Friday, February 09, 2007

January Nubbins

Here are some January nubbins. Swish and spit as needed...
  • Roger, V.L., et al, Circulation 114:790, August 22, 2006: Basically a "redefinition" of MI's. Mayo study that considers an elevated troponin to be the deciding factor for MI's. Of note, the study only looked at pts w/ elevated trop's. What about MI's w/ elevated CK-Mb but normal trop's? That obviously affects the study. Patients w/ only an elevated troponin were "less sick". Only half of the patients were diagnosed w/ an AMI by their docs if they only had an elevated troponin.
  • Chase, M., et al, Acad Emerg Med 13(10):1034, October 2006: 80% of patients w/ active CP had normal EKG's or non-specific EKG findings, but were later diagnosed w/ an MI. No difference b/w patients w/ symptoms or currently asymptomatic.
  • Morris, A.C., et al, Heart 92:1333, September 2006: British study in pts w/ ED CP (TIMI study). 1 in 30 patients w/ a TIMI 1 score (low risk) had a significantly bad outcome. TIMI score is not effective in determining risk in patients for cardiac event, MI, etc. TIMI scores are just not of use.
  • Masoudi, F.A., et al, Circulation 114:1565, October 10, 2006: Compared an ED docs vs. 4 cardiologists reading of an EKG that eventually were an MI. HOWEVER, the cardiologists were not blinded and knew that they were patients who earlier were diagnosed as an MI. The ED docs did it in real time. 12% of patients were missed by the ED docs and thus didn't get ASA, etc. However, it was based on the doc's documentation but not necessarily given a form to ask their opinion. Doesn't portray ED docs in a good light, but a VERY fundamentally poorly structured study. They need to improve their methods significantly.
  • Lenderink, T., et al, Eur Hear J 27(15):1799, August 2006: Patients w/ ACS who were treated w/ statins in the first 24 hours did better w/ regards to mortality. However, if a patient is too sick they usually don't get statins pushed in the first 24 hours, while the patients who are not too sick get them w/ 24 hours. Sponsored by the drug company. Again, flawed methods. Other RCT's have shown no benefit.
  • Kearon, C., et al, JAMA 296(8):935, August 23-30, 2006: Randomized study of outpatient trx of DVT's w/ either lovenox of subQ heparin. Cost of standard heparin was $37 vs $712 for lovenox. Obviously a huge difference. No statistic difference in outcome of all important factors. Traditional thinking is you would use lovenox b/c it saved you inpatient costs. However, standard subQ heparin works just as well and is much cheaper. This is a very important study. Do we start patients on this now? I'd be interested in what you guys think.
  • Kaji, A.H., et al, Pediatrics 118(4):1493, October 2006: Use of Braslow tape in pre-hospital setting shows it's a not very good estimate of true weight and correct epi doses.
  • Barone, J.E., et al, J Trauma 61:468, August 2006: Is the Allen test necessary prior to radial artery puncture? They reviewed six studies w/ varying results. There have been no RCT's, it doesn't predict ischemia, you can't use it on pt's who can't do it, etc. It's neither accurate nor reliable. Nice to know.
  • Detsky, M.E., et al, JAMA 296(10):1274, September 13, 2006: If it looks like a migraine, it's probably going to be diagnosed as a migraine. Interesting logic.... Nothing from this study that answers any questions it's trying to ask- to headache patients all need a CT? Prior studies have shown there is no yield for a CT head in patients w/o any worrisome neuro sx's.
  • Doran, T., et al, N Engl J Med 355(4):375, July 27, 2006: British study about pay-for-performance. The strongest indicator for the best P4P was that they excluded patients b/c they "don't qualify" for any particular reason and get your bonus. Basically gaining the system by going through the checklist. Who will decide what the checklist will consist of? As long as you scheme and gain the system, you can meet the criteria. What happens if pharm companies gain influence w/ the committees and determine you have to give drug "X" to meet a criteria. In Britain, they had PCP's making up to an extra $40K a year (so obviously financial incentive to gain the system).
  • Cutler, D.M., et al, N Engl J Med 355(9):920, August 31, 2006: Harvard study looking at the medical costs on society and healthcare. Lot of flaws here.
  • Akkad, A., et al, Br Med J 333:528, September 2006: British study looking at consent forms. Patients frequently don't know what they're signing, the benefit of consent, etc. Not much surprise here.
  • Potts, M., et al, Br Med J 333:701, September 30, 2006: "Parachute" approach of evidence based medicine. Spoofs the thought that only RCT's are pristine and we've made several decisions based on observational studies. In conditions w/ high morbidity and mortality, you can't always wait for RCT's and balance all the benefits and costs of methods.
  • Lazare, A., JAMA 296(11):1401, September 20, 2006: Medical apologies are good in error. A little harsh in that he wants doctors to express "shame", etc. A little tough to consider shame when people make mistakes. It probably decreases the risk of legal action, but can't be sure.
  • Spiro, D.M., et al, JAMA 296(10):1235, September 13, 2006: Wait and see approach to acute OM in pediatrics. 40% of wait and see group got Abx. Not as much as you'd expect. Interesting thing was there was no difference in outcome b/w either group. Only side effect was more diarrhea in the grop who got Abx.
  • Khan, J., Emerg Med J 23:726, September 2006: What's the best approach for a floater(s)? They feel it's best to call ophtho at any time. High liability item. They rarely get called and the pt put the time into to come to the ED to be seen for it.
  • Stork, C.M., et al, Acad Emerg Med 13(10):1027, October 2006: Zofran worked better on peds N/V vs. dexamethasone (interesting trx).
  • May, G., Emerg Med J 23:722, September 2006: Best evidence study for the use of somatostatin in the control of UGIB non-variceal bleeds. Other studies have been mixed and not shown a benefit or decrease in mortality. Vasoconstrictors can cause ischemia and increase bleeding. Let GI decide...
  • Newman, D.H., et al, Ann Emerg Med 48(2):182, August 2006: Do you need to check an INR on every ED pt on coumadin? What if they have no clinical reason? I still take the conservative approach and check it. I've found abnormalities requiring admission w/o symptoms more than once. What if they had one checked one day before and it was normal?
  • Bottieau, E., et al, Arch Intern Med 166:1642, August 14-28, 2006: Any patient traveling from the tropics and have a fever should be checked for malaria. Most are non-faliparum. The one that will kill you is falciparum. Recurrent were ricketssia, malaria, dengue and typhoid.
  • Taylor, R.W., et al, Crit Care Med 34(9):2302, 2006: Blood transfusion in critical care pts and nosocomial infections. People who are sicker get more transfusions and are at increased risk for nosocomial ifx. 14% in those who got blood vs. 6% in those not transfused. Of course, patients getting blood are usually sicker. There seems to be an immunosuppression associated w/ those receiving blood.
  • Gallagher, T.H., et al, Arch Intern Med 166:1605, August 14-28, 2006: American vs. Canadian docs in admitting error. Malpractice environment doesn't seem to affect whether you disclose an error. 85% who disclosed an error were glad that they did.
  • Seehusen, D.A., et al, Br Med J 333:171, July 2006: Use of stirrups during a routine pelvic exam w/ speculum and bimanual. They preferred not to have the stirrups. On many exams you don't need a speculum and how often is it performed when we don't need to? Either way, I'll have to take their word that it's more comfortable w/o...
  • Coakley, G., et al, Rheumatology 45(8):1039, August 2006: When a patient presents w/ the first episode of a hot, red joint? What if it looks like gout? Some say to tap them, I don't think so. Of note, 30% who have gout have normal uric acid levels. Blood work isn't of any utility in gout.
  • Ong, A.W., et al, Am Surg 72:773, September 2006: Routine c-spine in alert, oriented geriatric patients after blunt trauma. A negative neuro exam, no c-spine TTP, no EtOH, etc. had x-rays and CT's. 3% ended up w/ an injury that required intervention. 8 of the 9 interventions involved a collar. This is taken from a chart review.
  • Antevil, J.L., et al, J Trauma 61:382, August 2006: The study suggests that CT c-spine be the intial study for trauma patients. The CT will find injuries that x-rays miss. The study has enough flaws that I'll keep my approach of x-ray first.
  • Beynnon, B.D., et al, Am J Sports Med 34(9):1401, September 2006: Randomized treatment to ankle sprains. The best treatment for mild sprain was ace wrap. The best thing a patient can do is early activity on the joint. The sooner they're back to activity, the better they do.
  • Norris, R.L., et al, Am J Emerg Med 24(5):618, September 2006: Case report of a med student who applied tube gauze to a finger that caused digital necrosis and amputation. How would you like to be that med stud?
  • Nieman, C.T., et al, Acad Emerg Med 13(10):1011, October 2006: A study looking at the use of Broslow tapes from the prestigious Case Western Reserve Univeristy (ahem). It's not very accurate and can cause under-dose of obese and larger infants/peds pts.
  • Cravero, J.P., et al, Pediatrics 118(3):1087, September 2006: Peds procedural sedation. 1.5% had desats. No significant outcomes, no deaths, etc. Only one aspiration. Just shows that it's a safe when done in the appropriate situation.
  • Salpeter, S.R., et al, J Gen Intern Med 21(10):1011, October 2006: Looked at anticholinergics vs. albuterol in COPD pts. For chronic use anticholinergics are of benefit.
  • Fortin, J.L., et al, Clin Toxicol 44(Suppl 1):37, 2006: Use of Hydroxocobalamin in the treatment of acute smoke inhalation. Not in the US- done in France. Anecdotal evidence is that it works.
  • Mangione-Smith, R., et al, Arch Ped Adol Med 160:945, September 2006: In pediatric patients we're more likely to prescribe Abx when we assume that the parents want them by asking if it may be dx "X" or question the plan.
  • Yoder, K.E., et al, Clin Ped 45:633, September 2006: No benefit in trx w/ steroids, benadryl or placebo for pediatric uri sx's and cough.
  • Sinha, M., et al, Pediatrics 117(4):1162, April 2006: From the copa- distracting peds pts during lac repairs is of benefit.
  • Vaillancourt, C., et al, Can J Emerg Med 6(3):147, May 2004: In acute compartment syndrome, how long before muscle necrosis. Some as quickly as 3 hours. Quite variable in time to injury and times. Bottom line is muscle can die early on and you can't miss this dx.


Post a Comment

<< Home