Lunacy, Animal Bites, and You

A guest post by Justin Hensley (@EBMGoneWild) of Evidence-Based Medicine Gone Wild.

The word “lunacy” receives its etymology from the belief the moon can cause disorders of the mind.  Multiple things – including crime, crisis incidence, and human aggression – are all positively correlated with the phases of the moon.  It is obvious that the moon affects human behavior, but does it affect other animals?

From 1 January 1997 to 31 December 1999 there were 1621 patients seen at the Bradford Royal Infirmary ambulatory and emergency department with a diagnosis of “bite”. The overwhelming majority of these bites (95.1%) are from dogs, with the rest from cats, horses, and rats in descending order. To break down the 29.530589 day lunar cycle, the authors divided it into 10 periods, 9 with 3 days, and 1 with 2 days. Using that breakdown they were able to get a statistically significant difference in the incidence of animal bites at or about the full moon. 

What to take from this? Well, we can’t determine causation from this study certainly. Is it still human behavior causing increased bites, or are animals also influenced by lunar cycles? Notwithstanding the confidence intervals for the “high period” covering the entirety of their chart, they don’t break down the data for each day of the lunar cycle. Most human behavior differences in the full moon have to do with increased nocturnal light, and this doesn’t apply during the day. No reasons are given for the seemingly arbitrary divisions of the lunar cycle either.

Perhaps “lunacy” is every bit a misnomer as “hysteria”.

“Do animals bite more during a full moon? Retrospective observational analysis”

Lunacy, Animal Bites, and You

A guest post by Justin Hensley (@EBMGoneWild) of Evidence-Based Medicine Gone Wild.

The word “lunacy” receives its etymology from the belief the moon can cause disorders of the mind.  Multiple things – including crime, crisis incidence, and human aggression – are all positively correlated with the phases of the moon.  It is obvious that the moon affects human behavior, but does it affect other animals?

From 1 January 1997 to 31 December 1999 there were 1621 patients seen at the Bradford Royal Infirmary ambulatory and emergency department with a diagnosis of “bite”. The overwhelming majority of these bites (95.1%) are from dogs, with the rest from cats, horses, and rats in descending order. To break down the 29.530589 day lunar cycle, the authors divided it into 10 periods, 9 with 3 days, and 1 with 2 days. Using that breakdown they were able to get a statistically significant difference in the incidence of animal bites at or about the full moon. 

What to take from this? Well, we can’t determine causation from this study certainly. Is it still human behavior causing increased bites, or are animals also influenced by lunar cycles? Notwithstanding the confidence intervals for the “high period” covering the entirety of their chart, they don’t break down the data for each day of the lunar cycle. Most human behavior differences in the full moon have to do with increased nocturnal light, and this doesn’t apply during the day. No reasons are given for the seemingly arbitrary divisions of the lunar cycle either.

Perhaps “lunacy” is every bit a misnomer as “hysteria”.

“Do animals bite more during a full moon? Retrospective observational analysis”

Time to Move to the HEART Score

A couple posts ago I mentioned it was time for the TIMI Risk Score for UA/nSTEMI to go the way of the dodo for evaluation of chest pain in the Emergency Department.  It wasn’t derived from an Emergency Department population, doesn’t have great predictive skill in identifying very-low-risk patients, and includes nonsensical elements (did you take an aspirin within the last 7 days?).

Alternatively, we have the HEART score: History, ECG, Age, Risk factors, Troponin.  This was derived – like the Wells score – from the elements of clinical gestalt, and ought to at least make better intuitive sense than the occasionally frizzy outputs from multivariate logistic regression.  It was initially derived and refined retrospectively, and this represents the prospective validation study.  These authors prospectively enrolled 2,440 patients from 10 centers in the Netherlands and followed them for a primary endpoint of a major adverse cardiac event (AMI, PCI, CABG, death) for six weeks.  They also collected the variables of interest necessary to calculate TIMI and GRACE risk scores for comparison of c-statistic.

Obviously, I’m recommending the HEART score because it outperformed the others – the c-statistic for HEART was 0.83, 0.75 for TIMI, and 0.70 for GRACE.  Most importantly, for the Emergency Department, it was superior at the low-end of the spectrum.  For the 34% of the population that was TIMI 0-1, 23/811 (2.8%) had 6-week MACE.  14.0% had GRACE 0-60, and 10/335 (2.9%) had MACE.  For HEART, 36.4% were 0-3 and ultimately 15/870 (1.7%) had MACE.

Even though there are 2,400 patients in this study, there are few enough in each individual category that confidence intervals for each predictive bucket are still relatively wide.  Then, you can still have a HEART score in the “very low risk” 0-3 range with a troponin >3x the normal limit and an abnormal EKG – which is seemingly counterintuitive.  They also don’t compare their rule to clinical judgment, so we can’t measure the performance of the rule in actual decision-making.

A couple other studies have either prospectively or retrospectively validated these findings with reasonable consistency.  It isn’t perfect – but it’s better than TIMI or GRACE – and it’s what I currently use to support my shared decision-making discussions at disposition of the appropriate chest pain cohort.

http://www.heartscore.nl/en/

“A prospective validation of the HEART score for chest pain patients at the emergency department”
http://www.ncbi.nlm.nih.gov/pubmed/23465250