Jeffrey A. Tabas

Electrocardiographic Criteria for Detecting Acute Myocardial Infarction in Patients With Left Bundle Branch Block: A Meta-analysis

STUDY OBJECTIVE Numerous investigators have evaluated the ECG algorithm described by Sgarbossa et al to predict acute myocardial infarction in the presence of left bundle branch block and have arrived at divergent conclusions. To clarify the utility of the Sgarbossa ECG algorithm, we perform a systematic review and meta-analysis of these trials. METHODS A structured search was applied to MEDLINE and Scopus databases, beginning with the year that the algorithm was derived (1996). Two reviewers independently screened citations, assessed for method quality, and extracted data (individual study characteristics, screening performance, and interobserver agreement) with a standardized extraction tool. We assessed qualifying studies for heterogeneity and generated summary estimates for the sensitivity, specificity, and positive and negative likelihood ratios with fixed-effect models. RESULTS We identified 11 studies with 2,100 patients that met criteria for at least 1 component of the analysis. Ten studies with 1,614 patients reported a Sgarbossa ECG algorithm score of greater than or equal to 3. These yielded a summary sensitivity of 20% (95% confidence interval [CI] 18% to 23%), specificity of 98% (95% CI 97% to 99%), a positive likelihood ratio of 7.9 (95% CI 4.5 to 13.8), and a negative likelihood ratio of 0.8 (95% CI 0.8 to 0.9). The summary diagnostic odds ratio revealed homogeneity. Seven studies with 1,213 patients reported a Sgarbossa ECG algorithm score of greater than or equal to 2. These yielded sensitivities ranging from 20% to 79% and specificities ranging from 61% to 100%. Positive likelihood ratios ranged from 0.7 to 6.6 and negative likelihood ratios ranged from 0.2 to 1.1. The summary diagnostic odds ratio revealed heterogeneity. Intra- and interobserver agreement was substantial. Sensitivity analysis using the highest-quality studies yielded similar results. CONCLUSION A Sgarbossa ECG algorithm score of greater than or equal to 3, representing greater than or equal to 1 mm of concordant ST elevation or greater than or equal to 1 mm ST depression in leads V1 to V3, is useful for diagnosing acute myocardial infarction in patients who present with left bundle branch block on ECG. The scoring system demonstrates good to excellent overall interobserver variability. A score of 2, representing 5 mm or more of discordant ST deviation, demonstrated ineffective positive likelihood ratios. A Sgarbossa ECG algorithm score of 0 is not useful in excluding acute myocardial infarction.

Blood cultures for community-acquired pneumonia: are they worthy of two quality measures: a systematic review

BACKGROUND Obtaining blood cultures (BCs) for patients hospitalized with community-acquired-pneumonia (CAP) has been recommended by experts and used as a measure of quality of care. However, BCs are infrequently positive in these patients and their effect on clinical management has been questioned. PURPOSE We performed a systematic review of the literature to determine the impact of BCs on clinical management in CAP requiring hospitalization and thus its appropriateness as a quality measure. DATA SOURCES We searched MEDLINE, MEDLINE In-Process, and the Cochrane databases for English-language studies that reported the effect of BCs on management of adults hospitalized with CAP. We also searched the reference lists of included studies and background articles and asked experts to review our list for completeness. STUDY SELECTION Studies were chosen if they included adults admitted to the hospital with CAP, BCs were obtained at admission, and BC-directed management changes were reported. DATA EXTRACTION We abstracted study design, BC positivity, and frequency of BC-directed management changes. DATA SYNTHESIS Fifteen studies, all with observational cohort design, were identified and reviewed. Two included only patients with BCs positive for pneumococcus, yielding 13 studies for the primary analysis. BCs were true-positive in 0% to 14% of cases. They led to antibiotic narrowing in 0% to 3% of patients and to antibiotic broadening ultimately associated with a resistant organism in 0% to 1% of patients. CONCLUSIONS BCs have very limited utility in immunocompetent patients hospitalized with CAP. Pneumonia quality measures that include BCs should be reassessed.

Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients !

OBJECTIVE Guidelines recommend treating patients with a new or presumed new left bundle-branch block (LBBB) similar to those with an acute ST-segment elevation myocardial infarction. It is often unclear which emergency department (ED) patients with potentially ischemic symptoms actually have an acute myocardial infarction (AMI), even in the setting of LBBB. Our null hypothesis was that in ED patients with potential AMI, the presence of a new or presumed new LBBB would not predict an increased likelihood of AMI. METHODS This was an observational cohort study. Patients older than 30 years who presented with chest pain or other ischemic equivalent and had an electrocardiogram (ECG) to evaluate potential acute coronary syndrome (ACS) were enrolled. Data collected include demographics, history, ECG, and cardiac markers. Electrocardiograms were classified according to the standardized guidelines, including LBBB not known to be old (new or presumed new LBBB), LBBB known to be old, or no LBBB. The hospital course was followed, and 30-day follow-up was performed on all patients. Our main outcome was AMI. RESULTS There were 7937 visits (mean age, 54.3 +/- 15 years, 57% female, 68% black): 55 had new or presumed new LBBB, 136 had old LBBB, and 7746 had no LBBB. The rate of AMI was not significantly different between the 3 groups (7.3% vs 5.2% vs 6.1%; P = .75). Revascularization (7.8% vs old 5.2% vs 4.3%; P = .04) and coronary artery disease were more common in patients with new or presumed new LBBB (19.2% vs 11.9% vs 10.1%; P = .0004). CONCLUSIONS Despite guideline recommendations that patients with potential ACS and new or presumed new LBBB should be treated similar to STEMI, ED patients with a new or presumed new LBBB are not at increased risk of AMI. In fact, the presence of LBBB, whether new or old, did not predict AMI. Caution should be used in applying recommendations derived from patients with definite AMI to ED patients with potential ACS that may or may not be sustaining an AMI.

Clinician Attitudes About Commercial Support of Continuing Medical Education: Results of a Detailed Survey

BACKGROUND Pharmaceutical and medical device company funding supports up to 60% of accredited continuing medical education (CME) costs in the United States. Some have proposed measures to limit the size, scope, and potential influence of commercial support for CME activities. We sought to determine whether participants at CME activities perceive that commercial support introduces bias, whether this is affected by the amount or type of support, and whether they would be willing to accept higher fees or fewer amenities to decrease the need for such funding. METHODS We delivered a structured questionnaire to 1347 participants at a series of 5 live CME activities about the impact of commercial support on bias and their willingness to pay additional amounts to eliminate the need for commercial support. RESULTS Of the 770 respondents (a 57% response rate), most (88%) believed that commercial support introduces bias, with greater amounts of support introducing greater risk of bias. Only 15%, however, supported elimination of commercial support from CME activities, and less than half (42%) were willing to pay increased registration fees to decrease or eliminate commercial support. Participants who perceived bias from commercial support more frequently agreed to increase registration fees to decrease such support (2- to 3-fold odds ratio). Participants greatly underestimated the costs of ancillary activities, such as food, as well as the degree of support actually provided by commercial funding. CONCLUSION Although the medical professionals responding to this survey were concerned about bias introduced from commercial funding of CME, many were not willing to pay higher fees to offset or eliminate such funding sources.

Do Medications Affect Vital Signs in the Prehospital Treatment of Acute Decompensated Heart Failure

Introduction. Prehospital treatment of patients with acute decompensated heart failure (ADHF) has been shown to decrease mortality andmorbidity. Vital sign changes have been proposed as clinical endpoints in the evaluation of prehospital treatment for this condition. Objective. To examine the effect of prehospital treatments on vital signs among patients with ADHF. Methods. Records of an urban emergency medical services system from September 1, 2002, through September 1, 2003, were queried for patients who had a paramedic impression of shortness of breath or respiratory distress andhad received nitroglycerin and/or furosemide. Demographics, initial andrepeat vital signs (blood pressure, heart rate, respiratory rate, andoxygen saturation), andmedications anddoses were collected. Results. Three hundred nineteen patients were included; the average age was 77 (±12) years and47% were male. Treatments administered to these patients included nitroglycerin, 296 (93%); furosemide, 194 (61%); albuterol, 189 (59%); aspirin, 57 (18%); morphine, 20 (6%); andprehospital intubation, 15 (5%). Patients were initially hypertensive [mean ± standard deviation of systolic blood pressure (SBP) was 167 ±37 mm Hg], tachycardic (heart rate 106 ± 24 beats/min), tachypneic (respiratory rate 33 ± 7 breaths/min), andhypoxic (pulse oximetry 88% ± 9.5%). After treatment, mean changes included decreases (95% confidence interval) in (SBP), −10.6 mm Hg (−14.1 to −7.1), heart rate, −2.3 beats/min (−4.0 to −0.7), andrespiratory rate, −3.0 (−3.6 to −2.3), andan increase in oxygen saturation, +8.2 (7.1 to 9.3). Changes in blood pressure andoxygen saturation after treatment correlated with initial values. There was no independent association of either nitroglycerin, furosemide, albuterol, or morphine with improvement in vital signs. Conclusion. Prehospital patients with ADHF are a heterogeneous group of patients with significant variability in vital signs. The change in systolic blood pressure or oxygen saturation after treatment depends greatly on the patients starting point. There was no association of either nitroglycerin or other medications with the improvement in vital signs.

Placement of a Femoral Venous Catheter

A femoral venous catheter may be necessary when peripheral access to the circulatory system is compromised and no other sites for placing a central catheter are available. This video demonstrates the insertion of a femoral venous catheter and explains the indications and potential complications.

Dexamethasone in adults with bacterial meningitis [2] (multiple letters)

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A Patient With a Paced Rhythm Presenting With Chest Pain and Hypotension

An86-year-oldwomanarrived intheemergencydepartmentcom-plainingof1hourofchestpain.Shehadahistoryofmyocardialin-farction(MI),atrialfibrillation,placementofadual-chamberpace-maker,stroke,gout,andhypertension.Onarrival,herbloodpressurewas88/68mmHg,heartratewas75beats/minandirregular,respirationswere22/min,andbloodoxy-gen saturation was 97% with 2 L/min supplemental oxygen. Shelookeduncomfortableandhadnoappreciablejugularvenousdis-tention,noabnormalheartsounds,clearlungfields,tracelowerex-tremityedema,andweakradialpulses.Thebloodlactatelevelwas4.0mg/dL(referencevalue,<2.3mg/dL)(toconverttomillimolesper liter, multiply by 0.111). A chest radiograph was normal exceptforpacemakerleadsintheexpectedpositionsandanenlargedcar-diacsilhouette.Anelectrocardiogram(ECG)wasobtained(Figure1).Question: Should this patient be taken for emergent cardiaccatheterizationformanagementofsuspectedacuteMI?

The effect of diabetes on the diagnostic and prognostic performance of mid-region pro-atrial natriuretic peptide and mid-region pro-adrenomedullin in patients with acute dyspnea

Serum mid-regional pro-atrial natriuretic peptide (MR-proANP) and pro-adrenomedullin (MR-proADM) are novel biomarkers for acute heart failure (AHF). Like other AFH biomarkers, the performance of these tests are affected by the presence of clinical variables such as renal failure and obesity. In a substudy of the Biomarkers from Acute Heart Failure Study, we show that diabetes did not influence the performance of these markers with regards to AHF diagnosis or 90-day all cause death. However, in patients without AHF, increased MR-proADM alone was associated with the presence of diabetes.

Commercial funding of accredited continuing medical education

Is decreasing but more needs to happen