Reliability of Parent-Measured Axillary Temperatures: Klein M, DeWitt TG. Clin Pediatr (Phila)...
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linergic medications at some point. Most of the individuals in the cohort (93%) received short-acting beta agonists. Over a total of 274,025 patient years, there were a total of 6234 CVEs. Incidence of CVEs was higher in those patients exposed to anticholinergics within 6 months compared to those who were not exposed. Over- all, exposure to anticholinergic medications was associated with a 29% higher risk of CVEs over 1 year as compared to those who were not exposed. Increased risk was confined to those receiving anticholinergic medications within 6 months, and no increased risk was found in those who received anticholinergic medications more than 6 months before enrollment. [Charles M Reynolds, MD Denver Health Medical Center, Denver, CO] Comment: Despite its limitations related to being non-random- ized, this study raises concern about the routine use of anticholin- ergic medications as first-line treatment for COPD. These findings are consistent with previous studies that showed an increased incidence of myocardial infarction and all-cause mortality with the use of anticholinergic medications. It is unclear how anticholin- ergic medications might result in cardiovascular events or if this risk extends to the use of these medications in the ED. e RELIABILITY OF PARENT-MEASURED AXIL- LARY TEMPERATURES. Klein M, DeWitt TG. Clin Pedi- atr (Phila) 2010;49:271–3. This was a prospective cohort study examining the discrep- ancy between temperatures measured in the axilla vs. those measured rectally, and assessing the reliability of axillary tem- peratures measured by parents vs. those measured by medical staff. The study was designed around two hypotheses: first, that the discrepancy between measured rectal and axillary temper- atures will persist despite the use of new digital thermometers; and secondly, that temperatures measured by parents are not as reliable as those measured by medical staff. Participants were selected from multiple centers including outpatient suburban private practice clinics, urban health centers, urgent care cen- ters, and the children’s hospital emergency department. Chil- dren over 2 months of age and weighing 16 –28 pounds were eligible for inclusion. Selected participants were divided into two groups based on the presence or absence of fever, which was defined as a rectal temperature 38.0°C. They used a calibrated digital thermometer to measure rectal and axillary temperatures at presentation and 1 and 2 h later. Both medical providers and parents measured axillary temperatures. Parents were given no instruction regarding the method for measure- ment, but 50% of the time they obtained their measurement after the medical provider first performed theirs. Demographic data about the participants found that there were no statistically significant differences between the febrile and afebrile groups on the basis of gender, weight, and age. Analysis of the tem- perature data demonstrated a small difference between rectal and axillary temperature measurements, with rectal tempera- tures being a mean of 0.3– 0.4° higher than axillary. This difference, although not statistically significant, was greater in the febrile group. There was no significant difference between the measurements taken by parents vs. those taken by staff members. [Colleen Foster, MD Denver Health Medical Center, Denver, CO] Comments: This study confirms the belief that rectal tem- peratures are higher than axillary temperatures, although not to the level previously held (1°). Unexpectedly, parents obtained similar results as health care providers, refuting the notion that parental axillary temperatures are incorrect. Nonetheless, it would seem to be prudent to choose rectal over axillary tem- peratures when accuracy is important. e COPEPTIN: A NOVEL, INDEPENDENT PROGNOS- TIC MARKER IN PATIENTS WITH ISCHEMIC STROKE. Katan M, Fluri F, Morgenthaler NG, et al. Ann Neurol 2009;66:799 – 808. Copeptin is a fragment of provasopression, the biochemical precursor to vasopressin. As vasopressin levels increase in the setting of physiologic stress, copeptin levels increase in the systemic circulation. This prospective observational study mea- sured copeptin levels in plasma obtained on admission from 362 consecutive patients with an acute ischemic stroke with symptoms of 72 h duration during a 1-year period at a single hospital. A total of 605 patients were evaluated for inclusion, with 243 patients excluded for discovery of an alternative diagnosis, onset of symptoms more than 72 h before arrival, or no informed consent. The primary outcome measured was favorable functional outcome after 90 days, defined as a mod- ified Rankin score of 0 to 2. The secondary outcome measured was mortality from all causes within 90 days. Overall, patients with unfavorable functional outcomes at 90 days and patients who did not survive past 90 days both had elevated copeptin levels compared to those patients with favorable outcomes (19.4 vs. 8.2 for functional outcome, p 0.001; 35.6 vs. 9.5 for mortality, p 0.001). The copeptin levels were also found to correlate with the National Institutes of Health Stroke Scale (NIHSS) score, with an NIHSS score of 0 – 6 points having an average copeptin level of 8.6, an NIHSS score of 7–15 having an average copeptin level of 15.8, and an NIHSS score of 15 having an average copeptin level of 30.1. The predictive accu- racy of the copeptin level was measured using the area under the receiver operating characteristic curve (AUC). The AUC for copeptin alone for predicting poor outcome as measured by modified Rankin score of 2 was 0.73, compared to an AUC for NIHSS score of 0.75. The combined score of both copeptin level and NIHSS score performed better than either individual measure, with an AUC of 0.79 (p 0.001). When examining the prediction of all-cause 90-day mortality, copeptin level had an AUC of 0.83, and NIHSS score had an AUC of 0.85. Once again, the combined score significantly improved the accuracy, as compared to NIHSS score alone, with an AUC of 0.89 (p 0.02). The authors conclude that the addition of copeptin level to NIHSS score improves the prognostic accuracy of clinicians when predicting the outcome of patients with ischemic stroke. [Janetta Iwanicki, MD Denver Health Medical Center, Denver, CO] The Journal of Emergency Medicine 129
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Transcript of Reliability of Parent-Measured Axillary Temperatures: Klein M, DeWitt TG. Clin Pediatr (Phila)...
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The Journal of Emergency Medicine 129
inergic medications at some point. Most of the individuals in theohort (93%) received short-acting beta agonists. Over a total of74,025 patient years, there were a total of 6234 CVEs. Incidencef CVEs was higher in those patients exposed to anticholinergicsithin 6 months compared to those who were not exposed. Over-
ll, exposure to anticholinergic medications was associated with a9% higher risk of CVEs over 1 year as compared to those whoere not exposed. Increased risk was confined to those receiving
nticholinergic medications within 6 months, and no increased riskas found in those who received anticholinergic medicationsore than 6 months before enrollment.
[Charles M Reynolds, MD
Denver Health Medical Center, Denver, CO]
Comment: Despite its limitations related to being non-random-zed, this study raises concern about the routine use of anticholin-rgic medications as first-line treatment for COPD. These findingsre consistent with previous studies that showed an increasedncidence of myocardial infarction and all-cause mortality with these of anticholinergic medications. It is unclear how anticholin-rgic medications might result in cardiovascular events or if thisisk extends to the use of these medications in the ED.
RELIABILITY OF PARENT-MEASURED AXIL-ARY TEMPERATURES. Klein M, DeWitt TG. Clin Pedi-tr (Phila) 2010;49:271–3.
This was a prospective cohort study examining the discrep-ncy between temperatures measured in the axilla vs. thoseeasured rectally, and assessing the reliability of axillary tem-
eratures measured by parents vs. those measured by medicaltaff. The study was designed around two hypotheses: first, thathe discrepancy between measured rectal and axillary temper-tures will persist despite the use of new digital thermometers;nd secondly, that temperatures measured by parents are not aseliable as those measured by medical staff. Participants wereelected from multiple centers including outpatient suburbanrivate practice clinics, urban health centers, urgent care cen-ers, and the children’s hospital emergency department. Chil-ren over 2 months of age and weighing 16–28 pounds wereligible for inclusion. Selected participants were divided intowo groups based on the presence or absence of fever, whichas defined as a rectal temperature � 38.0°C. They used a
alibrated digital thermometer to measure rectal and axillaryemperatures at presentation and 1 and 2 h later. Both medicalroviders and parents measured axillary temperatures. Parentsere given no instruction regarding the method for measure-ent, but 50% of the time they obtained their measurement
fter the medical provider first performed theirs. Demographicata about the participants found that there were no statisticallyignificant differences between the febrile and afebrile groupsn the basis of gender, weight, and age. Analysis of the tem-erature data demonstrated a small difference between rectalnd axillary temperature measurements, with rectal tempera-ures being a mean of 0.3–0.4° higher than axillary. Thisifference, although not statistically significant, was greater in
he febrile group. There was no significant difference betweenhe measurements taken by parents vs. those taken by staffembers.
[Colleen Foster, MD
Denver Health Medical Center, Denver, CO]
Comments: This study confirms the belief that rectal tem-eratures are higher than axillary temperatures, although not tohe level previously held (1°). Unexpectedly, parents obtainedimilar results as health care providers, refuting the notion thatarental axillary temperatures are incorrect. Nonetheless, itould seem to be prudent to choose rectal over axillary tem-eratures when accuracy is important.
COPEPTIN: A NOVEL, INDEPENDENT PROGNOS-IC MARKER IN PATIENTS WITH ISCHEMICTROKE. Katan M, Fluri F, Morgenthaler NG, et al. Anneurol 2009;66:799–808.
Copeptin is a fragment of provasopression, the biochemicalrecursor to vasopressin. As vasopressin levels increase in theetting of physiologic stress, copeptin levels increase in theystemic circulation. This prospective observational study mea-ured copeptin levels in plasma obtained on admission from62 consecutive patients with an acute ischemic stroke withymptoms of � 72 h duration during a 1-year period at a singleospital. A total of 605 patients were evaluated for inclusion,ith 243 patients excluded for discovery of an alternativeiagnosis, onset of symptoms more than 72 h before arrival, oro informed consent. The primary outcome measured wasavorable functional outcome after 90 days, defined as a mod-fied Rankin score of 0 to 2. The secondary outcome measuredas mortality from all causes within 90 days. Overall, patientsith unfavorable functional outcomes at 90 days and patientsho did not survive past 90 days both had elevated copeptin
evels compared to those patients with favorable outcomes19.4 vs. 8.2 for functional outcome, p � 0.001; 35.6 vs. 9.5 forortality, p � 0.001). The copeptin levels were also found to
orrelate with the National Institutes of Health Stroke ScaleNIHSS) score, with an NIHSS score of 0–6 points having anverage copeptin level of 8.6, an NIHSS score of 7–15 havingn average copeptin level of 15.8, and an NIHSS score of � 15aving an average copeptin level of 30.1. The predictive accu-acy of the copeptin level was measured using the area underhe receiver operating characteristic curve (AUC). The AUCor copeptin alone for predicting poor outcome as measured byodified Rankin score of � 2 was 0.73, compared to an AUC
or NIHSS score of 0.75. The combined score of both copeptinevel and NIHSS score performed better than either individualeasure, with an AUC of 0.79 (p � 0.001). When examining
he prediction of all-cause 90-day mortality, copeptin level hadn AUC of 0.83, and NIHSS score had an AUC of 0.85. Oncegain, the combined score significantly improved the accuracy,s compared to NIHSS score alone, with an AUC of 0.89 (p �.02). The authors conclude that the addition of copeptin levelo NIHSS score improves the prognostic accuracy of clinicianshen predicting the outcome of patients with ischemic stroke.
[Janetta Iwanicki, MD
Denver Health Medical Center, Denver, CO]
