Monday, October 23, 2006

September Abstracts

Here are the September abstracts. Sorry about the delay- had some technical difficulties and my computer crashed. I guess i'm a Mac man now. For any of you who use Mac's, feel free to educate me. I'm sure I'm not utilizing most of its utilities and features. Ok, now on to the abstracts...

- Bare, M., et al, Internat J Technol Assess Health Care 22(2):242, April 2006: A retrospective Spanish study looking at intra-abdominal infections and the choice of Abx utilized initially. First off numbers weren't statistically significant. Also there were a lot of variables (co-morbidities), poor methods section w/ no info and poor chart review. Overall, nothing that would change your management and a flawed study.
- Steele, R., et al, Can J Emerg Med 8(3):164, May 200: The use of NTG in CP (not obvious AMI) with regards to pain relief- does this help you diagnose ACS? The answer is no. 2/3 of the people, regardless of the ultimate dx, had pain relief w/ NTG. Therefore, do not bother using pain relief or lack thereof in distinguishing ACS.
- Sen, A., et al, Emerg Med J 23:401, May 2006: Very few studies (two) have examined the utilization fo Beta-blockers in cocaine CP. Remember, that that's traditionally a "no-no" for concern of un-blocked Alpha-adrenergic activity. I was taught to use benzos and phentolamine (if needed) for alpha-blockade in cocaine CP. Only two human studies before. The studies that were done were in patients undergoing aniograms w/ known CAD. They were administered cocaine in the cath lab (not sure which IRB went for that). Alpha blockade, NTG, etc helped w/ the measurements. Howevever, when the pt was given B-blockers their cath numbers worsened (but no clinical events). The bottom line is do not use B-blockers in cocaine CP. Versed or ativan if needed and if they require it then use phentolamine. If you use B-blockers and have a bad outcome, you won't have any support from the literature.
- Briel, M., et al, JAMA 295(17):2046, May 3, 2006: They looked at the early use of statins in ACS. There is no statistical effect even if you delay up to 14 days.
- Bjorklund, E., et al, Eur Heart J 27(10):1146, May 2006: Swedish study looking at pre-hospital EKG and pre-hospital thrombolytics vs in-hospital PCI. However, pre-hospital patients were less sick and did do better. However, better studies have shown that even if there's a delay up to two hours in randomized patients, PCI is better.
- Ray, P., et al, Am J Emerg Med 24:313, May 2006: The use of ELISA D-dimer in the exclusion of DVT. Poor sensitivity (78%) and there were still DVT's missed by negative D-dimer. Again, only use a D-dimer in low-prob patient. There is no point in an intermediate or high prob patient. A negative D-dimer doesn't give you any comfort. You must get the Duplex U/S AND CT chest in these patients.
- Imberti, D., et al, J Thromb Hemost 4:1037, May 2006: A paper that looked at the use of lovenox in patients with suspected DVT prior to them receiving their duplex U/S. This doesn't affect us as much b/c we can get the U/S 24 hours. You can delay treatment if you can't get the U/S immediately in a suspected duplex U/S. There were no complications (death, etc) if you delayed the work-up 12 hours later.
- van der Hooft, C.S., et al, Arch Intern Med 165:1016, May 8, 2006: The use of corticosteroids and the possible risk of developing A-fib. Those w/ new A-fib had a 6x more common chance of being on high-dose steroids (their high dose was only 7mg a day of prednisone, so actually a small dose). This wasn't randomized, however, something interesting to note and look at in your patients w/ new A-fib.
- Ohlmann, P., et al, Crit Care Med 34(5):1358, May 2006: The use of d-dimer to dx aortic dissection. Patients with aortic dissection have elevated d-dimers. 99% sensitive, 34% specific. I don't think this changes my management. I'm going to order the CT and not order the d-dimer.
- Bailey, P.L., et al, Anesth Analg 102:1327, May 2006: The use of the central landmark approach in right IJ venous cannulation. The use of the SCM triangle, ipsilateral nipple, etc (traditional approach) is the central landmark approach. They used an U/S probe instead of a needle to see what the success would have been. The bottom line is if you're going to use this approach and miss, it's better to redirect laterally (vs. medially).
- Quinn, J., et al, Ann Emerg Med 47(5):448, May 2006: Examines the San Francisco syncope rule to identify pts w/ high-risk events. By a rule, they have to have a negative ED work-up. The factors are h/o CHF, HCT <> 30 and age > 50. The more predictors you had, the greater the probability that it was an UGIB (92-93% w/ 2-3 factors).
- Murphy, F.L., et al, Ped Surg Int 22(5):413, May 2006: A study where they took all acute pediatric scrotums (the name of my next band) to the OR. 1/4 had torsion, the rest were benign (torsed appendage, etc). The felt that it was better to go straight to the OR and bypass the U/S, etc. I can't imagine that peds urologists will ever go for this. They'll want the U/S, especially given the likelihood that it isn't torsion.
- Lankiewicz, M.W., et al, J Thromb Haemost 4(5):967, May 2006: Acute reversal of warfarin-induced coagulopathy with prothrombin complex concentrate. They didn't compare it w/ FFP. There's nothing here that would change your management.
- Leonhardt, G., et al, J Thromb Thrombolysis 21(3):271, June 2006: 28 German pregnant woman who received thrombolytics. 18 of 28 had normal pregnancies.
-Webster, A.P., et al, Emerg Med J 23:354, May 2006: British study identifying pediatric wrist fx's. Who cares? You're going to get the x-ray b/c none of us want to miss one and it's easy.
- Sard, B., et al, Ped Emerg Care 22(5):295, May 2006: Pediatric blood cxs. 3.5% had bacterial growth, but 80% were contaminant. Only 1% had positive cultures. The bottom line is most positive cultures are false positive, so why do the test now that we have pneumococcal vaccine? Another study shows that of the 1% who had a positive blood cx, none were pneumoccocus.
- Hsiao, A.L., et al, Pediatrics 117(5):1695, May 2006: Two-six month children w/ acute febrile illness. Again almost all kids had negative blood cultures (0.9%). 10% had positive urine cx's. Several false positive urine cx's (had positive viral test, OM, etc). Between these two studies, I still don't see us changing our practice until community standards change (and pediatricians). Just be aware of the low likelihood of positive blood cx (about 1%) and that many of the usual algorithms (Rochester criteria, etc) will eventually become moot b/c they were created to find bacteremia. If bacteremia is so rare now due to vaccines, do we need to implement these protocols? WBC count don't assist in the treatment. Blood cx are rarely positive and quite a few urine cx are contaminants as well. If the kid is sick, Abx and admit.
- Erlewyn-Lajeunesse, M.D.S., et al, Arch Dis Child 91:414, May 2006: Combined tylenol (15 mg/kg) + ibuprofen (5 mg/kg) in trx of pediatric fever. There was no additional benefit by giving them concominantly.
- Bar-Meir, E., et al, Plast Reconstr Surg 117(5):1571, April 15, 2006: Use of nitrous while plastic surgeons repaired pediatric facial lacs. Significant pain decrease. You might as well just use procedural sedation vs. brutaine.
- Nowak, R., et al, Am J Emerg Med 24:259, May 2006: Use of xopenex vs. albuterol in acute asthma exac. A lot of data mining (drug study sponsored). The bottom line, is there still shows no benefit of xopenex vs. albuterol.
- Sohne, M., et al, J Thromb Hemost 4:1042, 2006: A good study that shows that a sensitive d-dimer test INCREASES testing for PE, but NO INCREASE in diagnosing PE. This shows why a d-dimer is not a good test, because you ending up doing more tests without finding more cases. In a low-risk patient, a d-dimer is ok. Don't bother doing it in the no-risk patient, because if it's elevated, you then CT needless patients with no dz, but an elevated d-dimer (due to other factors). In a no-risk patient, don't check. In a low-risk, use it. All others, don't bother.
- Rodriguez, R.M., et al, Ann Emerg Med 47(5):415, May 2006: Use of CXR in blunt chest trauma. Sats < 90% on RA (100% sensitive, but 15% specific). The bottom line, is clinical judgment is still your best tool.
- Heal, C., et al, Br Med J 332:1053, May 2006: Can sutures get wet? Standard care being keep it dry for 48 hours vs within 12 hours. No difference in outcome b/w the two. Not a well-structured study and had a 8% infection rate in both (pretty high- ED standards is 5%).
- Salim, A., et al, Arch Surg 141:468, May 2006: The authors recommend whole-body scanning in trauma (head, neck, chest, abd/pelvis) in stable blunt-trauma pt. They had liberal use of who got the scans. Some had no evidence of visible trauma and still got all these tests. A poor study (for example they didn't even both checking the c-spine, they just CT'd them). Nothing that would change your management.
- Green, S.M., Ann Emerg Med 47(5):405, May 2006: Routine need of trauma surgeon on arrival of trauma pts. This was before ED docs were well trained or unable to manage life-threatening injuries, diagnostic modalities, etc. The need for a surgeon to be there is probably outdated.

That's it.


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