Friday, October 26, 2012

ALTEs That Need Admission Need Admission

Coming from the west-coast PEM powerhouses of Harbor-UCLA, CHLA, and USC, this prospective observational study attempts to distill the clinical characteristics of "apparent life threatening events" requiring hospitalization.  Traditional teaching has always errs on the side of admission for ALTEs, despite the typical low-yield nature of the admission.

They collected data on 832 ALTEs, 191 (23%) of which they felt truly necessitated admission for a set of predefined criteria.  Based on this data, they came up with a simple decision rule to identify ALTEs for admission:
 - They obviously need to be admitted.
 - Concerning medical history/prematurity/congenital comorbidities.
 - >1 ALTE in 24 hours.

This captured 89% of necessary hospitalizations with a specificity of 61%, with an AUC of 0.71.

It's a bit of an odd rule that includes "obvious need for admission", but, I suppose it's rather pragmatic.  However, the adoption of a rule such as this – after prospective validation – would depend on the "acceptable miss rate" in an infant with a possible life-threatening condition.  A sensitivity of 89% probably isn't going to cut it, so, in the end, what this study is only good for is perusing the interesting data they've collected along the way.

"Apparent Life-Threatening Event: Multicenter Prospective Cohort Study to Develop a Clinical Decision Rule for Admission to the Hospital"

Thursday, October 25, 2012

November Annals of EM Journal Club

Our EM Journal Club group down here at UT-Houston collaborated to write the Annals of Emergency Medicine monthly Journal Club installment, published in the November issue.

You get the questions now – at least, they're available online starting today – but you'll have to wait in suspense for months to hear our "answers".

I don't know if it was an editorial decision to put our thinly veiled IST-3 critique on page 666 of this year's volume, but I can't imagine it's just a coincidence....

"rt-PA and Stroke: Does IST-3 Make It All Clear or Muddy the Waters?"
http://www.ncbi.nlm.nih.gov/pubmed/23089093

Wednesday, October 24, 2012

More Probably Unnecessary Head CTs/Admissions

I work at one of only two trauma centers in a city of four million potential patients, and I have firsthand experience with this issue.  The issue is to determine the best management strategy for patients with mild traumatic brain injury and bleeding.  We already know what to do with major bleeding – but patients with minor bleeding are a little more of a dilemma.  They almost universally do well, but we observe them and repeat tests on nearly all of them.

This is a retrospective review of 36 months of trauma admissions to a level one trauma center in New Jersey, trying to describe the natural progression of mild traumatic intracranial bleeding.  Historically, 1/3rd of these patients have bleeding that progresses, but only 1-3% will require neurosurgical intervention.  This review found 341 patients with mild injuries and bleeding, and noted that 69% of these patients had no interval change in head CT results when repeated at 24 hours.  Of the remaining patients, either no CT was performed (25 patients) because the injury was too insignificant or there was interval progression – including 11 patients who received neurosurgical intervention.  But, the point of the article is generally supposed to be shown in Figure 2 – estimating the number of ongoing hemorrhages at each time point in the first 24 hours.  Essentially, >80% of the bleeding ceases to expand within the first few hours from injury.

This is a useful jumping off point to perform the sort of work that isn't featured in this article – characterizing the characteristics of patients and bleeding that progresses.  If patients with bleeding unlikely to progress can be safely discharged rather than being observed for interval CT, this is a useful reduction in ED length of stay, observation admissions, or CT use.

"The temporal course of intracranial haemorrhage progression: How long is observation necessary?"
www.ncbi.nlm.nih.gov/pubmed/22658418

Monday, October 22, 2012

The Emergency Medicine Literature is Tragic


This is a survey of the top twelve Emergency Medicine journals, as ranked by impact factor, providing a descriptive analysis of the features of the studies contained within.  The authors manually reviewed 330 articles and found a mere 8.8% were randomized studies.  Most (65.5%) were cross-sectional studies and 23.6% were cohort studies.  57.3% were prospective, 47.9% were from the U.S., and the minority of studies (31.2%) used informed consent or mentioned waivers of informed consent.

Compared with other fields, the surveyed EM literature was less likely to mention IRB approval, less likely to be prospective, less likely to be blinded and controlled, and enrolled fewer patients per study.

There are many barriers to research in the Emergency Deparment – particularly prospective, randomized, controlled research.  However, the establishment of an office for emergency services research at the National Institutes of Health may improve the ability of U.S. researchers to obtain grant funding.  

Of course, this will then only exacerbate the bias inherent in the already U.S.-centric published literature.


"Quality of publications in emergency medicine"