Malkeet Gupta

Is the use of pan-computed tomography for blunt trauma justified? A prospective evaluation.

OBJECTIVE Many trauma centers use the pan-computed tomography (CT) scan (head, neck, chest, and abdomen/pelvis) for the evaluation of blunt trauma. This prospective observational study was undertaken to determine whether a more selective approach could be justified. METHODS We evaluated injuries in blunt trauma victims receiving a pan-CT scan at a level I trauma center. The primary outcome was injury needing immediate intervention. Secondary outcome was any injury. The perceived need for each scan was independently recorded by the emergency medicine and trauma surgery service before patients went to CT. A scan was unsupported if at least one of the physicians deemed it unnecessary. RESULTS Between July, 1, 2007, and December, 28, 2007, 284 blunt trauma patients (average Injury Severity Score = 11) underwent a pan-CT after the survey form was completed. A total of 311 CT scans were judged to be unnecessary in 143 patients (27%), including scans of the head (62), neck (50), chest (116), and abdomen/pelvis (83). Of the 284 patients, 48 (17%) had injuries on 52 unsupported CT scans. An immediate intervention was required in 2 of the 48 patients (4%). Injuries that would have been missed included 5 of 62 unsupported head scans (8%), 2 of 50 neck scans (4%), 33 of 116 chest scans (28%), and 12 of 83 abdominal scans (14%). These missed injuries represent 5 of the 61 patients with closed head injuries (8%) in the series, 2 of the 23 with C-spine injuries (9%), 33 of the 112 with chest injuries (29%), and 12 of the 86 with abdominal injuries (14%). In 19 patients, none of the four CT scans was supported; nine of these had an injury identified, and six were admitted to the hospital (1 to the intensive care unit). Injuries that would have been missed included intraventricular and intracerebral hemorrhage (4), subarachnoid hemorrhage (2), cerebral contusion (1), C1 fracture (1), spinous and transverse process fractures (3), vertebral fracture (6), lung lacerations (1), lung contusions (14), small pneumothoraces (7), grade II-III liver and splenic lacerations (6), and perinephric or mesenteric hematomas (2). CONCLUSIONS In this small sample, physicians were willing to omit 27% of scans. If this was done, two injuries requiring immediate actions would have been missed initially, and other potentially important injuries would have been missed in 17% of patients.

Selective Use of Computed Tomography Compared With Routine Whole Body Imaging in Patients With Blunt Trauma

STUDY OBJECTIVE Routine pan-computed tomography (CT, including of the head, neck, chest, abdomen/pelvis) has been advocated for evaluation of patients with blunt trauma based on the belief that early detection of clinically occult injuries will improve outcomes. We sought to determine whether selective imaging could decrease scan use without missing clinically important injuries. METHODS This was a prospective observational study of 701 patients with blunt trauma at an academic trauma center. Before scanning, the most senior emergency physician and trauma surgeon independently indicated which components of pan-CT were necessary. We calculated the proportion of scans deemed unnecessary that: (a) were abnormal and resulted in a pre-defined critical action or (b) were abnormal. RESULTS Pan-CT was performed in 600 of the patients; the remaining 101 underwent limited scanning. One or both physicians indicated a willingness to omit 35% of the individual scans. An abnormality was present in 18% of scans, including 22% of desired scans and 10% of undesired scans. Among the 95 patients who had one of the 102 undesired scans with abnormal results, 3 underwent a predefined critical action. There is disagreement among the authors about the clinical significance of the abnormalities found on the 99 undesired scans that did not lead to a critical action. CONCLUSION Selective scanning could reduce the number of scans, missing some injuries but few critical ones. The clinical importance of injuries missed on undesired scans was subject to individual interpretation, which varied substantially among authors. This difference of opinion serves as a microcosm of the larger debate on appropriate use of expensive medical technologies.

Conflict of Interest Disclosure Policies and Practices in Peer‐reviewed Biomedical Journals

OBJECTIVE: We undertook this investigation to characterize conflict of interest (COI) policies of biomedical journals with respect to authors, peer-reviewers, and editors, and to ascertain what information about COI disclosures is publicly available. METHODS: We performed a cross-sectional survey of a convenience sample of 135 editors of peer-reviewed biomedical journals that publish original research. We chose an international selection of general and specialty medical journals that publish in English. Selection was based on journal impact factor, and the recommendations of experts in the field. We developed and pilot tested a 3-part web-based survey. The survey included questions about the presence of specific policies for authors, peer-reviewers, and editors, specific restrictions on authors, peer-reviewers, and editors based on COI, and the public availability of these disclosures. Editors were contacted a minimum of 3 times. RESULTS: The response rate for the survey was 91 (67%) of 135, and 85 (93%) of 91 journals reported having an author COI policy. Ten (11%) journals reported that they restrict author submissions based on COI (e.g., drug company authors’ papers on their products are not accepted). While 77% report collecting COI information on all author submissions, only 57% publish all author disclosures. A minority of journals report having a specific policy on peer-reviewer 46% (42/91) or editor COI 40% (36/91); among these, 25% and 31% of journals state that they require recusal of peer-reviewers and editors if they report a COI. Only 3% of respondents publish COI disclosures of peer-reviewers, and 12% publish editor COI disclosures, while 11% and 24%, respectively, reported that this information is available upon request. CONCLUSION: Many more journals have a policy regarding COI for authors than they do for peer-reviewers or editors. Even author COI policies are variable, depending on the type of manuscript submitted. The COI information that is collected by journals is often not published; the extent to which such “secret disclosure” may impact the integrity of the journal or the published work is not known.

Injury Severity Score Inflation Resulting From Pan–Computed Tomography in Patients With Blunt Trauma

STUDY OBJECTIVE All articles that demonstrate a mortality benefit from liberal pan-computed tomography (CT) use in patients with blunt trauma have relied on Injury Severity Score (ISS) to control for morbidity. This mortality benefit may be artifact, the result of an increased use of a sensitive diagnostic modality rather than a true benefit. We quantify the magnitude of ISS inflation in patients with blunt trauma who are undergoing routine pan-CT compared with patients who receive more selective scanning. METHODS This study re-analyzes data collected from a previous study of pan-CT use in patients with blunt trauma in which surveyed emergency physicians prospectively indicated which portion of a pan-CT they wished to obtain. The trauma surgeons who jointly managed all patients in this study ultimately decided which CTs to obtain. We recalculated the ISS excluding injuries found on the undesired CT scans that did not lead to a predefined set of critical actions and compared original and recalculated ISS. RESULTS There were 701 study subjects who received a total of 2,615 scans. Of these, there were 992 undesired scans. Ninety-nine of the obtained undesired scans, performed in 92 patients, had noncritical abnormalities. The original ISS for these 92 patients was 10 (IQR 5, 18); the recalculated ISS was 5 (interquartile range 1, 10), a 50% decrease. CONCLUSION Although the median ISS for our study was lower than that of previous studies claiming a mortality benefit, ISS inflation appears to be a real phenomenon and may confound studies that use ISS to control for morbidity.

Every Peddler Praises His Own Needle: Have Clinical Rules in the Diagnosis of Subarachnoid Hemorrhage Supplanted Lumbar Punctures Yet?: Answers to the July 2013 Journal Club Questions

Editor’s Note: You are reading the 34th installment of Annals of Emergency Medicine Journal Club. This Journal Club refers to the Mark et al article published in the July 2013 edition. Information about Journal Club can be found at http://www.annemergmed. com/content/journalclub. Readers should recognize that these are suggested answers. We hope they are accurate; we know that they are not comprehensive. There are many other points that could be made about these questions or about the article in general. Questions are rated “novice,” ( ) “intermediate,” ( ) and “advanced ( ) so that individuals planning a journal club can assign the right question to the right student. The “novice” rating does not imply that a novice should be able to spontaneously answer the question. “Novice” means we expect that someone with little background should be able to do a bit of reading, formulate an answer, and teach the material to others. Intermediate and advanced questions also will likely require some reading and research, and that reading will be sufficiently difficult that some background in clinical epidemiology will be helpful in understanding the reading and concepts. We are interested in receiving feedback about this feature. Please e-mail journalclub@ acep.org with your comments.

Every Peddler Praises His Own Needle: Have Clinical Rules in the Diagnosis of Subarachnoid Hemorrhage Supplanted Lumbar Punctures Yet?

Editor’s Note: You are reading the 34th installment of Annals of Emergency Medicine Journal Club. This Journal Club refers to the Mark et al article published in the July 2013 edition. This bimonthly feature seeks to improve the critical appraisal skills of emergency physicians and other interested readers through a guided critique of actual Annals of Emergency Medicine articles. Each Journal Club will pose questions that encourage readers—be they clinicians, academics, residents, or medical students—to critically appraise the literature. During a 2to 3-year cycle, we plan to ask questions that cover the main topics in research methodology and critical appraisal of the literature. To do this, we will select articles that use a variety of study designs and analytic techniques. These may or may not be the most clinically important articles in a specific issue, but they are articles that serve the mission of covering the clinical epidemiology curriculum. Journal Club entries are published in 2 phases. In the first phase, a list of questions about the article is published in the issue in which the article appears. Questions are rated “novice,” ( ) “intermediate,” ( ), and “advanced” ( ) so that individuals planning a journal club can assign the right question to the right student. The answers to this journal club will be published in the December 2013 issue. US residency directors will have immediate access to the answers through the Council of Emergency Medicine Residency Directors Share Point Web site. International residency directors can gain access to the questions by going to http://www. emergencymedicine.ucla.edu/annalsjc/ and following the directions. Thus, if a program conducts its journal club within 5 months of the publication of the questions, no one will have access to the published answers except the residency director. The purpose of delaying the publication of the answers is to promote discussion and critical review of the literature by residents and medical students and discourage regurgitation of the published answers. It is our hope that the Journal Club will broaden Annals of Emergency Medicine’s appeal to residents and medical students. We are interested in receiving feedback about this feature. Please e-mail journalclub@acep.org with your comments.

Symptomatic Pneumorrhachis After an Epidural Blood Patch

BACKGROUND Pneumorrhachis (PR), the presence of air within the spinal canal, is a rare, radiologic epiphenomenon arising from traumatic, nontraumatic, and iatrogenic causes. Often asymptomatic, PR is usually managed conservatively. However, PR can be associated with underlying serious pathology and can become symptomatic, requiring more aggressive diagnostic and treatment modalities from the treating physician. Although well known in the anesthesia literature, this case report is the first in the emergency medicine literature to describe iatrogenic, symptomatic PR presenting in the emergency department (ED). CASE REPORT A 34-year-old woman presented to the ED with a postural puncture headache after epidural anesthesia for a vaginal delivery. An epidural blood patch was administered, after which the patient acutely developed cervical radicular pain. Computed tomography angiography of the head and neck revealed epidural PR. Conservative treatment with analgesia, intravenous fluids, and bed rest was administered. Her pain improved significantly, and at 5-month follow-up, she remained symptom-free. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: PR is a rare and usually benign disease, especially in the setting of an iatrogenic cause such as lumbar puncture. However, in traumatic settings, PR in the intradural space should alert the emergency physician to search for underlying serious pathology if it has not already been found. Finally, PR can become symptomatic, and treatment will depend on the severity of symptoms.