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October 13, 2009
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Volume 4
Issue 41
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DynaMed Systematic Literature Surveillance
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For the week ending October 9, 2009
Last week 646 articles were evaluated via DynaMed’s Systematic Literature Surveillance and 226 were added to DynaMed content.
Based on the editors’ criteria of selecting “articles most likely to change clinical practice,” one article of significant interest was selected for the DynaMed Weekly Update.
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Prediction Rule Identifies Low Risk Children after Minor Head Trauma
Computed tomography (CT) is often performed on children with head trauma to diagnose clinically important traumatic brain injuries. Attempts have been made to develop criteria that might safely avoid unnecessary procedures. The Pediatric Emergency Care Applied Research Network study (PECARN) has now developed a prediction rule that identifies children at very low risk of clinically important injury for whom CT imaging may be avoided (level 1 [likely reliable] evidence). The derivation and validation cohorts included 42,412 children < 18 years old (10,718 children < 2 years old) presenting to emergency departments within 24 hours of head trauma with Glasgow Coma Scale scores of 14-15. CT scans were performed in 35% of the children at the discretion of the attending physician, and clinically important trauma was identified in 0.32% of the children.
Based on the results of this study, CT can safely be withheld for children > 2 years old meeting all of the following criteria: normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache. CT can be withheld in children < 2 years old if they meet all of the following criteria: normal mental status, no scalp hematoma except frontal, loss of consciousness 0-5 seconds, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents. The rule had sensitivity of 97%-100%, specificity of 54%-60%, and negative predictive value of 99%-100% (Lancet 2009 Oct 3;374(9696):1160).
For more information, see the Decision rules for computed tomography in head injury in children topic in DynaMed.
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DynaMed Extra
Role of Proton-Pump Inhibitors Increasing Cardiovascular Events in Patients Taking Anti-Platelet Agents Questioned
A previous DynaMed Weekly Update reported results of 2 retrospective studies showing an association between the combined use of proton pump inhibitors (PPIs) and clopidogrel (Plavix) and increased adverse cardiovascular events in patients with acute coronary syndrome or myocardial infarction. A new study has presented conflicting evidence, based on analyses comparing outcomes in patients taking vs. not taking PPIs in 2 trials evaluating clopidogrel vs. prasugrel. There were no significant differences associated with PPI use in the composite outcomes of cardiovascular death, myocardial infarction, and stroke in patients receiving clopidogrel (level 2 [mid-level] evidence). In another study noted in the same report, mean inhibition of platelet aggregation was lower with PPIs compared to no PPIs at 6 hours after clopidogrel 600 mg loading dose (p = 0.02) (Lancet 2009 Sep 19;374(9694):989).
For more information, see the Clopidogrel topic in DynaMed.
Semmes-Weinstein Monofilament Exam for Diabetic Peripheral Neuropathy Screening
A recent systematic review evaluated the performance of the Semmes-Weinstein monofilament exam for detecting diabetic peripheral neuropathy compared to a variety of reference tests (J Vasc Surg 2009 Sep;50(3):675) (level 2 [mid-level] evidence). In 4 studies using nerve conduction testing as the reference standard, sensitivity of the monofilament exam ranged from 57%-93% and specificity ranged from 75%-100%, varying with monofilament size, number and location of testing sites, and diagnostic thresholds. Based on limited evidence, the authors suggest that optimal sensitivity can be achieved by using a 5.07/10 g monofilament to test at 3 sites on each foot: the plantar aspects of great toe and the third and fifth metatarsal heads.
For more information, see the Diabetic neuropathy topic in DynaMed.
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Subscribe FREE to DynaMed Weekly Update
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Medical Calculators
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DynaMed now includes more than 500 clinical calculators, decision rules and statistics calculators to give clinicians even more decision making tools to use at the point of care.
After logging in, click on Calculators in the upper right corner of the screen to access this new feature.
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DynaMed Weekly Update is a compilation of 1 to 5 articles that are of significant interest to clinicians. Articles are selected from DynaMed's Systematic Literature Surveillance as articles most likely to change clinical practice. Updates are prepared by the DynaMed Editorial Team which includes 28 clinicians from multiple disciplines. Send comments to DynaMedEditor@epnet.com. To learn more about DynaMed, go to www.dynamicmedical.com.
Published by
Copyright © 2009 EBSCO Publishing. All rights reserved.
DynaMed® is a registered trademark of and published by DynaMed LLC. Original date of on-line publication December 15, 1995 with continuous daily updating. ISSN: 1554-1177. Subscriptions and queries can be addressed to DynaMed LLC, EBSCO Publishing, 10 Estes St., Ipswich, Massachusetts, USA 01938-0602, telephone (978) 356-6500, facsimile (978) 356-6565, e-mail Editor@DynamicMedical.com.
The opinions expressed herein are solely those of the authors and editors and may or may not represent the official position of cooperating or endorsing Medical Societies.
Development of DynaMed was supported in part by the National Science Foundation through a Small Business Innovative Research grant. (All other support comes from subscriptions. No advertisements are accepted.) 
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