Cystic fibrosis medicines that help to break down mucus in the lungs may carry an unexpected long-term benefit, a study suggests.
The treatments not only help breathing in the short term - they may also make lung infections develop to be less harmful in the long run, research from the University of Edinburgh shows.
Scientists studied how bacteria which infect the lungs of cystic fibrosis patients gather nutrients from their surroundings. The work builds on the knowledge that most bacteria co-operate to scavenge what they need from their environment, but some bacteria do not actively hunt, instead stealing nutrients from neighbouring bacteria.
Scientists found that in a viscous environment, similar to thick mucus, the co-operating type of bacteria is most common. However, in a more liquid environment - similar to mucus having been broken down by medicine - the number of thieving bacteria increases, eventually outnumbering the scavenging type. In this environment, because the thieving bacteria are less adept at obtaining food, the bacterial growth slows down.
The results suggest that liquefying lung mucus would be expected to limit the impact of infection in cystic fibrosis.
Dr Rolf Kuemmerli, formerly a researcher at the University of Edinburgh, who led the study, said: "Treating cystic fibrosis patients with drugs that clear their lungs delivers short-term relief for the patient, but may have long-term health benefits too. We hope that our findings will underline the need for treatments that target mucus in the lungs."
Dr Freya Harrison of the University of Bath, who took part in the study, added: "Bacterial infections develop over time, and understanding how medical treatments affect this could be very important for managing long-term infections such as those found in cystic fibrosis."
Cystic fibrosis is an inherited condition that affects more than 8,000 people in the UK, according to the Cystic Fibrosis Trust. Thick mucus can clog the internal organs, especially the lungs and digestive system, making it hard to breathe and digest food.
The study, carried out by researchers at the Universities of Edinburgh, Oxford and Bath, was published in Proceedings of the Royal Society B. Work was supported by the Royal Society and the Leverhulme Trust.
Infants who weigh less than five and a half pounds at birth often enter the world with a host of medical complications, including respiratory problems. New research shows that these respiratory problems may persist well beyond their infancy and childhood and into adulthood.
"We report a previously unrecognized excess risk of hospitalization for respiratory illnesses in young adults with a history of low birth weight," wrote lead researcher Eric C. Walter, M.D., of the University of Washington Division of Pulmonary and Critical Care. "Our findings suggest that not only are [low birth weight] survivors at increased risk for long-term respiratory disorders, but that these disorders are clinically significant and associated with increased health care utilization."
The researchers used hospitalization records from the Washington State Comprehensive Hospital Abstract Reporting System's discharge database between January 1, 1998 and December 31, 2007. They selected as potential cases any person who was 18 years old at the time of hospitalization and who was discharged with a respiratory code listed among the top four diagnoses. They then linked these cases to birth weight data listed on birth certificates where possible. Control subjects were randomly selected from birth certificate data.
They found that individuals with very low birth weight (less than 1.5 kg, or 3.3 lbs.) or moderately low birth weight (1.5 to 2.5 kg or 3.3 to 5.5 pounds) had a 83 and 34 percent higher risk of hospitalization for respiratory diagnoses respectively. Those who had a history of very low birth weight had twice the risk of being hospitalized for asthma or respiratory infection and 2.6 times the risk of respiratory failure requiring mechanical ventilation.
After adjusting for covariates, including demographic characteristics and maternal smoking, the significant association between birth weight and risk of hospitalization persisted. Furthermore, while the data could not definitively prove a linear link, researchers did note a trend toward greater risk of respiratory problems with lower birth weights.
"In our study the percentage of respiratory disease attributable to moderately or very low birth weight was estimated to be 1.8 percent. If this were extrapolated to the 1.2 million U.S. hospitalizations for respiratory illnesses per year for ages 18 to 44, low birth weight may account for over 22,000 adult hospitalizations per year, with charges in excess of $225 million per year," said Dr. Walter.
While the study did not distinguish between premature birth and retardation of in utero development as causes of low birth weight, previous research has found that both conditions increase risk of abnormal pulmonary function in adolescence and adulthood.
Dr. Walter notes that maternal smoking is a risk factor for low birth weight, and that children of mothers who smoked are more likely to smoke themselves. The relationship, therefore, is difficult to fully tease apart. "It is unknown if adults with a history of low birth weight are more likely to smoke than adults with a history of normal birth weight," he said. "[In this study] we did not find that maternal smoking confounded the affect of low birth weight on adult respiratory disease, but further research is needed comparing hospitalization and smoking rates between adults with history of low birth weight and normal birth weight to better understand this relationship."
While more research is needed to further clarify the relationship between birth weight and subsequent respiratory problems, these results do strongly suggest a looming public health issue. Since the mid-1980s, the proportion of low- and very low birth weight births in the U.S. has increased by more than 20 percent, and in 2005, there were 330,000 combined low- and very low birth weight births in the U.S.
"Given the data from the present study, it would seem prudent to include such a bleak forecast in long-term planning for the provision of health care services," wrote Anne Greenough, M.D. of King's College, London in an accompanying editorial.
Journal reference:
Walter et al. Low Birth Weight and Respiratory Disease in Adulthood: A Population-based Case-Control Study. American Journal of Respiratory and Critical Care Medicine, 2009; 180 (2): 176 DOI: 10.1164/rccm.200901-0046OC
A new study shows that for elderly people at risk of cardiovascular disease, the presence of inflammatory markers in the blood can identify that an individual is at a higher risk of a fatal rather than a non-fatal heart attack or stroke.
Inflammation is an immune response to injury. However, inflammation is also thought to play a role in cardiovascular disease. Previous studies have shown an association between high levels of markers of inflammation in the circulation with a greater risk of a cardiovascular event, such as a heart attack or stroke. In this study, Naveed Sattar of the University of Glasgow and colleagues used data from an existing trial known as PROSPER (the Prospective Study of Pravastatin in the Elderly at Risk), which involved participants aged between 70 and 82 who had or were at risk of cardiovascular disease.
They examined if three inflammatory markers—interleukin-6 (IL-6), C-reactive protein (CRP) and fibrinogen—were each more strongly massociated with fatal cardiovascular events than with non-fatal cardiovascular events in the period of over three years in which the patients in the trial were monitored.
Using several statistical models, the researchers found that in this group of elderly patients increased levels of all three inflammatory markers, and in particular IL-6, were more strongly associated with a fatal heart attack or stroke than with a non-fatal heart attack or stroke. They also investigated the predictive value of these inflammatory markers—in other words, whether it was useful to include these markers in tools designed to distinguish between individuals with a high and a low risk of heart attacks, strokes and other cardiovascular events.
They report that adding IL-6 to the established risk factors in predictive tools—including lifestyle factors such as smoking, high blood pressure and high blood cholesterol, all of which greatly increase the risk of cardiovascular disease—could help better identify those individuals at a risk of a fatal stroke or heart attack, but not those at risk of a non-fatal cardiovascular event.
The findings of the study suggest inflammatory markers may be more strongly associated with fatal heart attacks and strokes than non-fatal cardiovascular events. The researchers acknowledge that these findings now need to be confirmed in younger populations and larger studies to demonstrate an outright association and the design of the current study cannot show whether the proposed association is a causal one. Nevertheless, the findings should stimulate further investigation into whether the application of inflammatory markers may help better predict the risk of deaths from cardiovascular disease, and whether novel treatments which dampen inflammation might help prolong life.
Journal reference:
Sattar N, Murray HM, Welsh P, Blauw GJ, Buckley BM, et al. Are Markers of Inflammation More Strongly Associated with Risk for Fatal Than for Nonfatal Vascular Events?PLoS Med, 6(6): e1000099 DOI: 10.1371/journal.pmed.1000099
Because radiographic pneumonia in children with wheezing but without fever is uncommon, the routine use of chest radiography in these children should be discouraged, according to the results of a prospective cohort study reported in the July issue of Pediatrics.
"The diagnosis of pneumonia in children with wheezing can be difficult, because the clinical history and auscultatory findings may be difficult to distinguish from those for children without pneumonia," write Bonnie Mathews, MD, from Children's Hospital Boston and Harvard Medical School in Boston, Massachusetts, and colleagues. "Limited data exist regarding predictors of pneumonia among children with wheezing. The goal was to identify factors associated with radiographically confirmed pneumonia among children with wheezing in the emergency department (ED) setting."
The study sample consisted of 526 individuals not older than 21 years who were seen in the ED, who had wheezing on clinical examination, and who underwent chest radiography because of possible pneumonia. Before learning the chest radiograph results, treating physicians obtained a medical history and performed and recorded a physical examination. Two blinded radiologists independently read the chest radiographs.
Among the included patients, median age was 1.9 years (interquartile range, 0.7 - 4.5 years), 47% had a history of wheezing, 36% were hospitalized, and 4.9% (95% confidence interval [CI], 3.3% - 7.3%) had radiographic pneumonia. Children with wheezing who were afebrile, defined as a temperature of less than 38°C, had a very low rate of pneumonia (2.2%; 95% CI, 1.0% - 4.7%).
Factors linked to an increased risk for radiographic pneumonia were a history of fever at home (positive likelihood ratio [LR], 1.39; 95% CI, 1.13 - 1.70), a history of abdominal pain (positive LR, 2.85; 95% CI, 1.08 - 7.54), triage temperature of 38°C or higher (positive LR, 2.03; 95% CI, 1.34 - 3.07), maximal temperature in the ED of 38°C or higher (positive LR, 1.92; 95% CI, 1.48 - 2.49), and triage oxygen saturation of less than 92% (positive LR, 3.06; 95% CI, 1.15 - 8.16).
Limitations of this study include time constraints, preventing enrollment of all eligible children; reliance on blinded radiologist review; and chest radiographs ordered at the discretion of the physicians caring for the patients, which may have introduced selection bias. The findings are not generalizable to all children with wheezing, and the rate of pneumonia may have been overestimated.
"Radiographic pneumonia among children with wheezing is uncommon," the study authors write. "Historical and clinical factors may be used to determine the need for chest radiography for wheezing children. The routine use of chest radiography for children with wheezing but without fever should be discouraged."
For treatment of obstructive sleep apnea in children, a high-flow open nasal cannula may be as effective as a continuous positive airway pressure (CPAP) mask but less intrusive and easier to tolerate.
At Johns Hopkins Hospital in Baltimore, Maryland, Dr. Brian McGinley and colleagues assessed the effect of warm, humidified air delivered at a rate of 20 L/min via open nasal cannula in 12 obese children (mean age, 10 years) with mild to severe obstructive apnea-hypopnea syndrome.
In the July issue of Pediatrics, the researchers note that while the home treatment with CPAP had been prescribed for these children, adherence was low and most were not being effectively treated.
According to the article, treatment with nasal insufflation reduced patients' inspiratory flow limitation, respiratory rate, and inspiratory duty cycle. Furthermore, oxygen stores improved and the children experienced fewer arousals, which reduced the occurrence of obstructive apnea from a mean of 11 events to 5 events per hour.
Ten of the children had previously undergone CPAP titration, and in eight of these patients "the reduction in the apnea-hypopnea index on treatment with nasal insufflation was comparable to that on CPAP," the authors report
When subanalyses were performed for sleep stages, the mean apnea-hypopnea index fell from 8 to 4 events per hour during non-REM sleep (p<0.01) p="0.01).
This "marked reduction in apneic events during REM sleep" was greater than the researchers had expected on the basis of their earlier studies of this approach in adults. It's possible, they speculate, that nasal insufflation might be increasing pharyngeal pressure to a greater extent in children because the cannula is relatively large compared with the nares.
It's also possible that higher chest wall and lung compliance during REM sleep in the children might have allowed a slight increase in pharyngeal pressure to produce a relatively larger increase in lung volume, leading to improvements in oxygen stores and upper airway patency, or that the treatment stimulated upper airway neuromuscular responses.
Noting that studies in larger and more varied pediatric populations are still necessary, the researchers conclude that "the minimally intrusive nasal interface (of the cannula) may improve adherence to treatment in children and may ultimately prove more effective in managing the long-term morbidity and mortality of sleep apnea."
The US Food and Drug Administration (FDA) has approved pemetrexed (Alimta, Eli Lily) for the maintenance therapy of advanced or metastatic nonsquamous non–small-cell lung cancer (NSCLC). Pemetrexed is the first drug indicated as a maintenance therapy in this setting.
"This drug represents a new approach in the treatment of advanced non–small-cell lung cancer," said Richard Pazdur, MD, director of the Office of Oncology Drug Products in the FDA's Center for Drug Evaluation and Research, in a press statement. "Typically, patients whose tumors respond to chemotherapy do not receive further treatment after four to six chemotherapy cycles. This study demonstrates an advantage in overall survival in certain patients who received Alimta for maintenance therapy."
In a phase 3 trial recently presented at the American Society of Clinical Oncology (ASCO) meeting, patients received either pemetrexed (n = 441) or placebo (n = 222), along with the best supportive care. Patients had advanced or metastatic (stage 3B or 4) NSCLC (both squamous and nonsquamous subtypes) that had not progressed after 4 cycles of initial platinum-based chemotherapy.
For all patients in the study, the pemetrexed treatment group had an overall survival of 13.4 months, compared with 10.6 months for the placebo group. However, for the nonsquamous subgroup, overall survival was 15.5 months for patients taking pemetrexed and 10.3 months for patients taking placebo. The difference was statistically significant (P = .002).
However, as reported by Medscape Oncology from ASCO, 2 lung-cancer experts attending the meeting questioned the appropriateness of using pemetrexed as a maintenance therapy. Neither was involved with this phase 3 trial.
"I don't think we have the answer as to when it is best to start pemetrexed. Should we start immediately after standard chemotherapy or later on? All you can say is that it improves survival in nonsquamous-cell patients. In my clinic, I will present maintenance therapy as an option," said Julie Brahmer, MD, from the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, in Baltimore, Maryland.
"I endorse the use of pemetrexed as a second-line therapy for advanced non–small-cell lung cancer, but I don't think that all patients need immediate maintenance therapy following first-line treatment," said Nasser H. Hanna, MD, from the department of medicine at Indiana University, in Indianapolis, adding that the trial design did not allow it to definitively establish pemetrexed as a maintenance therapy.
Dr. Hanna explained the phase 3 trial was not designed to indicate whether maintenance therapy was superior to using pemetrexed at time of disease progression.
"Only 19 patients who were on placebo received pemetrexed at time of disease progression because, in part, the drug was not available at all of the centers involved in the study. In short, we know the drug improves survival but not that maintenance therapy is the best way to use it," he said.
A form of chemotherapy, pemetrexed is a folate analog metabolic inhibitor, which means that it disrupts metabolic processes that depend on the B-vitamin folate, a necessary ingredient for cell replication.
In the phase 3 study presented at ASCO, severe adverse effects (grade 3 or 4) were more common in the pemetrexed than in the placebo group, including fatigue (5% vs 0.5%) and low white-blood-cell counts (2.9% vs 0%).
Other reported adverse events included nausea, loss of appetite, tingling or numbness in the hands and feet, and skin rash, according to the FDA statement.
Elevated depression symptoms are linked to cardiovascular mortality in patients with comorbid atrial fibrillation (AF) and congestive heart failure (CHF) who receive optimal treatment, according to the results of a study reported online in the June 29 issue of Circulation.
"Depression predicts prognosis in many cardiac conditions, including...CHF," write Nancy Frasure-Smith, PhD, from the Montreal Heart Institute and Université de Montréal in Canada, and colleagues from the Atrial Fibrillation and Congestive Heart Failure Investigators (AF-CHF).
"Despite heightened cardiac risk in patients with comorbid...AF and CHF, depression has not been studied in this group. This substudy, from the AF-CHF Trial of rate- versus rhythm-control strategies, investigated whether depression predicts long-term cardiovascular mortality in patients with left ventricular ejection fraction ≤35%, CHF symptoms, and AF history who receive optimal medical care."
Of 974 participants (833 men) who completed a Beck Depression Inventory-II (BDI-II) measuring symptoms of depression, 32.0% had elevated scores (BDI-II ≥ 14). During a mean follow-up of 39 months, the primary outcome of cardiovascular death occurred in 246 patients. Secondary outcomes were presumed arrhythmic deaths (n = 111) and all-cause deaths (n = 302). Cox proportional hazards models were used to adjust for prognostic factors including age, marital status, cause of CHF, creatinine level, left ventricular ejection fraction, paroxysmal AF, previous hospitalization for AF, previous electrical conversion, and baseline medications.
After adjustment, elevated depression score was a significant predictor of cardiovascular mortality (adjusted hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.20 - 2.07; P < .001), arrhythmic death (HR, 1.69; 95% CI, 1.13 - 2.53; P = .01), and all-cause mortality (HR, 1.38; 95% CI, 1.07 - 1.77; P = .01). Mortality risks associated with depression and marital status were additive, with the highest risk in unmarried depressed patients.
"Elevated depression symptoms are related to cardiovascular mortality even after adjustment for other prognostic indicators in patients with comorbid AF and CHF who receive optimized treatment," the study authors write. "Unmarried patients are also at increased risk. Mechanisms and treatment options deserve additional study."
Limitations of this study include lack of generalizability to all patients with CHF and AF, lack of clinician ratings and reliance on self-report of depression symptoms, and only 1 measurement of depressive symptoms. In addition, data were not available on the use of antidepressant medications, and the sample size in most of the participating countries was too small to allow evaluation of country-specific factors.
"The American Heart Association recently recommended depression screening in CAD [coronary artery disease] patients to identify those who might benefit from additional evaluation or treatment, and there is evidence that selective serotonin reuptake inhibitor antidepressant medications are as safe and efficacious in CAD patients as in the nonmedically ill," the study authors conclude. "In the absence of clinical trials specifically addressing these psychosocial risks among CHF patients with AF, we believe that depression and lack of a marital partner should be considered as risk markers identifying patients who may require additional treatment efforts to manage their cardiac conditions and modify other known risks."
"... the secret of the care of the patient is in caring for the patient." -Frances Peabody, 1925
There was a time not long ago, when physicians and nurses didn’t have much else to offer patients other than personal attention, comfort, compassion and concern for their ailments. Medical professionals were revered and respected for that and for what little they could do in regard to symptomatic treatment for incurable conditions.
The Twenty-First Century has thrust health care into an era of modernization, precipitated by advances in medical technology and computerization of everything in sight. We have made fantastic strides in the diagnosis and treatment of many serious illnesses. Patients are living longer and more productive lives as a result of these wonderful advances.
However, concomitant with these changes, we have experienced the indisputable depersonalization of patient care. Patients are often treated as diseases or numbers. We often hear medical personnel referring to a patient as “the gallbladder in room 232” or “the COPDer in 476”. We order test after test instead of taking a history because if we don’t “prove” our diagnosis with a test, we may be subjected to a lawsuit later if something goes wrong.
Health care costs have spun out of control. Forty-three million people in the US can no longer afford health insurance. Access to care has deteriorated. Prenatal care and birth rates are suffering. Doctors’ salaries are restricted by insurance companies. Busy primary care physicians have to see 30-40 patients a day to make enough income to pay off their own expenses beginning with a $250,000 debt for medical training.
There is no time to spend 20 minutes with an 80 year-old patient with diabetes, arthritis, heart failure, and hypertension out of control who has just developed shortness of breath recently, and who needs 6 prescriptions rewritten. Other patients in the waiting room are feeling ignored.
These are very difficult challenges. Unfortunately, in the middle of it all, we often lose site of the fact that our patients are people – in many cases, very ill people - who are looking to us for support and guidance as well as medical care. There is an art to providing this support and to personalizing care for each and every patient in the midst of an imperfect environment.
Anyone who works in the health care profession knows there is a right way and a wrong way to approach patient care. They also know this is somewhat different for every patient they encounter due to multiple variables – type of illness, gender, age, background, etc. This is an art that we learn mostly by experience – both by our own personal experience and by observing the experiences of others. How well we assimilate the information from these experiences and how well we use that knowledge determines a very large part of how we interact with patients and how we are perceived as medical professionals.
The key word here is the art of patient care. For the purposes of this site, the reference is not so much on the science of medicine per se, but rather on how medical personnel can interact with patients to improve the healing process, rather than dismantle it.
This is not to say that science is unimportant; but rather that concern for the humanity of the patient should not be so overwhelmed by science as to be nonexistent at the bedside. Indeed, true clinical competence is a blend of knowledgeable application of medical science along with the recognition and understanding of the human condition. The art of this blend, the integration of these two disciplines, and how well it is done, is what determines the quality of patient care that we provide. One without the other is not sufficient.
This can be a science unto itself. One of the influences that this site will hopefully promote is more discussion and ultimately more research on how to practice this art in a more meaningful and fulfilling way for both ourselves and our patients alike. In addition, the more formal exploration and inclusion of these concepts into medical training programs would have a huge effect on the future of medicine in this country.
Some people say you have to be born with this talent. I don’t think so. I do think it comes easier to some than others; but, whatever the genetics and background of the individual, patient care is an art that can be learned and practiced and improved upon, just as drawing or painting a thoughtful picture can be learned and practiced to the point where it can be greatly appreciated by others.
So what kind of doctor or nurse or care partner do you want to be?
What is your approach to patient care?
How do patients perceive your approach to them and your overall competence?
If you long to be one of those caring, well-respected and revered medical professionals that patients (and even other professionals) admire and tell their friends and neighbors about, you’ve found the right place.
Read and study the pages on this site. You will become a much more people-oriented professional, knowledgeable about how to approach all kinds of patients and challenging situations, and who will at the very least be perceived as someone who cares and is concerned about his or her patients.
If you practice what you learn here, you may find yourself actually rediscovering virtues you didn’t know you had. If you already have the nurturing gene, these pages will help you hone that talent into something very special; and your patients will benefit from it in ways you never thought possible.
The American Heart Association (AHA) has issued a scientific statement on the use of prehospital electrocardiograms (ECGs) to improve the quality of care delivered to patients with ST-segment-elevation MI (STEMI), published online August 13, 2008 in Circulation [1]. The central challenge, say the authors, will not be in acquiring the ECG, but rather in using and integrating the diagnostic information obtained by emergency medical service (EMS) personnel into existing systems of care.
"First medical contact with a patient is usually with the EMS, and this is the next phase of coordination that we need to reach out to," said lead author Dr Henry Ting (Mayo Clinic, Rochester, MN). "We've coordinated the emergency department, the cath lab, and the cardiology group and have done well with reducing door-to-balloon times, but we've not truly engaged the prehospital phase of care. This is critically important."
The AHA national guidelines, as well as other consensus and scientific statements, recommend the acquisition and use of prehospital ECGs by EMS for the evaluation of patients with suspected acute coronary syndrome. The current recommendation is class 2a with a B level of evidence. Speaking with heartwire, Ting said that the technology is currently available, but that hospitals do not have protocols in place that allow prehospital ECGs to serve any useful purpose.
"For the past 10 years, this equipment has been available to many paramedics, but what is happening is that when they acquire the ECG it's not really utilized," said Ting. "It's acquired, then the patient is brought to the emergency department, and in hospitals without these systems of care, they're told this is a patient with chest pain, and we have an ECG, but then the patient is placed in a critical-care room and receives another ECG. Where's the value in that?"
Not a One-Size-Fits-All Solution
In the scientific statement, the authors review the benefits of using prehospital ECGs and the barriers and challenges to routine use and recommend approaches for using the diagnostic information for improving quality of care. In terms of benefits, Ting said the Mayo Clinic has been incorporating the use of prehospital ECGs for one year, and in doing so, has reduced door-to-balloon times to consistently less than 30 minutes, with 25 minutes being the average.
Ting said there are many ways of interpreting the ECG once it has been obtained. Computer algorithms, paramedic interpretation, and wirelessly transmitting the data to a physician for interpretation are three ways to interpret the data. The diversity of the EMS providers and the differing sizes of cities they cover, as well as wireless coverage available to transmit data, are not likely to lead to a one-size-fits-all solution, he said.
A recent survey found that 90% of EMS systems serving the largest US cities have 12-lead ECG equipment, and there are prehospital ECG programs in Boston, Los Angeles County, and North Carolina, as well as in Ottawa, ON. Paramedics in Boston, for example, are allowed to bypass non–percutaneous coronary intervention (PCI) hospitals and have an emergency-department physician activate the cardiac cath lab. North Carolina, on the other hand, allows paramedics to occasionally divert some STEMI patients to PCI hospitals and activate the cath lab directly (or have it activated by an emergency-department physician). Paramedics in Ottawa can also activate the cath lab directly through a central operator. Los Angeles County paramedics use a computer algorithm to interpret the ECG, and the cath lab is activated by the emergency department based on this diagnosis.
Allowing paramedics to "do something downstream" with the information is critical, said Ting, as is changing when the paramedics perform the ECG. "If you truly want to coordinate things,you want to start the prehospital ECG as early as possible in the examination," he said. "Once you establish that the patient has stable vital signs and doesn't have a cardiac arrhythmia, you probably want to do a prehospital ECG at the scene, as early as possible. If you detect ST elevation, the next steps are very different from treating a patient who has chest pain but no ST elevation."
Implementing prehospital ECGs into existing systems of care has the potential to "change the ball game," said Ting. He noted that the focus should begin to move away from door-to-balloon times toward a measure that provides a gauge of quality and performance that is more patient centered. The national "Door to Balloon: An Alliance for Quality" campaign launched in 2006 has helped improve the timeliness of lifesaving therapy for myocardial infarction (MI) patients at all US hospitals that perform emergency angioplasty, but from a patient perspective, first medical contact to balloon is a more relevant measure of quality of care.
Ting added that too many patients still take themselves to the emergency department or are driven there by friends or family, a decision that affects the course of care because it's impossible to obtain a prehospital ECG and then activate all the necessary hospital teams.
"The public doesn't perceive EMS as transforming care," said Ting. "They view it as transportation with sirens. They think, 'If Uncle Joe can drive me there just as fast, then why do I need to call 911 and create all the hassle in the neighborhood?' But the prehospital ECG can really change the course of treatment, something that can't happen when you drive yourself or have a friend take you."
Dr. Ting has received research grants from the American College of Cardiology and the Mayo Foundation for Medical Education and Research. A complete list of disclosures is available in the original article.
Ting HH, Krumholz HM, Bradley EH et al. Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome. Circulation. 2008;118:published online before print. DOI:10.1161/circulationaha.108.190402.
A 10-month-old girl is transferred from an outside urgent care center to the emergency department (ED) for dehydration and a change in her level of alertness. According to her mother's boyfriend, she had been crying in her crib before she was noted to throw her arms in the air for approximately 5 minutes and then breathe irregularly. She vomited once and continued to cry inconsolably before she arrived at the urgent care center. An abdominal radiograph was performed at the urgent care center and interpreted as consistent with possible constipation, but it was otherwise unremarkable. She has had multiple episodes of nonbloody, nonbilious emesis on the way to the ED. There is no recent history of diarrhea or change in bowel habits.
The patient was recently diagnosed with an upper respiratory infection and has received several doses of acetaminophen over the last few days. Her symptoms have included tactile fevers, runny nose, and raspy cough. Before this occurrence, her breathing had been normal and without increased effort. She had been feeding well earlier today. She is currently taking no prescription medications and has no reported allergies. Her immunizations are not up-to-date; she only received immunizations at 2 months of age. She lives at home with her mother, her mother's boyfriend, and her 2-year-old brother.
The physical examination is most notable for her general appearance; she appears somnolent, is lying motionless, is not making eye contact or engaging in other social interactions, and is not crying. She vomits several times during the evaluation. Her vital signs include an axillary temperature of 99.1°F (37.3°C), a heart rate of 90 bpm, a blood pressure of 101/56 mm Hg, a respiratory rate of 12 breaths/min, and an oxygen saturation of 100% while breathing room air. Her pupils are equal and 5 mm in diameter; they are measured at 3 mm in response to light. The anterior fontanel is flat. A small, 5-mm, purple ecchymosis overlying the left maxilla is noted. Two lacerations on the inferior mucosal surface of the upper lip are identified that line up with the upper incisors. The lungs are clear to auscultation and the heart sounds are normal. The abdomen feels soft and appears nondistended and nontender. Bowel sounds are present. The stool is guaiac-negative. Capillary refill of the fingernails is less than 2 seconds. The neurologic examination is notable for diffuse hypotonia.
In the ED, she is given a bolus of 200 mL of normal saline with 5% dextrose and continued on maintenance fluid. The initial laboratory results are significant for leukocytosis and anemia, with a white blood cell (WBC) count of 18.4 × 103/µL (18.4 × 109/L), with 72% neutrophils (0.72), a hemoglobin of 9.7 g/dL (97 g/L), and a hematocrit of 27.1% (0.271). Her serum glucose is normal at 108 mg/dL (5.99 mmol/L), and the electrolytes are likewise within normal limits. An ophthalmologic examination (see Figure 1) and computed tomography (CT) scanning of the head (see Figure 2) are performed. A skeletal survey is ordered as well.
Questions answered correctly will be highlighted.
What is the diagnosis?
Hint: The findings of the retinal examination are very characteristic of this diagnosis.
Meningitis
Abusive head trauma
Cysticercosis
Discussion
The initial CT scan of the head obtained in the ED (see Figure 2) shows bilateral subdural hematomas outlining bilateral cerebral convexities, with hyperdense blood noted in the left frontal lobe. The patient was started on fosphenytoin for seizure prophylaxis. The ophthalmologic examination revealed bilateral retinal hemorrhages extending into the periphery (see Figure 1). Intraretinal hemorrhages of the macula were noted in the left eye, with possible choroidal rupture. On careful questioning, the caretaker repeatedly denied any history of trauma. A skeletal survey was performed that revealed a healing right radial neck fracture. The medical record from the urgent care center was obtained; this included a clinical note dated 4 months prior to patient's presentation to the ED, which described a visit for repeated emesis and irritability. A bruise on the chin was noted on that visit, and the explanation given was a fall inside the patient's crib that occurred 4 days prior to that visit. A report to the Department of Children and Families was found to have been made for missed well-child visits. The level of suspicion for suspected abusive head trauma (AHT) and child abuse was extremely high. It is important for emergency clinicians to be mindful of the diagnosis of AHT, but there are other rare causes that can mimic abuse.
Abusive head injury, sometimes referred to as "shaken baby syndrome,"[1] is the most common cause of death resulting from child abuse.[2] The majority of cases occur in infants less than 1 year old.[3] Head injury among infants in this age group is often the result of abuse and the mechanism of injury, although much debated, is usually thought to be significant forces generated from angular deceleration with or without impact. AHT in this population represents a significant fraction of young children admitted for head injury.[4] Approximately 30% of children aged 0-3 years admitted to pediatric hospitals for intracranial injury have been found to meet the criteria for abuse.[5] Many children with AHT also have a clinical history or findings consistent with prior maltreatment. Crying is thought to be a trigger for many cases of AHT and prevention efforts are directed toward caregiver response to colicky babies and crying infants.
The diagnosis of AHT can be difficult to establish; the clinical presentations may be nonspecific, children are often too young to give history, and witnesses and confessions are rare. The reasons for seeking care in children include seizure, breathing difficulty, apnea, and apparent lifelessness. A history of trauma is often lacking. Approximately 30% of children with AHT may be missed on the initial presentation.[6] Common misdiagnoses include viral gastroenteritis, sepsis, and accidental head injury. A history of injury mechanism incompatible with an infant's developmental stage or degree of force required to inflict severe injury may raise the suspicion for AHT. Common symptoms at presentation are often the result of acute brain injury (ie, lethargy, decreased level of consciousness, vomiting, apnea, hypotonia, and seizures).
The physical examination findings may include evidence of soft tissue injury, particularly swelling or bruising; however, the absence of bruising or other evidence of trauma neither excludes injury nor abuse.[7] Funduscopic examination should be performed in any child suspected to have abusive head injury, preferably by an ophthalmologist with sufficient pediatric experience to determine the significance of any identified injury.[8] Retinal hemorrhages are a hallmark finding in abusive head injury, and they are present in a majority of children who carry the diagnosis.[9] They may be unilateral or bilateral and involve 1 or more layers. Not all retinal hemorrhages are the same with respect to their significance in predicting an abusive mechanism. The most specific pattern of retinal hemorrhages is numerous hemorrhages involving several layers of the retina and extending to the periphery.[10] No pattern of hemorrhages, however, is pathognomonic for abuse. The mechanism of retinal hemorrhages is unclear, but the leading theory is that they are caused by vitreous traction on the retina during acceleration/deceleration. Lasting visual impairment in those children who survive AHT is common.[11]
CT scanning is an essential part of the initial workup of suspected head trauma. CT scanning can also be helpful as a screening neuroimaging study in children with suspected abuse. Even without clinical examination findings of brain injury, a significant number of abused infants will have important findings on neuroimaging.[12,13] Unilateral, bilateral, or parafalcine subdural hemorrhages are the most common radiologic finding in infants with AHT. Subdural hemorrhages of mixed attenuation have previously been considered as evidence for repeated head injury, with hyperdense components of the hemorrhage associated with injury occurring in the past 48-72 hours and hypodense components representing older injury occurring more than 3 weeks prior to the scan. Hyperacute bleeding or the mixing of blood and cerebrospinal fluid (CSF), however, can produce mixed-density lesions from a single injury.[14] While the presence of subdural hemorrhage lends supporting evidence to the diagnosis of head trauma, inferences about the timing and mechanism of injury cannot be drawn with certainty from a single noncontrast CT scan.[15] Magnetic resonance imaging (MRI) can be a useful study for demonstrating parenchymal contusion, axonal shearing, extra-axial hemorrhages, and posterior fossa injuries. Diffusion-weighted imaging and apparent diffusion coefficient mapping are particularly useful in identifying acute hypoxic-ischemic injury.
Additional supportive evidence for child abuse is obtained through a skeletal survey. The presence of previously healed fractures in infants is strongly suggestive of chronic abuse.
While the cause of subdural hematoma in association with retinal hemorrhage will most commonly be abusive head injury, a differential diagnosis for these findings must be considered. Coagulopathies have been associated with retinal and intracranial hemorrhage in infants, including hemophilia, vitamin-K deficiency, and disseminated intravascular coagulopathy. Retinal hemorrhages in these disorders are typically confined to the posterior pole, and the nature of the bleeding problem can be detected by laboratory tests. It is recommended to perform a prothrombin time, activated partial-thromboplastin time, and a platelet count as minimum screening tests.
Glutaric aciduria type I, a rare metabolic disease, is associated with developmental delay and subdural hemorrhages. Performing an assay for organic acids in the urine can test for this disease. Other causes of intracerebral hemorrhage include cerebral malaria, intracranial aneurysms, galactosemia, and meningitis. Osteogenesis imperfecta is an uncommon connective tissue disorder that frequently results in fractures. Subdural hemorrhage has rarely been described as a complication of this disease.[22] Because these disorders can closely mimic abusive head trauma, it is important to maintain a nonaccusatory and open-minded posture during the initial evaluation, as parents are understandably sensitive to the possibility that they are being accused of harming their children. Some helpful statements include "I'm concerned that someone may have harmed your child" and "several diseases can explain this pattern of injury, including trauma. We need to check for other signs of these illnesses to make sure your child is safe."
AHT is likely underdiagnosed and underreported, which contributes to the dismal outcomes for children eventually diagnosed with abuse.[24] In multiple series, the mortality is approximately 20%.[11,25] The neurologic outcome is also poor, with many survivors having persistent neurologic and behavioral deficits.[11,26] Having a high suspicion for abusive head injury is critical in the appropriate setting. Clinicians should have a low threshold for performing CT scans of the head on infants coming in with nonspecific findings that could be explained by head injury, when appropriate. While reporting a reasonable suspicion for abuse is mandatory, it is not the job of the healthcare provider to determine the social or legal management of any case. A child protection team, if available, should be consulted with any concerns of abusive injury.
The patient in this case was admitted to the pediatric intensive care unit (ICU). A repeat CT scan of the head was performed 10 hours after presentation because her somnolence failed to improve. It showed an interval increase in subdural blood located above the tentorium. She was then taken emergently to the operating room (OR) for evacuation of the subdural hematomas and placement of bilateral subdural external drains. The subdural pressure was noted to be markedly elevated. Subdural membranes were noted to separate layers of blood in the left frontal lobe. She was again taken to the OR several days later for removal of the subdural drains. She gradually became more alert and playful. The child protection team was contacted in the ED and suspicion for abuse was reported. Further conversations with the mother revealed a history of physical abuse at the hands of her current boyfriend. The Department of Children and Families (the regional department responsible for addressing issues of child safety and potential abuse) assumed immediate temporary custody of the patient and of her older brother. Testing for conditions that mimic the signs of abuse was completed, and no sign of other medical illnesses was found. The patient was discharged 12 days after admission and has had follow-up visits with neurosurgery and ophthalmology. She is currently living with her second foster family and is noted to have persistent developmental delay. Her retinal findings have improved and her foster parents have not noticed any evidence of visual impairment.
Questions answered correctly will be highlighted.
You suspect that a patient you are examining is being abused. Which of the following injuries, if they were present in the patient you are examining, would be pathognomonic for abusive injury?
Bilateral subdural hemorrhages
Rib fractures
Retinal hemorrhages
Bruising in infants
None of the above
During the course of several days, you evaluate a number of children with injuries as reported by their parents. You obtain a history and perform a physical examination on each child, and radiographs are subsequently performed. Which of the following situations should alert you to a strong possibility of abuse/nonaccidental injury?
A spiral tibia fracture in a 3-year-old boy who fell and twisted his leg while jumping on a couch.
A supracondylar fracture in a 6-year-old who fell from the monkey bars onto an outstretched arm.
A posterior rib fracture in a 13-month-old who fell backwards off a single step.
The mechanism of injury must always be considered when evaluating for whether or not there is any suspicion that any given fracture may have occurred by nonaccidental means. Infants and young toddlers typically cannot generate enough force to result in a fracture unless falling from a height. In this case, a fall from 1 step is not sufficient to result in a rib fracture. Certain types of fractures also should raise concern, such as spiral fractures of long bones. The exception to this is a spiral fracture of the tibia, often referred to as a "toddler fracture" since it is particularly seen amongst toddlers. These children are often rambunctious and, although lacking in coordination, they have the physical capacity to climb, jump, and fall while running, all of which may result in an accident that will generate enough energy to cause this type of fracture.
References
Christian CW, Block R Committee on Child Abuse and Neglect; American Academy of Pediatrics. Abusive head trauma in infants and children. Pediatrics. 2009;123:1409-11.
Schnitzer PG, Ewigman BG. Child deaths resulting from inflicted injuries: household risk factors and perpetrator characteristics. Pediatrics. 2005;116:e687-93.
Duhaime AC, Christian CW, Rorke LB, Zimmerman RA. Nonaccidental head injury in infants--the "shaken-baby syndrome". N Engl J Med. 1998;338:1822-9.
Billmire M, Myers P. Serious head injury in infants: accident or abuse? Pediatrics. 1985;75:340-2.
Hettler J, Greenes DS. Can the initial history predict whether a child with a head injury has been abused? Pediatrics. 2003;111:602-7.
Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999;281:621-6.
Peters ML, Starling SP, Barnes-Eley ML, Heisler KW. The presence of bruising associated with fractures. Arch Pediatr Adolesc Med. 2008;162:877-81.
Morad Y, Kim YM, Mian M, Huyer D, Capra L, Levin AV. Nonophthalmologist accuracy in diagnosing retinal hemorrhages in the shaken baby syndrome. J Pediatr. 2003;142:431-4.
Levin AV, Morad Y. Ocular Manifestations of Child Abuse. In: Reece RM, Christian CW, editors. Child Abuse Medical Diagnosis & Management. 3rd ed. American Academy of Pediatrics;2009:211-26.
Adams G, Ainsworth J, Butler L, Bonshek R, Clarke M, Doran R, et al. Update from the ophthalmology child abuse working party: Royal College ophthalmologists. Eye. 2004;18:795-8.
Barlow KM, Thomson E, Johnson D, Minns RA. Late neurologic and cognitive sequelae of inflicted traumatic brain injury in infancy. Pediatrics. 2005;116:e174-85.
Rubin DM, Christian CW, Bilaniuk LT, Zazyczny KA, Durbin DR. Occult head injury in high-risk abused children. Pediatrics. 2003;111:1382-6.
Laskey AL, Holsti M, Runyan DK, Socolar RR. Occult head trauma in young suspected victims of physical abuse. J Pediatr. 2004;144:719-22.
Vinchon M, Noule N, Tchofo PJ, Soto-Ares G, Fourier C, Dhellemmes P. Imaging of head injuries in infants: temporal correlates and forensic implications for the diagnosis of child abuse. J Neurosurg. 2004;101:44-52.
Tung GA, Kumar M, Richardson RC, Jenny C, Brown WD. Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography. Pediatrics. 2006;118(2):626-33.
Merten DF, Radkowski MA, Leonidas JC. The abused child: a radiological reappraisal. Radiology. 1983;146:377-81.
Diagnostic imaging of child abuse. Pediatrics. 2009;123:1430-5.
Kleinman PK, Marks SC, Blackbourne B. The metaphyseal lesion in abused infants: a radiologic-histopathologic study. AJR Am J Roentgenol. 1986;146:895-905.
Scherl SA, Miller L, Lively N, Russinoff S, Sullivan CM, Tornetta P, 3rd. Accidental and nonaccidental femur fractures in children. Clin Orthop Relat Res. 2000:96-105.
Strait RT, Siegel RM, Shapiro RA. Humeral fractures without obvious etiologies in children less than 3 years of age: when is it abuse? Pediatrics. 1995;96:667-71.
Islam O, Soboleski D, Symons S, Davidson LK, Ashworth MA, Babyn P. Development and duration of radiographic signs of bone healing in children. AJR Am J Roentgenol. 2000;175:75-8.
Tokoro K, Nakajima F, Yamataki A. Infantile chronic subdural hematoma with local protrusion of the skull in a case of osteogenesis imperfecta. Neurosurgery. 1988;22:595-8.
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Theodore AD, Chang JJ, Runyan DK, Hunter WM, Bangdiwala SI, Agans R. Epidemiologic features of the physical and sexual maltreatment of children in the Carolinas. Pediatrics. 2005;115:e331-7.
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Two new editorials debate the question of whether healthy people should take stimulants, especially methylphenidate, to enhance cognitive performance.
John Harris, DPhil, from the school of law at the University of Manchester, in the United Kingdom, argues that it is unethical to stop healthy adults from taking methylphenidate to enhance cognitive performance and asserts that chemical cognitive enhancers should be freely available to those who choose to use them.
Anjan Chatterjee, MD, from the Center for Cognitive Neuroscience at the University of Pennsylvania, in Philadelphia, disagrees, maintaining that making methylphenidate freely available to those who want to enhance performance would cause undue medical risk and that these drugs should be reserved for those who suffer from attention-deficit/hyperactivity disorder (ADHD). The risks of methylphenidate include potential for abuse and dependence and risk for sudden death and serious cardiovascular events, he points out.
Their discussion is published online June 18 in BMJ.
Risk for Sudden Death
Methylphenidate was also the subject of a recent case-control study published in the American Journal of Psychiatry that showed an increased risk for sudden death in healthy children and adolescents who take the medication (Gould MS et al. Am J Psychiatry. 2009;AIA:1-10). In response, however, the US Food and Drug Administration (FDA) issued an advisory noting that children with ADHD should not stop stimulants based on this study, because its conclusions were limited by several flaws.
Dr. Harris argues that methylphenidate is safe enough to be used widely in children and adults with ADHD, and its significant advantages for healthy adults include improved executive function, study skills, and the ability to focus. In an interview, he noted that access to methylphenidate could be improved by taking it off prescription or allowing it with a pharmacist consultation.
Methylphenidate's health risks should be dealt with in the same way as are those of cigarettes; while adults who use the drug should be warned of its potential for abuse and cardiac risks, sale should not be prohibited. "We should not police healthy adults," he said. "We can issue them a warning as we do on other dangerous products."
Social Coercion?
Dr. Chatterjee, however, warns of the public-health risks that could occur should methylphenidate be freely available. He notes that the risks for serious cardiovascular events with methylphenidate are likely to be higher in older people with undetected cardiac disease — 1 group that might be likely to use the drug if it were sold over the counter.
He also said that expanding access to methylphenidate would invite subtle societal coercion to use the drug to enhance performance in school or in the workplace. "We live in a very competitive society, where people think that every little bit that gets you ahead is advantageous," he said in an interview. Were methylphenidate freely available, there might be implicit pressures to use the drug to improve school grades or cognitive abilities during long working hours, he writes in his editorial.
Dr. Chatterjee also argues that the use of methylphenidate might pose another risk for society that is rarely considered in debates about the subject. He notes that enhancing focus with methylphenidate might mean sacrificing creativity. "Most models of creativity suggest that you have to have some down time in order to have the leaps of imagination that end up being creative insights; it requires not being focused," he said.
Dr. Harris, however, equated methylphenidate with electric light — a valuable technology that may also have the adverse effect of potential overuse. "With the advent of synthetic sunshine, work and social life could continue into and through the night, creating competitive pressures and incentives for those able or willing to use it to their advantage," he writes in his editorial.
"The solution, however, was not to outlaw synthetic sunshine but to regulate working hours and improve access," he adds. "The same is or will be true of chemical cognitive enhancers."
