Vomiting, Pyloric Mass, and Point-of-Care Ultrasound: Diagnostic Test Accuracy for Hypertrophic Pyloric Stenosis-A Meta-Analysis

BACKGROUND

Hypertrophic pyloric stenosis is a common cause of nonbilious vomiting in infants younger than 6 months. Its history, physical examination, and point-of-care ultrasound (POCUS) have not been compared for their diagnostic test accuracy.

OBJECTIVE

The aim of this systematic review was to quantify and compare the diagnostic test accuracy of a history of vomiting, a pyloric mass on palpation, and POCUS.

METHODS

We performed three searches of the literature from 1977 to March 2022. We evaluated bias using the QUADAS-2 (Quality Assessment Tool for Diagnostic Accuracy-2) tool. We performed a bivariate analysis.

RESULTS

From 5369 citations, we identified 14 studies meeting our inclusion criteria. We quantified three diagnostic elements: POCUS, a pyloric mass on palpation, and vomiting. We identified five studies that analyzed POCUS, which included 329 patients. POCUS had a sensitivity of 97.7% (95% confidence interval (CI) 93.1-99.3%) and a specificity of 94.1% (95% CI 88.7-97.1%) for detecting pyloric stenosis. We identified six studies that analyzed the presence of a pyloric mass, which included 628 patients. The palpation of a pyloric mass had a sensitivity of 73.5% (95% CI 62.6-82.1%) and a specificity of 97.5% (95% CI 93.8-99.0%). We identified four studies that analyzed vomiting, which included 355 patients. Vomiting had a sensitivity of 91.3% (95% CI 82.1-96.0) and a specificity of 60.8% (95% CI 8.5-96.3). Both POCUS and palpation of a pyloric mass had a high positive likelihood ratio (LR+: 17 and 33, respectively). The LR+ for vomiting was 5.0.

CONCLUSIONS

Both POCUS and palpable mass had high specificity and positive LR, whereas vomiting provided the lowest diagnostic test measures.

The prescription drug monitoring program in a multifactorial approach to the opioid crisis: PDMP data, Pennsylvania, 2016-2020

BACKGROUND

Prescription opioids remain an important contributor to the United States opioid crisis and to the development of opioid use disorder for opioid-naïve individuals. Recent legislative actions, such as the implementation of state prescription drug monitoring programs (PDMPs), aim to reduce opioid morbidity and mortality through enhanced tracking and reporting of prescription data. The primary objective of our study was to describe the opioid prescribing trends in the state of Pennsylvania (PA) as recorded by the PA PDMP following legislative changes in reporting guidelines, and discuss the PDMP's role in a multifactorial approach to opioid harm reduction.

METHODS

State-level opioid prescription data summaries recorded by the PA PDMP for each calendar quarter from August 2016 through March 2020 were collected from the PA Department of Health. Data for oxycodone, hydrocodone, and morphine were analyzed by quarter for total prescription numbers and refills. Prescription lengths, pill quantities, and average morphine milliequivalents (MMEs) were analyzed by quarter for all 14 opioid prescription variants recorded by the PA PDMP. Linear regression was conducted for each group of variables to identify significant differences in prescribing trends.

RESULTS

For total prescriptions dispensed, the number of oxycodone, hydrocodone, and morphine prescriptions decreased by 34.4, 44.6, and 22.3% respectively (p < 0.0001). Refills fluctuated less consistently with general peaks in Q3 of 2017 and Q3 of 2018 (p = 0.2878). The rate of prescribing for all opioid prescription lengths decreased, ranging in frequency from 22 to 30 days (47.5% of prescriptions) to 31+ days of opioids (0.8% of prescriptions) (p < 0.0001). Similarly, decreased prescribing was observed for all prescription amounts, ranging in frequency from 22 to 60 pills (36.6% of prescriptions) to 60-90 pills (14.2% of prescriptions) (p < 0.0001). Overall, the average MME per opioid prescription decreased by 18.9%.

CONCLUSIONS

Per the PA PDMP database, opioid prescribing has decreased significantly in PA from 2016 to 2020. The PDMP database is an important tool for tracking opioid prescribing trends in PA, and PDMPs structured similarly in other states may enhance our ability to understand and influence the trajectory of the U.S. opioid crisis. Further research is needed to determine optimal PDMP policies and practices nationwide.

The prevalence for the risk of serious infection in hypothermic infants ≤ 60 days: A systematic review

BACKGROUND

Temperature abnormalities in infants may be a sign of a serious infection (SI) and there is literature regarding the workup of the febrile infant to help guide management. The prevalence of SIs in hypothermic infants and the development of established guidelines for this population has not been established. Our primary objective was to determine the prevalence of SI in hypothermic infants who are 60 days old or younger presenting to the emergency department (ED). In addition, we calculated the prevalence of SI by organ system and identified its microorganism.

METHODS

We performed a systematic review by searching the literature in Medline, Embase, Web of Science, and CINAHL. We limited our search to infants ≤ 60 days with a rectal temperature <36.5°C who presented to the ED. We defined SI as bacteremia, urinary tract infection (UTI), meningitis, herpes simplex virus infections, or pneumonia. We calculated the prevalence of SI. Quality of studies and bias was assessed using QUADAS-2. Our study was registered with PROSPERO, 2020 CRD42020153477.

RESULTS

We identified 1242 articles from our initial search in December 2019 followed by a second search in February 2021 to capture any recent publications. We identified four studies meeting our inclusion criteria. We estimated the prevalence of SI as 4.86% (95% confidence Interval [CI] 1.97-8.82) for infants ≤ 60 days old. In a subgroup analysis of infants ≤ 28 days (n = 16/374), we estimated the prevalence of SI as 5.15 (95% CI 0.95-12.0). The most common source for SI was UTI, with a prevalence of 2.16% (95% CI 1.18-3.60).

CONCLUSION

The overall prevalence of SI was 4.86% in hypothermic young infants ≤ 60 days old presenting to the ED. Infants ≤ 28 days had a slightly higher prevalence of 5.15%. The most common source for serious bacterial infection was UTI.

Methadone Prescribing for Pain Management in Pennsylvania per the Prescription Drug Monitoring Program, 2016–2020

Introduction

Methadone is a schedule II opioid traditionally used to treat opioid use disorder (OUD) and chronic pain. However, following the identification of its contribution to opioid overdose deaths, methadone has become less commonly used for chronic pain indications. In Pennsylvania (PA), prescribers are required to report methadone prescriptions written for pain indications to the prescription drug monitoring program (PDMP), which is an electronic database that enhances the tracking and reporting of prescription data. The primary objective of our study was to describe the geographic methadone prescribing trends recorded by the PA PDMP in order to report methadone’s current use for only pain indications. 

Methods

State- and county-level methadone prescription data summaries recorded by the PA PDMP for each calendar quarter from August 2016 through March 2020 were collected from the PA Department of Health. The metric reported per quarter consisted of the total number of methadone prescriptions dispensed for pain indications unrelated to OUD.

Results

A total of 341,949 methadone prescriptions were dispensed in PA from the third quarter (Q3) of 2016 to the first quarter (Q1) of 2020 (range = 1106) with an overall 38.7% decrease in methadone prescriptions and a change in the rate of 85.97 per 100,000 population. The counties with the five highest prescription totals were Philadelphia, Allegheny, Bucks, Montgomery, and York (range = 46,969), and the counties with the five highest rates per 100,000 were Montour, Green, Columbia, Northumberland, and Forest (range = 964).

Conclusions

Methadone prescribing for pain management unrelated to OUD has decreased in PA from 2016 to 2020 per the PA PDMP. However, it is still prescribed in appreciable amounts for pain management. Further studies are required to understand the prescribing rationale and potential areas for harm reduction interventions.

US local public health department spending between 2008 and 2016 did not increase for communities in need

BACKGROUND

Greater US local public health department (LPHD) spending has been associated with decreases in population-wide mortality. We examined the association between changes in LPHD spending between 2008 and 2016 and county-level sociodemographic indicators of public health need.

METHODS

Multivariable linear regression was used to estimate the association between changes in county-level per-capita LPHD spending and 2008 sociodemographic indicators of interest: percent of population that was over 65 years old, Black, Hispanic, in poverty, unemployed, and uninsured. A second model assessed the relationship between changes in LPHD spending and sociodemographic shifts between 2008 and 2016.

RESULTS

LPHD spending increases were associated with higher percentage points of 2008 adults over 65 years of age (+$0.53 per higher percentage point; 95% CI: +$0.01 to +$1.06) and unemployment (-$1.31; 95% CI: -$2.34 to -$0.27). Spending did not increase for communities with a higher proportion of people who identified as Black or Hispanic, or those with a greater proportion of people in poverty or uninsured, using either baseline or sociodemographic shifts between 2008 and 2016.

CONCLUSION

Future LPHD funding decisions should consider increasing investments in counties serving disadvantaged communities to counteract the social, political, and structural barriers which have historically prevented these communities from achieving better health.

Evidence-Based Diagnostic Test Accuracy of History, Physical Examination, and Imaging for Intussusception: A Systematic Review and Meta-analysis

INTRODUCTION

Intussusception is the most common cause of pediatric small bowel obstruction. Timely and accurate diagnosis may reduce the risk of bowel ischemia. We quantified the diagnostic test accuracy of history, physical examination, abdominal radiographs, and point-of-care ultrasound.

METHOD

We conducted a systematic review for diagnostic test accuracy of history, physical examination, and imaging concerning for intussusception. Our literature search was completed in June 2019. Databases included Medline via Ovid, Embase, Scopus, and Wiley Cochrane Library. We conducted a second review of the literature up to June 2019 for any additional studies. Inclusion criteria were younger than 18 years and presenting to the emergency department for abdominal complaints, consistent with intussusception. We performed data analysis using mada, version 0.5.8. We conducted univariate and bivariate analysis (random effects model) with DerSimonian-Laird and Reitsma model, respectively. QUADAS-2 was used for bias assessment.

RESULTS

The literature search identified 2639 articles, of which 13 primary studies met our inclusion criteria. Abdominal pain, vomiting, and bloody stools had positive likelihood ratios LR(+) between 1 and 2, whereas the negative likelihood ratio, LR(-), ranged between 0.4 and 0.8. Abnormal abdominal radiograph had LR(+) of 2.5 and LR(-) of 0.20, whereas its diagnostic odds ratio was 13. Lastly, point-of-care ultrasound had LR(+) of 19.7 and LR(-) of 0.10. The diagnostic odds ratio was 213.

CONCLUSIONS

History and physical examination had low diagnostic test accuracy. Abdominal radiographs had low diagnostic test accuracy, despite moderate discriminatory characteristics. Point-of-care ultrasound had the highest diagnostic test accuracy to rule in or rule out intussusception.

Topical mydriatics as adjunctive therapy for traumatic iridocyclitis

BACKGROUND

Traumatic eye complaints account for 3% of all hospital emergency department visits. The most common traumatic injury to the eye is blunt trauma, which accounts for 30% of these visits. Blunt trauma frequently leads to traumatic iridocyclitis, thus causing anterior uveitis. Iridocyclitis frequently causes tearing, photophobia, eye pain, and vision loss. These symptoms are a result of the inflammatory processes and ciliary spasms to iris muscles and sphincter. The inflammatory process is usually managed with topical corticosteroids, while the ciliary spasm is blunted by dilating the pupils with topical mydriatic agents, an adjuvant therapy. However, the effectiveness of mydriatic agents has not been quantified in terms of reduction of ocular pain and visual acuity loss.

OBJECTIVES

To evaluate the effectiveness and safety of topical mydriatics as adjunctive therapy to topical corticosteroids for traumatic iridocyclitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) which contains the Cochrane Eyes and Vision Trials Register (2019, issue 6); Ovid MEDLINE; Embase.com; Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus; PubMed; ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 12 June 2019.

SELECTION CRITERIA

We planned to include randomized controlled trials (RCTs) that compared topical mydriatic agents in conjunction with topical corticosteroid therapy versus topical corticosteroids alone, in participants with traumatic iridocyclitis.

DATA COLLECTION AND ANALYSIS

Two review authors (JH, MK) independently screened titles and abstracts, then full-text reports, against eligibility criteria. We planned to have two authors independently extract data from included studies. We resolved differences in opinion by discussion.

MAIN RESULTS

There were no eligible RCTs that compared the interventions of interest in people with traumatic iridocyclitis.

AUTHORS' CONCLUSIONS

We did not find any evidence from RCTs about the efficacy of topical mydriatic agents as an adjunctive therapy with topical corticosteroids for treating traumatic iridocyclitis. In the absence of these types of studies, we cannot draw any firm conclusions. Controlled trials that compare the combined use of topical mydriatic agents and corticosteroid drops against standard corticosteroid drops alone, in people with traumatic iridocyclitis are required. These may provide evidence about the efficacy and risk of topical mydriatic drops as adjuvant therapy for traumatic iridocyclitis.

Overdose Awareness and Reversal Trainings at Philadelphia Public Libraries

PURPOSE

To evaluate an overdose response training program in public libraries.

DESIGN

Mixed methods evaluation including pre- and post-intervention questionnaires and debriefing interviews.

SETTING

Ten Philadelphia public libraries.

SAMPLE

Overdose response training participants (library staff and community members).

INTERVENTION

Public, hour-long overdose response trainings run by the Philadelphia Department of Public Health, the Free Library of Philadelphia, and the University of Pennsylvania between March and December 2018.

MEASURES

Questionnaires assessed motivation for attending trainings, overdose response readiness, and intention to acquire and carry naloxone. Debriefing interviews elicited training feedback.

ANALYSIS

We assessed changes in overdose response readiness and intention to carry naloxone and performed thematic analysis on interview data.

RESULTS

At 29 trainings, 254 people attended, of whom 203 (80%) completed questionnaires and 23 were interviewed. 30% of participants had witnessed an overdose, but only 3% carried naloxone at baseline. Following training, overdose response readiness and intention to acquire/carry naloxone improved significantly (P < .01). Interviewees nonetheless noted that they experienced barriers to naloxone acquisition, including cost, stigma, and concern regarding future insurability. Trainings subsequently included naloxone distribution. Interviewees reported that public libraries were welcoming, nonstigmatizing venues.

CONCLUSION

In Philadelphia, library-based overdose response trainings were well-attended and reached a population with prior overdose encounters. Similar trainings could be deployed as a scalable overdose prevention strategy in the nation's 16 568 public libraries.

2018 Academic Emergency Medicine Consensus Conference: Advancing Pediatric Emergency Medicine Education Through Research and Scholarship

To achieve high-quality emergency care for pediatric patients nationwide, it is necessary to define the key elements for pediatric emergency medicine (PEM) education and scholarship that would: 1) close the gaps in fundamental PEM education and 2) promote systems and standards that assure an ongoing communication of best practices between tertiary pediatric institutions, general (nonchildren's) hospital emergency departments, and urgent care centers. A working group of medical educators was formed to review the literature, develop a framework for consensus discussion at the breakout session, and then translate their findings into recommendations for future research and scholarship. The breakout session consensus discussion yielded many recommendations. The group concluded that future progress depends on multicenter collaborations as a PEM education research network and a unified vision for PEM education that bridges organizations, providers, and institutions to assure the best possible outcomes for acutely ill or injured children.

Beta2-agonists for acute cough or a clinical diagnosis of acute bronchitis

BACKGROUND

The diagnosis of acute bronchitis is made on clinical grounds and a variety of clinical definitions have been used. There are no clearly effective treatments for the cough of acute bronchitis. Beta2-agonists are often prescribed, perhaps because clinicians suspect many patients also have reversible airflow restriction (as seen in asthma or chronic obstructive pulmonary disease (COPD)) contributing to the symptoms.

OBJECTIVES

To determine whether beta2-agonists improve acute bronchitis symptoms in people with no underlying pulmonary disease (such as asthma, COPD or pulmonary fibrosis).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2015, Issue 5, MEDLINE (January 1966 to May 2015), EMBASE (1974 to May 2015), Web of Science (2011 to May 2015) and LILACS (1982 to May 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) which allocated people (adults, or children over two years of age) with acute bronchitis or acute cough and without known pulmonary disease to beta2-agonist versus placebo, no treatment or alternative treatment.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected outcomes and extracted data while blinded to study results. Two review authors independently assessed each trial for risk of bias. We analysed trials in children and adults separately.

MAIN RESULTS

Two trials of moderate quality in children (n = 134) with no evidence of airflow restriction did not find any benefits from oral beta2-agonists. Five trials in adults (n = 418) had mixed results but overall summary statistics did not reveal any significant benefits from oral (three trials) nor from inhaled (two trials) beta2-agonists. Three studies with low-quality evidence demonstrated no significant differences in daily cough scores, nor in the percentage of adults still coughing after seven days (control group 71%; risk ratio (RR) 0.86, 95% confidence interval (CI) 0.63 to 1.18; 220 participants). In one trial, subgroups with evidence of airflow limitation had lower symptom scores if given beta2-agonists. The trials that noted quicker resolution of cough with beta2-agonists were those with a higher proportion of people wheezing at baseline. Low-quality evidence suggests that adults given beta2-agonists were more likely to report tremor, shakiness or nervousness (RR 7.94, 95% CI 1.17 to 53.94; 211 participants; number needed to treat for an additional harmful outcome (NNTH) 2).

AUTHORS' CONCLUSIONS

There is no evidence to support the use of beta2-agonists in children with acute cough who do not have evidence of airflow restriction. There is also little evidence that the routine use of beta2-agonists is helpful for adults with acute cough. These agents may reduce symptoms, including cough, in people with evidence of airflow restriction. However, this potential benefit is not well supported by the available data and must be weighed against the adverse effects associated with their use.

Intranasal fentanyl for the management of acute pain in children

BACKGROUND

Pain is the most common symptom in the emergency setting; however, timely management of acute pain in children continues to be suboptimal. Intranasal drug delivery has emerged as an alternative method of achieving quicker drug delivery without adding to the distress of a child by inserting an intravenous cannula.

OBJECTIVES

We identified and evaluated all randomized controlled trials (RCTs) and quasi-randomized trials to assess the effects of intranasal fentanyl (INF) versus alternative analgesic interventions in children with acute pain, with respect to reduction in pain score, occurrence of adverse events, patient tolerability, use of "rescue analgesia," patient/parental satisfaction and patient mortality.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 1); MEDLINE (Ovid SP, from 1995 to January 2014); EMBASE (Ovid SP, from 1995 to January 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO Host, from 1995 to January 2014); the Latin American and Caribbean Health Science Information Database (LILACS) (BIREME, from 1995 to January 2014); Commonwealth Agricultural Bureaux (CAB) Abstracts (from 1995 to January 2014); the Institute for Scientific Information (ISI) Web of Science (from 1995 to January 2014); BIOSIS Previews (from 1995 to January 2014); the China National Knowledge Infrastructure (CNKI) (from 1995 to January 2014); International Standard Randomized Controlled Trial Number (ISRCTN) (from 1995 to January 2014); ClinicalTrials.gov (from 1995 to January 2014); and the International Clinical Trials Registry Platform (ICTRP) (to January 2014).

SELECTION CRITERIA

We included RCTs comparing INF versus any other pharmacological/non-pharmacological intervention for the treatment of children in acute pain (aged < 18 years).

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed each title and abstract for relevance. Full copies of all studies that met the inclusion criteria were retrieved for further assessment. Mean difference (MD), odds ratio (OR) and 95% confidence interval (CI) were used to measure effect sizes. Two review authors independently assessed and rated the methodological quality of each trial using the tool of The Cochrane Collaboration to assess risk of bias, as per Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Three studies (313 participants) met the inclusion criteria. One study compared INF versus intramuscular morphine (IMM); another study compared INF versus intravenous morphine (IVM); and another study compared standard concentration INF (SINF) versus high concentration INF (HINF). All three studies reported a reduction in pain score following INF administration. INF produced a greater reduction in pain score at 10 minutes post administration when compared with IMM (INF group pain score: 1/5 vs IMM group pain score: 2/5; P value 0.014). No other statistically significant differences in pain scores were reported at any other time point. When INF was compared with IVM and HINF, no statistically significant differences in pain scores were noted between treatment arms, before analgesia or at 5, 10, 20 and 30 minutes post analgesia. Specifically, when INF was compared with IVM, both agents were seen to produce a statistically significant reduction in pain score up to 20 minutes post analgesia. No further reduction in pain score was noted after this time. When SINF was compared with HINF, a statistically and clinically significant reduction in pain scores over study time was observed (median decrease for both groups 40 mm, P value 0.000). No adverse events (e.g. opiate toxicity, death) were reported in any study following INF administration. One study described better patient tolerance to INF compared with IMM, which achieved statistical significance. The other studies described reports of a "bad taste" and vomiting with INF. Overall the risk of bias in all studies was considered low.

AUTHORS' CONCLUSIONS

INF may be an effective analgesic for the treatment of patients with acute moderate to severe pain, and its administration appears to cause minimal distress to children. However, this review of published studies does not allow any definitive conclusions regarding whether INF is superior, non-inferior or equivalent to intramuscular or intravenous morphine. Limitations of this review include the following: few eligible studies for inclusion (three); no study examined the use of INF in children younger than three years of age; no study included children with pain from a "medical" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a "medical" cause.

Efficacy of 3-day versus 5-day antibiotic therapy for clinically diagnosed nonsevere pneumonia in children from developing countries

Pneumonia is the leading cause of mortality in young children in developing countries. A short course of antibiotics in the treatment of nonsevere pneumonia has been suggested as feasible and could lead to decreased costs, risk of adverse events, and development of antimicrobial resistance. This review evaluates the evidence regarding the duration of antibiotic treatment in this population. The PubMed, EMBASE, Cochrane Library, and other databases were searched. Studies were selected for inclusion if they enrolled patients in developing countries between the ages of 2 months to 18 years clinically diagnosed with nonsevere pneumonia, and compared the clinical outcomes of a short course of oral antibiotics with a long course. The outcomes of interest included failure rate, relapse rate, and safety. Four randomized controlled trials were identified, which enrolled 9235 patients cumulatively. All patients were aged between 2 to 59 months and diagnosed using World Health Organization defined criteria. All four trials showed no significant difference in relapse rates between 3-day and 5-day courses. In one study, the 3-day course was associated with higher rates of treatment failure and adverse events, with no adverse event classified as severe. Overall, short and long courses of antibiotics produce similar outcomes treating clinically diagnosed, nonsevere pneumonia in children in developing countries between the ages of 2 to 59 months. Three out of four studies in this review, representing two-thirds of the patients in aggregate, showed no significant difference in treatment failure or relapse rates between a 3-day and 5-day course of antibiotics.

The low rate of bacterial meningitis in children, ages 6 to 18 months, with simple febrile seizures

OBJECTIVES

This evidence-based review examines the risk of bacterial meningitis as diagnosed by lumbar puncture (LP) in children presenting to the emergency department (ED) with a simple febrile seizure. The study population consists of fully immunized children between ages 6 and 18 months of age with an unremarkable history and normal physical examination.

METHODS

MEDLINE, EMBASE, and Cochrane Library databases were searched for studies that enrolled children who presented with simple febrile seizure to the ED and had LP performed to rule out meningitis. The primary outcome measure was the risk of bacterial meningitis based on findings of the LP. The secondary outcome was the rate of cerebrospinal fluid (CSF) pleocytosis in children who were pretreated with antibiotics.

RESULTS

Two studies enrolling a total of 150 children met the inclusion and exclusion criteria. The overall rate of meningitis was 0% (95% confidence interval [CI] = 0.0% to 3.0%). The rate of CSF pleocytosis in children who were pretreated with antibiotics was 2.5% (95% CI = 0.0% to 14.0%).

CONCLUSIONS

The sample size of the studies included in this review is too small to draw any definitive conclusion. However, their findings suggest that that the risk of bacterial meningitis in children presenting with simple febrile seizure is very low.

Beta2-agonists for acute bronchitis

BACKGROUND

There are no clearly effective treatments for the cough of acute bronchitis. Beta2-agonists are often prescribed, perhaps because clinicians suspect many patients also have reversible airflow restriction contributing to the symptoms.

OBJECTIVES

To determine whether beta2-agonists improve acute bronchitis symptoms in patients with no underlying pulmonary disease.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2011, issue 1 which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1966 to February week 1, 2011) and EMBASE (1974 to February 2011).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which patients (adults, or children over two years of age) with acute bronchitis or acute cough and without known pulmonary disease were allocated to beta2-agonist versus placebo, no treatment or alternative treatment.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected outcomes and extracted data while blinded to study results. Two review authors independently assessed each trial for risk of bias. We analysed trials in children and adults separately.

MAIN RESULTS

Two trials in children (n = 109) with no evidence of airway obstruction did not find any benefits from oral beta2-agonists. Five trials in adults (n = 418) had mixed results but overall summary statistics did not reveal any significant benefits from oral (three trials) nor inhaled (two trials) beta2-agonists. There were no significant differences in daily cough scores nor in the percentage of adults still coughing after seven days (control group 73%; risk ratio (RR) 0.77, 95% confidence interval (CI) 0.54 to 1.09). in one trial, subgroups with evidence of airflow limitation had lower symptom scores if given beta2-agonists. The trials that noted quicker resolution of cough with beta2-agonists were those with a higher proportion of wheezing patients at baseline. Adults given beta2-agonists were more likely to report tremor, shakiness or nervousness (RR 7.94, 95% CI 1.17 to 53.94; number needed to treat to harm (NNTH) 2.3).

AUTHORS' CONCLUSIONS

There is no evidence to support the use of beta2-agonists in children with acute cough who do not have evidence of airflow obstruction. There is also little evidence that the routine use of beta2-agonists is helpful for adults with acute cough. These agents may reduce symptoms, including cough, in people with evidence of airflow obstruction. However, this potential benefit is not well-supported by the available data and must be weighed against the adverse effects associated with their use.

Blood-brain barrier permeability assessed by perfusion CT predicts symptomatic hemorrhagic transformation and malignant edema in acute ischemic stroke

BACKGROUND AND PURPOSE

SHT and ME are feared complications in patients with acute ischemic stroke. They occur >10 times more frequently in tPA-treated versus placebo-treated patients. Our goal was to evaluate the sensitivity and specificity of admission BBBP measurements derived from PCT in predicting the development of SHT and ME in patients with acute ischemic stroke.

MATERIALS AND METHODS

We retrospectively analyzed a dataset consisting of 32 consecutive patients with acute ischemic stroke with appropriate admission and follow-up imaging. We calculated admission BBBP by using delayed-acquisition PCT data and the Patlak model. Collateral flow was assessed on the admission CTA, while recanalization and reperfusion were assessed on the follow-up CTA and PCT, respectively. SHT and ME were defined according to ECASS III criteria. Clinical data were obtained from chart review. In our univariate and forward selection-based multivariate analysis for predictors of SHT and ME, we incorporated both clinical and imaging variables, including age, admission NIHSS score, admission blood glucose level, admission blood pressure, time from symptom onset to scanning, treatment type, admission PCT-defined infarct volume, admission BBBP, collateral flow, recanalization, and reperfusion. Optimal sensitivity and specificity for SHT and ME prediction were calculated by using ROC analysis.

RESULTS

In our sample of 32 patients, 3 developed SHT and 3 developed ME. Of the 3 patients with SHT, 2 received IV tPA, while 1 received IA tPA and treatment with the Merci device; of the 3 patients with ME, 2 received IV tPA, while 1 received IA tPA and treatment with the Merci device. Admission BBBP measurements above the threshold were 100% sensitive and 79% specific in predicting SHT and ME. Furthermore, all patients with SHT and ME--and only those with SHT and ME--had admission BBBP measurements above the threshold, were older than 65 years of age, and received tPA. Admission BBBP, age, and tPA were the independent predictors of SHT and ME in our forward selection-based multivariate analysis. Of these 3 variables, only BBBP measurements and age were known before making the decision of administering tPA and thus are clinically meaningful.

CONCLUSIONS

Admission BBBP, a pretreatment measurement, was 100% sensitive and 79% specific in predicting SHT and ME.

Dynamic perfusion-CT assessment of early changes in blood brain barrier permeability of acute ischaemic stroke patients

BACKGROUND AND PURPOSE

Damage to the blood brain barrier (BBB) may lead to haemorrhagic transformation after ischaemic stroke. The purpose of this study was to evaluate the effect of patient characteristics and stroke severity on admission BBB permeability (BBBP) values measured with perfusion-CT (PCT) in acute ischaemic stroke patients.

METHODS

We retrospectively identified 65 patients with proven ischaemic stroke admitted within 12 hours after symptom onset. Patients' charts were reviewed for demographic variables and vascular risk factors. The Patlak's model was applied to calculate BBBP values from the PCT data in the infarct core, penumbra and non-ischaemic tissue in the contralateral hemisphere. Mean BBBP values and their 95% confidence intervals (CI) were calculated in the different tissue types. Effects of demographic variables and risk factors on BBBP were analyzed using a multivariate, generalized estimating equations (GEE) model.

RESULTS

BBBP values in the infarct core (mean [95%CI]: 2.48 [2.16-2.85]) and penumbra (2.48 [2.21-2.79]) were significantly higher than in non-ischaemic tissue (2.12 [1.88-2.39]). Multivariate analysis demonstrated that collateral filling has effect on BBBP. Less elevated BBBP values were associated with more than 50% collateral filling.

CONCLUSIONS

BBBP values are increased in ischaemic brain tissue on the admission PCT scan of acute ischaemic stroke patients. Less abnormally elevated BBBP values were observed in patients with more than 50% collateral filling, possibly explaining why there is a relationship between more collateral filling and a lower incidence of haemorrhagic transformation.

Delay correction for the assessment of blood-brain barrier permeability using first-pass dynamic perfusion CT

SUMMARY

Hemorrhagic transformation is a serious potential complication of ischemic stroke with damage to the BBB as one of the contributing mechanisms. BBB permeability measurements extracted from PCT by using the Patlak model can provide a valuable assessment of the extent of BBB damage. Unfortunately, Patlak assumptions require extended PCT acquisition, increasing the risk of motion artifacts. A necessary correction is presented for obtaining accurate BBB permeability measurements from first-pass PCT.

The risk of intra-abdominal injuries in pediatric patients with stable blunt abdominal trauma and negative abdominal computed tomography

OBJECTIVES

This review examines the prevalence of intra-abdominal injuries (IAI) and the negative predictive value (NPV) of an abdominal computed tomography (CT) in children who present with blunt abdominal trauma.

METHODS

MEDLINE, EMBASE, and Cochrane Library databases were searched. Studies were selected if they enrolled children with blunt abdominal trauma from the emergency department (ED) with significant mechanism of injury requiring an abdominal CT. The primary outcome measure was the rate of IAI in patients with negative initial abdominal CT. The secondary outcome measure was the number of laparotomies, angiographic embolizations, or repeat abdominal CTs in those with negative initial abdominal CTs.

RESULTS

Three studies met the inclusion criteria, comprising a total of 2,596 patients. The overall rate of IAI after a negative abdominal CT was 0.19% (95% confidence interval [CI] = 0.08% to 0.44%). The overall NPV of abdominal CT was 99.8% (95% CI = 99.6% to 99.9%). There were five patients (0.19%, 95% CI = 0.08% to 0.45%) who required additional intervention despite their initial negative CTs: one therapeutic laparotomy for bowel rupture, one diagnostic laparotomy for mesenteric hematoma and serosal tear, and three repeat abdominal CTs (one splenic and two renal injuries). None of the patients in the latter group required surgery or blood transfusion.

CONCLUSIONS

The rate of IAI after blunt abdominal trauma with negative CT in children is low. Abdominal CT has a high NPV. The review shows that it might be safe to discharge a stable child home after a negative abdominal CT.

Optimal duration of acquisition for dynamic perfusion CT assessment of blood-brain barrier permeability using the Patlak model

BACKGROUND AND PURPOSE

A previous study demonstrated the need to use delayed acquisition rather than first-pass data for accurate blood-brain barrier permeability surface product (BBBP) calculation from perfusion CT (PCT) according to the Patlak model, but the optimal duration of the delayed acquisition has not been established. Our goal was to determine the optimal duration of the delayed PCT acquisition to obtain accurate BBBP measurements while minimizing potential motion artifacts and radiation dose.

MATERIALS AND METHODS

We retrospectively identified 23 consecutive patients with acute ischemic anterior circulation stroke who underwent a PCT study with delayed acquisition. The Patlak model was applied for the full delayed acquisition (90-240 seconds) and also for truncated analysis windows (90-210, 90-180, 90-150, 90-120 seconds). Linear regression of Patlak plots was performed separately for the full and truncated analysis windows, and the slope of these regression lines was used to indicate BBBP. The full and truncated analysis windows were compared in terms of the resulting BBBP values and the quality of the Patlak fitting.

RESULTS

BBBP values in the infarct and penumbra were similar for the full 90- to 240-second acquisition (95% confidence intervals for the infarct and penumbra: 1.62-2.47 and 1.75-2.41 mL x100 g(-1) x min(-1), respectively) and the 90- to 210-second analysis window (1.82-2.76 and 2.01-2.74 mL x 100 g(-1) x min(-1), respectively). BBBP values increased significantly with shorter acquisitions. The quality of the Patlak fit was excellent for the full 90- to 240-second and 90- to 210-second acquisitions, but it degraded with shorter acquisitions.

CONCLUSIONS

The duration for the delayed PCT acquisition should be at least 210 seconds, because acquisitions shorter than 210 seconds lead to significantly overestimated BBBP values.

Age- and anatomy-related values of blood-brain barrier permeability measured by perfusion-CT in non-stroke patients

BACKGROUND AND PURPOSE

The goal of this study was to determine blood-brain barrier permeability (BBBP) values extracted from perfusion-CT (PCT) using the Patlak model and possible variations related to age, gender, race, vascular risk factors and their treatment and anatomy in non-stroke patients.

MATERIALS AND METHODS

We retrospectively identified 96 non-stroke patients who underwent a PCT study using a prolonged acquisition time up to 3 minutes. Patients' charts were reviewed for demographic data, vascular risk factors and their treatment. The Patlak model was applied to calculate BBBP values in regions of interest drawn within the basal ganglia and the gray and white matter of the different cerebral lobes. Differences in BBBP values were analyzed using a multivariate analysis considering clinical variables and anatomy.

RESULTS

Mean absolute BBBP values were 1.2 ml 100 g(-1) min(-1) and relative BBBP/CBF values were 3.5%. Statistical differences between gray and white matter were not clinically relevant. BBBP values were influenced by age, history of diabetes and/or hypertension and aspirin intake.

CONCLUSION

This study reports ranges of BBBP values in non-stroke patients calculated from delayed phase PCT data using the Patlak model. These ranges will be useful to detect abnormal BBBP values when assessing patients with cerebral infarction for the risk of hemorrhagic transformation.

Dynamic perfusion CT assessment of the blood-brain barrier permeability: first pass versus delayed acquisition

BACKGROUND AND PURPOSE

The Patlak model has been applied to first-pass perfusion CT (PCT) data to extract information on blood-brain barrier permeability (BBBP) to predict hemorrhagic transformation in patients with acute stroke. However, the Patlak model was originally described for the delayed steady-state phase of contrast circulation. The goal of this study was to assess whether the first pass or the delayed phase of a contrast bolus injection better respects the assumptions of the Patlak model for the assessment of BBBP in patients with acute stroke by using PCT.

MATERIALS AND METHODS

We retrospectively identified 125 consecutive patients (29 with acute hemispheric stroke and 96 without) who underwent a PCT study by using a prolonged acquisition time up to 3 minutes. The Patlak model was applied to calculate BBBP in ischemic and nonischemic brain tissue. Linear regression of the Patlak plot was performed separately for the first pass and for the delayed phase of the contrast bolus injection. Patlak linear regression models for the first pass and the delayed phase were compared in terms of their respective square root mean squared errors (square root MSE) and correlation coefficients (R) by using generalized estimating equations with robust variance estimation.

RESULTS

BBBP values calculated from the first pass were significantly higher than those from the delayed phase, both in nonischemic brain tissue (2.81 mL x 100 g(-1) x min(-1) for the first pass versus 1.05 mL x 100 g(-1) x min(-1) for the delayed phase, P < .001) and in ischemic tissue (7.63 mL x 100 g(-1) x min(-1) for the first pass versus 1.31 mL x 100 g(-1) x min(-1) for the delayed phase, P < .001). Compared with regression models from the first pass, Patlak regression models obtained from the delayed data were of better quality, showing significantly lower square root MSE and higher R.

CONCLUSION

Only the delayed phase of PCT acquisition respects the assumptions of linearity of the Patlak model in patients with and without stroke.

Neuroprotection with herpes simplex vectors expressing virally derived anti-apoptotic agents

A large body of literature dealing with neurotoxicity has focused on trying to define the exact nature of cell death following a neurological insult. While there is some debate in the field, it has been shown that a number of neurons in a given population can respond to an acute insult stimulus by activating the apoptotic cascade. To what extent, however, these insults result in the classical manifestations of either apoptosis or necrosis, or whether a mixture of the two results, is highly controversial, in part dependent on the particular system utilized. In this paper, we investigate the role of particular apoptotic signals in cultured rat hippocampal neurons, following acute excitotoxicity, metabolic poisoning, and heat stress. In particular, we examine these effects by utilizing a modified herpes simplex viral vector to specifically deliver viral anti-apoptotic genes. We have selected a battery of viral genes (crmA, p35, gamma34.5, KsBcl-2) that have evolved to suppress suicidal host responses to infection. We examine these inhibitors in the face of the above classes of insults and report that each viral agent tested has a unique profile in its ability to protect hippocampal neurons following acute neurological insults. Specifically, the effects of domoic acid excitotoxicity can be alleviated only with crmA, p35 and gamma34.5 whereas all genes tested can protect against heat stress. Conversely, no genes tested can protect against metabolic poisoning by cyanide. Such a study helps us to further understand the nature of apoptotic signals in different insults.

Evaluation of neurologic function in Gulf War veterans. A blinded case-control study

OBJECTIVE

To determine whether Gulf War-related illnesses are associated with central or peripheral nervous system dysfunction.

DESIGN

Nested case-control study.

PARTICIPANTS

Twenty-three veterans with factor analysis-derived syndromes (the cases), 10 well veterans deployed to the Gulf War (the deployed controls), and 10 well veterans not deployed to the Gulf War (the nondeployed controls).

METHOD

With investigators blinded to group identities, participants underwent objective neurophysiological, audiovestibular, neuroradiological, neuropsychological, and blood tests.

MAIN OUTCOME MEASURES

Evidence of neurologic dysfunction.

RESULTS

Compared with the 20 controls, the 23 cases had significantly more neuropsychological evidence of brain dysfunction on the Halstead Impairment Index (P=.01), greater interside asymmetry of the wave I to wave III interpeak latency of brain stem auditory evoked potentials (P=.02), greater interocular asymmetry of nystagmic velocity on rotational testing, increased asymmetry of saccadic velocity (P=.04), more prolonged interpeak latency of the lumbar-to-cerebral peaks on posterior tibial somatosensory evoked potentials (on right side, P=.03, and on the left side, P=.005), and diminished nystagmic velocity after caloric stimulation bilaterally (P values range from .02 to .04). Cases (n=5) with syndrome 1 ("impaired cognition") were the most impaired on brain stem auditory evoked potentials (P=.005); those (n=13) with syndrome 2 ("confusion-ataxia") were the most impaired on the Halstead Impairment Index (P=.006), rotational testing (P=.01), asymmetry of saccadic velocity (P=.03), and somatosensory evoked potentials (P< or =.01); and those (n=5) with syndrome 3 ("arthro-myo-neuropathy") were the most impaired on caloric stimulation (P< or =.01).

CONCLUSIONS

The 3 factor-derived syndromes identified among Gulf War veterans appear to represent variants of a generalized injury to the nervous system.

Neuropsychological correlates of Gulf War syndrome

As part of a comprehensive multispecialty project, the present study reports on the neurocognitive and psychological function of veterans who report Persian Gulf War-related symptoms. The neuropsychological and psychological performances of 26 ill Gulf War veterans were compared to 20 well veterans from the same military unit. Neurocognitive functions assessed included intelligence, abstraction and problem-solving, attention and concentration, memory and learning, language and visual-spatial function, and sensorimotor abilities. Psychological function was measured by self-report questionnaires. Results indicated global and consistently poorer intellectual and neurocognitive function among the ill veterans compared to the control veterans. A generalized pattern of neuropsychological deficit was evident for the ill veterans. Psychological profiles of the ill veterans were similar to those in general medical patients. Based on these findings and results from the multispecialty investigation, we conclude that some of the ill veterans have experienced neurotoxic injury resulting in chronic neuropsychological impairment that is related to their service in the Persian Gulf War.

Cognitive deficits in asymptomatic first-degree relatives of Alzheimer's disease patients

The present study was designed to determine whether neuropsychological deficits exist in asymptomatic first-degree relatives of Alzheimer's disease (AD) patients. The neuropsychological performances of 20 first-degree asymptomatic relatives of NINCDS-ADRDA diagnosed AD patients were compared to 20 normal controls without family history of AD. Cognitive functions assessed included intelligence, memory, overall brain function, verbal learning, and language and constructional abilities. Significant statistical differences were found between the groups across several cognitive areas indicating lower functioning in the first-degree relatives of AD patients. Fifty percent of the first-degree subjects but only 20% of controls showed a pattern of significant neuropsychological deficit. The results demonstrate neuropsychological deficits in asymptomatic first-degree relatives of AD patients, suggesting that preclinical markers for AD may be present long before the clinical manifestation of the disease.

Xenon-133 SPECT-determined regional cerebral blood flow in Alzheimer's disease: what is typical?

A study of 76 consecutive xenon-133 SPECT studies of regional cerebral blood flow was undertaken to determine the frequency of various patterns of blood flow in cases of clinically diagnosed probable and possible Alzheimer's disease. The reference tomographic section was a slice 6 cm above and parallel to the canthomeatal line. With the use of this technique, the "classic" finding of bilateral temporoparietal (TP) flow reductions as the sole abnormality occurred in only 28% of cases. Bilateral TP reductions accompanied by bilateral or unilateral frontal flow reductions were nearly as common (24%), and other patterns accounted for the other 48% of cases.

Left cerebral dominance for bilateral simultaneous sensory stimulation?

Hom and Reitan (1982) reported findings with respect to sensorimotor deficits in groups with lateralized cerebral lesions, but evaluated the results only within a framework that related cerebral dominance to deficits that resulted from lateralized lesions. Some of the variables they studied, however, depend upon evidence of retention of functions by one hemisphere under conditions of distracting input. While the right cerebral hemisphere appears to be dominant for tactile-perceptual abilities in terms of resulting deficits, the present study suggests that the left cerebral hemisphere is dominant for certain non-language functions that reflect maintenance of sensory-perceptual abilities under conditions of distracting stimuli.

General and specific cognitive dysfunctions in patients with Alzheimer's disease

The purpose of the present study was to investigate the effect of Alzheimer's disease (AD) on general and specific neuropsychological function. Thirty-five subjects diagnosed with AD were compared to 30 medically normal aging control subjects using measures from the Halstead-Reitan Battery (HRB). All AD subjects were classified as "probable" AD (NINCDS-ADRDA) and found to be in the "late confusional" to "early dementia" stages of the disease (Global Deterioration Scale, GDS = 4-5). The AD group performed significantly worse than the controls on all measures of general neuropsychological function and almost all measures of specific functions. However, no differences were found between groups on motor abilities or many simple sensory functions. The findings demonstrate dramatic brain-behavior changes involving both general and specific cognitive functions which go beyond memory dysfunction even in the earlier stages of the disease. The neuropsychological pattern found may be the basis of a useful clinical-behavioral AD pattern in the earlier stages of the disease.