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350 Abstracts

Comment: Although primary arthroscopic repair after arst-time shoulder dislocation has advantages over lavagelone, there are no data in this study that compare arthroscopicepair with non-operative treatment. Furthermore, it would beelpful to study the effects of an arthroscopic repair afterailure of non-operative treatment.

GUILLAN-BARRÉ SYNDROME: INCIDENCE ANDORTALITY RATES IN US HOSPITALS. Alshekhlee A,ussain Z, Sultan B, Katirji B. Neurology 2008;70:1608–13.

This study sought to determine the current incidence andn-hospital mortality of Guillan-Barré syndrome (GBS) in thenited States and to identify predictors of mortality. A cohortf 6101 patients with an admission diagnosis of GBS wasdentified from the Nationwide Inpatient Sample database be-ween 2000 and 2004. Patients younger than 18 years of agend patients who had other possible causes of paralysis werexcluded, yielding 4594 in the study sample. Logistic regres-ion was used to identify mortality predictors. The incidence ofBS remained relatively steady over the 5-year period and

anged between 1.65 and 1.79 per 100,000. Of all patientsdmitted with GBS, 2.58% died. Predictors of mortalityncluded older age, government payor, higher Charlson Co-

orbidity index, and associated conditions while in theospital, including cardiac, pulmonary, sepsis, and endotra-heal intubation. The authors concluded that the mortalityssociated with GBS is relatively low and the predictors ofeath are similar to those that predict death after any hospitaldmission.

[Nathan J. Cleveland, MD,

Denver Health Medical Center, Denver, CO]

Comment: This study quantifies the impact of a disease thats relatively rare. It highlights the importance of comorbidi-ies in predicting a patient’s mortality while admitted to theospital.

CORTICOSTEROIDS IN THE PREVENTION ANDREATMENT OF ACUTE RESPIRATORY DISTRESSYNDROME (ARDS) IN ADULTS: META-ANALYSIS.eter JV, John P, Graham PL, Moran JL, George IA, Bersten. BJM 2008;336:1006–9.

Acute respiratory distress syndrome (ARDS) is associatedith high rates of mortality, and studies concerning corticoste-

oids’ effects on ARDS have been conducted for over 20 years.n this meta-analysis, the authors assessed whether corticoste-oids are associated with a mortality benefit in adults withRDS. The analysis included nine randomized controlled trialsating from 1985 to 2007. Three trials defined ARDS based onhe American-European consensus definition, whereas the cri-eria of the six other trials differed slightly. Four trials evalu-ted the effect of preventative steroids on the development ofRDS, whereas the other five trials evaluated the effect of

herapeutic steroids on mortality in patients with defined u

RDS. Preventative steroids were associated with a trend to-ard an increase in ARDS development (odds ratio [OR] 1.55)

nd an increased mortality risk in those that developed ARDSOR 1.52). Of note, the credible interval (CrI) for both over-apped 1. Administration of therapeutic steroids after the onsetf ARDS was associated with a trend toward a reduction inortality (OR 0.62), though this CrI also overlapped 1. Steroid

herapy was not associated with increase of new infections inatients, though the definition of secondary infections variedetween studies.

[Zachary D. Tebb, MD,

Denver Health Medical Center, Denver, CO]

Comment: This meta-analysis is limited by the variability ofncluded data and the small number of high-quality randomizedrials available. The authors show that steroids do not signifi-antly increase or decrease the mortality of patients with ARDShen given in either a preventative or therapeutic fashion.iven the variability of corticosteroid administration dosing

nd timing over the past 20 years, the current review providesittle to the debate of current ARDS management. Steroidshould not be given in a preventative fashion in patients with-ut ARDS, and therapeutic steroids for patients with ARDS inhe Emergency Department should be considered on a case-pecific basis.

DIAGNOSING ACUTE APPENDICITIS IN ADULTS:CCURACY OF COLOR DOPPLER SONOGRAPHYND MDCT COMPARED WITH SURGERY AND CLIN-

CAL FOLLOW-UP. Gaitini D, Beck-Razi N, Mor-Yosef D,t al. AJR Am J Roentgenol 2008;190:1300–6.

This study out of Israel compared the sensitivity, specificity,ositive predictive value (PPV), negative predictive valueNPV), and accuracy of color Doppler sonography for theiagnosis of acute appendicitis in the adult population, includ-ng pregnant patients. The gold standard for definitive appen-icitis was surgery with pathologic confirmation of appendicitisr clinical follow-up. Sonography was performed by both senioradiologists and radiology residents. There were 420 Doppleronography examinations performed. The overall sensitivity,pecificity, PPV, NPV, and accuracy for sonography was4.2%, 97%, 88%, 93%, and 92%, respectively. A total of 132atients (31.4% of the population) underwent computed tomog-aphy (CT) after sonography examination. The sensitivity,pecificity, PPV, NPV, and accuracy of CT was 100%, 98.9%,7.4%, 100%, and 90%, respectively. Furthermore, the sensi-ivity for Doppler sonography was 63.8% vs. 85%, respec-ively, when performed by a radiology resident compared to aenior radiologist. The authors conclude that sonographyhould be the first imaging technique for adult patients for theiagnosis of acute appendicitis, with CT being used as a com-limentary study.

[Andrew French, MD,

Denver Health Medical Center, Denver, CO]

Comment: Although interesting, this study is limited by the

se of surgical findings as the gold standard. There is no way

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The Journal of Emergency Medicine 351

o know how accurate the studies were when surgery was noterformed. Furthermore, appendicitis is a condition that mostmergency Physicians are concerned with ruling out. Based on

hat consideration and the fact that CT had sensitivity of 100%nd a NPV of 100% compared to 74.2% and 93%, respectively,or Doppler sonography, CT may be the more definitive studyor use in Emergency Medicine.

CABIN FEVER. Tonks A. BMJ 2008;336:584–6.This commentary from the United Kingdom looks at

ealth emergencies on airplanes. In particular, it looks atow often medical emergencies occur in flight, the roles ofhysicians during these events, and the risk of litigation. Therue incidence of medical professionals being asked to helpuring flights is unknown, as there is no official database oregistry system for all airlines. However, this article sug-ests the incidence to be somewhere between 1 in 10,000nd 1 in 40,000 passengers. It also suggests that the chancesf encountering an in-flight medical emergency are rising asying becomes easier and older/sicker people are flyingore frequently. When a medical emergency does occur,

octors do not have a legal obligation to respond (except inrance), but they do have a humanitarian duty to offer helpccording to the World Medical Association’s internationalode of medical ethics. When responding, the risk of litiga-ion is minimal, as most medical professionals are protectedy a combination of national “Good Samaritan” legislation,he airline, and their medical defense organizations. Mostirlines have a well-trained cabin crew and rarely require thessistance of a medical professional. Also, airlines are in-reasingly using technology to obtain advice from doctorsn the ground via satellite phone and telemedicine.

[Brad Talley, MD,

Denver Health Medical Center, Denver, CO]

Comment: This is an interesting commentary on healthmergencies when flying. It gives an overview of how oftenhese events actually occur and what our roles, as physicians,hould be. It also provides a nice prospective from the airlinendustry and how they view the roles of physicians who assistn emergencies. It is interesting how few data are actually keptr known in the airline industry about when medical profes-ionals are asked to help. It might be useful in the future to lookt patient outcomes when a medical professional providesssistance during an in-flight medical emergency.

HYPONATREMIA AND HYPOKALAEMIA DURINGNTRAVENOUS FLUID ADMINISTRATION. Armon K,iordan A, Playfor S, et al. Arch Dis Child 2008;93:285–7.

This study examined the use of intravenous (i.v.) fluids inhildren. A cross-sectional survey of 17 hospitals was conductedor 1 day in 2004. Ninety-nine children were identified as receiv-ng i.v. fluids with a median age of 3.6 years and a quarter of the9 younger than 12 months. Of the children receiving i.v. fluids,7% were administered hypotonic fluids and 16% were receiving

ore than 120% of calculated maintenance fluids (maintenance

as calculated at 100 mL/kg/day for the first 10 kg, 50 mL/kg/dayor the second 10 kg, and 20 mL/kg/day for the remainder).lectrolytes had been measured in the prior 24 h for 54% andetween 24 and 48 h for an additional 25%. Of those who hadlectrolytes measured, 24% were hyponatremic (sodium � 135)nd 4 had a sodium level � 130. In addition, 24% of children wereypokalemic (potassium � 2.3). Of the hospitals surveyed, 12 of7 did not have clinical guidelines in place for pediatric patients.he authors acknowledge that the study can comment only onssociations and not causality, thus its conclusions are limited.owever, the authors propose that the degree of hypotonic fluid

dministration and electrolyte abnormalities are concerning. Theyall for clinical guidelines for pediatric i.v. fluid administration andemind the reader that i.v. fluids should be treated with the sameegree of caution as other drugs.

[Benjamin Hatten, MD,

Denver Health Medical Center, Denver, CO]

Comment: This study offers a very limited data set consist-ng of 1 day’s worth of voluntary surveys regarding pediatric.v. fluid administration in an inpatient setting. Nevertheless, itoes serve as a reminder that i.v. fluids are a medicine and theirosage must be individualized to volume and electrolyte status.oreover, i.v. fluid requirements, just like other drugs, areeight based in pediatric patients. If possible, a standardizedrotocol or formula serves as a good starting point for calcu-ating pediatric i.v. fluid dosing.

CARDIAC TAMPONADE IN MEDICAL PATIENTS:10-YEAR FOLLOW-UP SURVEY. Cornily JC, Pennec

Y, Castellant P, et al. Cardiology 2008;111:197–201.The goal of this study from University Hospital in Brest,

rance is to review the common causes of pericardial effusion ando determine the prognostic significance of those causes. The studyrovides a prospective look at all patients admitted to the Cardi-logy and Cardiothoracic Surgery departments at University Hos-ital from 1996 through 2005 who had a pericardial effusionequiring drainage. Of the 114 patients who were enrolled in thetudy, 74 (65%) had a malignant source, 11 (9.6%) had a viralistory, 4 (3.5%) were undergoing anti-coagulation treatment, 32.6%) had undergone cardiac intervention, 3 (2.6%) hadremia, and 19 (16.7%) were for miscellaneous or unknownauses. Of note, pericardial effusion was the first sign ofalignancy in 23 of the 74 patients (31%) with neoplastic

amponade. In-hospital mortality was 10% without any sig-ificant difference between malignant and non-malignantffusions. One-year mortality was 76.5% in patients withalignant disease and 13.3% in patients with non-malignant dis-

ase. Among those with malignant disease, lymphomas and arevious history of thoracic radiotherapy independently pre-icted improved survival. The study concludes that medicalamponade remains a relatively common emergency situation;istorical causes of tamponade such as tuberculosis, myx-dema, and uremia are now much less common; and cancer, theeading cause of tamponade, implies a poor prognosis.

[Matt Mendenhall, MD, MPH,

Denver Health Medical Center, Denver, CO]