Saturday, November 12, 2011

When Parents Refuse a Septic Workup

This is a brief commentary and discussion regarding the implications of parental refusal of hospitalization and evaluation of a potentially septic neonate.  It is absolutely an issue we all hope to never face, but probably will at some point in our careers.

Two pediatricians offer differing opinions on the extent to which social work and child protective services need be involved, raising such issues as the threshold percentage for likelihood of serious bacterial infection/bacteremia should be for "imminent harm" to the child, and the perceived benefits of therapy.  No specific answers are gleaned from the article, but it is worth reading and thinking through the discussions you would have in a similar situation.

"When Parents Refuse a Septic Workup for a Newborn"
www.ncbi.nlm.nih.gov/pubmed/22025599

Thursday, November 10, 2011

Ethanol - Miracle Drug (For Stroke)

From China, in Stroke, an animal model (poor rats, as usual) of MCA ischemia, collagenase-induced ICH, and post-TPA ICH.  Rats received either 0.5 mg/kg, 1.0 mg/kg, or 1.5 mg/kg ethanol after two hours of MCA occlusion.  Performance on various foot, balance, and parallel behavioral testing significantly favored the ethanol treatment group with initial and sustained reduction in errors as compared to the no-treatment group.

No difference was found between groups in induced ICH volume, and in their (small) series, no increase in ICH after TPA administration.  A transient increase in expression of hypoxia-inducible factor 1-alpha favoring ethanol was seen at 3 hours after reperfusion, gone by 24 hours.

I cannot wait to see the day where we give IV ethanol for acute stroke.

"Beer, the cause and solution to all the world's problems."

"Neuroprotective Effect of Acute Ethanol Administration in a Rat With Transient Cerebral Ischemia"

Wednesday, November 9, 2011

Computers - Probably Better Doctors for UTI

Uncomplicated urinary tract infections are probably one of the diagnoses that Emergency Physicians handle the worst - if they come to the ER, they're likely to get some sort drawn-out testing, whereas, if they went to their regular physician or called the nurse hotline, there would be antibiotics waiting for them at the pharmacy before they finished talking.

This is a prospective study in which patients with possible UTI were referred to a triage kiosk to complete a standardized computer questionnaire.  624 patients with possible UTI interacted with the kiosk - and unfortunately, only 103 qualified for the study by having enough features of typical, low-risk illness.  Patients were then randomized to protocolized antibiotic prescription as reviewed by a triage physician or usual care.

The good news - the kiosk saved a lot of time (89 minutes vs. 146 minutes).  The bad news - there were only 41 patients  followed-up in the intervention group and 26 followed-up in the control group, so we end up with only a tiny number of patients in each arm.  The kiosk group received more antibiotics for negative urine cultures than the control group (93% vs. 67%), so there is some additional element of harm secondary to antibiotic exposure - and, with a limited protocol, there are potential misses - and this study isn't large enough to identify them.

But, really, uncomplicated, typical UTI symptoms in women shouldn't be rocket science - and you shouldn't necessarily be doing any testing.  I would say the computer is a better physician - except, it would be absolutely simple for a physician to simply narrow their approach to match the efficiency of the kiosk with, in theory, some added skill.

"A Randomized Trial of Computer Kiosk–expedited Management of Cystitis in the Emergency Department"

Tuesday, November 8, 2011

Conflict of Interest in TPA Literature

Another tiny bit of self-promotion - a new publication published today.  Stems essentially from a literature review I did after clawing through ECASS-III and noting that 12 of the 14 investigators were paid, sponsored, or employed by the manufacturers of alteplase - which muddied my estimation of the reliability of the conclusions.  Turns out, ECASS-III wasn't the only one....

"Pharmaceutical Sponsorship Bias Influences Thrombolytic Literature in Acute Ischemic Stroke"

Monday, November 7, 2011

Resident Productivity Does Not Predict ABEM Scores

Simple, single-institution study of 11 years of resident in-service scores, patients-per-hour, and ABEM qualifying examination scores - and, as previously shown, only PGY-3 in-service examination scores predicted ABEM oral and written examination scores.

Simulated oral board examination scores did not correlate with ABEM oral examination scores, and the relative number of patients-per-hour had no significant correlations between any testing.

I would say that bears out my observational experience - doing more has no bearing on whether you might be doing more incorrectly.

"Outcome Measures for Emergency Medicine Residency Graduates: Do Measures of Academic and Clinical Performance During Residency Training Correlate With American Board of Emergency Medicine Test Performance?"
www.ncbi.nlm.nih.gov/pubmed/21999560

Good luck to everyone taking their ABEM exam today!

Sunday, November 6, 2011

CTA Contrast Probably Increases ICH With TPA

...although the authors of this study draw the opposite conclusion.

In an effort to decrease the administration of TPA to stroke mimics and TIAs, some institutions are moving to the use of CT angiographic and perfusion studies after the initial non-contrast scan.  Previous studies have suggested an association between iodinated contrast administration and ICH after TPA.

These authors beg to differ.  In their study cohort, they retrospectively evaluate 319 patients receiving TPA for acute stroke, 69 of whom receive contrast and 243 who do not.  Depending on whether the ECASS or SITS-MOST definition of symptomatic ICH is used:
 ECASS - 4 of 69 (5.8%) with contrast, 12 of 243 (4.9%) without contrast
 SITS-MOST: 3 of 69 (4.4%) with contrast, 9 of 243 (3.7%) without contrast

...and that small absolute difference does not reach statistical significance because their numbers are so small.  This does not prevent the authors from stating "we found no association of either IV contrast administration or contrast dose with SICH in our series of patients treated with IV rtPA."  They're not wrong - but they barely address how underpowered their study is, or how every baseline characteristic (age, stroke severity, comorbid conditions) favored their contrast group, yet they still trended towards increased ICH.

Does the author of every TPA article live in a distortion field that blinds them to reasonable consideration of safety issues and study limitations?

"Iodinated Contrast Media and Cerebral Hemorrhage After Intravenous Thrombolysis"
http://stroke.ahajournals.org/content/42/8/2170.short?rss=1