Lit Bits: Jan 14, 2012

From the recent medical literature...

1. Serial Changes in Highly Sensitive Troponin I Assay and Early Diagnosis of Myocardial Infarction

Keller T, et al. JAMA 2011;306(24):2684-2693.

Context: Introduction of highly sensitive troponin assays into clinical practice has substantially improved the evaluation of patients with chest pain.

Objective: To evaluate the diagnostic performance of a highly sensitive troponin I (hsTnI) assay compared with a contemporary troponin I (cTnI) assay and their serial changes in the diagnosis of acute myocardial infarction (AMI).

Design, Setting, and Patients: A total of 1818 patients with suspected acute coronary syndrome were consecutively enrolled at the chest pain units of the University Heart Center Hamburg, the University Medical Center Mainz, and the Federal Armed Forces Hospital Koblenz, all in Germany, from 2007 to 2008. Twelve biomarkers including hsTnI (level of detection, 3.4 pg/mL) and cTnI (level of detection, 10 pg/mL) were measured on admission and after 3 and 6 hours.

Main Outcome Measures: Diagnostic performance for AMI of baseline and serial changes in hsTnI and cTnI results at 3 hours after admission to the emergency department.

Results: Of the 1818 patients, 413 (22.7%) were diagnosed as having AMI. For discrimination of AMI, the area under the receiver operating characteristic (ROC) curve was 0.96 (95% CI, 0.95-0.97) for hsTnI on admission and 0.92 (95% CI, 0.90-0.94) for cTnI on admission. Both were superior to the other evaluated diagnostic biomarkers. The use of hsTnI at admission (with the diagnostic cutoff value at the 99th percentile of 30 pg/mL) had a sensitivity of 82.3% and a negative predictive value (for ruling out AMI) of 94.7%. The use of cTnI (with the diagnostic cutoff value at the 99th percentile of 32 pg/mL) at admission had a sensitivity of 79.4% and a negative predictive value of 94.0%. Using levels obtained at 3 hours after admission, the sensitivity was 98.2% and the negative predictive value was 99.4% for both hsTnI and cTnI assays. Combining the 99th percentile cutoff at admission with the serial change in troponin concentration within 3 hours, the positive predictive value (for ruling in AMI) for hsTnI increased from 75.1% at admission to 95.8% after 3 hours, and for cTnI increased from 80.9% at admission to 96.1% after 3 hours.

Conclusions: Among patients with suspected acute coronary syndrome, hsTnI or cTnI determination 3 hours after admission may facilitate early rule-out of AMI. A serial change in hsTnI or cTnI levels from admission (using the 99th percentile diagnostic cutoff value) to 3 hours after admission may facilitate an early diagnosis of AMI.

2. Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study

Subramanian P, et al. BMJ 2011;343:d7506

Introduction: A humorous anaesthetic colleague recently repeated the following popular saying while an operating table was being repaired with a mallet: “typical orthopaedic surgeon—as strong as an ox but half as bright.” Making fun of orthopaedic surgeons is a popular pastime in operating theatres throughout the country. This pursuit has recently spread to the internet; a humorous animation entitled “orthopedia vs anesthesia” had received more than half a million hits at the time of writing.1 Several comparisons of orthopaedic surgeons to primates have been published, and the medical literature contains suggestions that orthopaedic surgery requires brute force and ignorance.2 3 4

The stereotypical image of the strong but stupid orthopaedic surgeon has not been subject to scientific scrutiny. Previous studies have shown that the average hand size of orthopaedic surgeons is larger than that of general surgeons.2 3 However, a search of the worldwide scientific literature found no studies assessing the strength or intelligence of orthopaedic surgeons. In the absence of a cohort of willing oxen as a control group, and given that the phrase is popular with anaesthetists, we designed this study to compare the mean grip strength of the dominant hand and the intelligence test score of orthopaedic surgeons and anaesthetists..

Abstract: Objective: To compare the intelligence and grip strength of orthopaedic surgeons and anaesthetists.

Design: Multicentre prospective comparative study. Setting: Three UK district general hospitals in 2011.

Participants: 36 male orthopaedic surgeons and 40 male anaesthetists at consultant or specialist registrar grade.

Main outcome measures: Intelligence test score and dominant hand grip strength.

Results: Orthopaedic surgeons had a statistically significantly greater mean grip strength (47.25 (SD 6.95) kg) than anaesthetists (43.83 (7.57) kg). The mean intelligence test score of orthopaedic surgeons was also statistically significantly greater at 105.19 (10.85) compared with 98.38 (14.45) for anaesthetists.

Conclusions: Male orthopaedic surgeons have greater intelligence and grip strength than their male anaesthetic colleagues, who should find new ways to make fun of their orthopaedic friends.

Full-text (free): http://www.bmj.com/content/343/bmj.d7506

3. Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis

Singh B, et al. Ann Emerg Med. 2012; in press

Study objective: To perform a systematic review and meta-analysis to define the diagnostic performance of pulmonary embolism rule-out criteria (PERC) in deferring the need for D-dimer testing to rule out pulmonary embolism in the emergency department (ED).

Methods: We searched EMBASE, MEDLINE, Scopus, Web of Knowledge, and all the evidence-based medicine reviews that included the Cochrane Database of Systematic Reviews through August 14, 2011, and hand searched references in potentially eligible articles and conference proceedings of major emergency medicine organizations for the previous 2 years. We selected studies that reported diagnostic performance of PERC, reported original research, and were conducted in the ED, with no language restrictions. Two investigators independently identified eligible studies and extracted data. We used contingency tables to calculate sensitivity, specificity, and likelihood ratios.

Results: We found 12 qualifying cohorts (studying 13,885 patients with 1,391 pulmonary embolism diagnoses), 10 prospective and 2 retrospective, from 6 countries. Pooled sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios for 10 included studies were 0.97 (95% confidence interval [CI] 0.96 to 0.98), 0.23 (95% CI 0.22 to 0.24), 1.24 (95% CI 1.18 to 1.30), and 0.17 (95% CI 0.13 to 0.23), respectively. Significant heterogeneity was observed in specificity (I2=97.2%) and positive likelihood ratio (I2=84.2%).

Conclusion: The existing literature suggests consistently high sensitivity and low but acceptable specificity of the PERC to rule out pulmonary embolism in patients with low pretest probability.

_______________________

The related Reuters article can be found here: http://www.medscape.com/viewarticle/756136

For dissenting evidence, see, for example, Hugli O, et al. The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism. J Thromb Haemost. 2011;9:300-4. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21091866

About this study, Singh et al explain: “Two of the included studies (Hugli et al and Righini et al) report a higher frequency of missed pulmonary embolism and have raised concern about the reliability of PERC. However, their higher failure rate likely results from the higher pulmonary embolism prevalence observed in their European settings. The threshold for pulmonary embolism diagnostic imaging in the United States is substantially lower than that in Europe, presumably because of the higher litigation risk. The PERC rule was developed for use in low probability settings.”

See too Hennessey A, et al. A Patient with a Large Pulmonary Saddle Embolus Eluding Both Clinical Gestalt and Validated Decision Rules. Ann Emerg Med 2012; in press. Abstract: http://www.annemergmed.com/article/S0196-0644(11)01801-4/abstract

See also a helpful essay reviewing PE by Rick Bukata at Emergency Physicians Monthly: http://www.epmonthly.com/columns/in-my-opinion/pe-still-a-challenging-diagnosis/

4. Modest Public Health Impact of Nontargeted Human Immunodeficiency Virus Screening in 29 EDs

Kayigan Wilson d’Almeida, MD; Arch Intern Med. 2012;172(1):12-20.

Background: To lower the number of undiagnosed infections and to improve early detection, international health agencies have promoted nontargeted human immunodeficiency virus (HIV) screening in health care settings, including emergency departments (EDs). This strategy remains controversial and has yet to be tested on a large scale. We assessed the public health impact of nontargeted HIV–rapid test (RT) screening among ED patients in the metropolitan area of Paris (11.7 million inhabitants), where half of France's new HIV cases are diagnosed annually.

Methods: During a randomly assigned 6-week period for each of the 29 participating EDs, 18- to 64-year-old patients who were able to provide consent for HIV testing were offered a fingerstick whole-blood HIV RT. Main outcome measures were the number of patients tested for HIV and their characteristics vs those of the general metropolitan Paris population and the proportion of newly diagnosed HIV-positive patients among those tested and their characteristics vs those from the national HIV case surveillance.

Results: Among 138 691 visits, there were 78 411 eligible patients, 20 962 of whom (27.0%) were offered HIV RT; 13 229 (63.1%) accepted testing and 12 754 (16.3%) were tested. The ED patients' characteristics reflected the general population distribution. Eighteen patients received new HIV diagnoses (0.14%; 95% confidence interval, 0.08%-0.22%). Like national HIV case surveillance patients, they belonged to a high-risk group (n = 17), were previously tested (n = 12), and were either symptomatic or had a CD4 lymphocyte count lower than 350/µL, suggesting late-stage infections (n = 8); 12 patients were linked to care.

Conclusions: Nontargeted HIV testing in EDs was feasible but identified only a few new HIV diagnoses, often at late stages, and, unexpectedly, most patients belonged to a high-risk group. Our findings do not support the implementation of nontargeted screening of the general population in EDs.

5. Do Emergency Physicians Admit More or Fewer Patients on Busy Days?

Albrecht R, et al. J Emerg Med. 2011;41:709-712.

Background: Although the issues concerning the impact of emergency department (ED) overcrowding have been the subject of much recent concern, there are few data regarding the effect of ED census on emergency physician behavior with respect to the decision to admit patients. Admission rates might either increase or decrease on busy days, when the system and the physician are under stress.

Study Objective: The purpose of this study was to determine if ED physicians change their admitting behavior depending on ED census.

Methods: This was a retrospective review of 3 months' data (92 consecutive days, July 9–October 9, 2006) in a community ED with an annual census of approximately 70,000 patients and an emergency medicine residency program. We defined each of the 92 days to be either “busy” (over 180 patients seen), “slow” (fewer than 147 patients seen) or “medium” (147–180 patients seen). We then compared the rates of admission to the hospital on the “busy,” “medium,” and “slow” days. We also compared each attending physician's personal rates of admission on slow days to his or her rate of admission on medium or busy days. ED staffing was constant throughout the study period. All comparisons were with chi-squared.

Results: There were 14,969 patients seen in the ED during the 92 study days. On “busy” days, 20.1% of the 3400 patients were admitted to the hospital; on “medium” days, 20.6% of the 9057 patients were admitted; on “slow” days, 19.7% of the 2512 patients were admitted. There was no significant association between the level of patient volume in the ED and rate of admission (p = 0.55). When comparing each of 14 attending physicians to him- or herself, there was no significant association found between rate of admission and ED census (all p values above 0.3). All three categories of days, “busy,” “medium,” and “slow” did not differ in terms of acuity as judged by triage level distribution.

Conclusion: The likelihood of a patient's admission vs. discharge is not affected by ED patient volume. Furthermore, we found no evidence that an individual physician's admitting behavior was associated with ED patient volume.

6. Is Nasogastric Lavage Beneficial for Acute Gastrointestinal Bleeding?

The procedure increased the likelihood of early endoscopy but not better patient outcomes, such as lower mortality. The question merits prospective analysis.

Nasogastric lavage (NGL) was once a standard initial procedure for all patients with acute gastrointestinal (GI) bleeding, but its use is now under debate. Although some data suggest that patients with a bloody NGL are more likely to have severe bleeding (Gastrointest Endosc 2004; 59:172), the test's presumed benefits — confirming an upper GI source of bleeding, clearing the stomach for better endoscopic visualization, and reducing the risk for aspiration — have not been tested.

To evaluate the effects of NGL during triage on clinical outcomes, investigators conducted a retrospective database study of 632 patients from a Veterans Administration hospital. To control for confounding factors that might influence the decision to perform lavage, researchers identified 24 variables a priori that were associated with receiving NGL and used them to develop a propensity score — or likelihood of undergoing NGL — among patients with acute GI bleeding. They then matched 193 patients who received lavage and 193 who did not by propensity score and compared clinical outcomes.

Patients who underwent NGL were more likely to have an endoscopy (odds ratio, 1.71) and to receive it sooner (hazard ratio, 1.49) than other patients. Lavage did not affect mortality, length of hospital stay, or the need for transfusions or surgery. Bloody aspirates were associated with high-risk lesions at endoscopy (OR, 2.69).

The authors conclude that NGL is associated with receiving early endoscopy and might be useful in triage but does not affect clinical outcomes.

Comment: This paper will be of interest to many physicians caring for patients with upper GI bleeding and likely will be interpreted differently, depending on when they are seeing the patient and what they are trying to accomplish. One thing remains clear though — routine use of NGL in these patients is not justified. We already know that NGL cannot be used to exclude ongoing upper GI bleeding as one sixth of patients with active bleeding will have a negative NGL. Now, this study demonstrates that NGL results in no difference in a number of important clinical outcomes. However, certain targeted uses of NGL — such as to enhance visualization before endoscopy, thereby assisting in lesion identification — were not part of this study. These possible roles for NGL as an adjunctive tool to enhance endoscopy or to improve specific patient outcomes will require appropriately designed prospective studies. Until then, routine use of NGL in patients with upper GI bleeding is not indicated, but there are likely selected patients who might benefit from this intervention.

— David J. Bjorkman, MD, MSPH (HSA), SM (Epid.). Published in Journal Watch Gastroenterology December 2, 2011. Citation(s): Huang ES et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc 2011 Nov; 74:971.
Medline abstract (Free): http://www.ncbi.nlm.nih.gov/pubmed/21737077

Pallin DJ and Saltzman JR. Is nasogastric lavage in patients with acute upper GI bleeding indicated or antiquated? Gastrointest Endosc 2011 Nov; 74:981.
Medline abstract (Free): http://www.ncbi.nlm.nih.gov/pubmed/22032314

7. Emergency Medicine Top Stories of 2011 from Journal Watch

A perspective on the most important research in the field from the past year

We are pleased to provide you with our Top 10 list for 2011. In other years, we have provided two lists: one reflecting our editors' selections and one based on total number of page views. We have come to know that the latter list, while interesting, does not reflect the needs or interests of emergency medicine clinicians but rather reflects the final common pathway of a very large, heterogeneous pool of Web searches. So, we no longer will provide that list. Instead, we have selected the most important studies covered by Journal Watch Emergency Medicine in 2011. Each of these summaries is worth a read, and, in many cases, linking to the original source — the published study — is valuable.

We hope that you continue to enjoy our annual lists and our ongoing efforts to keep you informed about medical information that will affect how you think and how you practice.

Full-text (free): http://emergency-medicine.jwatch.org/cgi/content/full/2011/1230/1

8. "Wait and see" approach to the ED cardioversion of acute AF

Doyle B, et al. Emerg Med Int. 2011. Epub 2011 Nov 17.

Objective. Acute atrial fibrillation often spontaneously resolves. This study aimed to investigate the outcomes and satisfaction of an evidence-based ED protocol employing a "wait and see" approach.

Methods. A prospective observational cohort study of adult patients presenting to the Emergency Department with stable acute atrial fibrillation was performed. Patients were excluded if they were considered to be unstable, need hospitalization, or poor candidates for ED procedural sedation. Routine care was provided on the index visit, and suitable candidates were discharged and asked to return to the ED the following day for possible electrical cardioversion. Outcome measures included spontaneous reversion to sinus rhythm, success of cardioversion, length of stay, adverse event and return visits for AF within 30 days, and patient satisfaction.

Results. Thirty five patient encounters were analysed over a 21-month period. Twenty two of the 35 patients (63%) had spontaneous resolution of atrial fibrillation upon presentation for potential cardioversion. All of the remaining patients underwent successful cardioversion to normal sinus rhythm without significant adverse events recorded. No patients required hospitalization. Three patients (9%) returned to the ED within 30 days for recurrence of atrial fibrillation. All patients were reported to be "very satisfied" with this approach.

Conclusion. A "wait and see" approach to the ED electrical cardioversion of atrial fibrillation showed that almost two-thirds of patients had spontaneous resolution without requiring cardioversion or observation in the ED or hospital. All patients were successfully reverted to normal sinus rhythm and had a high degree of satisfaction.

Full-text (free): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226298/

9. Video + Direct Laryngoscopy

by Richard Levitan, MD. Emergency Physicians Monthly, December 22, 2011

While some still debate the relative merits of direct vs. video laryngoscopy, the newest set of laryngoscopes make it easy, offering the best of both worlds.

At the recent Society for Airway Management conference there was a debate on Direct Laryngoscopy (DL) vs. Video Laryngoscopy (VL). While I love imaging and the mechanical and teaching advantages of look-around-the-curve video laryngoscopes, there is beauty in the simplicity, speed, and emergency applicability of direct laryngoscopy. DL is faster and does better with fluids, bleeding, and vomitus while tube delivery is much more straightforward with hyperangulated video devices. When VL is used in large series it does not perform better overall than DL, although there are cases when DL is very hard and VL easy. Alternatively, I have had some hard or impossible VL cases where DL was a slam dunk.

It occurred to me after the conference that the debate was in some ways pointless, given the new array of DL/VL devices which make both options available to you. With hyperangulated devices like the Glidescope, McGrath Series 5, or Storz Dorges Blade video laryngoscope, the angulation of the blade prevents any direct view. If the video fails, from fluids or any other reason, there is no direct view. This is not the case with DL/VL combination devices. Intubation can be done via direct line of sight, just as a standard instrument would be used, or under video, or as a combination. In the setting of emergency airways, especially trauma airways, I think this has great value.

Currently available DL/VL devices include the Storz C-Mac, the new McGath Mac (now to be distributed by Covidien), and the Glidescope Direct Trainer…

The remainder of the text (free) here: http://www.epmonthly.com/subspecialties/technology/video--direct-laryngoscopy-/

10. Effective Antibiotic Treatment Prescribed by Emergency Physicians in Patients Admitted to the ICU with Severe Sepsis or Septic Shock: Where is the Gap?

Capp R, et al. J Emerg Med. 2011;573-580.

Background: Antibiotic selection made within the first hour of recognition of severe sepsis and septic shock has been shown to decrease mortality.

Objective: The purpose of this study was to determine what antibiotics are being prescribed and to identify factors influencing ineffective antibiotic coverage in patients with severe sepsis or septic shock. In addition, we explore an alternative method for antibiotic selection that could improve organism coverage.

Methods: This was a retrospective review of emergency department (ED) patients admitted to an intensive care unit (ICU) over a 12-month period with a culture-positive diagnosis of either severe sepsis or septic shock. Appropriate antibiotic therapy was defined as effective coverage of the offending organism based on final culture results.

Results: Of the 1400 patients admitted to the ICU, 137 patients were culture positive and met the criteria for severe sepsis or septic shock. Effective antibiotic coverage was prescribed by emergency physicians in 82% (95% confidence interval [CI] .74–.88) of cases. Of the 25 patients who received ineffective antibiotics, the majority had infections caused by resistant Gram-negative organisms. Health care-associated pneumonia guidelines were applied to all patients, regardless of the source of infection, and were 100% sensitive (95% CI .93–1) for selecting patients who had infections caused by highly resistant organisms.

Conclusion: Emergency physicians achieved 82% effective antibiotic coverage in patients with severe sepsis or septic shock. The gap seems to be in coverage of highly resistant Gram-negative organisms. An alternative approach to antibiotic prescription, utilizing a set of guidelines for community- and health care-associated infections, was found to be 100% sensitive in selecting patients who had infections caused by the more resistant organisms.

11. Ciclesonide Trumps Antibiotics for Pediatric Otitis Media

Fran Lowry, Medscsape. November 22, 2011 (Boston, Massachusetts) — The nasal corticosteroid spray ciclesonide is more effective than a broad-spectrum oral antibiotic for the treatment of children with otitis media with effusion, according to a small study presented in an oral session here at the American College of Allergy, Asthma & Immunology 2011 Annual Scientific Meeting.

A resolution of otitis media with effusion occurred after 8 days of treatment with the aqueous nasal spray, but it took 14 days for a resolution in children treated with amoxicillin and clavulanate, Safa Nsouli, MD, director of the Danville Asthma and Allergy Clinic in California, reported.

In an open-label study, Dr. Nsouli and colleagues randomized 40 atopic children, 6 to 11 years of age, with otitis media with effusion to 1 of 2 groups: 2 sprays of ciclesonide 50 µg per nostril daily (n = 20); or amoxicillin and clavulanate potassium 90 mg/kg per day in 2 divided doses every 12 hours (n = 20). Both treatments were given for a 2-week period.

The effectiveness of the 2 treatments was assessed objectively using pneumatic otoscopy, impedance tympanometry, and audiometry.

"There is a nasal obstruction that occurs with otitis media. If we eliminate the nasal obstruction with ciclesonide, we decrease the aspiration reflex of the nasopharyngeal secretions into the middle ear that occur via the eustacian tube," Dr. Nsouli told Medscape Medical News.

"We also reduce the allergic inflammatory obstruction of the eustacian tube. Ciclesonide decreases those mechanisms, which helps clear the otitis media much faster than a plain antibiotic treatment that works only on the bacteria," he said. "It's like having a clogged sink. You can try to clean the sink but it is impossible unless the sink is unplugged and drained."

In addition to resolving otitis media symptoms more rapidly, ciclesonide is a safer option, Dr. Nsouli said.

"I am sure many doctors and parents have noticed that their pediatric patients with otitis media can be on several antibiotic courses, sometimes for 6 to 8 months, with no results. They have even inserted an ear tube for drainage of the secretions. Our study shows that we can eliminate the long-term course of antibiotics," Dr. Nsouli said.

Heartening Results

Medscape Medical News invited Chitra Dinakar, MD, professor of pediatrics at the University of Missouri at Kansas City, for her views on this study.

"Studies have shown that only about 1 in 3 children with middle-ear effusion who undergo myringotomy and placement of ventilation tubes have a bacterial pathogen identified; in general, qualitative studies suggest low bacterial densities in such effusions," Dr. Dinakar noted. "Additionally, inflammatory exudates or infiltration of neutrophils in the fluid is typically not found.

Despite this, pediatricians encounter patients with "fluid in the ear" who are given multiple course of antibiotics, raising concerns about "the development of multidrug-resistant pathogens and the effects of antibiotics on a young child's natural flora and immune system," she said.

"It is heartening to note that this small open-label study showed more rapid resolution of symptoms with a nasal steroid, compared to a course of an appropriate antibiotic, at least in the short-term assessment period of 2 weeks," Dr. Dinakar said.

Dr. Nsouli has disclosed no relevant financial relationships. Dr. Dinakar reports financial relationships with AstraZeneca and GlaxoSmithKline.

American College of Allergy, Asthma & Immunology (ACAAI) 2011 Annual Scientific Meeting: Abstract 62. Presented November 6, 2011.

12. Images in Medicine

Lung Herniation after Cough-Induced Rupture of Intercostal Muscle
http://www.nejm.org/doi/full/10.1056/NEJMicm1106070

Pneumopericardium Associated with a Peptic Ulcer
http://www.nejm.org/doi/full/10.1056/NEJMicm1107529

Image Challenge: What’s This?
http://www.nejm.org/image-challenge?ci=12222011

A Head Shot
http://www.nejm.org/doi/full/10.1056/NEJMicm1009118

13. Low-dose diltiazem in atrial fibrillation with rapid ventricular response.

Lee J, et al. Am J Emerg Med. 2011 Oct;29(8):849-54.

OBJECTIVES: Diltiazem is one of the most commonly used medications to control the rapid ventricular response in atrial fibrillation (AF). The recommended starting dose is an intravenous bolus of 0.25 mg/kg over 2 minutes. To avoid hypotension, we have empirically used a lower dose of diltiazem. We compared the efficacy and safety of different doses of diltiazem in rapid AF.

METHODS: A retrospective chart review was undertaken in patients who presented to the emergency department with rapid AF. Patients were divided into 3 groups according to diltiazem dosage: low dose (≤ 0.2 mg/kg), standard dose (greater than 0.2 and ≤ 0.3 mg/kg), and high dose (more than 0.3 mg/kg). We compared the rates of therapeutic response (adequate rate control) and complications (such as hypotension). Multivariate regression analysis was used to determine the effect of diltiazem dose on the occurrence of complications.

RESULTS: A total of 180 patients were included in the analysis. There were no significant differences in the rates of therapeutic response for the low-, standard-, and high-dose groups (70.5%, 77.1%, and 77.8%; P = .605). The rates of hypotension in the low-, standard-, and high-dose groups were 18%, 34.9%, and 41.7%, respectively. After adjusting confounding variables, the rate of hypotension was significantly lower in the low-dose group in comparison with the standard-dose group (adjusted odds ratio, 0.39; 95% confidence interval, 0.16-0.94).

CONCLUSIONS: Low-dose diltiazem might be as effective as the standard dose in controlling rapid AF and reduce the risk of hypotension.

14. When balance is bias (in scientific journalism)

Trevor Jackson, magazine editor. BMJ 2011;343:d8006

Sometimes the science is strong enough for the media to come down on one side of a debate

In his 2010 BBC television series Wonders of the Solar System, the physicist Brian Cox made a remark that offended some horoscope lovers. “Despite the fact that astrology is a load of rubbish, Jupiter can in fact have a profound influence on our planet. And it’s through a force . . . gravity.” The BBC received a number of complaints, including one from a viewer who said that Cox made his comment without an “alternative opinion being allowed.” The complainant griped that the programme made no attempt to “consider such questions from the perspective of an astrologer, who draws upon a very different body of observation and knowledge built over thousands of years.” Cox later gave the BBC a statement (which it declined to issue) saying, “I apologise to the astrology community for not making myself clear. I should have said that this new age drivel is undermining the very fabric of our civilisation.”

This tale, which beautifully points up the ridiculousness of always demanding balance in science communication, is told by Steve Jones, emeritus professor of human genetics at University College London, in a report published this year. The BBC Trust commissioned Jones to review the impartiality and accuracy of the BBC’s coverage of science; and although Jones found much to praise, he expresses concern about the BBC’s guidelines on “due impartiality.” These, Jones found, had a distorting effect, creating a sense of equivalence where there was none, and privileging maverick and dissident views so that they appeared as valid as established scientific fact. (This is not to say that established facts cannot be disproved. But the onus is on the claimants to prove or disprove their case within the rigorous paradigms of modern scientific research—witness the current debates on the invariability of the speed of light.)

Jones found that BBC journalists, in their quest for objectivity and impartiality—entirely understandable aims in coverage of politics and arts—risked giving the impression in their science reporting that there were two equal sides to a story when clearly there were not. As Jones says, “There is widespread concern that [the BBC’s] reporting of science sometimes gives an unbalanced view of particular issues because of its insistence on bringing in dissident voices into what are in effect settled debates.”

The dangers of this approach are clear in journalistic coverage of subjects such as the MMR (measles, mumps, rubella) vaccine—as the BMJ has previously shown—and climate change. A 2003 study into coverage of MMR showed that the media’s insistence on giving equal weight to both the views of the anti-vaccine camp and to the overwhelming body of scientific evidence exonerating the vaccine from its alleged adverse effects made people think that scientists themselves were divided over the safety of the vaccine, when they were not. The quest for balance created what Jones and others have called “false balance,” and in the case of the MMR vaccine helped fuel a public health disaster.

The investigative journalist Nick Davies, in his 2008 book Flat Earth News—an examination of falsehood, distortion, and propaganda in the world’s media—says that the insistence on balance is one of the factors that stops journalists getting at the truth. “Neutrality requires the packaging of conflicting claims, which is precisely the opposite of truth telling. If two men go to mow a meadow and one comes back and says ‘The job’s done’ and the other comes back and says ‘We never cut a single blade of grass,’ neutrality requires the journalist to report a controversy surrounding the state of the meadow, to throw together both men’s claims and shove it out to the world with an implicit sign over the top declaring, ‘We don’t know what’s happening—you decide’.” Another seasoned UK journalist, Malcolm Dean, takes a similar line on balance in his 2011 book Democracy Under Attack, as does the Science Media Centre, in its evidence to the ongoing Leveson inquiry into media ethics. If journalists will not decide where the truth lies, this puts the onus on readers and viewers; and given that scientists are not always expert communicators, there is a real risk that the anti-science view will hold sway.

Davies’s and Dean’s position reflects that of the US academics Maxwell T Boykoff and Jules M Boykoff, who have researched the reporting of climate change. In two seminal papers, the Boykoffs identified the journalistic norm of balance—the refusal to privilege the high level consensus that anthropogenic climate change is a reality over the views of right wing mavericks and oil industry funded commentators—as one of the factors that has sown doubt and confusion among the public.

In his recent book Who Speaks for the Climate?, Maxwell Boykoff shows that the journalistic norm of balance in news reporting “has served to amplify outlier views on anthropogenic climate change, and concurrently engendered an appearance of increased uncertainty regarding anthropogenic climate science. This, in turn, has entered into an already highly contested arena where it has permeated climate policy discourse and decision-making.”

Part of the problem is that it takes time for a scientific consensus to emerge, and the media are impatient. Few scientists would nowadays argue that smoking does not cause lung cancer, that the world was created in six days, or that the earth is flat, but that wasn’t always the case. Davies shows how the oil industry began mobilising its public relations campaign against the notion of anthropogenic climate change in 1989, years before any scientific consensus could emerge on global warming.

So what is to be done? In the current climate, as media outlets have to produce ever more copy with fewer resources, the outlook is bleak. The BBC hopes that a new stipulation in its editorial guidelines—“due weight,” the recognition that, for example, minority views should not necessarily be given equal weight to the prevailing consensus12—and an online training module on the specific demands of science reporting will help. Steve Jones says he is yet to see any evidence of the difference this can make, but it is a start. Also, researchers themselves should hone their communication skills.

Meanwhile, some science journalism will continue to be weighed in the balance and found wanting.

References: http://www.bmj.com/content/343/bmj.d8006

15. Surge Reported in Energy Drink ED Visits

Laird Harrison. Medscape. November 28, 2011 — The number of emergency department visits associated with nonalcohol energy drinks is surging, according to a report from the US Substance Abuse and Mental Health Services Administration (SAMHSA).

In 2005, the agency recorded 1,128 such visits and in 2009 it recorded 13,114 such visits, with the highest number occurring in 2008 (16,055). Data are not yet available for 2010.

"Energy drinks used in excess or in combination with alcohol or drugs can pose a serious health risk," said SAMHSA administrator Pamela S. Hyde in a press release.

The agency defines energy drinks as flavored beverages containing high amounts of stimulants such as caffeine. The drinks are marketed to youth and are consumed by up to 50% of children, adolescents, and young adults.

The report, entitled Emergency Department Visits Involving Energy Drinks, is based on data from SAMHSA's 2005 to 2009 Drug Abuse Warning Network (DAWN) reports. DAWN is a public health surveillance system that monitors drug-related hospital emergency department visits reported in the United States.

The report found that in 44% of emergency department visits involving energy drinks, the drinks were taken together with other substances, such as alcohol, pharmaceuticals, and illicit drugs. This combination of energy drinks and other substances of abuse was greatest in young adults 18 to 25 years of age (52%).

The vast majority (77%) of these visits were made by people 18 to 39 years of age, and 64% were made by males, according to the report.

Energy-drink-related emergency department visits involving males were twice as likely as those involving females to include the use of alcohol (20% vs 10%) or illicit drugs (12% vs 5%).

Female visits were more likely than male visits to involve the combined use of energy drinks and pharmaceuticals (35% vs 23%).

Studies indicate that excessive caffeine intake from energy drinks can cause adverse reactions, such as arrhythmias, hypertension, and dehydration. Combining energy drinks with substances of abuse raises the risk for serious, even life-threatening, injury and for the likelihood of engaging in risky behaviors, such as driving under the influence.

The National Institute on Alcohol Abuse and Alcoholism has developed a pocket guide for healthcare professionals and others to help with screening and brief intervention for youth who might have alcohol problems, including cases involving energy drinks.

"The beverage industry, consumer groups, community coalitions, the healthcare community, teachers, parents, and others must get the word out that quick-fix energy drinks are not a solution and carry great risks, especially in combination with other substances of abuse," said Ms. Hyde.

The report (full-text, free): http://www.samhsa.gov/data/2k11/WEB_DAWN_089/WEB_DAWN_089_HTML.pdf

Pocket Guide: http://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuidePocket.pdf

16. Acetaminophen May Be Bad for Asthmatic Kids

McBride JT. Pediatrics. 2011;128;1181.

A growing number of studies have documented such a strong association between acetaminophen exposure and asthma that it is possible that much of the dramatic increase in childhood asthma over the past 30 years has been related to the use of acetaminophen. Although this possibility has been widely acknowledged, commentators have been reluctant, without a randomized clinical trial, to conclude that acetaminophen causes asthma and, with rare exception, have not recommended changes in practice. As a pediatric pulmonologist, I am entrusted with the care of many asthmatic children and, at some level, with the respiratory health of all children in my area. Given this role, I must decide when and how to act on the possibility that acetaminophen is detrimental to asthmatic children. Considering currently available data, I now recommend that any child with asthma or a family history of asthma avoid using acetaminophen.

The epidemiologic association between acetaminophen use and asthma prevalence and severity in children and adults is well established. A variety of observations suggest that acetaminophen use has contributed to the recent increase in asthma prevalence in children: (1) the strength of the association; (2) the consistency of the association across age, geography, and culture; (3) the dose-response relationship; (4) the timing of increased acetaminophen use and the asthma epidemic; (5) the relationship between per-capita sales of acetaminophen and asthma prevalence across countries; (6) the results of a double-blind trial of ibuprofen and acetaminophen for treatment of fever in asthmatic children; and (7) the biologically plausible mechanism of glutathione depletion in airway mucosa. Until future studies document the safety of this drug, children with asthma or at risk for asthma should avoid the use of acetaminophen.

Full-text in Pediatrics (free): http://pediatrics.aappublications.org/content/128/6/1181.full

New York Times Essay: http://www.nytimes.com/2011/12/20/health/evidence-mounts-linking-acetaminophen-and-asthma.html

17. Consensus Criteria Predict Futile Prehospital Trauma Resuscitation

None of 294 patients had meaningful survival, and EMS resuscitation triggered hospital costs approaching $4 million.

In 2003, the National Association of Emergency Medical Services (EMS) Physicians and the American College of Surgeons Committee on Trauma published guidelines on when to withhold or terminate prehospital resuscitation in traumatic cardiopulmonary arrest (TCPA). Using data from a level I trauma registry from 2003 through 2010, researchers studied prehospital TCPA patients aged 18 years for whom these guidelines were violated. Criteria to withhold or terminate care were (1) blunt trauma with apnea, pulselessness, and no organized electrocardiogram activity; (2) penetrating trauma with the preceding clinical presentation and no other signs of life; (3) 15 minutes of cardiopulmonary resuscitation without return of spontaneous circulation; or (4) EMS-witnessed TCPA followed by 15 minutes of unsuccessful resuscitation en route to the emergency department (ED).

Among 294 patients, mechanism of injury was blunt in 90 (31%) and penetrating in 204 (69%). Overall, 274 patients (93%) died in the ED, and 12 (4%) died during surgery. Of the 8 patients who reached the intensive care unit, 7 died in the ICU, and 1 (0.3%) survived but had a Glasgow Coma Scale score of 6 and was discharged to a long-term care facility.

Comment: The charges for hospital care for these 294 patients totaled nearly US$4 million, and the one surviving patient had a horrible outcome. These data strongly support the existing guidelines and the need to ensure that EMS personnel understand and adhere to them.

— John A. Marx, MD, FAAEM. Published in Journal Watch Emergency Medicine December 9, 2011. Citation: Mollberg NM et al. The consequences of noncompliance with guidelines for withholding or terminating resuscitation in traumatic cardiac arrest patients. J Trauma 2011 Oct; 71:997.

18. The Wait that Matters

Maa J. N Engl J Med. 2011 Jun 16;364(24):2279-81.

She was 69 years old and, with the exception of mild heart disease, was in excellent health. One day, around mid-morning, she noticed that her heartbeat was irregular and she felt slightly short of breath. Using her home blood-pressure cuff, she found that her pulse was 130. Since her blood pressure was stable, she decided to forgo a call to 911 and instead asked her husband to drive her to the local hospital — one of the most highly regarded academic medical centers on the West Coast.

After waiting about an hour to be seen, she was diagnosed with rapid atrial fibrillation around 8 o'clock on a Thursday evening. Given her age, the emergency department (ED) staff and the consulting cardiologist decided to admit her to the hospital. The medical team started giving her intravenous heparin for anticoagulation and planned to perform electrical cardioversion the following day if a transesophageal echocardiogram (TEE) confirmed the absence of an atrial thrombus.

Because no inpatient bed was available, the patient was kept in the ED overnight. The narrowness of the stretcher and the noise and bright lights of the ED hallway made it hard for her to get much sleep. The following day, shortly before noon, she was wheeled upstairs to a bed.

Early in the afternoon, the cardiologist stopped by to let her know that because her admission had been delayed, it would not be possible to complete her procedures before the end of the workday. Therefore, she would remain in the hospital receiving intravenous heparin and oral warfarin throughout the weekend and would undergo TEE and cardioversion the following Monday.

The next day, without warning, the patient sustained a massive embolic stroke…

The remainder of the essay (free): http://www.nejm.org/doi/full/10.1056/NEJMp1101882

19. How fast does the Grim Reaper walk? Receiver operating characteristics curve analysis in healthy men aged 70 and over

Stanaway FF, et al. BMJ 2011;343:d7679

Introduction

The Grim Reaper, the personification of death, is a well known mythological and literary figure. Reported characteristics include a black cloak with cowl, a scythe, and cachexia. High quality scientific research linking the Grim Reaper to mortality has been scarce, despite extensive anecdotes.

Walking speed is a commonly used objective measure of physical capability in older people, predicting survival in several cohort studies. A recent meta-analysis found that being in the lowest fourth of walking speed compared with the highest was associated with a threefold increased risk of mortality. Moreover, the association between slow walking speed and mortality seems consistent across several ethnic groups and shows a dose-response relation.8 Although the association between walking speed and mortality has been well documented, the plausible biological relation between the two remains unclear.

We assessed whether the relation between slow walking speed and mortality results from the increased likelihood of being caught by Death. By assessing this relation using receiver operating characteristics curve analysis, we hypothesised we would be able to determine the walking speed of the Grim Reaper—information of importance to public health…

Abstract

Objective: To determine the speed at which the Grim Reaper (or Death) walks.

Design: Population based prospective study.

Setting: Older community dwelling men living in Sydney, Australia.

Participants: 1705 men aged 70 or more participating in CHAMP (Concord Health and Ageing in Men Project).

Main outcome measures: Walking speed (m/s) and mortality. Receiver operating characteristics curve analysis was used to calculate the area under the curve for walking speed and determine the walking speed of the Grim Reaper. The optimal walking speed was estimated using the Youden index (sensitivity+specificity−1), a common summary measure of the receiver operating characteristics curve, and represents the maximum potential effectiveness of a marker.

Results: The mean walking speed was 0.88 (range 0.15-1.60) m/s. The highest Youden index (0.293) was observed at a walking speed of 0.82 m/s (2 miles (about 3 km) per hour), corresponding to a sensitivity of 63% and a specificity of 70% for mortality. Survival analysis showed that older men who walked faster than 0.82 m/s were 1.23 times less likely to die (95% confidence interval 1.10 to 1.37) than those who walked slower (P=0.0003). A sensitivity of 1.0 was obtained when a walking speed of 1.36 m/s (3 miles (about 5 km) per hour) or greater was used, indicating that no men with walking speeds of 1.36 m/s or greater had contact with Death.

Conclusion: The Grim Reaper’s preferred walking speed is 0.82 m/s (2 miles (about 3 km) per hour) under working conditions. As none of the men in the study with walking speeds of 1.36 m/s (3 miles (about 5 km) per hour) or greater had contact with Death, this seems to be the Grim Reaper’s most likely maximum speed; for those wishing to avoid their allotted fate, this would be the advised walking speed.

20. Corticosteroids Impart No Benefit after Single-Dose Etomidate for Intubation

Moderate-dose hydrocortisone infusion did not affect outcomes in intubated patients without septic shock who had etomidate-related adrenal insufficiency.

Some physicians have expressed concern about adrenal suppression associated with etomidate use, but is this suppression clinically relevant? Researchers in France prospectively studied 97 patients with acute medical or traumatic conditions without septic shock who underwent intubation with etomidate plus succinylcholine in the prehospital or emergency department settings. Patients were randomized to receive continuous infusions of hydrocortisone (200 mg/day) or saline for 42 hours, starting 6 hours after intubation. Postintubation sedation was maintained with a variety of sedative and analgesic agents (not etomidate). Patients received vasopressor support and insulin as required to maintain target mean arterial blood pressure of 65 to 90 mm Hg and serum glucose levels of below 10 mmol/L.

Six hours after etomidate administration, 91% of patients randomized to the hydrocortisone group and 84% randomized to the control group met criteria for adrenal insufficiency based on corticotrophin stimulation tests and serum hormonal assays. No significant differences were noted between groups in rate of decline of Sequential Organ Failure Assessment scores, duration of mechanical ventilation, length of stay in the intensive care unit, or 28-day mortality.

Comment: Hydrocortisone treatment is not without risk and does not seem to benefit the group of patients studied. Etomidate, with its stable cardiovascular profile, remains an induction agent of choice for emergency intubation, particularly in multitrauma patients with brain injury whose outcomes might be worsened by inadequate systemic blood pressure for cerebral perfusion.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine January 13, 2012. Citation: Payen JF et al. Corticosteroid after etomidate in critically ill patients: A randomized controlled trial. Crit Care Med 2012 Jan; 40:29.

Medline abstract (Free): http://www.ncbi.nlm.nih.gov/pubmed/21926601

Marik PE. Etomidate in critically ill patients: Is it safe? Crit Care Med 2012 Jan; 40:301.
Medline abstract (Free): http://www.ncbi.nlm.nih.gov/pubmed/22179348

21. How to keep those New Year’s resolutions

Psychologists have identified successful ways of meeting self-determined goals, but they may not work if you’re a perfectionist.

Harv Health Lett. 2006 Jan;31(3):1-2.

Full-text (free): http://harvardhealth.staywell.com/viewNewsletter.aspx?NLID=47&INC=yes

“Exploring Change” as a New Year’s Resolution

In preparation to making changes, I will be exploring how changes are made. (A clever deferral strategy, wouldn’t you say?)

An introduction to the psychology of decision making can be found here: “The Mechanics of Choice” by Eric Wargo. The Observer, Vol.25, No.1 January, 2012

After years of tinkering, psychological scientists are figuring out how the gears turn when we make decisions. Full-text (free): http://tinyurl.com/dx62hfj

Some Fascinating Reading for Winter 2012 on Change: Cognitive, social, and historical

Daniel Kahneman (Nobel Laureate), Thinking: Fast and Slow (New York: Farrar, Straus and Giroux, 2011). http://www.amazon.com/dp/0374275637/ Ranked by the New York Times among their top 5 best non-fiction books of 2011 http://www.nytimes.com/2011/12/11/books/10-best-books-of-2011.html

Chip Heath and Dan Heath, Switch: How to Change Things when Change is Hard (New York: Broadway Books, 2010). http://www.amazon.com/dp/0385528752/

Timothy D. Wilson, Redirect: The Surprising New Science of Psychological Change (New York: Little, Brown and Company, 2011). http://www.amazon.com/dp/0316051888/

Steven Pinker, The Better Angels of our Nature: Why Violence Has Declined (New York: Penguin Group, 2011). http://www.amazon.com/dp/0670022950/

Lit Bits: Dec 17, 2011

From the recent medical literature...

1. Do Boarding and Overcrowding Have Measurable Adverse Clinical Consequences?

A. The Association between Length of ED Boarding and Mortality

Singer AJ, et al. Acad Emerg Med. 2011;18:1324-1329.

Objectives: Emergency department (ED) boarding has been associated with several negative patient-oriented outcomes, from worse satisfaction to higher inpatient mortality rates. The current study evaluates the association between length of ED boarding and outcomes. The authors expected that prolonged ED boarding of admitted patients would be associated with higher mortality rates and longer hospital lengths of stay (LOS).

Methods: This was a retrospective cohort study set at a suburban academic ED with an annual ED census of 90,000 visits. Consecutive patients admitted to the hospital from the ED and discharged between October 2005 and September 2008 were included. An electronic medical record (EMR) system was used to extract patient demographics, ED disposition (discharge, admit to floor), ED and hospital LOS, and in-hospital mortality. Boarding was defined as ED LOS 2 hours or more after decision for admission. Descriptive statistics were used to evaluate the association between length of ED boarding and hospital LOS, subsequent transfer to an intensive care unit (ICU), and mortality controlling for comorbidities.

Results: There were 41,256 admissions from the ED. Mortality generally increased with increasing boarding time, from 2.5% in patients boarded less than 2 hours to 4.5% in patients boarding 12 hours or more (p less than 0.001). Mean hospital LOS also showed an increase with boarding time (p less than 0.001), from 5.6 days (SD ± 11.4 days) for those who stayed in the ED for less than 2 hours to 8.7 days (SD ± 16.3 days) for those who boarded for more than 24 hours. The increases were still apparent after adjustment for comorbid conditions and other factors.

Conclusions: Hospital mortality and hospital LOS are associated with length of ED boarding.

B. The Association of ED Crowding and Time to Antibiotics in Febrile Neonates

Kennebeck SS, et al. Acad Emerg Med. 2011;18:1380-1385.

Objectives: The objective was to assess the relationship between emergency department (ED) crowding and timeliness of antibiotic administration to neonates presenting with fever in a pediatric ED.

Methods: This was a retrospective cohort study of febrile neonates (aged 0–30 days) evaluated for serious bacterial infections (SBIs) in a pediatric ED from January 2006 to January 2008. General linear models were used to evaluate the association of five measures of ED crowding with timeliness of antibiotic administration, controlling for patient characteristics. A secondary analysis was conducted to determine which part of the ED visit for this population was most affected by crowding.

Results: A total of 190 patients met inclusion criteria. Mean time to first antibiotic was 181.7 minutes (range = 18–397 minutes). At the time of case presentation, the number of patients waiting in the waiting area, total number of hours spent in the ED by current ED patients, number of ED patients awaiting admission, and hourly boarding time were all positively associated with longer times to antibiotic. The time from patient arrival to room placement exhibited the strongest association with measures of crowding.

Conclusions: Emergency department crowding is associated with delays in antibiotic administration to the febrile neonate despite rapid recognition of this patient population as a high-risk group. Each component of ED crowding, in terms of input, throughput, and output factors, was associated with delays. Further work is required to develop processes that foster a more rapid treatment protocol for these high-risk patients, regardless of ED crowding pressures.

C. An Empirical Assessment of Boarding and Quality of Care: Delays in Care among Chest Pain, Pneumonia, and Cellulitis Patients

Liu SW, et al. Acad Emerg Med. 2011;18:1339–1348.

Background: As hospital crowding has increased, more patients have ended up boarding in the emergency department (ED) awaiting their inpatient beds. To the best of our knowledge, no study has compared the quality of care of boarded and nonboarded patients.

Objectives: This study sought to examine whether being a boarded patient and boarding longer were associated with more delays, medication errors, and adverse events among ED patients admitted with chest pain, pneumonia, or cellulitis.

Methods: This study was a retrospective cohort design in which data collection was accomplished via medical record review from two urban teaching hospitals. Patients admitted with chest pain, pneumonia, or cellulitis between August 2004 and January 2005 were eligible for inclusion. Our outcomes measures were: 1) delays in administration of home medications, cardiac enzyme tests, partial thromboplastin time (PTT), and antibiotics; 2) medication errors; and 3) adverse events or near misses. Primary independent variables were boarded status, boarding time, and boarded time interval. Multiple logistic regression models controlling for patient, ED, and hospital characteristics were used.

Results: A total of 1,431 patient charts were included: 811 with chest pain, 387 with pneumonia, and 233 with cellulitis. Boarding time was associated with an increased odds of home medication delays (adjusted odds ratio [AOR] = 1.07, 95% confidence interval [CI] = 1.05 to 1.10), as were boarded time intervals of 12, 18, and 24 hours. Boarding time also was associated with lower odds of having a late cardiac enzyme test (AOR = 0.93, 95% CI = 0.88 to 0.97).

Conclusions: Boarding was associated with home medication delays, but fewer cardiac enzyme test delays. Boarding was not associated with delayed PTT checks, antibiotic administration, medication errors, or adverse events/near misses. These findings likely reflect the inherent resources of the ED and the inpatient units.

D. ED Crowding is Associated with Decreased Quality of Analgesia Delivery for Children with Pain Related to Acute, Isolated, Long-bone Fractures

Sills MR, et al. Acad Emerg Med. 2011;18:1330-1338.

Objectives: The authors sought to determine which quality measures of analgesia delivery are most influenced by emergency department (ED) crowding for pediatric patients with long-bone fractures.

Methods: This cross-sectional, retrospective study included patients 0–21 years seen for acute, isolated long-bone fractures, November 2007 to October 2008, at a children’s hospital ED. Nine quality measures were studied: six were based on the timeliness (1-hour receipt) and effectiveness (receipt/nonreceipt) of three fracture-related processes: pain score, any analgesic, and opioid analgesic administration. Three equity measures were also tested: language, identified primary care provider (PCP), and insurance. The primary independent variable was a crowding measure: ED occupancy. Models were adjusted for age, language, insurance, identified PCP, triage level, ambulance arrival, and time of day. The adjusted risk of each timeliness or effectiveness quality measure was measured at five percentiles of crowding and compared to the risk at the 10th and 90th percentiles. The role of equity measures as moderators of the crowding-quality models was tested.

Results: The study population included 1,229 patients. Timeliness and effectiveness quality measures showed an inverse association with crowding—an effect not moderated by equity measures. Patients were 4% to 47% less likely to receive timely care and were 3% to 17% less likely to receive effective care when each crowding measure was at the 90th than at the 10th percentile (p less than 0.05). For three of the six quality measures, quality declined steeply between the 75th and 90th crowding percentiles.

Conclusions: Crowding is associated with decreased timeliness and effectiveness, but not equity, of analgesia delivery for children with fracture-related pain.

E. Crowding Does Not Adversely Affect Time to PCI for AMI in a Community ED

Harris B, et al. Ann Emerg Med. 2012;59:13-17.

Study objective: Multiple studies have linked emergency department (ED) crowding to delays in patient care, such as treatment with antibiotics and analgesics. Multiple studies have also demonstrated the benefit of timely percutaneous coronary intervention for patients with acute ST-segment elevation myocardial infarction (STEMI). We therefore study whether increased occupancy rates in our community ED might correlate with delays in door-to-balloon time for patients with acute STEMI who are referred for emergency percutaneous coronary intervention.

Methods: This study was a single-institution prospective observational study. For every patient arriving in our ED from June 2007 through October 2009 with acute STEMI treated with percutaneous coronary intervention, we measured the ED occupancy rate on arrival and the door-to-balloon time and determined the correlation between these variables in univariate and multivariate analyses controlling for patient characteristics, occupancy rate, times to ECG and catheter laboratory activation, and the availability of the catheterization laboratory team (in-house versus on-call).

Results: During the study period, 210 patients were treated with emergency percutaneous coronary intervention in accordance with the hospital protocol. For these patients, the mean ED occupancy rate at arrival was 127% (range 28% to 214%). The mean time to balloon inflation was 65 minutes (range 25 to 142 minutes). The time to balloon inflation did not significantly change with increasing occupancy rate in univariate analysis (Spearman's correlation −0.02; 95% confidence interval −0.13 to 0.11) or in multivariate analysis, with the only significant variable being the availability of the catheterization laboratory team in house, which was associated with reduced time to balloon inflation.

Conclusion: Times to achieve emergency percutaneous coronary intervention for acute STEMI do not correlate positively with crowding as measured by the occupancy rate in our ED.

2. CHADS2 Telling in AF Patients on Oral Anticoagulants

Megan Brooks. November 22, 2011 — In patients with atrial fibrillation, higher CHADS2 score is associated with increased risk for stroke or systemic embolism, bleeding, and death, even with optimal anticoagulation with warfarin or dabigatran, according to a subgroup analysis of the RE-LY trial.

In anticoagulated patients, "the commonly used CHADS2 risk score not only predicts stroke (as it was developed for) but also mortality and major bleeding," first author Jonas Oldgren, MD, associate professor of cardiology, Uppsala Clinical Research Centre and Department of Medical Sciences, Uppsala University Hospital, Sweden, told Medscape Medical News.

The analysis was published November 15 in Annals of Internal Medicine.

Prediction Rule

CHADS2 is a simple and validated clinical prediction rule for estimating stroke risk in patients with atrial fibrillation not receiving anticoagulants, the authors note in their paper. Its value in predicting thrombotic and bleeding complications in patients receiving anticoagulant therapy is unclear.

Dr. Oldgren and colleagues used data from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial to assess thrombotic and bleeding risk according to the baseline CHADS2 score.

The study involved 18,112 patients with atrial fibrillation at risk for stroke who were randomly assigned to treatment with dabigatran (Pradaxa, Boehringer Ingelheim), 110 mg or 150 mg twice daily, or warfarin at a dose adjusted to an international normalized ratio (INR) of 2.0 to 3.0 for a median of 2 years.

The main RE-LY results, published in 2009 in the New England Journal of Medicine, showed that the rates of stroke or systemic embolism and death each decreased by 0.5% per year with dabigatran, 150 mg twice daily, compared with dose-adjusted warfarin. Rates of major bleeding did not differ, but intracranial bleeding was less common with dabigatran.

The CHADS2 risk score assigns 1 point for a history of congestive heart failure, hypertension, diabetes, or age older than 75 years and 2 points for a history of stroke or transient ischemic attack.

In the RE-LY cohort, 5775 patients had CHADS2 scores of 0 to 1, 6455 had scores of 2, and 5882 patients had scores of 3 to 6.

Even with anticoagulation, the risk for the primary outcome of stroke or systemic embolism increased with increasing CHADS2 score, the authors report.

There was also a progressive near-linear increase in the risk for other outcomes with increasing CHADS2 score, the authors report.

Regardless of CHADS2 score, "rates of stroke or systemic embolism were lower with dabigatran, 150 mg twice daily, and rates of intracranial bleeding were lower with both dabigatran doses than with warfarin treatment," Dr. Oldgren told Medscape Medical News.

These findings "extend our knowledge in important ways," write the authors of a linked commentary.

"CHADS2 scores of 3 or higher identify patients with the most to gain and the most to lose by using anticoagulant therapy," note Rebecca J. Beyth, MD, University of Florida, Gainesville, and C. Seth Landefeld, MD, University of California, San Francisco.

"Whether they receive warfarin or dabigatran, 150 mg twice daily, these patients have a 2% to 3% annual risk for stroke or systemic embolism, a nearly 5% risk for major bleeding, and a nearly 6% risk for death," they add.

Interpret Cautiously

Dr. Oldgren and colleagues caution that these subgroup analyses were not prespecified and "should be deemed exploratory."

Nonetheless, "we believe these results are valuable for clinicians in their daily practice and useful in the decision on oral anticoagulant treatment in patients with atrial fibrillation at risk for stroke," Dr. Oldgren told Medscape Medical News.

Dr. Beyth and Dr. Landefeld agree. They say these data along with other studies performed to date can help physicians choose whether to use dabigatran or warfarin.

"On the one hand, dabigatran is more effective and safer for many patients with nonvalvular atrial fibrillation, especially younger patients, patients with CHADS2 scores of 0 or 1, and those in whom the INR is not maintained within the therapeutic range at least 60% of the time," they point out.

"On the other hand, the relative benefits of warfarin and dabigatran depend on the proportion of time that the INR is maintained within the therapeutic range in patients receiving warfarin and on patients adhering to a twice-daily regimen of dabigatran," they note.

The study was funded by Boehringer Ingelheim Pharmaceuticals. A complete list of disclosures for the RE-LY investigators and editorial writers can be found on the journal's Web site.

Ann Intern Med. 2011;155:660-667, 714-715.

Abstract: http://www.annals.org/content/155/10/660.abstract

3. Acutely Injured ED Patients on Dabigatran: Problematic

Cotton BA, et al. N Engl J Med 2011; 365:2039-2040.

To the Editor:

Trauma remains the fourth leading cause of death in the United States, with 40,000 deaths annually in persons over the age of 65. U.S. trauma centers are seeing an increasing number of severely injured elderly patients,1 and hemorrhagic complications and head injuries account for a substantial proportion of these fatalities.1 Although the preinjury use of warfarin is increasing and is associated with a considerable increase in morbidity and mortality, these complications can be dramatically reduced with methods that rapidly reverse the anticoagulant effect.1 Moreover, numerous options are available to achieve warfarin reversal (e.g., vitamin K, plasma, factor VIIa, and factor concentrates).1 Warfarin reversal can also be easily monitored with readily available laboratory and point-of-care tests.

Warfarin has long been the mainstay of anticoagulation therapy in atrial fibrillation. However, dabigatran etexilate (a new oral direct thrombin inhibitor) has recently been reported to have a similar or lower bleeding risk as compared with warfarin.2,3 Unlike warfarin, dietary restrictions and frequent blood sampling to monitor the degree of anticoagulation are unnecessary with dabigatran. Enthusiasm for this agent, however, must be tempered by three notable concerns: there is no readily available means for assessing the degree of anticoagulation with dabigatran, there is no readily available reversal strategy, and life-threatening bleeding complications can occur after an injury in patients taking this drug.

Lack of a readily available method to determine the degree of anticoagulation creates a major challenge to those treating injured patients. Moreover, the irreversible coagulopathy of dabigatran is of great concern to trauma and emergency physicians. Currently, the only reversal option for dabigatran is emergency dialysis (as suggested in a single line in the package insert). The ability to perform rapid dialysis in patients with bleeding whose condition is unstable or in those with large intracranial hemorrhages will present an incredible challenge, even at level 1 trauma centers.

Recently, we have cared for several injured patients receiving dabigatran, all of whom had poor outcomes. Although the results of conventional coagulation studies were normal, the values obtained on rapid thromboelastography (rTEG) at the time of admission were grossly abnormal. Specifically, the values for activated clotting time on rTEG (normal range, 86 to 118 seconds), which correspond to the inhibition of enzymatic clotting, were markedly prolonged. Figure 1 (link below) is the tracing from a patient who fell from a standing position, deteriorated neurologically, and died shortly after emergency craniotomy. It shows that all values except activated clotting time were normal. Unfortunately, even with the aid of rTEG, supportive care is all that is available in the emergency setting.

As dabigatran and other similar therapeutic agents move into the marketplace, we urge the Food and Drug Administration to consider the generalizability of study findings and to support more pragmatic trials. As such, we strongly urge that hemorrhagic complications and death resulting from trauma be included as part of the routine surveillance of all newly approved oral anticoagulants.

Link to figure (free): http://www.nejm.org/doi/full/10.1056/NEJMc1111095

Related Medscape Article: http://www.medscape.com/viewarticle/754332

4. Elevated HCG with an Empty Uterus Does Not Always Mean Ectopic Pregnancy

Live birth can occur in women with elevated HCG and no gestational sac seen on initial transvaginal ultrasound.

Until recently, common teaching was that when serum β human chorionic gonadotropin (β-HCG) is above 1000–2000 mIU/mL — the "discriminatory zone" — a gestational sac should be seen on transvaginal ultrasound in normal intrauterine pregnancy. To test this, researchers at a Boston hospital analyzed data for 202 patients during an 11-year period who had elevated β-HCG on the same day as transvaginal ultrasound showing no intrauterine fluid collection and then had subsequent ultrasound evidence of a live intrauterine embryo or fetus.

On the day of initial scan, β-HCG levels were less than 1000 mIU/mL in 80% of patients, 1000–1499 in 9%, 1500–1999 in 6%, and above 2000 mIU/mL in 5%. None of the 9 patients with β-HCG levels above 2000 mIU/mL had fibroids or other anatomic abnormalities that would have interfered with visualization of intrauterine fluid collection. The highest initial β-HCG level in a pregnancy that culminated in a live birth was 4336 mIU/mL. Initial β-HCG levels were not associated with pregnancy outcomes.

Comment: The Society of Radiologists in Ultrasound is planning a consensus conference on early first trimester sonography in 2012, which might well end the notion of the HCG "discriminatory zone" for diagnosis of ectopic pregnancy. Nevertheless, in hemodynamically stable patients with elevated β-HCG and no gestational sac or adnexal masses suggestive of ectopic pregnancy on transvaginal ultrasound, serial β-HCG measurement and repeat ultrasound to assess for a viable fetus is a reasonable option before diagnosing ectopic pregnancy.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine December 16, 2011. Citation: Doubilet PM and Benson CB. Further evidence against the reliability of the human chorionic gonadotropin discriminatory level. J Ultrasound Med 2011 Dec; 30:1637.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22123998

5. Prevalence of Clinically Important TBI in Children with Minor Blunt Head Trauma and Isolated Severe Injury Mechanisms

Nigrovic LE, et al.for the Traumatic Brain Injury (TBI) Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). Arch Pediatr Adolesc Med. Published online December 5, 2011.

Objective: To determine the prevalence of clinically important traumatic brain injuries (TBIs) with severe injury mechanisms in children with minor blunt head trauma but with no other risk factors from the Pediatric Emergency Care Applied Research Network (PECARN) TBI prediction rules (defined as isolated severe injury mechanisms).

Design: Secondary analysis of a large prospective observational cohort study.

Setting: Twenty-five emergency departments participating in the PECARN.

Patients: Children with minor blunt head trauma and Glasgow Coma Scale scores of at least 14.

Intervention: Treating clinicians completed a structured data form that included injury mechanism (severity categories defined a priori).

Main Outcome Measures: Clinically important TBIs were defined as intracranial injuries resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for at least 2 nights. We investigated the rate of clinically important TBIs in children with either severe injury mechanisms or isolated severe injury mechanisms.

Results: Of the 42 412 patients enrolled in the overall study, 42 099 (99%) had injury mechanisms recorded, and their data were included for analysis. Of all study patients, 5869 (14%) had severe injury mechanisms, and 3302 (8%) had isolated severe injury mechanisms. Overall, 367 children had clinically important TBIs (0.9%; 95% CI, 0.8%-1.0%). Of the 1327 children younger than 2 years with isolated severe injury mechanisms, 4 (0.3%; 95% CI, 0.1%-0.8%) had clinically important TBIs, as did 12 of the 1975 children 2 years or older (0.6%; 95% CI, 0.3%-1.1%).

Conclusion: Children with isolated severe injury mechanisms are at low risk of clinically important TBI, and many do not require emergent neuroimaging.

6. Emergency Hospitalizations for Adverse Drug Events in Older Americans

Adverse drug events (ADEs) cause an estimated 100,000 emergency hospitalizations for seniors each year, yet two thirds involve just a handful of anticoagulants and diabetes medications, according to a study published in the November 24 issue of the New England Journal of Medicine.

The study, by researchers from the US Centers for Disease Control and Prevention (CDC), singles out 4 drugs and drug classes — warfarin, oral antiplatelet medications, insulins, and oral hypoglycemic agents. Alone or together, they account for 67% of emergency ADE hospitalizations of adults 65 years and older. Warfarin was implicated in 33%, lead author Daniel Budnitz, MD, MPH, director of the CDC's Medication Safety Program, and coauthors write.

Budnitz DS, et al. N Engl J Med 2011; 365:2002-2012.

Introduction: Decreasing the number of preventable rehospitalizations by 20% by the end of 2013 is a goal of the $1 billion federal initiative Partnership for Patients, and the pursuit of this goal represents an opportunity to reduce harm to patients and reduce health care costs. Adverse drug events are a direct consequence of clinical care and a key focus of the partnership.

Hospitalizations for adverse drug events are likely to increase as Americans live longer, have greater numbers of chronic conditions, and take more medications. Among adults 65 years of age or older, 40% take 5 to 9 medications and 18% take 10 or more. Age-related physiological changes, a greater degree of frailty, a larger number of coexisting conditions, and polypharmacy have been associated with an increased risk of adverse events, and older adults are nearly seven times as likely as younger persons to have adverse drug events that require hospitalization.

In a previous study, we found that medications classified as always potentially inappropriate were implicated in only 3.6% of emergency department visits for adverse drug events in older adults, whereas three medications (warfarin, insulin, and digoxin) were implicated in 33.3% of such emergency department visits. Data on the medications that most commonly cause hospitalizations for adverse drug events in the United States have been limited. Detailed and drug-specific data are needed to help focus current patient-safety efforts. We used nationally representative public health surveillance data to describe emergency hospitalizations for adverse drug events in persons 65 years of age or older and to assess the contribution of specific medications, including those identified as high-risk or inappropriate by current national health care quality measures.

Background: Adverse drug events are important preventable causes of hospitalization in older adults. However, nationally representative data on adverse drug events that result in hospitalization in this population have been limited.

Methods: We used adverse-event data from the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project (2007 through 2009) to estimate the frequency and rates of hospitalization after emergency department visits for adverse drug events in older adults and to assess the contribution of specific medications, including those identified as high-risk or potentially inappropriate by national quality measures.

Results: On the basis of 5077 cases identified in our sample, there were an estimated 99,628 emergency hospitalizations (95% confidence interval [CI], 55,531 to 143,724) for adverse drug events in U.S. adults 65 years of age or older each year from 2007 through 2009. Nearly half of these hospitalizations were among adults 80 years of age or older (48.1%; 95% CI, 44.6 to 51.6). Nearly two thirds of hospitalizations were due to unintentional overdoses (65.7%; 95% CI, 60.1 to 71.3). Four medications or medication classes were implicated alone or in combination in 67.0% (95% CI, 60.0 to 74.1) of hospitalizations: warfarin (33.3%), insulins (13.9%), oral antiplatelet agents (13.3%), and oral hypoglycemic agents (10.7%). High-risk medications were implicated in only 1.2% (95% CI, 0.7 to 1.7) of hospitalizations.

Conclusions: Most emergency hospitalizations for recognized adverse drug events in older adults resulted from a few commonly used medications, and relatively few resulted from medications typically designated as high-risk or inappropriate. Improved management of antithrombotic and antidiabetic drugs has the potential to reduce hospitalizations for adverse drug events in older adults.

Medscape Review: http://www.medscape.com/viewarticle/754138

7. Does primary stroke center certification change ED diagnosis, utilization, and disposition of patients with acute stroke?

Ballard DW, et al. Am J Emerg Med. 2011 Nov 17. [Epub ahead of print]

BACKGROUND AND PURPOSE: We examined the impact of primary stroke center (PSC) certification on emergency department (ED) use and outcomes within an integrated delivery system in which EDs underwent staggered certification.

METHODS: A retrospective cohort study of 30 461 patients seen in 17 integrated delivery system EDs with a primary diagnosis of transient ischemic attack (TIA), intracranial hemorrhage, or ischemic stroke between 2005 and 2008 was conducted. We compared ED stroke patient visits across hospitals for (1) temporal trends and (2) pre- and post-PSC certification-using logistic and linear regression models to adjust for comorbidities, patient characteristics, and calendar time, to examine major outcomes (ED throughput time, hospital admission, radiographic imaging utilization and throughput, and mortality) across certification stages.

RESULTS: There were 15 687 precertification ED visits and 11 040 postcertification visits. Primary stroke center certification was associated with significant changes in care processes associated with PSC certification process, including (1) ED throughput for patients with intracranial hemorrhage (55 minutes faster), (2) increased utilization of cranial magnetic resonance imaging for patients with ischemic stroke (odds ratio, 1.88; 95% confidence interval, 1.36-2.60), and (3) decrease in time to radiographic imaging for most modalities, including cranial computed tomography done within 6 hours of ED arrival (TIA: 12 minutes faster, ischemic stroke: 11 minutes faster), magnetic resonance imaging for patients with ischemic stroke (197 minutes faster), and carotid Doppler sonography for TIA patients (138 minutes faster). There were no significant changes in survival.

CONCLUSIONS: Stroke center certification was associated with significant changes in ED admission and radiographic utilization patterns, without measurable improvements in survival.

8. Do outcomes of near syncope really parallel those of syncope? Uh…yup.

Grossman SA, et al. Amer J Emerg Med. 2012;30:203-206.

Background: Limited information on the evaluation of emergency department (ED) patients complaining of “near syncope” exists. Multiple studies of syncope exclude near syncope claiming near syncope is poorly defined and its definition is nonuniform.

Objective: The aim of this study was to determine the incidence of critical interventions or adverse outcomes associated with near syncope and compare these outcomes with syncope.

Methods: Prospective, observational study enrolling (August 2007–October 2008) consecutive ED patients (age, ≥18 years) presenting with near syncope was conducted. Near syncope was defined as an episode in which the patient felt they might lose consciousness but did not. Critical intervention/adverse outcome was defined as hemorrhage, cardiac ischemia/intervention, alteration in antidysrhythmics, pacemaker/defibrillator placement, sepsis, stroke, death, dysrhythmia, sepsis, pulmonary embolus, or carotid stenosis. Primary outcome was an adverse outcome or critical intervention in hospital or less than 30 days. Near syncope and syncope outcomes and admission rates were compared using the χ2 test.

Results; After 1870 patients were screened, 244 met the study definition. Of the 244 patients, follow-up was achieved in 242 (99%). Emergency department hospitalization or 30-day adverse outcomes occurred in 49 (20%) of 244 compared with 68 (23%) of 293 of patients with syncope (P = .40). The most common adverse outcomes/critical interventions were hemorrhage (n = 6), bradydysrhythmia (n = 6), alteration in antidysrhythmics (n = 6), and sepsis (n = 10). Of patients with near syncope, 49% were admitted compared with 69% with syncope (P = .001).

Conclusion: Patients with near syncope are as likely those with syncope to experience critical interventions or adverse outcomes; however, near-syncope patients are less likely to be admitted. Given similar risk of adverse outcomes for near syncope and syncope, future studies are warranted to improve the treatment of ED patients with near syncope.

9. National Performance is Poor on Door-In to Door-Out Time among Patients Transferred for Primary PCI

Herrin J, et al. Arch Intern Med. 2011;171(21):1879-1886.

Background: Delays in treatment time are commonplace for patients with ST-segment elevation acute myocardial infarction who must be transferred to another hospital for percutaneous coronary intervention. Experts have recommended that door-in to door-out (DIDO) time (ie, time from arrival at the first hospital to transfer from that hospital to the percutaneous coronary intervention hospital) should not exceed 30 minutes. We sought to describe national performance in DIDO time using a new measure developed by the Centers for Medicare & Medicaid Services.

Methods: We report national median DIDO time and examine associations with patient characteristics (age, sex, race, contraindication to fibrinolytic therapy, and arrival time) and hospital characteristics (number of beds, geographic region, location [rural or urban], and number of cases reported) using a mixed effects multivariable model.

Results: Among 13 776 included patients from 1034 hospitals, only 1343 (9.7%) had a DIDO time within 30 minutes, and DIDO exceeded 90 minutes for 4267 patients (31.0%). Mean estimated times (95% CI) to transfer based on multivariable analysis were 8.9 (5.6-12.2) minutes longer for women, 9.1 (2.7-16.0) minutes longer for African Americans, 6.9 (1.6-11.9) minutes longer for patients with contraindication to fibrinolytic therapy, shorter for all age categories (except older than 75 years) relative to the category of 18 to 35 years, 15.3 (7.3-23.5) minutes longer for rural hospitals, and 14.4 (6.6-21.3) minutes longer for hospitals with 9 or fewer transfers vs 15 or more in 2009 (all P less than .001).

Conclusion: Among patients presenting to emergency departments and requiring transfer to another facility for percutaneous coronary intervention, the DIDO time rarely met the recommended 30 minutes.

10. Effect of IV ondansetron on QT interval prolongation in patients with cardiovascular disease and additional risk factors for torsades: a prospective, observational study.

Hafermann MJ, et al. Drug Healthc Patient Saf. 2011;3:53-8.

BACKGROUND: The 5-hydroxytryptamine type 3 antagonists, or setrons (eg, ondansetron), are commonly used for nausea and vomiting in the hospital setting. In 2001, droperidol was given a black box warning because it was found to prolong the QT interval and induce arrhythmias. The setrons share with droperidol the same potential proarrhythmic mechanisms, but limited data exist concerning their effects on the QT interval in individuals at high risk for torsades de pointes.

METHODS: Forty hospitalized patients admitted for heart failure or acute coronary syndromes with one or more risk factors for torsades de pointes and an order for intravenous ondansetron 4 mg were enrolled in this prospective, observational study. The QT interval corrected for heart rate (QTc) was obtained via a 12-lead electrocardiogram on admission and again 120 minutes after the first dose of ondansetron in order to determine the mean change in QTc following ondansetron exposure.

RESULTS: The mean time interval between obtaining the baseline electrocardiogram and the second electrocardiogram following ondansetron administration was 3.5 ± 2.14 hours. In the total population, the QTc interval was prolonged by 19.3 ± 18 msec (P less than 0.0001) 120 minutes after ondansetron administration. For patients with an acute coronary syndrome and those with heart failure, QTc was prolonged by 18.3 ± 20 msec (P less than 0.0001) and 20.6 ± 20 msec (P less than 0.0012), respectively. Following ondansetron exposure, 31% and 46% in the heart failure and acute coronary syndromes groups, respectively, met gender-related thresholds for a prolonged QTc.

CONCLUSION: Our study found QTc prolongation due to ondansetron administration similar to that found in previous studies. When used in patients with cardiovascular disease (eg, heart failure or acute coronary syndromes) with one or more risk factors for torsades de pointes, ondansetron may significantly increase the QTc interval for up to 120 minutes after administration. From a patient safety perspective, patients who are at high risk for torsades de pointes and receiving ondansetron should be followed via telemetry when admitted to hospital.

Full-text (free): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202761/

11. The Role of Triage Nurse Ordering on Mitigating Overcrowding in EDs: A Systematic Review

Rowe BH, et al. Acad Emerg Med. 2011;18:1349-1357.

Objectives: The objective was to examine the effectiveness of triage nurse ordering (TNO) on mitigating the effect of emergency department (ED) overcrowding.

Methods: Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, SCOPUS, Web of Science, HealthSTAR, Dissertation Abstracts, ABI/INFORM Global), controlled trial registry websites, conference proceedings, study references, experts in the field, and correspondence with authors were used to identify potentially relevant studies. Interventional studies in which TNO was used to influence ED overcrowding metrics (length of stay [LOS] and physician initial assessment [PIA]) were included in the review. Two reviewers independently assessed study eligibility and methodologic quality. Mean differences were calculated and reported with corresponding 95% confidence intervals (CIs).

Results: From more than 14,000 potentially relevant studies, 14 were included in the systematic review. Most were single-center ED studies; the overall quality was rated as weak, due to methodologic deficiencies and variable outcome reporting. TNO was associated with a 37-minute mean reduction (95% CI = −44.10 to −30.30 minutes) in the overall ED LOS in one randomized clinical trial (RCT); a 51-minute mean reduction (95% CI = −56.3 to −45.5 minutes) was observed in non-RCTs. When applied to injured subjects with suspected fractures, TNO interventions reduced ED LOS by 20 minutes (95% CI = −37.5 to −1.9 minutes) in three RCTs and by 18 minutes (95% CI = −23.2 to −13.2) in two non-RCTs. No significant reduction in PIA was observed in two RCTs.

Conclusions: Overall, TNO appears to be an effective intervention to reduce ED LOS, especially in injury and/or suspected fracture cases. The available evidence is limited by small numbers of studies, weak methodologic quality, and incomplete reporting. Future studies should focus on a better description of the contextual factors surrounding these interventions and exploring the impact of TNO on other indicators of productivity and satisfaction with health care delivery.

12. Corticosteroids Useful in Acute COPD Exacerbation Requiring Ventilatory Support

Alia I, et al. Arch Intern Med 2011;171:1939-1948.

NEW YORK (Reuters Health) Dec 01 - Patients with an acute exacerbation of chronic obstructive pulmonary disease (COPD) receiving invasive or noninvasive mechanical ventilation benefit from systemic corticosteroid therapy, a randomized controlled trial in this critically ill patient population confirms.

Compared with placebo, corticosteroid therapy cut the duration of mechanical ventilation and intensive care by one day each, although the latter effect did not reach statistical significance.

For patients initially requiring non-invasive ventilation, corticosteroids eliminated the need for rescue mechanical ventilation.

Dr. Inmaculada Alia, from Hospital Universitario de Getafe in Spain and colleagues report their study in the Archives of Internal Medicine November 28.

A commentary appearing in the journal notes that the shorter intensive care unit (ICU) stay is "certainly clinically significant."

Given the "economic burden" of acute COPD exacerbations, reducing time spent in the ICU, and the need for rescue mechanical ventilation, can lead to "substantial savings," write Dr. Andrew Shorr and Dr. Chee Chan from the Pulmonary and Critical Care Medicine Section, Washington Hospital Center and Georgetown University in Washington, D.C.

Roughly 10% of patients with acute exacerbations of COPD need mechanical ventilation. Yet studies assessing the effect of corticosteroid therapy on COPD exacerbations have excluded those requiring mechanical ventilation or admitted to the ICU because they are prone to complications associated with corticosteroids, such as infections, hyperglycemia and ICU-acquired paresis.

Dr. Alia and colleagues performed a double-blind, placebo-controlled trial in 83 patients with an acute exacerbation of COPD who were receiving invasive or non-invasive mechanical ventilation. Participants were randomly assigned to receive intravenous methylprednisolone (0.5 mg/kg every 6 hours for 72 hours, 0.5 mg/kg every 12 hours on days 4 through 6, and 0.5 mg/kg/d on days 7 through 10) or placebo.

The groups were well-matched in terms of demographics, severity of illness, reasons for COPD exacerbation, gas exchange variables and corticosteroid rescue treatment.

Receipt of corticosteroids led to a reduction in the median duration of mechanical ventilation (3 days vs. 4 days; p=0.04); a trend toward a shorter median length of ICU stay (6 days vs. 7 days; p=0.09); and a reduction in the rate of failure of noninvasive mechanical ventilation (0% vs. 37%; p=0.04).

Importantly, say the investigators, giving systemic corticosteroids to this critically ill group of patients did not appear to raise the risk of gastrointestinal bleeding, superinfections, psychiatric disorders, or acquired neuromuscular weakness.

The major complication was hyperglycemia, a well-known consequence of corticosteroid therapy. However, it had no unfavorable clinical consequences in this study, the researchers say.

Dr. Alia and colleagues acknowledge that these findings "may not have a great impact on the current clinical treatment of ICU patients with COPD exacerbations because most of them are probably treated with corticosteroids."

However, the results "do provide strong evidence of the beneficial effects of systemic corticosteroid therapy on clinically relevant outcomes in a patient population that has never previously been enrolled in a clinical trial," they say.

Drs. Shorr and Chan say the findings are "important," noting that "few researchers venture into the ICU for clinical trials. As a consequence, intensivists are often left extrapolating data from non-critically ill patients."

However, they suggest that equipoise -- the concept that there must be uncertainty as to the relative benefit of the intervention(s) under evaluation - was "at least potentially in question for the current trial."

"If clinical trials of what are considered standard treatments are to be conducted...they must be performed with full consideration of equipoise," they contend.

SOURCE: http://archinte.ama-assn.org/cgi/content/abstract/171/21/1939

13. The non-utility of routine CXR in initial evaluation of stable blunt trauma patients

Paydar S, et al. Amer J Emerg Med. 2012;30:1-4.

Background: Radiology plays an important role in evaluation of a trauma patient. Although chest radiography is recommended for initial evaluation of the trauma patient by the Advanced Trauma Life Support course, we hypothesized that precise physical examinations and history taking accurately identify those blunt trauma patients at low risk for chest injury, making routine radiographs unnecessary. Thus, this study was performed to investigate the role of chest radiography in initial evaluation of those trauma patients with normal physical examination.

Methods: In this prospective cross-sectional study, all the hemodynamically stable blunt trauma patients with negative physical examination result referred to our trauma center during a 4-month period (March-June 2009) were included. Chest radiographies were performed and reviewed for abnormalities.

Results: During the study period, 5091 blunt trauma patients referred to our center, out of which, 1008 were hemodynamically stable and had negative physical examination result. Only 1 (0.1%) patient had abnormal chest radiography that showed perihilar lymphadenopathy, unrelated to trauma.

Conclusion: Performing routine chest radiography in stable blunt trauma patients is of low clinical value. Thus, decision making for performing chest radiography in blunt trauma patients based on clinical findings would be efficacious and resource saving.

14. Images in (Emergency) Medicine

Lingual Zoster
http://www.nejm.org/doi/full/10.1056/NEJMicm1107466

A Lucent Hemithorax Not Due to Pneumothorax
http://www.nejm.org/doi/full/10.1056/NEJMicm1101918

Zoster of the Tympanic Membrane
http://www.nejm.org/doi/full/10.1056/NEJMicm1104444

Thrombosis of a Mechanical Mitral Valve
http://www.nejm.org/doi/full/10.1056/NEJMicm1100131

Internal-Carotid-Artery Dissection and Cranial-Nerve Palsies
http://www.nejm.org/doi/full/10.1056/NEJMicm1009319

Can You Name these Foot Bones?
http://www.bmj.com/content/343/bmj.d7830

Adult Female with Ocular Lens Injury
http://www.annemergmed.com/article/S0196-0644(11)00500-2/fulltext

Young Man with Stab Wound to the Neck
http://www.annemergmed.com/article/S0196-0644(11)00389-1/fulltext

Adult Female with Abdominal Pain
http://www.annemergmed.com/article/S0196-0644(11)00717-7/fulltext

15. Medscape’s Highlights of the Year

In Medicine Generally
http://www.medscape.com/features/year-in-medicine/2011

In Emergency Medicine Research in Particular
http://www.medscape.com/viewarticle/753872

16. Variables Associated with Discordance between Emergency Physician and Neurologist Diagnoses of TIA in the ED

Schrock JW, et al. Ann Emerg Med. 2012;59:19-26.

Study objective: Transient ischemic attack is a common clinical diagnosis in emergency department (ED) patients with acute neurologic complaints. Accurate diagnosis of transient ischemic attack is essential to help guide evaluation and avoid treatment delays. We seek to determine the prevalence of discordant diagnosis for patients receiving an ED diagnosis of transient ischemic attack compared with neurologist final diagnosis. Secondary goals are to evaluate the influence of atypical transient ischemic attack symptoms, the ABCD2 score, and emergency physician experience on discordant diagnoses.

Methods: We performed a retrospective cohort study evaluating all ED patients receiving a diagnosis of transient ischemic attack during a 4-year period. The emergency physician diagnosis was compared with that of the neurologist. The neurologist's final diagnosis was considered the criterion standard diagnosis. Subject demographic and clinical information was collected with a structured instrument. The following atypical symptoms present at the ED evaluation were evaluated with logistic regression: headache, tingling, involuntary movement, seeing flashing lights or wavy lines, dizziness, confusion, incontinence, and ABCD2 score of 4 or greater. Bivariate analysis was used to evaluate the influence of emergency physician experience (≤6 years versus more than 6 years) on discordant diagnosis. Odds ratios (ORs) and proportions are reported with 95% confidence intervals (CIs), interquartile range was used where appropriate.

Results: We evaluated 436 subjects, of whom 7 were excluded, allowing 429 subjects for evaluation. Of these individuals, 156 (36%; 95% CI 32% to 41%) received a discordant diagnosis. The median emergency physician time in clinical practice was 6 years (interquartile range 2 to 12 years). Features associated with a discordant transient ischemic attack diagnosis included headache (OR 2.52; 95% CI 1.59 to 3.99), involuntary movement (OR 3.19; 95% CI 1.35 to 7.54), and dizziness (OR 1.92; 95% CI 1.22 to 3.02). Incontinence, confusion, and seeing wavy lines or flashing lights were not significantly associated with a discordant diagnosis. Patients with tingling and a high ABCD2 score had an increased odds of concordant transient ischemic attack diagnosis (OR 0.54, 95% CI 0.32 to 0.92; OR 0.53, 95% CI 0.35 to 0.82, respectively).

Conclusion: Discordant diagnoses between emergency physicians and neurologists were observed in 36% of patients. The presence of headache, involuntary movement, and dizziness predicted discordant diagnoses, whereas the presence of tingling and an increased ABCD2 score predicted concordant transient ischemic attack diagnosis.

17. How Prevalent Is Pulmonary Thrombosis During Acute Chest Syndrome?

In a French study, PT occurred in 17% of ACS episodes.

Mekontso Dessap A, et al. Am J Respir Crit Care Med 2011 Nov 1; 184:1022

Rationale: The pathophysiology of acute chest syndrome (ACS) in patients with sickle cell disease is complex, and pulmonary artery thrombosis (PT) may contribute to this complication.

Objectives: To evaluate the prevalence of PT during ACS using multidetector computed tomography (MDCT).

Methods: We screened 125 consecutive patients during 144 ACS episodes. One hundred twenty-one MDCTs (in 103 consecutive patients) were included in the study.

Measurements and Main Results: Twenty MDCTs were positive for PT, determining a prevalence of 17% (95% confidence interval, 10–23%). Revised Geneva clinical probability score was similar between patients with PT and those without. D-dimer testing was very often positive (95%) during ACS. A precipitating factor for ACS was less frequently found in patients with PT as compared with those without. Patients with PT exhibited significantly higher platelet counts (517 [273–729] vs. 307 [228–412] 109/L, P less than 0.01) and lower bilirubin (28 [19–43] vs. 44 [31–71] µmol/L, P less than 0.01) levels at the onset of ACS as compared with others. In addition, patients with PT had a higher platelet count peak (537 [345–785] vs. 417 [330–555] 109/L, P = 0.048) and smaller bilirubin peak (36 [18–51] vs. 46 [32–83] µmol/L, P = 0.048) and lactate dehydrogenase peak (357 [320–704] vs. 604 [442–788] IU/L, P = 0.01) during hospital stay as compared with others.

Conclusions: PT is not a rare event in the context of ACS and seems more likely in patients with higher platelet counts and lower hemolytic rate during ACS. Patients with sickle cell disease presenting with respiratory symptoms suggestive of ACS may benefit from evaluation for PT.

18. CTA Shows Promise for Diagnosing Lower GI Bleeding

James Brice. Medscape. November 28, 2011 — Computed tomography (CT) angiography could emerge as a viable option for detecting the presence and origin of lower intestinal hemorrhage in patients who present to the emergency department.

A prospective study, conducted at La Paz University Hospital in Madrid, Spain, has established the feasibility of CT angiography in this setting. The imaging technique had 100% sensitivity (19 of 19 patients) and 96% specificity (27 of 28 patients) for diagnosing active or recent lower gastrointestinal (GI) tract bleeding in a series of 47 consecutive patients. The results of the study were published online November 14 in Radiology.

Milagros Martí, MD, and coauthors stressed the importance of quickly obtaining an accurate assessment of suspected lower GI bleeding for effective treatment. Hemorrhage can occur anywhere in the GI tract from the esophagus to the rectum, and can range from mild to massive acute bleeding. Mortality rates range from 8% to 16%, but can be as high as 40% when bleeding is severe, the authors note.

Currently, diagnosis can require a multimodal approach. Optical colonoscopy is the preferred choice for initial evaluation distal to the ligament of Treitz, but problems with staff availability during off hours, proper bowel preparation, and poor bowel visualization from obstructions caused by intraluminal blood clots make it difficult to apply. Additionally, the source of bleeding is extracolonic in about 10% of cases.

Technetium-99m red blood cell imaging is another accepted option because of its high sensitivity to moderate and severe bleeding. However, it cannot be relied upon to identify the precise source and cause of bleeding.

Conventional angiography and emergency surgery are often performed to address persistent bleeding, but physicians generally try to avoid these invasive and expensive procedures when possible.

Previous studies have suggested that CT angiography might be useful in this setting, but have been limited by their small size or retrospective nature.

In this prospective study, Dr. Martí and colleagues tested a triphasic CT protocol that ranged from the diaphragm to the inferior pubic ramus. Imaging was performed on a 64-slice scanner. Tube voltage was 120 kVp, with automatic tube current modulation to reduce dosage. Oral contrast was not used.

The investigators used a preliminary unenhanced CT scan to uncover preexisting intraluminal hyperattenuating material. The unenhanced scan helped prevent the misinterpretation of hyperattenuating material that can mimic contrast medium extravasation and result in false-positive findings, the authors explain.

Intravenous contrast material (4 mL/s) was administered before the acquisition of an arterial phase scan. It was obtained using automated bolus triggering and began when attenuation in the proximal abdominal aorta reached 150 HU. A portal venous phase scan was acquired 70 seconds after the start of contrast injection.

CT angiography identified extravasation, indicating active hemorrhage, in 14 patients. Seven patients were transferred directly to the angiography suite for possible embolization. Conventional angiography confirmed the presence and location of bleeding suggested by CT angiography in 6 of the 7 cases — 2 in the jejunum/ileum, 3 in the colon, and 1 in the rectosigmoid region. In 1 patient, CT angiography depicted active extravasation in the colon, but bleeding had stopped before angiography was performed. The researchers classified that case as a false positive.

The remaining 7 patients underwent surgery.

The authors conclude that CT angiography helped identify active bleeding and the site of bleeding in 83% of the cases (39 of 47 patients). Imaging results helped guided therapy and helped select the most appropriate hemostatic intervention. The ability to localize the point of origin of bleeding allowed targeted endovascular embolization to stanch it.

Study limitations include the small sample size from a single hospital, the lack of a control group, and the focus on patients from whom emergent colonoscopy was requested. More sophisticated multicenter trials are needed to determine if CT angiography qualifies as a front-line exam for diagnosing lower GI hemorrhage.

Radiology. Published online November 14, 2011.

Abstract: http://radiology.rsna.org/content/early/2011/11/08/radiol.11110326.abstract

19. Hospital Admission Decision for Patients with Community-Acquired Pneumonia: Variability among Physicians in an ED

Dean NC, et al. Ann Emerg Med. 2012;59:35-41.

Study objective: We examine variability among emergency physicians in rate of hospitalization for patients with pneumonia and the effect of variability on clinical outcomes.

Methods: We studied 2,069 LDS Hospital emergency department (ED) patients with community-acquired pneumonia who were aged 18 years or older during 1996 to 2006, identified by International Classification of Diseases, Ninth Revision coding and compatible chest radiographs. We extracted vital signs, laboratory and radiographic results, hospitalization, and outcomes from the electronic medical record. We defined “low severity” as PaO2/FiO2 ratio greater than or equal to 280 mm Hg, predicted mortality less than 5% by an electronic version of CURB-65 that uses continuous and weighted elements (eCURB), and less than 3 Infectious Disease Society of America-American Thoracic Society 2007 severe pneumonia minor criteria. We adjusted hospitalization decisions and outcomes for illness severity and patient demographics.

Results: Initial hospitalization rate was 58%; 10.7% of patients initially treated as outpatients were secondarily hospitalized within 7 days. Median age of admitted patients was 63 years; median eCURB predicted mortality was 2.65% (mean 6.8%) versus 46 years and 0.93% for outpatients. The 18 emergency physicians (average age 44.9 [standard deviation 7.6] years; years in practice 8.4 [standard deviation 6.9]) objectively calculated and documented illness severity in 2.7% of patients. Observed 30-day mortality for inpatients was 6.8% (outpatient mortality 0.34%) and decreased over time. Individual physician admission rates ranged from 38% to 79%, with variability not explained by illness severity, time of day, day of week, resident care in conjunction with an attending physician, or patient or physician demographics. Higher hospitalization rates were not associated with reduced mortality or fewer secondary hospital admissions.

Conclusion: We observed a 2-fold difference in pneumonia hospitalization rates among emergency physicians, unexplained by objective data

20. Treating secondary spontaneous PTX: Is a pigtail catheter sufficient?

Chen C, et al. Amer J Emerg Med. 2012;30:45-50.

Objective: The study aimed to assess the clinical efficacy of pigtail catheter drainage for patients with a first episode of secondary spontaneous pneumothorax (SSP) and different associated conditions.

Methods: We retrospectively reviewed the records of patients with SSP who received pigtail catheter drainage as their initial management between July 2002 and October 2009. A total of 168 patients were included in the analysis; 144 (86%) males and 24 (14%) females with a mean age of 60.3 ± 18.3 years (range, 17-91 years). Data regarding demographic characteristics, pneumothorax size, complications, treatments, length of hospital stay, and associated conditions were analyzed.

Results: In total, 118 (70%) patients were successfully treated with pigtail catheter drainage, and 50 (30%) patients required further management. Chronic obstructive lung disease was the most common underlying disease (57% of cases). Secondary spontaneous pneumothorax associated with infectious diseases had a higher rate of treatment failure than SSP associated with obstructive lung conditions (19/38 [50%] successful vs 78/104 [75%] successful, P = .004) and malignancy (19/38 [50%] successful vs 13/16 [81%] successful, P = .021). Moreover, patients with SSP associated with infectious diseases had a longer length of hospital stay than those with obstructive lung conditions (23.8 vs 14.5 days, P = .003) and malignancy (23.8 vs 12.1 days, P = .017). No complications were associated with pigtail catheter drainage.

Conclusions: A higher rate of treatment failure was noted in SSP patients with infectious diseases; thus, pigtail catheter drainage is appropriate as an initial management for patients with SSPs associated with obstructive lung conditions and malignancy.

21. Likelihood That a Woman with Screen-Detected Breast Cancer Has Had Her "Life Saved" by That Screening

Welch HG, et al. Arch Intern Med. 2011;171(22):2043-2046.

Background: Perhaps the most persuasive messages promoting screening mammography come from women who argue that the test "saved my life." Because other possibilities exist, we sought to determine how often lives were actually saved by mammography screening.

Methods: We created a simple method to estimate the probability that a woman with screen-detected breast cancer has had her life saved because of screening. We used DevCan, the National Cancer Institute's software for analyzing Surveillance Epidemiology and End Results (SEER) data, to estimate the 10-year risk of diagnosis and the 20-year risk of death—a time horizon long enough to capture the downstream benefits of screening. Using a range of estimates on the ability of screening mammography to reduce breast cancer mortality (relative risk reduction [RRR], 5%-25%), we estimated the risk of dying from breast cancer in the presence and absence of mammography in women of various ages (ages 40, 50, 60, and 70 years).

Results: We found that for a 50-year-old woman, the estimated risk of having a screen-detected breast cancer in the next 10 years is 1910 per 100 000. Her observed 20-year risk of breast cancer death is 990 per 100 000. Assuming that mammography has already reduced this risk by 20%, the risk of death in the absence of screening would be 1240 per 100 000, which suggests that the mortality benefit accrued to 250 per 100 000. Thus, the probability that a woman with screen-detected breast cancer avoids a breast cancer death because of mammography is 13% (250/1910). This number falls to 3% if screening mammography reduces breast cancer mortality by 5%. Similar analyses of women of different ages all yield probability estimates below 25%.

Conclusions: Most women with screen-detected breast cancer have not had their life saved by screening. They are instead either diagnosed early (with no effect on their mortality) or overdiagnosed.