachnoid hemorrhage, aneurysm size, or aneurysm location was found between the groups. Poor World Federation of Neurological Surgeons clinical grade patients were overrepresented in the ultra-early group. Increasing age and higher World Federation of Neurological Surgeons clinical grade were predictors of poor outcome. Eight point zero percent of cases treated within 24 hours of subarachnoid hemorrhage (ultra-early) were dependent or dead at 6 months compared with 14.4% of those treated beyond 24 hours (delayed), a 44.0% relative risk reduction and a 6.4% absolute risk reduction (2, P=0.044). A total of 3.5% of cases coiled within 24 hours were dependent or dead at 6 months compared with 12.5% of cases coiled at 1 to 3 days, an 82% relative risk reduction and a 10.2% absolute risk reduction (2, P=0.040). These groups did not differ in age, World Federation of Neurological Surgeons clinical grade, aneurysm size, or aneurysm location.
Conclusions—Treatment of ruptured aneurysms within 24 hours is associated with improved clinical outcomes compared with treatment beyond 24 hours. The benefit is more pronounced for coiling than clipping.
18. Cluster of Suspected Guillain-Barre Syndrome Cases: U.S. – Mexico Border Areas
The California Department of Public Health (CDPH) is cooperating with the Arizona Department of Health Services (AZDHS) and the U.S. Centers for Disease Control and Prevention (CDC) in the investigation of a cluster of human cases suspected to be Guillain-Barre Syndrome (GBS) in Arizona and Mexico. GBS is a rare neurological disorder presenting as acute flaccid paralysis. The cases have occurred in the U.S.-Mexico border areas of Yuma County, Arizona as well as San Luis Rio Colorado, Sonora, and possibly Mexicali, Baja California.
As of June 29, 2011, sixteen patients from the Yuma-San Luis Rio Colorado border region have been diagnosed with GBS; these include residents of San Luis Rio Colorado, Sonora (10), San Luis, AZ (4), and Yuma, AZ (2). An additional 10 suspect cases are under investigation. There are also unconfirmed reports of a small cluster of acute flaccid paralysis in Mexicali, Baja California, which may be unrelated to the Yuma-San Luis Rio Colorado cluster. The median age of the confirmed case-patients is 53 years (range, 11-76 years); 88% are male, and all are Hispanic. Onset date of neurologic symptoms range from May 14 through June 19, 2011, and began within 16 days of a diarrheal illness for fourteen of the case-patients. Laboratory test results from three case-patients suggest that the antecedent diarrheal illness was due to Campylobacter infection. Campylobacter is the most commonly recognized pathogen associated with GBS, although GBS as result of campylobacteriosis is uncommon. AZDHS has also detected an increase in Campylobacter reports from Yuma County, and investigation is underway.
The cluster of GBS cases in Yuma County, Arizona, is a public health event of international concern (PHEIC) and was reported to the World Health Organization by CDC on June 25, 2011. A binational team consisting of CDC, AZDHS, Yuma County Health Department, and state and federal Mexican public health officials are collaborating on a joint investigation. CDPH Infectious Diseases Branch (IDB) has notified California border counties regarding this situation. No cases that are potentially associated with the clusters in Mexico or Arizona have been identified in California to date.
If you are notified of any cases of acute flaccid paralysis with a history of travel to the U.S.-Mexico border regions mentioned above, and with an antecedent diarrheal illness, please recommend obtaining stool cultures for Campylobacter and notify Dr. Akiko Kimura of the Infectious Diseases Branch, CDPH at akiko.kimura@cdph.ca.gov.
19. Clinical Data Can Predict Pneumonia Risk in Pediatric ED
Laurie Barclay, MD. July 11, 2011 — Clinical data can predict risk for radiographic pneumonia among children seen in the pediatric emergency department (ED), according to the results of a prospective cohort study reported online July 11 in Pediatrics.
"Use of chest radiography in the evaluation of children with possible pneumonia varies widely," write Mark I. Neuman, MD, MPH, from the Division of Emergency Medicine and Clinical Research Program, Children's Hospital Boston, Massachusetts, and colleagues. "Although studies have identified certain historical features and physical examination findings associated with pneumonia, none have specifically addressed the criteria for obtaining a chest radiograph."
The study goals were to examine the association between historical and physical examination findings and radiographic pneumonia among children seen in the ED for suspected pneumonia, and to develop a clinical decision rule for the use of chest radiography. The study cohort consisted of 2574 patients younger than 21 years who were evaluated and underwent chest radiography at an urban pediatric ED for suspected pneumonia.
On the basis of the interpretation of the chest radiograph by an attending radiologist, pneumonia was categorized as definite pneumonia or radiographic pneumonia (including definite and equivocal cases of pneumonia). Using pneumonia status as the dependent variable and historical and physical examination data as the independent variables, the investigators estimated a multivariate logistic regression model and conducted a recursive partitioning analysis.
Radiographic pneumonia was present in 16% of patients. Significant predictors of pneumonia were history of chest pain, focal rales, fever duration, and oximetry levels at triage, but not tachypnea, retractions, or grunting. The strongest predictor of pneumonia was hypoxia, defined as oxygen saturation 92% or less (odds ratio, 3.6; 95% confidence interval [CI], 2.0 - 6.8).
Among patients with oxygen saturation greater than 92% and absence of fever, of focal decreased breath sounds, and of focal rales, radiographic pneumonia was present in 7.6% (95% CI, 5.3 - 10.0) and definite pneumonia in 2.9% (95% CI, 1.4 - 4.4), based on recursive partitioning analysis.
"Clinical data can stratify children for pneumonia risk," the study authors write. "Children with hypoxia and focal lung findings are high risk whereas those without hypoxia, fever, and ausculatory findings are low risk. For low-risk patients, clinical follow-up should be considered over obtaining a radiograph."
Limitations of this study include the enrollment of half of all eligible patients, low generalizability to other practice settings or to all patients presenting with cough or fever, inability to evaluate the reliability of specific physical examination findings, inability to evaluate children in whom there was suspicion of pneumonia but a radiograph was not obtained, and lack of blinding of the radiologists to the clinical data.
"Validation of these findings requires multicenter research and should include the assessment of the reliability of physical examination findings," the study authors conclude.
The study authors have disclosed no relevant financial relationships.
Pediatrics. Published online July 11, 2011. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21746723
20. Patient Perceptions of CT Imaging and Their Understanding of Radiation Risk and Exposure
Baumann BM, et al. Ann Emerg Med. 2011;58:1-7.e2
Study objective: We describe patient perceptions of computed tomography (CT) and their understanding of radiation exposure and risk.
Methods: This was a cross-sectional study of acute abdominal pain patients aged 18 years or older. Confidence in medical evaluations with increasing levels of laboratory testing and imaging was rated on a 100-point visual analog scale. Knowledge of radiation exposure was ascertained when participants compared the radiation dose of one abdomen-pelvis CT with 2-view chest radiography. To assess cancer risk knowledge, participants rated their agreement with these factual statements: “Approximately 2 to 3 abdominal CTs give the same radiation exposure as experienced by Hiroshima survivors” and “2 to 3 abdominal CTs over a person's lifetime can increase cancer risk.” Previous CT was also assessed.
Results: There were 1,168 participants, 67% women and mean age 40.7 years (SD 15.9 years). Median confidence in a medical evaluation without ancillary testing was 20 (95% confidence interval [CI] 16 to 25) compared with 90 (95% CI 88 to 91) when laboratory testing and CT were included. More than 70% of participants underestimated the radiation dose of CT relative to chest radiography, and cancer risk comprehension was poor. Median agreement with the Hiroshima statement was 13 (95% CI 10 to 16) and 45 (95% CI 40 to 45) with the increased lifetime cancer risk statement. Seven hundred ninety-five patients reported receiving a previous CT. Of 365 patients who reported no previous CT, 142 (39%) had one documented in our electronic medical record.
Conclusion: Patients are more confident when CT imaging is part of their medical evaluation but have a poor understanding of the concomitant radiation exposure and risk and underestimate their previous imaging experience.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)01716-6/fulltext
21. Emergency Physician–Turned-Governor Overhauls Oregon's Health Care
Joanne Kenen. Ann Emerg Med. 2011;58:A13-A14.
Take an “emergency department (ED) doc,” plunk him in the governor's mansion, and ask him to figure out how to provide great health care in a state awash in red ink and you get—triage.
At least that's how Oregon Governor John Kitzhaber, MD, an emergency physician before he went into politics full time, describes his job. “It's triage. It's recognizing that we have to set priorities.”
Emergency physicians are held accountable for both the decisions they make and how they carry them out. Dr. Kitzhaber believes the same accountability should apply in the political and policy realms.
“In public policy, we make triage decisions but are not as accountable,” said Dr. Kitzhaber, who was elected to two 4-year terms (1995 to 2003) and won an unprecedented third term in November 2010.
Now he's facing the challenge of implementing federal health reform, which he generally favors, while trying to vanquish a huge deficit. And of course health care isn't the governor's only problem. He also has to worry about schools, jobs, roads, and the environment. More triage.
But health care has long been Dr. Kitzhaber's signature issue, as a practicing emergency physician, as a state lawmaker and governor, and, in the years between his terms, in the policy worlds. Oregon is way ahead of much of the nation in terms of how much it's already innovated and experimented with how to cover people and how to deliver quality care—and the relationship between taming costs and expanding coverage.
Dr. Kitzhaber didn't set out to be an emergency physician. In fact, he didn't plan on being a physician at all. He has said he wanted to study anatomy and be a naturalist. But that was the late 1960s, and, amid all the social upheaval of the time, Dr. Doolittle ceased being his main inspiration. He decided to become a physician and was drawn into emergency medicine partly because of the fast pace and that sharply limned immediate accountability. He also realized that the schedule of an emergency practitioner in rural Oregon would let him serve as a part-time state legislature.
Misdiagnosed
What's needed at this critical moment, he said in an interview with Annals of Emergency Medicine, is “the right diagnosis.”
For decades the national Dx was “coverage deficiency,” and the prescribed remedies included employer mandates, individual mandates, “consumer-directed” medicine, health savings accounts, public plans, private plans, and single-payer plans. Dr. Kitzhaber's ED experience helped convince him the problem was misdiagnosed. Sure he wants to cover more people; he learned plenty in his old hospital ED about people who don't have insurance or who can't easily access primary care to manage their asthma or diabetes or heart disease. But he doesn't want to do more of the same. He wants to radically rethink how care is delivered—how to manage care without all the baggage of “managed care.”
“The diagnosis isn't how you pay. It's around what you are buying. Is what you are buying improving health? And is it doing so in a way we can afford?” Federal health reform didn't go far enough to answer this, he said. “You are still paying for the same broken delivery system.”
He gave the example of an elderly woman with congestive heart failure, an example all too familiar to emergency physicians. When the summer weather heats up, her health deteriorates. Medicaid pays for her to go in an ambulance to the ED, where she is stabilized and often admitted. This happens over and over and over again, at tremendous cost. Wouldn't it make more sense if the taxpayer could just buy her an air conditioner? The coverage “prescriptions” don't solve that problem. He sees the proof every time he travels around the state and visits a hospital, a clinic, an ED.
His ED roots have not left him. In fact, it was when he was first entering state government, dividing his time between the legislature and his medical career, that the ED really illustrated for him the real-life impact of policy. In the 1990s, when he was a state legislator, Oregon cut off some adults from the Medicaid rolls. It was highly controversial, but on paper it seemed to make economic sense. But not in the ED. There he saw why it was topsy-turvy. Removing patients' access to Medicaid doesn't make them healthy. It may even make them sicker. So without access to primary care and disease management, they ended up in the ED, sicker and more expensive to treat. He remembers one patient in particular, a man who could no longer pay for his blood pressure medicine, who ended up having a massive stroke. The experience left its mark…
For the remainder of the essay (free): http://www.annemergmed.com/article/S0196-0644(11)00465-3/fulltext
1. TIA Work-Up as Outpatient Assessment of Clinical Evaluation and Safety
Olivot J, et al. Stroke. 2011;42:1839-1843.
Background and Purpose—To evaluate a novel emergency department-based TIA triage system.
Methods—We developed an approach to TIA triage and management based on risk assessment using the ABCD2 score in combination with early cervical and intracranial vessel imaging. It was anticipated that this triage system would avoid hospitalization for the majority of TIA patients and result in a low rate of recurrent stroke. We hypothesized that the subsequent stroke rate among consecutively encountered patients managed with this approach would be lower than predicted based on their ABCD2 scores.
Results—From June 2007 to December 2009, 224 consecutive patients evaluated in the Stanford emergency department for a possible TIA were enrolled in the study. One hundred fifty-seven were discharged to complete their evaluation at the outpatient TIA clinic; 67 patients were hospitalized. One hundred sixteen patients had a final diagnosis of TIA/minor stroke or possible TIA. The stroke rates at 7, 30, and 90 days were 0.6% (0.1%–3.5%) for patients referred to the TIA clinic and 1.5% (0.3%–8.0%) for the hospitalized patients. Combining both groups, the overall stroke rate was 0.9% (0.3%–3.2%), which is significantly less than expected based on ABCD2 scores (P=0.034 at 7 days and P=0.001 at 90 days).
Conclusions—This emergency department-based inpatient versus outpatient TIA triage system led to a low rate of hospitalization (30%). Recurrent stroke rates were low for both the hospitalized and outpatient subgroups.
2. Does Epinephrine Help Cardiac Arrest Victims Survive?
By Kerry Grens. NEW YORK (Reuters Health) Jul 14 - Epinephrine is a standard component of resuscitation for cardiac arrest, but in a controversial study from Australia it did little to increase patients' survival.
Researchers did find, however, that patients who received epinephrine were more likely to have pre-hospital return of spontaneous circulation, a result the researchers say supports the use of adrenaline.
"My guess is (the study) probably is not going to change how we practice currently, but it may stimulate a larger study on the role of epinephrine in out-of-hospital cardiac arrests," said Dr. Gordon Tomaselli, the president of the American Heart Association and the director of the Division of Cardiology at Johns Hopkins University School of Medicine, who was not involved in this new work.
In the randomized trial, reported online July 2nd in Resuscitation, more than 500 patients in Western Australia received either epinephrine or saline from emergency teams.
On the primary outcome of the study - survival to hospital discharge - the difference was not statistically significant: 1.9% in the saline group vs 4.0% in the adrenaline group.
However, the epinephrine-treated patients were more likely to have had a return of spontaneous circulation by the time they arrived at the hospital (23.5% vs 8.4%; odds ratio, 3.4).
"Although the results were statistically negative on the important outcomes, the trend was in the right direction," Dr. Tomaselli told Reuters Health.
Dr. Ian Jacobs, the lead author of the study and a professor at the University of Western Australia, told Reuters Health in an email that epinephrine should still be part of routine care.
"This is particularly so as we further identify and understand those post (return-to-circulation) factors which contribute to survival," Dr. Jacobs said.
He believes that if he had been able to include more patients in the study, he might have found an actual improvement in survival with epinephrine. But he had difficulty getting ambulance crews to participate.
"In short, the fact that adrenaline was considered standard of care -- albeit unproven -- some paramedics felt that this trial was unethical and went to the media," Dr. Jacobs said. Ultimately, those paramedics did not participate.
He said that the Human Research Ethics Committee under the Australian National Health and Medical Research Council, which funded the study, provided the researchers with a waiver for consent from the patients to participate.
The study was approved by "numerous Human Research Ethics Committees, Guardianship Boards and Departments of Crown Law," Dr. Jacobs added.
Consent from patients in an emergency setting is very difficult, Dr. Tomaselli said, which explains why there have been no studies like this to date.
"If we say, 'because you can't get consent, you can't do any studies,' then we should give up on any studies in cardiac arrest at all. I don't think that's the way we should go," Dr. Tomaselli said.
Resuscitation. 2011 Jul 2. [Epub ahead of print]
PubMed Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21745533
3. Loading Dose of Clopidogrel Safe in Elderly MI Patients
NEW YORK (Reuters Health) Jul 12 - Giving elderly patients with acute MI a clopidogrel loading dose of 300 mg or more rather than a lower conventional dose doesn't increase the risk of serious bleeding -- but it doesn't increase survival, either.
Those findings are reported in the American Journal of Cardiology online July 4 by Dr. Etienne Puymirat, with Hopital Europeen Georges Pompidou, Paris, and L'Universite Paris Descartes, and colleagues.
The authors examined data from a nationwide registry on more than 3,000 MI patients admitted to the ICU within 48 hours of symptom onset, including 791 patients at least 75 years old (mean age 81 years) given a known dose of clopidogrel.
Within this cohort, 466 patients (59%) received a loading dose of at least 300 mg (ranging from 300 mg in the majority up to 900 mg in one patient). The other 325 patients (41%) received a conventional dose (75 mg in most cases but up to 225 mg in some patients).
The rate of major bleeding was not significantly different in patients who received a higher loading dose than in those given a conventional dose (3.2% vs. 3.7%). Similarly, there was no significant difference in proportions of patients needing blood transfusions (5.4% vs. 6.2%, respectively).
On logistic regression analysis, giving a loading dose rather than a conventional dose of clopidogrel did not affect mortality at 30 days (odds ratio 1.15) or at 12 months (hazard ratio 1.00). Survival free of stroke or repeat MI was also not significantly different (HR 0.92)
"The present data, gathered from a nationwide 'real-world' registry of patients admitted for acute MI, indicate that in an elderly population the use of a clopidogrel loading dose at the acute stage of MI is not associated with an increase in major bleeding or a significant independent effect on mortality or hard events at one year," Dr. Puymirat and colleagues conclude.
That said, they add, "Large-scale randomized trials are still needed to identify the optimal loading dose of clopidogrel for elderly patients admitted for acute MI."
Am J Cardiol. 2011 Jul 2. [Epub ahead of print]
PubMed abstract: http://www.ncbi.nlm.nih.gov/pubmed/21726837
4. When the Snake Bites ... Try Ointment
by Mitch Leslie, Science Now, 26 June 2011.
Don't tread on me. An ointment might help people bitten by the eastern brown snake of Australia or other snakes.
Time is the foe for people who have been bitten by a poisonous snake, but a new study may give them a bit more of it. Researchers have identified an ointment that slows the spread of some kinds of snake venom through the body, potentially giving snakebite victims longer to reach a hospital or clinic.
Although poisonous snakes kill only a handful of people in the United States each year, the World Health Organization puts the global toll at about 100,000 people. When some snakes strike, the bulky proteins in their venom don't infiltrate the bloodstream immediately but wend through the lymphatic system to the heart. In Australia, a country slithering with noxious snakes, the recommended first aid for a bite includes tightly wrapping the bitten limb to shut the lymphatic vessels—a method called pressure bandage with immobilization (PBI). The idea is to hamper the venom's spread until the victim can receive antivenom medicine, essentially antibodies that lock onto and neutralize the poison. But PBI is not practical if the bite is on the torso or face, and one study found that even people trained to perform the technique do it right only about half the time. As a result, some people don't get antivenom in time.
So physiologist Dirk van Helden of the University of Newcastle in Australia and colleagues went looking for a chemical method to detain the venom. They settled on an ointment that contains glyceryl trinitrate, the compound better known as nitroglycerin that doctors have used to treat everything from tennis elbow to angina. The ointment, prescribed for a painful condition called anal fissures, releases nitric oxide, causing the lymphatic vessels to clench. The researchers first injected volunteers in the foot with a harmless radioactive mixture that, like some snake toxins, moves through the lymphatic vessels. In control subjects that didn't receive the ointment, the mixture took 13 minutes to climb to the top of the leg. But it required 54 minutes if the researchers immediately smeared the ointment around the injection site, the team reports online today in Nature Medicine.
To determine whether the ointment improved survival, the researchers injected the feet of anesthetized rats with venom from the eastern brown snake, a cobra relative that is one of Australia's deadliest, and measured how much time elapsed before the rodents stopped breathing. Rats lived about 50% longer if the researchers slathered the rodents' hind limbs with the cream.
Although the team can't specify how many minutes or hours the treatment might buy, the findings suggest that "it gives you time and a half to get help," says van Helden. "I'd prefer that to just time." He says that hikers and people who work in rural areas might consider carrying the cream in case they get bitten when they are far from medical facilities.
The method is "very exciting," says Steven Seifert, medical director of the New Mexico Poison and Drug Information Center in Albuquerque. "It makes sense to try to slow the passage of the venom into the circulation." Medical toxicologist Eric Lavonas, associate director of the Rocky Mountain Poison and Drug Center in Denver, Colorado, is also impressed. "This is really promising," he says. The authors "did the right studies to evaluate this approach."
Still, Seifert and Lavonas question whether such a treatment would do much good in the United States. Australian snakes largely inject neurotoxic venom that spreads through the body and attacks the nervous system, triggering paralysis. The perpetrators of most U.S. snakebites are rattlesnakes, copperheads, and cottonmouths, which inject a different type of venom that mainly destroys the tissue near the bite. But the researchers note that the ointment could prove valuable in many other countries inhabited by dangerous snakes, such as cobras, mambas, and kraits, that produce neurotoxic venom. "If this treatment pans out, it may revolutionize first aid for snakebite in parts of the world where venom causes paralysis," Lavonas says.
Nat Med. 2011 Jun 26;17(7):809-11.
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21706027
5. What reverses overanticoagulation in the elderly?
Reversal of Overanticoagulation in Very Elderly Hospitalized Patients with an INR above 5.0: 24-Hour INR Response after Vitamin K Administration
Pautas E, et al. Amer J Med, 2011;124:527-533.
In elderly inpatients with INR above or equal to 5.0, both vitamin K antagonist dose omission and vitamin K1 administration according to recommendations were effective in reversing overanticoagulation, allowing most INRs to return to the 1.8-3.2 range without excessive overcorrection. These authors conclude that the American College of Chest Physicians recommendations may be applied to elderly inpatients.
PubMed abstract: http://www.ncbi.nlm.nih.gov/pubmed/21605730
To see how UCLA has adapted the ACCP guidelines, cf http://medres.med.ucla.edu/Practices/Guidelines_anticoagulation.pdf
6. Believe It or Not: Painless Reduction of Dislocated Shoulders
Shaw, Gina. EM News. June 2011.
There are literally dozens of methods emergency physicians can use to reduce a dislocated shoulder, but they all have one thing in common: they hurt. Some are less painful than others, but in most emergency departments, the majority of patients undergoing closed shoulder reduction need at least some level of sedation to help them manage their pain during the procedure.
That's why Graham Walker, MD, was so skeptical when he saw an online video in which Australian physician Neil Cunningham, MBBS, reduced a dislocated shoulder in less than two minutes, using only massage.
“I didn't believe it,” said Dr. Walker, the chief resident in emergency medicine at St. Luke's-Roosevelt Hospital in New York City. “A painless shoulder reduction with no pulling and no sedation?”
Impossible — or so he thought until early March, when he got the chance to try the technique for himself. The pediatric emergency room at St. Luke's-Roosevelt was swamped, and when a 16-year-old boy came in after having been pushed and fallen onto his shoulder, Dr. Walker decided to give the Cunningham technique a try to avoid tying up a nurse with a procedural sedation.
Within three minutes, the patient's shoulder was back in place. “I was amazed,” he said.
Dr. Cunningham's technique works like this: Seat the patient comfortably, as upright as possible, with shoulders relaxed. Supporting the affected arm, slowly and gently move the humerus into full adduction. Gently massage the trapezius and deltoids; this helps to relax the patient and reassures them that the doctor is not going to do anything painful.
Then, move on to gently massaging the biceps at the mid-humeral level. Ask the patient to shrug her shoulders, continuing the biceps massage. Wait for the patient to relax fully, and the humeral head will slip back into place. (Warn the patient that it may feel strange as this happens and not to fight against the movement.)
Dr. Cunningham, now a staff specialist in the emergency department at St. Vincent's Hospital in Melbourne, Australia, developed the technique while working in a busy ED that was often so full that he would see patients on gurneys in the ambulance bay and sitting in corridors. “While holding patients' arms waiting for analgesia to be drawn up, I found that I could relieve their pain with positioning and by encouraging them to relax the spasming muscles with a combination of talking and massaging the muscles,” he explains. “After shoulders started reducing faster than the analgesia could be drawn up, I returned to the anatomy books to work out both the different positions of structures, and the different forces resulting from overstretched ligaments, joint capsules, and spasming muscles.”
As Dr. Walker found, the technique is not difficult to learn. “The combination of humerus and scapular positioning and specific muscle massage is fairly straightforward to grasp,” Dr. Cunningham said. “I have seen emergency physicians surprise themselves with this technique when they find the correct position and reduce a shoulder in less than five minutes on a patient twice their size.”
Because the technique is so simple, painless, and requires no sedation, should it be used for all shoulder dislocations? Absolutely not, Dr. Cunningham said. He doesn't even always use it himself (although he starts with it in about 70% of cases). If the patient can't relax enough to cooperate, or the arm can't be adducted, for example, the approach won't work. “The technique should match the patient, not the other way round,” Dr. Cunningham said.
To maximize the chance of success, Dr. Cunningham takes time to prepare the patient before laying a hand on him. “Explaining to a patient what you are going to do and that you are not going to pull their arm at any point is really important to reduce anxiety,” he says.
Instead of supporting underneath the affected limb, he grips the forearm or elbow with gentle but steady pressure, which moves the humeral head back slightly toward its usual position, which reduces the patient's pain. ”Encouraging the patient to relax verbally and with massage, followed by slow, gentle movements will allow you to get to your starting position,” he said.
With some patients, you'll never get to this point — they're simply too agitated to attempt a technique like this. For them, analgesia and sedation is a must. “Using drugs in these patients is a recognition that muscle relaxation is going to be impossible otherwise, meaning that either your chosen technique will not work, or you will hurt your patient as they fight any movement you attempt,” Dr. Cunningham said. “Once you have sedated your patient, it is then important to use a technique suitable for your patient, not just pulling hard.”
In Dr. Walker's ED, the other residents and attendings are now looking for shoulder dislocations, eager to try the Cunningham technique for themselves. “I've had a patient for whom it didn't work,” he said. “She was obese and very tense, and just not a good candidate. But with the right patient, it's so simple and a great alternative to techniques that require sedation.”
The hardest part of the technique, Dr. Cunningham said, has been convincing others that it works. “There has been such a reliance on drugs and traction techniques that it can be difficult to persuade some people to change their thinking. But anyone who has reduced a shoulder within a couple of minutes with no drugs and no pain will certainly see the benefits of a non-traction technique.”
To view videos of the technique in action and read detailed instructions, visit Dr. Cunningham's website at www.shoulderdislocation.net
7. Unimpressive Effect of Nesiritide in Patients with Acute Decompensated Heart Failure
O'Connor CM, et al. N Engl J Med 2011; 365:32-43.
Background: Nesiritide is approved in the United States for early relief of dyspnea in patients with acute heart failure. Previous meta-analyses have raised questions regarding renal toxicity and the mortality associated with this agent.
Methods: We randomly assigned 7141 patients who were hospitalized with acute heart failure to receive either nesiritide or placebo for 24 to 168 hours in addition to standard care. Coprimary end points were the change in dyspnea at 6 and 24 hours, as measured on a 7-point Likert scale, and the composite end point of rehospitalization for heart failure or death within 30 days.
Results: Patients randomly assigned to nesiritide, as compared with those assigned to placebo, more frequently reported markedly or moderately improved dyspnea at 6 hours (44.5% vs. 42.1%, P=0.03) and 24 hours (68.2% vs. 66.1%, P=0.007), but the prespecified level for significance (P≤0.005 for both assessments or P≤0.0025 for either) was not met. The rate of rehospitalization for heart failure or death from any cause within 30 days was 9.4% in the nesiritide group versus 10.1% in the placebo group (absolute difference, −0.7 percentage points; 95% confidence interval [CI], −2.1 to 0.7; P=0.31). There were no significant differences in rates of death from any cause at 30 days (3.6% with nesiritide vs. 4.0% with placebo; absolute difference, −0.4 percentage points; 95% CI, −1.3 to 0.5) or rates of worsening renal function, defined by more than a 25% decrease in the estimated glomerular filtration rate (31.4% vs. 29.5%; odds ratio, 1.09; 95% CI, 0.98 to 1.21; P=0.11).
Conclusions: Nesiritide was not associated with an increase or a decrease in the rate of death and rehospitalization and had a small, nonsignificant effect on dyspnea when used in combination with other therapies. It was not associated with a worsening of renal function, but it was associated with an increase in rates of hypotension. On the basis of these results, nesiritide cannot be recommended for routine use in the broad population of patients with acute heart failure.
8. Doctors often struggle to show compassion while dealing with patients
Manoj Jain, Washington Post. May 16, 2011
I was standing at my patient’s bedside. Mike Venata was having chills with a temperature of 103. Sweat covered his balding scalp like dew, then coalesced and rolled down past his staring eyes.
Just 20 minutes earlier, a specialist had informed him that he had metastatic pancreatic cancer and could expect to live less than six months. He was alone. I’d seen him once before; as an infectious-disease specialist, I’d been called in because his fever might be due to an underlying infection.
I wondered: How do I show him compassion?
Many say our health-care system lacks compassion. I too at times feel that pills and surgeries, CT scans and radiation therapies, biopsies and blood tests have become a priority in medicine and that compassion — the “touchy-feely” part of medicine — has become an afterthought in patient care.
After a few days in the hospital, Mr. Venata’s fever subsided, and I asked if I could talk with him about his experience. He was a retired major who earned a Bronze Star in Vietnam, then became an executive for a multinational company, from which he had recently retired. He had never been married. I wanted to talk to him about how doctors should handle end-of-life situations.
I asked, “When you were told your diagnosis of the cancer, what went through your mind?” Sitting by his bedside, I expected to hear the usual description of shock or denial. But his case was different.
“Well, the first thing I wanted to do was — I wish I was 10 years younger, I would have reached across and slapped the [expletive] out of the doctor.” Despite his words, he didn’t look angry, just deeply saddened.
Startled, I asked why.
He told me that the specialist had pulled out a piece of paper with his biopsy results and said, “ ‘Well, this isn’t very good. This is terminal.’ . . . He didn’t talk to me, he talked to a piece of paper. I got a guy sitting here reading the piece of paper telling me I am going to die [then] walking out the door. That was not well executed.”
To him, the heartlessness of the doctor’s presentation was as painful as the news.
For the rest of the Post essay, cf http://tinyurl.com/3apk7y4
9. Diagnostic performance of multidetector CT for suspected acute appendicitis
Pickhardt PJ, et al. Ann Intern Med. 2011 Jun 21;154(12):789-96.
Background: Use of preoperative computed tomography for suspected acute appendicitis has dramatically increased since the introduction of multidetector CT (MDCT) scanners. Objective: To evaluate the diagnostic performance of MDCT for suspected acute appendicitis in adults. Design: Analysis of MDCT findings and clinical outcomes of consecutive adults referred for MDCT for suspected appendicitis from January 2000 to December 2009.
Setting: Single academic medical center in the United States. Patients: 2871 adults.
Measurements: Interpretation of nonfocused abdominopelvic MDCT scans by radiologists who were aware of the study indication. Posttest assessment of diagnostic performance of MDCT for acute appendicitis, according to the reference standard of final combined clinical, surgical, and pathology findings.
Results: 675 of 2871 patients (23.5%) had confirmed acute appendicitis. The sensitivity, specificity, and negative and positive predictive values of MDCT were 98.5% (95% CI, 97.3% to 99.2%) (665 of 675 patients), 98.0% (CI, 97.4% to 98.6%) (2153 of 2196 patients), 99.5% (CI, 99.2% to 99.8%) (2153 of 2163 patients), and 93.9% (CI, 91.9% to 95.5%) (665 of 708 patients), respectively. Positive and negative likelihood ratios were 51.3 (CI, 38.1 to 69.0) and 0.015 (CI, 0.008 to 0.028), respectively. The overall rate of negative findings at appendectomy was 7.5% (CI, 5.8% to 9.7%) (54 of 716 patients), but would have decreased to 4.1% (28 of 690 patients) had surgery been avoided in 26 cases with true-negative findings on MDCT. The overall perforation rate was 17.8% (120 of 675 patients) but progressively decreased from 28.9% in 2000 to 11.5% in 2009. Multidetector computed tomography provided or suggested an alternative diagnosis in 893 of 2122 patients (42.1%) without appendicitis or appendectomy.
Limitation: Possible referral bias, because some patients whose appendicitis was difficult to diagnose on clinical grounds may not have been referred for MDCT for evaluation of suspected appendicitis.
Conclusion: Multidetector computed tomography is a useful test for routine evaluation of suspected appendicitis in adults
10. Rebound Toxicity Rare After Discharge-On-Scene for Opioid Overdose
By Dave Levitan. NEW YORK (Reuters Health) Jul 14 - Ten years of experience with a discharge-on-scene policy for opioid overdose patients in Denmark suggests that there's a low risk of death due to rebound toxicity.
Under the policy, patients are released before hospital admission if "a substantial and lasting improvement of vital signs is obtained as assessed by the treating physician," according to a paper published online ahead of print July 4 in Resuscitation.
Lead author Dr. Soren Rudolph, of Copenhagen University Hospital, told Reuters Health by email that there may be significant advantages to this practice.
"We think that the discharge-on-scene policy leads to a positive attitude towards the MECU [medical emergency care unit] and we think that it may improve the long-term outcome for the entire patient group," he said. "Also, emergency admittances are lowered with more optimal use of resources."
In this study, the authors reported 4,762 cases of acute opioid overdose between 1994 and 2003; a positive identification was obtained in 3,245 of those cases. Patients were treated with naloxone. Among the 3,245 total patients studied, 2,241 were released on-scene, and 18 of those died within 48 hours of release (0.80%). In three of those cases, rebound opioid toxicity was the likely cause of death. (0.13%).
The authors noted that though the risk in the positively identified cohort was very low, the unidentified subjects may have been more likely to have poor social support or other problems that could put them at higher risk of complications.
"Safety is a difficult issue to address as it is difficult to define a specific upper number of deaths that is acceptable," Dr. Rudolph told Reuters Health. "The ideal would of course be not to find any deaths after treatment, but we are dealing with a very non-compliant patient population with a high mortality rate compared to the normal population. We think that it is important to establish a good relationship with these patients and we consider the discharge-on-scene policy as a compromise in that respect."
He added that it would be useful to further study this patient population to determine specific risk factors for rebound overdose, but given the very small number of patients suffering from rebound toxicity in this study, this may be a difficult or impossible task.
Resuscitation. 2011 Jul 2. [Epub ahead of print]
PubMed Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21745532
11. The Brady Bunch, Episode III: Dig Overdose
by Stuart P. Swadron, MD, on June 3, 2011
Overdoses that cause bradycardia and hypotension. Part III: Digitalis glycosides demystified
This is the third installment in a series focusing on the common overdoses that cause bradycardia, hypotension and altered mental status. Over the past several months during interviews with toxicologist Dr. Sean Nordt, we have discussed calcium channel blockers, beta blockers, clonidine and digitalis glycosides. All four classes of drugs can be fatal in overdose and all of them appear on the list of single tablets that can kill a child.
Digoxin is the most commonly encountered digitalis glycoside in the United States but, as Dr. Nordt reminded us, other prescribed forms exist such as digitoxin and ouabain. Digitalis glycosides are also found in the extracts of plants (foxglove, oleander and lily-of-the-valley among many others) and even on the skin of some toads!
Digoxin is somewhat perplexing for many EPs – it’s one of the cardioactive drugs to grasp. At the center of its clinical effect is its direct inhibition of membrane-bound sodium-and potassium-activated adenosine triphosphatase (Na+/K+ ATPase), which leads to an increase in the intracellular concentration of calcium and hence an increase in cardiac contractility. Digoxin is unique among cardiac drugs in that it is both a positive inotrope and a atrioventricular nodal blocker. In addition, digoxin has an pro-arrhythmogenic effect on both the atria and the ventricles. This gives rise to the classic electrocardiographic findings of regularized, slow atrial fibrillation and paroxysmal atrial flutter with a high grade block. Unfortunately, these rhythms are seen only in some cases, with ventricular arrhythmias such as premature ventricular contractions and sustained ventricular tachycardia being more common, and more life-threatening in chronic overdoses.
Digoxin differs from the other three of the “brady bunch” in that it has measurable serum levels. However, serum levels in chronic toxicity may actually be within the normal range of standard reference laboratory values. Moreover, laboratory values may be spurious or erratic in cases involving the more exotic sources of cardiac glycosides, like plant extract ingestion. Therefore, it is the patient’s clinical presentation that is paramount in determining toxicity and the need for therapy.
Acute toxicities are less of a diagnostic challenge. Typically these are younger patients who overdose intentionally. Serum levels will be markedly elevated but because it may take up to six hours for the drug to distribute and levels to stabilize, it is generally recommended that treatment decisions be based on clinical features rather than levels during this initial period. Hyperkalemia, an acute accumulation of extracellular potassium that results from sodium-potassium pump failure, is one of the most important indicators of a life-threatening overdose. Thus, a potassium above 5.0 or 5.5 meq/L is a key trigger for administration of expensive (yet effective) immunotherapy with intravenous digoxin-specific Fab fragments.
Other indications for Fab fragments include hemodynamic instability and ventricular dysrhythmias. In patients with marked bradycardia due to nodal blockade, a trial of atropine may also be effective. While it is acceptable to lower elevated potassium levels with traditional “shifting” agents such as intravenous insulin and bicarbonate boluses, the use of calcium as a membrane stabilizer remains controversial because of historical case reports of cardiac arrest following its use in this setting. Electrical cardioversion is acceptable in patients with sustained ventricular arrhythmias, but much lower energy levels (e.g. 10-50 J) are recommended than in non-poisoned patients. Lastly, gastrointestinal decontamination with activated charcoal can be used to decrease further absorption of digoxin after oral ingestion provided that the patient is alert and not otherwise at risk for aspiration.
In chronic overdoses, the extra-cardiac manifestations of digoxin toxicity may predominate. These include non-specific gastrointestinal symptoms, visual disturbances and altered mental status. Thus, it is not difficult to see why these cases are often missed; the presentation can easily be confused with other conditions such as myocardial ischemia, hypothyroidism and uremia, which by itself often precipitates digoxin toxicity due to decreasing clearance. Potassium values are often low, reflecting the chronic wasting that occurs when potassium is unable to move into cells and over time is eliminated in the urine – a process that is facilitated by concomitant diuretic therapy. Because digoxin toxicity is exacerbated in a low potassium state, repletion of potassium is a critical step in the management of these patients. As in other low potassium states, co-administration of magnesium is also often necessary.
Dr. Swadron is the Vice-Chair for Education in the Dept of EM at the LA County/USC Medical Center. He is an Assoc. Prof. of Clinical EM at USC’s Keck School of Medicine
12. For CO Measurement, Skip the Lab Test; Clip on a Special Pulse Ox
Accuracy of Noninvasive Multiwave Pulse Oximetry Compared with Carboxyhemoglobin From Blood Gas Analysis in Unselected ED Patients
Roth D, et al. Ann Emerg Med. 2011;58:74-79.
Study objective: Accurate and timely diagnosis of carbon monoxide (CO) poisoning is difficult because of nonspecific symptoms. Multiwave pulse oximetry might facilitate the screening for occult poisoning by noninvasive measurement of carboxyhemoglobin (COHb), but its reliability is still unknown. We assess bias and precision of COHb oximetry compared with the criterion standard blood gas analysis.
Methods: This was a prospective diagnostic accuracy study according to STARD (Standards for the Reporting of Diagnostic accuracy studies) criteria, performed at a tertiary care hospital emergency department. We included all patients for whom both invasive and noninvasive measurement within 60 minutes was available, regardless of their complaints, during a 1-year period.
Results: One thousand five hundred seventy-eight subjects were studied, of whom 17 (1.1%) received a diagnosis of CO poisoning. In accordance with this limited patient cohort, we found a bias of 2.99% COHb (1.50% for smokers, 4.33% for nonsmokers) and a precision of 3.27% COHb (2.90% for smokers, 2.98% for nonsmokers), limits of agreement from −3.55% to 9.53% COHb (−4.30% to 7.30% for smokers, −1.63% to 10.29% for nonsmokers). Upper limit of normal cutoff of 6.6% COHb had the highest sensitivity in screening for CO poisoning. Smoking status and COHb level had the most influence on the deviation between measurements.
Conclusion: Multiwave pulse oximetry was found to measure COHb with an acceptable bias and precision. These results suggest it can be used to screen large numbers of patients for occult CO poisoning.
ALSO: Victim of Carbon Monoxide Poisoning Identified by Carbon Monoxide Oximetry
Roth D. J Emerg Med 2011;40:640-642.
Background: Carbon monoxide (CO) is known as a leading cause of unintentional poisoning death in many countries. Diagnosis is usually made by measuring carboxyhemoglobin (COHb), but due to the non-specific symptoms, the crucial step is considering CO poisoning. A possible solution might be screening emergency department (ED) patients. A cutaneous sensor that measures oxygen and CO saturation simultaneously could accomplish that.
Objectives: We report a case in which CO-oximetry screening helped to identify CO poisoning in a patient with otherwise non-specific complaints presenting to a busy university hospital ED.
Case Report: A 53-year-old woman presented to our ED, reporting non-specific but common symptoms including emesis and diarrhea, one-sided headache, paresthesia, and palpitations. Whereas conventional pulse oximetry showed normal results, a COHb level of 28% was measured using a CO-oximeter. This allowed a diagnosis of CO poisoning to be made at admission. The patient was treated with 100% oxygen continuous positive airway pressure ventilation, and CO washout was monitored continuously and non-invasively. In the meantime, the local fire department was alerted and found a malfunctioning water heater as the source of CO in the patient's residence. As COHb fell to normal levels and the patient reported feeling well, she was discharged the next day.
Conclusion: CO-oximetry served as a powerful tool in both identifying and monitoring a CO-poisoned patient in a busy ED. Future studies should address possible sources of error using this method on a long-term basis and its level of acceptance by ED staff.
Related studies: http://www.ncbi.nlm.nih.gov/pubmed/18226877
http://www.ncbi.nlm.nih.gov/pubmed/18568803
13. Anticholinergic Effect Boosts Elderly Death Risk
By Kate Kelland. LONDON (Reuters) Jun 24 - Anticholinergic activity, a side effect of many commonly used drugs including antihistamines and antidepressants, appears to increase the risk of reduced brain function and early death in older people, according to a study published on Friday.
Scientists from Britain's University of East Anglia who led the work said the findings showed it was vital for doctors to regularly review drugs taken by elderly patients to ensure the cumulative risks of side-effects did not outweigh the benefits.
"Our results show a potentially serious effect on mortality," Chris Fox, of UEA's Norwich Medical School, told reporters at a briefing in London.
The study, published online June 24 in the Journal of the American Geriatrics Society, is the first systematic investigation into the long-term impact of anticholinergic activity, which affects the brain by blocking the key neurotransmitter acetylcholine.
"One of the issues is that as we age, we tend to be prescribed more medicines which have an anticholinergic effect, increasing the overall burden," said Ian Maidment, a mental health pharmacist in Britain's National Health Service (NHS).
The researchers devised a ranking system which they called the AntiCholinergic Burden (ACB) score for the anticholinergic effects of more than 80 common prescription and over-the- counter drugs. They assigned scores of 0 for no effect, 1 for mild effect, 2 for moderate effect and 3 for severe effect.
Then they studied more than 13,000 British men and women aged 65 and over for a two-year period.
They found that 20% of participants taking drugs with a total ACB of four or more had died by the end of the two-year study, compared with only 7% of those taking no anticholinergic drugs. For every extra ACB point, the odds of dying increased by 26%, they found.
Those taking drugs with a combined ACB of five or more scored more than 4% lower in a cognitive function tests than those taking no anticholinergic drugs -- a finding that confirmed evidence from previous smaller studies of a link between anticholinergics and mental decline.
And the increased risks from taking anticholinergic drugs were cumulative, based on the number of medicines taken and the strength of each drug's anticholinergic effect.
"It's important to scrutinize medications given to older people very carefully to try to minimize harm as well as gain the desired benefit," said Carol Brayne of the University of Cambridge, who also worked on the study.
The researchers said medications with the ACB impact include nifedipine , codeine, beclometasone, and carbamazepine, and certain tranquilizers.
Fox said that, wherever possible, doctors should "avoid prescribing multiple drugs with anticholinergic effects."
Susanne Sorensen, head of research at the Alzheimer's Society, who was not involved in the study, said its findings must be taken seriously, particularly since loss of cognitive function can be a precursor to the mind-robbing Alzheimer's disease and other forms of dementia.
J Am Geriatr Soc 2011. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21707557
14. Pretest probability estimation in the evaluation of patients with possible DVT
Vinson DR, et al. Am J Emerg Med. 2011 Jul;29(6):594-600.
INTRODUCTION: Most patients who undergo compression ultrasonography in the evaluation of possible deep vein thrombosis have a negative result. Does such a result fully exclude thrombosis from consideration? Not always. An estimation of pretest probability is essential to guide the diagnostic evaluation of such patients. Though compression ultrasonography is the current diagnostic method of choice in the evaluation of patients with possible deep vein thrombosis, a single negative thigh compression ultrasound requires the context of the patient’s pretest probability in order to be properly interpreted. If the probability estimation is low, then a negative compression ultrasound may terminate the diagnostic assessment. However, if the pretest probability is moderate-to-high, then further evaluation is necessary before the posttest incidence of venous thromboembolic disease drops safely below 1% [1].
Pretest probability estimations can be performed using serologic tools such as quantitative D-dimer levels, structured clinical decision tools including the Wells criteria, or the clinician’s unstructured empirical clinical impression of risk [2-6]. Though risk stratification is universally recommended [3-4, 7], implementation outside the regulated confines of clinical trials has been suboptimal [8-9]. Perhaps clinicians are unaware of the indispensible role of a pretest probability determination in the interpretation of ultrasound results. Little is known about the proportion of outpatients with negative compression ultrasound who receive pretest probability assessments and what factors predict risk estimations.
This retrospective health-records study was undertaken in a community hospital to describe the rate and methods of risk stratification performed in outpatients, from the emergency department and the clinics, with a negative compression ultrasound in the assessment of possible lower-extremity deep vein thrombosis. We also sought to determine predictors of pretest probability estimations. Short-term follow-up plans and three-month outcomes were also measured.
METHODS: This cross-sectional study of outpatients was conducted in a suburban community hospital in 2006. Estimation of pretest probability was done by enzyme-linked immunosorbent assay d-dimer, Wells criteria, and unstructured clinical impression. Using logistic regression analysis, we measured predictors of documented risk assessment. A cohort analysis was undertaken to compare 3-month thromboembolic outcomes between risk groups.
RESULTS: Among 524 cases, 289 (55.2%) underwent pretest probability estimation using the following methods: enzyme-linked immunosorbent assay d-dimer (228; 43.5%), clinical impression (106; 20.2%), and Wells criteria (24; 4.6%), with 69 (13.2%) patients undergoing a combination of at least two methods. Patient factors were not predictive of pretest probability estimation, but the specialty of the clinician was predictive; emergency physicians (P less than .0001) and specialty clinicians (P = .001) were less likely than primary care clinicians to perform risk assessment. Thromboembolic events within 3 months were experienced by 0 of 52 patients in the explicitly low-risk group, 4 (1.8%) of 219 in the explicitly moderate- to high-risk group, and 1 (0.4%) of 226 in the group that did not undergo explicit risk assessment.
CONCLUSIONS: Negative ultrasounds in the workup of deep vein thrombosis are commonly interpreted in isolation apart from pretest probability estimations. Risk assessments varied by physician specialties. Opportunities exist for improvement in the diagnostic evaluation of these patients.
Full-text available from me (DRV) upon request.
15. July Mortality Effect in Hospitals Is Real
Jim Kling. July 11, 2011 (UPDATED July 12, 2011) — During year-end changeovers in hospital trainees, mortality increases and efficiency decreases, according to a systematic review of studies published online July 12 in the Annals of Internal Medicine.
There is a common perception that healthcare quality suffers during trainee academic year-end changeovers, when the average healthcare worker experience abruptly declines and established teams are broken up. The researchers conducted a systematic review of studies that investigated the effects of changeover on patient outcomes.
They searched PubMed, the Educational Research Information Center, EMBASE, and the Cochrane Library for English-language studies conducted between 1989 and July 2010 that used a control group or period of comparison.
John Q. Young, MD, MPP, from the Department of Psychiatry, University of California–San Francisco, School of Medicine, and colleagues categorized studies by methodologic quality, sample size, and reported outcomes. Thirty-nine studies were included, most conducted in the United States and all focused on inpatient settings. Measured outcomes included mortality (27 studies, 69%), efficiency (length of stay, duration of procedure, hospital charges,19 studies, 49%), morbidity (23 studies, 59%), and medical errors (6 studies, 15%).
The studies varied widely in quality. For example, 16 studies (41%) did not adjust for risk, and thus were considered to be poor quality. In contrast, 8 (21%) used a concurrent control and adjusted for patient factors and time trends; these studies were considered to be very good quality. Overall, 13 studies (33%) were judged to be of higher quality, and these studies were more likely to report higher mortality and lower efficiency during changeovers.
Studies that focused on morbidity and medical error outcomes were more likely to be judged to be of lower quality, and their findings were inconsistent.
The study was limited by several factors, including a focus on English-language reports and the fact that none of the studies considered the effect of changeovers in ambulatory care settings. There were also inconsistencies in the definition of changeover, resident role in patient care, and supervision structure. In addition, few studies controlled for time trends or level of supervision, and few employed methods appropriate for hierarchical data.
Although the studies point to increased risks during changeovers, because of the heterogeneity among the studies, it is not possible to know the magnitude of the risk.
The researchers suggest that the "July effect" could be addressed by introducing changeover systems that incorporate human factor principles. They could also be designed to avoid cognitive overload and fatigue. Alternatively, system disruption could be reduced by staggering trainee start dates.
The review backs up long-held suspicions that standards of care suffer at the beginning of academic years, according to Paul Barach, MD, MPH, from the University Medical Center Utrecht, the Netherlands, and Ingrid Philibert, PhD, MBA, from the Accreditation Council for Graduate Medical Education, Chicago, Illinois, the authors of an accompanying editorial.
"Reliable-quality and safe patient care throughout the academic year will require a multipronged approach, one that recognizes the need to immerse trainees in a new clinical environment but with seasoned mentorship, close supervision, and graduated clinical responsibilities.... We need to better understand how best to protect patients and providers during cohort turnovers while developing a culture where trainees feel psychologically safe to speak up, admit error, challenge poor practices, and learn to be accountable for their actions," the editorialists write.
The senior author, Andrew D. Auerbach, MD, was supported by a grant from the National Heart, Blood, and Lung Institute. The other authors have disclosed no relevant financial relationships.
Ann Intern Med. Published online July 11, 2011.
16. ACEP Policies
A. Physician Reporting of Potentially Impaired Drivers
Ann Emerg Med. 2011;58:110.
The American College of Emergency Physicians (ACEP) believes:
• reporting of potentially impaired drivers should be individualized to the patient's clinical condition and the clear risk posed to the patient and public by continued driving; and
• physicians exercising good faith clinical judgments should have protection from liability for their reporting actions.
ACEP opposes mandatory reporting of entire classes of patients or diagnoses (eg, epilepsy) unless compelling evidence exists for a public health benefit for such reporting.
B. Boarding of Admitted and Intensive Care Patients in the Emergency Department
Ann Emerg Med. 2011;58:110.
Optimal utilization of the emergency department (ED) includes the timely evaluation, management, and stabilization of all patients. Boarding of admitted patients in the ED contributes to lower quality of care, reduced timeliness of care, and reduced patient satisfaction. The ED should not be utilized as an extension of the ICU and other inpatient units for admitted patients because this practice adversely affects patient safety, quality, and access to care. ED leadership, hospital administrators, emergency medical services (EMS) directors, community leaders, state and federal officials, hospital regulators, and accrediting bodies should work together to resolve this problem. ED boarding is a hospital-wide problem, and the most effective care of admitted patients is provided in an inpatient unit. ED crowding is a direct result of diminished bed and resource capacity created by boarding. For the ED to continue to provide quality patient care and access to that care, the American College of Emergency Physicians (ACEP) believes that:
• Hospitals have the responsibility to provide quality patient care and optimize patient safety by ensuring the prompt transfer of patients admitted to inpatient units as soon as the treating emergency physician makes such a decision. If such a transfer cannot be promptly effected for whatever reason, the hospital must provide the supplemental nursing staff necessary to care for these inpatients boarded in the ED.
• In the event that the number of patients needing evaluation or treatment in an ED is equal to or exceeds the ED's treatment space capacity, admitted patients should be promptly distributed to inpatient units regardless of inpatient bed availability.
• Hospitals should have staffing plans in place that can mobilize sufficient health care and support personnel to meet increased patient needs.
• Hospitals should develop appropriate mechanisms to facilitate availability of inpatient beds.
• Emergency physicians should work with their hospital administration and medical staff to monitor and improve the use of inpatient resources.
• Staffing patterns applicable to other specialized areas/units of the hospital should apply equally to the ED to ensure that patients receive a consistent standard of care, appropriate for the acuity of their condition, within the organization.
• Mutual aid agreements should be in place to assist any hospital that is unable to meet the emergency and intensive care needs of its community.
• Hospital diversion should be instituted only when internal resources have been exhausted and other community facilities have resources available to meet the needs of patients presenting to their facilities. EMS systems should develop mechanisms to address patient diversion by health care facilities, using the ACEP policy on ambulance diversion.
• Hospital regulatory and accrediting bodies should mandate standards for prompt transfer of admitted patients from the ED to inpatient units. When prompt transfer does not occur, established overcapacity contingency plans should be implemented.
17. Surgical Treatment of Ruptured Intracranial Aneurysms within 24 Hours Improve Clinical Outcome
Phillips TJ, et al. Stroke 2011;42:1936-1945.
Background and Purpose—The purpose of this study was to analyze whether treating ruptured intracranial aneurysms within 24 hours of subarachnoid hemorrhage improves clinical outcome.
Methods—An 11-year database of consecutive ruptured intracranial aneurysms treated with endovascular coiling or craniotomy and clipping was analyzed. Outcome was measured by the modified Rankin Scale at 6 months. Our policy is to treat all cases within 24 hours of subarachnoid hemorrhage. Treatment delays are due to nonclinical logistical factors.
Results—Two hundred thirty cases were coiled or clipped within 24 hours of subarachnoid hemorrhage and 229 beyond 24 hours. No difference in age, gender, smoking, family history of subarachnoid hemorrhage, aneurysm size, or aneurysm location was found between the groups. Poor World Federation of Neurological Surgeons clinical grade patients were overrepresented in the ultra-early group. Increasing age and higher World Federation of Neurological Surgeons clinical grade were predictors of poor outcome. Eight point zero percent of cases treated within 24 hours of subarachnoid hemorrhage (ultra-early) were dependent or dead at 6 months compared with 14.4% of those treated beyond 24 hours (delayed), a 44.0% relative risk reduction and a 6.4% absolute risk reduction (2, P=0.044). A total of 3.5% of cases coiled within 24 hours were dependent or dead at 6 months compared with 12.5% of cases coiled at 1 to 3 days, an 82% relative risk reduction and a 10.2% absolute risk reduction (2, P=0.040). These groups did not differ in age, World Federation of Neurological Surgeons clinical grade, aneurysm size, or aneurysm location.
Conclusions—Treatment of ruptured aneurysms within 24 hours is associated with improved clinical outcomes compared with treatment beyond 24 hours. The benefit is more pronounced for coiling than clipping.
18. Cluster of Suspected Guillain-Barre Syndrome Cases: U.S. – Mexico Border Areas
The California Department of Public Health (CDPH) is cooperating with the Arizona Department of Health Services (AZDHS) and the U.S. Centers for Disease Control and Prevention (CDC) in the investigation of a cluster of human cases suspected to be Guillain-Barre Syndrome (GBS) in Arizona and Mexico. GBS is a rare neurological disorder presenting as acute flaccid paralysis. The cases have occurred in the U.S.-Mexico border areas of Yuma County, Arizona as well as San Luis Rio Colorado, Sonora, and possibly Mexicali, Baja California.
As of June 29, 2011, sixteen patients from the Yuma-San Luis Rio Colorado border region have been diagnosed with GBS; these include residents of San Luis Rio Colorado, Sonora (10), San Luis, AZ (4), and Yuma, AZ (2). An additional 10 suspect cases are under investigation. There are also unconfirmed reports of a small cluster of acute flaccid paralysis in Mexicali, Baja California, which may be unrelated to the Yuma-San Luis Rio Colorado cluster. The median age of the confirmed case-patients is 53 years (range, 11-76 years); 88% are male, and all are Hispanic. Onset date of neurologic symptoms range from May 14 through June 19, 2011, and began within 16 days of a diarrheal illness for fourteen of the case-patients. Laboratory test results from three case-patients suggest that the antecedent diarrheal illness was due to Campylobacter infection. Campylobacter is the most commonly recognized pathogen associated with GBS, although GBS as result of campylobacteriosis is uncommon. AZDHS has also detected an increase in Campylobacter reports from Yuma County, and investigation is underway.
The cluster of GBS cases in Yuma County, Arizona, is a public health event of international concern (PHEIC) and was reported to the World Health Organization by CDC on June 25, 2011. A binational team consisting of CDC, AZDHS, Yuma County Health Department, and state and federal Mexican public health officials are collaborating on a joint investigation. CDPH Infectious Diseases Branch (IDB) has notified California border counties regarding this situation. No cases that are potentially associated with the clusters in Mexico or Arizona have been identified in California to date.
If you are notified of any cases of acute flaccid paralysis with a history of travel to the U.S.-Mexico border regions mentioned above, and with an antecedent diarrheal illness, please recommend obtaining stool cultures for Campylobacter and notify Dr. Akiko Kimura of the Infectious Diseases Branch, CDPH at akiko.kimura@cdph.ca.gov.
19. Clinical Data Can Predict Pneumonia Risk in Pediatric ED
Laurie Barclay, MD. July 11, 2011 — Clinical data can predict risk for radiographic pneumonia among children seen in the pediatric emergency department (ED), according to the results of a prospective cohort study reported online July 11 in Pediatrics.
"Use of chest radiography in the evaluation of children with possible pneumonia varies widely," write Mark I. Neuman, MD, MPH, from the Division of Emergency Medicine and Clinical Research Program, Children's Hospital Boston, Massachusetts, and colleagues. "Although studies have identified certain historical features and physical examination findings associated with pneumonia, none have specifically addressed the criteria for obtaining a chest radiograph."
The study goals were to examine the association between historical and physical examination findings and radiographic pneumonia among children seen in the ED for suspected pneumonia, and to develop a clinical decision rule for the use of chest radiography. The study cohort consisted of 2574 patients younger than 21 years who were evaluated and underwent chest radiography at an urban pediatric ED for suspected pneumonia.
On the basis of the interpretation of the chest radiograph by an attending radiologist, pneumonia was categorized as definite pneumonia or radiographic pneumonia (including definite and equivocal cases of pneumonia). Using pneumonia status as the dependent variable and historical and physical examination data as the independent variables, the investigators estimated a multivariate logistic regression model and conducted a recursive partitioning analysis.
Radiographic pneumonia was present in 16% of patients. Significant predictors of pneumonia were history of chest pain, focal rales, fever duration, and oximetry levels at triage, but not tachypnea, retractions, or grunting. The strongest predictor of pneumonia was hypoxia, defined as oxygen saturation 92% or less (odds ratio, 3.6; 95% confidence interval [CI], 2.0 - 6.8).
Among patients with oxygen saturation greater than 92% and absence of fever, of focal decreased breath sounds, and of focal rales, radiographic pneumonia was present in 7.6% (95% CI, 5.3 - 10.0) and definite pneumonia in 2.9% (95% CI, 1.4 - 4.4), based on recursive partitioning analysis.
"Clinical data can stratify children for pneumonia risk," the study authors write. "Children with hypoxia and focal lung findings are high risk whereas those without hypoxia, fever, and ausculatory findings are low risk. For low-risk patients, clinical follow-up should be considered over obtaining a radiograph."
Limitations of this study include the enrollment of half of all eligible patients, low generalizability to other practice settings or to all patients presenting with cough or fever, inability to evaluate the reliability of specific physical examination findings, inability to evaluate children in whom there was suspicion of pneumonia but a radiograph was not obtained, and lack of blinding of the radiologists to the clinical data.
"Validation of these findings requires multicenter research and should include the assessment of the reliability of physical examination findings," the study authors conclude.
The study authors have disclosed no relevant financial relationships.
Pediatrics. Published online July 11, 2011. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21746723
20. Patient Perceptions of CT Imaging and Their Understanding of Radiation Risk and Exposure
Baumann BM, et al. Ann Emerg Med. 2011;58:1-7.e2
Study objective: We describe patient perceptions of computed tomography (CT) and their understanding of radiation exposure and risk.
Methods: This was a cross-sectional study of acute abdominal pain patients aged 18 years or older. Confidence in medical evaluations with increasing levels of laboratory testing and imaging was rated on a 100-point visual analog scale. Knowledge of radiation exposure was ascertained when participants compared the radiation dose of one abdomen-pelvis CT with 2-view chest radiography. To assess cancer risk knowledge, participants rated their agreement with these factual statements: “Approximately 2 to 3 abdominal CTs give the same radiation exposure as experienced by Hiroshima survivors” and “2 to 3 abdominal CTs over a person's lifetime can increase cancer risk.” Previous CT was also assessed.
Results: There were 1,168 participants, 67% women and mean age 40.7 years (SD 15.9 years). Median confidence in a medical evaluation without ancillary testing was 20 (95% confidence interval [CI] 16 to 25) compared with 90 (95% CI 88 to 91) when laboratory testing and CT were included. More than 70% of participants underestimated the radiation dose of CT relative to chest radiography, and cancer risk comprehension was poor. Median agreement with the Hiroshima statement was 13 (95% CI 10 to 16) and 45 (95% CI 40 to 45) with the increased lifetime cancer risk statement. Seven hundred ninety-five patients reported receiving a previous CT. Of 365 patients who reported no previous CT, 142 (39%) had one documented in our electronic medical record.
Conclusion: Patients are more confident when CT imaging is part of their medical evaluation but have a poor understanding of the concomitant radiation exposure and risk and underestimate their previous imaging experience.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)01716-6/fulltext
21. Emergency Physician–Turned-Governor Overhauls Oregon's Health Care
Joanne Kenen. Ann Emerg Med. 2011;58:A13-A14.
Take an “emergency department (ED) doc,” plunk him in the governor's mansion, and ask him to figure out how to provide great health care in a state awash in red ink and you get—triage.
At least that's how Oregon Governor John Kitzhaber, MD, an emergency physician before he went into politics full time, describes his job. “It's triage. It's recognizing that we have to set priorities.”
Emergency physicians are held accountable for both the decisions they make and how they carry them out. Dr. Kitzhaber believes the same accountability should apply in the political and policy realms.
“In public policy, we make triage decisions but are not as accountable,” said Dr. Kitzhaber, who was elected to two 4-year terms (1995 to 2003) and won an unprecedented third term in November 2010.
Now he's facing the challenge of implementing federal health reform, which he generally favors, while trying to vanquish a huge deficit. And of course health care isn't the governor's only problem. He also has to worry about schools, jobs, roads, and the environment. More triage.
But health care has long been Dr. Kitzhaber's signature issue, as a practicing emergency physician, as a state lawmaker and governor, and, in the years between his terms, in the policy worlds. Oregon is way ahead of much of the nation in terms of how much it's already innovated and experimented with how to cover people and how to deliver quality care—and the relationship between taming costs and expanding coverage.
Dr. Kitzhaber didn't set out to be an emergency physician. In fact, he didn't plan on being a physician at all. He has said he wanted to study anatomy and be a naturalist. But that was the late 1960s, and, amid all the social upheaval of the time, Dr. Doolittle ceased being his main inspiration. He decided to become a physician and was drawn into emergency medicine partly because of the fast pace and that sharply limned immediate accountability. He also realized that the schedule of an emergency practitioner in rural Oregon would let him serve as a part-time state legislature.
Misdiagnosed
What's needed at this critical moment, he said in an interview with Annals of Emergency Medicine, is “the right diagnosis.”
For decades the national Dx was “coverage deficiency,” and the prescribed remedies included employer mandates, individual mandates, “consumer-directed” medicine, health savings accounts, public plans, private plans, and single-payer plans. Dr. Kitzhaber's ED experience helped convince him the problem was misdiagnosed. Sure he wants to cover more people; he learned plenty in his old hospital ED about people who don't have insurance or who can't easily access primary care to manage their asthma or diabetes or heart disease. But he doesn't want to do more of the same. He wants to radically rethink how care is delivered—how to manage care without all the baggage of “managed care.”
“The diagnosis isn't how you pay. It's around what you are buying. Is what you are buying improving health? And is it doing so in a way we can afford?” Federal health reform didn't go far enough to answer this, he said. “You are still paying for the same broken delivery system.”
He gave the example of an elderly woman with congestive heart failure, an example all too familiar to emergency physicians. When the summer weather heats up, her health deteriorates. Medicaid pays for her to go in an ambulance to the ED, where she is stabilized and often admitted. This happens over and over and over again, at tremendous cost. Wouldn't it make more sense if the taxpayer could just buy her an air conditioner? The coverage “prescriptions” don't solve that problem. He sees the proof every time he travels around the state and visits a hospital, a clinic, an ED.
His ED roots have not left him. In fact, it was when he was first entering state government, dividing his time between the legislature and his medical career, that the ED really illustrated for him the real-life impact of policy. In the 1990s, when he was a state legislator, Oregon cut off some adults from the Medicaid rolls. It was highly controversial, but on paper it seemed to make economic sense. But not in the ED. There he saw why it was topsy-turvy. Removing patients' access to Medicaid doesn't make them healthy. It may even make them sicker. So without access to primary care and disease management, they ended up in the ED, sicker and more expensive to treat. He remembers one patient in particular, a man who could no longer pay for his blood pressure medicine, who ended up having a massive stroke. The experience left its mark…
For the remainder of the essay (free): http://www.annemergmed.com/article/S0196-0644(11)00465-3/fulltext
