Thursday, December 07, 2006

November Abstracts

  • Here are your November abstracts- enjoy with your favorite nog...
  • Capraro, A.J., et al, Ped Emerg Care 22(7):480, July 2006: A study reviewing pediatric trauma patients and the routine labs ordered. There were no tests that were sensitive or specific. Bottom line is that they are not of benefit as a routine screening test.
  • Garcia, M.J., et al, JAMA 296(4):403, July 26, 2006: An interesting study that looked at the use of the new 64 slice CT scanners to evaluated CAD in ACS pts. The general thought are that these CT's will become the new screening tools and prevent needless angios. Or in CP pts in the ED, we'd CT them and if they had a low score, go home. In this study, if the pt had a high calcium score, they'd just go to angio. Of note, pts undergoing this test must lay perfectly still as any motion will cause difficulty in reading the tests. The bottom line is that the sensitivity was only 75% and specificity was only 79%. Ergo, there will be a lot of false positives. Why does this matter? Well consider this akin to the D-dimer. In theory, we should be doing these tests to r/o the low-risk pts. However, in the no-risk pts you'll do this CT and get a false positive result. Then you take them off for an unnecessary angio. Hence the problem with these tests so far. Until the technology improves, a test that's supposed to save people from angios could possibly cause needless angios to be performed. Interesting to note...
  • Mitchell, A.M., et al, Acad Emerg Med 13(7):803, July 2006: A new set of cardiac markers to r/o low-risk ACS. They all did worse than our current measures (and the authors agree). They included CRP, BNP, myeloperoxidase and one other lab.
  • Bhangoo, P., Emerg Med J 23:568, July 2006: A chart review of cocaine chest pain and trx options. The bottom line is that if they have CNS effects primarily use benzos. NTG works just as well in relieving CP. Also remember not to use B-blockers to prevent unopposed alpha-blockade (use phentolamine).
  • van 't Hoff, A.W.J., et al, Am Heart J 151:1255.e1, June 2006: A freaky-deaky Dutch study that examined pre-hospital dx of AMI in order to expedite PCI. Those who were dx'd pre-hospital made a significant change in mortality (10% vs 3%) but these numbers are suspicious and probably some confounding factors. This also wasn't a randomized study.
  • Ortolani, P., et al, Eur Heart J 27(13):1550, July 2006: An Italian study that again looks at direct referral to PCI from home based on early dx. They had relatively long door-needle times w/ average 90 minute drive times. There was no significant change in mortality in any of the different groups.
  • Bozeman, W.P., et al, Resuscitation 69:399, June 2006: A study you might be hearing about in the future. They looked at pts with arrest and failing resuscitative efforts (on average failed 8 rounds of meds). They were given an empiric dose of TNKase. 25% of these pts had spontaneous return of circulation and two walked about of the hospital later. Obviously this med would be for either AMI or PE. Also the question is whether spontaneous return of circulation translates into pts being neurologically intact and eventually walking out the door. Probably future studies will be done (especially since it's still on patent).
  • Holzer, M., et al, Stroke 37:1792, July 2006: An interesting Austrian study that utilizes induced hypothermia in witnessed cardiac arrest and remained comotose. They utilize the same technique that the "cool MI" study does (garden hose in the IVC to induce hypothermia). Either way pts who received this trx did significantly better. The 30 day survival rate was 69% vs 50% (control). Average time to 33 deg celsius was 4 hours (quite a delay). But neuro outcome again was 53% vs 34%. These are similar results to other studies. Cold is the way to go...
  • Oddo, M., et al, Crit Care Med 34(7):1865, July 2006: Another study looking at induced hypothermia again after cardiac arrest. Again they did better and they have low numbers needed to treat.
  • Cucchiara, B.L., et al, Stroke 37:1710, July 2006: A study that examined a risk stratification system for TIA's and future CVA's. They utilized the ABCD system. A(ge) B(lood pressure) C(linical features) D(uration of sx's). There is an association with these variables, but in this study only two pts went on to have a CVA (a very lower number). Ergo, they have such a low "N" that you can't really take much info from this or say it's a good study. Until proven otherwise, they're high-risk for a CVA and it's best to admit them and put them through the work-up (if they haven't already).
  • Dubinsky, R., et al, Neurology 66:1742, June 2006: A Nationwide CVA chart review. This again supports the following important info: only 1.2% of all pts with CVA's get tPA. Patients receiving tPA had a higher mortality rate (8.7% vs. 5.8%). Also patients receiving tPA. Patients receiving tPA had 10x higher rates of bleeds (4.2% vs. 0.4%). However, you're much more likely to be sued if you DON'T give tPA (for negligence). Stay tuned for more. But again, patients seem to do worse if they get tPA.
  • Mangurten, J., et al, J Emerg Nursing 32(3):225, June 2006: In brief, bring family members in during peds resuscitative efforts. Family members feel that they can see everything being done and preferred being there.
  • Fuda, K.K., et al, Ann Emerg Med 48(1):9, July 2006: A Massachusetts data set that showed that only 1% of all state patients visit the ED greater than 5x a year (considered frequent flyers). However this 1% accounted for 18% of all ED visits. This astounding number is similar to another study. This is interesting if you look at the reasons for the visits (true medical reasons or perhaps pain control?).
  • Styrud, J., et al, World J Surgery 30(6):1033, June 2006: A Swedish study that randomized probable cases of acute appendicitis w/o perf into either a) OR or b) IV Abx with surgery if they need it. 75% of the IV Abx group didn't have surgery and didn't have a recurrence of appendicitis. Interesting to note, but I don't see this changing the culture of trx of appy's in the US.
  • Mazaki, T., et al, Br J Surg 93(6):674, June 2006: A hot-button topic in the Barrali household- IV abx don't seem to change the outcome of acute necrotizing pancreatitis. A very small sample size.
  • Poehling, K.A., et al, N Engl J Med 355(1):31, July 6, 2006: Consider the flu in pediatric fevers. Do a simple swab and if positive, you have your answer and won't have to give Abx (and may be able to trx w/ the flu meds if caught early enough).
  • Poehling, K.A., et al, Arch Ped Adol Med 160:713, July 2006: Another flu study. 99% positive results were influenza A.
  • Hannafin, B., et al, Am J Emerg Med 24:487, July 2006: A study from the infamous Maricopa ED (of note the lead author is an applicant)- looking at administration of Rhogam to 1st trimester pregnant females undergoing SAB. All of our info is based on one trial in 1972 (I smell LoVecchio all over this one). The bottom line is there isn't really any evidence to support the claim. The thought is the cost/benefit is so high (hydrops fetalis) that a benign intervention should be continued (for fear of missing out on one). Doesn't make it right, but CYA medicine.
  • Knight, J.R., et al, Am J Emerg Med 24:423, July 2006: A study that reviewed calcaneal fx's and the use of Boehler's angle. I know Daniels calculates it on all his foot films. Bottom line: look at the trabeculae and if you're concerned and the plain film x-ray is negative, get a CT.
  • Mohr, B., Can J Emerg Med 8(4):247, July 2006: I haven't seen a Bier block used in the ED for about five years, but they looked at it for trx of wrist fx. Bier blocks consistently do better than hematoma blocks. However, w/ procedural sedation available, it's kind of a moot point.
  • Hendey, G.W., et al, J Emerg Med 31(1):23, July 2006: If someone has had prior shoulder dislocations and they didn't have trauma, you don't need a PRE OR POST reduction x-rays. Just reduce and send home as they have no trauma or complicating factors. It's nice to know, but I have a feeling that we'll still do it to prove there's no Hill-Sachs fx, etc.
  • Hampers, L.C., et al, Ped Emerg Care 22(7):465, July 2006: In simple febrile sz's you don't need to do any tests or w/u. Thus they looked at to see what tests the docs actually did- we did too many tests and work-ups. 5% got an LP, 11% had head CT, etc.
  • Merenstein, D., et al, Arch Ped Adol Med 160:707, July 2006: Infant response to benadryl 1 mg/kg for sleepless children. No difference b/w the trx group and placebo. Interesting to note.
  • Temple, A.R., et al, Clin Ther 28(2):222, February 2006: They compared tylenol (up to 4g qd) to naproxyn for trx of OA in older pts. Pts did just as well and had no lab abnormalities. This is opposed to the next study...
  • Watkins, P.B., et al, JAMA 296(1):87, July 5, 2006: They examined the results of taking 4g of tylenol qd and the effects on AST. They said 35-40% of tylenol receiving pts had a bump in their LFT's up to 3x normal. These were younger and healthier pts. So these two studies differ in their results. The second study was made by the manufacturer of the opioid compared to tylenol- so go figure...
  • Bijur, P.E., et al, J Pain 7(6):438, June 2006: MD understanding of pain by pts w/ long-bone fx's. Presence of fx matter more than pt's complaints of pain.
  • Gislason, G.H., et al, Circulation 113:2906, June 27, 2006: Another study showing COX-2 inhibitors increase risk of MI. Not a randomized control trial, but just more fuel for the fire.
  • Aggarwal, P., et al, Emerg Med J 23(5):358, May 2006: Nebulized Mag doesn't help in acute asthma exacerbation.
  • Harnden, A., et al, Br Med J 333:174, July 22, 2006: Consider pertussis in the persistent cough in the pediatric pt. Of pt's w/ a persistent cough, 1/3 unded up having pertussis on their titers. They usually have post-tussive emesis, copious sputum and paroxysms of cough.
  • Ramanujam, P., et al, Acad Emerg Med 13(7):740, July 2006: Something that we all know but is a thorn in our side (may want to forward to CHW HQ)- BLOOD CX'S DO NOT CHANGE THE MANAGEMENT OR OUTCOME OF PT'S ADMITTED W/ COMMUNITY-ACQUIRED PNEUMONIA.
  • Metersky, M.L., et al, Chest 130(1):16, July 2006: Does administering Abx w/in 4 hours of presentation of CAP matter? Often there will be atypical presentations thus docs give it to everybody for fear of missing the 4 hour window, etc. Sound familiar?
  • Sparrow, A., et al, Arch Dis Child 91:580, July 2006: In the trx of croup, they examined the use of decadron vs. methylprednisolone (orapred, etc). The bottom line, is decadron lasts longer and thus you only have to give it as a one time dose. Orapred, etc. requires repeated dosing. Hence our use of decadron.
  • Linder, J.A., et al, Arch Intern Med 166:1374, July 10, 20: Evaluation of pharyngitis- bottom line is people will sometimes follow the guidelines for dx, but still end up giving the Abx.
that's it- enjoy...

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