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For Gnostic Christians, Sophia was a central element in the cosmological understanding of the universe. Sophia observes with interest a study looking at the link between the moon and acute myocardial infarction (Am J Emerg Med 2007;25:256–8). The relationship of acute myocardial infarction (AMI) with circadian rhythm is well recognised. There have also been studies indicating a relationship with solar motion and the incidence of AMI. This paper from Japan reports no direct relationship between the lunar phase of the moon and AMI. However, with some complicated mathematics and the assistance of NASA Jet Propulsion Laboratory Solar System Simulator they propose that there may be a higher incidence of AMI when the gravitational effect of the moon is at its weakest. The precise mechanism of any relationship between the gravitation of the moon and cardiovascular system remains unclear.
Here is a prospective survey that tries to establish patient demographics and symptom presentation in Asian and Caucasian patients with acute coronary syndrome (Heart 2007;93:183–8). Higher rates of coronary artery disease in the Asian population are acknowledged, but differences in the mode of presentation are less well described. This study indicates Asian patients with acute coronary syndrome were younger, more likely to be diabetic, tended to report a higher intensity of pain and over a greater area of their body, with more frequent discomfort over the rear of their upper thorax than Caucasians.
Ever wondered if all that training in Advanced Life Support (ALS) actually makes any difference to patient outcome? Evidence has emerged from Brazil that there is a significant difference to patient outcomes of in‐hospital cardiac arrests if there is at least one person who is formally trained in ALS on the arrest team. This is the first study to show a significant improvement in long‐term survival, including one year survival after cardiac arrest, when rescuers are ALS trained. (Resuscitation 2007; 72:458–65)
In the aftermath of the Shipman inquiry, new proposals are imminent on death certification in the UK. Under current arrangements in the UK, the doctor responsible for a patient's care during their final illness completes the death certificate. The UK government's proposal is that death certificates should be subject to scrutiny by an independent medical examiner. In addition, the government also proposes clinical governance teams in hospitals or primary care trusts to look for unusual patterns of death. However, a pilot study in Northern Ireland has already placed doubt on the usefulness of this proposition. (Lancet 2007;369:716)
Differentiating between acute appendicitis and pelvic inflammatory disease (PID) in females of child bearing age with lower abdominal pain is a regular challenge. A simple clinical prediction tool suggests that the combination of no migration of pain, an absence of nausea/vomiting and bilateral abdominal tenderness could help to rule out appendicitis from PID with a sensitivity of 99%. (Am J Emerg Med 2007;25:152–7)
Emergency physicians who are enthusiastic about ultrasound might enjoy reading a report from Pennsylvania. The authors claim that ED residents can perform limited duplex examination with considerable accuracy after only limited training (J Emerg Med 2007; 32: 197–200).
There is often understandable concern about incorrectly diagnosing migraine and missing a more serious acute problem, such as subarachnoid haemorrhage. There is evidence that a combination of simple historical features can accurately diagnose migraine. These features are captured by the mnemonic POUNDing, when 4 or 5 features are present: Pulsating, 4–72 hOurs duration, Unilateral location, Nausea and Disabling intensity. Positive predictors for abnormal findings on neuroimaging are abnormal findings on neurological examination, ‘undefined headache' and the well recognised acute thunderclap headache. (Evid Based Med 2007;12:25)
The intranasal route for opioid analgesia in children is in widespread use in the UK, but is used much less infrequently in other parts of the world. A prospective, randomised, controlled clinical trial (Ann Emerg Med 2007;49:335–40) compared efficacy of intranasal fentanyl versus intravenous morphine in children with long‐bone fractures. Not surprisingly, intranasal fentanyl proved to be an effective analgesic.
Cost and lack of availability of commercially produced spacer devices may impair inhaled treatment for wheeze in some parts of the world. However, spacers constructed from cleaned plastic bottles may be just as effective at delivering bronchodilators in infants and younger children with acute airway obstruction (Arch Dis Child 2007;92:142–6).
Administration of oral steroids in the treatment of mild to moderate croup is standard practice, but the choice of steroid varies between hospitals. A trial comparing three different regimens revealed no significant differences in outcome. (Emerg Med Australas 2007;19:51–8.)
In recent years, hydrocortisone has been increasingly employed in the management of adult and paediatric patients with septic shock from various causes. An interesting review (Arch Dis Child 2007;92:165–9) describes the historical development of this treatment. It also presents the rationale for using titrated hydrocortisone treatment to reverse catecholamine resistant shock in children who have absolute adrenal insufficiency or pituitary, hypothalamic or adrenal axis insufficiency.