First EDition

Ottawa SAH clinical decision rule helps identify subarachnoid hemorrhage

BY MARY ANN MOON

From JAMA

A new clinical decision rule had sensitivity and specificity approaching 100% in ruling out subarachnoid hemorrhage among patients who presented to an emergency department with acute headache, a validation study showed.

Using this new tool, which requires only that the clinician answer six simple questions regarding the patient’s presentation, has the potential to reduce the number of costly and sometimes invasive procedures that are currently relied on to distinguish subarachnoid hemorrhage (SAH) from other pathologies, said Dr Jeffrey J. Perry of the department of emergency medicine at the University of Ottawa (Ont.) and the clinical epidemiology program at the Ottawa Hospital Research Institute and his associates.

Dr Perry and his colleagues devised three clinical decision rules to assist in ruling out SAH, then assessed the three rules for their accuracy, reliability, and acceptability to clinicians in a validation cohort of consecutive patients aged 16 years and older who presented to an ED with a nontraumatic headache that reached maximal intensity within 1 hour. There were 2,131 study subjects with a mean age of 44 years. Approximately 61% were women, and 26% arrived at the ED by ambulance.

All of these participants were treated by attending physicians certified in emergency medicine or by supervised residents at 10 university-affiliated urban, Canadian tertiary care teaching hospitals during a 4-year period. All patients were alert and oriented, with no neurologic deficits; 132 (6.2%) were found to have SAH.

After comparing the performances of the three candidate decision rules, the investigators refined the decision tool to identify six factors that were most predictive of SAH: age of 40 years or older, neck pain or stiffness, witnessed loss of consciousness, onset of headache during exertion, "thunderclap headache" (defined as instantly peaking pain), and limited neck flexion (defined as the inability to touch chin to chest when upright or to raise the head 8 cm off the bed when supine).

The presence of any one of these six factors indicates that SAH is possible and further investigation is required using CT and perhaps lumbar puncture, Dr Perry and his associates said.

This refined clinical decision rule, which they termed the Ottawa SAH rule, had an overall sensitivity of 99.2% and a specificity of 99.6% in identifying SAHs (JAMA. 2013;310[12]:1248-1255).

Following this rule would decrease the investigation rate"—the rate of further assessment using CT and lumbar puncture—"to 74% from the current investigation rate of 84%, the researchers added.

The Ottawa SAH rule must be evaluated further before it can be adopted into clinical practice. "An implementation study is the next step required to determine how the Ottawa SAH rule performs in clinical practice, assess the actual effects on patient care and patient outcomes, and conduct a formal health economic analysis," the researchers noted.

This study was supported by the Canadian Institutes for Health Research, the University of Ottawa, and the Vancouver Coastal Health Research Institute. No financial conflicts of interest were reported.

Novel two-biomarker strategy permits early ACS rule-out

BY BRUCE JANCIN

At the ESC Congress 2013

AMSTERDAM—An early rule-out strategy based upon using two cardiac biomarkers allowed for safe discharge within a couple hours from the emergency department for most low- to intermediate-risk patients who presented with suspected acute coronary syndromes, based on the results of a randomized, multicenter trial conducted in Europe.

Moreover, the 30-day rates of major adverse cardiovascular events in the Biomarkers in Cardiology–8 (BiC-8) study were similarly low in patients discharged from the ED using the early rule-out process and in those who received standard, guideline-recommended care, which includes 6-12 hours of serial ECGs and troponin measurements in the chest pain unit, Dr Martin Moeckel reported at the annual congress of the European Society of Cardiology.

"This biomarker strategy using a state-of-the-art quantitative troponin assay in combination with an ultrasensitive copeptin assay has the potential to change clinical practice with high patient safety," observed Dr Moeckel of Charite Hospital, Berlin. The copeptin test is approved for use in the European Union but remains investigational in the United States.

Based upon the results of BiC-8, this dual-biomarker for early rule-out of myocardial infarction is now standard clinical practice at Charite, he added.

Nearly 12% of all patients who present to the ED do so because of chest pain, yet after an extensive and time-consuming evaluation only 1 in 10 of those patients are found to actually be having an acute MI.

"Rapid rule-out of acute MI is therefore a major clinical need, saving the health care system time and resources, and saving patients unnecessary stress, anxiety, and other risks," he said.

Copeptin is a marker for vasopressin, a hemodynamic stress indicator that shoots up immediately in an acute MI. In earlier studies, a negative result for both troponin and copeptin in an initial blood sample drawn at ED presentation had a 99% negative predictive value for MI.

The BiC-8 trial included 902 low- to intermediate-risk patients who presented with suspected ACS to EDs in university medical centers. All had a negative initial cardiac troponin test. They were randomized to standard care in the chest pain unit, including serial troponin testing and ECGs, or to the experimental strategy, in which physicians were informed of the copeptin results from the same initial blood sample as the troponin. If the copeptin test was positive as defined by a level of 10 pmol/L or more, the patient was hospitalized for standard care. If the copeptin result was negative, however, the patient was immediately discharged with a scheduled outpatient visit within72 hours.

Of the patients in the copeptin group, 66% were discharged directly from the ED, compared to 12% in the standard care group.

The 30-day incidence of major adverse cardiovascular events (MACE) was 5.5% in the standard care group and nearly identical at 5.46% in the copeptin group. MACE was defined in BiC-8 as all-cause mortality, MI, rehospitalization for ACS, acute unplanned PCI, coronary artery bypass surgery, life-threatening arrhythmia, or resuscitation from cardiac arrest.

MACE occurred in 14 copeptin-negative patients. However, 12 of the 14 were not discharged early because physicians overruled the negative biomarker results based on patient history and moved the patients into standard in-hospital management. Two patients, or 0.6% of those discharged from the ED on the basis of a negative copeptin test, had adverse events: one was rehospitalized on day 23 and underwent acute unplanned PCI on the next day, and the other was rehospitalized on day 4 and underwent coronary artery bypass graft surgery on day 12.

American Heart Association Immediate Past President Donna K. Arnett, PhD, said in an interview that she’d really like to see a second, confirmatory randomized trial before this early rule-out strategy is widely adopted. She considers the lost-to-followup rate uncomfortably high: 63 patients in the intention-to-treat analysis, and another 75 not accounted for in the per protocol analysis, noted Dr Arnett, professor and chair of the department of epidemiology at the University of Alabama, Birmingham.

"The most important message from BiC-8, I think, is that these were patients at low- to-intermediate risk; they’re not the high-risk patients. And it’s also important that the physician didn’t rely only on the test result, but also took a final look at the clinical situation before releasing the patient. There is some overruling when patients are biomarker-negative but have typical risk markers. No test is 100% accurate. Clinical judgment remains extremely important," emphasized co-investigator Dr Kurt Huber, professor and director of cardiology and emergency medicine at Wilhelminen Hospital, Vienna.

The BiC-8 trial was sponsored by ThermoFisher Scientic and six university medical centers in German-speaking Europe. Dr Moeckel reported receiving a research grant from ThermoFisher Scientific and serving as a consultant to Bayer, AstraZeneca, and The Medicines Company. Drs Arnett and Huber had no conflicts to declare.

[email protected]

Two studies document a rise in gun wounds, homicides

BY SHERRY BOSCHERT

At th AAST Annual Meeting

SAN FRANCISCO—Deaths from gunshot wounds doubled between 2000 and 2012 in the region served by one New Jersey trauma center and gun-related homicides as a propor­tion of violent crimes increased by 27% in southern Arizona after the state stopped requiring permits for concealed weapons, separate studies found.

In 2000, 8% of patients treated for gunshot wounds died. That rate in­creased to 15% in 2011, according to a retrospective study of 6,323 gun­shot wounds seen at the New Jersey Trauma Center, a Level I trauma cen­ter in Newark.

The proportion of 15-minute time increments in which the hospital was treating two or more pa­tients for gunshot wounds increased from approximately 10% in 2000 to nearly 30% by the end of 2011, and the proportion of 15-minute incre­ments in which three or more gun­shot wounds were being treated increased from 1% to 16%, reported Dr David H. Livingston and his asso­ciates.

Surgery on 71% of these patients plus other services incurred $115 mil­lion in costs, 75% of it unreimbursed. The mean cost per patient increased by 282% during the study period, re­ported Dr Livingston of University Hospital, Newark, NJ, and a profes­sor of surgery at Rutgers University, also in Newark.

Half of the patients in his study needed ICU care, a third needed a ventilator, and just less than a third needed blood transfusions. All of these parameters increased by 50% to 180% during the study period, he said at the annual meeting of the American Association for the Surgery of Trauma.

Further, the proportion of cases with three or more gunshot wounds doubled from 10% to 20%, as did the proportion of cases with three or more body areas that had been shot, from 5% to 10%

Five cities in New Jersey (Newark, Irving­ton, East Orange, Orange, and Eliza­beth) accounted for 85% of gunshot wounds; 75% of patients were shot in the city in which they lived, 55% within a mile of home, 25% within a block of home, and 15% in their homes.

The New Jersey study included only interpersonal gunshot injuries, not self-inflicted wounds or shots from police.

A second, separate study, gun-re­lated injury and deaths were compared in Arizona for the 2 years before and the 2 years after July 2010, when the state made it legal to carry a concealed weapon without a permit or training.

The proportion of homicides related to guns in southern Arizona increased significantly from 2% to nearly 2.5% af­ter that law was passed. Deaths by firearms increased by 24% among victims of violent crimes and acci­dents, Dr Rashna F. Ginwalla and her associates reported.

The number of violent crimes and accidents stayed relatively stable, but the risk of any gun-related injury or death increased significantly by 11% after concealed-weapons regulations were eliminated, said Dr Ginwalla, who led the study while at the Uni­versity of Arizona, Tucson. Dr Gin­walla now works in Rwanda for the University of Virginia, Char­lottesville.

"While causality has not been es­tablished by this observational study, we have demonstrated an association between an increase in gun availabili­ty and gun-related homicides in the state," she said.

Dr Livingston and Dr Ginwalla re­ported having no financial disclo­sures.

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Report details rise in bath salt-related ED visits

BY NASEEM S. MILLER

From A SAMHSA REPORT

The synthetic drugs "bath salts" accounted for 23,000 of 2.5 million drug-related emergency department visits in 2011, ac­cording to a report by the Substance Abuse and Mental Health Services Administration.

The toxicities of the drugs are similar to those of other stimulants seen in the ED, Dr Elinore F. McCance-Katz, SAMHSA’s chief medical officer, said in reporting the first national study to track data on the relatively new drugs.

Treatment is symptomatic, as there are no treatments that are specific to the toxicities related to these drugs, Dr McCance-Katz said. The drugs’ adverse effects include hypertension and tachycardia, de­pression, suicidal thoughts, agitation and anxiety, and psychosis.

The report, based on the 2011 Drug Abuse Warning Network, or DAWN report, also showed that two-thirds (67%) of bath salt–related ED visits involved the use of another drug: 15% involved combined use of marijuana or synthetic forms of mar­ijuana, and the other 52% involved a variety of other drugs.

Bath salts began to gain national at­tention in 2011, when poison centers reported a sudden jump to more than 6,000 cases of exposure to the drug, up from 300 cases in 2010.

In April 2013, the DEA put one of the main chemicals in bath salts in the Schedule I category. Several large national drug busts also have taken place in connection with the substance.

Bath salts come in the form of white or brown powder and contain one or more chemicals related to cathinone, an amphetamine-like stimulant. Their labelling implies that they are household prod­ucts, such as bath salts or jewelry cleaner, and may contain words such as "legal high" or "not for human consumption." They can be taken by mouth, inhaled, or injected.

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ED visits spike among California Medicaid patients

BY MICHELE G. SULLIVAN

From JAMA

Medicaid patients in California in­creased their use of emergency de­partments by nearly 36% over a 5-year period while ED use by privately insured patients barely increased.

"Increasing ED use by Medicaid beneficiaries could reflect decreasing access to primary care, which is sup­

ported by our findings of high and increasing rates of ED use for ambu­latory care sensitive conditions by Medicaid patients," wrote Dr Renee Hsia.

Dr Hsia of the University of Cali­fornia, San Francisco, and her coau­thors examined rates of ED utilization in California from 2005 to 2010 and broke down the data by in­surance status (JAMA. 2013;310[11]:1181-1183). They looked at adult patients younger than 65 years, because these patients "have experienced the great­est changes in insurance coverage in recent years, and are likely to see the biggest shifts as a result of health care reform."

The investigators based their retro­spective analysis on the California Of­fice of Statewide Health Planning and Development’s Emergency Dis­charge Data and Patient Discharge Data. The study grouped patients by insurance status: Medicaid, private, uninsured or self-pay, or other (work­ers compensation, CHAMPUS/TRI­CARE, Title V, and Veterans Affairs, and similar coverage).

Overall, ED visits jumped from 5.4 million to 6.1 million over the 5-year period—a 13% increase. While visits for patients with private insurance barely increased, with a 5-year differ­ence of just 1%, visits by Medicaid patients increased by 36%, and vis­its by uninsured patients rose 25%. Visits by patients with coverage in the "other" category decreased by more than 10%, the authors noted.

Medicaid patients also maintained the highest rate of visits such as hy­pertension, which are potentially pre­ventable with primary care. Among Medicaid recipients, the average year­ly rate of ED visits for these prob­lems was 55 per 1,000, compared with 11 per 1,000 for those with pri­vate insurance and nearly 17 per 1,000 for those who were uninsured.These visits showed the same kinds of coverage-dependent increases over the study period: a nearly 7% hike among Medicaid beneficiaries and about 6% among the uninsured, but a decline of nearly 1% among privately insured pa­tients.

Neither Dr Hsia nor her coauthors reported any financial disclosures.

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Bicycle helmet use remains low

BY SHARON WORCESTER

At the AAP National Conference

ORLANDO—About 11% of more than 1,200 children involved in bicycle-related accidents in Los Angeles County were wearing a helmet at the time of the accident. Los Angeles County mandates bicycle helmet use.

Of the 1,248 children from Los Angeles County who were included in the retrospective study of all injuries related to pediatric bicycle accidents between 2006 and 2011, 85% were boys. The lowest rates of helmet use were seen in children over age 12, and those of minority background and lower socioeconomic status. More than a third (35%) of white children wore helmets, but the rates were much lower for Asian (7%), black (6%), and Hispanic children (4%), said Dr Veronica Sullins of the Harbor-UCLA Medical Center in Torrance, Calif. Helmets were worn by 15% of children with private insurance, compared with nearly 8% of those with public insurance, Dr Sullins noted.

Emergency surgery was required in 6% of the children, and only 34% returned to their preinjury status. Nine patients died as a result of their injuries; eight of those were not wearing a helmet, Dr Sullins reported at the annual meeting of the American Academy of Pediatrics.

More than 150,000 emergency department visits each year are due to bicycle-related head injuries.

Helmet use has been shown to reduce bicycle-related head injuries by 80%; yet the Centers for Disease Control and Prevention reports that only 15% of adults and 19% of children wear helmets most or all of the time when riding a bicycle. An estimated 33 million children ride bicycles—for a total of 10 billion hours —each year, and nearly 400 children die as a result of bicycle crashes. I

Dr Sullins reported having no relevant financial disclosures.

Choosing Wisely: ACEP issues 5 things to avoid in the ED

By M. ALEXANDER OTTO

At the 2013 ACEP Acientific Assembly

Avoiding CT scans of emergency department patients who have minor head injuries and are at low risk based on validated decision rules was one of five practices recommended by The American College of Emergency Physicians as part of the "Choosing Wisely" campaign.

The mission of "Choosing Wisely" - a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation - is to promote conversations among physicians and patients about using appropriate tests and treatments and avoiding care when harm may outweigh benefit.

Since launching in April 2012, more than 80 national, regional and state medical specialty societies and consumer groups have become "Choosing Wisely" partners. ACEP officially joined the campaign in February of this year. ACEP developed its five recommendations through a multi-step process that included input from members, its board of directors, and an expert panel.

The other four treatments and procedures chosen by ACEP and announced at their annual meeting include:

• Avoid placing indwelling urinary catheters in the ED for either urine output monitoring in stable patients who can urinate on their own, or for patient or staff convenience.

• Do not delay available palliative and hospice care services in ED patients who are likely to benefit, such as those who have chronic or incurable diseases. Early referral can improve both quality and quantity of life.

• Avoid antibiotics and wound cultures in ED patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up. Opening and draining the abscess is the appropriate treatment; antibiotics offer no benefit.

• Avoid instituting IV fluids before doing a trial of oral hydration in uncomplicated emergency department cases of mild to moderate dehydration of children. To avoid pain and potential complications, it’s preferable to give these fluids by mouth. I

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"One and done" vancomycin dosing disparaged

By M. ALEXANDER OTTO

At the 2013 ACEP Acientific Assembly

SEATTLE—One-and-done vancomycin dosing in the emergency department was associated with a high rate of ED returns for the same infection within 3 months, based on a single-center, retrospective study.

From Dec. 2008 to June 2010, 526 ED patients got vancomycin, mostly for cellulitis and abscesses, at the Barnes-Jewish Hospital ED in St. Louis, Mo., an academic ED that annually serves almost 100,000 patients; 67.9% got one dose, 26.6% got two, and 5.5% received three doses. Weight-based doses were too low in 73%, and too high in 3.4%. Less than half of the patients were sent home on an oral antibiotic; about one-third were back in the ED within 3 months for the same infection.

"It was very common just to order a dose of vancomycin and send people home, [but] none of the guidelines" from the Infectious Diseases Society of America and other groups "support the use of vancomycin in patients who have uncomplicated infections before going home" from the ED, said lead investigator Dr Kristen Mueller, a fourth-year emergency medicine resident at Barnes-Jewish. A single dose doesn’t keep inhibitory concentrations high enough for long enough to knock out infections entirely; although sensitive strains may die off, more robust and virulent ones are left to proliferate. Patients end up colonized by more resistant bacteria.

Several emergency physicians at the meeting said that they’ve noticed vancomycin dosing problems in their EDs, as well. Vancomycin dosing problems also were reported in a study published earlier this year by researchers from Christiana Care Health System in Newark Delaware (J Emerg Med. 2013;44[5]:979-984).

Vancomycin-intermediate Staphylococcus aureus was isolated from about 170 Barnes-Jewish patients in 2009. "It’s not as common as MRSA, but it’s there. What’s more concerning is that frank vancomycin resistant S. aureus is starting to establish itself in the US," and inappropriate use of vancomycin will just fuel the problem, she said.

Concerns about nephrotoxicity may be behind the low-dosing issue, but the hospital’s EHR system might also contribute to dosing inaccuracy, Dr Mueller said. At Barnes-Jewish, "our easiest order dose is 1 gram of vancomycin; it’s a one-click order in our order set. Whereas, to order a weight-appropriate dose, you actually have to calculate it out and type in the dose you want."

In response to the findings, Dr Mueller and her colleagues are adding a skin and soft tissue order set to the EHR system, with different tabs based on infection type and sub-tabs for patient disposition. Patients discharged home or to the observation unit will only have oral antibiotic options. Only inpatients will eligible for weight-based vancomycin dosing.

In an earlier study, Dr Mueller and her colleagues found that ED doses of vancomycin are frequently continued when patients are admitted, even if they’re wrong; 71% of the 2,560 inpatients in the earlier investigation were underdosed (J Emerg Med. 2013;44[5]:910-918).

Dr Mueller had no relevant disclosures.

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Prehospital bivalirudin reduced bleeding with PCI

BY SHERRY BOSCHERT

At TCT 2013

SAN FRANCISCO – Giving bivalirudin in the ambulance to patients with ST-segment elevation MI before primary percutaneous coronary intervention significantly improved 30-day bleeding outcomes in a randomized controlled European trial in 2,218 patients, compared with giving unfractionated or low-molecular-weight heparin and optional glycoprotein IIb/IIIa inhibitors.

In Europe, anticoagulation commonly is started in the ambulance. The practice has not yet caught on in most of the United States.

Compared with the control group, the bivalirudin group had a nearly 40% decrease in a composite outcome of death or major bleeding not associated with coronary artery bypass grafting (CABG). Rates

for the primary outcome were 5% in the bivalirudin group and over 8% in the control group at 30 days,

Dr Philippe Gabriel Steg and his associates reported at the Transcatheter Cardiovascular Therapeutics annual meeting.

The rates of the main secondary outcome – a composite of death, reinfarction, or non-CABG major bleeding at 30 days – also were significantly lower in the bivalirudin group (6.7%) than in the control group (9.1%), said Dr Steg, professor of cardiology at Université Paris-Diderot and director of the coronary care unit at Hôpital Bichat, Paris.

The 30-day rate of acute stent thrombosis was nearly sixfold higher in the bivalirudin group (1.1%) than in the control group (0.2%), but that did not translate into an increased risk of infarction, which occurred in 1.7% in the bivalirudin group and 0.9% in the control group (0.9%).

The study was published online simultaneously with the presentation (N Engl J Med. October 30, 2013 [doi: 10.1056/NEJMoa1311096]).

The benefit from bivalirudin came mainly from reduced bleeding, not reduced mortality. The risk of major bleeding not associated with CABG was 2.7% in the bivalirudin group and 6.1% in the control group, a significant 57% reduction.

Rates of cardiac or noncardiac death at 30 days did not differ significantly between groups. Cardiac death occurred in 2.4% in the bivalirudin group and in 3% in the control group; noncardiac death occurred in 0.5% and 0.1%, respectively.

The EUROMAX findings were consistent across subgroups of patients, including subgroups defined by PCI access site or by the choice of P2Y12 inhibitor, Dr Steg reported at the meeting, cosponsored by the American College of Cardiology.

Dr Steg received fees from The Medicines Company, which sponsored the study and markets bivalirudin, and he reported financial associations with 16 other companies. Four of his colleagues in the study were employees of The Medicines Company, and 12 other colleagues reported financial associations with that company and/or multiple other companies. Dr Stone reported financial associations with Boston Scientific, Eli Lilly, and other companies.

[email protected]

Ottawa SAH clinical decision rule helps identify subarachnoid hemorrhage

BY MARY ANN MOON

From JAMA

A new clinical decision rule had sensitivity and specificity approaching 100% in ruling out subarachnoid hemorrhage among patients who presented to an emergency department with acute headache, a validation study showed.

Using this new tool, which requires only that the clinician answer six simple questions regarding the patient’s presentation, has the potential to reduce the number of costly and sometimes invasive procedures that are currently relied on to distinguish subarachnoid hemorrhage (SAH) from other pathologies, said Dr Jeffrey J. Perry of the department of emergency medicine at the University of Ottawa (Ont.) and the clinical epidemiology program at the Ottawa Hospital Research Institute and his associates.

Dr Perry and his colleagues devised three clinical decision rules to assist in ruling out SAH, then assessed the three rules for their accuracy, reliability, and acceptability to clinicians in a validation cohort of consecutive patients aged 16 years and older who presented to an ED with a nontraumatic headache that reached maximal intensity within 1 hour. There were 2,131 study subjects with a mean age of 44 years. Approximately 61% were women, and 26% arrived at the ED by ambulance.

All of these participants were treated by attending physicians certified in emergency medicine or by supervised residents at 10 university-affiliated urban, Canadian tertiary care teaching hospitals during a 4-year period. All patients were alert and oriented, with no neurologic deficits; 132 (6.2%) were found to have SAH.

After comparing the performances of the three candidate decision rules, the investigators refined the decision tool to identify six factors that were most predictive of SAH: age of 40 years or older, neck pain or stiffness, witnessed loss of consciousness, onset of headache during exertion, "thunderclap headache" (defined as instantly peaking pain), and limited neck flexion (defined as the inability to touch chin to chest when upright or to raise the head 8 cm off the bed when supine).

The presence of any one of these six factors indicates that SAH is possible and further investigation is required using CT and perhaps lumbar puncture, Dr Perry and his associates said.

This refined clinical decision rule, which they termed the Ottawa SAH rule, had an overall sensitivity of 99.2% and a specificity of 99.6% in identifying SAHs (JAMA. 2013;310[12]:1248-1255).

Following this rule would decrease the investigation rate"—the rate of further assessment using CT and lumbar puncture—"to 74% from the current investigation rate of 84%, the researchers added.

The Ottawa SAH rule must be evaluated further before it can be adopted into clinical practice. "An implementation study is the next step required to determine how the Ottawa SAH rule performs in clinical practice, assess the actual effects on patient care and patient outcomes, and conduct a formal health economic analysis," the researchers noted.

This study was supported by the Canadian Institutes for Health Research, the University of Ottawa, and the Vancouver Coastal Health Research Institute. No financial conflicts of interest were reported.

Novel two-biomarker strategy permits early ACS rule-out

BY BRUCE JANCIN

At the ESC Congress 2013

AMSTERDAM—An early rule-out strategy based upon using two cardiac biomarkers allowed for safe discharge within a couple hours from the emergency department for most low- to intermediate-risk patients who presented with suspected acute coronary syndromes, based on the results of a randomized, multicenter trial conducted in Europe.

Moreover, the 30-day rates of major adverse cardiovascular events in the Biomarkers in Cardiology–8 (BiC-8) study were similarly low in patients discharged from the ED using the early rule-out process and in those who received standard, guideline-recommended care, which includes 6-12 hours of serial ECGs and troponin measurements in the chest pain unit, Dr Martin Moeckel reported at the annual congress of the European Society of Cardiology.

"This biomarker strategy using a state-of-the-art quantitative troponin assay in combination with an ultrasensitive copeptin assay has the potential to change clinical practice with high patient safety," observed Dr Moeckel of Charite Hospital, Berlin. The copeptin test is approved for use in the European Union but remains investigational in the United States.

Based upon the results of BiC-8, this dual-biomarker for early rule-out of myocardial infarction is now standard clinical practice at Charite, he added.

Nearly 12% of all patients who present to the ED do so because of chest pain, yet after an extensive and time-consuming evaluation only 1 in 10 of those patients are found to actually be having an acute MI.

"Rapid rule-out of acute MI is therefore a major clinical need, saving the health care system time and resources, and saving patients unnecessary stress, anxiety, and other risks," he said.

Copeptin is a marker for vasopressin, a hemodynamic stress indicator that shoots up immediately in an acute MI. In earlier studies, a negative result for both troponin and copeptin in an initial blood sample drawn at ED presentation had a 99% negative predictive value for MI.

The BiC-8 trial included 902 low- to intermediate-risk patients who presented with suspected ACS to EDs in university medical centers. All had a negative initial cardiac troponin test. They were randomized to standard care in the chest pain unit, including serial troponin testing and ECGs, or to the experimental strategy, in which physicians were informed of the copeptin results from the same initial blood sample as the troponin. If the copeptin test was positive as defined by a level of 10 pmol/L or more, the patient was hospitalized for standard care. If the copeptin result was negative, however, the patient was immediately discharged with a scheduled outpatient visit within72 hours.

Of the patients in the copeptin group, 66% were discharged directly from the ED, compared to 12% in the standard care group.

The 30-day incidence of major adverse cardiovascular events (MACE) was 5.5% in the standard care group and nearly identical at 5.46% in the copeptin group. MACE was defined in BiC-8 as all-cause mortality, MI, rehospitalization for ACS, acute unplanned PCI, coronary artery bypass surgery, life-threatening arrhythmia, or resuscitation from cardiac arrest.

MACE occurred in 14 copeptin-negative patients. However, 12 of the 14 were not discharged early because physicians overruled the negative biomarker results based on patient history and moved the patients into standard in-hospital management. Two patients, or 0.6% of those discharged from the ED on the basis of a negative copeptin test, had adverse events: one was rehospitalized on day 23 and underwent acute unplanned PCI on the next day, and the other was rehospitalized on day 4 and underwent coronary artery bypass graft surgery on day 12.

American Heart Association Immediate Past President Donna K. Arnett, PhD, said in an interview that she’d really like to see a second, confirmatory randomized trial before this early rule-out strategy is widely adopted. She considers the lost-to-followup rate uncomfortably high: 63 patients in the intention-to-treat analysis, and another 75 not accounted for in the per protocol analysis, noted Dr Arnett, professor and chair of the department of epidemiology at the University of Alabama, Birmingham.

"The most important message from BiC-8, I think, is that these were patients at low- to-intermediate risk; they’re not the high-risk patients. And it’s also important that the physician didn’t rely only on the test result, but also took a final look at the clinical situation before releasing the patient. There is some overruling when patients are biomarker-negative but have typical risk markers. No test is 100% accurate. Clinical judgment remains extremely important," emphasized co-investigator Dr Kurt Huber, professor and director of cardiology and emergency medicine at Wilhelminen Hospital, Vienna.

The BiC-8 trial was sponsored by ThermoFisher Scientic and six university medical centers in German-speaking Europe. Dr Moeckel reported receiving a research grant from ThermoFisher Scientific and serving as a consultant to Bayer, AstraZeneca, and The Medicines Company. Drs Arnett and Huber had no conflicts to declare.

[email protected]

Two studies document a rise in gun wounds, homicides

BY SHERRY BOSCHERT

At th AAST Annual Meeting

SAN FRANCISCO—Deaths from gunshot wounds doubled between 2000 and 2012 in the region served by one New Jersey trauma center and gun-related homicides as a propor­tion of violent crimes increased by 27% in southern Arizona after the state stopped requiring permits for concealed weapons, separate studies found.

In 2000, 8% of patients treated for gunshot wounds died. That rate in­creased to 15% in 2011, according to a retrospective study of 6,323 gun­shot wounds seen at the New Jersey Trauma Center, a Level I trauma cen­ter in Newark.

The proportion of 15-minute time increments in which the hospital was treating two or more pa­tients for gunshot wounds increased from approximately 10% in 2000 to nearly 30% by the end of 2011, and the proportion of 15-minute incre­ments in which three or more gun­shot wounds were being treated increased from 1% to 16%, reported Dr David H. Livingston and his asso­ciates.

Surgery on 71% of these patients plus other services incurred $115 mil­lion in costs, 75% of it unreimbursed. The mean cost per patient increased by 282% during the study period, re­ported Dr Livingston of University Hospital, Newark, NJ, and a profes­sor of surgery at Rutgers University, also in Newark.

Half of the patients in his study needed ICU care, a third needed a ventilator, and just less than a third needed blood transfusions. All of these parameters increased by 50% to 180% during the study period, he said at the annual meeting of the American Association for the Surgery of Trauma.

Further, the proportion of cases with three or more gunshot wounds doubled from 10% to 20%, as did the proportion of cases with three or more body areas that had been shot, from 5% to 10%

Five cities in New Jersey (Newark, Irving­ton, East Orange, Orange, and Eliza­beth) accounted for 85% of gunshot wounds; 75% of patients were shot in the city in which they lived, 55% within a mile of home, 25% within a block of home, and 15% in their homes.

The New Jersey study included only interpersonal gunshot injuries, not self-inflicted wounds or shots from police.

A second, separate study, gun-re­lated injury and deaths were compared in Arizona for the 2 years before and the 2 years after July 2010, when the state made it legal to carry a concealed weapon without a permit or training.

The proportion of homicides related to guns in southern Arizona increased significantly from 2% to nearly 2.5% af­ter that law was passed. Deaths by firearms increased by 24% among victims of violent crimes and acci­dents, Dr Rashna F. Ginwalla and her associates reported.

The number of violent crimes and accidents stayed relatively stable, but the risk of any gun-related injury or death increased significantly by 11% after concealed-weapons regulations were eliminated, said Dr Ginwalla, who led the study while at the Uni­versity of Arizona, Tucson. Dr Gin­walla now works in Rwanda for the University of Virginia, Char­lottesville.

"While causality has not been es­tablished by this observational study, we have demonstrated an association between an increase in gun availabili­ty and gun-related homicides in the state," she said.

Dr Livingston and Dr Ginwalla re­ported having no financial disclo­sures.

[email protected]

Report details rise in bath salt-related ED visits

BY NASEEM S. MILLER

From A SAMHSA REPORT

The synthetic drugs "bath salts" accounted for 23,000 of 2.5 million drug-related emergency department visits in 2011, ac­cording to a report by the Substance Abuse and Mental Health Services Administration.

The toxicities of the drugs are similar to those of other stimulants seen in the ED, Dr Elinore F. McCance-Katz, SAMHSA’s chief medical officer, said in reporting the first national study to track data on the relatively new drugs.

Treatment is symptomatic, as there are no treatments that are specific to the toxicities related to these drugs, Dr McCance-Katz said. The drugs’ adverse effects include hypertension and tachycardia, de­pression, suicidal thoughts, agitation and anxiety, and psychosis.

The report, based on the 2011 Drug Abuse Warning Network, or DAWN report, also showed that two-thirds (67%) of bath salt–related ED visits involved the use of another drug: 15% involved combined use of marijuana or synthetic forms of mar­ijuana, and the other 52% involved a variety of other drugs.

Bath salts began to gain national at­tention in 2011, when poison centers reported a sudden jump to more than 6,000 cases of exposure to the drug, up from 300 cases in 2010.

In April 2013, the DEA put one of the main chemicals in bath salts in the Schedule I category. Several large national drug busts also have taken place in connection with the substance.

Bath salts come in the form of white or brown powder and contain one or more chemicals related to cathinone, an amphetamine-like stimulant. Their labelling implies that they are household prod­ucts, such as bath salts or jewelry cleaner, and may contain words such as "legal high" or "not for human consumption." They can be taken by mouth, inhaled, or injected.

[email protected]

ED visits spike among California Medicaid patients

BY MICHELE G. SULLIVAN

From JAMA

Medicaid patients in California in­creased their use of emergency de­partments by nearly 36% over a 5-year period while ED use by privately insured patients barely increased.

"Increasing ED use by Medicaid beneficiaries could reflect decreasing access to primary care, which is sup­

ported by our findings of high and increasing rates of ED use for ambu­latory care sensitive conditions by Medicaid patients," wrote Dr Renee Hsia.

Dr Hsia of the University of Cali­fornia, San Francisco, and her coau­thors examined rates of ED utilization in California from 2005 to 2010 and broke down the data by in­surance status (JAMA. 2013;310[11]:1181-1183). They looked at adult patients younger than 65 years, because these patients "have experienced the great­est changes in insurance coverage in recent years, and are likely to see the biggest shifts as a result of health care reform."

The investigators based their retro­spective analysis on the California Of­fice of Statewide Health Planning and Development’s Emergency Dis­charge Data and Patient Discharge Data. The study grouped patients by insurance status: Medicaid, private, uninsured or self-pay, or other (work­ers compensation, CHAMPUS/TRI­CARE, Title V, and Veterans Affairs, and similar coverage).

Overall, ED visits jumped from 5.4 million to 6.1 million over the 5-year period—a 13% increase. While visits for patients with private insurance barely increased, with a 5-year differ­ence of just 1%, visits by Medicaid patients increased by 36%, and vis­its by uninsured patients rose 25%. Visits by patients with coverage in the "other" category decreased by more than 10%, the authors noted.

Medicaid patients also maintained the highest rate of visits such as hy­pertension, which are potentially pre­ventable with primary care. Among Medicaid recipients, the average year­ly rate of ED visits for these prob­lems was 55 per 1,000, compared with 11 per 1,000 for those with pri­vate insurance and nearly 17 per 1,000 for those who were uninsured.These visits showed the same kinds of coverage-dependent increases over the study period: a nearly 7% hike among Medicaid beneficiaries and about 6% among the uninsured, but a decline of nearly 1% among privately insured pa­tients.

Neither Dr Hsia nor her coauthors reported any financial disclosures.

[email protected]

Bicycle helmet use remains low

BY SHARON WORCESTER

At the AAP National Conference

ORLANDO—About 11% of more than 1,200 children involved in bicycle-related accidents in Los Angeles County were wearing a helmet at the time of the accident. Los Angeles County mandates bicycle helmet use.

Of the 1,248 children from Los Angeles County who were included in the retrospective study of all injuries related to pediatric bicycle accidents between 2006 and 2011, 85% were boys. The lowest rates of helmet use were seen in children over age 12, and those of minority background and lower socioeconomic status. More than a third (35%) of white children wore helmets, but the rates were much lower for Asian (7%), black (6%), and Hispanic children (4%), said Dr Veronica Sullins of the Harbor-UCLA Medical Center in Torrance, Calif. Helmets were worn by 15% of children with private insurance, compared with nearly 8% of those with public insurance, Dr Sullins noted.

Emergency surgery was required in 6% of the children, and only 34% returned to their preinjury status. Nine patients died as a result of their injuries; eight of those were not wearing a helmet, Dr Sullins reported at the annual meeting of the American Academy of Pediatrics.

More than 150,000 emergency department visits each year are due to bicycle-related head injuries.

Helmet use has been shown to reduce bicycle-related head injuries by 80%; yet the Centers for Disease Control and Prevention reports that only 15% of adults and 19% of children wear helmets most or all of the time when riding a bicycle. An estimated 33 million children ride bicycles—for a total of 10 billion hours —each year, and nearly 400 children die as a result of bicycle crashes. I

Dr Sullins reported having no relevant financial disclosures.

Choosing Wisely: ACEP issues 5 things to avoid in the ED

By M. ALEXANDER OTTO

At the 2013 ACEP Acientific Assembly

Avoiding CT scans of emergency department patients who have minor head injuries and are at low risk based on validated decision rules was one of five practices recommended by The American College of Emergency Physicians as part of the "Choosing Wisely" campaign.

The mission of "Choosing Wisely" - a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation - is to promote conversations among physicians and patients about using appropriate tests and treatments and avoiding care when harm may outweigh benefit.

Since launching in April 2012, more than 80 national, regional and state medical specialty societies and consumer groups have become "Choosing Wisely" partners. ACEP officially joined the campaign in February of this year. ACEP developed its five recommendations through a multi-step process that included input from members, its board of directors, and an expert panel.

The other four treatments and procedures chosen by ACEP and announced at their annual meeting include:

• Avoid placing indwelling urinary catheters in the ED for either urine output monitoring in stable patients who can urinate on their own, or for patient or staff convenience.

• Do not delay available palliative and hospice care services in ED patients who are likely to benefit, such as those who have chronic or incurable diseases. Early referral can improve both quality and quantity of life.

• Avoid antibiotics and wound cultures in ED patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up. Opening and draining the abscess is the appropriate treatment; antibiotics offer no benefit.

• Avoid instituting IV fluids before doing a trial of oral hydration in uncomplicated emergency department cases of mild to moderate dehydration of children. To avoid pain and potential complications, it’s preferable to give these fluids by mouth. I

[email protected]

"One and done" vancomycin dosing disparaged

By M. ALEXANDER OTTO

At the 2013 ACEP Acientific Assembly

SEATTLE—One-and-done vancomycin dosing in the emergency department was associated with a high rate of ED returns for the same infection within 3 months, based on a single-center, retrospective study.

From Dec. 2008 to June 2010, 526 ED patients got vancomycin, mostly for cellulitis and abscesses, at the Barnes-Jewish Hospital ED in St. Louis, Mo., an academic ED that annually serves almost 100,000 patients; 67.9% got one dose, 26.6% got two, and 5.5% received three doses. Weight-based doses were too low in 73%, and too high in 3.4%. Less than half of the patients were sent home on an oral antibiotic; about one-third were back in the ED within 3 months for the same infection.

"It was very common just to order a dose of vancomycin and send people home, [but] none of the guidelines" from the Infectious Diseases Society of America and other groups "support the use of vancomycin in patients who have uncomplicated infections before going home" from the ED, said lead investigator Dr Kristen Mueller, a fourth-year emergency medicine resident at Barnes-Jewish. A single dose doesn’t keep inhibitory concentrations high enough for long enough to knock out infections entirely; although sensitive strains may die off, more robust and virulent ones are left to proliferate. Patients end up colonized by more resistant bacteria.

Several emergency physicians at the meeting said that they’ve noticed vancomycin dosing problems in their EDs, as well. Vancomycin dosing problems also were reported in a study published earlier this year by researchers from Christiana Care Health System in Newark Delaware (J Emerg Med. 2013;44[5]:979-984).

Vancomycin-intermediate Staphylococcus aureus was isolated from about 170 Barnes-Jewish patients in 2009. "It’s not as common as MRSA, but it’s there. What’s more concerning is that frank vancomycin resistant S. aureus is starting to establish itself in the US," and inappropriate use of vancomycin will just fuel the problem, she said.

Concerns about nephrotoxicity may be behind the low-dosing issue, but the hospital’s EHR system might also contribute to dosing inaccuracy, Dr Mueller said. At Barnes-Jewish, "our easiest order dose is 1 gram of vancomycin; it’s a one-click order in our order set. Whereas, to order a weight-appropriate dose, you actually have to calculate it out and type in the dose you want."

In response to the findings, Dr Mueller and her colleagues are adding a skin and soft tissue order set to the EHR system, with different tabs based on infection type and sub-tabs for patient disposition. Patients discharged home or to the observation unit will only have oral antibiotic options. Only inpatients will eligible for weight-based vancomycin dosing.

In an earlier study, Dr Mueller and her colleagues found that ED doses of vancomycin are frequently continued when patients are admitted, even if they’re wrong; 71% of the 2,560 inpatients in the earlier investigation were underdosed (J Emerg Med. 2013;44[5]:910-918).

Dr Mueller had no relevant disclosures.

[email protected]

Prehospital bivalirudin reduced bleeding with PCI

BY SHERRY BOSCHERT

At TCT 2013

SAN FRANCISCO – Giving bivalirudin in the ambulance to patients with ST-segment elevation MI before primary percutaneous coronary intervention significantly improved 30-day bleeding outcomes in a randomized controlled European trial in 2,218 patients, compared with giving unfractionated or low-molecular-weight heparin and optional glycoprotein IIb/IIIa inhibitors.

In Europe, anticoagulation commonly is started in the ambulance. The practice has not yet caught on in most of the United States.

Compared with the control group, the bivalirudin group had a nearly 40% decrease in a composite outcome of death or major bleeding not associated with coronary artery bypass grafting (CABG). Rates

for the primary outcome were 5% in the bivalirudin group and over 8% in the control group at 30 days,

Dr Philippe Gabriel Steg and his associates reported at the Transcatheter Cardiovascular Therapeutics annual meeting.

The rates of the main secondary outcome – a composite of death, reinfarction, or non-CABG major bleeding at 30 days – also were significantly lower in the bivalirudin group (6.7%) than in the control group (9.1%), said Dr Steg, professor of cardiology at Université Paris-Diderot and director of the coronary care unit at Hôpital Bichat, Paris.

The 30-day rate of acute stent thrombosis was nearly sixfold higher in the bivalirudin group (1.1%) than in the control group (0.2%), but that did not translate into an increased risk of infarction, which occurred in 1.7% in the bivalirudin group and 0.9% in the control group (0.9%).

The study was published online simultaneously with the presentation (N Engl J Med. October 30, 2013 [doi: 10.1056/NEJMoa1311096]).

The benefit from bivalirudin came mainly from reduced bleeding, not reduced mortality. The risk of major bleeding not associated with CABG was 2.7% in the bivalirudin group and 6.1% in the control group, a significant 57% reduction.

Rates of cardiac or noncardiac death at 30 days did not differ significantly between groups. Cardiac death occurred in 2.4% in the bivalirudin group and in 3% in the control group; noncardiac death occurred in 0.5% and 0.1%, respectively.

The EUROMAX findings were consistent across subgroups of patients, including subgroups defined by PCI access site or by the choice of P2Y12 inhibitor, Dr Steg reported at the meeting, cosponsored by the American College of Cardiology.

Dr Steg received fees from The Medicines Company, which sponsored the study and markets bivalirudin, and he reported financial associations with 16 other companies. Four of his colleagues in the study were employees of The Medicines Company, and 12 other colleagues reported financial associations with that company and/or multiple other companies. Dr Stone reported financial associations with Boston Scientific, Eli Lilly, and other companies.

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Ottawa SAH clinical decision rule helps identify subarachnoid hemorrhage

BY MARY ANN MOON

From JAMA

A new clinical decision rule had sensitivity and specificity approaching 100% in ruling out subarachnoid hemorrhage among patients who presented to an emergency department with acute headache, a validation study showed.

Using this new tool, which requires only that the clinician answer six simple questions regarding the patient’s presentation, has the potential to reduce the number of costly and sometimes invasive procedures that are currently relied on to distinguish subarachnoid hemorrhage (SAH) from other pathologies, said Dr Jeffrey J. Perry of the department of emergency medicine at the University of Ottawa (Ont.) and the clinical epidemiology program at the Ottawa Hospital Research Institute and his associates.

Dr Perry and his colleagues devised three clinical decision rules to assist in ruling out SAH, then assessed the three rules for their accuracy, reliability, and acceptability to clinicians in a validation cohort of consecutive patients aged 16 years and older who presented to an ED with a nontraumatic headache that reached maximal intensity within 1 hour. There were 2,131 study subjects with a mean age of 44 years. Approximately 61% were women, and 26% arrived at the ED by ambulance.

All of these participants were treated by attending physicians certified in emergency medicine or by supervised residents at 10 university-affiliated urban, Canadian tertiary care teaching hospitals during a 4-year period. All patients were alert and oriented, with no neurologic deficits; 132 (6.2%) were found to have SAH.

After comparing the performances of the three candidate decision rules, the investigators refined the decision tool to identify six factors that were most predictive of SAH: age of 40 years or older, neck pain or stiffness, witnessed loss of consciousness, onset of headache during exertion, "thunderclap headache" (defined as instantly peaking pain), and limited neck flexion (defined as the inability to touch chin to chest when upright or to raise the head 8 cm off the bed when supine).

The presence of any one of these six factors indicates that SAH is possible and further investigation is required using CT and perhaps lumbar puncture, Dr Perry and his associates said.

This refined clinical decision rule, which they termed the Ottawa SAH rule, had an overall sensitivity of 99.2% and a specificity of 99.6% in identifying SAHs (JAMA. 2013;310[12]:1248-1255).

Following this rule would decrease the investigation rate"—the rate of further assessment using CT and lumbar puncture—"to 74% from the current investigation rate of 84%, the researchers added.

The Ottawa SAH rule must be evaluated further before it can be adopted into clinical practice. "An implementation study is the next step required to determine how the Ottawa SAH rule performs in clinical practice, assess the actual effects on patient care and patient outcomes, and conduct a formal health economic analysis," the researchers noted.

This study was supported by the Canadian Institutes for Health Research, the University of Ottawa, and the Vancouver Coastal Health Research Institute. No financial conflicts of interest were reported.

Novel two-biomarker strategy permits early ACS rule-out

BY BRUCE JANCIN

At the ESC Congress 2013

AMSTERDAM—An early rule-out strategy based upon using two cardiac biomarkers allowed for safe discharge within a couple hours from the emergency department for most low- to intermediate-risk patients who presented with suspected acute coronary syndromes, based on the results of a randomized, multicenter trial conducted in Europe.

Moreover, the 30-day rates of major adverse cardiovascular events in the Biomarkers in Cardiology–8 (BiC-8) study were similarly low in patients discharged from the ED using the early rule-out process and in those who received standard, guideline-recommended care, which includes 6-12 hours of serial ECGs and troponin measurements in the chest pain unit, Dr Martin Moeckel reported at the annual congress of the European Society of Cardiology.

"This biomarker strategy using a state-of-the-art quantitative troponin assay in combination with an ultrasensitive copeptin assay has the potential to change clinical practice with high patient safety," observed Dr Moeckel of Charite Hospital, Berlin. The copeptin test is approved for use in the European Union but remains investigational in the United States.

Based upon the results of BiC-8, this dual-biomarker for early rule-out of myocardial infarction is now standard clinical practice at Charite, he added.

Nearly 12% of all patients who present to the ED do so because of chest pain, yet after an extensive and time-consuming evaluation only 1 in 10 of those patients are found to actually be having an acute MI.

"Rapid rule-out of acute MI is therefore a major clinical need, saving the health care system time and resources, and saving patients unnecessary stress, anxiety, and other risks," he said.

Copeptin is a marker for vasopressin, a hemodynamic stress indicator that shoots up immediately in an acute MI. In earlier studies, a negative result for both troponin and copeptin in an initial blood sample drawn at ED presentation had a 99% negative predictive value for MI.

The BiC-8 trial included 902 low- to intermediate-risk patients who presented with suspected ACS to EDs in university medical centers. All had a negative initial cardiac troponin test. They were randomized to standard care in the chest pain unit, including serial troponin testing and ECGs, or to the experimental strategy, in which physicians were informed of the copeptin results from the same initial blood sample as the troponin. If the copeptin test was positive as defined by a level of 10 pmol/L or more, the patient was hospitalized for standard care. If the copeptin result was negative, however, the patient was immediately discharged with a scheduled outpatient visit within72 hours.

Of the patients in the copeptin group, 66% were discharged directly from the ED, compared to 12% in the standard care group.

The 30-day incidence of major adverse cardiovascular events (MACE) was 5.5% in the standard care group and nearly identical at 5.46% in the copeptin group. MACE was defined in BiC-8 as all-cause mortality, MI, rehospitalization for ACS, acute unplanned PCI, coronary artery bypass surgery, life-threatening arrhythmia, or resuscitation from cardiac arrest.

MACE occurred in 14 copeptin-negative patients. However, 12 of the 14 were not discharged early because physicians overruled the negative biomarker results based on patient history and moved the patients into standard in-hospital management. Two patients, or 0.6% of those discharged from the ED on the basis of a negative copeptin test, had adverse events: one was rehospitalized on day 23 and underwent acute unplanned PCI on the next day, and the other was rehospitalized on day 4 and underwent coronary artery bypass graft surgery on day 12.

American Heart Association Immediate Past President Donna K. Arnett, PhD, said in an interview that she’d really like to see a second, confirmatory randomized trial before this early rule-out strategy is widely adopted. She considers the lost-to-followup rate uncomfortably high: 63 patients in the intention-to-treat analysis, and another 75 not accounted for in the per protocol analysis, noted Dr Arnett, professor and chair of the department of epidemiology at the University of Alabama, Birmingham.

"The most important message from BiC-8, I think, is that these were patients at low- to-intermediate risk; they’re not the high-risk patients. And it’s also important that the physician didn’t rely only on the test result, but also took a final look at the clinical situation before releasing the patient. There is some overruling when patients are biomarker-negative but have typical risk markers. No test is 100% accurate. Clinical judgment remains extremely important," emphasized co-investigator Dr Kurt Huber, professor and director of cardiology and emergency medicine at Wilhelminen Hospital, Vienna.

The BiC-8 trial was sponsored by ThermoFisher Scientic and six university medical centers in German-speaking Europe. Dr Moeckel reported receiving a research grant from ThermoFisher Scientific and serving as a consultant to Bayer, AstraZeneca, and The Medicines Company. Drs Arnett and Huber had no conflicts to declare.

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Two studies document a rise in gun wounds, homicides

BY SHERRY BOSCHERT

At th AAST Annual Meeting

SAN FRANCISCO—Deaths from gunshot wounds doubled between 2000 and 2012 in the region served by one New Jersey trauma center and gun-related homicides as a propor­tion of violent crimes increased by 27% in southern Arizona after the state stopped requiring permits for concealed weapons, separate studies found.

In 2000, 8% of patients treated for gunshot wounds died. That rate in­creased to 15% in 2011, according to a retrospective study of 6,323 gun­shot wounds seen at the New Jersey Trauma Center, a Level I trauma cen­ter in Newark.

The proportion of 15-minute time increments in which the hospital was treating two or more pa­tients for gunshot wounds increased from approximately 10% in 2000 to nearly 30% by the end of 2011, and the proportion of 15-minute incre­ments in which three or more gun­shot wounds were being treated increased from 1% to 16%, reported Dr David H. Livingston and his asso­ciates.

Surgery on 71% of these patients plus other services incurred $115 mil­lion in costs, 75% of it unreimbursed. The mean cost per patient increased by 282% during the study period, re­ported Dr Livingston of University Hospital, Newark, NJ, and a profes­sor of surgery at Rutgers University, also in Newark.

Half of the patients in his study needed ICU care, a third needed a ventilator, and just less than a third needed blood transfusions. All of these parameters increased by 50% to 180% during the study period, he said at the annual meeting of the American Association for the Surgery of Trauma.

Further, the proportion of cases with three or more gunshot wounds doubled from 10% to 20%, as did the proportion of cases with three or more body areas that had been shot, from 5% to 10%

Five cities in New Jersey (Newark, Irving­ton, East Orange, Orange, and Eliza­beth) accounted for 85% of gunshot wounds; 75% of patients were shot in the city in which they lived, 55% within a mile of home, 25% within a block of home, and 15% in their homes.

The New Jersey study included only interpersonal gunshot injuries, not self-inflicted wounds or shots from police.

A second, separate study, gun-re­lated injury and deaths were compared in Arizona for the 2 years before and the 2 years after July 2010, when the state made it legal to carry a concealed weapon without a permit or training.

The proportion of homicides related to guns in southern Arizona increased significantly from 2% to nearly 2.5% af­ter that law was passed. Deaths by firearms increased by 24% among victims of violent crimes and acci­dents, Dr Rashna F. Ginwalla and her associates reported.

The number of violent crimes and accidents stayed relatively stable, but the risk of any gun-related injury or death increased significantly by 11% after concealed-weapons regulations were eliminated, said Dr Ginwalla, who led the study while at the Uni­versity of Arizona, Tucson. Dr Gin­walla now works in Rwanda for the University of Virginia, Char­lottesville.

"While causality has not been es­tablished by this observational study, we have demonstrated an association between an increase in gun availabili­ty and gun-related homicides in the state," she said.

Dr Livingston and Dr Ginwalla re­ported having no financial disclo­sures.

[email protected]

Report details rise in bath salt-related ED visits

BY NASEEM S. MILLER

From A SAMHSA REPORT

The synthetic drugs "bath salts" accounted for 23,000 of 2.5 million drug-related emergency department visits in 2011, ac­cording to a report by the Substance Abuse and Mental Health Services Administration.

The toxicities of the drugs are similar to those of other stimulants seen in the ED, Dr Elinore F. McCance-Katz, SAMHSA’s chief medical officer, said in reporting the first national study to track data on the relatively new drugs.

Treatment is symptomatic, as there are no treatments that are specific to the toxicities related to these drugs, Dr McCance-Katz said. The drugs’ adverse effects include hypertension and tachycardia, de­pression, suicidal thoughts, agitation and anxiety, and psychosis.

The report, based on the 2011 Drug Abuse Warning Network, or DAWN report, also showed that two-thirds (67%) of bath salt–related ED visits involved the use of another drug: 15% involved combined use of marijuana or synthetic forms of mar­ijuana, and the other 52% involved a variety of other drugs.

Bath salts began to gain national at­tention in 2011, when poison centers reported a sudden jump to more than 6,000 cases of exposure to the drug, up from 300 cases in 2010.

In April 2013, the DEA put one of the main chemicals in bath salts in the Schedule I category. Several large national drug busts also have taken place in connection with the substance.

Bath salts come in the form of white or brown powder and contain one or more chemicals related to cathinone, an amphetamine-like stimulant. Their labelling implies that they are household prod­ucts, such as bath salts or jewelry cleaner, and may contain words such as "legal high" or "not for human consumption." They can be taken by mouth, inhaled, or injected.

[email protected]

ED visits spike among California Medicaid patients

BY MICHELE G. SULLIVAN

From JAMA

Medicaid patients in California in­creased their use of emergency de­partments by nearly 36% over a 5-year period while ED use by privately insured patients barely increased.

"Increasing ED use by Medicaid beneficiaries could reflect decreasing access to primary care, which is sup­

ported by our findings of high and increasing rates of ED use for ambu­latory care sensitive conditions by Medicaid patients," wrote Dr Renee Hsia.

Dr Hsia of the University of Cali­fornia, San Francisco, and her coau­thors examined rates of ED utilization in California from 2005 to 2010 and broke down the data by in­surance status (JAMA. 2013;310[11]:1181-1183). They looked at adult patients younger than 65 years, because these patients "have experienced the great­est changes in insurance coverage in recent years, and are likely to see the biggest shifts as a result of health care reform."

The investigators based their retro­spective analysis on the California Of­fice of Statewide Health Planning and Development’s Emergency Dis­charge Data and Patient Discharge Data. The study grouped patients by insurance status: Medicaid, private, uninsured or self-pay, or other (work­ers compensation, CHAMPUS/TRI­CARE, Title V, and Veterans Affairs, and similar coverage).

Overall, ED visits jumped from 5.4 million to 6.1 million over the 5-year period—a 13% increase. While visits for patients with private insurance barely increased, with a 5-year differ­ence of just 1%, visits by Medicaid patients increased by 36%, and vis­its by uninsured patients rose 25%. Visits by patients with coverage in the "other" category decreased by more than 10%, the authors noted.

Medicaid patients also maintained the highest rate of visits such as hy­pertension, which are potentially pre­ventable with primary care. Among Medicaid recipients, the average year­ly rate of ED visits for these prob­lems was 55 per 1,000, compared with 11 per 1,000 for those with pri­vate insurance and nearly 17 per 1,000 for those who were uninsured.These visits showed the same kinds of coverage-dependent increases over the study period: a nearly 7% hike among Medicaid beneficiaries and about 6% among the uninsured, but a decline of nearly 1% among privately insured pa­tients.

Neither Dr Hsia nor her coauthors reported any financial disclosures.

[email protected]

Bicycle helmet use remains low

BY SHARON WORCESTER

At the AAP National Conference

ORLANDO—About 11% of more than 1,200 children involved in bicycle-related accidents in Los Angeles County were wearing a helmet at the time of the accident. Los Angeles County mandates bicycle helmet use.

Of the 1,248 children from Los Angeles County who were included in the retrospective study of all injuries related to pediatric bicycle accidents between 2006 and 2011, 85% were boys. The lowest rates of helmet use were seen in children over age 12, and those of minority background and lower socioeconomic status. More than a third (35%) of white children wore helmets, but the rates were much lower for Asian (7%), black (6%), and Hispanic children (4%), said Dr Veronica Sullins of the Harbor-UCLA Medical Center in Torrance, Calif. Helmets were worn by 15% of children with private insurance, compared with nearly 8% of those with public insurance, Dr Sullins noted.

Emergency surgery was required in 6% of the children, and only 34% returned to their preinjury status. Nine patients died as a result of their injuries; eight of those were not wearing a helmet, Dr Sullins reported at the annual meeting of the American Academy of Pediatrics.

More than 150,000 emergency department visits each year are due to bicycle-related head injuries.

Helmet use has been shown to reduce bicycle-related head injuries by 80%; yet the Centers for Disease Control and Prevention reports that only 15% of adults and 19% of children wear helmets most or all of the time when riding a bicycle. An estimated 33 million children ride bicycles—for a total of 10 billion hours —each year, and nearly 400 children die as a result of bicycle crashes. I

Dr Sullins reported having no relevant financial disclosures.

Choosing Wisely: ACEP issues 5 things to avoid in the ED

By M. ALEXANDER OTTO

At the 2013 ACEP Acientific Assembly

Avoiding CT scans of emergency department patients who have minor head injuries and are at low risk based on validated decision rules was one of five practices recommended by The American College of Emergency Physicians as part of the "Choosing Wisely" campaign.

The mission of "Choosing Wisely" - a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation - is to promote conversations among physicians and patients about using appropriate tests and treatments and avoiding care when harm may outweigh benefit.

Since launching in April 2012, more than 80 national, regional and state medical specialty societies and consumer groups have become "Choosing Wisely" partners. ACEP officially joined the campaign in February of this year. ACEP developed its five recommendations through a multi-step process that included input from members, its board of directors, and an expert panel.

The other four treatments and procedures chosen by ACEP and announced at their annual meeting include:

• Avoid placing indwelling urinary catheters in the ED for either urine output monitoring in stable patients who can urinate on their own, or for patient or staff convenience.

• Do not delay available palliative and hospice care services in ED patients who are likely to benefit, such as those who have chronic or incurable diseases. Early referral can improve both quality and quantity of life.

• Avoid antibiotics and wound cultures in ED patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up. Opening and draining the abscess is the appropriate treatment; antibiotics offer no benefit.

• Avoid instituting IV fluids before doing a trial of oral hydration in uncomplicated emergency department cases of mild to moderate dehydration of children. To avoid pain and potential complications, it’s preferable to give these fluids by mouth. I

[email protected]

"One and done" vancomycin dosing disparaged

By M. ALEXANDER OTTO

At the 2013 ACEP Acientific Assembly

SEATTLE—One-and-done vancomycin dosing in the emergency department was associated with a high rate of ED returns for the same infection within 3 months, based on a single-center, retrospective study.

From Dec. 2008 to June 2010, 526 ED patients got vancomycin, mostly for cellulitis and abscesses, at the Barnes-Jewish Hospital ED in St. Louis, Mo., an academic ED that annually serves almost 100,000 patients; 67.9% got one dose, 26.6% got two, and 5.5% received three doses. Weight-based doses were too low in 73%, and too high in 3.4%. Less than half of the patients were sent home on an oral antibiotic; about one-third were back in the ED within 3 months for the same infection.

"It was very common just to order a dose of vancomycin and send people home, [but] none of the guidelines" from the Infectious Diseases Society of America and other groups "support the use of vancomycin in patients who have uncomplicated infections before going home" from the ED, said lead investigator Dr Kristen Mueller, a fourth-year emergency medicine resident at Barnes-Jewish. A single dose doesn’t keep inhibitory concentrations high enough for long enough to knock out infections entirely; although sensitive strains may die off, more robust and virulent ones are left to proliferate. Patients end up colonized by more resistant bacteria.

Several emergency physicians at the meeting said that they’ve noticed vancomycin dosing problems in their EDs, as well. Vancomycin dosing problems also were reported in a study published earlier this year by researchers from Christiana Care Health System in Newark Delaware (J Emerg Med. 2013;44[5]:979-984).

Vancomycin-intermediate Staphylococcus aureus was isolated from about 170 Barnes-Jewish patients in 2009. "It’s not as common as MRSA, but it’s there. What’s more concerning is that frank vancomycin resistant S. aureus is starting to establish itself in the US," and inappropriate use of vancomycin will just fuel the problem, she said.

Concerns about nephrotoxicity may be behind the low-dosing issue, but the hospital’s EHR system might also contribute to dosing inaccuracy, Dr Mueller said. At Barnes-Jewish, "our easiest order dose is 1 gram of vancomycin; it’s a one-click order in our order set. Whereas, to order a weight-appropriate dose, you actually have to calculate it out and type in the dose you want."

In response to the findings, Dr Mueller and her colleagues are adding a skin and soft tissue order set to the EHR system, with different tabs based on infection type and sub-tabs for patient disposition. Patients discharged home or to the observation unit will only have oral antibiotic options. Only inpatients will eligible for weight-based vancomycin dosing.

In an earlier study, Dr Mueller and her colleagues found that ED doses of vancomycin are frequently continued when patients are admitted, even if they’re wrong; 71% of the 2,560 inpatients in the earlier investigation were underdosed (J Emerg Med. 2013;44[5]:910-918).

Dr Mueller had no relevant disclosures.

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Prehospital bivalirudin reduced bleeding with PCI

BY SHERRY BOSCHERT

At TCT 2013

SAN FRANCISCO – Giving bivalirudin in the ambulance to patients with ST-segment elevation MI before primary percutaneous coronary intervention significantly improved 30-day bleeding outcomes in a randomized controlled European trial in 2,218 patients, compared with giving unfractionated or low-molecular-weight heparin and optional glycoprotein IIb/IIIa inhibitors.

In Europe, anticoagulation commonly is started in the ambulance. The practice has not yet caught on in most of the United States.

Compared with the control group, the bivalirudin group had a nearly 40% decrease in a composite outcome of death or major bleeding not associated with coronary artery bypass grafting (CABG). Rates

for the primary outcome were 5% in the bivalirudin group and over 8% in the control group at 30 days,

Dr Philippe Gabriel Steg and his associates reported at the Transcatheter Cardiovascular Therapeutics annual meeting.

The rates of the main secondary outcome – a composite of death, reinfarction, or non-CABG major bleeding at 30 days – also were significantly lower in the bivalirudin group (6.7%) than in the control group (9.1%), said Dr Steg, professor of cardiology at Université Paris-Diderot and director of the coronary care unit at Hôpital Bichat, Paris.

The 30-day rate of acute stent thrombosis was nearly sixfold higher in the bivalirudin group (1.1%) than in the control group (0.2%), but that did not translate into an increased risk of infarction, which occurred in 1.7% in the bivalirudin group and 0.9% in the control group (0.9%).

The study was published online simultaneously with the presentation (N Engl J Med. October 30, 2013 [doi: 10.1056/NEJMoa1311096]).

The benefit from bivalirudin came mainly from reduced bleeding, not reduced mortality. The risk of major bleeding not associated with CABG was 2.7% in the bivalirudin group and 6.1% in the control group, a significant 57% reduction.

Rates of cardiac or noncardiac death at 30 days did not differ significantly between groups. Cardiac death occurred in 2.4% in the bivalirudin group and in 3% in the control group; noncardiac death occurred in 0.5% and 0.1%, respectively.

The EUROMAX findings were consistent across subgroups of patients, including subgroups defined by PCI access site or by the choice of P2Y12 inhibitor, Dr Steg reported at the meeting, cosponsored by the American College of Cardiology.

Dr Steg received fees from The Medicines Company, which sponsored the study and markets bivalirudin, and he reported financial associations with 16 other companies. Four of his colleagues in the study were employees of The Medicines Company, and 12 other colleagues reported financial associations with that company and/or multiple other companies. Dr Stone reported financial associations with Boston Scientific, Eli Lilly, and other companies.

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