Nontraumatic Subarachnoid Hemorrhage in the Setting of Negative Cranial Computed Tomography Results: External Validation of a Clinical and Imaging Prediction Rule

Nontraumatic Subarachnoid Hemorrhage in the Setting of Negative Cranial Computed Tomography Results: External Validation of a Clinical and Imaging Prediction Rule

Study objective
Clinical variables can reliably exclude a diagnosis of nontraumatic subarachnoid hemorrhage in patients with negative cranial computed tomography (CT) results. We externally validated 2 decision rules with 100% reported sensitivity for a diagnosis of subarachnoid hemorrhage, among patients undergoing lumbar puncture after a negative cranial CT result: (1) clinical rule: presence of any combination of age 40 years and older, neck pain or stiffness, loss of consciousness, or headache onset during exertion; and (2) imaging rule: cranial CT performed within 6 hours of headache onset.

Methods
This was a matched case-control study of patients presenting to 21 emergency departments between 2000 and 2011. Patients with a diagnosis of subarachnoid hemorrhage as determined by lumbar puncture after a negative cranial CT result were screened for inclusion. A matched control cohort was selected among patients with a diagnosis of headache after negative cranial CT and lumbar puncture results.

Results
Fifty-five cases of subarachnoid hemorrhage meeting inclusion criteria were identified, 34 (62%) of which were attributed to cerebral aneurysms. External validation of the clinical rule demonstrated a sensitivity of 97.1% (95% confidence interval [CI] 88.6% to 99.7%), a specificity of 22.7% (95% CI 16.6% to 29.8%), and a negative likelihood ratio of 0.13 (95% CI 0.03 to 0.61) for a diagnosis of subarachnoid hemorrhage. External validation of the imaging rule revealed that 11 of 55 subarachnoid hemorrhage cases (20%) had negative cranial CT results for tests performed within 6 hours of headache onset.

Conclusion
The clinical rule demonstrated useful Bayesian test characteristics when retrospectively validated against this patient cohort. The imaging rule, however, failed to identify 20% of subarachnoid hemorrhage patients with a negative cranial CT result.

 

2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker

2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker : The ADAPT Trial. Than, M, Cullen, L, et. al. Am Coll Cardiol. 2012 Jun 5;59(23):2091-­‐8.

In the ADAPT trial patients were enrolled between 2007 – 2011. Inclusion and exclusion criteria appear appropriate and relevant to our population with the exception one: the inability to contact the patient after follow-up. This exclusion could potentially apply to a large number of our patients. In addition the exclusion criteria included “staff considered recruitment to be inappropriate”, which could introduce bias into the study.  Of those recruited not a single person was lost to follow-up. Of those deemed low-risk only one had a MACE, which on further review had a rising trop, making it very unlikely that this patient would have been discharged from our ED. The negative likelihood ratio for the ADAPT trial was 0.01, which is very strong. Additionally it was noted that the negative likelihood ratio for TIMI 0 and non-ischemic ECG was 0.07, also very strong. This data is similar that found in other studies evaluating TIMI and low-risk ECG. While this data needs to be reproduced in additional studies a 2 hours protocol using TIMI, ECG, and high sensitivity troponin may be safe option in low-risk patients.

Overall the article was well received. It was felt that although the study was done in Australia, as we are currently using high-sensitivity troponin in our ED, this study could be applied to our patient population. In general the study receives a thumbs-up.

Zinc for the Common Cold

Zinc for the Common Cold
Singh, M., Das, R.R.  Zinc for the common cold.  Cochrane Database Syst Rev. 2011 Feb 16;(2):CD001364. doi: 10.1002/14651858.CD001364.pub3
http://www.ncbi.nlm.nih.gov/pubmed/21328251

1)      The common cold is one of the most common causes for illness, doctor visits, and missing school/work.  The average child gets eight colds per year and the average adult gets three colds per year.  This study proposed assessing zinc supplementation as beneficial for the common cold.  This was a Cochrane review that included randomized, double-blind placebo-controlled trials with zinc; both the treatment and prevention of colds were assessed.  Nine hundred sixty-six participants in 13 trials were assessed and findings showed that there was a significant reduction in the duration and severity of the colds with zinc.  In two preventative trials with 394 participants, there was decreased incidence of colds, less antibiotic use, and fewer school absences in the zinc group.  However, there was also a higher rate of nausea and bad taste in the zinc group.  Results showed that zinc should be administered within one day of symptoms at the onset of the cold to be effective and should continue for at least five days.

2)      The patients were randomized and they only included placebo-controlled trials.  This review used a total of 15 different studies that were very heterogeneous in the outcomes they measured and the type and amount of zinc that was used.  They included the best studies available to date with the best methodology, but given the variety in studies, it is hard to make clear statements on exact recommendations.  Patients may have also known what group they were in based solely on the taste of zinc and nausea associated with its use.  Treatment effects were clearly shown in some studies and not clear in others. However, overall the results showed that if zinc is taken within one day of symptoms, the patient had a two-day earlier resolution of their cold as well as decreased severity.  The patients in these studies tended to be outpatients and not ED patients.  Given that side effects are minimal and not life threatening, the benefits are worth the potential risk.

3)      Although this is not a lifesaving treatment, it is something that is safe and can provide patients with an additional way to fight off viral infections in lieu of only purchasing over- the-counter cold relievers. It has also been shown that patients who take zinc end up being prescribed fewer antibiotics, which is highly beneficial to both patients and healthcare at the national level.

Coben Thorn

A Phase 2 Randomized, Double-Blind, Placebo– Controlled Study of the Safety and Efficacy of Talactoferrin in Patients With Severe Sepsis*,

A Phase 2 Randomized, Double-Blind, Placebo–Controlled Study of the Safety and Efficacy ofTalactoferrin in Patients With Severe Sepsis*

Objectives:
Lactoferrin is a glycoprotein with anti-infective and antiinflammatory
properties found in secretions and immune cells. Talactoferrin
alfa, a recombinant form of human lactoferrin, has similar
properties and plays an important role in maintaining the gastrointestinal
mucosal barrier integrity. In experimental animal models, administration
of talactoferrin reduces translocation of bacteria from the gut
into the systemic circulation and mortality from sepsis. Our objective
was to determine if talactoferrin could reduce 28-day all-cause mortality
in patients with severe sepsis and to assess its safety.

Management of Minor Head Injury in Patients Receiving Oral Anticoagulant Therapy: A Prospective Study of a 24-Hour Observation Protocol

Management of Minor Head Injury in Patients Receiving OralAnticoagulant Therapy: A Prospective Study of a 24-HourObservation Protocol

Background
The indications for computed tomography (CT) scanning in
the setting of minor head injury have been the focus of
substantial research. Long-term oral anticoagulation has been
identified as a significant risk factor for intracranial injury,
and CT scanning is generally recommended for such patients
regardless of clinical presentation. However, it remains
unclear whether such patients should then be hospitalized for
observation or undergo a later second CT scan. Oral
anticoagulant therapy is prescribed to prevent thromboembolic
complications of atrial fibrillation, deep venous thrombosis, and
surgically placed cardiac valves.

Prospective Evaluation of a Clinical Practice Guideline for Diagnosis of Appendicitis in Children

Prospective Evaluation of a Clinical Practice Guideline for Diagnosis of Appendicitis in Children

Objectives:
The objective was to assess the performance of a clinical practice guideline for evaluation of possible appendicitis in children. The guideline incorporated risk stratification, staged imaging, and early surgical involvement in high-risk cases.

Patients With Rib Fractures Do Not Develop Delayed Pneumonia: A Prospective, Multicenter Cohort Study of Minor Thoracic Injury

Patients With Rib Fractures Do Not Develop Delayed Pneumonia: A Prospective, Multicenter Cohort Study of Minor Thoracic Injury

Background
In 2006, there were 119.2 million visits to hospital
emergency departments (EDs) in the United States, and
more than one third of them were injury-related. Thoracic
trauma frequency is estimated at 12 people per million per
day, representing more than 796,000 ED visits annually.
In the case of thoracic trauma, injuries of moderate
severity are most often sustained to the chest wall and thus
rarely require surgical intervention. Ziegler and Agarwal
reported a 10% incidence of rib fractures in trauma patients
treated at their site. In 2003, Liman et al observed that 2 of
3 patients could be safely discharged from EDs. As financial
pressures create more ambulatory care situations, minor
thoracic injury patients are rapidly discharged from EDs
without appropriate follow-up.

Treating primary headaches in the ED: can droperidol regain its role?

Treating primary headaches in the ED: can droperidol regain its role?

OBJECTIVE:
The aim of this study was to describe the use and efficacy of low-dose (≤2 mg) droperidol for the treatment of primary headaches (ie, migraine, cluster, tension-type headache and trigeminal autonomic cephalalgias, and other primary headaches) in the emergency department (ED).

Ketamine With and Without Midazolam for Emergency Department Sedation in Adults: A Randomized Controlled Trial

Ketamine With and Without Midazolam for Emergency Department Sedation in Adults: A Randomized Controlled Trial

Background
Procedural sedation and analgesia is a technique of administering
sedatives (midazolam, propofol, etomidate) or dissociative agents
(ketamine) with or without opioid analgesics (fentanyl, morphine,
meperidine) to induce a state that allows the patient to tolerate
unpleasant procedures while maintaining cardiorespiratory function.
Ketamine, first described in 1965, has been administered extensively for procedural sedation and analgesia in children and is a safe and effective sedative analgesic for painful procedures not only in the emergency department (ED) but also in the out-of-hospital setting.
The widespread acceptance of ketamine as an agent for procedural
sedation and analgesia in adult ED patients may be limited by
physician apprehension about dreaming and hallucinations during
recovery, and unpleasant reactions and nightmares, collectively referred to as recovery agitation.

Vasopression / Epinephrine / Dabigatran / Warfarin and Cardiopulmonary

UF EM Journal Club 06/14/2011

* Vasopressin and Epinephrine vs. Epinephrine Alone in Cardiopulmonary Resuscitation
BACKGROUND: During the administration of advanced cardiac life support for resuscitation from cardiac arrest, a combination of vasopressin and epinephrine may be more effective
than epinephrine or vasopressin alone, but evidence is insufficient to make clinical
recommendations.

* Dabigatran versus Warfarin in Patients with Atrial Fibrillation
BACKGROUND: Warfarin reduces the risk of stroke in patients with atrial fibrillation but increases the risk of hemorrhage and is difficult to use. Dabigatran is a new oral direct thrombin
inhibitor.

Do Emergency Department Blood Cultures Change Practice in Patients With Pneumonia?

UF EM Journal Club - 01/20/2011
Do Emergency Department Blood Cultures Change Practice in Patients With Pneumonia?

Study objective: Although it is considered standard of care to obtain blood cultures on patients hospitalized for pneumonia, several studies have questioned the utility and cost-effectiveness of this practice. The objective of this study is to determine the impact of emergency department (ED) blood cultures on antimicrobial therapy for patients with pneumonia.

Please print and have this article ready for conference.

Traumatic Pedatric Lacerations Repair / Gut vs Nylon Sutures

UF EM Journal Club - 01/25/11

Hi all
This is my article for our journal club on Jan 25th:

CLINICAL INVESTIGATIONS ARTICLE - LINK
A Randomized, Controlled Trial Comparing Long-term
Cosmetic Outcomes of Traumatic Pediatric
Lacerations Repaired with Absorbable Plain Gut
versus Nonabsorbable Nylon Sutures

AbstractObjectives: To show that the use of absorbable sutures in
pediatric traumatic lacerations affords good long-term
cosmesis and no increase in complications (infection, dehiscence
rates, and need for surgical scar revision) when
compared with wounds sutured with nonabsorbable sutures.

Please print article, and have on hand at meeting.

The benefits of steroids versus steroids plus antivirals for treatment of Bell’s palsy: a meta-analysis

The link below is for the EM Journal Club meeting on 10/19/2010.

The benefits of steroids versus steroids plus antivirals for treatment of Bell’s palsy: a meta-analysis

ABSTRACT:
Objective To determine whether steroids plus antivirals
provide a better degree of facial muscle recovery in
patients with Bell’s palsy than steroids alone.
Design Meta-analysis

Journal Club Assessment Form

Please be prepared, and have all materials printed for Journal Club.

Implementation of the Canadian C-Spine Rule

The link below is assigned reading for EM Journal Club on July 29,2010.

Implementation of the Canadian C-Spine Rule

Effects of tranexamic acid

EM Journal Club Assessment Form

Please print, and have ready for EM Journal Club

Management of suspected pulmonary embolism (PE) by D-dimer

Management of suspected pulmonary embolism (PE) by D-dimer
Attached are the articles for Journal Club.

Management of suspected pulmonary embolism (PE) by
D-dimer and multi-slice computed tomography in outpatients:
an outcome study

The performance of STA-Liatest D-dimer assay in out-patients
with suspected pulmonary embolism

The usefulness of five D-dimer assays in the exclusion of deep
venous thrombosis

Clinical Features From the History and Physical Examination
That Predict the Presence or Absence of Pulmonary Embolism in
Symptomatic Emergency Department Patients: Results of a
Prospective, Multicenter Study

Journal Club Assessment Form
There will be no paper copies distributed.
Please print these out if you wish to have a hard copy.
All residents should be prepared to discuss all of the articles

Dexamethasone as Add-On Therapy in Children

Dexamethasone as Add-On Therapy in Children
Attached are the articles for Journal Club for 12/15.

1 versus 3 Days of Dexamethasone Add-On Therapy in Children With Streptococcal Pharyngitis

CLINICAL EFFICACY OF DEXAMETHASONE FOR ACUTE EXUDATIVE PHARYNGITIS

Dr. Kaplan asks, "Do you think the benefits of pain reduction for pharyngitis outweigh potential risks associated with steroid use on the general population?"

Journal Club Assessment Form
There will be no paper copies distributed.
Please print these out if you wish to have a hard copy.
All residents should be prepared to discuss all of the articles

Pregnancy Risks and Birth Defects

Attached are the articles for EM Conference 11/19/09

Antibacterial Medication Use During Pregnancy and Risk of Birth Defects.

Effects of Pneumococcal Conjugate Vaccine on Pneumococcal Meningitis.

ED Throughput : Examining hospital and other significant factors.

The Effect of Hospital Bed Occupancy on Throughput in the Pediatric Emergency Department
Objective: Although it has been suggested that high hospital occupancy leads to emergency department (ED) overcrowding and impedes ED throughput, there are limited data defining this relationship. The objective of this study is to examine whether high inpatient hospital occupancy negatively affects throughput in a pediatric ED.

The Effect of Emergency Department Expansion on Emergency Department Overcrowding
Objective: To examine the effects of emergency department (ED) expansion on ambulance diversion at an urban, academic Level 1 trauma center.

Journal Club Assessment Form
There will be no paper copies distributed.
Please print these out if you wish to have a hard copy.
All residents should be prepared to discuss all of the articles.

Medical Treatment for Small Stones in the Lower Ureter

Tamsulosin for Ureteral Stones in the Emergency Department:
A Randomized, Controlled Trial

Study objective: The adrenergic antagonist tamsulosin hydrochloride has become an increasingly common adjunct in the treatment of ureteral calculi; however, its efficacy in a general emergency department (ED) population has not been investigated.

Attached are the articles for Journal Club which will be held on 09/15/09.

Medical Treatment for Small Stones in the Lower Ureter

Tamsulosin for Ureteral Stones in the Emergency Department


Journal Club Assessment Form
There will be no paper copies distributed.
Please print these out if you wish to have a hard copy.
All residents should be prepared to discuss all of the articles.

Respiratory Disease and Failure with (H1N1)

Respiratory Disease and Failure with (H1N1)
Attached are the articles for Journal Club which will be held on 08/20/09.

Severe Respiratory Disease Concurrent with the Circulation of H1N1 Influenza

Pneumonia and Respiratory Failure from Swine-Origin Influenza A (H1N1) in Mexico

The question to you is: "How will the Infuenza Pandemic affect the ED?"

What do you think?
Please leave a comment on this blog after reading the articles.

Journal Club Assessment Form
There will be no paper copies distributed.
Please print these out if you wish to have a hard copy.
All residents should be prepared to discuss all of the articles.