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Why fly burns?
Helicopter emergency medical services play an important role in transporting severely ill patients. A review from the Midlands Adult Burns Centre over a three year period determined that 26% of air ambulance transfers were not clinically indicated and that land transfer would have been more appropriate. The authors argue that criteria are needed to maximise the benefit and reduce costs related to unnecessary flights (Burns 2010;36:1201–7).
A song from under the floorboards
Classical music from great composers such as Bach and Mozart is not only relaxing, but also appears to improve quality of life (Heart 2010;96:1868–71). Various studies have demonstrated significant effects on the cardiovascular system with influences on heart rate, heart rate variability and blood pressure. Beneficial effects of musical therapy have been demonstrated in the settings of pre-operative care, cardiac catheterisation, prior to and after cardiac surgery and during cardiac rehabilitation. Sophia wonders if listening to the more modern tunes of Joe Strummer and Howard Devoto carry similar benefits?
Exercise induced hyponatraemia
Five marathon runners are known to have died from exercise associated hyponatraemia (EAH) in recent years. This is widely believed to reflect a dilutional hyponatraemia caused by an increase in total body water relative to the amount of exchangeable sodium. In an interesting study, 12.5% of healthy volunteers developed asymptomatic EAH after running in the London marathon (Br J Sports Med 2011;45:14–19). Although these runners consumed more fluid and gained more weight than non-hyponatraemic runners, fluid intake was not related to weight gain. Some of the hyponatraemic runners actually lost weight. It is postulated that inappropriate release of antidiuretic hormone might account for this phenomenon.
Frozen shoulder
There are a number of management strategies and interventions which aim to restore motion and improving pain in patients with frozen shoulder. However, despite a number of trials, there is controversy about the optimal treatment. A review article in the British Journal of Sports Medicine (2011;45:49–56) provides an evidence based overview of the effectiveness of various interventions used to treat frozen shoulder. There is strong evidence for steroid injections and laser therapy in the short-term, but little evidence about long-term outcomes.
Dizzy discharge
Many patients presenting to the ED with acute onset dizziness or vertigo are discharged without a definite diagnosis. There is some potential to miss serious underlying causes such as a posterior circulation stroke, transient ischaemic attack or arrhythmia. Researchers from San Francisco attempted to determine how often this group of patients experienced a major vascular event after discharge. In a retrospective cohort study of 31 159 discharged subjects, only 2% died or experienced a major neurologic or cardiac event during the 6 month follow-up period (Ann Emerg Med 2011;57:34–41). Most of these events occurred within the first month. Identifying which patients will suffer them remains a challenge.
Posterior circulation stroke
Ischaemic stroke of the posterior circulation may cause mild or non-specific acute symptoms that are not captured on the National Institutes of Health Stroke Scale (NIHSS). A study published in the Annals of Emergency Medicine (2011;57:42–5) reveaed that patients with an NIHSS score of 0 and a documented infarct on diffusion-weighted imaging, frequently presented with headache, vertigo, nausea and truncal ataxia. This highlights the need to be alert to this pattern of symptoms in order to investigate further and rule out a posterior circulation stroke.
Risk stratification in AF
Trying to achieve a balance between ensuring patient safety and the need to reduce admission rates for patients with symptomatic atrial fibrillation (AF) is a considerable challenge. A study published in the Annals of Emergency Medicine (2011;57:1–12) attempts to define those clinical factors which are associated with adverse events occurring in the first 30 days after an ED visit for symptomatic AF. Although the methodology was potentially flawed in certain respects, it was found that increased age, inadequate ventricular rate control, dyspnoea, current smoking and beta-blocker treatment were associated with adverse events. This is by no means a validated clinical decision rule, but is perhaps at least a starting point to inform future efforts to define optimal management strategies for this important problem.
Rate or rhythm control?
Continuing the theme, the wide variation in the management of recent onset atrial fibrillation (AF) observed in the ED is probably the result of ongoing controversy (and confusion!) surrounding the choice between rate and rhythm control strategies. There is a lack of robust evidence to guide ED physicians when attempting to choose between these two competing strategies. Few studies have addressed the optimal management strategy of recent onset AF in the ED. Canadian researchers have highlighted the considerable variation in practice and suggest further studies to define optimal strategy. Individual hospital site, age, previous cardioversion and associated heart failure were identified as independent predictors for the use of a rhythm control strategy (Ann Emerg Med 2011;57:13–21).
Ondansetron and paracetamol
The mechanism of action of paracetamol is not clearly understood, but may involve modulation of the serotoninergic pathways in the spinal cord. Recent research reports that the co-administration of some serotonin receptor blockers with paracetamol completely blocked the analgesic effects of paracetamol in humans. In a study (not for the faint hearted) on a model of post-fracture pain in mice, investigators aimed to assess if ondansetron blocked the effect of paracetamol. Besides generating ethical controversy about the use of placebo for fracture pain in animals, this study reports that ondansetron did not decrease the analgesic effects of paracetamol in this animal model (BJA 2010;106:112–18).