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Department of Emergency Medicine

Department of Emergency Medicine

2014 - February R3 Journal Review

 Jacobs JD et al. 7% Hypertonic Saline in Acute Bronchiolitis: A Randomized Controlled Trial. Pediatrics. 2013 Jan;133(1):e8-13.
This was a prospective, double-blind, randomized controlled trial that compared nebulized 7% hypertonic saline (HS) with epinephrine to 0.9% normal saline (NS) with epinephrine in the treatment of moderate to severe bronchiolitis.  A total of 101 infants were enrolled at single tertiary care center ED over the course of two years.  Ages of patient ranged from 6 weeks to <18 months.  Inclusion criteria included diagnosis of bronchiolitis (which was defined as viral respiratory illness and first episode of wheeze), bronchiolitis severity score (BSS) ≥4.  Exclusion criteria included history of wheezing, use of bronchodilators within 2 hours of presentation, prematurity, congenital heart disease, pulmonary or renal disease, oxygen saturation <85%, ICU admission.  Primary outcome measured was the change in the BSS, while secondary outcomes included hospitalization rate, proportion discharged at 23 hours and length of stay. 

The results of the study showed no statistical difference between the two groups in terms of the primary outcome (in  patients who did not require admission: BSS in HS 2.6 ± 1.9, BSS in NS 2.4 ± 2.3 with a p value of 0.61; in patients requiring admission: BSS at 24 hours was: HS 3.1 ± 2.5, BSS in NS 3.7 ± 1.9 with a p value of 0.37). There was no statistical difference between the two groups in terms of secondary outcomes as well, with LOS in ED in terms of hours (HS 4.1 ± 0.9, NS 3.9 ± 4.0, p-value of 0.8), proportion of patients admitted (HS 42%, NS 49%), proportion of patients discharged at 24 hours (HS 14% vs NS 13%).

Overall this negative study demonstrated that high dose hypertonic saline had no additional effect over normal saline.  Both groups received epinephrine in addition to the saline nebs.  It would be interesting to see if there is any difference between the two groups without epinephrine.  This study does not look at the more traditional 3% hypertonic saline that we commonly use.  This study would not change my current practice in the treatment of bronchiolitis.

- Chima

Miller L et al. Elevated Risk for Invasive Meningococcal Disease Among Persons with HIV. Ann Intern Med. 2014;160(1):30-37-37. 
This retrospective cohort study using a communicable disease surveillance database, attempts to assess whether HIV status confers an increased risk of infection with, and/or death from, N. meningitides and what role CD4 and HIV viral loads play. Using communicable disease surveillance data for the New York City area between 2000 and 2011, 265 patients between ages 15 and 64 in this area reported as having had invasive meningococcal disease (IMD) were retrospectively identified. This data was matched to HIV and death registries for the same geographic location to calculate risk and case-fatality ratios.

Non-HIV/AIDS patients were relatively well matched to HIV/AIDS patients. 265 of the IMD cases (65%) and 55 of the deaths (74%) reported in the registry were in patients aged 15-64.  The total average annual IMD incidence rate was 0.39 per 100,000 people. The incidence was 3.9 per 100,000 people in HIV/AIDS infected patients and 0.34 per 100,000 people in the uninfected cohort. Secondary outcomes assessing CD4 counts revealed an increased likelihood of IMD in those with CD4 counts less than 200 (LR 5.4, CI 1.4 to 20.4). Patients with an unsuppressed viral load were 4.5 times (CI 0.4 to 22.2) as likely to have IMD than those with suppressed viral loads. However, in this case-control analysis, only 16 and 14 patients were included for CD4 counts and viral loads, respectively.

HIV/AIDS patients are not currently included in the CDC recommendations for populations to be vaccinated against N. meningitides. This data shows that while CD4 counts and viral loads may be not as well elucidated for increased susceptibility, those living with HIV/AIDS have a 100 fold increased incidence of IMD. Serogroup analysis revealed that 90% of the meningococcal strains are included in the vaccine. Cost-Benefit analysis of routine vaccinations for HIV/AIDS patients was not performed.

Limitations of the study are its design, being a retrospective cohort study of surveillance data, unknown vaccination status of those in the registries, duplications and/or omissions of cases.

The data may be generalizable to a large dense urban population with similar prevalence of HIV/AIDS and meningococcal infection.

- Rathgeb

Livingston D et al. Unrelenting violence: An analysis of 6,322 gunshot wound patients at a Level I trauma center. J Trauma Acute Care Surg. 2014; Jan 76(1): 2-11.
This was a retrospective analysis of gunshot (GSW) injuries at a major level 1 trauma center from January 2000 to 2011. Patients were excluded if the GSW were sustained by self injury (accidental or non accidental) or by law enforcement. Goal of the study was to describe the health care burden by GSWs. Data collected included body regions injured, number of wounds per patient, and mortality. Geographic information of the location and home addresses were also collected to identify hot spots and characterizations of those neighborhoods. Cost of the hospitalization were calculated using Medicare cost charge modifiers. A total of 6322 patients met inclusion criteria. The population was overwhelmingly male (92%) and young (mean 27 years old). The distribution of race/ethnicity was as follows: black (86%), Hispanic (9%), white (4%), and Asian (1%).  There were a significant increase in patients with three or more wounds and three or more body regions injured. Geographic information mapping revealed significant clustering of GSWs with five cities accounting for 85% of the GSWs. Seventy percent of patients were shot in their home city with 25% within 168m and 55% within 1600m of their home. Total inpatient cost was 115 million with cost per patient increasing more than three times over the course of the study, 75% were uninsured. GSW remains a significant public health problem given the escalating mortality and health costs. This descriptive study showed that GSW violence tended to be geographically restricted and not random. The study was limited in that it was a single center retrospective study in a densely populated urban city with a history of gun violence. In hopes to combat this problem, we maybe should focus our efforts at the community level.

- Phan