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"There is little doubt that recommended indications for statin prescribing have been stretched by new guidelines." [ABSTRACT FROM AUTHOR]

Sevral letters to the editor is presented in response to the article "Cholesterol Treatment Trialists (CTT) Collaborators. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials," published in a previous issue of the periodical.

A letter to the editor is presented in response to the articles "Treatment of Acute Otitis Media in Children Under 2 Years of Age," by A. Hoberman, J. L. Paradise, H. E. Rockette and colleagues in the January 14, 2011 issue.

Despite mortality reductions found in early trials, recent population-based data suggest that breast and prostate cancer screening have not yielded expected benefits. Whereas evidence-based appraisals generally mistrust disease-specific mortality as a primary outcome measure, cancer screening trials have consistently used this endpoint, largely because of the impracticality of studies with enough statistical power to detect all-cause mortality reductions, which would require millions of subjects. The acceptance of disease-specific mortality as a practical surrogate for all-cause mortality may explain the discrepancy between expected and actual impact. Screening may reduce deaths from the target cancer but may increase deaths from other causes, most likely because of overdiagnosis, an increasingly recognized risk of cancer screening. Recognition of the discrepancy between the expected and the actual impact of screening and recognition of overdiagnosis as a source of harm may be critical for understanding and projecting the potential impact of cancer screening programs. [ABSTRACT FROM PUBLISHER]

This paper examines housing demand using an integrated approach that combines residential decisions about choices of community in the Southern Appalachian region with the application of a Geographical Information System (GIS). The empirical model infers a distinctive heterogeneity in the characteristics of community choices. The results also indicate that socio-economic motives strongly affect urban housing demands while environmental amenities affect those of rural housing demand. [ABSTRACT FROM AUTHOR]

Abstract: Out-of-hospital cardiac arrest (OOHCA) treatment produces dismal recovery rates. Newer, directed therapies such as thrombolysis may be best considered if possible etiologies can be assessed immediately. We conducted a prospective, pilot, feasibility study of on-scene physician assessments in non-traumatic OOHCA. Physicians responded to the scene and reported likelihood of thromboembolic etiology based on detailed history and physical assessments. Included were 136/148 OOHCAs during the 6-month study period; median age was 69.5 years and 72% were men. Physicians judged 103/136 (76%) of arrests to be of thromboembolic etiology and would have recommended thrombolytic bolus in 83/136 (61%). Among 19 instances of physician-reported contraindications, 17 (90%) were not true contraindications. Median age was lower in the group recommended for thrombolysis. Thromboembolic etiology as judged by on-scene physicians was common and physicians recommended thrombolytic bolus commonly. Contraindications were highly overestimated. These data may be useful in the consideration of innovative, directed therapies such as thrombolysis in attempts to improve outcomes from OOHCA. [Copyright &y& Elsevier]

Favorable neurological survival in out-of-hospital cardiac arrest (OOHCA) may be influenced by cerebral perfusion during resuscitation. Cerebral oximetry (COx) provides a portable, noninvasive, real-time index of cerebral perfusion that has not been studied in OOHCA. This study examined the feasibility of using COx to measure cerebral perfusion during OOHCA. As a secondary aim, we tested the hypothesis that cerebral perfusion, measured by COx, would decrease with hyperventilation. Subjects were patients with medical OOHCA. A physician responded to the scene of cardiac arrest calls and applied an INVOS 3000 COx probe (Somanetics) to the frontal skull. In a cross-over design, readings were recorded for 2 min while ventilation rate was maintained at 10/min, then for 2 min at 24/min. COx readings were recorded by the oximeter and manually by the investigator. Statistical analyses were done using a paired t-test. Sixteen subjects were enrolled, four had return of pulses. COx reliably detected cortical oxygenation in only one subject during cardiac arrest. None of 16 patients exhibited consistently detectable levels of oxygen during cardiac arrest. In three subjects with ROSC, readings increased with return of pulses and with increasing blood pressure. In a fourth subject the protocol was completed and the device removed, subsequently ROSC was noted and the device re-applied. No patient exhibited any change in oxygen levels with variation of ventilation rates during CPR. The use of cerebral oximetry during OOHCA is feasible. In our sample of OOHCA patients, cerebral perfusion is rarely detectable using an oximeter during CPR. Ventilation rate does not alter the oximeter readings. It is possible that the current standard mechanical method of cardiopulmonary resuscitation provides little or no cerebral oxygenation during OOHCA. [Copyright &y& Elsevier]

This study estimates the value of socioeconomic, spatial and environmental attributes on housing prices of both urban and rural communities in the primary and second home areas of the Southern Appalachian Highlands, using the hedonic property price model. Distance and environmental attributes are valued more heavily in the rural communities of the second home area than in the urban communities of the primary home area. The effect of second homes on housing prices is mainly evident in the rural communities. Second home development impacts a home's value by US$2,378, or 4.2% of $56,245, the average value of a rural home. [ABSTRACT FROM AUTHOR]

Negative people/wildlife interaction has raised public interest in wildlife population control. We present a contingent valuation study of alternative deer control measures considered for Hilton Head Island, SC. Lethal control using sharpshooters and nonlethal immuno-contraception techniques are evaluated. A mail-back survey was used to collect resident willingness-to-pay (WTP) information for reduced deer densities and consequent property damage. Residents are unwilling to spend more for the nonlethal alternative. The estimated WTP appears theoretically consistent as increasing levels of abatement for both lethal and nonlethal alternatives demonstrate diminishing marginal benefits. Over 60% of respondents bid zero regardless of control measure, suggesting a referendum would fail. However, only half of these zero bidders expressed no problem with deer, while the other half bid zero because of distaste for the control alternative, safety concerns, or doubt about effectiveness. Inclusion of these responses as legitimate zero bids depressed mean WTP estimates from 22 to 31%. [ABSTRACT FROM AUTHOR]

A letter to the editor and a reply are presented in response to the article "A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study," by Martin Than and colleagues in the March 26, 2011 issue.

Introduction: You are sitting for your oral surgery board exam and the examiner asks what you do when you realize that you have accidentally cut the posterior vagus nerve during a hiatal hernia repair. Is the answer to proceed with a gastric drainage procedure correct? The prevailing dogma seems to be that inadvertent vagotomy will produce gastric stasis/paresis and the stomach will not empty and hence should be accompanied by a gastric drainage procedure. This report presents clinical outcomes of 49 patients who underwent truncal vagotomy without a drainage procedure (pyloroplasty or gastrojejunostomy). Methods: 49 patients underwent truncal vagotomy with laparoscopic adjustable gastric banding in an IRB (Investigational Review Board)-approved clinical trial to determine if the addition of a vagotomy would increase achieved weight loss when compared to gastric banding alone. The details of this trial were presented at SAGES (Martin and Earle in Surg Endosc 25:2522–2525, 2011) in 2010. The patients in this study have been followed for over ten years and their histories were examined to look for evidence of gastric stasis or intractable diarrhea or if they required further surgery for these complaints. Results: 49 patients have been followed for a mean of 10.9 years. All except one have experienced a loss of hunger and cessation of gastric borborygmus. One patient showed mild delayed gastric emptying after developing diabetes. Two other patients with DM carry a diagnosis of gastroparesis. No patient has experienced intractable diarrhea. Five patients have had revisions to sleeve gastrectomy or gastric bypass for weight loss failure or esophageal dilatation and GERD. Conclusions: Review of these truncal vagotomy patients without drainage procedures at 10 years does not support the myth that the stomach will not empty after vagotomy and a gastric drainage procedure should always accompany truncal vagotomy. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Understanding bias -- the case for careful study" by L. Rosenbaum in the 2015 issue.

A letter to the editor is presented in response to the article "The Statins in Preventive Cardiology" by D. Steinberg in the October 2, 2008 issue.

A letter to the editor is presented in response to an article by Jonathan Emberson and colleagues on the meta-analysis of the effectiveness of intravenous thrombolysis with alteplase in the management of patients with acute ischemic stroke in the November 29, 2014 issue.

A letter to the editor is presented in response to the article by E. W. Gregg et. al. in the April 17, 2014 issue, concerning the article's speculative conclusion that reduction in diabetes-related complications is due to clinical interventions in the absence of the best available evidence.

A letter to the editor is presented in response to the article "Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association and the European Association for the Study of Diabetes" by Inzucchi S.E. in a 2015 issue.

Although the economic benefits of biomass heating in rural regions have been widely asserted, few studies have conducted a thorough economic impact analysis within the United States. This study proposes biomass district heating (BDH) as a means to stimulate the rural economy of the Tug Hill region of New York State by establishing a local industry and providing lower cost heat compared to the local alternative, #2 fuel oil, and examines the associated economic impacts. Since there are no BDH networks endogenous to the region, an expenditure pattern approach to input–output analysis is employed. The $11.4 million spent annually over the 20 year project payment period on the construction, biomass procurement, and production of heat with BDH would generate $18.7 million in local economic activity and create 143 jobs throughout the three county model region; a significant impact if concentrated around the rural study villages. These impacts are comparable, but less than, those modeled by other studies in countries with more established BDH networks. However, the precision of the impacts generated by the model are tempered by the significant discrepancy between the study region and the three county model region which included several larger urban areas. Ultimately, the limitations associated with the model scale and the absence of established expenditure patterns inhibit major conclusions in regards to the discreet impacts of BDH to the study villages, although a significant portion of the annual impacts estimated can be expected to occur in the villages given the location of the BDH networks. [ABSTRACT FROM AUTHOR]

The economic feasibility of Biomass District Heating (BDH) networks in rural villages is largely unknown. A cost-effective evaluation tool is developed to examine the feasibility of BDH in rural communities using secondary data sources. The approach is unique in that it accounts for all the major capital expenses: energy center, distribution network, and energy transfer stations, as well as biomass procurement. BDH would deliver heat below #2 fuel oil in eight of the ten rural study villages examined, saving nearly $500,000 per year in heating expenses while demanding less than 5% of the forest residues sustainably available regionally. Capital costs comprised over 80% of total costs, illuminating the importance of reaching a sufficient heat density. Reducing capital costs by 1% lowers total cost by $93,000 per year. Extending capital payment period length five years or lowering interest rates has the next highest influence decreasing delivered heat price 0.49% and 0.35% for each 1% change, respectively. This highlights that specific building heat is a strong determinant of feasibility given the relative influence of high-demanding users on the overall village heat-density. Finally, we use a stochastic analysis projecting future #2 fuel oil prices, incorporating historical variability, to determine the probability of future BDH feasibility. Although future oil prices drop below the BDH feasibility threshold, the villages retain a 22–53% probability of feasibility after 20 years as a result of high #2 fuel oil price variability. [ABSTRACT FROM AUTHOR]

As of September 2013, federal and state governments had nearly 500 policies to support production of electricity and heat from forest biomass. This research used a four-tier classification structure to categorize policy instruments used in these policies based on: approach (incentive, regulation, information), type (e.g. tax incentive), subcategory (e.g. tax exemption), and specification (e.g. sales tax exemption). More (113) of these policies were enacted in 2007 and 2008, more than in any other two-year period, and there was a significant increase in the number of forest bioenergy (46) and biomass specific (36) policies by 2013. Cluster analysis provided evidence that neighboring states adopted similar numbers and types of policies. Oregon (in cluster by itself) had the highest number of tax incentives and biomass-specific policies, while most Southern, Southeast, Southern Appalachia and Midwestern states (the most dissimilar cluster to Oregon) had a limited number of policies. Most states in remaining clusters offered a mix of integrated policies, rather than policies focused on regulations and technology improvement. Our findings provide guidance for policy development by enabling the transfer of policy approaches among different states and regions. [ABSTRACT FROM AUTHOR]

The risk of cancer from computed tomography (CT) scan radiation is a rising concern in the medical field. Our objectives were to determine how many patients received more than ten CT scans in an academic emergency department (ED) over the course of 7 years and to quantify their radiation exposure and lifetime attributable risk of cancer. An electronic chart review was performed at our urban academic institution with an annual census of 110,000 patients. All patients who underwent a CT scan performed during ED management between the dates of January 2001 and December 2007 were identified. Specific predetermined data elements (e.g., subject demographics, type of CT scan) were extracted by two researchers blinded to hypothesis, using a preformatted data form. After identifying patients with more than ten CTs performed during the study period, radiation exposure was calculated based on accepted and reported radiation doses for the respective anatomic CTs, and lifetime attributable cancer risk was calculated based on the seventh report of the Biological Effects of Ionizing Radiation (BEIR VII) projections. Over the 7-year study period, 24,393 patients received 34,671 CT scans. The vast majority of patients (17,909) received a single CT. Twenty-six (0.1 %) patients received more than ten CTs totaling 374 scans with an average radiation exposure of 83.4 mSv. The maximum lifetime attributable risk for any individual in this cohort was 1.7 % above the baseline cancer risk. Among those undergoing CT imaging in our ED, high-exposure patients (greater than ten scans) constituted a significant minority, while more than one in four patients underwent more than one CT scan during the study period. While the presumed overall risk of radiation-induced cancer continues to be low, it is important for the emergency physician to use clinical knowledge as well as concern for the patient when utilizing radiographic imaging. Increasing attributable cancer risk may have important public health implications in the future, regardless of the low individual risk. [ABSTRACT FROM AUTHOR]

Abstract: Background: The difficulties with gum elastic bougie (GEB) use in the emergency department (ED) have never been studied prospectively. Objectives: To determine the most common difficulties associated with endotracheal intubation using a GEB in the ED. Methods: We conducted a prospective, observational study of GEB practices in our two affiliated urban EDs with a 3-year residency training program and an annual census of 150,000 patients. Laryngoscopists performing a GEB-assisted intubation completed a structured data form after laryngoscopy, recording patient characteristics, grade of laryngeal view (using the modified Cormack-Lehane classification), reason for GEB use, and problems encountered. Data were analyzed using standard statistical methods and 95% confidence intervals. Results: A GEB was used for 88 patients. The overall success rate was 70/88 (79.6%; 95% confidence interval [CI] 71.1–88.0%). The GEB failure rate of the first laryngoscopist was 25/88 (28.4%; 95% CI 21.0–40.3%), with the two most common reasons being: inability to insert the bougie past the hypopharynx in 13 (52%; 95% CI 32.4–71.6%) and inability to pass the endotracheal tube over the bougie in six (24%; 95% CI 7.3–40.7). Conclusions: The GEB is a helpful rescue airway device, but emergency care providers should be aware that failure rates are relatively high at a teaching institution. [Copyright &y& Elsevier]

Abstract: Background: Current clinical practice in many emergency departments (EDs) includes checking a type and screen blood test (T&S) for Rhesus (Rh) status on all pregnant patients presenting with vaginal bleeding or abdominal pain. The test is expensive, and awaiting results may delay disposition. Objective: To determine if there is a subset of pregnant women who reliably know their blood type and for whom a T&S blood test to determine Rh status can be safely omitted or deferred. Methods: A prospective study at two associated urban academic centers with an annual ED census of 150,000 patients was performed between January 2007 and June 2008. Pregnant patients who had a T&S obtained as part of their ED evaluation were enrolled. Subjects completed a standardized data form that requested demographic information and were asked to select “no,” “maybe,” or “yes, definitely” if they knew their blood type. Standard descriptive statistics with 95% confidence intervals were performed. Results: There were 319 pregnant women enrolled in the study. Among the 106 subjects that reported “yes, definitely” they knew their blood type, 103 (97.2%; 95% confidence interval [CI] 94.0–100%]) identified their correct blood type and 105 (99.1%; 95% CI 97.2–100%) identified their correct Rh status. None of these subjects selected a positive Rh when they were in fact a negative Rh. All 14 (13.2%) subjects with a negative Rh status identified themselves as having a negative Rh. Conclusion: Pregnant women reporting that “yes, definitely” they know their blood type, are reliable. Deferring T&S testing test may be reasonable. [Copyright &y& Elsevier]

Abstract: Background: The gum elastic bougie (GEB) is a rescue airway device commonly found in the emergency department (ED). However, data documenting its efficacy are lacking in the emergency medicine literature. Study Objectives: To determine the success rate of endotracheal intubation using a GEB and the reliability of “palpable clicks” and “hold-up” in the ED setting. Methods: The GEB was introduced at our two affiliated urban EDs with a 3-year residency training program and an annual census of 150,000. Physicians were trained in the use of the GEB before initiation of the study. Over the course of 1 year, we conducted a prospective, observational study of GEB practices in the ED. The study population included all adult patients on whom intubation was attempted with a GEB. All emergency physicians attempting intubation completed a structured data form after laryngoscopy, recording patient characteristics, grade of laryngeal view (using the modified Cormack-Lehane classification), and presence of “palpable clicks” and “hold-up.” Indications for GEB use in our ED include a difficult or rescue airway and for training purposes. Data were analyzed using standard statistical methods and 95% confidence intervals. Results: In our study period, there were 26 patients on whom intubation was attempted with a GEB. The overall success rate was 20/26 (76.9%; 95% confidence interval [CI] 60.7–93.1%). Among cases where the GEB was used for training purposes (all grade 1 or 2a laryngeal view), six of seven (85.7%) intubations were successful. When the GEB was used for clinically indicated purposes, 14 of 19 (73.7%; 95% CI 53.9–93.5%) intubations were successful. Palpable clicks were appreciated in 11/20 successful intubations (sensitivity 55.0%; 95% CI 33.2–76.8%); there was one false positive (specificity 80%; 95% CI 40.9–98.2%). Of 20 successful intubations, hold-up was deferred in five cases; of 15 remaining cases, hold-up was appreciated in 5/15 (sensitivity 33.3%; 95% CI 9.5–57.2%); there were no false positives (specificity 100%; 95% CI 60.7–100%). Conclusions: In our ED setting, the GEB had a success rate of 73.7% when utilized as a rescue airway after failed attempts. The characteristics of “palpable clicks” and “hold-up” were unreliable. [Copyright &y& Elsevier]

Vasopressin administration has been suggested during cardiopulmonary resuscitation, and a previous clinical trial has suggested that vasopressin is most effective when administered with epinephrine. Adult subjects (n = 325) who received ≥1 dose of intravenous epinephrine during cardiopulmonary resuscitation for nontraumatic, out-of-hospital cardiac arrest were randomly assigned to receive 40 IU of vasopressin (n = 167) or placebo (n = 158) as soon as possible after the first dose of epinephrine. The rate of return of pulses was similar between the vasopressin and placebo groups (31% vs 30%), as was the presence of pulses at the emergency department (19% vs 23%). No subgroup appeared to be differentially affected, and no effect of vasopressin was evident after adjustment for other clinical variables. Additional open-label vasopressin was administered by a physician after the study drug for 19 subjects in the placebo group and 27 subjects in the vasopressin group. Results were similar if these subjects were excluded or were assigned to an actual drug received. Survival duration for subjects admitted to the hospital did not differ between groups. In conclusion, vasopressin administered with epinephrine does not increase the rate of return of spontaneous circulation. [Copyright &y& Elsevier]

Several letters to the editor in response to the article "Update on the third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke and baseline features of the 3035 patients recruited," by Peter Sandercock, Joanna Wardlaw, Martin Dennis in the previous issue of the periodical and a response by the authors to same, are presented.