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Sophia has previously pointed out the risks inherent in daily activities and now presents further evidence of the myriad ways that modern life can conspire to endanger the innocent. Recent novel case reports describe burns sustained from bouncy castles (Burns 2006;32:920–1), and exploding mobile phones (Burns 2006;32:922–4), while an article in Thorax (2006;61:1076–82) suggests that longstanding residency near heavy industry increases the risk of lung cancer (although this study was limited to risk in women).
Depression in couch potatoes may be related to their lifestyle. An unblinded study of 38 patients with depression (Br J Sports Med 2007;41:29–33) suggests that those who undertake regular aerobic exercise show a reduction in their depression scores. Perhaps it is time to don that Lycra©?
A neat pragmatic article in Anaesthesia (2006;61:5–19) promotes a simple method of improving internal jugular vein cannulation. The method is to anchor the internal jugular vein by leaving a pilot needle in place. In two groups of patients, the technique improved the success rate at first attempt from 64% to 81%. Ultrasound suggests that one reason underlying this success is prevention of indenting of the internal jugular vein by the second needle.
Much of emergency care is still being delivered by junior staff and so the competency of these staff is a constant concern. Curmudgeons may be pleased to read a study in the American Journal of Emergency Medicine (2007;25:45–8), which reviewed discrepancies between preliminary interpretations of computed tomography scans by residents and the attending radiologists' final report. 10% of the scans had major discrepancies (defined as resulting in a change of diagnosis, treatment, or disposition). Equally worrying was the finding that abnormal scans were more likely to have discrepancies. Residents might argue that the discrepancies may not all be inaccuracies.
A descriptive retrospective review of the use of BiPAP in children with refractory status asthmaticus (Am J Emerg Med 2007;25:6–9) suggests that the technique is safe (no adverse effects) and well tolerated by most children. The authors suggest that there was significant clinical improvement in clinical status in 88% (confirmed by oxygen saturation levels).
On the subject on non‐invasive ventilation, a paper in Anaesthesia (2006;61:20–3), examines tolerance of face mask versus mouthpiece for non‐invasive ventilation. A randomised, prospective cross‐over trial revealed less withdrawal of ventilation and less nursing time required with face masks, but no difference in tolerance scores or efficacy.
A recent study investigated the accuracy of tympanic membrane temperature in reflecting core body temperature (Crit Care Med 2007;35:155–64). The authors compared 6,703 tympanic temperature measurements with urinary, axillary and pulmonary artery (core) temperature in the intensive care unit. An impressive statistical analysis confirms Sophia's anecdotal findings: tympanic and axillary temperature measurements are poor surrogates for core temperature measurements.
A study in the American Journal of Emergency Medicine (2007;25:10–4) analysed more than 3000 patients who had urinalysis, urine culture and liver function tests performed at one admission. The specificity of urine nitrite for positive culture results fell with increasing bilirubin levels, as did the false positive nitrite tests. Most patients in this study with both positive nitrite and elevated bilirubin did not have a urinary infection confirmed on culture.
The journal Heart has dedicated a recent edition to atrial fibrillation in light of the recent guidelines, including that from the National Institute for Clinical Excellence (Heart 2007;93). Despite being a good read, there are some all too familiar themes, so the edition did not make Sophia's heart miss a beat. An interesting quote from the editorial sums up much of modern medicine: “not surprisingly, there were significant areas where there was little, or no, good quality evidence on which to base recommendations…”.
More on clinical guidelines: PIOPED II (Prospective Investigation of Pulmonary Embolism Diagnosis II) recommendations have been published simultaneously in Radiology and the American Journal of Medicine (2006;119:1048–55). The headline summary is that CT angiography/venography is suggested as the initial investigation after clinical score and enzyme‐linked immunosorbent assay D‐dimer. However, the article acknowledges that this is the opinion of most (but not all) of the investigators!
Two recent editorials may make interesting reading, especially when compared and contrasted. “Crisis in the Emergency Department” (N Engl J Med 2006;355:1300–1), argues that the strategic problems faced by emergency departments are essentially the same all over the world. Meanwhile, “Emergency care for children ‐ the next steps” (Arch Dis Child 2007;92:6–8) presents a grand view of the future for UK paediatric emergency medicine.