Journal of Trauma-Injury Infection & Critical Care. 65(6):1346-1353, December 2008.
Background: Although splenic angioembolization (SAE) has been introduced and adopted in many trauma centers, the appropriate selection for and utility of SAE in trauma patients remains under debate. This study examined the outcomes of proximal SAE as part of a management algorithm for adult traumatic splenic injury compared with splenectomy.
Methods: A retrospective cohort analysis was performed on all hemodynamically stable (HDS) blunt trauma patients with isolated splenic injury and computed tomographic (CT) evidence of active contrast extravasation that presented to a level 1 Trauma Center over a period of 5 years. The cohorts were defined by two separate 30 month periods and included 78 patients seen before (group I) and 76 patients seen after (group II) the introduction of an institutional SAE protocol. Demographics, splenic injury grade, and outcomes of the two groups were compared using Student's t test, or [chi]2 test. Analysis was by intention-to-treat.
Results: Six hundred eighty-two patients with blunt splenic injury were identified; 154 patients (29%) were HDS with CT evidence of active contrast extravasation. Group I (n = 78) was treated with splenectomy and group II (n = 76) was treated with proximal SAE. There was no difference in age (33 +/- 14 vs. 37 +/- 17 years), Injury Severity Score (31 +/- 13 vs. 29 +/- 11), or mortality (18% vs. 15%) between the two groups. However, the incidence of Adult Respiratory Distress Syndrome (ARDS) was 4-fold higher in those patients that underwent proximal SAE compared with those that underwent splenectomy (22% vs. 5%, p = 0.002). Twenty two patients failed nonoperative management (NOM) after SAE. This failure appeared to be directly related to the grade of splenic organ injury (grade I and II: 0%; grade III: 24%; grade IV: 53%; and grade V: 100%).
Conclusion: Introduction of proximal SAE in NOM of HDS splenic trauma patients with active extravasation did not alter mortality rates at a Level 1 Trauma Center. Increased incidence of ARDS and association of failure of NOM with higher splenic organ injury score identify areas for cautionary application of proximal SAE in the more severely injured trauma patient population. Better patient selection guidelines for proximal SAE are needed. Without these guidelines, outcomes from SAE will still lack transparency.
Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of morbidity and mortality in institutionalized patients, and community-acquired MRSA is now the most common cause of purulent skin and soft-tissue infections in adults. Healthcare workers colonized with MRSA can transmit it to patients and colleagues as well as develop clinical infections themselves. In a prospective cohort study, researchers assessed MRSA nasal-colonization rates in a convenience sample of 105 emergency department healthcare workers (attending physicians, nurses, and technicians) at a single institution in Illinois. Nasal samples from 16 workers (15%) were MRSA-positive.
The prevalence of MRSA colonization among ED healthcare workers in this single-site study is alarming and highlights the importance of following infection control practices, including hand washing.
Richard D. Zane, MD, FAAEMPublished in Journal Watch Emergency Medicine December 24, 2008
Citation(s): Bisaga A et al. A prevalence study of methicillin-resistant Staphylococcus aureus colonization in emergency department health care workers. Ann Emerg Med 2008 Nov; 52:525.
New Video and Optical Laryngoscopes Beat the Macintosh
In the recent ACCORD and ADVANCE trials, intensive glucose-lowering therapy did not lower risks for cardiovascular (CV) death, nonfatal myocardial infarction, or nonfatal stroke in people with type 2 diabetes and end-organ complications or CV risk factors (JW Jun 6 2008). The results of a similar trial, the Veterans Affairs Diabetes Trial (VADT), are now available.
Investigators randomized 1791 veterans (mean age, 60) with long-standing type 2 diabetes (mean duration, 11.5 years) to receive intensive glucose-lowering therapy or standard therapy. Other CV risk factors were treated uniformly in both groups. After a median follow-up of 5.6 years, the median glycosylated hemoglobin (HbA1c) level was significantly lower in the intensive-therapy group than in the standard-treatment group (6.9% vs. 8.4%). However, no between-group differences were noted for death from any cause, CV death, or time from randomization to first major CV event. Furthermore, researchers found no differences in microvascular events (e.g., retinopathy, nephropathy, neuropathy). However, hypoglycemic episodes were significantly more common in the intensive-therapy group.
Intensive glucose-lowering therapy does not lower risks for major CV events or death in patients with long-standing type 2 diabetes. In response to the results of the ACCORD, ADVANCE, and VADT trials, the American Diabetes Association, the American College of Cardiology Foundation, and the American Heart Association issued a joint position statement suggesting that less-stringent glycemic control is appropriate for patients with histories of severe hypoglycemic events, long-standing diabetes, or advanced microvascular and macrovascular complications. However, clinicians should continue to follow guidelines for healthy-lifestyle behaviors, smoking cessation, blood pressure control, and lipid lowering in these patients (J Am Coll Cardiol 2008; 52). Notably, the results of ACCORD, ADVANCE, and VADT might not apply to patients with newly diagnosed type 2 diabetes; evidence suggests such patients benefit from intensive glucose-lowering therapy (JW Oct 14 2008).
Paul S. Mueller, MD, MPH, FACPPublished in Journal Watch General Medicine December 24, 2008
Duckworth W et al for the VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009 Jan 8; 360:129. (http://dx.doi.org/10.1056/NEJMoa0808431)
A relative afferent pupillary defect was discovered in the right eye of this patient when the following responses were observed during the swinging-flashlight test. When light was shone into the healthy eye, there was symmetrical pupillary constriction. However, when the light was directed into the abnormal eye there was bilateral pupillary dilation. This phenomenon is due to reduced neural input reaching the pretectal region of the midbrain. A relative afferent pupillary defect is typically found in the presence of a unilateral optic neuropathy and occasionally with large macular abnormalities. It is usually present ipsilateral to the side of an injured optic nerve.
When a patient presents with blurred vision, the first and most important task is to determine whether the loss of vision is optical (i.e., refractive) or related to an ophthalmic, medical, or neurologic disorder. If the visual acuity improves when the patient looks through a pinhole, it means that the loss of vision is most likely caused by optical or refractive error. If the visual loss is not corrected by using the pinhole, the patient needs a more thorough evaluation, since a lack of improvement may indicate a more serious ophthalmic or neurologic process.
Is visual acuity a sensitive test for optic-nerve function?
Visual acuity is not always a sensitive test of optic-nerve function; visual acuity may remain normal in the setting of a profound optic neuropathy. For instance, a unilateral prechiasmal lesion can reduce visual acuity, but only when both the crossing and noncrossing fibers are affected.
What disease may be indicated by optic neuritis?
Optic neuritis, inflammation of the optic nerve, is most common in patients with multiple sclerosis. Isolated optic neuritis often heralds the onset of multiple sclerosis.
New England Journal of Medicine - Vol. 359, No. 26, December 25, 2008
The D-dimer test should not be used in patients with a high clinical probability of pulmonary embolism, since the negative predictive value of this test is low for these patients. A negative D-dimer level (below 0.5 mg per liter), as assessed with the use of a highly sensitive enzyme-linked immunosorbent assay, reliably rules out the presence of circulating fibrin and, thus, essentially rules out the diagnosis of venous thromboembolism in patients with low clinical probability of disease. This test can eliminate the need for further diagnostic testing in almost 30% of patients with suspected pulmonary embolism. However, D-dimer testing should be omitted as a diagnostic step in patients who are older than 80 years of age, are hospitalized, or have cancer, as well as in pregnant women, because D-dimer concentrations are frequently (and nonspecifically) elevated in such patients.
Multidetector computed tomography (CT) is the preferred diagnostic test for pulmonary embolism in most hospitals. This test provides potentially useful prognostic information by also permitting an assessment of the right ventricle. Bedside echocardiography may be a valuable alternative, if CT is not immediately available or if the patient's condition is too unstable for transfer to the radiology department. Ventilation-perfusion lung scanning remains an alternative to CT angiography when injection of a contrast dye is a concern. Unfortunately, inconclusive findings on ventilation-perfusion scans are frequent.
When is thrombolysis indicated in a patient with pulmonary embolism?
Thrombolysis is indicated in the case of patients with pulmonary embolism who have arterial hypotension or are in shock. In contrast, the benefits of thrombolysis in patients with pulmonary embolism who have normal blood pressure are less well established.
What role, if any, do cardiac biomarkers play in the diagnosis and treatment of pulmonary embolism?
Cardiac biomarkers, particularly troponins and natriuretic peptides, have been used to detect myocardial dysfunction and injury, respectively, in patients with acute pulmonary embolism. These biomarkers have high negative predictive value (i.e., normal levels indicate a low risk of death or complications) but low positive predictive values, such that elevated levels alone do not dictate the need for aggressive early treatment other than anticoagulation with heparin.
New England Journal of Medicine - Vol. 359, No. 26, December 25, 2008
In chronic heart failure, the higher the systolic blood pressure, the lower the mortality. The recommendation in an accompanying editorial is to maximise heart failure treatment but monitor blood pressure and don't let it drop below 110/70.
Source: Heart 2009;95:56-62
Is it true that the lower the blood glucose in diabetic patients, the better? Maybe not. A major study has found that high risk diabetic patients actually do worse with intensive control of their blood glucose.
Over 10,000 North American diabetics with cardiovascular disease or risk factors were randomised into two groups. One group had standard diabetes care with the aim of keeping their glycated haemoglobin (HbA1c) at 7-7.9%, the other group had intensive treatment to get their HbA1c below 6%.
Surprisingly, intensive glucose control increased mortality and didn't reduce cardiovascular disease or risk factors compared with standard glucose control. High risk diabetic patients may therefore be harmed by intensive lowering of their blood glucose.
Source: Evidence-Based Medicine 2008;13:169; doi:10.1136/ebm.13.6.169
What practical help can we offer to people who say they cannot sleep? A useful 10 Minute Consultation article in the BMJ suggests we do the following-
- Rule out causes of insomnia such as depression, anxiety, sleep apnoea, pain, daytime naps, evening caffeine intake or exercise
- Ask patients to keep a sleep diary and note how many hours they spend in bed and how many asleep
- Calculate sleep efficiency ((hours asleep/hours in bed)x100): 80-85% is optimum, <75%>90% may indicate sleep deprivation
- Advise sleep restriction. Restrict time spent in bed to time spent asleep - thus, if sleeping only 6 hours, spend just 6 hours in bed
- After two weeks, gradually increase the time spent in bed, but reduce this again if quality of sleep declines.
The McGrath, Airtraq, and GlideScope laryngoscopes were all preferred over the Macintosh.
Several optical and video-based laryngoscopes have recently become available. The notable advantage of these new devices over direct laryngoscopy is that they do not require alignment of the oral and laryngeal axes in such a way as to create a straight line of sight to the vocal cords. In a simulator-based trial, researchers conducted a head-to-head comparison of three of the most popular devices (the McGrath, Airtraq, and GlideScope) with the Macintosh laryngoscope.
Sixty anesthesia providers (faculty, residents, and nurses) who had experience with Macintosh direct laryngoscopy but not with video or optical scopes received individualized training in use of the devices, followed by five practice intubation attempts with each device on a simulated normal airway. Each provider then attempted intubation in three simulated difficult airway scenarios: pharyngeal obstruction, pharyngeal obstruction with cervical spine rigidity, and tongue edema. The Macintosh laryngoscope was always used first, and the order of use of the other three devices was randomized. For each intubation attempt, laryngeal grade of view, time to intubation, success rate, and subjective rating of difficulty were measured.
In all three difficult airway scenarios, the alternative scopes provided significantly better laryngeal views than the Macintosh did. Of the alternative devices, the Airtraq and the McGrath provided significantly better laryngeal views than the GlideScope did. Time to intubation for each device varied according to the airway scenario: The Macintosh and Airtraq laryngoscopes were significantly faster than the other devices in the two pharyngeal obstruction scenarios, whereas the Airtraq was fastest and the Macintosh was slowest in the most difficult scenario (tongue edema). In the tongue edema scenario, the Macintosh was associated with a high rate of failure (37%) compared with the GlideScope (2%), the Airtraq (2%), and the McGrath (0%). All three of the alternative laryngoscopes were judged by providers as easier to use than the Macintosh.
Comment: In this small, simulator-based trial with anesthesia providers who were skilled in use of the standard Macintosh laryngoscope, the video and optical scopes performed better and were preferred over the antiquated Macintosh. Although an airway simulator does not exactly represent human anatomy or real patients (it is neither wet nor bloody), this study highlights some distinct advantages related to improved laryngeal view obtained with video or optical laryngoscopy. If you haven't already tried video or optical laryngoscopy, do!
Aaron E. Bair, MD, MSc, FAAEM, FACEP
Published in Journal Watch Emergency Medicine December 19, 2008
Citation(s): Savoldelli GL et al. Comparison of the Glidescope®, the McGrath®, the Airtraq® and the Macintosh laryngoscopes in simulated difficult airways. Anaesthesia 2008 Dec; 63:1358.
Nonsmokers who ate healthful diets and exercised didn't benefit from alcohol.
In observational studies, researchers have found an association between moderate drinking and lower risk for myocardial infarction, but less is known about whether this benefit is limited to select groups. Researchers in London prospectively followed 9655 middle-aged adult civil servants (mean age, 44; none with known MI at enrollment) for a median of 17 years.
Subjects were characterized according to number of unhealthful behaviors (smoking, lack of exercise, poor diet). Among people who reported regular physical activity, daily fruit and vegetable consumption, and no smoking, alcohol use had no effect on incidence of fatal coronary heart disease or nonfatal MI in analyses that were adjusted for age, sex, and socioeconomic status. Among participants with two or three unhealthful behaviors, moderate alcohol intake (8–112 g, or about 1–9 standard U.S. drinks weekly) was associated with half the risk for CHD; in addition, adjusting for diabetes, angina, hypertension, and cardiovascular medication use yielded similar results.
Even if moderate drinking lowers risk for CHD (a hypothesis that has not been confirmed yet in clinical trials), alcohol ingestion appears to have no such benefit for people who exercise, eat fruits and vegetables, and do not smoke. The authors cite one large cohort study, done in the U.S., with similar results. Therefore, they recommend that this typically overlooked variability in the effect of moderate drinking be emphasized in public health messages and advice about alcohol use. Such a message — which would acknowledge potential benefits among people with certain unhealthful behaviors — also would emphasize lack of benefit in others and the importance of healthful behaviors. The message is complicated further by the lack of controlled trials, by research that suggests benefits accrue mainly to those with genetic predispositions to alcoholism, and by harms associated with moderate drinking (e.g., excess risk for certain cancers).
Richard Saitz, MD, MPH, FACP, FASAM
Published in Journal Watch General Medicine December 18, 2008
Britton A et al. Who benefits most from the cardioprotective properties of alcohol consumption — Health freaks or couch potatoes? J Epidemiol Community Health 2008 Oct; 62:905.
NEJM 2008 Dec. B.W. Bottiger et al: Thrombolysis during Resuscitation for Out-of-Hospital Cardiac Arrest.
In this randomized, double-blind, multicenter trial, adult patients with witnessed out-of-hospital cardiac arrest were assigned to receive either tenecteplase (thrombolytic agent) or placebo during resuscitation. The use of heparin, clopidogrel, ticlodipine, and aspirin were discouraged and the use of glycoprotein IIb/IIIa inhibitors was not permitted in this study. The researchers observed no significant differences between the tenecteplase and placebo groups in the efficacy end points that were evaluated, including the primary end point of 30-day survival and the secondary end points of return of spontaneous circulation, hospital admission, 24-hour survival, survival to hospital discharge, and neurologic outcome. However, the researchers do state the following: “Our findings do not suggest that thrombolytic therapy should be withheld in patients with cardiac arrest if the primary pathologic condition is known to be responsive to such treatment.”
Clinical Pearl Intracranial Hemorrhage and Thrombolysis
One of the biggest risk factors associated with the use of thrombolytic agents is intracranial hemorrhage. In this study, intracranial hemorrhage occurred with significantly greater frequency in the tenecteplase group (14 of 518 [2.7%]) than in the placebo group (2 of the 514 [0.4%], P=0.006). Four patients with intracranial hemorrhage (all in the tenecteplase group) were symptomatic.
Guidelines for Use of Thrombolytics in Cardiac Arrest
Current cardiopulmonary-resuscitation guidelines state that thrombolytic therapy should be considered in adult patients who have cardiac arrest with pulmonary embolism but there are insufficient data to make a recommendation for or against the use of thrombolysis in cardiac arrest. (American Heart Association Guidelines, Circulation, 2005.)
Comparison of Orbital Fracture Repair Performed Within 14 Days Versus 15 to 29 Days After Trauma.
Ophthalmic Plastic & Reconstructive Surgery. 24(6):437-443
Purpose: To examine whether orbital floor and/or medial wall fracture repair delayed for 15 to 29 days is as effective as early surgery.
Methods: A retrospective review is reported comparing outcomes of early fracture repairs (performed 1-14 days after trauma) to delayed fracture repairs (performed 15-29 days after trauma). Ocular motility, diplopia, and time to resolution of diplopia postoperatively are the main endpoints.
Results: Fifty-eight patients were included in the study: 36 underwent early fracture repair (average 9 days after trauma) and 22 underwent delayed fracture repair (average 19 days after trauma). Ocular motility was equivalent in both groups, both before and after surgery. Patient reports of diplopia and frequency of strabisumus surgery were also equivalent in both groups. The time to resolution or stability of diplopia postoperatively is independent of the time to surgery within the first 29 days after trauma.
Conclusions: Although 14 days after trauma is commonly cited as a timeline target for orbital blowout repair, these data show that effective fracture repair can be performed up to 29 days after trauma. Patients with improving diplopia and at low risk for enophthalmos can therefore be observed for 3 to 4 weeks prior to undergoing surgery. This may help prevent unnecessary surgery in some cases. Fourteen days need not be considered a deadline for orbital floor and/or medial wall fracture repair.
According to the Advisory Committee on Immunization Practices (ACIP), influenza vaccination is currently recommended for all persons 50 years of age or older, all children between 6 months and 18 years of age, and persons 19 to 49 years of age who have underlying medical conditions, are pregnant, are employed as health care workers, or are household contacts of high-risk persons (a group that includes all children in the household who are younger than 5 years of age). Infants younger than 6 months of age, who have the highest hospitalization rates, although ineligible for vaccination, can be protected by immunization of their mothers during pregnancy.
The older adamantanes, amantadine, and rimantadine are currently not recommended for use in the United States because almost all influenza A (H3N2) viruses are resistant to them, and they are not effective against influenza B viruses. When influenza A (H1N1) viruses predominate, however, these drugs may still be useful if they are used in combination with a neuraminidase inhibitor. An increasing proportion of influenza A (H1N1) viruses are resistant to oseltamivir, the oral neuraminidase inhibitor, but not to zanamivir. Zanamivir is a neuraminidase inhibitor that is administered by active inhalation, a method that may not be practical for debilitated patients or for children younger than 7 years of age, and is contraindicated in those with reactive airway disease.
New England Journal of Medicine - Vol. 359, No. 24, December 11, 2008
Severe myocardial ischemia is the leading cause of arrhythmic sudden cardiac death. It is unclear, however, in which percentage of patients sudden cardiac death is triggered by ST-elevation myocardial infarction (STEMI) and whether the diagnosis of STEMI can be reliably established immediately after resuscitation from out-of-hospital sudden cardiac death.
A 12-lead ECG was registered after return of spontaneous circulation after cardiac arrest. After hospital admission, further ECG, creatine kinase MB, and troponin measures; results of coronary angiograms; and autopsies were evaluated to confirm the definitive diagnosis of STEMI.
Seventy-seven patients were included in our study (67% men, age 64 [14 to 93] years). STEMI was diagnosed in 44 patients. The diagnosis of myocardial infarction was confirmed in 84% of the 77 patients who survived to hospital admission. The sensitivity of the out-of-hospital ECG was 88% (95% confidence interval [CI] 74% to 96%), the specificity 69% (95% CI 51% to 83%), the positive predictive value 77% (95% CI 62% to 87%), and the negative predictive value 83% (95% CI 64% to 87%). The accuracy of the out-of-hospital ECG and that registered on admission was the same.
The diagnosis of STEMI can be established in the field immediately after return of spontaneous circulation in most patients. This may enable an early decision about reperfusion therapy, ie, immediate out-ofhospital thrombolysis or targeted transfer for percutaneous coronary intervention. [Ann Emerg Med. 2008;52:658-664.]
The purpose of our study was to determine the clinical significance of the isolated finding of free intraperitoneal fluid on 64-MDCT in male patients who have undergone blunt trauma.
MATERIALS AND METHODS.
A retrospective study was performed of 669 consecutive male patients, ranging in age from 15 to 85 years, who underwent CT evaluation of the abdomen and pelvis at our level 1 trauma center over a 17-month period. Two radiologists evaluated the images for the presence of free intraperitoneal fluid and for an underlying cause. For patients with free intraperitoneal fluid, the mean attenuation and the size of the largest pocket of fluid on both portal venous and delayed phase images were measured for both those with and those without injury. For the patients who had free intraperitoneal fluid as an isolated finding, the electronic chart was reviewed to determine the clinical outcome, specifically whether these patients were observed, had short-interval follow-up imaging, or underwent exploratory laparotomy.
Forty-eight of the 669 patients (7.2%) had free intraperitoneal fluid. Twenty-nine (4.3%) of these patients had an identifiable solid organ, bowel, bladder, or pelvic injury to explain the free fluid. In the remaining 19 (2.8%) patients, free fluid was an isolated finding. The size of the largest collection of fluid was smaller for patients without identifiable injury on portal venous phase (1,236 vs 348 mm2) and delayed phase (1,325 vs 298 mm2) images (p = 0.0015 and p < 0.0001, respectively). Fluid in patients without identifiable injury was also shown to be less dense. A statistically significant difference between the mean attenuation coefficients of the fluid in the patients with and without injury was also found on both the portal venous phase (45.1 vs 13.1 HU, p < 0.0001) and delayed phase (45.6 vs 20.8 HU, p < 0.0001) images. All 19 patients without identifiable injury were admitted for observation and discharged without surgical intervention.
With 64 MDCT, the isolated finding of free intraperitoneal fluid in male patients who have undergone blunt trauma is seen in approximately 3% of patients. The size and mean attenuation coefficient measurements may add useful information regarding the clinical management of these patients, suggesting that small amounts of low-attenuation free fluid, in the absence of identifiable injury, may have no significant clinical implications.
AJR 2008; 191:1821-1826
American Journal of Roentgenology
OBJECTIVE: To systematically review and quantitatively synthesize the effects of ICS therapy on mortality and adverse events in patients with stable COPD.
DATA SOURCES: Search of MEDLINE, CENTRAL, EMBASE, CINAHL, Web of Science, and PsychInfo through February 9, 2008. STUDY SELECTION: Eligible studies were double-blind, randomized controlled trials comparing ICS therapy for 6 or more months with nonsteroid inhaled therapy in patients with COPD.
DATA EXTRACTION: Two authors independently abstracted data including study characteristics, all-cause mortality, pneumonia, and bone fractures. The I(2) statistic was used to assess heterogeneity. Study-level data were pooled using a random-effects model (when I(2) > or = 50%) or a fixed-effects model (when I(2) < 50%). For the primary outcome of all-cause mortality at 1 year, our meta-analysis was powered to detect a 1.0% absolute difference in mortality, assuming a 2-sided alpha of .05 and power of 0.80.
RESULTS: Eleven eligible randomized controlled trials (14,426 participants) were included. In trials with mortality data, no difference was observed in 1-year all-cause mortality (128 deaths among 4636 patients in the treatment group and 148 deaths among 4597 patients in the control group; relative risk [RR], 0.86; 95% confidence interval [CI], 0.68-1.09; P = .20; I(2) = 0%). In the trials with data on pneumonia, ICS therapy was associated with a significantly higher incidence of pneumonia (777 cases among 5405 patients in the treatment group and 561 cases among 5371 patients in the control group; RR, 1.34; 95% CI, 1.03-1.75; P = .03; I(2) = 72%). Subgroup analyses indicated an increased risk of pneumonia in the following subgroups: highest ICS dose (RR, 1.46; 95% CI, 1.10-1.92; P = .008; I(2) = 78%), shorter duration of ICS use (RR, 2.12; 95% CI, 1.47-3.05; P < .001; I(2) = 0%), lowest baseline forced expiratory volume in the first second of expiration (RR, 1.90; 95% CI, 1.26-2.85; P = .002; I(2) = 0%), and combined ICS and bronchodilator therapy (RR, 1.57; 95% CI, 1.35-1.82; P < .001; I(2) = 24%).
CONCLUSIONS: Among patients with COPD, ICS therapy does not affect 1-year all-cause mortality. ICS therapy is associated with a higher risk of pneumonia. Future studies should determine whether specific subsets of patients with COPD benefit from ICS therapy.
Overall, the tension with adding inhaled corticosteroid will continue to be:
- less exacerbations of COPD
- better quality of life
- more pneumonia without increased mortality
Drummond MB, Dasenbrook EC, Pitz MW, et al. Inhaled corticosteroids in patients with stable chronic obstructive pulmonary disease: a systematic review and meta-analysis. JAMA. 2008 Nov 26;300(20):2407-16.
Most exacerbations of COPD are caused by viral or bacterial infection. The clinical manifestations of exacerbations result from direct effects of viruses and bacteria from the host response. Antibiotics are not beneficial for a mild exacerbation but are beneficial in the treatment of moderate and severe COPD exacerbations, especially when purulent sputum is one of the presenting symptoms. Initial antibiotic choice (before any specific infectious agent is identified) should be based on the patient's age, risk factors, FEV1, number of exacerbations per year, recent antibiotic exposure, and presence of cardiac disease. Observational studies have identified advanced age, severe airflow obstruction, recurrent exacerbations, and coexisting cardiac disease as predictive factors for poor clinical outcomes after a COPD exacerbation.
Hint 1: The most prevalent bacterial pathogens in COPD are Haemophilus influenza and Pseudomonas aeruginosa. These pathogens enhance mucous secretion, disrupt normal ciliary activity, and cause airway epithelial injury, thereby further impairing mucociliary clearance.
Hint 2: Air pollution and other environmental conditions that increase airway inflammation or bronchomotor tone probably account for 15 to 20% of exacerbations. Increased respiratory symptoms resulting from coexisting conditions such as congestive heart failure and pulmonary emboli should be clinically ruled out in the evaluation of exacerbations.
NEJM - Vol. 359, No. 22, November 27, 2008
Ginkgo extract "cannot be recommended" as a preventive for dementia, concludes a JAMA study. Researchers randomized some 3000 patients to receive twice-daily doses of Ginkgo biloba extract or matching placebo. Participants averaged almost 80 years of age at entry, when they were either free of dementia or had only mild cognitive impairment; they underwent assessment every 6 months for a median 6 years' follow-up. By the end of follow-up, there were no differences between the groups in overall incidence of dementia or Alzheimer disease. An editorialist, calling this "the largest and longest randomized" trial to examine the effects of ginkgo extract, says it offers the "substantial bulk" of independently funded data on the substance. And writing in Journal Watch Psychiatry, Jonathan Silver comments that "in the present economy, people can put the [estimated annual $100 million expenditure for ginkgo] to better use."
Ginkgo extract "cannot be recommended" as a preventive for dementia, concludes a JAMA study.
Researchers randomized some 3000 patients to receive twice-daily doses of Ginkgo biloba extract or matching placebo. Participants averaged almost 80 years of age at entry, when they were either free of dementia or had only mild cognitive impairment; they underwent assessment every 6 months for a median 6 years' follow-up.
By the end of follow-up, there were no differences between the groups in overall incidence of dementia or Alzheimer disease.
An editorialist, calling this "the largest and longest randomized" trial to examine the effects of ginkgo extract, says it offers the "substantial bulk" of independently funded data on the substance. And writing in Journal Watch Psychiatry, Jonathan Silver comments that "in the present economy, people can put the [estimated annual $100 million expenditure for ginkgo] to better use."
JAMA article (Free)
- AAA is commoner in men but more likely to be fatal in women
- Most research into AAA until now has been done in men
- Age and smoking are the strongest risk factors for AAA in women
- Women with diabetes are less likely to have AAA
Source: BMJ 2008;337:a1724
In this cohort of 436 patients diagnosed with MS in 1985, 10% had the wrong diagnosis and just over 10% had benign MS. Benign MS is more likely if you are:
- Free of motor symptoms at presentation
The descending aorta is fixed to the chest wall, whereas the heart and great vessels are relatively mobile. Traditional views have held that sudden deceleration causes a tear at the junction between the fixed and mobile portions of the aorta, usually near the isthmus. However, injury may also occur to the ascending aorta, the distal descending thoracic aorta, or the abdominal aorta. Many blunt aortic injuries probably involve a combination of forces, including stretching, shearing, torsion, and a “waterhammer” effect which involves simultaneous occlusion of the aorta and a sudden elevation in blood pressure. The aorta may also become entrapped between the anterior chest and the vertebral column, in a so-called “osseous pinch” effect to cause blunt injury.
What is the diagnostic test of choice for blunt aortic injury?
Helical computed tomography (CT) is now the diagnostic test of choice for blunt aortic injury. Helical CT of the thorax is more sensitive for blunt aortic injury than angiography and is estimated to have a sensitivity of 100%, as compared with 92% for angiography. Other options for the diagnosis of blunt aortic injury include transesophageal echocardiography, intravascular ultrasonography, and magnetic resonance imaging.
Perioperative Management of Blunt Aortic Injury
Once the diagnosis of blunt aortic injury is made, treatment and surgical repair must be properly timed. Several studies have demonstrated the relative safety of a delayed approach, particularly if there are substantial coinjuries, using a regimen of beta-blockers and antihypertensive agents to decrease the shear force on the aortic wall. Fabian and colleagues performed a prospective study (Ann Surg, 1998) using beta blockers with and without vasodilators to maintain a systolic blood pressure of approximately 100 mm Hg (or 110 mm to 120 mm Hg in older patients) and a pulse rate of under 100 beats per minute in selected patients with blunt aortic injury and a coexisting head injury, pulmonary injury, or cardiac insufficiency. In this study, no patient had an aortic rupture while awaiting repair.
New England Journal of Medicine - Vol. 359, No. 16, October 16, 2008
Potential risks of long-term use of proton-pump inhibitors include secondary hypergastrinemia, malabsorption, and hypochlorhydria. These risks are mainly theoretical, but large, population-based, epidemiologic studies have suggested that long-term use of proton-pump inhibitors was associated with an increased risk of hip fracture by a factor of 1.4 in subjects over 50 years (presumably attributable to calcium malabsorption), an increase in the risk of infectious gastroenteritis by a factor of 1.5, and a doubling of the risk of Clostridium difficile colitis.
Lifestyle modifications that may be beneficial to patients with gastrointestinal reflux disease include dietary changes, if there are obvious dietary precipitants, (coffee, chocolate, or fatty foods), reduction of obesity, smoking, and excessive alcohol use, avoidance of eating within 3 hours of bedtime, elevation of head of bed, and eating smaller more frequent meals. However, lifestyle changes are often insufficient to eliminate symptoms and recommendation for use of a proton-pump inhibitor is usually the first line of therapy.
Even small amounts of caffeine consumed during pregnancy may increase the risk for fetal growth restriction, according to a BMJ study.
Using questionnaires and saliva samples, researchers assessed the caffeine consumption of 2600 healthy pregnant women throughout pregnancy.
After adjustment for tobacco and alcohol use, women who consumed over 200 mg of caffeine daily (roughly 2 cups of brewed coffee) were at increased risk for fetal growth restriction (birth weight less than the 10th percentile), compared with women who consumed less than 100 mg. This finding was consistent for consumption across all trimesters. Women who reduced their caffeine intake had infants with a higher mean birth weight, relative to those who maintained their prepregnancy intake.
The authors suggest that women who are contemplating pregnancy should consume fewer caffeinated foods and beverages. "Once pregnancy is confirmed, they should make every effort to stop or markedly reduce caffeine consumption."
Maternal caffeine intake during pregnancy and risk of fetal growth restriction: a large prospective observational study
- BMJ 2008;337:a2332
To examine the association of maternal caffeine intake with fetal growth restriction.
Prospective longitudinal observational study.
Two large UK hospital maternity units.
2635 low risk pregnant women recruited between 8-12 weeks of pregnancy.
Quantification of total caffeine intake from 4 weeks before conception and throughout pregnancy was undertaken with a validated caffeine assessment tool. Caffeine half life (proxy for clearance) was determined by measuring caffeine in saliva after a caffeine challenge. Smoking and alcohol were assessed by self reported status and by measuring salivary cotinine concentrations.
Main outcome measures
Fetal growth restriction, as defined by customised birth weight centile, adjusted for alcohol intake and salivary cotinine concentrations.
Caffeine consumption throughout pregnancy was associated with an increased risk of fetal growth restriction (odds ratios 1.2 (95% CI 0.9 to 1.6) for 100-199 mg/day, 1.5 (1.1 to 2.1) for 200-299 mg/day, and 1.4 (1.0 to 2.0) for >300 mg/day compared with <100 mg/day; test for trend P<0.001). Mean caffeine consumption decreased in the first trimester and increased in the third. The association between caffeine and fetal growth restriction was stronger in women with a faster compared to a slower caffeine clearance (test for interaction, P=0.06).
Caffeine consumption during pregnancy was associated with an increased risk of fetal growth restriction and this association continued throughout pregnancy. Sensible advice would be to reduce caffeine intake before conception and throughout pregnancy.
Diagnosis of DVT: 2-Point Ultrasound plus D-Dimer Is Comparable to Whole-Leg Ultrasound
Although simpler and more readily available, the 2-point ultrasound strategy requires follow-up study in nearly one third of patients.
Two-point ultrasound for the diagnosis of deep venous thrombosis (DVT) involves evaluation of the common femoral and popliteal veins. This strategy requires that patients with normal ultrasound results and elevated D-dimer results undergo follow-up study within 1 week to detect calf DVT that would have been missed by the initial 2-point ultrasound. Newer color-coded Doppler ultrasound allows evaluation of the small and large vessels of the entire leg. Researchers compared the two strategies in a prospective, randomized study of 2098 consecutive symptomatic patients who presented to 14 centers with first episodes of suspected DVT from 2003 through 2006. Patients with normal results were followed for 3 months.
The prevalence of DVT on the initial 2-point ultrasound was 22%. Among patients with normal 2-point ultrasound findings, 31% had positive D-dimer results and underwent repeat testing at 1 week (or earlier); 5.5% had DVT. Among the whole-leg color-coded ultrasound cohort, 26% of patients had positive findings on the initial test: 77% had proximal DVT, 13% had isolated posterior tibial or peroneal DVT, and 10% had isolated muscular vein thrombosis. At 3-month follow-up, the incidence of DVT in patients who had normal findings at the initial evaluation did not differ significantly between the 2-point ultrasound and color-coded ultrasound groups (0.9% vs. 1.2%).
Comment: This study demonstrates that the two ultrasound strategies are equivalent for diagnosing lower-extremity DVT. Two-point ultrasound is simple, convenient, and widely available, but this strategy requires repeat testing within 1 week in patients with normal ultrasound findings and elevated D-dimer results (30% of patients in this study). Whole-leg color-coded ultrasound provides a definitive result but might lead to unnecessary anticoagulation of small calf DVT that might otherwise resolve spontaneously.
Published in Journal Watch Emergency Medicine October 30, 2008
Bernardi E et al. Serial 2-point ultrasonography plus D-dimer vs whole-leg color-coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis: A randomized controlled trial. JAMA 2008 Oct 8; 300:1653.
It is important to prepare your manuscript properly, part of which is to follow the journal's guidelines. Using a checklist helps to ensure acceptance of your manuscript by the journal.
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Geneva Scoring for Pulmonary Embolism Simplified Further
Archives of Internal Medicine article
A further simplification of the Geneva score to evaluate the likelihood of pulmonary embolism retains the diagnostic accuracy of the original, reports Archives of Internal Medicine. Researchers evaluated the simplified approach retrospectively in some 1050 patients with suspected pulmonary embolism. Instead of receiving symptom-weighted scores, the patients received 1 point for each the following factors: Patients with scores of 2 or less were considered unlikely to have pulmonary embolism under the revised scoring. Although no patients in the "unlikely" group with normal D-dimer levels developed pulmonary embolism during 3 months' follow-up, the authors estimate that in clinical practice, the probability of pulmonary embolism would be up to 3% in this patient population.
A further simplification of the Geneva score to evaluate the likelihood of pulmonary embolism retains the diagnostic accuracy of the original, reports Archives of Internal Medicine.
Researchers evaluated the simplified approach retrospectively in some 1050 patients with suspected pulmonary embolism. Instead of receiving symptom-weighted scores, the patients received 1 point for each the following factors:
Patients with scores of 2 or less were considered unlikely to have pulmonary embolism under the revised scoring. Although no patients in the "unlikely" group with normal D-dimer levels developed pulmonary embolism during 3 months' follow-up, the authors estimate that in clinical practice, the probability of pulmonary embolism would be up to 3% in this patient population.
Statin Side Effects
In particular, researchers are looking at cognitive and musculoskeletal effects of statins.
Although statins generally are well tolerated, many clinicians believe that, in practice, statin-related side effects occur more commonly than was reported in randomized trials. Muscle symptoms, the most well-known statin side effect, can occur without elevated creatine kinase (CK) levels. Indeed, one study demonstrated reversible pathologic abnormalities on muscle biopsies in patients with normal CK levels who developed muscle pain or weakness while taking statins (JW Nov 1 2002). Recently, researchers identified a common variant of a gene on chromosome 12 that predisposes patients to statin myopathy.
Determining whether a statin users myalgias are related to the drug often is difficult. Thus, we would benefit by knowing whether statin users, as a group, experience muscle symptoms in excess of the background prevalence. In a recent study, in which researchers used the nationally representative NHANES database and excluded people with known arthritis, 22% of statin users and 17% of nonusers reported musculoskeletal pain. In a multivariable analysis, statin users exhibited significantly increased odds for musculoskeletal pain compared with nonusers (odds ratio, 1.5, after adjustment for many potentially confounding variables). Although this cross-sectional analysis has limitations, it suggests that statin-associated muscular symptoms are not rare.
A point of controversy is whether statins cause cognitive problems in some people. This issue made national headlines in February 2008, when a Wall Street Journal article described patients who had developed problems with memory and other cognitive skills while taking statins. The article included testimonials by academic physicians and an affected patient. Other experts have expressed concerns that these reports exaggerate statin risks and that negative publicity about statins will frighten patients unnecessarily.
Yet another concern about statins and cognition was raised in a recently published study. Canadian researchers used a national database to conduct a retrospective analysis of nearly 300,000 patients (age, 65) who had undergone elective surgery. Patients who had been prescribed statins during the previous 90 days had a significantly higher risk for developing postoperative delirium than did statin nonusers (OR, 1.3 after adjustment for many potential confounders). The database did not indicate when statin users last took statin drugs before surgery, ascertainment of delirium cases was incomplete, and hidden confounding that was not captured by the database is possible. Intriguingly, no other class of cardiovascular drugs was associated with postoperative delirium. The authors speculate that altered cerebral blood flow, resulting from the effects of statins on vascular smooth muscle, could be one mechanism for statin-induced postoperative delirium. If this theory is borne out, it would compete with other data that suggest an association between perioperative statin therapy and lower postoperative mortality.
The beneficial effects of statins in high-risk patient populations are indisputable. However, these drugs increasingly are being prescribed to asymptomatic people on the basis of somewhat arbitrary serum lipid thresholds, without regard to overall cardiovascular risk. Thus, gathering more information about potential adverse effects is imperative. One noteworthy effort comes from the University of California at San Diego, where researchers have conducted an NIH-funded randomized placebo-controlled trial to gather detailed information about statin side effects. The study focused particularly on statins effects on cognition and behavior but also tracked other adverse effects.6 Results should be available soon. In addition, the same group currently is conducting an observational study called the Statin Effects Study.
Published in Journal Watch General Medicine October 28, 2008
Source: BMJ 2008;337:a1302
Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial
To investigate whether paracetamol (acetaminophen) plus ibuprofen are superior to either drug alone for increasing time without fever and the relief of fever associated discomfort in febrile children managed at home.
Individually randomised, blinded, three arm trial.
Primary care and households in England.
Children aged between 6 months and 6 years with axillary temperatures of at least 37.8°C and up to 41.0°C.
Advice on physical measures to reduce temperature and the provision of, and advice to give, paracetamol plus ibuprofen, paracetamol alone, or ibuprofen alone.
Main outcome measures
Primary outcomes were the time without fever (<37.2°C) in the first four hours after the first dose was given and the proportion of children reported as being normal on the discomfort scale at 48 hours. Secondary outcomes were time to first occurrence of normal temperature (fever clearance), time without fever over 24 hours, fever associated symptoms, and adverse effects.
On an intention to treat basis, paracetamol plus ibuprofen were superior to paracetamol for less time with fever in the first four hours (adjusted difference 55 minutes, 95% confidence interval 33 to 77; P<0.001) and may have been as good as ibuprofen (16 minutes, –7 to 39; P=0.2). For less time with fever over 24 hours, paracetamol plus ibuprofen were superior to paracetamol (4.4 hours, 2.4 to 6.3; P<0.001) and to ibuprofen (2.5 hours, 0.6 to 4.4; P=0.008). Combined therapy cleared fever 23 minutes (2 to 45; P=0.025) faster than paracetamol alone but no faster than ibuprofen alone (–3 minutes, 18 to –24; P=0.8). No benefit was found for discomfort or other symptoms, although power was low for these outcomes. Adverse effects did not differ between groups.
Parents, nurses, pharmacists, and doctors wanting to use medicines to supplement physical measures to maximise the time that children spend without fever should use ibuprofen first and consider the relative benefits and risks of using paracetamol plus ibuprofen over 24 hours.
- High CRP (C-reactive protein)
- Internal fistulae
- Disease in the colon alone
- Avoidance style of coping with stress (ie avoiding social interaction)
Source: Gut 2008;57:1386-1392
- Headache affects 95% of people in their lifetime
- Headache affects 75% of people in any one year
- One in 10 people have migraine
- One in 30 people have headache more often than not, for 6 months or more
- At least 90% of patients seen in a neurology outpatient clinic with headache will have migraine, tension type headache, or a chronic daily headache syndrome
- Sinister causes of headache are rare, perhaps 0.1% of all headaches in primary care
Three Hours of Follow-Up Is Sufficient for Asymptomatic Penetrating Thoracic Trauma
Plain films at 6 hours did not detect any pneumothoraces or hemothoraces that were not seen at presentation or at 3 hours.
Penetrating thoracic trauma is termed "asymptomatic" if the patient has no symptoms, signs, or radiographic findings of intrathoracic injury, but delayed pneumothorax or hemothorax occurs in about 3% of such patients and usually necessitates tube thoracostomy. Patients with asymptomatic thoracic penetrating trauma usually are observed and undergo repeat chest radiography after 6 hours. However, findings from two studies suggest that 3 hours is sufficient for follow-up (JW Emerg Med May 16 2001 and Surg Gynecol Obstet 1992; 175:249).
In a prospective study, researchers compared chest radiography findings at 3 and 6 hours after presentation in patients who presented to a single emergency department within 2 hours after asymptomatic penetrating thoracic trauma (anatomic boundaries of injury: clavicles and base of the neck, superiorly; inferior costal margin and iliac crests, inferiorly). Supine anteroposterior chest radiographs were obtained at presentation, and upright posterioanterior and lateral chest radiographs were obtained at 3 and 6 hours. Patients with worrisome clinical or laboratory findings or findings of pneumothorax or hemothorax on the initial radiograph were excluded.
Of 100 patients who met inclusion criteria, 75% were men, 75% had stab wounds, and 25% had gunshot wounds. The average ED stay was 8.8 hours. Two patients had findings of pneumothorax on the 3-hour film; both patients underwent tube thoracostomy. No new cases of pneumothorax or hemothorax were detected on the 6-hour films. Patient charges, including the cost of radiographs and continuous pulse oximetry monitoring, were US$2802 for the 3-hour observation period and $4521 for the 6-hour period.
Comment: In the three studies published to date (including this study) that compared chest radiography findings at 3 and 6 hours, 8 of the combined total of 304 patients (2.6%) developed pneumothoraces within 3 hours, and no patients developed pneumothoraces or hemothoraces within the next 3 hours. The inherent value of a 3-hour follow-up chest radiography policy is that the stay is shortened, thereby relieving ED overcrowding, and associated healthcare costs are reduced considerably. Moreover, this approach limits radiation exposure, a matter of increasing concern. Some authors have advocated for the use of chest computed tomography (CT) at presentation, with immediate discharge if the scan is negative. However, that approach is a poor alternative because thoracic CT transmits 8 mSv of ionizing radiation — an amount that is 400 times the radiation dose of a two-view chest radiograph and is equivalent to 3 years of background radiation in the U.S. Finally, the evolving role of ED ultrasound, such as the extended FAST examination, and its ability to identify pneumothorax remain to be determined.
Published in Journal Watch Emergency Medicine October 10, 2008
Seamon MJ et al. Follow-up after asymptomatic penetrating thoracic injury: 3 hours is enough. J Trauma 2008 Sep; 65:549.
Early Goal-Directed Therapy for Sepsis: Show Me the Data!
A meta-analysis of randomized sepsis trials showed mortality benefit with early goal-directed therapy.
The validity of various aspects of early goal-directed therapy (EGDT) for patients with severe sepsis and septic shock has been challenged in non–peer-reviewed publications. Researchers conducted a meta-analysis of randomized controlled trials in adult patients with sepsis; eligible trials described the resuscitative protocol used to achieve predetermined hemodynamic endpoints and included control groups of patients who received standard care. The primary endpoint in the meta-analysis was mortality. Assessment of trial quality included evaluation of diagnostic criteria for patient selection and internal validity.
Of 903 reports identified in a comprehensive search, 29 were chosen for complete manuscript review, and 9 (involving a total of 1001 patients) were eligible for inclusion in the final analysis. Overall, mortality was significantly lower in patients who received resuscitation directed by quantitative endpoints than in those who received standard care (odds ratio, 0.64; 95% confidence interval, 0.43–0.96). Analysis of predefined subgroups of patients who received endpoint-directed resuscitation early (6 studies) demonstrated lower mortality with this procedure (OR, 0.50; 95% CI, 0.37–0.69). However, no mortality benefit resulted from late (>24 hours) resuscitation (OR, 1.16; 95% CI, 0.60–2.22). The results remained consistent in sensitivity analyses. Because the early endpoint-based resuscitation strategy had such a clear effect on mortality, the investigators performed a post hoc sensitivity analysis to determine whether any specific study had a disproportionate influence on the overall results; as each study was excluded and data from the remaining studies were reanalyzed, the significant mortality benefit of early goal-directed resuscitation remained consistent.
Comment: This meta-analysis showed a dramatic mortality benefit from early resuscitation that was targeted to achieve specified physiologic goals. The authors conclude that the data strongly support the Surviving Sepsis Campaign recommendations for EGDT in septic patients. Large multicenter studies evaluating the benefits of EGDT, including various individual components, currently are under way or nearing completion. Until those results are available, clinicians resuscitating patients with sepsis syndrome are well advised to embrace the principles of EGDT, which are supported by more than 14 peer-reviewed publications.
Published in Journal Watch Emergency Medicine October 3, 2008
Citation(s): Jones AE et al. The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: A meta-analysis. Crit Care Med 2008 Oct; 36:2734
Coronary Artery Spasm as a Cause of Acute Coronary Syndrome
About one in two ACS patients without artery occlusion exhibited vasospasm.
Coronary artery spasm is a potential cause of ischemia, but what is the incidence of spasm in patients who present to emergency departments with suspected acute coronary syndrome (ACS)? In this European study, investigators studied 488 consecutive patients with suspected ACS (defined as acute chest pain associated with ischemic changes on electrocardiogram or cardiac biomarker elevations) who underwent angiography.
In 138 patients (28%), epicardial coronary angiography did not reveal clear culprit lesions: 22 patients received alternative diagnoses (e.g., myocarditis) without spasm testing; 30 did not undergo spasm testing for various reasons; and 86 underwent provocative testing with intracoronary acetylcholine to see whether spasm (defined as a 75% constriction), associated with reproduction of symptoms, could be provoked. Spasm was confirmed in 42 patients. Among the 86 tested patients, cardiac enzyme levels generally were normal and were similar in patients with and without coronary spasm.
Comment: In this largely white cohort, angiography detected no culprit lesions in roughly one in four patients with suspected ACS. Of those who underwent acetylcholine challenges, almost half exhibited inducible vasospasms. As an editorialist notes, this study lacks outcome data to tell us whether vasospasm is associated with adverse outcomes in these patients and whether routine testing and treatment for spasm would be helpful in improving outcomes. However, clinicians should remember to consider vasospasm as an alternative diagnosis in patients with suspected ACS, especially when angiography reveals no clear culprit lesions.
Published in Journal Watch General Medicine September 30, 2008
Citation(s): Ong P et al. Coronary artery spasm as a frequent cause of acute coronary syndrome: The CASPAR (Coronary Artery Spasm in Patients With Acute Coronary Syndrome) study. J Am Coll Cardiol 2008 Aug 12; 52:523
- Most transient ischemic attacks last less than 1 hour.
- Almost half of transient ischemic attacks result in cerebral infarction on diffusion-weighted imaging; the chance of infarction increases with increasing duration of symptoms.
- According to new proposed criteria in 2002, the presence of a new infarction on CT or MRI in association with a referable symptom, regardless of symptom duration, is defined as a stroke.
- Isolated dizziness (including vertigo) and syncope are rarely transient ischemic attacks.
- Weakness in the face on the side opposite to weakness in the arm and leg suggests brainstem ischemia.
- Gaze deviation toward the side of weakness suggests brainstem ischemia, whereas gaze deviation away from the weakness suggests hemispheric ischemia.
Figure. One approach to management of patients with transient ischemic attack. ER, Extended-release; ICA, internal carotid artery; INR, international normalized ratio; IV, intravenous; LMWH, low-molecular-weight heparin; UFH, unfractionated heparin.
- Clinical features that predict increased short-term risk of stroke after transient ischemic attack include older age,hypertension, diabetes, symptoms of weakness or speechimpairment, and symptom duration greater than 10minutes.
- Magnetic resonance imaging with diffusion-weighted imaging and vascular imaging may play an important role in risk-stratifying patients with transient ischemic attack.
- Flat head positioning, isotonic fluid administration, and permissive hypertension are basic measures to improve cerebral blood flow and mitigate cerebral ischemia.
- For most patients with transient ischemic attack, aspirin should be started as soon as neuroimaging has ruled out the possibility of hemorrhage.
- The specific cause of the transient ischemic attack in individual patients must be determined to select the most appropriate long-term preventive therapy.
- Patients who experience stroke after transient ischemic attack
should be considered for thrombolysis.
A transient ischemic attack portends significant risk of a stroke. Consequently, the diagnostic evaluation in the emergency department is focused on identifying high-risk causes so that preventive strategies can be implemented. The evaluation consists of a facilitated evaluation of the patient’s metabolic, cardiac, and neurovascular systems. At a minimum, the following tests are recommended: fingerstick glucose level, electrolyte levels, CBC count, urinalysis, and coagulation studies; noncontrast computed tomography (CT) of the head; electrocardiography; and continuous telemetry monitoring. Vascular imaging studies, such as carotid ultrasonography, CT angiography, or magnetic resonance angiography, should be performed on an urgent basis and prioritized according to the patient’s risk stratification for disease. Consideration should be given for echocardiography if no large vessel abnormality is identified.
- The risk of stroke is greatest immediately after a transient ischemic attack; thus, a rapid evaluation to determine the cause of the event and potentially preventable risk factors is imperative.
- At a minimum, the ED evaluation of a transient ischemic attack should include noncontrast CT of the head, fingerstick glucose level, serum chemistry studies, CBC count, a coagulation profile, urinalysis, electrocardiography, and a pregnancy test when appropriate.
- The subsequent evaluation of a patient who has had a transient ischemic attack should focus on identifying highrisk causes and thus involve cardiac monitoring; vascular imaging such as carotid ultrasonography, computed tomographic angiography, or magnetic resonance angiography; and echocardiography if the previous evaluation result is negative or if there is a potential high-risk cardiac source.
- Carotid duplex ultrasonography is excellent for identifying internal carotid artery stenosis as a cause of a transient ischemic attack; however, it visualizes only a short segment of the carotid artery and is relatively insensitive for dissection.
- If cervicocephalic arterial dissection is suspected, MRI with axial fat-saturated T1 images or computed tomographic angiography should be ordered.
Despite advances in early detection and standard treatment, non–small-cell lung cancer is often diagnosed at an advanced stage and has a poor prognosis.
What type of lung cancer is most common among nonsmokers?
A: Adenocarcinoma is the most common type of lung cancer in patients who have never smoked.
What type of lung cancer is most common among smokers?
A: Smoking causes all types of lung cancer but is most strongly linked with small-cell lung cancer and squamous-cell carcinoma.
New England Journal of Medicine - Vol. 359, No. 13, September 25, 2008
Ipratropium carries a higher cardiovascular mortality risk than other drugs used to treat chronic obstructive pulmonary disease (COPD), according to an Annals of Internal Medicine report.
Using a nested case-control design, researchers examined mortality risks in a 145,000-member cohort of U.S. veterans recently diagnosed with COPD. Analysis of Veterans Affairs databases revealed a higher risk for cardiovascular death among those with ipratropium exposure in the 6 months preceding their death than among matched controls who had not received ipratropium in the same 6-month period (odds ratio, 1.34). Inhaled corticosteroids were associated with a decrease in cardiovascular deaths.
The authors, noting that their data suggest "a substantial number of premature deaths" due to ipratropium use, conclude that "caution is warranted" in using the drug alone in patients with a recent diagnosis of COPD.
Published in Physician's First Watch September 16, 2008
Inhaled Anticholinergics Linked to Increased Cardiovascular Risk in COPD
Patients using inhaled anticholinergics (ipratropium or tiotropium bromide) to treat chronic obstructive pulmonary disease face increased risk for cardiovascular events, according to a meta-analysis in JAMA.
The analysis included 17 trials that randomized nearly 15,000 patients with COPD to an inhaled anticholinergic or control therapy. Follow-up ranged from 6 weeks to 5 years.
Risk for the primary endpoint — a composite of cardiovascular death, myocardial infarction, and stroke — was significantly higher among patients on anticholinergics than among controls (1.8% vs. 1.2%). Increased incidence of MI and cardiovascular death appeared to account for the elevated risk.
When long- and short-term studies were analyzed separately, risk for the composite endpoint remained significantly elevated in long-term trials, while the increased risk in short-term studies was not statistically significant.
The authors conclude that COPD patients on long-term anticholinergics must be closely monitored for cardiovascular events.
At 5-year repeat colonoscopy, only 1% of 1250 participants had advanced neoplasms.
U.S. guidelines generally recommend a 10-year interval after a normal initial screening colonoscopy, but the optimal interval is uncertain. In this study, researchers examined the prevalence of abnormalities among employees of a company that offered routine colonoscopic screening at 5-year intervals.
A total of 2436 asymptomatic people (age, 50) had no adenomas on first-time screening colonoscopy; 1256 of them returned for rescreening at 5 years. One or more neoplastic polyps were found in 201 (16%) of these rescreened people, but only 16 (1.3%) had advanced neoplasms (tubular adenomas 1 cm, polyps with a villous component, or polyps with high-grade dysplasia).
Comment: In this study, people for whom initial screening colonoscopy results were normal had a very low prevalence of advanced neoplasia on 5-year follow-up colonoscopy. These findings suggest that the rescreening interval should be at least 5 years. For policy makers, a more relevant study would be a randomized trial in which 5-year and 10-year intervals are compared, but the requirement for long-term enrollment would make such a trial difficult to complete successfully. For now, we have no reason to change screening guidelines in the U.S.
Allan S. Brett, MDPublished in Journal Watch General Medicine September 23, 2008Citation(s):Imperiale TF et al. Five-year risk of colorectal neoplasia after negative screening colonoscopy. N Engl J Med 2008 Sep 18; 359:1218.
- No evidence of benefit from antibiotics or oral steroids
- Inhaled salbutamol, theophyllines, and adrenaline do not have strong evidence for their use
- Limited evidence for antiviral ribavirin - currently used for immunosuppressed children only
- Admit to hospital if child is hypoxic, dehydrated, or high risk, eg immunosupressed (oxygen and nasogastric feeding are still the mainstays of hospital treatment)
- After bronchiolitis, a child remains likely to get respiratory symptoms like wheeze, which can last until early adolescence
- Immunisation against RSV is an option - RSV is the commonest but not only cause of bronchiolitis
Source: Archives of Disease in Childhood 2008;93:793-798