Sunday, July 29, 2007

June EMA Abstracts

1. EMERGENCY DEPARTMENT MANAGEMENT AND SHORT-TERM OUTCOME OF CHILDREN WITH CONSTIPATION, Miller, M.K., et al, Ped Emerg Care 23(1):1, January 2007: Frequent presenting complaint. Wide variability in workup and treatment. Poor response to treatment in 42%. About 40% had prior visits and a quarter had further visits for same complaint. No big message here.
2. THE ROLE OF CARDIAC RISK FACTOR BURDEN IN DIAGNOSING ACUTE CORONARY SYNDROMES IN THE EMERGENCY DEPARTMENT SETTING, Han, J.H., et al, Ann Emerg Med 49(2):145, February 2007: Cardiac risk factors are useful for populations, but are not helpful in acute ED presentations, except for possibly in those under 40. Bottom line: If they have a lot of risk factors, let the cardiologist know, because they will still be impressed. If they have no or few risk factors, let them know how typical the presentation is. Nothing new here.
3. RELATIONSHIP BETWEEN A CLEAR-CUT ALTERNATIVE NONCARDIAC DIAGNOSIS AND 30-DAY OUTCOME IN EMERGENCY DEPARTMENT PATIENTS WITH CHEST PAIN, Hollander, J.E., et al, Acad Emerg Med 14(3):210, March 2007: Patients with clear-cut alternative diagnosis for chest pain still had bad outcomes 4% of time (versus 8% with no other diagnosis found in ED). Not really helpful in acute presentations.
4. COMPARISON OF EARLY MORTALITY OF PARAMEDIC-DIAGNOSED ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION WITH IMMEDIATE TRANSPORT TO A DESIGNATED PRIMARY PERCUTANEOUS CORONARY INTERVENTION CENTER TO THAT OF SIMILAR PATIENTS TRANSPORTED TO THE NEAREST HOSPITAL, Le May, M.R., et al, Am J Cardiol 98(10):1329, November 15, 2006: Two points: Early PCI versus thrombolyisis results in lower mortality (duh), and paramedics can be taught to do and read 12-leads relatively accurately.
5. THE DIAGNOSTIC ACCURACY OF 64-SLICE COMPUTED TOMOGRAPHY CORONARY ANGIOGRAPHY COMPARED WITH STRESS NUCLEAR IMAGING IN EMERGENCY DEPARTMENT LOW-RISK CHEST PAIN PATIENTS, Gallagher, M.J., et al, Ann Emerg Med 49(2):125, February 2007: Very small study showing 86% sensitivity and 92% specificity for Cardiac CT angiography in low risk patients (similar to stress testing). Needs large study with good follow-up to make any recommendation on this.
6. ROUTINE UPSTREAM INITIATION VS. DEFERRED SELECTIVE USE OF GLYCOPROTEIN IIB/IIIA INHIBITORS IN ACUTE CORONARY SYNDROMES: THE ACUITY TIMING TRIAL, Stone, G.W., et al, JAMA 297(6):591, February 14, 2007 : Should we start GPIIb/IIIa inhibitors in the ED or wait until cath lab shows lesion that requires intervention? No difference in outcome with less bleeding events in cath lab started group. Look for more on this.
7. A QUALITY GUARANTEE IN ACUTE CORONARY SYNDROMES: THE AMERICAN COLLEGE OF CARDIOLOGY'S GUIDELINES APPLIED IN PRACTICE PROGRAM TAKEN REAL-TIME, Vasaiwala, S., et al, Am Heart J 153(1):16, January 2007 Real-time monitoring of quality markers done while patient is still in hospital improves compliance with MOR criteria compared with just looking at it after the fact. Another duh kind of paper. Would it be possible to do this at our hospitals? Doubt it.
8. HEART FAILURE WITH A NORMAL EJECTION FRACTION, Sanderson, J.E., Heart 93:155, February 2007: Probably related to long-standing HTN and wall stiffness. No good EBM guidelines on how to treat, but probably use diuresis for acute treatment and long term treatment with ACE or ARB.
9. INCREASING USE OF CARDIOPULMONARY RESUSCITATION DURING OUT-OF- HOSPITAL VENTRICULAR FIBRILLATION ARREST: SURVIVAL IMPLICATIONS OF GUIDELINE CHANGES, Rea, T.D., et al, Circulation 114:2760, December 19-26, 2006 : More CPR, less time checking in vfib arrests improves outcome. Difficult to believe the data (as usual) from Seattle where everyone survives.
10. TRANSTHORACIC INCREMENTAL MONOPHASIC VERSUS BIPHASIC DEFIBRILLATION BY EMERGENCY RESPONDERS (TIMBER)Kudenchuk, P.J., et al, Circulation 114:2010, November 7, 2006 : No outcome difference between monophasic and biphasic shocks.
11. CALCULATING THE REQUIRED TRANSFUSION VOLUME IN CHILDREN, Davies, P., et al, Transfusion 47:212, February 2007 : 10 ml/kg transufusion volume leads to 2 gm/dl Hb increase – reasonable recommendation but based on poor methods.
12. VALIDATION OF THE ABCD SCORE IN IDENTIFYING INDIVIDUALS AT HIGH EARLY RISK OF STROKE AFTER A TRANSIENT ISCHEMIC ATTACK: A HOSPITAL- BASED CASE SERIES STUDY, Tsivgoulis, G., et al, Stroke 37:2892, December 2006 : Previously studied score to differentiate TIA patients with high and low risk for subsequent stroke is not sensitive enough to decide who to send home. Bottom line: Admit TIA’s for work-up for reversible or preventable causes to limit risk of debilitating subsequent stroke.
13. VALIDATION AND REFINEMENT OF SCORES TO PREDICT VERY EARLY STROKE RISK AFTER TRANSIENT ISCHAEMIC ATTACK, Johnston, S.C., et al, Lancet 369:283, January 27, 2007 : Despite complicating the assessment tool, you still can’t discharge TIA patients from the ED (see above)
14. ANALYSIS OF EMPIRIC ANTIMICROBIAL STRATEGIES FOR CELLULITIS IN THE ERA OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS Phillips, S., et al, Ann Pharmacother 41:13, January 2007 : Theoretical cost study shows that keflex is more cost effective if MRSA is unlikely, but clinda if high risk. Bottom line: We have high risk – use anti-MRSA meds for cellulitis.
15. CHARACTERISTICS AND TEMPORAL TRENDS OF "LEFT BEFORE BEING SEEN" VISITS IN US EMERGENCY DEPARTMENTS, 1995-2002, Sun, B.C., et al, J Emerg Med 32(2):211, February 2007 : Rate of LWBS is increasing over time (estimated at 1.92% in 2002), with younger, non-urgent, non-white, urban, uninsured being more likely to leave. Numbers probably higher now. With our yellow pod and nursing changes, our numbers are in this ballpark.
16. EXTRACTS FROM THE COCHRANE LIBRARY: ANTIHISTAMINES AND/OR DECONGESTANTS FOR OTITIS MEDIA WITH EFFUSION (OME) IN CHILDREN, Burton, M.J., et al, Otolaryngol Head Neck Surg 136(1):11, January 2007 : Doesn’t work, may harm. Don’t use them.
17. IS SKIN TURGOR RELIABLE AS A MEANS OF ASSESSING HYDRATION STATUS IN CHILDREN?, Fayomi, O., Emerg Med J 24:124, February 2007 : Only moderate inter-rater agreement. Utility not addressed.
18. META-ANALYSIS: ONDANSETRON FOR VOMITING IN ACUTE GASTROENTERITIS IN CHILDREN, Szajewska, H., et al, Aliment Pharmacol Ther 25(4):393, February 2007 : May be beneficial in some patients. May increase diarrhea. I have asked pharmacy to look into cost issues at CHW for us.
19. PAEDIATRIC INTUSSUSCEPTION: EPIDEMIOLOGY AND OUTCOME, Blanch, A.J.M., et al, Emerg Med Australasia 19(1):45, February 2007 : 94% ≤ 4yo, M:F = 2:1, often not classic presentation, frequently present with lethargy and irritability diagnosis missed initially 46% of time. Bottom line: think about this diagnosis.
20. POINT-OF-CARE URINE TRYPSINOGEN TESTING FOR THE DIAGNOSIS OF PANCREATITIS, Jang, T., et al, Acad Emerg Med 14(1):29, January 2007 : Amylase and lipase are not that accurate at times, but do we really have that much difficulty diagnosing pancreatitis? Do we need to make this diagnosis with a POC testing immediacy? No and no. So why do you even care about the results of this study? Look for bigger, better studies on this.
21. SIMPLE CLINICAL PREDICTORS MAY OBVIATE URGENT ENDOSCOPY IN SELECTED PATIENTS WITH NONVARICEAL UPPER GASTROINTESTINAL TRACT BLEEDING, Romagnuolo, J., et al, Arch Intern Med 167:265, February 12, 2007 : Impressive results in small study for clinical and lab findings looking for low risk for rebleeding or complications. But still risk present even with very low risk patients. Look for follow-up studies.
22. BLIND URETHRAL CATHETERIZATION IN TRAUMA PATIENTS SUFFERING FROM LOWER URINARY TRACT INJURIES, Shlamovitz, G.Z., et al, J Trauma 62:330, February 2007 : Small study. Reasonable to attempt a single, ‘gentle’ attempt at placing a Foley without evidence of increased injury.
23. CLINICAL PREDICTION RULE TO DISTINGUISH PELVIC INFLAMMATORY DISEASE FROM ACUTE APPENDICITIS IN WOMEN OF CHILDBEARING AGE, Morishita, K., et al, Am J Emerg Med 25:152, February 2007 : Low risk for appendicitis: no pain migration, absence of n/v and presence of bilat tenderness. Still some patients had appendicitis. No take-home point here.
24. FEVER AFTER A STAY IN THE TROPICS: DIAGNOSTIC PREDICTORS OF THE LEADING TROPICAL CONDITIONS, Bottieau, E., et al, Medicine 86(1):18, January 2007 : Think malaria with early onset fever with splenomegaly, thrombocytopenia, hyperbilirubinemia and absence of localizing source of fever. Think of tropical illnesses in any patient within one month of return. Late onset was often non-falciparum fever. Break-bone fever – dengue.
25. COMPARISON OF LABORATORY VALUES OBTAINED BY PHLEBOTOMY VERSUS SALINE LOCK DEVICES, Corbo, J., et al, Acad Emerg Med 14(1):23, January 2007 : No significant differences statistically and no clinical difference between paired tests. Useful take-home point: Saline-lock drawn blood is accurate for commonly used lab tests including potassium.
26. THE NATIONAL TREND IN QUALITY OF EMERGENCY DEPARTMENT PAIN MANAGEMENT FOR LONG BONE FRACTURES, Ritsema, T.S., et al, Acad Emerg Med 14(2):163, February 2007 : Some improvement over time in use of analgesics for fractures, but we are still not doing well. Broken bone should = good drugs.
27. CAN A NORMAL RANGE OF ELBOW MOVEMENT PREDICT A NORMAL ELBOW X-RAY?, Lennon, R.I., et al, Emerg Med J 24:86, February 2007 : 97% NPV for full pronation, full supination, full flexion and full extension – very low risk.
28. COMPUTED TOMOGRAPHY OF SUSPECTED SCAPHOID FRACTURES, Adey, L., et al, J Hand Surg 32A(1):61, January 2007 : CT is better than plain films but not perfect. Do not use this in the ED. Treat xray or conservatively on clinical findings. No change in your management because of this study.
29. ASSESSMENT OF UPPER GASTROINTESTINAL SAFETY OF ETORICOXIB AND DICLOFENAC IN PATIENTS WITH OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS IN THE MULTINATIONAL ETORICOXIB AND DICLOFENAC ARTHRITIS LONG-TERM (MEDAL) PROGRAMME: A RANDOMISED COMPARISON, Laine, L., et al, Lancet 369:465, February 10, 2007 : Statistically significant but clinically insignificant differences comparing an NSAID with high gi effects. Bad industry sponsored study.
30. NSAID USE AND PROGRESSION OF CHRONIC KIDNEY DISEASE, Gooch, K., et al, Am J Med 120(3):280.e1, March 2007 : Complex study, but possibly more NSAID use associated with higher risk of progression of kidney disease. Not a study to change management in the ED.
31. A RANDOMIZED CONTROLLED TRIAL COMPARING INTRANASAL FENTANYL TO INTRAVENOUS MORPHINE FOR MANAGING ACUTE PAIN IN CHILDREN IN THE EMERGENCY DEPARTMENT, Borland, M., et al, Ann Emerg Med 49(3):335, March 2007 : Essentially equivalent. Not powered for safety.
32. THE COST OF OVER-THE-COUNTER SUBSTANCE ABUSE, Feinberg, D.T., J Child Adol Psychopharm 16(6):801, December 2006 : 10% of teens abuse OTC meds, with dextromethorphan being the most common.
33. COMPARISON OF URINARY ON-SITE IMMUNOASSAY SCREENING AND GAS CHROMATOGRAPH-MASS SPECTROMETRY RESULTS OF 111 PATIENTS WITH SUSPECTED POISONING PRESENTING AT AN EMERGENCY DEPARTMENT, von Mach, M.A., et al, Ther Drug Monit 29(1):27, February 2007 : Rapid POC assay (Biosite Triage 8) is frequently worng (50% took something not measured on the assay and 20% had discordant results). Not accurate or helpful.
34. EFFECT OF NAIL POLISH ON OXYGEN SATURATION DETERMINED BY PULSE OXIMETRY IN CRITICALLY ILL PATIENTS, Hinkelbein, J., et al, Resuscitation 72:82, January 2007 : Nice little study. Nail polish does not seem to affect readings by more than 1.6%. Take-home: Leave the nail-polish on.
35. WHAT IS THE ROLE OF CHEST X-RAY IN THE INITIAL ASSESSMENT OF STABLE TRAUMA PATIENTS?, Wisbach, G.G., et al, J Trauma 62:74, January 2007 : Bad study with correct answer: No utility in hemodynamically stable patients with no chest complaints.
36. EFFECT OF AZITHROMYCIN AND CLARITHROMYCIN THERAPY ON PHARYNGEAL CARRIAGE OF MACROLIDE-RESISTANT STREPTOCOCCI IN HEALTHY VOLUNTEERS: A RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY, Malhotra-Kumar, S., et al, Lancet 369:482, February 10, 2007 : Yet another reason to not treat URI with abx: Increase in macrolide resisitant bacteria after a brief course of macrolides.
37. COMPARISON BETWEEN SINGLE-DOSE ORAL PREDNISOLONE AND ORAL DEXAMETHASONE IN THE TREATMENT OF CROUP: A RANDOMIZED, DOUBLE-BLINDED CLINICAL TRIAL, Fifoot, A.A., et al, Emerg Med Australasia 19(1):51, February 2007 : Although dexamethasone is standard, no difference between these steroids.
38. EFFICACY OF ANTIBIOTIC PROPHYLAXIS FOR INTRAFAMILIAL TRANSMISSION OF GROUP A BETA-HEMOLYTIC STREPTOCOCCI, Kikuta, H., et al, Ped Infect Dis J 26(2):139, February 2007 : Low rate of familial transmission to begin with resulted in no useful benefit. Useful info: familial transmission rate about 5% to sibs.
39. ARE SORE THROAT PATIENTS WHO HOPE FOR ANTIBIOTICS ACTUALLY ASKING FOR PAIN RELIEF?, van Driel, M.L., et al, Ann Fam Med 4(6):494, November/December 2006 : UK study, but those patients wanted a diagnosis and pain relief more than abx. Bottom line: Treat the pain, talk to the patient, hold abx unless absolutely needed.
40. RADIATION EXPOSURE FROM DIAGNOSTIC IMAGING IN SEVERELY INJURED TRAUMA PATIENTS, Tien, H.C., et al, J Trauma 62(1):151, January 2007 : Excess cancer deaths 1 in 500 trauma patients (by estimates from dosimeters). Be careful what you order.

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