Archive for September, 2008

OMNI Postings of 9/30/08

by Paul Rega, MD — published on September 30th, 2008

Q: What do you do to an elephant with 3 balls?

A: Walk him and pitch to the giraffe.

But I digress…

1)  Did you know that there was concern that statins could be linked to ALS (Lou Gehrig’s Disease)?  The FDA (Funny Dopers’ Association) received a higher than expected number of Adverse Event Reporting System reports of ALS in patients on statins.  However, its analysis provides new evidence that the use of statins does not increase incidence of amyotrophic lateral sclerosis (ALS),
2)  Weird things can happen while you’re flying, like in this case.  So it’s always a good idea to keep the tenets of situational awareness in mind even when you’re not transporting a patient.
3)  Prasugrel was supposed to compete with Plavix to prevent clots.  This is the second time the FDA has put its approval on hold.  Lilly is not happy with this turn of events.  However, is Prasugrel better than Plavix?  A head-to-head study released last year showed that fewer patients taking prasugrel developed blood clots in stents or suffered heart attacks, strokes or heart-related deaths when compared with patients taking Plavix.  However, the study also showed that major bleeding occurred in a higher percentage of patients taking prasugrel.   BTW, I wonder how many FDA people own stock in drug/medical device companies and in what amounts?  Shouldn’t that be public knowledge?  Maybe not, when they’re all honorable like most people in government.
4)  Research shows that smoking cannabis (you know, weed, a joint, Mary Jane) increases the risk of early psychosis symptoms in people at high risk of developing the mental health disorder.  “What?  Who’s that?  Why are you following me?  Aaaaargh!!!”                                                          http://omniphysicians.com/2008/09/29/cannabis-cuckoo/
5)  Did you know the AMA has a litigation center?  It sounds like it’s there for its members when they’re being railroaded by various entities, including hospital administration.  http://omniphysicians.com/2008/09/29/amas-litigation-center/

6)  This Am J Med study evaluated whether doxycycline and tetracycline are as good as penicillin in the treatment of primary syphilis.  The researchers examined rapid plasma reagin serological test results of all first-time primary syphilis patients (n=445) in Alberta, Canada from 1980 to 2001 and compared treatment with single dose of penicillin with 14-day course of oral doxycycline (100 mg twice a day) or oral tetracycline (500 mg 4 times a day).   420 (94.4%) received penicillin and 25 (5.6%) received doxycycline/tetracycline. The serological treatment success rate was 97.4% in the penicillin group (409/420) and 100% in the doxycycline/tetracycline group (25/25).  So, if you have someone with this diagnosis who is allergic to PCN, you have a satisfactory alternative.                                                                                            http://omniphysicians.com/2008/09/29/rx-of-primary-syphilis/

S’long,

Paul R.

 

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categories: Emergency Medicine

Shock in Pigs: Not a Good Thing

by Paul Rega, MD — published on September 30th, 2008

Eight Hours of Hypotensive versus Normotensive Resuscitation in a Porcine Model of Controlled Hemorrhagic Shock (p 845-852)
David E. Skarda, Kristine E. Mulier, Mark E. George, Greg J. Beilman
Acad Emerg Med, Published Online: Aug 20 2008 4:39AM
DOI: 10.1111/j.1553-2712.2008.00202.x

ABSTRACT

Objectives: The aim of this study was to compare hypotensive and normotensive resuscitation in a porcine model of hemorrhagic shock.

Methods: This was a prospective, comparative, randomized survival study of controlled hemorrhagic shock using 28 male Yorkshire-Landrace pigs (15 to 25 kg). In 24 splenectomized pigs, the authors induced hemorrhagic shock to a systolic blood pressure (sBP) of 48 to 58 mm Hg (∼35% bleed). Pigs were randomized to undergo normotensive resuscitation (sBP of 90 mm Hg, n = 7), mild hypotensive resuscitation (sBP of 80 mm Hg, n = 7), severe hypotensive resuscitation (sBP of 65 mm Hg, n = 6), or no resuscitation (n = 4). The authors also included a sham group of animals that were instrumented and splenectomized, but that did not undergo hemorrhagic shock (n = 4). After the initial 8 hours of randomized pressure-targeted resuscitation, all animals were resuscitated to a sBP of 90 mm Hg for 16 hours.

Results: Animals that underwent severe hypotensive resuscitation were less likely to survive, compared with animals that underwent normotensive resuscitation. Mean arterial pressure (MAP) decreased with hemorrhage and increased appropriately with pressure-targeted resuscitation. Base excess (BE) and tissue oxygen saturation (StO2) decreased in all animals that underwent hemorrhagic shock. This decrease persisted only in animals that were pressure target resuscitated to a sBP of 65 mm Hg.

Conclusions: In this model of controlled hemorrhagic shock, initial severe hypotensive pressure-targeted resuscitation for 8 hours was associated with an increased mortality rate and led to a persistent base deficit (BD) and to decreased StO2, suggesting persistent metabolic stress and tissue hypoxia. However, mild hypotensive resuscitation did not lead to a persistent BD or to decreased StO2, suggesting less metabolic stress and less tissue hypoxia.

 

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categories: Emergency Medicine

On keeping admitted patients in ER halls

by Paul Rega, MD — published on September 30th, 2008

The Effect of Emergency Department Crowding on Patient Satisfaction for Admitted Patients (p 825-831)
Jesse M. Pines, Sanjay Iyer, Maureen Disbot, Judd E. Hollander, Frances S. Shofer, Elizabeth M. Datner
Acad Emerg Med, Published Online: Aug 11 2008 11:43AM
DOI: 10.1111/j.1553-2712.2008.00200.x

ABSTRACT

Objectives: The objective was to study the association between factors related to emergency department (ED) crowding and patient satisfaction.

Methods: The authors performed a retrospective cohort study of all patients admitted through the ED who completed Press-Ganey patient satisfaction surveys over a 2-year period at a single academic center. Ordinal and binary logistic regression was used to study the association between validated ED crowding factors (such as hallway placement, waiting times, and boarding times) and patient satisfaction with both ED care and assessment of satisfaction with the overall hospitalization.

Results: A total of 1,501 hospitalizations for 1,469 patients were studied. ED hallway use was broadly predictive of a lower likelihood of recommending the ED to others, lower overall ED satisfaction, and lower overall satisfaction with the hospitalization (p < 0.05). Prolonged ED boarding times and prolonged treatment times were also predictive of lower ED satisfaction and lower satisfaction with the overall hospitalization (p < 0.05). Measures of ED crowding and ED waiting times predicted ED satisfaction (p < 0.05), but were not predictive of satisfaction with the overall hospitalization.

Conclusions: A poor ED service experience as measured by ED hallway use and prolonged boarding time after admission are adversely associated with ED satisfaction and predict lower satisfaction with the entire hospitalization. Efforts to decrease ED boarding and crowding might improve patient satisfaction.

 

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categories: Emergency Medicine

Assessing Kids with Blunt Head Trauma

by Paul Rega, MD — published on September 30th, 2008

Interobserver Agreement in Assessment of Clinical Variables in Children with Blunt Head Trauma (p 812-818)
Marc H. Gorelick, Shireen M. Atabaki, John Hoyle, Peter S. Dayan, James F. Holmes, Richard Holubkov, David Monroe, James M. Callahan, Nathan Kuppermann
Published Online (Acad Emerg Med): Aug 11 2008 11:41AM
DOI: 10.1111/j.1553-2712.2008.00206.x

ABSTRACT

Objectives: To be useful in development of clinical decision rules, clinical variables must demonstrate acceptable agreement when assessed by different observers. The objective was to determine the interobserver agreement in the assessment of historical and physical examination findings of children undergoing emergency department (ED) evaluation for blunt head trauma.

Methods: This was a prospective cohort study of children younger than 18 years evaluated for blunt head trauma at one of 25 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). Patients were excluded if injury occurred more than 24 hours prior to evaluation, if neuroimaging was obtained at another hospital prior to evaluation, or if the patient had a clinically trivial mechanism of injury. Two clinicians independently completed a standardized clinical assessment on a templated data form. Assessments were performed within 60 minutes of each other and prior to clinician review of any neuroimaging (if obtained). Agreement between the two observers beyond that expected by chance was calculated for each clinical variable, using the kappa (κ) statistic for categorical variables and weighted kappa for ordinal variables. Variables with a lower 95% confidence limit (LCL) of κ > 0.4 were considered to have acceptable agreement.

Results: Fifteen-hundred pairs of observations were obtained. Acceptable agreement was achieved in 27 of the 32 variables studied (84%). Mechanism of injury (low, medium, or high risk) had κ = 0.83. For subjective symptoms, kappa ranged from 0.47 (dizziness) to 0.93 (frequency of vomiting); all had 95% LCL > 0.4. Of the physical examination findings, kappa ranged from 0.22 (agitated) to 0.89 (Glasgow Coma Scale [GCS] score). The 95% LCL for kappa was <0.4 for four individual signs of altered mental status and for quality (i.e., boggy or firm) of scalp hematoma if present.

Conclusions: Both subjective and objective clinical variables in children with blunt head trauma can be assessed by different observers with acceptable agreement, making these variables suitable candidates for clinical decision rules.

 

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categories: Emergency Medicine

Headache: Olanzapine versus Droperidol

by Paul Rega, MD — published on September 30th, 2008

Olanzapine versus Droperidol for the Treatment of Primary Headache in the Emergency Department (p 806-811)
Chandler H. Hill, James R. Miner, Marc L. Martel
Published Online( Acad Emerg Med): Aug 11 2008 11:40AM
DOI: 10.1111/j.1553-2712.2008.00197.x

ABSTRACT

Objectives: The objective was to determine if there is a difference in pain relief or frequency and severity of side effects in emergency department (ED) patients with primary headache treated with either intramuscular (IM) olanzapine or IM droperidol.

Methods: This was a prospective, randomized nonblinded clinical trial of adult ED patients undergoing treatment for suspected primary headache. Consenting patients were randomized to receive either droperidol 5 mg IM or olanzapine 10 mg IM. Prior to receiving treatment, patients were asked to complete a 100-mm visual analog scale (VAS) describing their pain and a 4-point verbal rating scale (VRS) describing their pain as none, mild, moderate, or severe. Patients also completed a 100-mm VAS describing their level of nausea. Pain and nausea measurements were repeated 30 and 60 minutes after medication administration. Patients also completed the Barnes Akathisia Scale (BAS) 30 and 60 minutes after medication administration. Descriptive statistics were used as appropriate. Pain relief was compared both in terms of the decrease in VAS scores and in the proportion of patients who reported moderate or severe pain whose report later changed to mild or no pain.

Results: One-hundred patients were enrolled; 13 were withdrawn before administration of the study medication, 8 in the droperidol group and 5 in the olanzapine group, leaving 87 patients for analysis. Forty-two patients received droperidol and 45 received olanzapine. In the droperidol group, 35/40 (87.5%) patients who had reported moderate or severe pain at baseline reported mild or no pain at 60 minutes. In the olanzapine group, 38/44 (86.4%) reported this change (p = 0.89). The mean percent change from baseline VAS pain score at 60 minutes was −37% (95% CI = −84% to 11%) for droperidol and −37% (95% CI = −64% to 10%) for olanzapine (p = 0.30). The mean percent change from baseline for the VAS nausea score was −59% (95% CI = −70% to −47%) for droperidol and −64% (95% CI = −77% to −51%) for olanzapine (p = 0.83). There was no difference in any report of akathisia by the BAS between the groups (p = 0.63).

Conclusions: Both olanzapine and droperidol are effective treatments for primary headaches in the ED. No significant differences were found between the medications in terms of pain relief, antiemetic effect, or akathisia. Olanzapine may be used to treat primary headache and it is an effective alternative to droperidol.

 

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categories: Emergency Medicine

Screening for PE

by Paul Rega, MD — published on September 30th, 2008

Tandem Measurement of D-dimer and Myeloperoxidase or C-reactive Protein to Effectively Screen for Pulmonary Embolism in the Emergency Department (p 800-805)
Alice M. Mitchell, Kristen E. Nordenholz, Jeffrey A. Kline
Acad Emerg Med:  Published Online: Sep 8 2008 1:22PM
DOI: 10.1111/j.1553-2712.2008.00204.x

ABSTRACT 

Objectives: The hypothesis was that the tandem measurement of D-dimer and myeloperoxidase (MPO) or C-reactive protein (CRP) could significantly decrease unnecessary pulmonary vascular imaging in emergency department (ED) patients evaluated for pulmonary embolism (PE) compared to D-dimer alone.

Methods: The authors measured the sequential combinations of D-dimer and MPO and D-dimer and CRP in a prospective sample of ED patients evaluated for PE at two centers. Patients were followed for 90 days for venous thromboembolism (VTE, either PE or deep venous thrombosis [DVT]), which required the consensus of two of three blinded physician reviewers.

Results: The authors enrolled 304 patients, 22 with VTE (7%; 95% confidence interval [CI] = 5% to 10%). The sensitivity and specificity of a D-dimer alone (cutoff ≥ 500 ng/mL) were 100% (95% CI = 85% to 100%) and 59% (95% CI = 53% to 65%), respectively, and was followed by pulmonary vascular imaging negative for PE in 38% (115/304; 95% CI = 32% to 44%). The combination of either a negative D-dimer, or MPO < 22 mg/dL, had a sensitivity of 100% and specificity of 73% (95% CI = 67% to 78%). Thus, tandem measurement of D-dimer and MPO would have decreased the frequency of subsequent negative pulmonary vascular imaging from 38% to 25% (95% CI of the difference of −13% = −5% to −20%). The combination of CRP and D-dimer would not have significantly improved the rate of negative imaging.

Conclusions: The tandem measurement of D-dimer and MPO would have significantly decreased negative pulmonary vascular imaging compared with D-dimer alone and should be validated prospectively.

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categories: Emergency Medicine

D-dimer, CRP, and MPO

by Paul Rega, MD — published on September 30th, 2008

Academic Emergency Medicine

Volume 15 Issue 9, Pages 795 - 799
TITLE:  Direct Comparison of the Diagnostic Accuracy of Fifty Protein Biological Markers of Pulmonary Embolism for Use in the Emergency Department

ABSTRACT

Objectives: Pulmonary embolism (PE) is associated with abnormal concentrations of many proteins involved in inflammation, hemostasis, and vascular injury. The authors quantified the diagnostic accuracy of a battery of protein biological markers for the detection of PE in emergency department (ED) patients.

Methods: A random and a consecutive sample of ED patients evaluated for PE were prospectively enrolled at two academic EDs between August 2005 and April 2006. A plasma sample was obtained at enrollment, and all patients were followed by telephone and medical record review at 90 days for the development of venous thromboembolism (VTE) defined as PE or deep venous thrombosis (DVT), requiring the consensus of two of three blinded physician reviewers. Measurements of potential biological markers were performed by technicians blinded to the study objectives. The diagnostic accuracy of each biological marker was determined by the area under the receiver operating characteristic (ROC) curve.

Results: Fifty potential biological markers were measured in 304 ED patients, including 22 patients (7%, 95% confidence interval [CI] = 4% to 10%) with VTE. Fourteen biological markers demonstrated an area under the curve (AUC) with the lower limit of the 95% CI ≥ 0.5. Of these, three demonstrated an AUC ≥ 0.7: D-dimer (0.90), C-reactive protein (CRP; 0.78), and myeloperoxidase (MPO; 0.78).

Conclusions: From 50 candidate biological markers, only D-dimer, CRP, and MPO demonstrated sufficient diagnostic accuracy to suggest potential utility as biological marker of PE.

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categories: Emergency Medicine

Neonate, Fever, Rash = Trouble

by Paul Rega, MD — published on September 29th, 2008

Source:  http://www.idinchildren.com/200511/spot.asp 

This 3-week-old infant presented to the emergency room with a two-day history of fever and rash. On physical exam, he had a temperature of 100.4°F and was irritable, particularly when his skin was palpated. Marked facial edema was present as well as perioral radial furrowing. A generalized erythema with a fine stippled sandpaper appearance was accentuated in the flexural folds. What’s your diagnosis?

                                 1  1

This is staphylococcal scalded skin syndrome (SSSS), also known as Ritter’s disease. It is caused by an exfoliative toxin produced by certain strains of Staphylococcus aureus, most commonly phage group II. The elaborated S. aureus exotoxin enters the circulation, eventually reaching and binding to the mid-epidermis. It targets desmoglein-1, a desmosomal component that promotes cell-to-cell adhesion. The toxin causes disruption of these attachments, leading to a cleavage plane in the epidermis, with subsequent blistering and exfoliation of the superfi cial aspect of the skin.

SSSS typically begins with one to two days of fever and irritability followed by a generalized tender erythema. The characteristic rash is sandpaper-like, accentuated in the flexural folds and extremely tender to palpation. Fragile blisters then develop. Nikolsky’s sign is positive, which refers to the tendency toward separation of the upper epidermis with gentle pressure. Mucosal surfaces are spared, resulting in the characteristic perioral furrowing with a line of demarcation between the lips and surrounding edematous skin. There is a spectrum of disease severity, ranging from localized bullous impetigo to a generalized exfoliation of nearly the entire body surface area.

This syndrome most frequently affects neonates and children younger than 5. Various theories suggest that this is both due to a naive immune system and relatively decreased renal clearance of toxin. In the rare case that it is seen in adults, it is usually associated with a predisposition, such as immunosuppression or renal failure. Extent of disease in a given individual has been linked to the body’s ability to produce anti-toxin antibodies, the amount of toxin elaborated vs. excreted, and whether it is released locally or systemically.

Though SSSS can occur in association with a focus of infection such as conjunctivitis, pneumonia or endocarditis, it often results from colonization at sites such as the nares, umbilicus or perineum. In fact, a nosocomial outbreak has been reported which was attributed to carriage of toxin-producing S. aureus on the hands of a health care worker.

Diagnosis can often be made by clinical appearance alone, but cultures should be obtained from the blood as well as any suspected focus of infection, such as conjunctivae, nasopharynx, umbilicus, rectum or wound site. In childhood cases, a detection rate of S. aureus in blood cultures as low as a 3% has been noted. Fluid from bullae are also typically sterile. Various mechanisms for isolating the exfolative toxins exist, including polymerase chain reaction, ELISA and slide latex agglutination. A skin biopsy would reveal epidermal splitting at the granular layer without necrosis.

The differential diagnosis of SSSS primarily includes other toxin-mediated erythemas (scarlet fever), drug reactions (toxic epidermal necrolysis) and primary dermatoses (atopic dermatitis). Of note, in toxic epidermal necrolysis, the mucous membranes are involved, and biopsy would reveal a level of cleavage below the epidermis as well as full-thickness epidermal necrosis. Other less common considerations include congenital ichthyoses (bullous congenital ichthyosiform erythroderma), blistering disorders (pemphigus foliaceus), immunodeficiencies (Omenn’s syndrome), and nonaccidental injuries (scalding, chemical burn).

Treatment involves antibiotics, pain control, skin care with barrier ointments and fluid and electrolyte management. An IV penicillinaseresistant penicillin, such as nafcillin, should be administered. Several cases associated with MRSA have been reported, and this should be considered if there is no response to empiric antibiotic treatment. In addition, due to the compromised barrier function of the blistered and exfoliating epidermis, one must take care to protect against hypothermia, dehydration and secondary infections, which can be fatal complications, particularly in infants.

Prognosis is generally much better for infants than adults, with a 4% mortality rate vs. at least 60% in the latter group, likely because of serious underlying comorbidities in affected adults. After appropriate antibiotic treatment is initiated, exfoliation continues for up to 48 hours. Due to the superficial nature of the skin lesions, they tend to heal rapidly within one to two weeks without scarring.

For more information:

  • Ladhani S. Recent developments in staphylococcal scalded skin syndrome. Clin Microbiol Infect. 2001;7:301-307.
  • Patel GK, Finlay AY. Staphylococcal scalded skin syndrome: diagnosis and management. Am J Clin Dermatol 2003;4:165-175.
  • El Helali N, Carbonne A, Naas T, et al. Nosocomial outbreak of staphylococcal scalded skin syndrome in neonates: epidemiological investigation and control. J Hosp Infect. 2005;61:130-138.
  • Farrell AM. Staphylococcal scalded-skin syndrome. Lancet. 1999;354:880-881.
  • Hoeger PH, Harper JI. Neonatal erythroderma: differential diagnosis and management of the “red baby.” Arch Dis Child 1998;79:186-191.
  • Sterry W, Muche JM. Erythroderma. Dermatology. 2005:165-174.

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categories: Emergency Medicine

Herpes Simplex: Quick & Simple

by Paul Rega, MD — published on September 29th, 2008

 Source:  http://www.idinchildren.com/200510/spot.asp

            1

This is recurrent herpes simplex. A herpes simplex virus (HSV), a double-stranded DNA virus in the herpesvirus group, causes the rash. The initial infection in children is often herpetic gingivostomatitis, usually with HSV type 1, with an incubation of two to 20 days following exposure. Most patients with herpetic gingivostomatitis are younger than 5.

Symptoms of the initial infection include high fever, painful erosions in the mouth (especially anteriorly), tender cervical and submandibular lymphadenopathy, drooling and decreased appetite. Following the initial infection, the virus lies dormant in the sensory ganglia and can be activated by triggers. Common triggers for recurrent herpes simplex lesions are fever, illness, stress, sunlight, local trauma and menses. A prodrome of redness, itching and/or burning is noted with subsequent development of grouped vesicles with an erythematous surrounds most often at the mucocutaneous junctions (ie, around the nose and mouth). The lesions progress to become erosions and/or can be crusted; some lesions are painful.

Transmission of HSV can occur from both symptomatic and asymptomatic individuals. Direct person-to-person contact transmits HSV, usually to an area with a breech in the skin barrier (eg, wrestlers with skin abrasions or children with eczema [this is termed eczema herpeticum]).

Diagnosis can be made in one of four ways: demonstration of multinucleated giant cells in a Tzanck smear from a lesion (seen from all viruses in the herpesvirus group; this is an insensitive method that infectious disease physicians do not recommend any longer); direct immunofluorescence antibody test using monoclonal antibodies on skin/ulcer scrapings; polymerase chain reaction to detect HSV DNA from skin lesions; or a positive culture for HSV from a vesicle (better results are noted from newer lesions).

Differential diagnoses of herpetic gingivostomatitis include herpangina, aphthous ulcers and hand-foot-mouth disease. Differential diagnoses for recurrent lesions include varicella zoster, contact dermatitis and cytomegalovirus.

The treatment of recurrent lesions of herpes labialis can be topical or systemic. Patients keep topical docosanol 10% cream or topical penciclovir 1% cream at home and use the medications at the initial sign of a prodrome. These topical medications applied five times daily within hours of onset decrease the viral shedding and decrease the time to heal when used in this manner (a half day less than placebo). These products are labeled for use in children 12 and older.

Oral acyclovir, famciclovir and valacylovir can be used episodically (prescribed and kept at home to begin course at the first prodromal sign) or can be prescribed as suppressive therapy given on a daily basis. Clinical trial results with product use within 12 to 24 hours of onset showed healing and pain reduction one to two days sooner than placebo, in addition to less viral shedding. Suppressive therapy with oral antivirals has shown a decrease in recurrences when compared with placebo use. Acyclovir is approved for use from the neonatal period. Famciclovir does not have established safety and efficacy in children and are labeled for children 18 and older.

For more information:

  • Buccolo LS. Severe rash after dermatitis. J Fam Pract. 2004;53:613-615.
  • Burkhart CG. Herpes acquisition and transmission. J Drugs Dermatol. 2005;4:378-383.
  • Efstathiou S, Preston CM. Towards an understanding of the molecular basis of herpes simplex virus latency. Virus Res. 2005;111:108-119.
  • Johnson R. Herpes gladiatorum and other skin diseases. Clin Sports Med. 2004;23:473-484.
  • Sacks SL, Aoki FY, Martel AY, et al. Clinic-initiated, twice daily oral famciclovir for treatement of recurrent genital herpes: a randomized, double-blind, controlled trial. Clin Infect Dis. 2005;41:1097-1104.
  • Sacks SL, Thisted RA, Jones TM, et al. Clinical efficacy of topical docosanol 10% cream for herpes simplex labialis: a multicenter, randomized, placebo-controlled trial. J Am Academ Dermatol. 2001;45:222-230.
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categories: Emergency Medicine

Troponin & Bacteremia

by Paul Rega, MD — published on September 29th, 2008

Incidence and Significance of a Positive Troponin Test in Bacteremic Patients Without Acute Coronary Syndrome
Carmel Kalla, David Raveh, Nurit Algur, Bernard Rudensky, Amos M. Yinnon, Jonathan Balkin
The American Journal of Medicine – October 2008 (Vol. 121, Issue 10, Pages 909-915, DOI: 10.1016/j.amjmed.2008.05.037)

ABSTRACT

Background

Since the introduction of troponin for the diagnosis of myocardial infarction, several studies have shown additional conditions in which troponin is elevated, including sepsis. The objective of this study was to determine the incidence of an elevated troponin in patients with bacteremia and its significance.

Methods

This was a prospective, noninterventional study. Patients with a positive blood culture were included. Cardiac troponin I (cTnI) was determined within 4 days of blood culture. A repeat electrocardiogram was obtained in a sample of patients with elevated cTnI and in patients with a negative troponin test. Demographic, clinical, and microbiological data were obtained for all patients.

Results

A total of 159 bacteremic patients were included. Positive cTnI was detected in 69 patients (43%). Elevated cTnI was associated with a number of underlying diseases, hospitalization ward, severity of the systemic inflammatory condition, and kidney function (P<.05-.001). A repeat electrocardiogram was performed in 39 patients with a positive cTnI and in 28 patients with a negative cTnI. Two of 39 patients (5%) in the positive cTnI group had ischemic changes and 2 patients (5%) had nonspecific changes, whereas only 1 patient (4%) with a negative cTnI had nonspecific changes. Bivariate analysis revealed a statistically significant association for positive cTnI and mortality; however, on multivariate analysis this was no longer significant.

Conclusion

Forty-three percent of bacteremic patients had an elevated cTnI. Risk factors for elevated cTnI were severity of the underlying infection, renal function, and underlying cardiac disease. Increased cTnI was found to be a dependent risk factor and a surrogate marker for death.

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categories: Emergency Medicine

Rx of Primary Syphilis

by Paul Rega, MD — published on September 29th, 2008

Primary Syphilis: Serological Treatment Response to Doxycycline/Tetracycline versus Benzathine Penicillin
Tom Wong, Ameeta E. Singh, Prithwish De
The American Journal of Medicine – October 2008 (Vol. 121, Issue 10, Pages 903-908, DOI: 10.1016/j.amjmed.2008.04.042)

ABSTRACT

Background

Benzathine penicillin G is the treatment of choice for infectious syphilis, but tetracycline and doxycycline are believed to be effective second-line treatments. The objective of this study was to assess the serological response from treatment of primary syphilis with benzathine penicillin compared with doxycycline or tetracycline.

Methods

We examined rapid plasma reagin serological test results of all first-time primary syphilis patients in Alberta, Canada from 1980 to 2001 and compared treatment with single dose of penicillin with 14-day course of oral doxycycline (100 mg twice a day) or oral tetracycline (500 mg 4 times a day). Serological treatment success was defined as a minimum 4-fold decrease in baseline rapid plasma reagin test antibody titer within 6 months, or ≥8-fold decrease within 12 months, or ≥16-fold decrease by 24 months. The median time to successful response was estimated, and factors associated with treatment success were identified by unadjusted logistic regression.

Results

Of the 445 primary syphilis cases with available treatment outcome data, 420 (94.4%) received penicillin and 25 (5.6%) received doxycycline/tetracycline. The serological treatment success rate was 97.4% in the penicillin group (409/420) and 100% in the doxycycline/tetracycline group (25/25), and not significantly different. The estimated median time to serological treatment success was 72.0 days (mean=101.7, range 10-603) in penicillin and 43.0 days (mean=78.6, range 15-334) in doxycycline/tetracycline-treated patients; however, this difference was not statistically significant (P=0.16).

Conclusion

Doxycycline/tetracycline had a similarly high serological treatment success rate when compared with penicillin in the treatment of primary syphilis.

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categories: Emergency Medicine

AMA’s Litigation Center

by Paul Rega, MD — published on September 29th, 2008

In an AMA Leader Commentary, Joseph M. Heyman, M.D., chair of the AMA Board of Trustees, wrote in AMNews (10/6) that “in an era when physicians often feel that hospital governing boards and third-party payers have the upper hand,” he is thrilled to discuss the case of “Lawnwood Medical Center v. Randall Seeger, M.D.” The hospital’s “governing board thought it could tell the medical staff in no uncertain terms how to run the staff’s credentialing, peer review, and quality assurance functions. When the staff fought back, Lawnwood sought and received favorable legislation granting it almost supreme authority.”

 

Unbeknownst to Lawnwood, “the doctors had an ace in the hole — namely, the Litigation Center of the American Medical Association and State Medical Societies — which was more than ready to help,” since Dr. Seeger is an AMA member. Specifically, “the AMA and the Litigation Center backed up the medical staff with assistance from the Florida Medical Assn.”

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categories: Emergency Medicine

Cannabis & Cuckoo

by Paul Rega, MD — published on September 29th, 2008

MedWire News, 9/26/08 (http://www.medwire-news.md/news/article.aspx?k=265&id=77935)

Smoking cannabis increases the risk of early psychosis symptoms in people at high risk of developing the mental health disorder, research shows.

“Cannabis use is reported to increase the risk for psychosis,” explain Dr Cheryl Corcoran, from Columbia University in New York, USA, and team.

But they add that few studies have investigated the effects of cannabis use on symptoms in people at high risk of developing psychosis.

To investigate, the researchers studied 32 patients, aged 25 years or younger, who showed early signs of developing psychosis.

At the start of the 2-year study, all the participants completed questionnaires and underwent interviews and health assessments. They were then monitored for 2 years.

In total, 13 participants reported using drugs such as alcohol, tobacco or cannabis. Indeed, all these patients had a history of cannabis use.

As expected, the researchers found that cannabis users, who tended to be older than the other participants, experienced significantly more anxiety and other cannabis-associated effects than the other participants.

But the team also found that cannabis users experienced more early psychosis symptoms, such as perceptual disturbances, and worse functioning during episodes of increased cannabis use than at other times, and compared with other participants.

The association was not explained by the use of prescription medications and other drugs, notes the team.

“These data demonstrate that cannabis use may be a risk factor for the exacerbation of subthreshold psychotic symptoms, specifically perceptual disturbances, in high risk cases,” the researchers conclude in the journal Schizophrenia Research.

They add: “Understanding motivations for [cannabis] use in these vulnerable young people can inform the development of preventive interventions.”

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categories: Emergency Medicine

FDA: Prasugrel’s approval on hold

by Paul Rega, MD — published on September 29th, 2008

AP, 9/27/08 (http://www.chicagotribune.com/business/sns-ap-eli-lilly-prasugrel,0,6604579.story)

“Federal health regulators delayed a decision on a blood thinner from Eli Lilly for a second time Friday, raising concerns on Wall Street about the potential blockbuster medication.

The drug, called prasugrel, is considered crucial to Indianapolis-based Lilly, which faces a wave of patent expirations in the next few years.

Lilly said in a statement the Food and Drug Administration has still not completed its review of the drug, which was submitted in January. Agency scientists already delayed a decision on June, saying they needed more time.

“This is a very large, complex submission, and it should not be surprising that delays occur,” Jennifer Stotka, a vice president with Lilly, said in a statement. The company said it would not speculate on the cause of the delay.
Lilly developed the drug with Japanese drugmaker Daiichi Sankyo Co. Prasugrel is designed to treat patients with acute heart problems such as heart attacks or unstable angina who are at risk of developing blood clots.

The drug’s approval is key for Lilly’s financial outlook, as the patent on its best-selling drug, the anti-psychotic Zyprexa, is due to expire in 2011. Zyprexa contributed more than a quarter of the company’s $18.6 billion in sales last year.

Analysts said prasugrel could bring in anywhere from $600 million to $1 billion in revenue.

UBS analyst Roopesh Patel said it was hard to draw conclusions from Lilly’s statement because it simply said the FDA had not completed its review.

“Based on this, one can’t necessarily conclude as to whether or not the final outcome would be positive or negative,” Patel said.

He thinks Lilly will have to wait weeks or maybe months to hear more from the FDA.

“You’re not talking about two or three years before the FDA comes back with an answer,” he said.

A delay that long, or a request for more trials could be just as bad as a rejection.

Prasugrel would compete against the blockbuster blood thinner Plavix, which loses patent protection in 2011. Analysts say prasugrel needs time to establish itself in the market before facing generic versions of Plavix, which will sell for a fraction of that drug’s original price.

Plavix, made by Sanofi-Aventis SA and Bristol-Myers Squibb Co., was the second-best-selling prescription medicine in the world last year, with sales of $7.3 billion, according to pharmaceutical data provider IMS Health.

Bristol-Myers executives have said they consider prasugrel a niche drug that targets only a small percentage of Plavix patients.

A head-to-head study released last year showed that fewer patients taking prasugrel developed blood clots in stents or suffered heart attacks, strokes or heart-related deaths when compared with patients taking Plavix.

However, the study also showed that major bleeding occurred in a higher percentage of patients taking prasugrel.

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categories: Emergency Medicine

Logistical Nightmare: Flu shots for all the kids

by Paul Rega, MD — published on September 29th, 2008

LA Times, 9/29/08 (http://www.latimes.com/features/health/la-he-fluhurdles29-2008sep29,1,7449383.story)

Rapid, mass vaccination of the young presents a new logistical problem, one that many communities aren’t yet able to solve.

“There are really two avenues to do this,” says Dr. Peter Szilagyi, a pediatrician and expert in child immunizations at the University of Rochester Medical Center. “One is to grab every child when they are already there [at the doctor's office], use reminder mechanisms to bring people in and have special hours like weekends and evenings — just make it very efficient. The other path is to think about using schools or other places for vaccination.”

Some county health departments and school districts are doing just that.

“It’s an appealing way to reach children,” says Dr. Jeanne Santoli of the CDC. “But the primary business of schools is education. Schools don’t want that to be compromised, and physicians don’t want that to be compromised.”

More than 30 of California’s 58 counties will offer some form of school-based flu vaccine clinics this year, says John Talarico of the California Department of Health Services, up from 18 last year.

But a 2004 pilot study using schools to provide flu vaccination in San Bernardino County revealed the complexity of such an approach, says Dr. Gerald R. Greene, a pediatrician in Highland who helped coordinate the study.

The project required detailed planning, coordinated schedules and a multitude of volunteers, he says. Further, it was difficult to provide the immunization to students in the junior high and high schools because they change classrooms throughout the day and have busy schedules.

Even vaccinating elementary school children was a challenge, Greene says. Parental consent had to be obtained. And children under age 9 who were being vaccinated for the first time needed two doses of vaccine, which required a second trip to the school.

“Trying to bring vaccine to that many schools in a short amount of time requires effort and personnel that would go beyond those supplied by most school districts,” Greene says.

Other health experts say families should turn to their regular doctor. “We think the best place for kids to get vaccinations is with the primary care provider,” says Dr. Jonathan Fielding, director of L.A. County’s Department of Public Health. “This should not require specialized care.”

The CDC, however, wants to make vaccination more accessible. Store-based clinics are one option, and the company that runs Minute Clinics, located in CVS drug stores, recently changed its policy to provide flu vaccines to children as young as 18 months. The previous policy required a child to be at least 4 years old.

The CDC also suggests that flu vaccination continue through the holidays instead of the typical October-through-November schedule. Studies since 1968 have shown that, 80% of the time, flu cases reach a peak in January or later, and 60% of the time in February or later.

More flu clinics should be aimed at families, experts note. Some HMOs, such as Kaiser Permanente, offer special flu shot clinics for its members of all ages throughout the flu season — often on weekends.

Unlike the Minute Clinics at CVS, most pharmacies will not vaccinate children under middle-school age.

Considering the nation’s goal of delivering flu shots to more than 80% of Americans, it needs more places where mom, dad, the kids and grandparents could walk in, get the vaccine in a few minutes and be done with it, experts acknowledge.

But, as Talarico points out: “We don’t do one-stop shopping with our healthcare. Women go to the gynecologist, children go to the pediatrician, other family members go to a general practitioner. It’s a reflection of our current medical care system.”

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categories: Emergency Medicine