In this issue:

Building Blocks of Trust in the Emergency Department

How Well do Physicians Follow the National Heart, Lung and Blood Institute  Guidelines for Asthma?

From the November AHA Annual Scientific Meetings
1. Cellular Patches Grown; Trial Cardiac Applications Reported
2. Progress in Endothelial Growth Factor Treatments for Cardiac Patients
3. New Combination with Streptokinase Enhances Efficacy

Another Shortage: This time it's Tetanus and Diptheria Toxoids

Smoke Inhalation and the Possibility of Cyanide Poisoning

Cool Web Sites

Quotable Quotes

ERDOCS e-mail group (listserv)

Financial sponsorship statement & How to contact us

Building Blocks of Trust in the Emergency Department

In a recent abstract presented to the Society for Academic Emergency Medicine, researchers reportedly developed a valid and reliable instrument for identifying factors that lead to trust in patient care within an emergency department. The study was conducted in a Level I urban trauma center seeing in excess of 50,000 patients per year. A variety of sources were utilized--literature review, focus group discussions, and direct patient interviews-to identify potential items for surveys by researchers at Albert Einstein Medical Center (Philadelphia) and Leicester General hospital (Great Britain). They hoped to be able to design an instrument that could be administered by telephone, direct interview, or mail and to identify factors leading to trust in an ED.

Two hundred thirty-eight patients seen in the ED were surveyed. Direct interviews with 148 patients were obtained. Input was also obtained from nurses, physicians and residents. The following themes were identified as important to trust: 

1. Previous personal experiences (with the ED), 

2. Reputation of the medical center, 

3. Customer service, 

4. Perceived physician and nurse competence, 

5. Complete and accurate information giving, and 

6. Staff courtesy.

In the study's conclusion it was stated that "This study designed a valid and reliable instrument that measures trust in an ED. It can be used for direct patient interview or telephone survey of patients' trust in EDs. In many cases, patients being seen in the ED have in many cases no previous contact with the physicians treating them. A physician-patient relationship has to be developed in a short space of time. Trust is an essential ingredient of this relationship. This study outlines 6 key areas that encompass trust in an ED setting. These themes provide insight into the process of trust formation. They could be useful in an intervention aimed at improving trust."

How Well do Physicians Follow the National Heart, Lung and Blood Institute Guidelines for Asthma?

In 1997, the National Heart Lung and Blood Institute (NHLBI) published clinical guidelines for acute asthma exacerbation treatment, in an effort to improve care for asthma patients. This study (at North Shore University Hospital, Manhasset, NY) was designed to compare management of asthma in a tertiary care university hospital with the NHLBI recommendations, using retrospective chart review. Trained data abstractors used a closed-question data instrument to assess compliance by comparing documented care with historical, physical examination, and treatment guidelines.

Sixty patients were enrolled in the study; 16 (27%) of those were admitted. Highlights of the study's findings: only fifteen percent of the 3 history data points (previous intubation, previous hospitalization, and previous ICU admission) were completely documented; 29% of charts did not have a single data point documented. The physical examination data points (vital signs, use of accessory muscles, pulse oximetry, and FEV1) were all present on 65% of charts, and 100% of the charts had at least 2 data points documented; There was a 22% compliance with aggressive nebulization (3 aerosolized nebulizations within the first 60 minutes); 73.3% of patients with 3 nebulizations within 60 minutes were discharged versus 73.9% of those without 3 nebulizations within 60 minutes. Sixty-five percent of patients received steroids. Ten percent of the initial incomplete responders did not receive steroids as part of their therapeutic intervention; all of these patients were admitted. Sixty-nine percent of charts documented patient education.

The study concludes that there appears to be poor compliance with the published guidelines.

From the November AHA Annual Scientific Meetings---

Cellular Patches Grown; Trial Cardiac Applications Reported

At the annual scientific meetings of the AHA, several researchers reported progress in efforts to assist patients with the lack of effective cardiac muscle inherent in congestive heart failure. It is estimated that some 5 million Americans suffer from CHF.

Researchers in France reported on a case first made public last month. A 72-year-old man with a history of severe CHF and an AMI, had muscle removed from his thigh and placed in a lab where some 800 million skeletal myoblasts were grown and then injected in and around the scarred area of his myocardium on June 15, 2000. The new tissue appears to be contracting rhythmically and the patient's  ondition is said to have improved drastically (perhaps due, at least in part, to a coronary bypass that he also received). The French hope to introduce eight more patients to this trial procedure within a year.

Dr. Ray C.J. Chiu of McGill University in Montreal reported the use stromal cells injected into the hearts of 22 genetically identical rats. The new tissue quickly began to work with the original heart cells, beating in unison, and were "… hard to distinguish'' from original cardiac tissue, as
stated by Dr. Chiu.

Dr. Jeffrey Isner from St. Elizabeth's Hospital in Boston used a similar approach with endothelial cells, attempting to promote the growth of new intracardiac vasculature. Immature endothelial cells which occur naturally in the blood stream, were gathered from rats and grown in vitro. Following injection of millions of the replicated immature endothelial cells into damaged areas of cardiac muscle, new cardiac vessel growth was noted in followup and cardiac function was noted to be significantly better than in control animals.

Both animal experiments were using alternatives to the controversial embryonic stem cells. Since these experiments involved reinjecting tissue from the same organism, immunosuppresion and rejection appear to be non-issues. An advantage over the French experiment is that both animal studies resulted in "real" heart tissue. One concern expressed is the possibility that injection of these "impressionable" immature cells near scarred tissues may lead to replication of scar instead of healthy tissue.

Progress in Endothelial Growth Factor Treatments for Cardiac Patients

Timothy Henry, MD, associate professor of medicine at the University of Minnesota in Minneapolis, reported that one year after patients with severe angina received an injection of vascular endothelial growth factor (VEGF), nearly 50 percent reported "almost no" or "no" chest pain. During the year, the high-dose VEGF group had only 12 percent of their enrollees experience "adverse coronary events" compared to the 31 percent in the placebo group. While no deaths were reported in the high-dose VEGF group of 35 patients, there was one death in the 34-patient low-dose group, and two deaths in the the placebo group of 37 patients.

Cancer rates were tracked, as well, since VEGF is often targeted in anticancer treatments. No cancer was detected in the high-dose VEGF group, while four in the placebo group and one in the low-dose group reported development of cancer.

Patients with histories of unstable angina but ineligible for conventional treatments such as bypass surgery volunteered for this study.

Several pharmaceutical companies are currently pursuing extended tests of VEGF.

New Combination with Streptokinase Enhances Efficacy

Results were reported from a Phase II trial demonstrating for the firsttime that combining enoxaparin sodium and streptokinase significantly improves restoration of normal coronary blood flow and improves outcome in patients with acute myocardial infarction, compared to conventional treatment with streptokinase. These findings are based on results from the AMI-SK (Acute Myocardial Infarction -- StreptoKinase) study.

The study of 496 acute myocardial infarction patients showed that the combination of subcutaneous enoxaparin/streptokinase vs. streptokinase/placebo resulted in:

1. Blocked artery's blood flow restored by a relative increase of 22 percent;

2. Better early reperfusion as measured by  ST-segment resolution;

3. Relative risk reduction of 36 percent in the triple endpoint (death, reinfarction and recurrent angina).

4. Improved patency at days 5-10; and 

5. fewer clinical events, suggestive of less reocclusion.

"This is an important therapeutic advance because streptokinase is the most widely used thrombolytic agent worldwide. The efficacy of streptokinase has been well documented in earlier studies (GISSI, ISIS-II). This efficacy is significantly improved by adding enoxaparin. As the standard of care advances, physicians need to be able to safely combine treatments like fibrinolytics (streptokinase) and anticoagulants (enoxaparin). All patients also received aspirin. Such combination therapy is especially important in the field of cardiology, where new combinations like this one have the potential to save more lives," said Professor Maarten L. Simoons, MD, chairman, Steering Committee, from the Thoraxcenter, Erasmus University and University Hospital Rotterdam, in the Netherlands.

Because enoxaparin has a number of advantages over the use of unfractionated heparin (noted in clinical trials, such as TIMI 11b and ESSENCE), it was chosen  for the AMI-SK study. Low-molecular-weight heparins such as enoxaparin are easier to administer and do not require laboratory monitoring and frequent dose adjustments as unfractionated heparin. Enoxaparin's unique properties include a reliable anticoagulant effect, resistance to inactivation by platelet 4, lack of platelet activation, and high anti-Xa to anti-IIa ratio.

There was a slightly higher, but statistically insignificant rate of bleeding incidences in the enoxaparin treatment group when compared to placebo. However, the bleeding rate observed in the enoxaparin and streptokinase combination was favorably comparable to rates observed with unfractionated heparin or other thrombolytic combinations.

Further clinical trials are anticipated to validate these results.

Another Shortage: This time it's Tetanus and Diptheria Toxoids

A temporary shortage of adult tetanus and diphtheria toxoids (Td) in the US has resulted from two situations: 1) a decrease in the number of lots released by Wyeth Lederle and 2) a temporary decrease in inventory of vaccine following routine maintenance activities at the production facilities by Aventis Pasteur that lasted longer than anticipated. Approximately one half of the usual number of Td doses has been distributed this year. Although there have been no decreases in production of tetanus toxoid (TT), availability is low because of increased use during the Td shortage. On the basis of information provided by Aventis Pasteur, the Public Health Service expects vaccine supplies to be restored early in 2001. Until then, Aventis Pasteur will be limiting orders to assure the widest possible distribution of available doses.

The shortage impacts persons aged 7 years and older who 

1) require tetanus prophylaxis in wound management, 

2) have not completed a primary series (three doses) of vaccine containing Td, or 

3) have not been vaccinated during the preceding 10 years with Td, diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) or diphtheria and tetanus toxoids (DT). 

This shortage will not affect vaccination of children aged less than 7 years who require additional doses of a vaccine-containing TT; they should receive DTaP or pediatric DT, which are not in short supply. Td is preferred to TT because Td provides protection against both tetanus and diphtheria. However, during this shortage, if Td is not available, TT can be used as an alternative for persons aged 7 years and older who require immediate boosting with TT (e.g., wound management), or who are unlikely to return to a clinic if vaccination is delayed. If TT is administered, patients and health-care providers must weigh risks and benefits of subsequent vaccination with Td. Arthus-type reactions may occur among persons who receive multiple doses of TT, especially within short intervals (less than 10 years). However, if vaccination with Td is delayed for greater than 10 years following their last Td administration, persons may be protected inadequately against diphtheria.

Clinics experiencing shortages of Td may need to prioritize their use of available supplies. If administration of Td is delayed, clinics should implement a call-back system when vaccine is available.

Recommendations for use (highest to lowest priority) of Td are:

1. Persons traveling to a country where the risk for diphtheria is high.

2. Persons requiring tetanus vaccination for prophylaxis in wound management.

3. Persons who have received fewer than 3 doses of vaccine containing Td.

4. Pregnant women and persons at occupational risk fortetanus-prone injuries who have not been vaccinated with Td within the preceding ten years. 

5. Adolescents who have not been vaccinated with a vaccine containing Td within the preceding ten years. 

6. Adults who have not been vaccinated with Td within the preceding ten years.

Smoke Inhalation and the Possibility of Cyanide Poisoning

When managing patients subjected to smoke inhalation, the physician's attention is often focused on looking for and treating burns, hypoxia and carbon monoxide. Clinicians should also be aware of the possibility of cyanide poisoning. During combustion of nitrogen-containing natural and synthetic products (wool, silk, plastics) large amounts of cyanide can be produced.

Rapid diagnosis and treatment of cyanide toxicity can be challenging. Not only is making the diagnosis often difficult, administering treatment routinely can be detrimental. The sodium nitrite component of the Lilly Cyanide Antidote Kit results in the production of methemoglobin which will enhance the toxicity of an already high concentration of COHb.

Consider the following when treating a patient with signs and symptoms of smoke inhalation: 

1. Recognizing that there is a high correlation of cyanide poisoning when serum lactate levels are greater than 10 mmol/L; 

2. If the patient is critically ill  (coma, seizures, cardiac dysrhythmias, acidemia, hypotension) all findings suggestive of cyanide poisoning, consider giving the patient the 12.5 g dose of sodium thiosulfate from the cyanide kit, which has no risk of enhancing toxicity. If the patient remains unstable, particularly if the lactate level is above 10 mmol/L and the patient's status cannot be explained by other causes (for example, the COHb level is low) then consider carefully administering the rest of the antidote kit.

Simultaneous toxicity from both carbon monoxide and cyanide has been widely reported and appears to be a major contributor to the mortality associated with smoke inhalation.

Cool Web Sites

THE WEIRD AND THE INCREDIBLE
http://www.guinnessworldrecords.com/home.asp 
You can watch a man balance a car on his head, view the longest cat,or see a record number of worms eaten in 30 seconds.

SEARCH ENGINES
http://www.invisibleweb.com 
Considered the search engine of search engines.

SCHOOL WORK
http://www.factmonster.com/index.html 
One of those all-in-one reference centers, especially useful for kids' homework. Includes a searchable atlas, almanac, dictionary and an encyclopedia.

SPACE
http://www.thespacestore.com/ 
Where else can you go to buy a used space capsule with only 79 million miles on it?

Quotable Quotes

From George S. Kaufman, dramatist, journalist (1889-1961):

"The kind of doctor I want is one who when he's not examining me is home studying medicine."

"I like terra firma; the more firma, the less terra."

"At dramatic rehearsals, the only author that's better than an absent one is a dead one."

"I thought the play was frightful but I saw it under particularly unfortunate circumstances. The curtain was up."

ERDOCS e-mail group (listserv)

As a Clinician providing acute and emergency medical care, you are invited to visit and participate in our new ERDOCS group at eGroups, a free, easy-to-use email group service! You have plenty of experiences to share, questions to ask, concerns and opinions to voice, suggestions, news to post, tips to offer, etc.and can do so within this framework. this is a versatile system for posting things to be sent to a group to peruse, respond to, or simply be aware of. It eliminates conventional mail delays and allows you to review and post at your leisure. (We still have the more open-ended [any visitor can observe/post] discussion group at the ACUTE CARE, INC. web site). Our goal is to give you a variety of feedback and communication tools.

The manager/moderator for this ERDOCS egroup is the webmaster for the ACUTE CARE, INC. website (www.acutecare.com), Paul Hudson. You can subscribe by sending an e-mail indicating your wish to be included to Paul at paul@acutecare.com

As this site grows, it will feature news, calendars, links to references, resources, and other useful features. We hope you will support this effort to foster ongoing communication amongst EM providers.