(+)W.

Richard Bukata, MD Clinical Professor, Emergency Medicine, Los Angeles County/University of Southern California; President, The Center for Medical Education, Inc., Creamery, Pennsylvania; Medical Editor, Emergency Medical Abstracts (+)Jerome R. Hoffman, MA, MD, FACEP Professor of Emergency Medicine, Los Angeles County - USC School of Medicine, Los Angeles, California; Professor of Medicine Emeritus, UCLA School of Medicine, Los Angeles, California

Clinical Pearls From the Recent Medical Literature (Part II)

Dr. Bukata and Dr. Hoffman will review and analyze the second half of the most significant studies published throughout the medical literature in the past two years. Each article presented will be assessed to determine its relevance to the practice of clinical emergency medicine. Identify advances in emergency medicine by reviewing the recent literature. Describe the limitations of recent studies on the practice of emergency medicine. Discuss the implication of recent studies regarding clinical emergency medicine.

SU-84 10/16/2011 8:00 AM - 9:50 AM Moscone Convention Center

(+)No significant financial relationships to disclose

#1 THERAPEUTIC ACETAMINOPHEN IS NOT ASSOCIATED WITH LIVER INJURY IN CHILDREN: A SYSTEMATIC REVIEW Lavonas, E.J., et al, Pediatrics 126(6):e1430, December 2010 BACKGROUND: In the average week, 11% of American children are given acetaminophen. Acetaminophen toxicity in the overdose setting has been well-described. Some researchers feel that hepatotoxicity can also occur with therapeutic dosing. METHODS: The th METHODS Th authors, f from th R k M the Rocky Mountain P i t i Poison and D d Drug C t reviewed th fi di Center, i d the findings of 62 clinical trials and other defined population studies involving 32,414 children aged 4 weeks to 18 years receiving therapeutic doses of acetaminophen (defined as 75mg/kg or less per 24 hours with a total daily dose not to exceed 4g) to determine the risk of hepatotoxicity with therapeutic dosing. Th authors also reviewed 22 pediatric case reports of h d i The th l i d di t i t f hepatotoxicity ascribed t t t i it ib d to therapeutic dosing of acetaminophen. The definition of major hepatic adverse events included liver transplant, death due to liver failure, AST or ALT elevation exceeding five times the upper limit of normal, alkaline phosphatase elevation more than two times the upper limit of normal, or a specific combination of j bi ti f jaundice or serum bili bi elevation with elevation of li di bilirubin l ti ith l ti f liver enzymes. RESULTS: In the clinical trials, hepatic adverse effects of at least mild severity were reported in ten children (0.03%), five of whom (0.01%) fulfilled criteria for a major hepatic adverse event. No child, however, developed signs or symptoms of liver disease, required administration of an antidote or liver transplantation, or died. The case reports were noted to be of variable methodologic quality and to frequently involve chronic acetaminophen use. Acetaminophen was judged to be "probably" causative in only nine of the 22 cases. p y p g p CONCLUSIONS:Hepatotoxicity associated with therapeutic dosing of acetaminophen in children appears to be rare, at most. 106 references (eric.lavonas@rmpdc.org - no reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 6/11 - #23

#2 TREATMENT OF ACUTE COUGH/LOWER RESPIRATORY TRACT INFECTION BY ANTIBIOTIC CLASS AND ASSOCIATED OUTCOMES: A 13 EUROPEAN COUNTRY OBSERVATIONAL STUDY IN PRIMARY CARE Butler, C.C., et al, J AntimicrobChemother 65(11):2472, November 2010 BACKGROUND: Various antibiotics have been recommended in different guidelines for the treatment of primary care patients with acute cough and/or lower respiratory infection, and some studies have found that treatment with antibiotics is not more effective than no treatment in these patients. ti t METHODS: These multinational authors analyzed outcomes according to type of antibiotic treatment prescribed for 2,714 adults presenting to 387 general practitioners participating in 14 primary care research networks in 13 European countries with acute or worsening cough (for up to 28 days) and/or a clinical presentation suggestive of lower respiratory infection The effects of infection. treatment with eight different antibiotic classes were compared with those of treatment with amoxicillin (the reference standard) or no antibiotics. RESULTS: Nearly half of the patients (46%) were not treated with antibiotics, and 14% were treated with amoxicillin. Other antibiotic classes prescribed included macrolides/lincosamides (14%), co-amoxiclav (9%), tetracyclines (8%), cephalosporins (4%), quinolones (3%), phenoxymethylpenicillin/penicillin G (2%), and sulphonamides/trimethoprim or other antibiotics (less than 1% each). There were no significant differences between no antibiotic treatment, amoxicillin treatment or treatment with one of the other antibiotic classes for the outcomes of symptomatic improvement over ti i t time or i t interval t complete recovery. B 28 d l to l t By days, 6 3% of th patients f lt th t 6.3% f the ti t felt that they had not recovered. CONCLUSIONS: No antibiotic class appeared to be superior to any other class, or to no antibiotic treatment, in adults presenting to primary care with acute cough and/or lower respiratory infection. 12 references (kellymj1@cf ac uk - no reprints) (kellymj1@cf.ac.uk Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 3/11 - #25

#3 CODEINE FOR ACUTE COUGH IN CHILDREN Goldman, R.D., Can Fam Phys 56(12):1293, December 2010

Use of over-the-counter cough and cold preparations in children between the ages of two and five years has been relatively common, but the safety of this practice has been subjected to increasing scrutiny. The author, from British Columbia Children's Hospital in Vancouver, comments on the use of codeine f acute cough i children. C d i f d i for t h in hild Codeine, when given i smaller d h i in ll doses, h b has been f found t d to have a centrally-mediated antitussive effect. However, studies of the use of codeine for the treatment of acute cough due to upper respiratory infection (the most common source of acute cough in children) have yielded conflicting results. Furthermore, recent studies have reported substantial variability in the response to codeine and a potential f significant h b t ti l i bilit i th t d i d t ti l for i ifi t harmful effects. I f l ff t In view of this evidence, the American Academy of Pediatrics Committee on Drugs has suggested that the use of codeine for cough suppression in patients with pulmonary or inflammatory diseases and other illnesses associated with increased or abnormal secretions "might be contraindicated and dangerous." Th C d " The Committee f th noted th t acute cough due t respiratory infection is a selfitt further t d that t h d to i t i f ti i lf limiting condition that might be adequately treated with humidity and fluids, and observed that dosing guidelines for cough medications in children have been extrapolated from adult data and might be imprecise for use in the pediatric population. This author concludes that, in view of currently available evidence, codeine i not useful as an antitussive agent. 20 references tl il bl id d i is t f l tit i t f (rgoldman@cw.bc.ca - no reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 6/11 - #28

#4 EFFECT OF ANTIBIOTIC PRESCRIBING IN PRIMARY CARE ON ANTIMICROBIAL RESISTANCE IN INDIVIDUAL PATIENTS: SYSTEMATAIC REVIEW AND META-ANALYSIS Costelloe, C., et al, Br Med J 340:c2096, May 18, 2010 BACKGROUND: Although various studies have cited increasing rates of antibiotic resistance and the role played by indiscriminate use of antibiotics, clinicians often fail to appreciate the importance of this phenomenon in the context of an individual patient. METHODS: These B iti h authors performed a systematic review and meta-analysis of 24 studies METHODS Th British th f d t ti i d t l i f t di examining relationships between antibiotics prescribed in primary care and subsequent antimicrobial resistant at the level of the individual patient. These studies included 15,505 adults and 12,103 children. RESULTS: In five studies that involved patients with urinary tract infection, pooled odds ratios (ORs) for development of resistance in patients exposed to antibiotics were 4.40 up to one month after treatment decreasing to 2.48 at three months, 2.18 at six months and 1.33 at one year (all 95% CIs exceeded 1.0). In seven studies involving respiratory tract bacteria, pooled ORs for development of resistance with antibiotic exposure at one month, two months, three months, six months and one year were 2.10, 2.37, 1.48, 1.90 and 2.37, respectively (95% CIs exceed 1.0 at one and two months and one year). In three studies that examined MRSA and resistance in bacteria sampled from skin abrasions, the pooled OR for resistance among individuals exposed to antibiotics in the previous year was 1.04 (95% CI 0.47-2.29). In general, a longer duration of antibiotic treatment and multiple courses of treatment were associated with higher rates of resistance. y quantitates the risk of development of resistance to an antibiotic in p CONCLUSIONS: This study q patients treated with antibiotics for respiratory or urinary tract infection in the primary care setting. 45 references (alastair.hay@bristol.ac.uk - no reprints) Copyright 2010 by Emergency Medical Abstracts - All Rights Reserved 11/10 - #21

#5 WHEN "DON'T WORRY" COMMUNICATES FEAR: CHILDREN'S PERCEPTION OF PARENTAL REASSURANCE AND DISTRACTION DURING A PAINFUL MEDICAL PROCEDURE McMurtry, C.M., et al, Pain 150(1):52, July 2010 BACKGROUND: Some prior studies have suggested that distraction might be more effective than attempts to provide reassurance in mitigating the distress of a child undergoing a painful procedure. METHODS: This study, from Dalhousie University in Canada, examined the response to reassurance vs. distraction, as well as the influence of a parent's facial expression and tone, on the perceptions of 100 children aged 5-10 years (mean, 8 years) undergoing venipuncture. The children were shown videos of their own parents' behavior during their venipuncture, as well as twelve videos of an actor portraying a parent during pediatric venipuncture and exhibiting various types of behavior with differing facial expressions and tone of voice. RESULTS: Although th RESULTS Alth h there were no significant diff i ifi t differences i mean child-rated scores f th i own in hild t d for their parents' fear or happiness in videos depicting parental reassurance or distraction, the pattern of effect sizes was consistent with higher ratings for parental fear and lower ratings for parental happiness when reassurance was utilized rather than distraction. When viewing the videos of simulated parental behavior, ratings for parental fear were higher for portrayal of reassurance rather than distraction. A happy rather than fearful parental facial expression was associated with more favorable child-rated scores for both reassurance and distraction behaviors. In general, child-rated scores were influenced more by the actors' facial expressions than their tone of voice. Vocal tone did not seem to influence the children's responses when a happy facial expression was portrayed, but b t vocal cues were more i fl l influential when th f i l expression was f f l ti l h the facial i fearful. CONCLUSIONS: These findings suggest that distraction is more effective than reassurance for the mitigation of children's distress during painful procedures, and demonstrate the influence of facial expression and vocal tone. 48 references (mcmurtry@dal.ca - no reprints) Copyright 2010 by Emergency Medical Abstracts - All Rights Reserved 11/10 - #14

#6 IMPACT OF SCRIBES ON PERFORMANCE INDICATORS IN THE EMERGENCY DEPARTMENT Arya, R., et al, Acad Emerg Med 17(5):490, May 2010 BACKGROUND: Although the use of scribes to assist with clerical tasks in the ED has been suggested to increase physician productivity, published data to substantiate or refute this claim are limited. METHODS: This retrospective observational study, from the University of Medicine & Dentistry of New J N Jersey, examined measures of physician productivity i th ED f shifts worked with and i d f h i i d ti it in the for hift k d ith d without the use of a scribe. The study involved 13 emergency physicians, 243 shifts and more than 3,562 clinical hours. Scribe duties included medical record documentation, and timely communication of test results to the emergency physician. RESULTS: For every 10% increment in use of scribes during a shift, there was an increase of 0.24 RVUs per hour and 0.08 patients seen per hour. The use of scribes had no significant effect on patient turn-around time. Based on 2008 Medicare reimbursement levels, it was estimated that use of a scribe to full capacity could result in an additional $91 billed per hour. At the authors' institution, the salary of a scribe is just under $20 per hour. CONCLUSIONS: This study provides documentation of increased physician productivity with the use of scribes in the ED and suggests that this intervention could be anticipated to improve an ED's financial "bottom line." 7 references (Merlinma@umdnj.edu for reprints) ( @ j p ) Copyright 2010 by Emergency Medical Abstracts - All Rights Reserved 9/10 - #14

REPORTING USE OF FORCE INJURIES BY LAW ENFORCEMENT OFFICERS IN THE EMERGENCY DEPARTMENT Smith, H.P., et al, Ann Emerg Med 56(4):424, October 2010
#7

While reporting of child abuse and gunshot and stab wounds is mandatory, reporting of suspected abuse, mandatory excessive use of force by police has received only limited attention. The authors, coordinated at the Department of Criminology and Criminal Justice at the University of South Carolina, comment on the responsibility of emergency physicians to report these events. It has been estimated that about 1.5% 1 5% of contacts between civilians and police officers involve a police threat or use of force (more than 650,000 in 2002), and that excessive force is claimed in about three-fourths of such cases but that about 8% of such claims are substantiated. While it is not in the purview of emergency physicians to make judgments regarding claims of excessive force by police, evaluation of the extent and severity of sustained injuries and observation of inconsistencies between reported events and the apparent injuries fall within the scope of emergency care. The authors cite a survey of nearly 400 academic emergency physicians which found that nearly all (97.8%) reported treatment of cases potentially involving excessive use of force by police, but that only 2.8% had reported their suspicions and there appeared to be a widespread lack of training and departmental policy regarding this issue. They propose, therefore, that emergency physicians who observe such inconsistencies or have concerns about the possibility of excessive force (which might involve not only blunt trauma but also the use of neuromuscular incapacitating devices [Tasers] or K9 units) report these concerns to the internal affairs department of the involved police department possibly department, using a standardized form that is not included in the medical chart. 10 references (smithhp@mailbox.sc.edu - no reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 3/11 - #13

#8 REEVALUATION OF THE EFFECT OF MANDATORY INTERPRETER LEGISLATION ON USE OF PROFESSIONAL INTERPRETERS FOR ED PATIENTS WITH LANGUAGE BARRIERS Ginde, A.A., et al, Patient Educ Counsel 81(2):204, November 2010 BACKGROUND: The use of professional medical interpreters during healthcare encounters for patients with language barriers has been reported to improve patient outcomes and decrease costs, and was mandated by law in Massachusetts in 2001. METHODS: The th METHODS Th authors, f from th U i the University of C l d and H it f Colorado d Harvard, surveyed 498 adults d d d lt presenting to one of four Boston-area EDs in 2008 to assess language barriers and the use of interpreters. Responses were compared to those elicited in an identical survey administered in 2002, one year after passage of the Massachusetts law. RESULTS: It was estimated that an interpreter was needed for 8% of the patients (compared with 11% in 2002). Nearly two-thirds of these patients were aware of the law mandating availability of professional interpreter services (64%), but 79% stated that they were comfortable with use of a friend or family member. For patients who needed an interpreter, an interpreter was actually used during clinical care for 69% (89% in 2002, p=0.02), and a professional medical interpreter was utilized for only 18% (15% in 2002, p=NS). There were no significant differences between 2002 and 2008 in the frequency of use of professional interpreters, but the use of family or friends was significantly increased in 2008 (nearly 60% vs. just over 20% in 2002) while the use of hospital staff was significantly decreased (about 10% vs. about 45%). CONCLUSIONS: Utilization of professional medical interpreters in the ED was low, and relatively unchanged seven years after passage of a law mandating the right to such services. Professional , p y services should be offered, but patients' wishes to utilize family or friends should be honored. 10 references (adit.ginde@ucdenver.edu - no reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 3/11 - #14

#9 BEDSIDE SHIFT REPORT IMPROVES PATIENT SAFETY AND NURSE ACCOUNTABILITY Baker, S.J., J Emerg Nurs 36(4):355, July 2010 The author from the Studer Group in Gulf Breeze FL comments on implementation of patient author, Breeze, FL, handoff at the bedside for emergency department nurses. Such programs directly address specific safety goals of the Joint Commission by improving the accuracy of patient identification and the effectiveness of communication among caregivers, and by encouraging involvement of patients in their own care Although nursing staff might initially resist the implementation of this innovation care. innovation, leadership should stress the benefits of this approach to patient care, which include creation of a sense of "ownership" of the process, enhancing trust and reassurance on the part of patients, and reducing the patients' perception that "no one is around" during shift change. Time spent at the bedside during handoffs need not exceed several minutes The oncoming nurse will briefly review minutes. the patient's chart, after which the off-going and oncoming nurses will approach the patient together for introduction of the new nurse. This interchange provides the opportunity to double-check the patient's identity and the function of IV medication pumps during the actual shift-change process. A template is provided to guide bedside communication which incorporates inclusion of the patient communication, into the process. The author encourages the participation of leadership in the implementation of a bedside shift change program to secure "buy in" and a sense of ownership on the part of participating nurses, as well as assessment of the effects of the program through solicitation of patient feedback. She notes that a bedside handoff is not the time for expression of personal feedback opinions regarding the care being provided or the physicians involved in the case. Any clarification relating to sensitive issues should occur after the bedside handoff has been completed. 5 references (stephanie.baker@studergroup.com - no reprints) Copyright 2010 by Emergency Medical Abstracts - All Ri ht R C i ht b E M di l Ab t t Rights Reserved 12/10 - #10 d

#10 POST-VISIT PHONE CALLS SAVE LIVES, IMPROVE CLINICAL OUTCOMES, AND REDUCE READMISSIONS Baker, S.J., J Emerg Nursing 36(3):256, May 2010 More than 80% of ED patients are discharged to home after treatment One study reported that treatment. 65% of discharged patients stated that no one spoke with them about their post-discharge care, and another study reported that nearly one in five patients experience an adverse event following ED discharge, most often within 72 hours. The author, from Studer Group in Gulf Breeze, FL, comments on the implementation of a post visit phone call program as a means of improving post-visit patient outcomes and satisfaction and reducing unnecessary return visits. Prior to implementation of a post-visit call program, leader assessment is recommended to identify aspects of the ED visit that can be optimized. Attempts should be made to call all eligible patients (non-psychiatric patients who are discharged to home) within 72 hours after discharge Calls should be made by physicians discharge. and nurses and, possibly, nonmedical personnel who are instructed to summon medical personnel if the patient has a medical question. Night shift personnel can prepare a list of eligible patients, which is distributed to staff members by the day-shift charge nurse. Calls should be brief (2-3 minutes) and should follow a standardized format and patient responses should be documented format, documented. Each day, call sheets can be reviewed by the ED manager to identify "wins" and "losses" for subsequent discussion and remedial action if necessary. Tracking of results is integral to the success of the program. Participation of all ED staff creates buy-in and a sense of employee engagement. engagement Successful post visit call programs have been found to increase patient satisfaction post-visit satisfaction, understanding of discharge instructions and compliance, decrease return visits, and inspire patient loyalty. A "return on investment" can be anticipated within 60 to 90 days. 4 references (Stephanie.baker@studergroup.com - no reprints) Copyright 2010 by Emergency Medical Abstracts - All Ri ht R C i ht b E M di l Ab t t Rights Reserved 10/10 - #15 d

#11 MANDATORY INFLUENZA VACCINATION OF HEALTHCARE WORKERS: A 5-YEAR STUDY Rakita, R.M., et al, Infect Control Hosp Epidem 31(9):881, September 2010 BACKGROUND: The annual mortality rate for influenza in the USA (36 000) is similar to that of (36,000) breast cancer. Vaccination has been recommended for healthcare workers to prevent the spread of influenza, but immunization rates in healthcare personnel are typically only about 40-50%. METHODS: The authors report on the implementation of a mandatory influenza immunization program f the approximately 4 700 employees of Virginia M for th i t l 4,700 l f Vi i i Mason M di l C t i S ttl and Medical Center in Seattle d vaccination rates achieved in 2005-2010. The program was developed by a multidisciplinary group with strong support from administration, and included a variety of methods to engage employee participation. Multiple vaccine options were offered, and requests for accommodation based on medical or religious grounds were reviewed. E l di l li i d i d Employees who were granted exceptions were h t d ti required to wear surgical masks while at work during the influenza season. RESULTS: Vaccination rates were 54% during the 2003-2004 flu season (pre-program), but 9899% during 2005-2010 after implementation of the program. Only about 30 employees were granted exceptions each year, and only two of seven workers reporting a history of allergy or vaccine reaction in the past tested positive for such allergy. Although a grievance against the program by unionized nurses was upheld in the courts, the requirement for use of masks by nonvaccinated nurses while at work was also upheld and about 90-95% of unionized nurses have agreed to be vaccinated. Fewer than 0.5% of workers left or were terminated for refusal to comply. CONCLUSIONS: A well-designed program of mandatory influenza vaccination for healthcare workers is feasible and capable of sustaining high rates of immunization. 67 references ( y (Joyce.Lammert@vmmc.org for reprints) @ g p ) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 1/11 - #20

#12 POTENTIAL UNINTENDED CONSEQUENCES DUE TO MEDICARE'S "NO PAY FOR ERRORS RULE"? A RANDOMIZED CONTROLLED TRIAL OF AN EDUCATIONAL INTERVENTION WITH INTERNAL MEDICINE RESIDENTS Mookherjee, S., et al, J Gen Intern Med 25(10):1097, October 2010 ( ) , BACKGROUND: In 2008, Medicare implemented a policy of withholding reimbursement for the care of selected problems that develop after the time of admission, and are presumed to be due to an in-hospital adverse event The potential impact of this policy has not been fully explored in hospital event. explored. METHODS: In this study, from the University of California, San Francisco, 119 internal medicine residents who agreed to participate (71% response rate) were randomized to an intervention or control group. The intervention group was instructed in the Medicare "no pay for errors" rule and provided with a li t of t relevant conditions. A multiple-choice survey was administered t id d ith list f ten l t diti lti l h i d i i t d to participants that presented five clinical vignettes, each of which had a single most clinically appropriate answer and two clinically inappropriate answers that would nevertheless be more likely to protect Medicare reimbursement to the hospital. RESULTS: Most of the participants were aware of the "basics" regarding Medicare, but the majority harbored misconceptions and uncertainties about the scope of the "no pay for errors" rule. The intervention group was 8 to 22 percentage points less likely than the control group to select the most clinically appropriate response for four of the five vignettes. CONCLUSIONS: Instruction of internal medicine residents in the Medicare "no pay for errors" rule tended to be associated with clinically inappropriate treatment choices that were more supportive of hospital reimbursement than optimal patient care. 21 references (smookherjee@medicine.ucsf.edu - no reprints) p ) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 2/11 - #13

#13 USE OF ADVANCED RADIOLOGY DURING VISITS TO US EMERGENCY DEPARTMENTS FOR INJURY-RELATED CONDITIONS, 1998-2007 Korley, F.K., et al, JAMA 304(13):1465, October 6, 2010 BACKGROUND: Advanced imaging modalities (CT and MRI) are superior to standard x-rays for the identification of significant injuries. However, the reported yield of increased use of CT/MRI in ED trauma patients has been very low in several studies. METHODS: The th METHODS Th authors, f from Johns H ki U i J h Hopkins University, examined d t f it i d data from th N ti the National H l Hospital it l Ambulatory Medical Care Survey (NHAMCS) for 1998 to 2007 to assess patterns of CT and MRI use for ED patients with an injury-related condition. RESULTS: An injury-related condition accounted for 20% of the 324,569 sampled ED visits. Imaging with CT or MRI was performed in 6% of such ED visits in 1998, but increased to 15% in 2007. After adjustment for confounders, the odds ratio for performance of CT or MRI in 2007 compared with 1998 was 3.43. CT scanning accounted for the overwhelming majority (about 99%) of advanced imaging for an injury-related condition. A life-threatening condition was diagnosed in 1.7% of injury-related visits in 1998 and for 2.0% in 2007. There was no change in hospital or ICU admissions for injury. Although patients aged 18 or younger were less likely to undergo CT or MRI than those aged 18-45, the likelihood of performance of CT or MRI in this younger population increased more than two-fold from 1998 to 2007 (OR 2.16). The mean ED length of stay for injuryrelated visits increased by 126 minutes when CT or MRI was performed. CONCLUSIONS: A vast three-fold increase in use of advanced imaging for injury-related ED visits over a ten-year period was not associated with an increase in the diagnosis of life-threatening j y g patient disposition. 36 references ( p (fkorley1@jhmi.edu - no reprints) y @j p ) injuries or any change in p Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 4/11 - #29

#14 IMPROVED SURVIVAL AFTER HEMOSTATIC RESUSCITATION: DOES THE EMPEROR HAVE NO CLOTHES? Magnotti, L.J., et al, J Trauma 70(1):97, January 2011 BACKGROUND: Recent studies in the trauma literature have generated substantial enthusiasm for the use of higher fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratios during the early resuscitation of patients requiring massive transfusion (10 or more units of PRBCs within the first 24 hours). METHODS: This t d f METHODS Thi study, from the University of Tennessee Health S i th U i it f T H lth Science C t assessed th Center, d the relationship between survival and the FFP:PRBC ratio delivered during the first 24 hours in 103 trauma patients aged 14-74 requiring massive transfusion as defined above. A cut-off FFP:PRBC ratio of 1:2 was used to differentiate a low ratio from a high ratio group. RESULTS: Nearly two-thirds of the patients (64%) were categorized as belonging to the high-ratio group. Overall mortality was lower in the high-ratio group than in the low-ratio group (36% vs. 59%). Massive transfusion during the first six hours after admission was documented in 75 patients, 39% of whom achieved a high FFP:PRBC ratio within six hours. This high-ratio subgroup had less severe shock on admission than those in the low-ratio subgroup. All deaths occurring during the first six hours were due to exsanguinating hemorrhage, and many patients in the normal ratio group apparently died before they could receive large amounts of FFP. After accounting for early mortality due to uncontrolled bleeding, survival was similar in the high-ratio and low-ratio study groups. CONCLUSIONS: These findings suggest that, among trauma patients requiring massive transfusion during the first 24 hours, the apparent mortality advantage associated with a high FFP:PRBC ratio may actually be explained by survival bias, with early death among the sickest p patients being falsely attributed to non-use of large amounts of FFP, such that "patients die with a g y g , p low ratio, not because of a low ratio." 30 references lmagnott@utmem.edu for reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 8/11 - #6

#15 EFFECTS OF TRANEXAMIC ACID ON DEATH, VASCULAR OCCLUSIVE EVENTS, AND BLOOD TRANSFUSION IN TRAUMA PATIENTS WITH SIGNIFICANT HAEMORRHAGE (CRASH-2): A RANDOMISED, PLACEBO-CONTROLLED TRIAL The CRASH-2 Trial Collaborators Lancet 376(9734):23, July 3, 2010 ( ) , y , BACKGROUND: About one-third of inpatient trauma deaths are due to hemorrhage. Tranexamic acid inhibits fibrinolysis and has been reported to reduce the need for blood transfusion in patients undergoing surgery. surgery METHODS: In the multinational "Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage 2" study, coordinated in the United Kingdom, 20,211 adult trauma patients managed in one of 274 hospitals in 40 countries were randomized to treatment with tranexamic acid (1g given over 10 minutes and th i f i of 1 over eight h i t d then infusion f 1g i ht hours - purchase grant supplied b Pfi ) or h t li d by Pfizer) saline placebo. The study included only patients with significant bleeding (systolic pressure below 90mm Hg or pulse above 110/minute) or at risk for significant bleeding who were treated within eight hours after injury and who had no clear indications for treatment with tranexamic acid. RESULTS: All-cause mortality was 14.5% in the tranexamic acid group vs. 16.0% in controls (95% CI 0.85-0.97, relative risk [RR] 0.91, p=0.0035) and corresponding rates of death due to bleeding were 4.9% vs. 5.7%, respectively (RR 0.85, p=0.0077). There was no significant difference between the groups in the percentage of patients receiving blood product transfusions (50.4% in the tranexamic acid group [mean 6.06 units) and 51.3% in controls [mean, 6.29 units]), the occurrence of vascular occlusive events (1.7% vs. 2.0%), or death due to vascular occlusive events (0.3% vs. 0.5%). g gg y CONCLUSIONS: The results of this large trial suggest that early treatment with tranexamic acid in trauma patients with, or at risk for, significant bleeding reduces the risk of hemorrhagic mortality without increasing the risk of vascular occlusion. 25 references (crash@ishtm.ac.uk - no reprints) Copyright 2010 by Emergency Medical Abstracts - All Rights Reserved 11/10 - #29

#16 USE OF THE TRENDELENBURG POSITION TO IMPROVE HAEMODYNAMICS DURING

HYPOVOLAEMIC SHOCK Kettaneh, N., Emerg Med J 27(11):877, November 2010 BACKGROUND: Placement of hypotensive patients in the Trendelenburg head down tilt position is head-down widely believed to improve hemodynamics. METHODS: This paper, from the "Best Evidence Topic Reports" series, addresses the effect of the Trendelenburg position on hemodynamics. Five studies (three observational and two nonrandomized controlled t i l ) i d i d t ll d trials) involving patients with h l i ti t ith hypotension d t various etiologies were t i due to i ti l i identified that were felt to be relevant to this issue. RESULTS: The studies were generally small (ranging from 8 to 60 patients) and methodologically limited. The studies generally reported no significant change in the cardiac index and/or mean arterial pressure on placing patients in the Trendelenburg position, and one 12-patient study reported a significant decrease in the cardiac index and MAP on returning patients to the supine position. CONCLUSIONS: These studies provide no evidence of a benefit of the Trendelenburg p p g position for improving hemodynamics in hypotensive patients, and provide some suggestion that this maneuver might be detrimental. 9 references (no PMID available) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 5/11 - #7

#17 NORMAL PRESENTING VITAL SIGNS ARE UNRELIABLE IN GERIATRIC BLUNT TRAUMA VICTIMS Heffernan, D.S., et al, J Trauma 69(4):813, October 2010 BACKGROUND: Standard vital sign cut offs to trigger trauma team activation derived in younger cut-offs trauma patients might not be reliable markers of injury severity in the elderly. METHODS: The authors, from Rhode Island Hospital, reviewed trauma registry data collected prospectively over a five-year period to evaluate relationships between heart rate, blood pressure and mortality i 2 081 i j d patients aged 18 35 and 2 194 patients aged 65 or older managed at d t lit in 2,081 injured ti t d 18-35 d 2,194 ti t d ld d t a level 1 trauma center. RESULTS: The mean Injury Severity Score was 12 in both groups, but head injury was more common in the older patients (50% vs. 31%). Mortality was more frequent in the older patients (11.4% vs. 2.4%) throughout the entire range of vital signs. Mortality increased progressively with a presenting heart rate higher than 110/min in the elderly (12.6% at 110/min, 22.4% at 120/min and 69.6% at 150/min), but such an increase in mortality among the younger patients was not observed until the presenting heart rate was about 150/min (10.2% mortality). Mortality rates were about 19% in both cohorts in the setting of bradycardia (50/min). A similar pattern was observed for initial blood pressure, independent of the initial heart rate. At systolic pressures ranging from 120-160mm Hg, mortality was nine to ten times more frequent in the older cohort. With regard to hypotension, an increase in mortality was noted at a systolic pressure of 90mm Hg or lower in the younger cohort, while such an increase was first observed at a SBP below 114mm Hg in the elderly. CONCLUSIONS: Failure to recognize differences in heart rate and blood pressure markers of injury severity between younger and elderly trauma patients might result in a delay in trauma team gg group. activation and initiation of aggressive resuscitation in the latter g p 19 references (dheffernan@Brown.edu for reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 2/11 - #30

#18 SERIAL HEMATOCRIT TESTING DOES NOT IDENTIFY MAJOR INJURIES IN TRAUMA PATIENTS IN AN OBSERVATION UNIT Madsen, T., et al, Am J Emerg Med 28(4):472, May 2010 METHODS: These authors from the University of Utah performed an implicit chart review to try to authors, Utah, evaluate the contribution of serial hematocrit determination to the management of 310 trauma patients with an initially negative evaluation in a level I trauma center who were placed in a trauma observation unit in lieu of hospital admission. RESULTS: Three or more h RESULTS Th hematocrit l t it levels were d l drawn i 70% of th patients. Th average in f the ti t The duration of the observation unit stay was 12 hours 44 minutes. The trauma evaluation prior to placement in the observation unit included FAST and CT scanning at the discretion of managing physicians. A hematocrit decrease of at least 5 points during the observation unit stay was documented f 20.6% of the patients, but a decrease in hematocrit contributed to the identification d t d for 20 6% f th ti t b t d i h t it t ib t d t th id tifi ti of a significant intraabdominal injury in only one patient (0.32%). This patient had a positive FAST exam at the time of initial evaluation, and thus did not appear to meet criteria for placement in the observation unit. An occult injury was diagnosed in two additional observation unit patients but serial h i l hematocrit measurement did not contribute to their identification. The rate of admission to the t it t t t ib t t th i id tifi ti Th t f d i i t th hospital from the observation unit was 19% in patients with a decrease in hematocrit (12/64) and 9% among those without such a decrease (23/246), but a decrease in hematocrit was cited as the reason for admission in only one of the former patients. CONCLUSIONS: These findings suggest that routine serial hematocrit measurement to screen for occult injury in trauma patients with a negative initial evaluation at a level I center by itself rarely provides additional useful information. 13 references (troy.madsen@hsc.utah.edu - no reprints) py g y g y g Copyright 2010 by Emergency Medical Abstracts - All Rights Reserved 10/10 - #30

#19 IS THE FAST EXAM RELIABLE IN SEVERELY INJURED PATIENTS? Becker, A., et al, Injury 41(5):479, May 2010 BACKGROUND: The "focused assessment with sonography for trauma" (FAST) exam is being focused trauma used with increasing frequency for the initial evaluation of blunt trauma patients and has been reported to be highly accurate in identifying injuries requiring intervention in hemodynamically unstable patients. It has been observed, however, that it might underestimate intraabdominal injuries in stable patients with blunt abdominal trauma trauma. METHODS: The authors, from the University of Miami, retrospectively reviewed findings in 3,181 hemodynamically stable blunt trauma patients (mean age 39, mean Injury Severity Score [ISS] 23) who underwent both FAST and CT scanning of the abdomen. A positive FAST exam was defined by the th presence of f f free fl id and studies were considered t b t fluid, d t di id d to be true-positive if thi fi di was iti this finding confirmed on CT or on laparotomy. A negative FAST exam was considered true-negative if the patient had a negative CT or an uneventful course. RESULTS: Overall, the FAST exam had a sensitivity, specificity and diagnostic accuracy of 75%, 98% and 95%, respectively. FAST was falsely negative in 4% of the patients and falsely positive in 1.4%. The sensitivity decreased with an increasing severity of injury (86.4% in patients with an Injury Severity Score [ISS] of 1-14, 80.4% in those with an ISS of 16-24, and 65.1% among patients with an ISS of 25 or higher), and diagnostic accuracy in the three ISS groups decreased from 97.5% in the least severely injured patients to 90.6% in the most severely injured. Among the patients with injuries missed on FAST, 18% underwent surgical intervention and 59% of these patients had an ISS of 25 or higher. y y p g CONCLUSIONS:Hemodynamically stable blunt trauma patients with a high ISS are at increased risk for a false-negative FAST exam. 31 references (alexb20042000@yahoo.com - no reprints) Copyright 2010 by Emergency Medical Abstracts - All Rights Reserved 10/10 - #1

#20 THE QUALITY OF EMERGENCY DEPARTMENT PAIN CARE FOR OLDER ADULT PATIENTS Hwang, U., et al, J Am Ger Soc 58(11):2122, November 2010 METHODS: This methodologically excellent explicit chart review study from Mount Sinai School of study, Medicine in New York, compared ED pain management for older and younger adults presenting with one of a number of painful conditions. RESULTS: Of 1,031 adult visits warranting pain care over a two-month period, 79% involved patients aged 18 65 16% i ti t d 18-65, involved th l d those aged 65 84 and 5% i d 65-84, d involved patients aged 85 or older. l d ti t d ld Older patients were more likely than younger patients to have a musculoskeletal diagnosis, had higher Charlsoncomorbidity scores, and took more chronic medications. Patients below age 65 more often reported severe pain (31% vs. 20% of those aged 65-84 and 10% of the oldest patients), while pain was more often mild to moderate among the older patients. The median time t ti t ) hil i ft ild t d t th ld ti t Th di ti to pain assessment tended to be shorter for the oldest patients (77 minutes vs. more than 90 minutes for the other groups). The time to analgesic administration was 112-124 minutes in the three groups. Patients in the 65-84 age group were less likely than their younger counterparts to be treated ith t t d with an opioid analgesic f moderate t severe pain ( dd ratio [OR] 0 44) and more lik l i id l i for d t to i (odds ti 0.44), d likely to be treated with an NSAID for mild pain (OR 3.72). The youngest patients had a significantly greater difference between the initial and final recorded pain scores than their older counterparts. The median duration of the ED stay was 274 minutes in the youngest group, 364 minutes in older patients, and 326 minutes in the oldest patients. ti t d i t i th ld t ti t CONCLUSIONS: These findings are consistent with less use of opioid analgesics in older ED patients with a painful condition, and less overall reduction in pain during the visit. 31 references (ula.hwang@mountsinai.org - no reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 4/11 - #25

#21 AGREEMENT REGARDING DIAGNOSIS OF TRANSIENT ISCHEMIC ATTACK FAIRLY LOW AMONG STROKE-TRAINED NEUROLOGISTS Castle, J., et al, Stroke 41(7):1367, July 2010 BACKGROUND: Based on a reported increased risk of a completed stroke soon after a transient ischemic attack (TIA), emergent performance of a comprehensive workup following a TIA has been recommended. However, limited inter-observer agreement on the presence or absence of TIA has been reported. reported METHODS: In this study, from Stanford University, the likelihood of a TIA among 55 patients referred from the ED by neurology residents to a stroke clinic was independently rated by three stroke-trained neurologists based on retrospective review of initial documentation by separate fellowship-trained stroke neurologists at the time of the clinic visit. Th reviewers were asked t rate f ll hi t i d t k l i t t th ti f th li i i it The i k d to t the likelihood of a TIA for each patient using three different scales. RESULTS: Positive responses regarding the likelihood of a TIA ranged from a low of 9% (one reviewer using a four-item scale [very likely, likely, possible, unlikely]) to a high of 51% (one reviewer using a two-item scale [likely, unlikely]). Negative responses regarding the likelihood of a TIA ranged from a low of 9% (one reviewer using a four-item scale) to a high of 75% (one reviewer using a two-item scale). Raw rates of inter-observer agreement were 72% based on use of the twoitem scale, 56% when a three-item scale was used (likely, possible, unlikely), and 46% when a fouritem scale was used. In general, "TIA unlikely" ratings decreased with an increase in the number of scale items. CONCLUSIONS: Agreement regarding the presence or absence of a TIA was only moderate g p g among fellowship-trained stroke neurologists based on review of case notes. The authors cite the need for objective indicators of a TIA in order to optimize expedited evaluation of patients at risk for a subsequent stroke. 13 references (jmolivot@stanford.edu - no reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 1/11 - #11

#22 SAFETY OF TPA IN STROKE MIMICS AND NEUROIMAGING-NEGATIVE CEREBRAL ISCHEMIA Chernyshev, O.Y., et al, Neurology 74(17):1340, April 27, 2010 BACKGROUND: Previous studies reporting on a total of 13 patients have suggested that 3 7% of 3-7% patients treated with IV tPA for presumed acute cerebral ischemia were ultimately diagnosed with stroke mimics. There is concern that in some patients a definitive diagnosis of stroke cannot be established within the three-hour time frame for tPA treatment and that patients without an ultimate diagnosis of stroke might be placed in jeopardy by such treatment treatment. METHODS: The authors, coordinated at the University of Texas, report on a retrospective cohort of 106 patients who were treated with full-dose tPA for presumed ischemic stroke who were ultimately found on follow-up imaging to have a stroke mimic or "neuroimaging-negative cerebral ischemia" (NNCI). (NNCI) RESULTS: The 106 patients represented 21% of all patients treated with tPA in a stroke center setting for suspected stroke over a four-year period. Stroke mimics were diagnosed in 69 patients (14% of all patients treated with tPA), and most commonly included seizures, complicated migraine and conversion disorder. NNCI was diagnosed in 7% of patients treated with tPA, and was attributed to a presumptive diagnosis of TIA or recanalization and reperfusion after tPA. None of the 106 patients sustained a systemic or intracerebral hemorrhage or angioedema after tPA. In one case, there was evidence of bleeding of an epidural cervical spinal mass after tPA that was ultimately found to be a tumor. Rates of functionally independent discharge to home were 81% in the patients with a stroke mimic or NNCI (the remaining patients had baseline neurologic deficits or weakness) but 21% in those treated for a verified ischemic stroke. g pp y CONCLUSIONS: The authors feel that these findings support the safety of tPA treatment within three hours after symptom onset in patients with stroke mimics or neuroimaging-negative cerebral ischemia. 12 references Copyright 2010 by Emergency Medical Abstracts - All Rights Reserved 9/10 - #10

#23 LOW RATES OF ACUTE RECANALIZATION WITH INTRAVENOUS RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR IN ISCHEMIC STROKE: REAL-WORLD EXPERIENCE AND A CALL FOR ACTION Bhatia, R., et al, Stroke 41(10):2254, October 2010 BACKGROUND: IV recombinant tissue plasminogen activator (rt-PA) is advocated by some for selected patients with acute ischemic stroke (AIS), but data on angiographic recanalization with IV rt-PA are limited. METHODS: The th METHODS Th authors, f from the University of C l th U i it f Calgary, reviewed procedure l i d d logs at th C l t the Calgary stroke program for 388 patients with AIS and proximal vessel occlusion on baseline CT angiography (CTA) who were treated with IV rt-PA (0.9mg/kg), of whom 149 had a repeat study following treatment. RESULTS: The median interval to rt-PA treatment was 136 minutes. In 46 patients, transcranialdoppler imaging performed simultaneously with rt-PA administration demonstrated early recanalization in only 79%. Emergent angiography for endovascular intervention was performed in 103 patients, and the recanalization rate after endovascular treatment was 46%. The median overall interval to recanalization was 272 minutes. Outcomes were associated with the presence of recanalization. Early recanalization was associated with the lowest three-month mortality rate (7.4% in those achieving recanalization with rt-PA vs. 13.6% in patients achieving recanalization with endovascular intervention and 36.6% in patients with no recanalization). Corresponding rates of recovery with no or minimal disability at three months were 77.8% vs. 52.5% and 24.4%, respectively. CONCLUSIONS: There was a low rate of acute recanalization after IV rt-PA in these patients with p , p acute ischemic stroke due to proximal vessel occlusion, and no relationship between time to treatment and recanalization. Early recanalization was, however, strongly associated with better outcome. 19 references (rohitbhatia71@yahoo.com - no reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 6/11 - #7

#24 AN ASSESSMENT OF THE INCREMENTAL VALUE OF THE ABCD2 SCORE IN THE EMERGENCY DEPARTMENT EVALUATION OF TRANSIENT ISCHEMIC ATTACK Stead, L.G., et al, Ann Emerg Med 57(1):46, January 2011 BACKGROUND: The ABCD2 score has been proposed as a useful risk stratification tool to identify transient ischemic attack (TIA) patients at increased risk for a subsequent stroke. It has been reported that the stroke rate in patients with low-, intermediate- and high-risk ABCD2 scores is 2%, 6% and 10.9%, respectively, at 7 days and 3 7% 9 9% and 17 5% respectively at 90 days 10 9% respectively days, 3.7%, 9.9% 17.5%, respectively, days. METHODS: The authors, from the Mayo Clinic, retrospectively applied the ABCD2 tool to 637 adult TIA patients in whom data were collected prospectively at presentation. All of the patients underwent a standard observation unit protocol for TIA, which included performance of an EKG, head CT, h d CT carotid D tid Doppler i l imaging and l b t i d laboratory t t with i l tests, ith implementation of preventive t ti f ti management as indicated. The ABCD2 assigns 1 point each for an age above 60; a systolic pressure above 140 or a diastolic pressure above 90; isolated speech disturbance; a duration of symptoms of 10-59 minutes (0 points for a shorter duration); and the presence of diabetes. Two points are assigned f th presence of unilateral weakness and a d ti of symptoms exceeding i t i d for the f il t l k d duration f t di 60 minutes. Risk categories are low (0-3 points), intermediate (4-5 points) or high (6-7 points). RESULTS: By 90 days, strokes developed in 2.4% of the patients (15/637). The actual stroke rate in patients with low, intermediate or high-risk ABCD2 scores was 1.1%, 0.3% and 2.7% at 7 days, and 2.1%, 2.1% and 3.6% at 90 days. CONCLUSIONS: In a setting that incorporates brain and carotid imaging for risk stratification of TIA patients with implementation of preventive strategies, calculation of the ABCD2 scores does not pp provide useful additional information. 16 references ( (stead.latha@mayo.edu - no reprints) @ y p ) appear to p Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 7/11 - #7

#25 WHAT ARE THE UNINTENDED CONSEQUENCES OF CHANGING THE DIAGNOSTIC PARADIGM FOR SUBARACHNOID HEMORRHAGE AFTER BRAIN COMPUTED TO COMPUTED TOMOGRAPHIC ANGIOGRAPHY IN PLACE OF LUMBAR PUNCTURE? Edlow, J.A., AcadEmerg Med 17(9):991, September 2010 , g ( ) , p The author, from Beth Israel Deaconess Medical Center, comments on a proposed change to the diagnostic algorithm for suspected subarachnoid hemorrhage (SAH) in ED patients. The standard algorithm calls for a CT scan followed by lumbar puncture (LP) if the CT is normal or nondiagnostic nondiagnostic. Based on mathematical modeling, several researchers have proposed that CT angiography (CTA) replace the LP as the follow-up test. This author expresses concern that this diagnostic pathway might be viewed as being "easier," and that it will be adopted without consideration of potentially dangerous unintended consequences. This strategy would shift the focus away from actual consequences intracranial bleeding to identification of an aneurysm (which occurs in about 2.5% of the normal population) that may or may not be the cause of symptoms. While some factors are associated with greater or lesser risk that an existing cerebral aneurysm will ultimately rupture, none of these can distinguish adequately in any individual. Thus in a hypothetical cohort of 1000 patients presenting individual with a "thunderclap" headache, while about 150 will have an acute SAH, about 21 others will have an incidental aneurysm that was not responsible for symptoms mistakenly identified as the likely "cause." These latter patients will almost certainly be exposed to the risks of unnecessary additional tests and (in many cases) neurosurgical procedures while those for whom a strategy of "watchful procedures, watchful waiting" is adopted will suffer substantial anxiety; all these patients may well experience deleterious employment and insurance consequences. This author concludes that the current CT/LP strategy should remain in place for the investigation of possible SAH. 42 references (jedlow@bidmc.harvard.edu (jedlow@bidmc harvard edu - no reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 1/11 - #10

#26 RISK OF VASCULAR EVENTS IN EMERGENCY DEPARTMENT PATIENTS DISCHARGED HOME WITH DIAGNOSIS OF DIZZINESS OR VERTIGO Kim, A.S., et al, Ann Emerg Med 57(1):34, January 2011 BACKGROUND: Some patients who present to the ED with dizziness or vertigo have an important underlying cause but most do not, and extensive diagnostic evaluation in the ED for all such patients is highly impractical. METHODS: The th METHODS Th authors, f from th U i the University of C lif i S F it f California San Francisco, examined statewide i i d t t id databases to identify six-month outcomes in 31,159 adults (median age 56, 63.5% female) who were discharged home from the ED with a primary diagnosis of dizziness (77.8%) or vertigo (22.2%). RESULTS: During the six months after the ED visit, 1% of the patients were hospitalized for a major cerebrovascular (most often ischemic stroke) or cardiovascular (most often myocardial infarction) event, and 0.9% died. The six-month cumulative incidence was 0.32% for a major cardiovascular event, 0.63% for a cerebrovascular event (compared with 0.13% in the general population), and 0.93% for a major vascular event or death. The incidence rate for cardiovascular events remained relatively stable over the six-month period (about 9-10 per 10,000 personmonths), while the incidence rate for cerebrovascular events was 30.2 per 10,000 person-months during the first month after ED discharge, declining to 6.5 per 10,000 person-months thereafter. Advancing age and male gender were associated with an adverse vascular event. CONCLUSIONS: A major vascular event during the six months after an ED discharge to home is rare among patients who presented with dizziness or vertigo. The authors cite the need for studies yp p (akim@ucsf.edu - no reprints) @ p ) to identify populations at increased or decreased risk. 31 references ( Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 6/11 - #3

#27 VALUE OF COMPUTED TOMOGRAPHY SCANS IN ED DIZZINESS VISITS: ANALYSIS FROM A NATIONALLY REPRESENTATIVE SAMPLE Kerber, K.A., et al, Am J Emerg Med 28(9):1030, November 2010 BACKGROUND: Although a serious central nervous system (CNS) cause of dizziness in the ED setting is uncommon, emergency physicians typically feel compelled to identify any patient with a serious CNS condition. A recent study reported a 169% increase in the performance of head CT scanning in patients reporting dizziness from 1995 to 2004 although the sensitivity of CT in 2004, detecting a source of dizziness is limited at best. METHODS: The authors, from the University of Michigan, analyzed data for 6,589 ED visits by adults with dizziness reported in the National Hospital Ambulatory Medical Care Survey (NHAMCS) for th f the period 1995 2004 in order to assess the use and yield of head CT scanning i thi i d 1995-2004 i d t th d i ld f h d i in this population. RESULTS: The visits included in this sample translate to a weighted estimate of 24 million ED visits for dizziness in the USA. Head CT scanning was performed in 17% of the sample visits. The proportion of ED visits for dizziness in which a CT scan was performed and a relevant CNS diagnosis was made decreased from 15.2% in 1995 to 5.9% in 2004. There was a positive association between the performance of a head CT scan and the ED length of stay. When no tests other than CT scanning are performed, it was estimated that the expected ED length of stay will be increased by 72% for the patient having a head CT. CONCLUSIONS: These findings illustrate an increase in the use of head CT scanning for patients presenting to the ED with dizziness, with a corresponding large decrease in the yield of this imaging y, g y p modality, as well as a substantial increase in the ED length of stay when a CT was performed. The authors cite the importance of methods of identifying those adults with dizziness who would be likely to benefit from diagnostic imaging. 23 references (kakerber@umich.edu - no reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 5/11 - #9

#28 URINARY CATHETERS IN THE EMERGENCY DEPARTMENT: VERY ELDERLY WOMEN ARE AT HIGH RISK FOR UNNECESSARY UTILIZATION Fakih, M.G., et al, Am J Infect Contr 38(9):683, November 2010 BACKGROUND: Urinary catheters, which are frequently placed in the ED, are the most common source of hospital-acquired urinary tract infection (UTI). Because catheter-associated UTI in hospitalized patients is believed to be avoidable, the Centers for Medicare and Medicaid Services discontinued reimbursement for these infections in 2008 2008. METHODS: This implicit chart review study, from Wayne State University, evaluated factors associated with noncompliance with institutional guidelines for urinary catheter placement in the ED in 4,521 patients admitted through the ED over three four-week periods, including one from before, one di tl after, and one three months after an educational i t directly ft d th th ft d ti l intervention f residents f ti for id t focused on d these guidelines. RESULTS: A urinary catheter was placed in the ED in 538 patients (11.8%). Nearly one-third of the catheters (30.3%) were placed without any of the indications noted on the institutional guidelines, and in about one-sixth of cases there was no apparent reason for catheterization. On multivariate analysis that adjusted for potential confounders, independent predictors of the likelihood of noncompliance with institutional guidelines included female patient gender (odds ratio [OR] 1.88) and an age of 80 or older (OR 2.89). CONCLUSIONS: Even including patients seen up to a year after dissemination of institutional guidelines for urinary catheterization in patients hospitalized via the ED, there was no guidelinerelevant indication for nearly a third of the catheters placed in this study. Very elderly patients and pp pp p y women each appear to be at increased risk for inappropriate urinary catheterization in the ED. 27 references (mohamad.fakih@stjohn.org - no reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 4/11 - #16

#29 TAMSULOSIN HYDROCHLORIDE VS PLACEBO FOR MANAGEMENT OF DISTAL URETERAL STONES Vincendeau, S., et al, Arch Intern Med 170(22):2021, December 13/27, 2010 BACKGROUND: Some clinical trials of the alpha blocker tamsulosin (brand name Flomax) have alpha-blocker, name, reported that this agent facilitates passage of distal ureteral stones while others have reported negative results. METHODS: In this study, from the Tamsulosin Study Group in France and funded by Yamanouchi Pharmaceuticals/Astella (d Ph ti l /A t ll (developer of t l f tamsulosin), 129 adults t t d at six h l i ) d lt treated t i hospitals f i it l for imagingi confirmed distal ureteral calculi 2-7mm in diameter were randomized to treatment with tamsulosin (0.4mg daily) or placebo and followed for six weeks. Other initial management was identical in the two groups. RESULTS: There was no significant difference between the groups in mean stone size (2.9mm in the tamsulosin group and 3.2mm in controls) or in the percentage with smaller stones (2-3mm) (73% vs. 72%, respectively). There were, likewise, no statistically significant intergroup differences in the interval to stone expulsion (average 9.6 days in the tamsulosin group and 10.1 days in controls), the percentage experiencing expulsion by day 42 (77% vs. 75% in the group with smaller stones, and 75% vs. 59%, respectively, in the group with stones measuring 4-7mm in diameter), the percentage experiencing a relapse of pain or requiring urgent hospitalization and intervention during follow-up, or in analgesic requirements during follow-up (although these outcomes tended to favor tamsulosin). There was, likewise, no significant difference between the groups in side effects. CONCLUSIONS: In this study, administration of tamsulosin (0.4mg daily) did not significantly improve outcomes related to the passage of distal ureteral stones. 25 references ( (Eric.Bellissant@univ-rennes1.fr - no reprints) @ p ) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 5/11 - #17

#30 ALPHA-BLOCKERS INCREASE THE CHANCES OF A SUCCESSFUL TRIAL WITHOUT CATHETER AFTER ACUTE URINARY RETENTION Rendell, S., Emerg Med J 28(2):161, February 2011 METHODS: This paper, from the "Best Evidence Topic Reports" series, addresses the question of whether treatment with an alpha-blocker increases the likelihood of a successful trial without catheter in men presenting with acute urinary retention due to benign prostatic hyperplasia (BPH). A literature search identified seven relevant clinical trials (3 166 total patients) (one retrospective) and (3,166 one Cochrane review (696 patients included in five double-blind prospective randomized controlled trials [RCTs]). RESULTS: The trials included men who were catheterized due to acute urinary retention, after which they were treated with an alpha-blocker (alfuzosin, t hi h th t t d ith l h bl k ( lf i tamsulosin, d l i doxazosin, prazosin, or i i terazosin) or placebo, or received no treatment. The duration of treatment and the duration of follow-up were variable. Nearly all of the studies reported that active treatment was more often associated with a successful trial without catheter. Studies included in the Cochrane review reported success rates of 48-62% with active t t t d t f 48 62% ith ti treatment vs. 26 57% without such treatment. The t 26-57% ith t ht t t Th available data do not provide sufficient information regarding the effect of alpha-blockers on the risk of recurrent urinary retention, differences between alpha-blockers, or an optimal duration of treatment. CONCLUSIONS: There is limited evidence suggesting that use of an alpha-blocker leads to a small increase in the likelihood of a successful trial without catheter in men presenting with acute urinary retention. It is unclear whether or to what extent this would be offset by adverse effects (such as orthostatic hypotension) from use of such an agent. 8 references Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 7/11 - #18

#31 FROM EVIDENCE-BASED MEDICINE TO MARKETING-BASED MEDICINE: EVIDENCE FROM INTERNAL INDUSTRY DOCUMENTS Spielmans, G.I., et al, Bioethical Inquiry 7:13, 2010 According to conventional wisdom randomized controlled trials are the supreme source of wisdom, randomized, "evidence" on which to base the practice of medicine. These authors, from Metropolitan State University in St. Paul, MN, and Australia, review internal documents released by the pharmaceutical industry in a variety of lawsuits that indicate that "marketing-based medicine" has replaced the concept of "evidence based medicine " Pharmaceutical companies typically provide the largest evidence-based medicine. share of funding for the performance of clinical trials relating to their products, and it has been clearly demonstrated that industry-funded trials are much more likely to yield positive results than studies of the same drug that are not funded by industry. Examples are provided of manipulation of study results by industry including suppression of negative findings (even those that are related to industry, safety) and exaggeration of positive findings, with the intent of placing their drug or device in the most positive light. Because physicians are likely to view trials with corporate authorship as suspect, the practice of "ghostwriting," often by firms with extensive experience in marketing but listing academics as the primary researchers is common Other pharmaceutical industry practices researchers, common. that are designed to expand the market for drugs of interest include "disease mongering," or the expansion of the boundaries of a disease entity to include subclinical, borderline and normal-range symptoms in order to increase the indications for their drugs, and "market segmentation," or tailoring their messages to physician groups according to their specific characteristics These characteristics. authors decry the practice of "marketing-based medicine," and express skepticism about current lofty beliefs concerning "evidence-based medicine." 95 references (glen.spielmans@metrostate.edu - no reprints) (No PMID available) Copyright 2011 b E C i ht by Emergency M di l Ab t t - All Ri ht R Medical Abstracts Rights Reserved 5/11 - #26 d

#32 THE INVERSE BENEFIT LAW: HOW DRUG MARKETING UNDERMINES PATIENT SAFETY AND PUBLIC HEALTH Brody, H., et al, Am J Public Health 101(3):399, March 2011 Challenging the commonly held belief that heavily marketed new drugs are safer and more efficacious than older drugs, these authors (from the University of Texas Medical Branch at Galveston and the University of Medicine & Dentistry of New Jersey) propose the "pharmaceutical inverse benefit law," which states that the benefit-to-harm ratio of drugs tends to vary inversely with how aggressively they are marketed The authors note that the greatest chance of benefit of a marketed. newly developed drug is concentrated among patients with the most severe clinical manifestations of a given disease, who have the highest levels of risk (resulting in a low number-needed-to-treat to benefit [NNT-B]). Expansion of a drug's target population, which substantially increases its profit margin, margin dilutes the chance of benefit (resulting in a high NNT B) while increasing the number NNT-B), exposed to adverse effects. Pharmaceutical industry marketing strategies designed to expand the use of a given drug include campaigns to reduce thresholds for diagnosing disease, reliance on surrogate endpoints rather than patient outcomes in industry-sponsored studies, exaggeration of safety and efficacy claims creation of new "diseases" (consider for example, the emergence of claims, diseases (consider, example "pre-diabetes" and "pre-hypertension"), and efforts to encourage unapproved uses; the authors cite examples of each of these strategies. Healthcare providers should be aware of such marketing strategies and make efforts to avoid being unduly influenced by them. These authors also cite a study that found that in 2003 2004 94% of US physicians engaged with pharmaceutical sales that, 2003-2004, representatives or other industry marketing activities. They discourage this type of activity, which is known to decrease the likelihood of evidence-based prescribing. 50 references (habrody@utmb.edu - no reprints through the author) Copyright 2011 b E C i ht by Emergency M di l Ab t t - All Ri ht R Medical Abstracts Rights Reserved 8/11 - #25 d

#33 PREVALENCE OF DEEP VENOUS THROMBOSIS IN PATIENTS WITH ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE Duan, S.C. et al, Chin Med J 123(12):1510, June 2010 BACKGROUND: Several previous studies have reported a link between exacerbations of chronic obstructive pulmonary disease (COPD) and venous thromboembolism, including pulmonary embolism (PE) and deep vein thrombosis (DVT). METHODS: In thi METHODS I this prospective Chi ti Chinese study, 520 patients ( t d ti t (average age, 72) h hospitalized f an it li d for exacerbation of COPD underwent evaluations for lower extremity DVT on average about five to seven days after admission. RESULTS: Color Doppler ultrasonography evidence of lower extremity DVT was identified in 9.7% of the patients. DVT was distal in 59% of these patients and proximal in 41%. When compared with patients without DVT, the group with DVT had a significantly longer duration of hospitalization (median 14 vs. 11 days) and more often required mechanical ventilation (52% vs. 25%). Significant risk factors for DVT included current smoking (odds ratio [OR] 2.23), pneumonia (OR 2.52), and immobility in excess of three days (OR 2.91). There were no significant differences between the groups in other comorbid conditions. Patients with DVT more often noted lower extremity pain (34.8% vs. 15.2%, OR 2.81), but there were no differences between patients with and without DVT in other signs or respiratory symptoms. CONCLUSIONS: Clinicians are advised to be aware of the potential for DVT both before and after hospital admission in patients with exacerbations of COPD. 21 references (cyh-birm@263.net - no reprints) Copyright 2010 by Emergency Medical Abstracts - All Rights Reserved 12/10 - #27

#34 THE PULMONARY EMBOLISM RULE-OUT CRITERIA (PERC) RULE DOES NOT SAFELY EXCLUDE PULMONARY EMBOLISM Hugli, O., et al, J Thromb Haemost 9(2):300, February 2011 BACKGROUND: D dimer testing has been suggested as a means of excluding pulmonary D-dimer embolism (PE), but a false-positive rate of 50% or higher has been reported, thus exposing many patients to unnecessary testing for PE. A lowered threshold for diagnostic testing might play a role in the decreasing prevalence of PE in patients undergoing diagnostic work-ups (from 30% to less than 10% according to one study) The "Pulmonary Embolism Rule Out Criteria" (PERC) rule has study). Pulmonary Rule-Out Criteria been suggested as a means of safely excluding PE without the need for D-dimer testing. According to the PERC rule, the risk of PE is very low in patients below the age of 50 with a pulse rate below 100 and oxygen saturation above 94%, without unilateral leg swelling, hemoptysis, surgery or trauma within the previous four weeks prior deep vein thrombosis or PE or oral hormone use weeks, PE, use. METHODS: These multinational European authors examined the reliability of the PERC rule as applied to prospectively collected data from 1,675 adult outpatients being evaluated in EDs for suspected PE. RESULTS: Of the 1,675 patients, 13.2% were "PERC-negative" (i.e., fulfilled all of the PERC criteria) and, of these 221 patients, 85.1% had a low clinical pretest probability of PE while 14.9% had an intermediate probability according to the revised Geneva score. PE was diagnosed at the time of initial evaluation or during three months of follow-up in 21.3% of the patients overall, including 5.4% of the PERC-negative group and 6.4% of the PERC-negative patients with a low pretest probability according to the revised Geneva score. CONCLUSIONS: Application of the PERC rule, with or without the revised Geneva score, is not a y g patients with p possible PE who do not require further diagnostic q g reliable method of identifying those p testing. 24 references (olivier.hugli@chuv.ch - no reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 7/11 - #27

#35 SAFETY OF OUTPATIENT TREATMENT IN ACUTE PULMONARY EMBOLISM Erkens, P.M.G., et al, J Thromb Haemost 8(11):2412, November 2010 BACKGROUND: The safety of outpatient management of pulmonary embolism (PE) is a topic of debate. METHODS: This study, from Ottawa Hospital in Canada, retrospectively compared outcomes in 473 patients diagnosed with PE who were managed as inpatients (45%) or outpatients (55%). Candidates for t ti t C did t f outpatient management included patients who were h t i l d d ti t h hemodynamically stable, did d i ll t bl not require supplemental oxygen, and had no contraindications to low-molecular-weight heparin (LMWH) or comorbidity requiring hospital admission. Outpatient treatment included daily LMWH for a minimum of five days with concomitant oral vitamin K antagonist therapy, and follow-up within 2448 hours in the O t ti t Th h i th Outpatient Thrombosis A b i Assessment and T t t d Treatment U it t Unit. RESULTS: At 14 days, overall mortality was 0.4% in the outpatient group (one patient with metastatic cancer) and 12.7% in the inpatient group, and PE-specific mortality rates were 0% vs. 2.3%. Rates of recurrent venous thromboembolism (VTE) at 14 days were 0.4% in the outpatient group vs. 1.9% in the inpatient group, and rates of major bleeding were 0% vs. 6.1%. Rates of readmission at 14 days for VTE or treatment-related issues were 1.5% in the outpatient group and 1.9% in the inpatient group. With regard to three-month outcomes, mortality rates were 5% in those initially treated as outpatients vs. 26.7% in the inpatient group, and rates of PE-specific mortality were 0% vs. 2.3%, respectively. Major hemorrhage was more common in patients initially admitted (8% vs. 1.5%), but there were no differences between the groups in VTE recurrence (3.8% in the outpatient group vs. 4.7% in the inpatient group). g gg percentage of p g patients with PE can be CONCLUSIONS: These findings suggest that a substantial p managed without hospital admission. 30 references (mcarrier@Ottawahospital.on.ca - no reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 7/11 - #28

#36 EARLY ANTICOAGULATION IS ASSOCIATED WITH REDUCED MORTALITY FOR ACUTE PULMONARY EMBOLISM Smith, S.B., et al, Chest 137(6):1382, June 2010 BACKGROUND: Although guidelines suggest consideration of anticoagulation even before confirmatory testing for some patients with a high clinical suspicion of pulmonary embolism (PE), only limited information is available regarding the timing of anticoagulation and mortality. METHODS: The authors, from the Mayo Clinic in Rochester, MN, performed an implicit chart review regarding the timing of initiation of h di th ti i f i iti ti f heparin th i therapy, th i t the interval t th l to therapeutic anticoagulation and ti ti l ti d mortality in 400 patients (median age, 68) with PE diagnosed in the ED with CT angiography. RESULTS: Heparin was started in the ED for 70% of the patients and prior to establishing the diagnosis of PE in 5%. Most of the patients (85.8%) had a therapeutic aPTT within 24 hours of ED arrival. When compared with initiation of heparin after hospital admission, initiation of treatment in the ED was associated with lower mortality during the inpatient stay (1.4% vs. 6.7%, odds ratio [OR] 0.20) and at 30 days (4.4% vs. 15.3%, OR 0.25). A similar pattern was noted for patients who achieved a therapeutic aPTT within 24 hours (1.5% vs. 5.6% inpatient mortality in those achieving a therapeutic aPTT after 24 hours, and 5.6% vs. 14.8% 30-day mortality, respectively). The median time to achievement of a therapeutic aPTT was 20.9 hours among patients who died in the hospital vs. 10.7 hours among those who did not. Administration of heparin in the ED remained predictive of decreased mortality on multiple logistic regression analyses that controlled for some potential confounders - although the data cannot address the fact that in most if not all cases the delay to heparin was based on a delayed diagnosis of PE, which almost certainly reflects not only a different presentation, but also importantly different comorbidity. pp promote early initiation of anticoagulant therapy y g py CONCLUSIONS: The authors support initiatives to p in patients with acute PE. 42 references (tmorgenthaler@mayo.edu - no reprints) Copyright 2010 by Emergency Medical Abstracts - All Rights Reserved 11/10 - #26