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Thrombolysis Followed by Early Revascularization: An Effective Reperfusion Strategy in Real World Patients with ST-Elevation Myocardial Infarction
354 were for a chief complaint of CP, the rates of hospital admission for CP, the number of repeat ED visits within 30 days, and the daily all-cause hospital admissions from the ED for 1 year before and after the intervention. The percentage of ED visits for chest pain increased 16% at hospitals with CPUs and only 3.5% at control hospitals ( p ⫽ 0.08). There was no change in the proportion of hospital admissions for CP at control or intervention hospitals (adjusted odds ratio for hospitals with CPUs 0.998, 95% confidence interval [CI] 0.940 –1.059; p ⫽ 0.945). Hospitals that instituted CPUs showed a slight increase in the number of repeat ED visits for CP (adjusted odds ratio 1.10, 95% CI 1.00 –1.21; p ⫽ 0.036). The presence of a CPU was associated with a small increase of 1.0 (95% CI 0.4 –1.5; p ⫽ 0.001) patient per day in all-cause admissions through the ED. The authors conclude that the creation of a CPU does not decrease the proportion of hospital admissions for patients who present to the ED with a chief complaint of CP. [Nathan J. Cleveland, MD, Denver Health Medical Center, Denver, CO] Comment: This was an understandably difficult study to design and implement, and therefore possesses some inherent flaws such as lack of uniformity in the CPUs. Nevertheless, it calls into question whether CPUs can, in fact, reduce the costs and improve the efficiency of evaluating patients who present to the ED with a complaint of CP.
e THERMAL INJURY WITH CONTEMPORARY CAST APPLICATION TECHNIQUES AND METHODS TO CIRCUMVENT MORBIDITY. Halanski MA, Halanski AD, Oza A, et al. J Bone Joint Surg Am 2007;89:2369 –77. This study assessed the propensity of different casting materials and techniques to cause thermal burns. Tissue damage is known to occur when temperatures inside a cast reach ⬎50°C. Experiments were performed on cylindrical and “L”-shaped artificial limbs (to simulate the forearm and leg, respectively, with foot) made of polyvinylchloride pipe with diameters of 27 mm, 48 mm, and 89 mm, and coated with a polyurethane carbon fiber heating element to simulate human skin temperatures of 33–35°C. Temperature sensors were placed both within and on the outside of the casts. The experimental model was validated on humans using 12-ply plaster casts with the same temperature measuring systems and dip water temperatures of up to 50°C. The effects on internal temperature were analyzed with varying artificial limb diameter, limb shape, plaster thickness, cast type, dip-water temperature, and placement of the cast on a pillow during hardening of the cast. They also measured the effect on temperature of isopropyl alcohol and ice application to hardening casts. Casting with only fiberglass material did not produce temperatures high enough to cause thermal injury across all variables. With plaster, using dipwater temperatures of ⬍24°C was unlikely to cause thermal injury regardless of other variables, including cast thickness. The use of 24-ply plaster, 50°C dip water, or over-wrapping of plaster casts with fiberglass all caused temperatures high enough to cause burns. Curing a cast against a pillow also
Abstracts raised internal temperatures to dangerous levels. The application of isopropyl alcohol to the exterior of casts that were prone to causing thermal injury did not significantly lower the interior peak temperature. Ice application between a curing 12-ply plaster cast and standard hospital pillow averted the increase in temperature to a damaging level, and the use of a plaster slab on the convexity of the “L” shaped limb and reduction of the plaster in the concavity to 6 ply would reduce thermal injury risk. [Maria G. Frank, MD, Denver Health Medical Center, Denver, CO] Comment: This was a well-designed experimental study that should remind emergency physicians of an important potential patient risk for burns when using plaster casts. By modifying technique to use cooler dip-water, thinner casts— especially in the convexity of joints, applying ice between a pillow and a curing cast or by using fiberglass-only casts, this risk may be averted.
e THROMBOLYSIS FOLLOWED BY EARLY REVASCULARIZATION: AN EFFECTIVE REPERFUSION STRATEGY IN REAL WORLD PATIENTS WITH STELEVATION MYOCARDIAL INFARCTION. Jaffe R, Halon DA, Karkabi B, et al. Cardiology 2007;107:329 –36. The authors of this Israeli study hypothesized that in patients with hemodynamically stable ST-elevation myocardial infarction (STEMI), initial thrombolysis followed by early, definitive revascularization could achieve salutary short- and long-term outcomes. They prospectively evaluated 276 STEMI patients at a single center. Thrombolysis was initially chosen in 212 patients with aggressive rescue angioplasty if there was no or inadequate evidence of coronary reperfusion. Reperfusion strategy was tailored according to the patient’s clinical status, time from onset of symptoms, and availability of catheterization facilities. Primary percutaneous coronary angioplasty (PCI) was selected as the initial management strategy in 64 high-risk patients who were hemodynamically unstable, in those with contraindications to thrombolysis, in those presenting late, and in others with extensive STEMI where there was ready availability of the catheterization suite. Thirty-day and 1-year mortality was compared between the two groups as well as to the PCI arm of several previously published randomized clinical trials. Ninety-two percent underwent pre-discharge coronary angiography, followed by PCI in 79% and coronary bypass surgery in 8%. No patients were lost to follow-up. Twenty-five percent of the patients in the thrombolysis cohort underwent rescue angioplasty within 6 h of administration of thrombolytics. The 30-day and 1-year mortality in the thrombolytic cohort was 4.7% and 6.7%, respectively, compared to a 1-year mortality of 17.2% in the PCI group. The authors state that the findings in the thrombolytic cohort compare very favorably with the outcome reported in the PCI arm of randomized clinical trials. The authors conclude that in real-world STEMI patients, an initial thrombolytic strategy retains an important role as a practical and effective therapeutic option
The Journal of Emergency Medicine when followed by a policy of early in-hospital rescue or semielective revascularization (tailored reperfusion strategy). [Matt Ledges, MD, Denver Health Medical Center, Denver, CO] Comment: Although this was a single-center, small, prospective cohort study, the observations add to the growing body of evidence that initial thrombolytics, followed by early definitive revascularization should be considered in stable patients presenting with NSTEMI. This is especially important for patients presenting to centers that do not have a cardiac catheterization laboratory.
e PROTECTIVE EFFECT OF ANTIBIOTICS AGAINST SERIOUS COMPLICATIONS OF COMMON RESPIRATORY TRACT INFECTIONS: RETROSPECTIVE COHORT STUDY WITH THE UK GENERAL PRACTICE RESEARCH DATABASE. Peterson I, Johnson AM, Islam A, et al. BMJ 2007;335:982. This study from the United Kingdom used data from 162 practices that contributed to the UK General Practice Research Database from 1991 to 2001 to examine the extent to which antibiotics reduce the risk of serious complications within 1 month after common respiratory tract infections. Serious complications were defined as mastoiditis after otitis media, quinsy (peritonsillar abscess) after sore throat, and pneumonia after upper respiratory tract infection and chest infection. This retrospective cohort study used a data source of 3.36 million episodes of respiratory tract infection. Logistic regression adjusted for age, sex, and social status was used to calculate odds ratios (OR) for the potential protective effect of antibiotics. Although a protective effect was seen with antibiotic use for serious complications after upper respiratory tract infections (OR 0.68, 95% confidence interval [CI] 0.58 – 0.79), otitis media (OR 0.56, 95% CI 0.37– 0.86), and sore throat (OR 0.84, 95% CI 0.73– 0.97), these complications were so rare in both treated and untreated populations that the number needed to treat was over 4000 for each complication. The risk of pneumonia after chest infection was substantially reduced with antibiotic use, with the greatest effect seen in those aged 65 years and older. The number needed to treat in this age group was 39, and between 96 and 119 in younger age groups. The authors conclude that antibiotics do not have a protective effect toward reducing the risk of serious complications after upper respiratory tract infections, otitis media, or sore throat, but may have a role in reducing the risk of pneumonia after chest infections, particularly in elderly patients. [Susan Brion, MD, Denver Health Medical Center, Denver, CO] Comments: This study relied upon diagnostic codes assigned to conditions by general practitioners to identify significant data, and the authors admit that in routine practice, doctors are unlikely to apply strict case definitions when allocating these codes. Nonetheless, the significant power of this study to examine the effect of interventions on rare outcomes cannot be overlooked. The findings support the growing body
355 of evidence and clinical guidelines that discourage the routine use of antibiotics for simple infections.
e THE BENEFIT OF HIGHER LEVEL OF CARE TRANSFER OF INJURED PATIENTS FROM NONTERTIARY HOSPITAL EMERGENCY DEPARTMENTS. Newgard CD, McConnell KJ, Hedges JR, Mullins RJ. J Trauma 2007;63:965–71. This study out of Oregon attempted to determine whether there is a reduction in mortality associated with the transfer of injured patients from non-tertiary emergency departments (EDs) to higher level trauma centers. Data from the Oregon State Trauma Registry was analyzed retrospectively and included all adults and children who presented to one of 42 level III or IV EDs and were admitted to the hospital or transferred directly from the ED to one of six level I or II trauma centers over a 6-year period. In-hospital mortality was the primary outcome measure. A total of 10,176 patients were included in the cohort and 37% were transferred to higher level trauma centers. Patients selected for transfer had a higher propensity for in-hospital mortality (unadjusted odds ratio 2.83, 95% confidence interval [CI] 2.06 –3.89). In an attempt to compensate for this fact, a propensity score was developed as a means of eliminating confounders and getting a better sense of mortality rates independent of the reasons for transfer. When propensity scores were used for this purpose, transfer was found to be associated with a reduction in in-hospital mortality (adjusted odds ratio 0.67, 95% CI 0.48 – 0.94). This reduction in mortality was seen primarily in patients transferred to level I centers (odds ratio 0.62, 95% CI 0.40 – 0.95) rather than level II centers (odds ratio 0.82, 95% CI 0.47–1.43). The authors conclude that trauma patients transferred to major trauma centers from non-tertiary EDs have lower in-hospital mortality, especially when transferred to a level I trauma center. [Nathan J. Cleveland, MD, Denver Health Medical Center, Denver, CO] Comment: As expected, patients who are transferred to higher level trauma centers are more gravely injured and at higher risk for mortality. This study suggests, however, the benefit of early recognition of injury severity and early transfer of trauma patients to tertiary care centers. A critical element in determining the validity of this study is the propensity scores used to adjust the data.
e USE OF ADMISSION SERUM LACTATE AND SODIUM LEVELS TO PREDICT MORTALITY IN NECROTIZING SOFT-TISSUE INFECTIONS. Yaghoubian A, de Virgilio C, Dauphine C, Lewis RJ, Lin M. Arch Surg 2007; 142:840 – 6. This is a retrospective chart review of 124 patients with necrotizing soft tissue infections (NSTI) presenting from January 1, 1997 to December 31, 2006 at UCLA Medical Center. The primary outcome measure was in-hospital mortality. Patient selection was based on discharge International Classification of
e THERMAL INJURY WITH CONTEMPORARY CAST APPLICATION TECHNIQUES AND METHODS TO CIRCUMVENT MORBIDITY. Halanski MA, Halanski AD, Oza A, et al. J Bone Joint Surg Am 2007;89:2369 –77. This study assessed the propensity of different casting materials and techniques to cause thermal burns. Tissue damage is known to occur when temperatures inside a cast reach ⬎50°C. Experiments were performed on cylindrical and “L”-shaped artificial limbs (to simulate the forearm and leg, respectively, with foot) made of polyvinylchloride pipe with diameters of 27 mm, 48 mm, and 89 mm, and coated with a polyurethane carbon fiber heating element to simulate human skin temperatures of 33–35°C. Temperature sensors were placed both within and on the outside of the casts. The experimental model was validated on humans using 12-ply plaster casts with the same temperature measuring systems and dip water temperatures of up to 50°C. The effects on internal temperature were analyzed with varying artificial limb diameter, limb shape, plaster thickness, cast type, dip-water temperature, and placement of the cast on a pillow during hardening of the cast. They also measured the effect on temperature of isopropyl alcohol and ice application to hardening casts. Casting with only fiberglass material did not produce temperatures high enough to cause thermal injury across all variables. With plaster, using dipwater temperatures of ⬍24°C was unlikely to cause thermal injury regardless of other variables, including cast thickness. The use of 24-ply plaster, 50°C dip water, or over-wrapping of plaster casts with fiberglass all caused temperatures high enough to cause burns. Curing a cast against a pillow also
Abstracts raised internal temperatures to dangerous levels. The application of isopropyl alcohol to the exterior of casts that were prone to causing thermal injury did not significantly lower the interior peak temperature. Ice application between a curing 12-ply plaster cast and standard hospital pillow averted the increase in temperature to a damaging level, and the use of a plaster slab on the convexity of the “L” shaped limb and reduction of the plaster in the concavity to 6 ply would reduce thermal injury risk. [Maria G. Frank, MD, Denver Health Medical Center, Denver, CO] Comment: This was a well-designed experimental study that should remind emergency physicians of an important potential patient risk for burns when using plaster casts. By modifying technique to use cooler dip-water, thinner casts— especially in the convexity of joints, applying ice between a pillow and a curing cast or by using fiberglass-only casts, this risk may be averted.
e THROMBOLYSIS FOLLOWED BY EARLY REVASCULARIZATION: AN EFFECTIVE REPERFUSION STRATEGY IN REAL WORLD PATIENTS WITH STELEVATION MYOCARDIAL INFARCTION. Jaffe R, Halon DA, Karkabi B, et al. Cardiology 2007;107:329 –36. The authors of this Israeli study hypothesized that in patients with hemodynamically stable ST-elevation myocardial infarction (STEMI), initial thrombolysis followed by early, definitive revascularization could achieve salutary short- and long-term outcomes. They prospectively evaluated 276 STEMI patients at a single center. Thrombolysis was initially chosen in 212 patients with aggressive rescue angioplasty if there was no or inadequate evidence of coronary reperfusion. Reperfusion strategy was tailored according to the patient’s clinical status, time from onset of symptoms, and availability of catheterization facilities. Primary percutaneous coronary angioplasty (PCI) was selected as the initial management strategy in 64 high-risk patients who were hemodynamically unstable, in those with contraindications to thrombolysis, in those presenting late, and in others with extensive STEMI where there was ready availability of the catheterization suite. Thirty-day and 1-year mortality was compared between the two groups as well as to the PCI arm of several previously published randomized clinical trials. Ninety-two percent underwent pre-discharge coronary angiography, followed by PCI in 79% and coronary bypass surgery in 8%. No patients were lost to follow-up. Twenty-five percent of the patients in the thrombolysis cohort underwent rescue angioplasty within 6 h of administration of thrombolytics. The 30-day and 1-year mortality in the thrombolytic cohort was 4.7% and 6.7%, respectively, compared to a 1-year mortality of 17.2% in the PCI group. The authors state that the findings in the thrombolytic cohort compare very favorably with the outcome reported in the PCI arm of randomized clinical trials. The authors conclude that in real-world STEMI patients, an initial thrombolytic strategy retains an important role as a practical and effective therapeutic option
The Journal of Emergency Medicine when followed by a policy of early in-hospital rescue or semielective revascularization (tailored reperfusion strategy). [Matt Ledges, MD, Denver Health Medical Center, Denver, CO] Comment: Although this was a single-center, small, prospective cohort study, the observations add to the growing body of evidence that initial thrombolytics, followed by early definitive revascularization should be considered in stable patients presenting with NSTEMI. This is especially important for patients presenting to centers that do not have a cardiac catheterization laboratory.
e PROTECTIVE EFFECT OF ANTIBIOTICS AGAINST SERIOUS COMPLICATIONS OF COMMON RESPIRATORY TRACT INFECTIONS: RETROSPECTIVE COHORT STUDY WITH THE UK GENERAL PRACTICE RESEARCH DATABASE. Peterson I, Johnson AM, Islam A, et al. BMJ 2007;335:982. This study from the United Kingdom used data from 162 practices that contributed to the UK General Practice Research Database from 1991 to 2001 to examine the extent to which antibiotics reduce the risk of serious complications within 1 month after common respiratory tract infections. Serious complications were defined as mastoiditis after otitis media, quinsy (peritonsillar abscess) after sore throat, and pneumonia after upper respiratory tract infection and chest infection. This retrospective cohort study used a data source of 3.36 million episodes of respiratory tract infection. Logistic regression adjusted for age, sex, and social status was used to calculate odds ratios (OR) for the potential protective effect of antibiotics. Although a protective effect was seen with antibiotic use for serious complications after upper respiratory tract infections (OR 0.68, 95% confidence interval [CI] 0.58 – 0.79), otitis media (OR 0.56, 95% CI 0.37– 0.86), and sore throat (OR 0.84, 95% CI 0.73– 0.97), these complications were so rare in both treated and untreated populations that the number needed to treat was over 4000 for each complication. The risk of pneumonia after chest infection was substantially reduced with antibiotic use, with the greatest effect seen in those aged 65 years and older. The number needed to treat in this age group was 39, and between 96 and 119 in younger age groups. The authors conclude that antibiotics do not have a protective effect toward reducing the risk of serious complications after upper respiratory tract infections, otitis media, or sore throat, but may have a role in reducing the risk of pneumonia after chest infections, particularly in elderly patients. [Susan Brion, MD, Denver Health Medical Center, Denver, CO] Comments: This study relied upon diagnostic codes assigned to conditions by general practitioners to identify significant data, and the authors admit that in routine practice, doctors are unlikely to apply strict case definitions when allocating these codes. Nonetheless, the significant power of this study to examine the effect of interventions on rare outcomes cannot be overlooked. The findings support the growing body
355 of evidence and clinical guidelines that discourage the routine use of antibiotics for simple infections.
e THE BENEFIT OF HIGHER LEVEL OF CARE TRANSFER OF INJURED PATIENTS FROM NONTERTIARY HOSPITAL EMERGENCY DEPARTMENTS. Newgard CD, McConnell KJ, Hedges JR, Mullins RJ. J Trauma 2007;63:965–71. This study out of Oregon attempted to determine whether there is a reduction in mortality associated with the transfer of injured patients from non-tertiary emergency departments (EDs) to higher level trauma centers. Data from the Oregon State Trauma Registry was analyzed retrospectively and included all adults and children who presented to one of 42 level III or IV EDs and were admitted to the hospital or transferred directly from the ED to one of six level I or II trauma centers over a 6-year period. In-hospital mortality was the primary outcome measure. A total of 10,176 patients were included in the cohort and 37% were transferred to higher level trauma centers. Patients selected for transfer had a higher propensity for in-hospital mortality (unadjusted odds ratio 2.83, 95% confidence interval [CI] 2.06 –3.89). In an attempt to compensate for this fact, a propensity score was developed as a means of eliminating confounders and getting a better sense of mortality rates independent of the reasons for transfer. When propensity scores were used for this purpose, transfer was found to be associated with a reduction in in-hospital mortality (adjusted odds ratio 0.67, 95% CI 0.48 – 0.94). This reduction in mortality was seen primarily in patients transferred to level I centers (odds ratio 0.62, 95% CI 0.40 – 0.95) rather than level II centers (odds ratio 0.82, 95% CI 0.47–1.43). The authors conclude that trauma patients transferred to major trauma centers from non-tertiary EDs have lower in-hospital mortality, especially when transferred to a level I trauma center. [Nathan J. Cleveland, MD, Denver Health Medical Center, Denver, CO] Comment: As expected, patients who are transferred to higher level trauma centers are more gravely injured and at higher risk for mortality. This study suggests, however, the benefit of early recognition of injury severity and early transfer of trauma patients to tertiary care centers. A critical element in determining the validity of this study is the propensity scores used to adjust the data.
e USE OF ADMISSION SERUM LACTATE AND SODIUM LEVELS TO PREDICT MORTALITY IN NECROTIZING SOFT-TISSUE INFECTIONS. Yaghoubian A, de Virgilio C, Dauphine C, Lewis RJ, Lin M. Arch Surg 2007; 142:840 – 6. This is a retrospective chart review of 124 patients with necrotizing soft tissue infections (NSTI) presenting from January 1, 1997 to December 31, 2006 at UCLA Medical Center. The primary outcome measure was in-hospital mortality. Patient selection was based on discharge International Classification of