2-Point Ultrasound

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.

— John A. Marx, MD, FAAEM, FACEP

Published in Journal Watch Emergency Medicine October 30, 2008

Citation(s):

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.

Journal Submission Checklist

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.

Almost all journals have their guidelines on their website as well as publish their guidelines quarterly or in every issue. Guidelines are subject to change, so be sure you have the most recent guidelines. Below is a general checklist to assist you in ensuring your manuscript meets all the journal's requirements. Every journal is different and not all journals will require all of the items listed. Depending upon the journal you are targeting, you might want to add specific items to this list.

Cover Letter

❑ Determine whether a cover letter is needed
❑ Address the correct editor according to the manuscript subject
❑ Use the correct address
❑ Review what is required in the cover letter

General

❑ Determine the article type you are submitting
❑ Use the correct font type and size
❑ Adjust the line spacing (single or double spacing)
❑ Check the format for section headings
❑ Put the sections in the correct order
❑ Check the word length limits
❑ Use line numbering, if required
❑ Use page numbers, if required
❑ Adjust the margin size
❑ Confirm that the nomenclature is correct
❑ Check spelling
❑ Determine whether the Results and Discussion are separate sections or included together in one section

Title Page

❑ Verify the allowed Title length
❑ Determine whether a running or short title is needed
❑ Check whether Keywords are needed
❑ Confirm whether a List of Abbreviations is needed
❑ Ensure that all authors are listed
❑ Make sure the author's names and address are in the correct format
❑ Include all corresponding author information

Abstract

❑ Confirm the word limit
❑ Determine whether a structured or unstructured abstract is needed

References

❑ Confirm that the in-text citation format is correct
❑ Verify that all references cited in the text are included in the Reference List
❑ Make sure that all references in the Reference List are cited in the text
❑ Determine whether the references are formatted correctly
❑ Check the accuracy of the references

Tables and Figures

❑ Ensure that the in-text mention of figures and tables is formatted correctly
❑ Determine whether the Tables and Figures are located in the correct location
❑ Verify that the correct fonts and font size are used in the tables and figures
❑ Confirm numbering format for tables and figures (Roman or Arabic)
❑ Ensure that the size of figures and tables are correct
❑ Check that the correct file format is used (pdf, jpeg, gif, etc.)
❑ Determine the type of list for table titles and figure legends
❑ Make sure that all tables and figures are mentioned in the text
❑ Determine whether vertical lines are allowed in tables

Other

❑ Determine whether a conflict of interest statement is needed
❑ Check to see whether funding sources are required
❑ For medical manuscripts: Include an ethical and patient approval statement

For more detailed information regarding writing manuscripts for publication, please review some of our other articles at http://www.sfedit.net/newsletters.htm. These articles approach such subjects as Writing the First Draft, Writing Effective Results, Methods and Materials, Discussions, Selecting a Journal, Responding to Reviewers, etc.

Geneva Score

Geneva Scoring for Pulmonary Embolism Simplified Further

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:

• age over 65
• history of deep venous thrombosis or pulmonary embolism
• surgery under general anesthesia or lower-limb fracture within 1 month
• active malignancy
• unilateral lower-limb pain
• hemoptysis
• heart rate between 75 and 94, or 95 and above
• pain on lower-limb palpation and unilateral edema

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.

Archives of Internal Medicine article

Statin Side Effects

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 user’s 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.

— Allan S. Brett, MD

Published in Journal Watch General Medicine October 28, 2008

小兒發燒...

Many parents use paracetamol and ibuprofen to bring down their young child's high temperature. But this study shows that ibuprofen alone is the better choice because it lasts longer than paracetamol. There's no good evidence for combining the two drugs, and ibuprofen can't be given to babies under three months or those weighing less than 5 kg.

Source: BMJ 2008;337:a1302
Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial

Objective
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.

Design
Individually randomised, blinded, three arm trial.

Setting
Primary care and households in England.

Participants
Children aged between 6 months and 6 years with axillary temperatures of at least 37.8°C and up to 41.0°C.

Intervention
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.

Results
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.

Conclusion
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.

Crohn's Disease 復發的因子

Which of our patients with Crohn's Disease are most likely to relapse? This study found that the following factors make relapse more likely:

• High CRP (C-reactive protein)
• Internal fistulae
• Disease in the colon alone
• Avoidance style of coping with stress (ie avoiding social interaction)
  

Learning more effective ways of coping with stress may reduce relapses.

Source: Gut 2008;57:1386-1392

在急診看頭痛病人時...

Source: Practical Neurology 2008;8:335-343

• 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

切記：在急診看頭痛病人時，不能用好發率來思考，要反過來，應該優先排除那 0.1% 的 sinister causes，尤其是致命的 SAH！

胸部穿刺傷無症狀－3小時後照CXR

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.

— John A. Marx, MD, FAAEM, FACEP

Published in Journal Watch Emergency Medicine October 10, 2008

Citation(s):

Seamon MJ et al. Follow-up after asymptomatic penetrating thoracic injury: 3 hours is enough. J Trauma 2008 Sep; 65:549.

自殺風險評估 ... SAD PERSONS

若急診處理 Depression 病人時，記得病史該問的內容口訣如下：『傷心人的逃離 - SAD PERSON'S ESCAPE』。

請詳閱：
http://jack119.org/jackdocs/suiciderisk.pdf

EGDT for sepsis

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.

— Tiffany M. Osborn, MD

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