Friday, September 21, 2007

August 2007 EMA Abstract Review

1. BENEFITS OF ROUTINE USE OF CORONAL AND SAGITTAL REFORMATIONS IN MULTI-SLICE CT EXAMINATION OF THE ABDOMEN AND PELVIS, Sandrasegaran, K., et al, Clin Rad 62(4):340, April 2007 : The authors feel that they get more info when the CT images are reformatted in multiple planes, and suggest this should be routine. Will not change our practice (we already do this with stone ct’s).
2. EXTERNAL VALIDITY OF ST ELEVATION MYOCARDIAL INFARCTION TRIALS: THE ZWOLLE STUDIES, Rasoul, S., et al, Cath Cardiovasc Interventions 69(5):632, April 1, 2007 : Patients who are older, sicker and female are less likely to be enrolled in clinical trials and registries, even if they meet criteria. They are more likely to die, and less likely to get standard of care. Another study (this one Dutch) indicating significant bias where we think there isn’t any.
3. DOES THIS PATIENT WITH A PERICARDIAL EFFUSION HAVE CARDIAC TAMPONADE?, Roy, C.L., et al, JAMA 297(16):1810, April 25, 2007 : No clinical findings are sufficient to rule out tamponade. TAKE HOME POINT: ECHO is required if tamponade is a consideration.
4. FREQUENCY OF AND INAPPROPRIATE TREATMENT OF MISDIAGNOSIS OF ACUTE AORTIC DISSECTION, Hansen, M.S., et al, Am J Card 99(6):852, March 15, 2007 : 39% of patients were initially misdiagnosed, (usually as ACS, most with ST changes or marker elevation) and were more likely to die or bleed. Despite frequent reminders to consider TAD, we still miss it 4 out of 10 times. Keep a high index of suspicion, yada yada…
5. RECOGNIZING ASYMPTOMATIC ELEVATED BLOOD PRESSURE IN ED PATIENTS: HOW GOOD (BAD) ARE WE?, Tilman, K., et al, Am J Emerg Med 25(3):313, March 2007 : Only 7% of patients w/ new onset asymptomatic elevated BP had this addressed during the ED visit. Appropriate management might be just to put it on the dc instructions and encourage patients to get it followed up.
6. EXTERNAL VALIDATION OF THE SAN FRANCISCO SYNCOPE RULE, Sun, B.C., et al, Ann Emerg Med 49(4):420, April 2007 : Validation study for the SFSR showed lower sensitivity and specificity (89%/42%) than the derivation study. I’m not willing to risk an 11% adverse event rate upon discharge from the ED. I will continue to admit most syncope’s I can’t otherwise clearly explain.
7. PREDICTING INTRACRANIAL TRAUMATIC FINDINGS ON COMPUTED TOMOGRAPHY IN PATIENTS WITH MINOR HEAD INJURY: THE CHIP PREDICTION RULE, Smits, M., et al, Ann Intern Med 146(6):397, March 20, 2007 : Complex rule (read: You are not going to be able to use this rule) found all patients requiring neurosurgery, but missed 5% with abnormal CT findings and only reduced CT use only moderately. No.
8. EVALUATION OF A MODIFIED PREDICTION INSTRUMENT TO IDENTIFY SIGNIFICANT PEDIATRIC INTRACRANIAL INJURY AFTER BLUNT HEAD TRAUMA, Sun, B.C., et al, Ann Emerg Med 49(3):325, March 2007 : Attempt at external validation of a 5 part rule (altered mental status, evidence of skull fx, scalp hematoma (if <2yo), vomiting and headache) with the pediatric group of the NEXUS 2 data set. Sensitivity of 90.4% would have missed 13 patients with ICI. Not ready for prime time.
9. SUMATRIPTAN-NAPROXEN FOR ACUTE TREATMENT OF MIGRAINE, Brandes, J.L., et al, JAMA 297(13):1443, April 4, 2007: Worked better than sumatriptan alone, but as it didn’t include wooly mammoth doses of narcotics, there were frequent treatment failures and recurrences. You might want to try this from Yellow Pod, but by the time they make it to us, they often require more.
10. MISSED DIAGNOSIS OF SUBARACHNOID HEMORRHAGE IN THE EMERGENCY DEPARTMENT, Vermeulen, M.J., et al, Stroke 38:1216, April 2007 : Multicenter study showed a 5% initial miss rate (lower than previously published). More likely to not look sick, and more likely to show up at a non-teaching hospital. Interestingly, mortality was much lower in these missed patients (6.2 v 33.9%). Keep a high index of suspicion, yada, yada…
11. THE OPPORTUNITY LOSS OF BOARDING ADMITTED PATIENTS IN THE EMERGENCY DEPARTMENT, Falvo, T., et al, Acad Emerg Med 14(4):332, April 2007 : In a 62,000 visit ED, this study estimated a $4 million annual loss for the hospital ($1M of which was professional fees) due to patients that could have been seen but were not due to boarding inpatients in the ED. Boarding: Bad for patients, bad for business.
12. ACUTE OTITIS MEDIA AND RESPIRATORY VIRUSES, Bulut, Y., et al, Eur J Ped 166(3):223, March 2007 : 54% of middle ear cultures grew bacteria, 33% viruses, and the rest were unidentified. It’s a coin toss if it’s bacterial. Does this mean go back to treating all OM with abx? Let’s wait and see…
13. JUDICIOUS ANTIBIOTIC USE AND INTRANASAL CORTICOSTEROIDS IN ACUTE RHINOSINUSITIS, Small, C.B., et al, Am J Med 120(4):289, April 2007 : Review article. Only 38% of acute sinusitis is bacterial. May improve with antihistamines, nasal steroids, decongestants alone. Suggest wait-and-see abx if symptoms persist or worsen in 5-7 days, or for high risk patients (unilateral tenderness, facial or dental pain, mucopurulent drainage).
14. OMEPRAZOLE BEFORE ENDOSCOPY IN PATIENTS WITH GASTROINTESTINAL BLEEDING, Lau, J.Y., et al, N Engl J Med 356(16):1631, April 19, 2007 : H1 blocker prior showed improved surrogate findings at endoscopy, but did not change real outcomes (units transfused, need for surgery, death). I will continue to use them on the bleeding ulcer patients in the ED until someone tells me it makes them worse.
15. A COMPARATIVE STUDY ON BACTERIAL CULTURES OF URINE SAMPLES OBTAINED BY CLEAN-VOID TECHNIQUE VERSUS URETHRAL CATHETERIZATION, Lau, A.Y., et al, Acta Paed 96(3):432, March 2007 : Hong Kong study: Suprapubic aspiration suggested for uncircumcised boys, and cath for girls below age 2 to minimize false positive cultures. No recs for circumcised boys (what’s a Jew to do?), as all males in this study were uncircumcised.
16. DISCORDANCE BETWEEN SERUM CREATININE AND CREATININE CLEARANCE FOR IDENTIFICATION OF ED PATIENTS WITH ABDOMINAL PAIN AT RISK FOR CONTRAST-INDUCED NEPHROPATHY, Band, R.A., et al, Am J Emerg Med 25(3):268, March 2007 : We use serum creatinine (in this study a 1.5mg/dl cut-off) as a surrogate marker of low creatinine clearance (<60ml/min). It is a low clearance that increases risk for contrast induced nephropathy. This study showed that 40% of those with low clearance had a serum creatinine < 1.5. Although they suggest calculating clearance on all patients getting a contrast study. One commonly used formula: (140-age)*wt in kg/([Cr]*72) for males, with a 0.85 correction factor for females. I will not be doing this any time soon.
17. IMPACT OF AN EMERGENCY DEPARTMENT PAIN MANAGEMENT PROTOCOL ON THE PATTERN OF VISITS BY PATIENTS WITH SICKLE CELL DISEASE, Givens, M., et al, J Emerg Med 32(3):239, April 2007 : Discontinuing use of Demerol, discharging with a handful of hydrocodone and referring all to hematology clinic shifted sicklers out of ED and into the hematology clinic. This is good stuff. Now if we could only do this with migraines and back pain…
18. EMERGENCY DEPARTMENT MANAGEMENT OF ACUTE PAIN EPISODES IN SICKLE CELL DISEASE, Tanabe, P., et al, Acad Emerg Med 14(5):419, May 2007 : The American Pain Society recommends 0.1 to 0.15mg/kg of morphine or 0.015 to 0.02mg/kg of dilaudid within 15 minutes of arrival for SS pain crises. The hospitals studied did not do that well with this, often treating other patients with less reported pain prior to the sicklers. Bottom line: Treat their pain aggressively, skip the Demerol.
19. ORAL RIFAMPIN FOR ERADICATION OF STAPHYLOCOCCUS AUREUS CARRIAGE FROM HEALTHY AND SICK POPULATIONS: A SYSTEMATIC REVIEW OF THE EVIDENCE FROM COMPARATIVE TRIALS, Falagas, M.E., et al, Am J Infect Control 35:106, March 2007 : Use of rifampin reduced risk of infection in asymptomatic carriers at the risk of 17% developed rifampin-resistant SA.
20. IMPLEMENTATION OF A BUNDLE OF QUALITY INDICATORS FOR THE EARLY MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK THAT IS ASSOCIATED WITH DECREASED MORTALITY, Nguyen, H.B., et al, Crit Care Med 35(4):1105, April 2007 : Early goal-directed therapy takes work and time, but consistently saves lives in multiple studies, including this one. TAKE HOME POINT: Follow the sepsis protocol!!!
21. COST EFFECTIVENESS OF PERTUSSIS VACCINATION IN ADULTS, Lee, G.M., et al, Am J Prev Med 32(3):186, March 2007 : Using dTaP either as a mass-immunization plan or every 10-years is cost effective at the current incidence of pertussis (360 cases per 100,000 population). Another push towards dTaP and away for Td.
22. LITIGATION OF MISSED CERVICAL SPINE INJURIES IN PATIENTS PRESENTING WITH BLUNT TRAUMATIC INJURY, Lekovic, G.P., et al, Neurosurgery 60(3):516, March 2007: BNI study of 20 closed cases, with 8 for defendant (yea!) and 12 for plaintiff (boo!), with an average settlement of $2.9M per case. Most cases were an error in reading a study.
23. TRAMADOL/ACETAMINOPHEN OR HYDROCODONE/ACETAMINOPHEN FOR THE TREATMENT OF ANKLE SPRAIN: A RANDOMIZED, PLACEBO-CONTROLLED TRIAL, Hewitt, D.J., et al, Ann Emerg Med 49(4):468, April 2007 : Essentially equivalent pain relief with ultraset or vicodin and better than placebo (go figure). No reason to go for the more expensive new toy on the block.
24. SINGLE FASCIA ILIACA COMPARTMENT BLOCK FOR POST-HIP FRACTURE PAIN RELIEF, Monzon, D.G., et al, J Emerg Med 32(3):257, April 2007 : The procedure consisted of injection of 0.3ml/kg of 0.25% bupivacaine into the lumbar plexus at the juncture of the medial and lateral thirds of a line connecting the pubic symphysis and the anterior superior iliac spine. Results in significantly diminished pain and lower need for other meds. It’s worth a shot (get it, worth a shot!).
25. THORACIC INTERVERTEBRAL DISK HERNIATION: A COMMONLY MISSED DIAGNOSIS, Linscott, M.S., et al, J Emerg Med 32(3):235, April 2007 : Rare and frequently missed cause of back pain, often with radiation to buttocks, abdomen, chest and extremities, sometimes with neuro findings on exam. Diagnosis is by MRI (94% sensitive). Keep a high index of suspicion, yada, yada…
26. CORTICOSTEROID INJECTIONS IN THE TREATMENT OF TRIGGER FINGER: A LEVEL I AND II SYSTEMATIC REVIEW, Fleisch, S.B., et al, J Am Acad Orth Surg 15(3):166, March 2007 : Very little data on the practice, none of it well done, showing 50% of patients appear to improve. In appropriate patients, due to low risk and simplicity of procedure, it is worth a shot (get it? Oh, never mind.)
27. ACUTE ROTATOR CUFF TEAR: DO WE MISS THE EARLY DIAGNOSIS? A PROSPECTIVE STUDY SHOWING A HIGH INCIDENCE OF ROTATOR CUFF TEARS AFTER SHOULDER TRAUMA, Sorensen, A.K.B., et al, J Shoulder Elbow Surg 16:174, March/April 2007 : Poor correlation between blinded physical exam and ultrasound findings, showing frequent missed tears, especially in the older patient population. Not sure how diagnosing tear in ED changes anything, but may be helpful to tell patients there may be a tear, may need treatment for it later.
28. IN CHILDREN UNDER AGE THREE DOES PROCALCITONIN HELP EXCLUDE SERIOUS BACTERIAL INFECTION IN FEVER WITHOUT FOCUS?, Herd, D., Arch Dis Child 92:362, April 2007 : Baseline risk of bacteremia in the Hib vaccine era is <2%. Procalcitonin is sensitive, but probably not useful enough to exclude bacteremia.
29. RANDOMIZED DOUBLE-BLIND PLACEBO-CONTROLLED TRIAL OF TWO INTRAVENOUS MORPHINE DOSAGES (0.10MG/KG AND 0.15MG/KG) IN EMERGENCY DEPARTMENT PATIENTS WITH MODERATE TO SEVERE ACUTE PAIN, Birnbaum, A., et al, Ann Emerg Med 49(4):445, April 2007 : More morphine, slightly better pain relief, with no downside risk. MY PERSONAL TAKE: Treat pain and reassess. You can always give more morphine.
30. THE FDA AND THE CASE OF KETEK, Ross, D.B., N Engl J Med 356(16):1601, April 19, 2007 : Fraud in the studies; FDA in the pocket of the drug companies. Evil everywhere.
31. A NATIONAL SURVEY OF PHYSICIAN-INDUSTRY RELATIONSHIPS, Campbell, E.G., et al, N Engl J Med 356(17):1742, April 26, 2007 : Many surveyed docs took bribes, I mean food, CME money, and ‘gifts’ from drug reps. Cardiologists and FP’s are the most likely to report getting stuff.
32. PHARMACEUTICAL COMPANY PAYMENTS TO PHYSICIANS: EARLY EXPERIENCES WITH DISCLOSURE LAWS IN VERMONT AND MINNESOTA, Ross, J.S., et al, JAMA 297(11):1216, March 21, 2007: Lots of payments still being made, and access to supposed public documents were not available. Evil pharmaceutical companies again.
33. LOW-DOSE PROPOFOL REDUCES THE INCIDENCE OF MODERATE TO SEVERE LOCAL PAIN INDUCED BY THE MAIN DOSE, Liljeroth, E., et al, Acta Anesthesiol Scand 51(4):460, April 2007 : Using a small priming dose of propofol ameliorates some of the discomfort associated with injection, but not compared to lidocaine, only placebo. Probably not worth the effort.
34. PEDIATRIC PROCEDURAL SEDATION IN THE COMMUNITY EMERGENCY DEPARTMENT: RESULTS FROM THE PRO-SCED REGISTRY, Sacchetti, A., et al, Ped Emerg Care 23(4):218, April 2007 : Over 1000 patients, with one case of apnea and one case of hypoxemia. Bottom line: Sedation of kids for procedures in the ED is very safe and effective.
35. EFFECTS OF REPLACING OXITROPIUM WITH TIOTROPIUM ON PULMONARY FUNCTION IN PATIENTS WITH COPD, Incorvaia, C., et al, Resp Med 101(3):476, March 2007 : Bad study. Some improvement in pulm function tests with Spiriva, but no real outcomes measured.
36. SYSTEMIC CORTICOSTEROIDS IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE: AN OVERVIEW OF COCHRANE SYSTEMATIC REVIEWS, Wood-Baker, R., et al, Resp Med 101(3):371, March 2007 : Not helpful in stable COPD with risk of adverse events (Number needed to harm: 9).
37. DECLINING ANTIBIOTIC PRESCRIPTIONS FOR UPPER RESPIRATORY INFECTIONS, 1993-2004, Vanderweil, S.G., et al, Acad Emerg Med 14(4):366, April 2007 : We are still giving abx for viral URI’s in up to 1/3rd of patients with that diagnosis. Stop. Now.
38. THROAT CULTURE IS NECESSARY AFTER NEGATIVE RAPID ANTIGEN DETECTION TESTS., Mirza, A., et al, Clin Ped 46(3):241, April 2007 : About 7% of neg rapid stress tests followed by cultures were positive. The authors suggest culture everyone. I say do neither, but treat appropriately based on clinical criteria (Centor criteria: fever, tender lympadenopathy, exudates, absence of uri symptoms).
39. EMERGENCY ROOM MANAGEMENT OF PATIENTS WITH BLUNT MAJOR TRAUMA: EVALUATION OF THE MULTISLICE COMPUTED TOMOGRAPHY PROTOCOL EXEMPLIFIED BY AN URBAN TRAUMA CENTER, Weninger, P., et al, J Trauma 62:584, March 2007 : Weird study, small-volume resuscitation and intubation (if needed) by pre-hospital physicians followed by immediate transfer to CT from ambulance. Pan-scanning upon arrival included: head, face, c-spine, chest, abd/pelvis. Post-protocol implementation showed less MSOF, shorter ED, CU and hospital stays, but no mortality difference. Is this really where we want to go?
40. THE INCREASING USE OF CHEST COMPUTED TOMOGRAPHY FOR TRAUMA: IS IT BEING OVERUTILIZED?, Plurad, D., et al, J Trauma 62(3):631, March 2007 : CT chest went from 2.7% in 1998 to 28.7% in 2004, but only 12 occult injuries found were actually treated. Opposite of above, article. Bottom line of these two: Think before you order that CT.

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