What’s New in Emergency Medicine

Use of Azithromycin and Death from Cardiovascular Causes: Svanstrom H, Pasternak B, Hviid A. N Engl J Med 2013;368:1704–12.

In this cohort analysis involving millions of Danish citizens aged 18–64 years, authors assessed the incidence of cardiovascular death related to azithromycin usage compared with no antibiotics and Penicillin V. Data were obtained from the Danish Nat…

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Fibrinolysis or Primary PCI in ST-segment Elevation Myocardial Infarction: Armstrong PW, Gershlick AH, Goldstein P, et al. N Engl J Med 2013;368:1379–87.

In this open-label, prospective, randomized, multinational study involving 1892 patients from 99 sites in 15 countries, the authors sought to compare the efficacy of prehospital fibrinolysis (by tenecteplase) with primary percutaneous coronary interven…

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Systematic Review of Accuracy of Dual-Source Cardiac CT for Detection of Arterial Stenosis in Difficult to Image Patient Groups: Westwood ME, Raatz HDI, Misso K, et al. Radiology 2013;267:387–95.

The objective of this study was to evaluate the ability of dual-source cardiac (DSC) computed tomography (CT) to assess coronary artery disease among individuals who are difficult to image with 64-section CT, specifically those with irregular rhythm (e.g., atrial fibrillation) or fast heart rate (rate > 65 beats/min or intolerance to beta-blockers), obese individuals (body mass index ≥ 30 kg/m2), and those in whom high coronary calcium (> 400) or history of coronary artery stents or bypass graft may affect image quality.

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Systematic Review of Accuracy of Dual-Source Cardiac CT for Detection of Arterial Stenosis in Difficult to Image Patient Groups: Westwood ME, Raatz HDI, Misso K, et al. Radiology 2013;267:387–95.

The objective of this study was to evaluate the ability of dual-source cardiac (DSC) computed tomography (CT) to assess coronary artery disease among individuals who are difficult to image with 64-section CT, specifically those with irregular rhythm (e.g., atrial fibrillation) or fast heart rate (rate > 65 beats/min or intolerance to beta-blockers), obese individuals (body mass index ≥ 30 kg/m2), and those in whom high coronary calcium (> 400) or history of coronary artery stents or bypass graft may affect image quality.

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Position Paper Update: Ipecac Syrup for Gastrointestinal Decontamination: Hojer J, Troutman WG, Hoppu K, et al. Clin Toxicol (Phila) 2013;51:134–9.

The goal of this systematic review article was to summarize recommendations for the use of ipecac for treatment of acute toxic ingestions. The authors referenced a position paper published in 2004 and aimed to compare this article with the current lite…

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Body CT Scanning in Young Adults: Examination Indications, Patient Outcomes, and Risk of Radiation-induced Cancer: Zondervan RL, Hahn PF, Sadow CA, et al. Radiology 2013;267:460–9.

Due to the increasing use of computed tomography (CT) in the United States, there has been increasing concern for the safety of those scanned with regards to radiation-induced cancers. CT use now accounts for over 50% of the population’s radiation expo…

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Body CT Scanning in Young Adults: Examination Indications, Patient Outcomes, and Risk of Radiation-induced Cancer: Zondervan RL, Hahn PF, Sadow CA, et al. Radiology 2013;267:460–9.

Due to the increasing use of computed tomography (CT) in the United States, there has been increasing concern for the safety of those scanned with regards to radiation-induced cancers. CT use now accounts for over 50% of the population’s radiation expo…

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Lithium Poisoning: The Value of Early Digestive Tract Decontamination: Bretaudeau Deguigne M, Hamel JF, Boels D, Harry P. Clin Toxicol (Phila) 2013;51:243–8.

Lithium is a medication commonly used to treat mood disorders. There are three different types of lithium poisoning. These include acute poisoning in patients not regularly taking lithium, acute poisoning in patients receiving long-term therapy (acute-…

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Lithium Poisoning: The Value of Early Digestive Tract Decontamination: Bretaudeau Deguigne M, Hamel JF, Boels D, Harry P. Clin Toxicol (Phila) 2013;51:243–8.

Lithium is a medication commonly used to treat mood disorders. There are three different types of lithium poisoning. These include acute poisoning in patients not regularly taking lithium, acute poisoning in patients receiving long-term therapy (acute-…

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Unintentional Domestic Non-fire Related Carbon Monoxide Poisoning: Data from Media Reports, UK/Republic of Ireland 1986–2011: Fisher DS, Bowskill S, Saliba L, Flanagan RJ. Clin Toxicol (Phila) 2013;51:409–16.

Carbon monoxide (CO) poisoning is difficult to diagnose when the context of exposure is not known, as is the case in most unintentional poisonings excluding fires. This article sought to collect data from media databases over a 25-year period to assess…

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Acute Kidney Injury in the Critically Ill: Is Iodinated Contrast Medium Really Harmful? Ehrmann S, Badin J, Savath L, et al. Crit Care Med 2013;41:1017–26.

It is commonly known that iodinated contrast medium (CM) is a nephrotoxic agent and a frequent cause of acute kidney injury (AKI). However, there is debate as to whether contrast-associated AKI (CA-AKI) is clinically significant when weighed against th…

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Acute Kidney Injury in the Critically Ill: Is Iodinated Contrast Medium Really Harmful? Ehrmann S, Badin J, Savath L, et al. Crit Care Med 2013;41:1017–26.

It is commonly known that iodinated contrast medium (CM) is a nephrotoxic agent and a frequent cause of acute kidney injury (AKI). However, there is debate as to whether contrast-associated AKI (CA-AKI) is clinically significant when weighed against th…

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Increasing Critical Care Admissions from U.S. Emergency Departments, 2001–2009: Herring A, Ginde A, Fahimi J, et al. Crit Care Med 2013;41:1197–204.

The aim of this study was to analyze the difference in the number of critical care-based Emergency Department (ED) visits, critical care admissions, and ED lengths of stay from 2001 to 2009. Further, this study investigates several characteristics of c…

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Increasing Critical Care Admissions from U.S. Emergency Departments, 2001–2009: Herring A, Ginde A, Fahimi J, et al. Crit Care Med 2013;41:1197–204.

The aim of this study was to analyze the difference in the number of critical care-based Emergency Department (ED) visits, critical care admissions, and ED lengths of stay from 2001 to 2009. Further, this study investigates several characteristics of c…

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Diagnostic Accuracy and Radiation Dose of CT Coronary Angiography in Atrial Fibrillation: Systematic Review and Meta-Analysis: Vorre MM, Abdulla J. Radiology 2013;267:376–86.

In this meta-analysis of seven studies with a total of 247 patients, authors assessed the diagnostic accuracy of computed tomography (CT) coronary angiography compared with conventional angiography among patients with atrial fibrillation. There was a m…

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Diagnostic Accuracy and Radiation Dose of CT Coronary Angiography in Atrial Fibrillation: Systematic Review and Meta-Analysis: Vorre MM, Abdulla J. Radiology 2013;267:376–86.

In this meta-analysis of seven studies with a total of 247 patients, authors assessed the diagnostic accuracy of computed tomography (CT) coronary angiography compared with conventional angiography among patients with atrial fibrillation. There was a m…

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Penicillin to Prevent Recurrent Leg Cellulitis: Thomas KS, Crook AM, Nunn AJ, et al. N Engl J Med 2013;368:1695–703.

The objective of this study was to evaluate the effectiveness of low-dose penicillin compared to placebo for the prevention of recurrent leg cellulitis. This was a double-blind, randomized, controlled trial comparing 12 months of low-dose (250 mg twi…

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Penicillin to Prevent Recurrent Leg Cellulitis: Thomas KS, Crook AM, Nunn AJ, et al. N Engl J Med 2013;368:1695–703.

The objective of this study was to evaluate the effectiveness of low-dose penicillin compared to placebo for the prevention of recurrent leg cellulitis. This was a double-blind, randomized, controlled trial comparing 12 months of low-dose (250 mg twi…

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Position Paper Update: Gastric Lavage for Gastrointestinal Decontamination: Benson BE, Hoppu K, Troutman WG, et al. Clin Toxicol (Phila) 2013;51:140–6.

The objective of this study was to summarize previous recommendations for the use of gastric lavage in poisoned patients and to review new data since the previous position paper was published in 2004.

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Position Paper Update: Gastric Lavage for Gastrointestinal Decontamination: Benson BE, Hoppu K, Troutman WG, et al. Clin Toxicol (Phila) 2013;51:140–6.

The objective of this study was to summarize previous recommendations for the use of gastric lavage in poisoned patients and to review new data since the previous position paper was published in 2004.

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In reply

We thank Dr. Schwartz for his letter about our recent article. He raised the concern that pulmonary embolism rule-out criteria (PERC) were not defined consistently among the studies, which may have affected the calculated sensitivities and suitability of pooled results. Special concern was raised about the study by Hugli et al, from which all patients (low, medium, and high risk) were included in the meta-analysis. We agree that PERC was designed to be used in a low-risk population; however, even after excluding the moderate- and high-risk patients from the study by Hugli et al, overall sensitivity decreased minimally (from 97% to 96%), but the heterogeneity increased significantly (I2=71%; P<.001). On sensitivity analysis, after excluding the study by Hugli et al from the meta-analysis, pooled sensitivity (97%) was similar to that of our original study, with no significant heterogeneity (I2=24%, P=.26) observed between the studies. Similar results were found after we excluded the study by Hugli et al from another meta-analysis with a larger number of patients (sensitivity 0.97%; I2=30.7%; P=.15).

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In reply

We thank Dr. Schwartz for his letter about our recent article. He raised the concern that pulmonary embolism rule-out criteria (PERC) were not defined consistently among the studies, which may have affected the calculated sensitivities and suitability of pooled results. Special concern was raised about the study by Hugli et al, from which all patients (low, medium, and high risk) were included in the meta-analysis. We agree that PERC was designed to be used in a low-risk population; however, even after excluding the moderate- and high-risk patients from the study by Hugli et al, overall sensitivity decreased minimally (from 97% to 96%), but the heterogeneity increased significantly (I2=71%; P<.001). On sensitivity analysis, after excluding the study by Hugli et al from the meta-analysis, pooled sensitivity (97%) was similar to that of our original study, with no significant heterogeneity (I2=24%, P=.26) observed between the studies. Similar results were found after we excluded the study by Hugli et al from another meta-analysis with a larger number of patients (sensitivity 0.97%; I2=30.7%; P=.15).

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