UCONN Emergency Medicine Interest Group

Archive for the ‘JOURNAL CLUB’ Category

Journal Article Synopsis: Chronic Illness and Socioeconomics

In JOURNAL CLUB on November 20, 2011 at 7:00 AM

Summary of  “The relationship between chronic illness, chronic pain, and socioeconomic factors in the ED” by Owen Hanley, James Miner, Erik Rockswold, Michelle Biros. The American Journal of Emergency Medicine, Volume 29, Issue 3, March 2011, pp. 286-292.

With chronic health problems becoming the main focus of health care efforts and dollars in the United States there have been increased efforts to identify patient populations who are at the greatest risk for these diseases. This cross-sectional study was aimed to determine the prevalence of chronic illness and pain in the emergency department in patients of varying demographic backgrounds. Previous studies have shown that a small number of “frequent flyers” represent a substantially larger proportion of total ED visits.  Furthermore, other studies have shown that socioeconomic status and ethnicity can play an important role in ascertaining ones risk for illness, as certain populations disproportionately use emergency medical services. To appropriately address the rise of chronic health problems it is important to characterize populations at risk that are presenting to the ED. This study sought to identify these characteristics of patients that present to the ED with higher rates of chronic illness and chronic pain and to identify social mechanisms that are related to the disproportionate disease occurrence.

The study concluded that having limited access to primary care correlated with a higher perceived incidence of chronic illness, followed by family income and housing status.  The quality of a person’s environment was found to contribute the largest  to a persons perceived chronic pain as those in poor housing status reported to be in the most discomfort.

These conditions being tremendous strains on Emergency Departments across the United States raise an interesting question: can improvementsto a patients living situation and access to medical care in lower socioeconomic levels alleviate the financial and physical burden on Emergency Departments across the country?

Advertisements

Journal Article Synopsis: Apixaban and ACS

In JOURNAL CLUB on October 30, 2011 at 7:00 AM

Summary of “Apixaban with Antiplatelet Therapy after Acute Coronary Syndrome” by John Alexander et. al, New England Journal of Medicine ePub ahead of print: July 24th 2011: pp. 1-10

What is already known on this topic:
Patients with acute coronary syndromes frequently have recurrent ischemic events despite the use of currently recommended antiplatelet therapy, revascularization procedures, and other evidence based secondary preventative measures. Anticoagulation therapy with oral vitamin K antagonists reduces the recurrence of ischemic events following MI however, when added to aspirin or aspirin and clopidogrel combined it increases the risk of bleeding. Previous studies of the use of the factor Xa inhibitor apixiban were conducted in patients who had recent acute coronary syndrome and were receiving aspirin or aspirin and clopidogrel. Treatment with apixiban resulted in dose related increase in bleeding with a trend towards fewer ischemic events.

What question this study addressed:
Does the benefit of adding apixiban to standard acute coronary treatment outweigh the increased risk of bleeding in high-risk patients?

What was the study design:
The Apixiban for Prevention of Acute Ischemic Events 2 (APPRAISE-2) trial was a double blind, placebo-controlled, randomized clinical trial conducted at 858 sites in 39 countries. Patients included in this study must have had an acute coronary syndrome (myocardial infarction, with or without ST-segment elevation, or unstable angina) within the previous 7 days, with symptoms of myocardial ischemia lasting more than 10 minutes with the patient at rest plus either elevated cardiac biomarkers or dynamic ST-segment elevation or depression of 0.1mV or more. Patients meeting these criteria were eligible for the study if their condition was clinically stable and they were receiving standard treatment for acute coronary syndrome, including aspirin or aspirin and any P2Y12-receptor antagonist. Eligible patients were also required to have two high-risk characteristics which included: an age of at least 65 years, diabetes mellitus, MI within the previous 5 years, cerebrovascular disease, peripheral vascular disease, clinical heart failure or a left ventricular ejection fraction of less than 40% in association with the index event, impaired renal function with a calculated creatinine clearance of less than 60ml per minute, and no revascularization after the index event.

What this study adds to our knowledge:
Administration of apixiban at a dose of 5mg twice daily in high risk patients taking either aspirin or aspirin plus clopidogrel significantly increases bleeding events, including events of fatal and intracranial bleeding, without significant reduction in recurrent ischemic events.

How this is relevant to clinical practice:
The current standard of care for patients after acute coronary syndrome includes dual antiplatelet therapy, usually with aspirin and clopidogrel. Even with this aggressive antiplatelet therapy patients still frequently experience recurrent ischemic events. Newer P2Y12 antagonists are more potent and provide additional reductions in ischemic events and mortality but at the cost of increased risk of bleeding. The combination of antiplatelet and anticoagulant therapy seems attractive, yet it may pose an unacceptable risk of bleeding.

Other considerations:
The population included in the study comprised only high-risk patients, with large proportions of those patients having diabetes, heart failure, or renal insufficiency. The lack of significant reduction in recurrent ischemic events could partially be a product of such a high-risk population. As the authors noted, there may be other patient populations for which the results may be different.

Journal Article Synopsis: Vascular Access during Out-of-Hospital Cardiac Arrest

In JOURNAL CLUB on October 16, 2011 at 8:00 AM

Summary ofJournal Article Synopsis: Intraosseous Versus Intravenous Vascular Access During Out-of-Hospital Cardiac Arrest: A Randomized Controlled Trial,” Reades, Rosalyn, MD; Studnek, Jonathan R., PhD, NREMT-P; Vandeventer, Steven, EMT-P; Garret, John, MD.  Annals of Emergency Medicine. 2011 Aug 17. [Epub ahead of print]

What is already known on this topic:
Intraosseous vascular access was originally used mainly in children.  However, it has recently been shown that this method is also a rapid and effective way to obtain vascular access in the adult population, especially when a peripheral intravenous line fails.  Therefore, this technique is used commonly in out-of-hospital settings when rapid vascular access is needed during cardiac arrest.  Emergency Medical Services (EMS) protocols in the US list sternal, humeral, and tibial locations as available sites for intraosseous vascular access.

What question this study addressed:
The humeral and tibial locations are better sites during cardiac arrest due to constant chest compressions.  However, data regarding the effectiveness of the humeral site versus the tibial site are limited.  This study assessed the frequency of first-attempt success between humeral intraosseous, tibial intraosseous, and peripheral intravenous routes during out-of hospital cardiac arrest.

What was the study design:
This study was a prospective, nonblinded, triple-arm, randomized control trial of 182 adult patients over 18 years of age experiencing a non-traumatic out-of-hospital cardiac arrest in which resuscitation was initiated.  Patients were randomized to one of 3 vascular access routes: tibial intraosseous, humeral intraosseous, or peripheral intravenous.  Paramedics received extensive training in each method.  The outcome measure was first-attempt success, defined as secure needle position in the marrow cavity or a peripheral vein with normal fluid flow.  If a needle dislodged, it was considered a failure.

What this study adds to our knowledge:
Tibial intraosseous vascular access was determined to be the optimal method with regards to highest success rate and fastest time to access.  However, peripheral intravenous access was associated with a higher volume of infused fluid.

How this is relevant to clinical practice:
Tibial intraosseous vascular access is beneficial for patients in who are in cardiac arrest or unconscious and who are unlikely to need large-volume fluid resuscitation.  Its location is more removed from the primary site of resuscitation efforts, and is generally not beneath large amounts of soft tissue.

Other considerations:
The cost of intraosseous vascular access is much greater than the cost of peripheral intravenous vascular access.  Further studies should be conducted to determine the cost effectiveness of tibial intraosseous over peripheral intravenous access.

Journal Article Synopsis: Triage and High-Acuity Patients

In JOURNAL CLUB on September 2, 2011 at 7:00 AM

Summary of “Mandatory Triage Does Not Identify High-Acuity Patients Within Recommended Time Frames. ” Weber, Ellen J.; McAlpine, Ian; Grimes, Barbara. Annals of Emergency Medicine. Vol 58, Issue 2. Aug 2011. pp. 137-142

What is already known on this topic:
Structured triage is commonly thought to identify the most acutely ill walk-in patients. While there is mandatory triage at most US emergency rooms, there is currently no published data showing that is effective in recognizing the most high-acuity patients within timeframe targets. In England, triage (in the traditional sense) was abandoned, as it was thought to be more of a hindrance than a help.

What question this study addressed:
This study looked to see if the process of triaging identified the most acutely ill patients within the “appropriate” timeframe, as determined by the Emergency Severity Index (ESI). By ESI standards, level-1 walk-in patients should be treated by a physician upon arrival, and level-2 walk-in patients should be treated within 10 minutes.

What was the study design:
This was a retrospective cross-sectional study which took place over the course of one year. It examined time from arrival to treatment all ESI 1 or 2 walk-in patients in the ED of a US, urban, tertiary-care hospital with an annual census of 39,000 patients (15% of whom arrive via ambulance.) The majority of walk-in patients were subject to ESI 5-tier triage, unless they were in “emergency condition,” in which case they were taken immediately to a treatment room where triage was completed.

What this study adds to our knowledge:
The study examined data from one ED over the course of one year, and found that triaging resulted in prolonged triage times (greater than those proposed by the ESI). Less than half of high-acuity patients were seen within ten minutes of arrival to the ED. Overall, median interval time from triage to treatment was 12.3 minutes, with a range of 128 minutes, and a 95th percentile of 38.6 minutes. Three quarters of these high-acuity patients arrived during peak hours, during which time median interval time was 13.5 minutes.

How this is relevant to clinical practice:
ED clinicians count on triage to identify the most acutely ill patients within a reasonable timeframe. The effectiveness of triage should therefore be examined in light of its value to both patients and physicians. A large amount of resources, time, and staffing are necessary for triage practice. As hospitals are considering cost and benefit carefully, triage should be evaluated for its utility in meeting the goal of triaging patients within the recommended time-frame. If it is not working to the advantage of physician and patient, alternative approaches for providing care without unnecessary delays should be considered.

Other considerations:
Several innovations for patient intake are being considered for implementation in the US. Some ED’s fill patient rooms as patients arrive, however, this is not useful once rooms are full. Some ED’s have a physician or mid-level provider staffed specifically to help triage. In England, ambulance arrivals and high-acuity walk-ins are brought immediately to patient rooms. Others remain in the waiting area where they are treated in order of arrival. There is no formal triaging or taking of vitals, although nurses continually asses patients for possible accelerated need for treatment, including need for pain medication. With this system in place, more nurses are available to work within the treatment area.

Journal Article Synopsis: β-hCG, Ultrasound, and Ectopic Pregnancies

In JOURNAL CLUB on August 8, 2011 at 3:32 PM

Summary of “Use of a β-hCG Discriminatory Zone With Bedside Pelvic Ultrasonography” By Ralph Wang et al, Annals of Emergency Medicine vol 58: pp. 12-20. 2011.

What is already known on this topic:
Currently, pregnant women presenting to the ED with abdominal pain, vaginal bleeding, or syncope are assessed with pelvic ultrasonography and quantitative serum β-human chorionic gonadotropin (β-hCG) to rule out the possibility of an ectopic pregnancy. In 10-30% of these cases pelvic ultrasound is unable to reveal either an intrauterine (IUP) or ectopic pregnancy- an “indeterminate result”. A level of β-hCG above the “discriminatory zone” of 1500-3000 mIU/mL, in combination with an indeterminate ultrasound, has been shown to be associated with ectopic pregnancy.

What question this study addressed:
What is the utility of the β-hCG discriminatory zone in differentiating between ectopic and intrauterine pregnancies after an indeterminate bedside pelvic ultrasonography in symptomatic pregnant patients presenting to the ED?

What was the study design:
Cross-sectional study of 256 first-trimester pregnant patients presenting to ED with symptoms of abdominal pain or vaginal bleeding. All pelvic ultrasonography was performed by emergency physicians who were blinded to the patient’s β-hCG levels. Research assistants (blinded to the ultrasound results) contacted and performed a standardized interview with all enrolled patients at 8 weeks.

What this study adds to our knowledge:
A β-hCG cutoff of 3000 mIU/mL is not acceptable for use in clinical practice when attempting to identify ectopic pregnancy in symptomatic patients with an indeterminate result on bedside pelvic ultrasonography (sensitivity of 35% and specificity of 58%). On follow up, it was found that 65% of patients with an ectopic pregnancy have a β-hCG < 3000 mIU/mL.

How this is relevant to clinical practice:
When pelvic ultrasound is indeterminate for intrauterine pregnancy, serum β-hCG level alone does not differentiate intrauterine and ectopic pregnancy. A β-hCG cutoff of 3,000 mIU/mL will not aid with the exclusion of ectopic pregnancy and will cause 65% of cases to be missed.

Other considerations:
In the future the discriminatory zone of β-hCG must be re-evaluated. The bedside pelvic ultrasound can reliably exclude ectopic pregnancy only when they demonstrate a clear intrauterine pregnancy in symptomatic pregnant ED patients. Practitioners should avoid an inappropriate interpretation of β-hCG levels in patients without a clear diagnostic result.

Journal Article Synopsis: Glidescope vs. Direct Laryngoscopy

In JOURNAL CLUB on July 31, 2011 at 2:57 PM

Summary for “Tracheal Intubation in the Emergency Department: A Comparison of GlideScope® Video Laryngoscopy to Direct Laryngoscopy in 822 Intubations” by John C. Sakles et al. in The Journal of Emergency Medicine.

What is already known on this topic:
While video laryngoscopy has been available for ED physicians, there hasn’t been much done in terms of study in comparing the success rates of video versus conventional direct laryngoscopy, especially in the ED. Most studies have been conducted in the OR or simulation laboratory.

What question this study addressed:
This study addresses the question, “How successful are first attempt intubations of using video versus conventional direct laryngoscopy?” It also addresses the success rate of second attempts, the key features and reasons for failure between the two devices.

What was the study design:
This study is a 24 month retrospective observation study on data collected concurrently between July 1, 2007 to June 30, 2009 on all ED patients intubated in a single academic ED with a Level I trauma center, belonging to a tertiary urban university. A one-page data collection sheet was completed by the operator upon completion of each intubation. The data forms were cross-referenced with the billing form to make sure missing forms were filled out. Video laryngoscopy (GVL) was done using GlideScope® standard, Colbat or Ranger. Conventional direct larygoscopy  (DL) was done using a traditional Miller/Macintosh laryngoscope.

What this study adds to our knowledge:
Prior studies in the OR and/or simulation laboratory have shown GVL to have faster and greater first time success rates compared to DL, especially in cases of cervical immobilization. However, most studies showed minimal to no difference in the use of either of these devices.

From this study, it showed that GVL indeed had a higher first time success rate in comparison to DL, especially in instances where there were two or more predicators for a difficult airway. However, in instances where more than one attempt was required, DL had better success rate than GVL. This is because the factors that cause GVL failure usually can’t be improved much, and physicians often abandon GVL for another device after failure of a first attempt, whereas with a DL, more attempts are usually tried before switching to another device, and failed attempts were usually improvable by adjusting the laryngoscope into a better position for a view of the glottic opening. Also, there were fewer esophageal intubations using GVL versus using DL.

How this is relevant to clinical practice:
This is relevant to clinical practice because intubation is a life-saving procedure that is performed in the ED on a daily basis. For patients with difficult airways, GVL is a viable solution to assist the physician in being able to acquire a view of the glottic opening for the intubation. GVL has been used by anesthesia in OR patients, and studies of its efficacy has been published. With these results of the use of GVL versus DL in the ED, this could possibly assist ED physicians in their choice of laryngoscopic device for patients.

Other considerations:
Future studies should be conducted regarding the comparison of each device in difficult airway situations.

Journal Article Synopsis: Is ED Hyperglycemia a Poor Prognostic Marker in Intracerebral Hemorrhage?

In JOURNAL CLUB on July 11, 2011 at 3:21 PM

Summary of “Emergency Department Hyperglycemia as a Predictor of Early Mortality and Worse Functional Outcome after Intracerebral Hemorrhage” By Latha G Stead et al, Neurocritical Care vol 13: pp. 67-74. 2010.

What is already known on this topic:
Hyperglycemia upon admission was already known to be a predictor for poor outcome in ischemic stroke. A relationship between hyperglycemia and mortality in intracerebral hemorrhage (ICH) had been suggested, but little data was present to define its prognostic ability.

What question this study addressed:
Is hyperglycemia at arrival associated with early mortality and functional outcome in patients with non-traumatic ICH?

What was the study design:
A prospective, cohort study of 237 adults presenting to the ED with CT confirmed, spontaneous ICH between 1/06 to 12/08, with a blood glucose measurement at presentation. Data was collected by two independent, blinded abstractors.

What this study adds to our knowledge:
This study showed that hyperglycemia (defined as blood glucose of ≥140) in both diabetic and non-diabetic patients is a prognostic predictor of higher mortality within 7 days. Among non-diabetics, it is also a predictor of poor clinical outcome  when controlled for stroke severity, age, and volume of hemorrhage. Furthermore, higher blood glucose values correlated with more severe stroke, measured by the NIH Stroke Scale. There was no significant difference shown among diabetic patients when glucose levels were used as a predictor for poor clinical outcome or stroke severity.

How is this relevant to clinical practice:
This study allows confirms that hyperglycemia is a red flag among patients presenting to the Emergency Department with ICH and gives clinicians an early, easily obtained prognostic indicator for mortality and outcome in these patients.

Other considerations:
Further research can be done to see if control of hyperglycemia may lead to better outcomes among ICH patients. This study is limited in its design- it only considered outcome at the end of the hospital stay, but did not control for the length of stay. More research should be done to determine if there is a difference in outcome at  specific time points over a greater length of time (eg. 3, 6, and 12 months).

Journal Article Synopsis: Air mattress vs. backboard in patient comfort and tissue pressure

In JOURNAL CLUB on July 7, 2011 at 3:26 PM

Summary for “Revolutionary advances in enhancing patient comfort on patients transported on a backboard” by Richard F. Edlich, Shelley S. Mason, Rober J, Vissers, et al. American Journal of Emergency Medicine Vol 29 (2); pp. 181-186.  2011.

What is already known on this topic:
Spinal cord injuries can cause short term discomfort and lead to long term disability. Stabilization of patients with spinal cord injuries is an import aspect of prehospital care. Care of trauma patients involves the use of backboards to immobilize the patient’s head, neck, and back. Studies have shown that the use of backboards causes discomfort and frequently leads to the formation of pressure ulcers.

What question this study addressed:
The Back Raft system is designed to reduce skin interphase pressure as well as patient discomfort. The purpose of this study is to record the rating of patient pain and to measure the tissue interface pressures at the occipital, scapula, and sacral regions.

What was the study design:
The Back Raft is an inflatable air mattress that can be applied to standard 16 and 18 inch spinal backboards. Ten healthy volunteers who had taken no pain medication and were not experiencing back pain were studied lying on backboards with and without the raft for 30 minutes. Pain was measured at the start and in 15 minute intervals using the 10-point Visual Analog Scale. Additionally, patients were asked to access their comfort level. Contact pressures between the patients and surface of the raft or backboard were measured at the occipital, scapula, and sacrum regions using a Tactilus pressure evaluator. Tactilus software converts the pressure recording in measurements of millimeters of mercury.

What this study adds to our knowledge:
Subjects of different genders and BMIs reported there was a less drastic difference in pain level during the 30 minutes when using the Back Raft. Tissue interface pressure levels were higher in all subjects when using only the backboard.

How this is relevant to clinical practice:
In addition to providing an increase in patient comfort, use of the Back Raft could benefit the cost of care because the use of the raft lowers the risk of developing pressure ulcers. Implementing the raft in prehospital care of trauma patients can help avoid the development of hospital acquired conditions. Additionally, the Back Raft is radiolucent, a characteristic that would be beneficial in time critical situations.

Other considerations:
This study was only conducted on healthy patient subjects. One would hope patients with injuries would report the same benefits from using the Back Raft.

Journal Article Synopsis: Bedside Ultrasound for Pediatric Long Bone Fractures

In JOURNAL CLUB on June 13, 2011 at 11:00 AM

Summary for “Bedside Ultrasound for Pediatric Long Bone Fractures ” by Keith Cross in Clinical Pediatric Emergency Medicine Vol 12 (1); pp 27-36

What is already known on this topic:
Almost all suspected fractures are currently evaluated by radiographs, with fractures requiring reduction often requiring multiple radiographs and/or fluoroscopy. Bedside ultrasound may provide an alternate imaging modality with advantages of decreased radiation exposure, identifying occult fractures in young children with poorly ossified bones, and use in austere conditions without ready access to X-rays.

What question this study addressed:
Can bedside ultrasound be used in pediatric patients with suspected long bone fracture to diagnose fracture accurately?

Which long bone fractures have the best evidence for ultrasound diagnosis?

What was the study design:
Brief reviews of several studies for diagnosis of radius/ulna injuries and fractures, reduction of forearm fractures, humerus injuries, clavicle injuries, femur injuries, tibia/fibula injuries. The technique for identifying long bone fractures by ultrasound is described with recommendations on transducer choice and imaging settings.

What this study adds to our knowledge:
Sensitivity and specificity for diagnosing pediatric long bone fractures was high for a wide variety of suspected fractures. One study demonstrated highest accuracy for simple fractures of the femur, humerus, and forearm bones, and lowest accuracy for compound fractures, small bone fractures, and Salter-Harris type I injuries. Several studies showed ultrasound-guided forearm fracture reduction was very frequently successful on first attempt. Diagnosis of proximal and midshaft humerus fractures has good evidence; diagnosis of supracondylar fractures has less evidence and may be more challenging. Diagnosis of clavicle fractures has excellent evidence and may be suitable as a primary imaging modality, and offers the advantages of avoiding radiation to thyroid tissue. Femur fracture diagnosis currently has limited evidence, but some case reports and case series suggest it may be feasible for midshaft fractures. Tibia and fibula fracture diagnosis also has limited evidence, and the largest study thus performed shows a lower sensitivity for identification of these fractures.

The author recommends using a 10 to 15 Mhz linear transducer with the vascular preset setting. Fractures may be identified as a disruption of the echogenic line of cortical bone, a hematoma over the bone at the point of fracture, an avulsed bone fragment, or callus formation appearing as a hypoechoic mass around the bone.

How this is relevant to clinical practice:
Ultrasound diagnosis may be a more rapid and less painful way to diagnose some pediatric fractures with less radiation exposure and potentially less time required and decreased pain to the patient, particularly for forearm and clavicle fractures.

Other considerations:
Many of the studies were performed by radiologists or orthopedists as the sonographers; it would be helpful to see more studies using emergency physicians as the primary sonographers.

Journal Article Synopsis: Ibuprofen and Acetazolamide as Prophylaxis for High Altitude Headache

In JOURNAL CLUB on May 18, 2011 at 5:50 PM

Summary for “Prospective, Double-Blind, Randomized, Placebo-Controlled Comparison of Acetazolamide Versus Ibuprofen for Prophylaxis Against High Altitude Headache: The Headache Evaluation at Altitude Trial (HEAT) by Jeffery Gertsch, MD, et al. in Wilderness and Environmental Medicine vol 21 pp: 236-243.

What is already known on this topic:
Headaches are one of the most common complaints from those who venture into high altitudes. Termed High Altitude Headaches (HAH), these can occur as benign incidents but are also considered a sentinel symptom of the development of Acute Mountain Sickness (AMS). AMS is defined at altitudes above 2500m with the presence of headache and one other symptom (anorexia, fatigue, insomnia, or dizziness).  Left untreated, AMS can lead to High Altitude Cerebral Edema (HACE) which is associated with a significant mortality rate. Ibuprofen was widely been used in the treatment of HAH through its inhibition of the inflammatory pathway. Acetazolamide, a diuretic and carbonic anhydrase inhibitor, has also been documented in the prevention of altitude headaches. The mechanisms of AMS prevention include renally induced metabolic acidosis resulting in diuresis and increased ventilation and inhibition of CSF production.

What questions this study addressed:
Despite the frequency with which HAH occur, there is a relative lack of literature pertaining to its prevention. This study was designed to compare the effects of treatment with ibuprofen with acetazolamide while also better establishing clinical standards for HAH prevention.

What was the study design:
This study was a prospective, double-blind, randomized, placebo-controlled trial.

What this study adds to our knowledge:
Both ibuprofen and acetazolamide proved effective in the prevention of HAH and can be recommended for prophylaxis at altitude with the inference that acetazolamide may prevent more severe headaches. The clinical efficacy of low-dose acetazolamide in the prevention of AMS has been reconfirmed and ibuprofen was also found to be effective against symptoms of AMS.

How this is relevant to clinical practice:
The use of these drugs in high altitude situations may help lower the incidence of AMS and thus prevent the onset of HACE and decrease the incidence of HACE-related mortality.

Other considerations:
Would other NSAIDs provide the same or similar protection? Is the action of ibuprofen simply masking the pain of a true underlying HAH? The participants were already at a high altitude before they began the study. What then, would be the effect of ibuprofen and acetazolamide on people going from low altitude to high. Are these drugs really preventing HAPE/HACE or are they simply preventing one of the symptoms?

%d bloggers like this: