Journal Club

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Journal Club

• 21 April 2006
• Stephen Langford

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Journal Club

• Obstetrics
• Aviation Medicine
• Gynaecology
• Public Health
• Trauma
• Critical Care

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Journal Club

• ANZJOG Feb 2006
• NEJM Mar 2006
• JASAM Jan 2006
• Air Med J Mar 2006
• Annals EM Oct 2005
• Annals EM Apr 2006
• NEJM Apr 2006

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Adverse outcome of pregnancy following air
travel A myth or concern?

• Australian New Zealand Journal of Obstets
  Gynecol Feb 2006 4624-28
• Chibber, R et al

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Aim

• To assess whether air travel elevates risk of
  adverse pregnancy outcomes
• healthy women
• single pregnancies
• gt 20 weeks

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Background

• King Faisal University, Damman, Saudi Arabia
• Large expatriate workforce from Asia, Australia
  NZ
• Health care or academic workers
• Travel home frequently by air
• Antenatal care delivery at Uni Hospital

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Methods

• 992 women delivering over 12 months
• 546 (55) study group
• At least one flight
• 447 (45) control group
• No flights

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Methods

• Full antenatal history
• Detailed flight history
• Excluded
• Medical conditions eg. Renal, Cardiac
• Neonatal Chromosomal abnormalities
• Bleeding or Tocolysis

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Methods

• Socioeconomic group and occupation gt reliable
  histories
• Pregnancies dated by early U/S
• Stratified by parity age etc.
• Long vs. short flights
• Avg. gestation age at flight

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Methods

• Composite outcome variable
• Stillbirth
• Apgar 5 min
• Delivery lt 37 weeks
• Preeclampsia
• Birthweight lt 10th centile

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Results

• Well matched by age, parity, socioeconomic
  status, education, except
• More expats in study group

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In primigravidae

• Increased preterm birth gt34 and lt37 wks (36.1 vs
  39.2)
• Lower birth weights
• (2684 vs. 3481g)
• Definite relationship between gestation delivered
  and
• Gestation first flew
• Hours airborne

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In multigravidae

• No significant findings
• In all groups, no difference in
• Bleeding
• Preeclampsia
• Caesarean
• Neonatal asphyxia / death

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Discussion

• Prim. travel early (11wks)
• longer hours (7.8hrs)
• frequently (median 7 flights)
• Multi. live in region and travelled later (14wks)
• Shorter (5.6hrs)
• Less frequent (median 4)

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Discussion

• Large numbers, well matched, accurate records,
  unique study opportunity
• Despite prematurity, outcomes satisfactory
• Risk of prem delivery if frequent long flights
  during early pregnancy
• Aetiology uncertain

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Other papers

• Freeman et al,
• Arch Gynecol Obstets 2003
• 222 US women
• shorter flights, less flights
• no apparent problems
• Aspholm et al,
• J Occ Environ Med 1999
• 1751 pregnancies Flight Attendants
• Spontanous abortions increased

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The potential of Human Papillomavirus vaccines.

• NEJM
• 16 March 2006
• 354(11) 1109-1112
• Steinbrook, R

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Vaccine against HPV

• Expected release by June
• FDA priority review
• Two vaccines under development
• Merck
• GlaxoSmithKline

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HPV and Cervical Cancer

• 6.2 million infections per year in USA
• Cervical cancer gt10,000 cases and gt3700 deaths
  per year
• Many not screened
• Second most common cancer in women in developing
  countries (11th in USA)

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Vaccine

• Merck Quadrivalent
• Three doses 0,2 6 months
• Women and men
• Types 16 18, cause 70 of cancers
• Types 6 11 cause 90 genital warts
• GSK Bivalent against types16 18

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Potential Impact

• Reduction in cervical cancer
• Associated screening, follow-up, biopsy
  surgical costs
• High efficacy
• Suggested routine use in 11-12 year olds
  immunity before sexually active

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Public Health Policy

• Community issues sexuality
• Doesnt prevent other STDs
• Prevention in those who are unscreened
• Costly initially
• Benefit seen in decades

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Contrast sensitivity a brief review.

• Journal of the Australasian Society of Aerospace
  Medicine
• Jan 2006, 2(2) 12-13
• Black, D
• Ophthalmologist Brisbane
• RAAF Reservist

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Background

• Snellen Chart in use since late 1800s
• Useful test with high contrast
• In real life, low contrast and low light levels
• Black cat on white snow versus grey cat on
  snow

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Clinical

• Patients can pass Snellen chart but have poor
  visual performance
• Evidence that poor contrast sensitivity
  associated with increased road crash in elderly
• Can be caused by early cataracts

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Testing

• Qualitative rather than quantitative
• Audiogram vs. single frequency test
• Likely to see increased use
• Computer on-line testing
• www.contrastsensitivity.net

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Pelvic Antishock Sheeting

• Air Medical Journal
• March 2006
• 25(2) 88-90
• Higgins, TF Swanson, ER

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Summary

• Describes the application of a folded sheet to
  stabilize the pelvis and tamponade pelvic
  bleeding
• Refers to other pelvic binding options

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Procedure

• Place folded sheet under patient at level of
  greater trochanters
• Compresses pelvis via femoral necks
• Frees lower abdo and groin for examination
  lines
• Knot or clamp

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Pre Post Pelvic Binding
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Pelvic Binding Devices

• Sheet
• London Splint
• Geneva Belt
• TPOD
• KED
• MAST

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London Splint
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Geneva Belt
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TPOD Pelvic Binder
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Pelvic Binder

• A choice of Desert Camo, Green Camo or Yellow!

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MAST Splints compresses
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What are we trying to achieve?

• Splint the bones of pelvis pain, reduce
  bleeding
• Tamponade pelvis?
• More difficult, retroperitoneal, limited impact
  with arterial bleeding
• Controversy over early management ext. fixators
  /arterial embolisation

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• We could do better with our pelvic splinting for
  transport

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Airway management by US Canadian Emergency
Medicine Residents A multicenter analysis of
more than 6,000 intubation attempts.

• Annals of Emergency Med
• Oct 2005
• 46(4) 328-336
• Sagarin MJ et al

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Methods

• 31 University-affiliated ED training programs
• 58 months (Sep 96-Jun 01)
• Emergency residents to PGY 6 and attending
  physicians
• Prospective study of intubations

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Overview

• 7,498 intubations in US Canada
• 6,661 by EM staff
• 5,768 by EM residents
• 68 medical cases
• 32 trauma cases

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Results

• Initial intubator
• 83 success 1st attempt
• 6 success 2nd attempt
• 1 success 3rd attempt
• Total success by First Intubator 90

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Results

• Technique for Initial Attempt
• Rapid Sequence 78
• Oral no Rx 11
• Oral sedation 4
• Nasotracheal 5
• Cricothryotomy 0.2

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Results

• Rapid sequence used
• Etomidate 69
• Midazolam 16
• Fentanyl 6
• Ketamine 3
• Sux 82
• Roc 12
• Vec 5

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Results

• Rescue intubations by second person
• First attempt 80
• Total success 88
• Cricothyrotomy rate overall was 0.9
• Success rate improved with years of experience

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Discussion

• Most likely easy cases for more junior staff
• Crico rate 1 falling from previous 10 rate
  (1995)
• A benchmark for EM staff in University-affiliate
  d EDs
• Supports role of EM physicians in initial airway
  management?

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!
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Safety belt use in 2005 Nearly an epidemic of
safety.

• Annals Emergency Med
• April 2006
• 47(4) 371-2
• McKay, MP

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Commentary

• 50th anniversary of optional accessory in
  vehicles
• National Highway Traffic Safety Administration
  (NHTA)
• Overall use in USA now
• 82 front seat
• 68 rear seat use
• Most other countries 95 usage

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• Only 31 States primary law for front seat use
• Only 19 States - rear seat use
• One State no legislation lt50 usage
• Calls for education in ED

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e-Journals

• Most journals available electronically
• NEJM has had audio articles and now includes
  video papers
• NEJM 13 April 2006
• 354e13
• Tegtmeyer, K et al (FREE)

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www.nejm.org
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Copies of articles (pdf)

• G\everyone\Training\Thursday Videoconferences