Sunday, October 07, 2007

September EMA Abstract Review

1. USEFULNESS OF 64-SLICE MULTIDETECTOR COMPUTED TOMOGRAPHY IN DIAGNOSTIC TRIAGE OF PATIENTS WITH CHEST PAIN AND NEGATIVE OR NONDIAGNOSTIC EXERCISE TREADMILL TEST RESULT. Rubinshtein, R., et al, Am J Card 99(7):925, April 1, 2007: 100 patients after neg or non-dx exercise treadmill had CTA with a PPV of 90% (all positives had a cath) and a NPV of 93% (but only those with persistent issues had a cath). More limited, wishy-washy evidence that CTA may be helpful.
2. USEFULNESS OF 64-SLICE CARDIAC COMPUTED TOMOGRAPHIC ANGIOGRAPHY FOR DIAGNOSING ACUTE CORONARY SYNDROMES AND PREDICTING CLINICAL OUTCOME IN EMERGENCY DEPARTMENT PATIENTS WITH CHEST PAIN OF UNCERTAIN ORIGIN. Rubinshtein, R., et al, Circulation 115:1762, April 3, 2007: Similar study, with intermediate risk patients. Only 52% PPV and 97% NPV in this study. See above.
3.A PRACTICAL APPROACH WITH OUTCOME FOR THE PROGNOSTIC ASSESSMENT OF NON-ST-SEGMENT ELEVATION CHEST PAIN AND NORMAL TROPONIN. Sanchis, J., et al, Am J Card 99(6):797, March 15, 2007: Combined previously published risk strat model (One point each was assigned for four of the items ("typical" chest pain presentation, two or more episodes in the previous 24 hours, age 67 years or older, previous PTCA) and two points were assigned if the patient had insulin-dependent diabetes.) with presence of ST-depression or Trop elevation. No surprise that the lowest risk group had lower outcome measures than other groups, but still had a 9% event rate by 15 months.
4. COLD INFUSIONS ALONE ARE EFFECTIVE FOR INDUCTION OF THERAPEUTIC HYPOTHERMIA BUT DO NOT KEEP PATIENTS COOL AFTER CARDIAC ARREST. Kliegel, A., et al, Resuscitation 73(1):46, April 2007: Infusion of cold fluids can get patients to target temp (32-34 C) but could not maintain it without adjunctive cooling measures. We will be seeing a lot of these studies looking at how to keep the post-dead patients cold. How’s about not wasting resources on dead patients in the first place? Sorry, sarcasm got away from me there.
5. IMPLEMENTATION OF A STANDARDISED TREATMENT PROTOCOL FOR POST RESUSCITATION CARE AFTER OUT-OF-HOSPITAL CARDIAC ARREST. Sunde, K., et al, Resuscitation 73(1):29, April 2007: Multifaceted goal directed approach (sound familiar?) to post-resuscitation care (therapeutic hypothermia and PCI when appropriate) as well as therapies to maintain blood pressure and heart rate targets, ventilation goals, blood sugar, electrolyte and hemoglobin values, diuresis and seizure control) improved survival to neurologically good hospital discharge (56% v. 26%). I can see this coming down the road, and will need to be started in the ED. Can’t you just see a ‘Surviving Death’ campaign?
6. MAJOR HEMORRHAGE AND TOLERABILITY OF WARFARIN IN THE FIRST YEAR OF THERAPY AMONG ELDERLY PATIENTS WITH ATRIAL FIBRILLATION. Hylek, E.M., et al, Circulation 115:2689, May 29, 2007: 5% of patients bleed in the first year of starting warfarin. Many stop the drug due to complications. Those at highest risk for CVA are also the ones at risk for complications and for stopping the drug.
7. PROACTIVE ADMINISTRATION OF PLATELETS AND PLASMA FOR PATIENTS WITH A RUPTURED ABDOMINAL AORTIC ANEURYSM: EVALUATING A CHANGE IN TRANSFUSION PRACTICE. Johansson, P.I., et al, Transfusion 47:593, April 2007: These researchers transfused platelets, pRBC’s and FFP as soon as the diagnosis was made and again before unclamping the aorta in the OR. 50% survival increase (44% without protocol and 66% with protocol). Increasing BP and blood volume leading to increasing uncontrolled bleeding need to be considered as well. Needs to be reproduced to start to use.
8. WHAT VASOPRESSORS SHOULD BE USED TO TREAT SHOCK. Jones, A.E., Ann Emerg Med 49(3):367, March 2007: Review of 7 studies looking mainly at septic shock show trivial hemodynamic improvement with norepi and dobut v. epi, and potentially worse outcome with vasopressin v. placebo. No clear answers here and the existing evidence sucks. Don’t believe the BS when someone berates you for using the ‘wrong’ pressor.
9. EXTERNAL VALIDATION OF THE SAN FRANCISCO SYNCOPE RULE IN THE AUSTRALIAN CONTEXT. Cosgriff, T.M., et al, Can J Emerg Med 9(3):157, May 2007: Yet another look at the SFSR. This one from Oz showed higher admission and equal outcome when comparing SFSR to clinician judgment. That’s right: The SFSR did worse!
10. DEPRESSION AND COST-RELATED MEDICATION NONADHERENCE IN MEDICARE BENEFICIARIES. Bambauer, K.Z., et al, Arch Gen Psych 64:602, May 2007: Large survey of medicare recipients showing that all are at risk for not taking meds because of cost, but that those who were depressed were even more likely to have this issue. Ask your patients if they are taking their meds, and if not, is it because of financial reasons. Financial counselors may be able to help. Switch to generics, etc…
11. SECONDARY PREVENTION OF STROKE AND TRANSIENT ISCHEMIC ATTACK: IS MORE PLATELET INHIBITION THE ANSWER? Liao, J.K., Circulation 115:1615, March 27, 2007: Review of available studies. Benefit of extended-release dipyramidole plus aspirin as opposed to asa alone: 1 less CVA per 100-person-years. Risk v. benefits need to be discussed in choosing therapy for prophylaxis in this population.
12. COST-EFFECTIVENESS OF ECHOCARDIOGRAPHY TO IDENTIFY INTRACARDIAC THROMBUS AMONG PATIENTS WITH FIRST STROKE OR TRANSIENT ISCHEMIC ATTACK. Meenan, R.T., et al, Med Dec Making 27:161, March-April 2007: Always questionable cost-effective analysis suggests TTE or TEE is unlikely to be cost-effective for first stroke or TIA unless patient is at high risk (i.e. prior cardiac disease). I suspect the hospitalists will continue to want this on the TIA/CVA patients we admit, however.
13. PATIENTS DEROGATE PHYSICIANS WHO USE A COMPUTER-ASSISTED DIAGNOSTIC AID. Arkes, H.R., et al, Med Dec Making 27:189, March-April 2007: Using an electronic decision aid during a patient encounter decreased patient satisfaction in this interesting study. Leave the Palm in the pocket, look at it outside the room, and explain why you are doing or not doing a test/procedure without dragging in the decision aid.
14. THE EFFECT OF EMERGENCY DEPARTMENT EXPANSION ON EMERGENCY DEPARTMENT OVERCROWDING. Han, J.H., et al, Acad Emerg Med 14(4):338, April 2007: Fascinating study (for a geek like me) looking at an ED that expanded from 28 to 53 beds. No change in ambulance diversion and an increase in ED LOS. It indicates that efficiency is a multifactorial problem, not isolated to having limited space in which to work. Bottom line: It’s not how big your ED is, it’s how you use it.15. PHYSICIAN CONSIDERATION OF PATIENTS' OUT-OF-POCKET COSTS IN MAKING COMMON CLINICAL DECISIONS. Pham, H.H., et al, Arch Intern Med 167:663, April 9, 2007: Physicians consider patient costs when prescribing drugs, but not so much when ordering tests or admitting patients. It is very difficult to discuss these issues in the ED, where we have little knowledge of costs and insurance coverage, and where we do what we think is necessary. But 90% of medical costs flow from the physician’s pen. Think about what you write.
16. VALACYCLOVIR AND PREDNISOLONE TREATMENT FOR BELL'S PALSY: A MULTICENTER, RANDOMIZED, PLACEBO-CONTROLLED STUDY. Hato, N., et al, Otol Neurotol 28(3):408, April 2007: Perisistent question: Do antivirals help Bell’s? In this Japanese study, those with severe or total paralysis may have benefit if valtrex is started early. I will continue to prescribe it for my Bell’s patients who present early.
17. CARDIAC MONITORING OF HIGH-RISK PATIENTS AFTER AN ELECTRICAL INJURY: A PROSPECTIVE MULTICENTRE STUDY. Bailey, B., et al, Emerg Med J 24:348, May 2007: 134 patients with high-risk electrical injuries with no arrhythmia at baseline monitored for 24-hours showed no delayed arrhythmias. CI’s wide, but pretty good evidence here.
18. INTRAVENOUS DEXTROSE DURING OUTPATIENT REHYDRATION IN PEDIATRIC GASTROENTERITIS. Levy, J.A., et al, Acad Emerg Med 14(4):324, April 2007: Treatment with glucose containing IV fluids decreased return revisit rate (OR 1.9), but treatment with antiemetics had a bigger effect (OR 4.4). TAKE HOME POINT: If using IV to rehydrate these tykes, use dextrose containing fluids.
19. LOPERAMIDE THERAPY FOR ACUTE DIARRHEA IN CHILDREN: SYSTEMATIC REVIEW AND META-ANALYSIS. Li, S.T.T., et al, PLoS Med 4(3):e98, March 2007: Use of loperamide was helpful for children with diarrhea who were not really sick (no bloody diarrhea, no severe dehydration), but increase risk (lethargy, ileus, even death) for those younger than 3.
20. EARLY ANTIBIOTIC TREATMENT FOR SEVERE ACUTE NECROTIZING PANCREATITIS. Dellinger, E.P., et al, Ann Surg 245(5):674, May 2007: Sponsored study by the makers of meropenem on using it prophylactically with necrotizing pancreatitis patients without evidence of pancreatic infection at study onset showed no benefit in any outcome measure. Bottom line: Do not use meropenem just to use it.
21. COST-EFFECTIVE DIAGNOSIS OF INGESTED FOREIGN BODIES. Shrime, M.G., et al, Laryngoscope 117:785, May 2007: Based on the authors’ assumptions, CT should be considered the first test for fb sensation in the throat in adults. They failed to account for differences between glass/metal versus radiolucent fb’s, which I think make the conclusions of this study almost useless. My personal opinion: You may want to consider CT first if the object is felt to be radiolucent (i.e. meat) but for our glass and metal eaters out there, I would still go for xray first. Or if you really think it’s there, send them straight to laryngoscopy.
22. CASE-SERIES OF NURSE-ADMINISTERED NITROUS OXIDE FOR URINARY CATHETERIZATION IN CHILDREN. Zier, J.L., et al, Anesth Analg 104(4):876, April 2007: Nice study of 1018 kids getting urinary caths given laughing gas by nurses trained to use and monitor it. It worked, with low adverse event rate (4%), 1% failure rate and 1% over-sedation rate, with no serious adverse events. This is really cool, but it is hard enough for the docs to get NO2 approved, let alone nurses.
23. THE RENO-PROTECTIVE EFFECT OF HYDRATION WITH SODIUM BICARBONATE PLUS N-ACETYLCYSTEINE IN PATIENTS UNDERGOING EMERGENCY PERCUTANEOUS CORONARY INTERVENTION: THE RENO STUDY. Recio-Mayoral, A., et al, J Am Coll Cardiol 49(12):1283, March 27, 2007: IV NAC and bicarb decreased the risk of CIN in high risk patients (Most CIN is a lab diagnosis only, but occasionally real events occur: anuric renal failure in 1 in placebo and 7 in control group). Another study looking at NAC for preventing CIN, this one with more positive results than others. The jury is still out.
24. UPDATE ON EMERGING INFECTIONS FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION: REVISED RECOMMENDATIONS FOR HIV TESTING OF ADULTS, ADOLESCENTS AND PREGNANT WOMEN IN HEALTH-CARE SETTINGS. Rothman, R.E., et al, Ann Emerg Med 49(5):575, May 2007: The CDC now recommends all patients btw 13 and 64 get screened (with their consent) for HIV in all healthcare settings. This would include the ED. This is clearly not the appropriate place to screen for most patients, with a decided lack of follow-up and counseling available. It may be reasonable in some situations (rape, evidence of opportunistic infection in at-risk patient, STD’s), but not everyone.
25. SEVERE DENGUE VIRUS INFECTION IN TRAVELERS: RISK FACTORS AND LABORATORY INDICATORS. Wichmann, O., et al, J Infect Dis 195:1089, April 15, 2007: Common and increasingly prevalent infection, seen more in the US due to more frequent travel to endemic regions (almost anywhere warm and moist). Although most infections are minor or even sub-clinical, some develop anemia, thrombocytopenia, elevated LFTs. Dengue hemorrhagic fever, although rare is potentially fatal. Supportive care is indicated. Also called colloquially ‘breakbone fever.’ Confirmatory testing takes too long for the ED.
26. IMPLEMENTING AN HIV AND SEXUALLY TRANSMITTED DISEASE SCREENING PROGRAM IN AN EMERGENCY DEPARTMENT. Silva, A., et al, Ann Emerg Med 49(5):564, May 2007: Here is a hospital (Sinai in Chicago) that implemented a program as described in 24. In this higher risk than general US population set, HIV was id’ed in 8 patients, but they were only able to hook up 3 w/ care. Again, I feel the ED is not the appropriate location to do screening due to follow-up and counseling limitations.
27. ALARM SYMPTOMS IN EARLY DIAGNOSIS OF CANCER IN PRIMARY CARE: COHORT STUDY USING GENERAL PRACTICE RESEARCH DATABASE. Jones, R., et al, Br Med J 334:1040, May 2007: Review of extensive FP records in UK showed that the first episode of hematuria, rectal bleeding, hemoptysis or dysphagia increased the risk of finding a related cancer by 100-fold. Suggest that CA screening be initiated if any one of these findings occur, particularly in older male patients. Lesson for ED: Strongly suggest follow-up for any of these episodes if not otherwise well explained (i.e. kidney stone).
28. COMPARISON OF ORAL PREDNISOLONE-PARACETAMOL AND ORAL INDOMETHACIN- PARACETAMOL COMBINATION THERAPY IN THE TREATMENT OF ACUTE GOUTLIKE ARTHRITIS. Man, C.Y., et al, Ann Emerg Med 49(5):670, May 2007: Traditional treatment of gout includes indomethacin. This study showed prednisolone was as effective as indocin with fewer side effects. TAKE HOME POINT: Steroids for gout should be something to consider, particularly if the patient cannot take NSAIDs.
29. NECK COLLAR, "ACT-AS-USUAL" OR ACTIVE MOBILIZATION FOR WHIPLASH INJURY? Kongsted, A., et al, Spine 32(6):618, March 15, 2007: Whiny patients at ‘high-risk’ for continued pain (whiplash associated disorder) randomized to above treatment groups with no significant differences found between groups at 1 year, but a surprising number with perisistent symptoms (~25% with interference with job and >50% still using analgesics). This study is from Holland, and we thought all the wimps were in the US.
30. USE OF SELECTED CEPHALOSPORINS IN PENICILLIN-ALLERGIC PATIENTS: A PARADIGM SHIFT. Pichichero, M.E., Diagn Microbiol Infect Dis 57(3):13S, March 2007: Due to multiple factors, early studies concluded higher risk of cross-reactivity between pcn-allergic patients given cephalosporins. More recent studies suggest much less risk, particularly with later generation cephalosporins. Take Home Point: It is almost always ok to use 2nd or higher gen cephalosporins in patients with PCN allergy history.
31. RECALL AFTER PROCEDURAL SEDATION IN THE EMERGENCY DEPARTMENT. Swann, A., et al, Emerg Med J 24:322, May 2007: Less than 5% of patients could recall the sedation and procedure in follow-up phone-calls. Sedation agents used were not standardized, but study too small to make specific drug recommendations. Lesson to be learned: Sedation – oh, never mind. I can’t remember.
32. EVIDENCE-BASED REVIEW OF THE BLACK-BOX WARNING FOR DROPERIDOL. Jackson, C.W., et al, Am J Health Syst Pharm 64:1174, June 1, 2007: Structured eval of reports that led to black box warning. Almost all were either felt to be not related to droperidol, or were related to doses 50 to 100 times higher than typically used in the ED for N/V or acute psychosis. There are hints at nefarious drug company-FDA collusion, as this warning comes decades after droperidol first came on the market, but only a few years after zofran was approved.
33. EVALUATION OF THE UTILITY OF RADIOGRAPHY IN ACUTE BRONCHIOLITIS. Schuh, S., et al, J Ped 150:429, April 2007: Use of xrays increased treatment with antibiotics, but most use of abx was felt to be not indicated by the authors in this study. <1% of patients had a real change of management based on xray. Take Home: If it looks like bronchiolitis, skip the film.
34. IDENTIFICATION OF 90% OF PATIENTS ULTIMATELY DIAGNOSED WITH COMMUNITY-ACQUIRED PNEUMONIA WITHIN FOUR HOURS OF EMERGENCY DEPARTMENT ARRIVAL MAY NOT BE FEASIBLE. Fee, C., et al, Ann Emerg Med 49(5):553, May 2007: A third of the patients in this UCSF study did not get their abx within 4 hours, and many of those did not have an ED diagnosis of CAP. They suggest that it would be impossible to meet the 90% goal. The goal has shifted somewhat, so that we only have to make it on those diagnosed in the ED, but the documentation must support that.
35. UTILIZATION OF ARTERIAL BLOOD GAS MEASUREMENTS IN A LARGE TERTIARY CARE HOSPITAL. Melanson, S.E.F., et al, Am J Clin Path 127(4):604, April 2007: Hospital wide review at the mecca (Brigham and Women’s) found that 30% of ABG’s were probably not necessary. I suspect they were being generous. ED Lesson: Order the ABG only if you are going to do something with the results.
36. ATROPINE: RE-EVALUATING ITS USE DURING PAEDIATRIC RSI. Bean, A., Emerg Med J 214:361, May 2007: Very little evidence found by these authors. The one good study showed no difference in episodes of bradycardia with or without atropine for RSI. Authors suggest that adding atropine to pediatric RSI may not be necessary.
37. ADVANCED LIFE SUPPORT FOR OUT-OF-HOSPITAL RESPIRATORY DISTRESS. Stiell, I.G., et al, N Engl J Med 356(21):2156, May 24, 2007: There was a 1.9% absolute decrease in mortality after initiation of a large pre-hospital ACLS program, even though only 1.4% of patients got tubed in the field, and other ACLS interventions were also used on a limited basis. This is one of the few studies (and a well done one) that showed any benefit to pre-hospital advanced interventions.
38. THE EVIDENCE BASE FOR CEPHALOSPORIN SUPERIORITY OVER PENICILLIN IN STREPTOCOCCAL PHARYNGITIS. Casey, J.R., et al, Diagn Microbiol Infect Dis 57(3):39S, March 2007: Meta-analysis suggests cephalosporins should be first line for strep throat, due to increasing resistance to pcn. Not sure if I am ready to make the switch. Any thoughts from P&T on the strep antimicrobial spectra in our neck of the woods?
39. THE ROLE OF ANTIBIOTIC PROPHYLAXIS FOR PREVENTION OF INFECTION IN PATIENTS WITH SIMPLE HAND LACERATIONS. Zehtabchi, S., Ann Emerg Med 49(5):682, May 2007: Like last months study, there is no convincing evidence to use prophylactic antibiotics in simple hand lacerations. Does anyone actually do this anymore? I hope not.
40. A MULTICENTER COMPARISON OF TAP WATER VERSUS STERILE SALINE FOR WOUND IRRIGATION. Moscati, R.M., et al, Acad Emerg Med 14(5):404, May 2007: Once again, tap water irrigation is safe, effective and cheaper than using sterile saline. I think this is very useful, especially for hand and forearm wounds where I often have patients clean their own wounds.

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