Friday, December 29, 2017

Lit Bits: Dec 29, 2017

From the recent medical literature...

0. Samples from the Annual BMJ Comic Christmas Issue

A. Does the Full Moon Cast a Spell on Motorcyclists? The Data Suggest So

Redelmeier DA, et al. The full moon and motorcycle related mortality: population based double control study. BMJ 2017;359:j5367

Motorcycle crashes are a common cause of mortality worldwide, resulting in more than 100 000 fatalities in America since 1975.123 Motorcycle crashes in the United States account for nearly 5000 deaths annually, amounting to about one in seven road traffic fatalities and $6.0bn (£4.5bn; €5.1bn) to $12bn in societal costs.4 The average motorcyclist in the US faces a greater risk of death than a drunk driver with no seatbelt traveling the same distance.56 Unlike the case with other vehicles, few advances in engineering and enforcement in recent years have been effective at reducing motorcycle related fatalities.789 For millions of adults, riding a motorcycle may be perhaps the single most dangerous behavior engaged in on a regular basis.10

A full moon occurs about 12 times a year and has been a source of fascination since antiquity.11 It grabs people’s attention, has been the subject of popular books and songs (ranging from “After the Gold Rush” by Neil Young to “Amazing” by Kanye West), is the topic of legends and myths worldwide, and is a frequent image in advertising campaigns.1213141516 We hypothesized that because people’s attention is naturally drawn to a full moon, it might contribute to fatal motorcycle crashes.17 In particular, glancing at a full moon takes the motorcyclist’s gaze off the road, which could result in a loss of control.18 A full moon might also lead to changes in surrounding traffic behaviors, such as distracting other motorists or pedestrians from noticing an oncoming motorcycle.19

For safe motorcycling, riders need to orient their attention, ignore distractions, and continuously monitor the dynamic surroundings. Research on perception distinguishes between goal directed attention and stimulus driven attention, the latter denoting moments where attention is temporarily diverted by an extraneous object.2021 The three features most likely to attract stimulus driven attention are large size, bright luminance, and abrupt onset,222324 all of which the full moon possesses (including occasional abrupt onset when the full moon suddenly appears after being occluded). To test for potential distraction, we analyzed the largest database available in the US with the most rigorous safety data to ascertain whether a full moon might contribute to fatal motorcycle crashes.

B. Does Pet Ownership Confer a Health Advantage? Maybe Not.

Batty GD, et al. Associations of pet ownership with biomarkers of ageing: population based cohort study. BMJ 2017;359:j5558

The notion that animal companionship might be linked to human health can be traced to ancient writings and, with the first population based study conducted at least four decades ago,1 the specialty has a long research pedigree. This is particularly the case for the study of patient groups, with rather fewer investigations of the general population.234 That present day surveys indicate that around half of UK households own a pet5—reflecting secular increases over recent years—suggests that interaction with animals is perceived as life enhancing.

There are persuasive prima facie reasons to anticipate that pet ownership may have both negative and positive health consequences. Deleterious impacts on human health could occur if owners delayed their own medical care in preference to pet welfare; grief and distress occurred after a companion animal’s death6; or, most obviously, owners were attacked by their pet.7 The numerous potential zoonotic hazards that might accompany pet ownership have been described, but occurrences seem rare, at least in Western societies.89 Alternatively, psychological health may be improved by the perceived sense of companionship provided by pets. The increased physical exertion commensurate with dog ownership1011 may influence weight regulation and therefore cardiometabolic factors. Additionally, case reports in diagnostic medicine describe the ability of pet dogs to detect the early stages of an epileptic fit and even selected malignancies.8 These supposed benefits arising from human-animal relationships have led to ambitious calls for the comprehensive integration of human, animal, environmental, and ecosystem health.12

Although some empirical evidence links animal companionship with apparent protection against a series of important health outcomes in middle aged populations, including premature mortality, obesity, hypertension, and hyperlipidaemia, systematic reviews13 and position statements3 suggest that these associations are not universal. Despite 12% of older Australians indicating that an animal was their predominant form of company,14 little is known about the impact of such companionship on physical and psychological biomarkers of ageing in older people—factors that are related to life expectancy, chronic disease, and disability.15 If there is a relation with ageing biomarkers, which may be anticipated given the described links with physical exertion and sense of companionship, the public health implications of animal ownership could be important.

The few studies in this area have almost exclusively utilised a cross-sectional design and focused on single, self reported biomarkers of ageing, particularly depression, which provide only a partial understanding of the health consequences of pet ownership and raise concerns of recall bias, particularly in older groups. Reverse causality may also be a problem, whereby decreased mobility in older age may be the reason for seeking animal companionship, rather than the reverse, and this may have led to the apparent deleterious relation of certain pets with poor health status,16 including suboptimal mental health17 in some studies of older people. Accordingly, we examined the prospective link between pet ownership and a selected range of objective biomarkers of ageing proposed for use in large scale population based studies of older people.15

C. No association between rainfall and diagnoses of joint or back pain: retrospective claims analysis

Jena AB, et al. BMJ 2017;359:j5326

Many people believe that changes in weather conditions—including increases in humidity, rainfall, or barometric pressure—lead to worsening symptoms of joint or back pain, particularly among those with arthritis. Several studies have explored the relation between various weather patterns and joint pain, reaching mixed conclusions,12345678910 including the possibility that people perceive patterns (eg, an association between rainfall and joint pain) where none exist.11 Although previous studies have explored a variety of weather conditions and used detailed measures of joint pain, they were survey based and included small numbers of patients.

Using data on millions of outpatient visits of older Americans, linked to data on daily rainfall, we analyzed the relation between rainfall and outpatient visits for joint or back pain, or both.

D. Ever heard of Thunderstorm Asthma? New to Me.

Andrew E, et al. Stormy weather: a retrospective analysis of demand for emergency medical services during epidemic thunderstorm asthma. BMJ 2017;359:j5636

Weather and climatic conditions have been associated with exacerbation of various health conditions, including cardiovascular diseases, mental health and sleep disorders, and infectious diseases.1 Thunderstorm asthma is a rare phenomenon, thought to occur when a source of allergen, typically pollen, and appropriate weather conditions, such as a thunderstorm, combine to trigger severe asthma among susceptible people in the vicinity.2 Pollen grains are too large to enter the lower respiratory tract; rain is thought to cause the grains to expand and burst, discharging their allergenic contents as fine respirable particles.345 Asthma symptoms, such as coughing and wheezing, arise when sensitised patients breathe in these particles, which inflame the lining of airways.6 Thunderstorm asthma can affect patients with or without a history of asthma, but patients who experience hay fever are at increased risk.6789

2. Medical Therapy Alone Rivals Medical Therapy with Surgical Treatment of Peritonsillar Abscess. Cool!!

Battaglia A, et al. Otolaryngol Head Neck Surg. 2017 Nov 1 [Epub ahead of print].

Objective This study was performed to determine whether the efficacy and safety of medical management of uncomplicated peritonsillar abscess (PTA) presenting in the emergency department is equivalent to medical plus surgical therapy.

Study Design Case series with chart review.

Setting Southern California Permanente Medical Group (SCPMG).

Subjects and Methods Upon successful completion of a prospective study comparing medical treatment (MT) to surgical treatment (ST) of PTA in 2008, MT was adopted by 12 SCPMG centers while 7 centers continued standard surgical drainage. Clinical outcomes are now reviewed on a random sampling of 211 patients with PTA treated with MT and 96 patients treated with ST between 2008 and 2013 at the respective medical centers. Patients were treated with intravenous (IV) fluids, weight-appropriate IV ceftriaxone, clindamycin, and dexamethasone, and then discharged on clindamycin × 10 days (MT). Patients in the ST group received MT but also surgical drainage. Primary end points were complication rates and failure rates.

Results MT and ST resulted in no significant difference in treatment success or complications. However, patients in the MT group obtained significantly less liquid opioid prescriptions (MT, 30.8 ± 5.65; ST, 77.75 ± 13.41; P less than .0001), reported fewer sore days (MT, 4.48 ± 0.27; ST, 5.77 ± 0.49; P = .0004), and required less days off from work (MT, 3.4 ± 0.44; ST, 4.9 ± 0.82; P = .044).

Conclusions Compared to ST, MT appears to be equally safe and efficacious, with less pain, opioid use, and days off work, especially if patients with PTA present without trismus. MT for PTAs reduces the possibility of surgical complications, as well as the cost and inconvenience associated with ST.

3. Randomized Controlled Double-blind Trial Comparing Haloperidol Combined With Conventional Therapy to Conventional Therapy Alone in Patients With Symptomatic Gastroparesis

Roldan CJ, et al. Acad Emerg Med. 2017 Nov;24(11):1307-1314.

OBJECTIVE: Gastroparesis is a debilitating condition that causes nausea, vomiting, and abdominal pain. Management includes analgesics and antiemetics, but symptoms are often refractory. Haloperidol has been utilized in the palliative care setting for similar symptoms. The study objective was to determine whether haloperidol as an adjunct to conventional therapy would improve symptoms in gastroparesis patients presenting to the emergency department (ED).

STUDY DESIGN AND METHODS: This was a randomized, double-blind, placebo-controlled trial of adult ED patients with acute exacerbation of previously diagnosed gastroparesis. The treatment group received 5 mg of haloperidol plus conventional therapy (determined by the treating physician). The control group received a placebo plus conventional therapy. The severity of each subject's abdominal pain and nausea were assessed before intervention and every 15 minutes thereafter for 1 hour using a 10-point scale for pain and a 5-point scale for nausea. Primary outcomes were decreased pain and nausea 1 hour after treatment.

RESULTS: Of the 33 study patients, 15 were randomized to receive haloperidol. Before treatment, the mean intensity of pain was 8.5 in the haloperidol group and 8.28 in the placebo group; mean pretreatment nausea scores were 4.53 and 4.11, respectively. One hour after therapy, the mean pain and nausea scores in the haloperidol group were 3.13 and 1.83 compared to 7.17 and 3.39 in the placebo group. The reduction in mean pain intensity therapy was 5.37 in the haloperidol group (p ≤ 0.001) compared to 1.11 in the placebo group (p = 0.11). The reduction in mean nausea score was 2.70 in the haloperidol group (p ≤ 0.001) and 0.72 in the placebo group (p = 0.05). Therefore, the reductions in symptom scores were statistically significant in the haloperidol group but not in the placebo group. No adverse events were reported.

CONCLUSIONS: Haloperidol as an adjunctive therapy is superior to placebo for acute gastroparesis symptoms.

4. PE Research

A. Outpatient management of ED patients with acute PE: variation, patient characteristics and outcomes.

Vinson DR, et al for the MAPLE Investigators of the KP CREST Network. Ann Emerg Med. 2017 Dec 13 [Epub ahead of print].

Study objective
Outpatient management of emergency department (ED) patients with acute pulmonary embolism is uncommon. We seek to evaluate the facility-level variation of outpatient pulmonary embolism management and to describe patient characteristics and outcomes associated with home discharge.

The Management of Acute Pulmonary Embolism (MAPLE) study is a retrospective cohort study of patients with acute pulmonary embolism undertaken in 21 community EDs from January 2013 to April 2015. We gathered demographic and clinical variables from comprehensive electronic health records and structured manual chart review. We used multivariable logistic regression to assess the association between patient characteristics and home discharge. We report ED length of stay, consultations, 5-day pulmonary embolism–related return visits and 30-day major hemorrhage, recurrent venous thromboembolism, and all-cause mortality.

Of 2,387 patients, 179 were discharged home (7.5%). Home discharge varied significantly between EDs, from 0% to 14.3% (median 7.0%; interquartile range 4.2% to 10.9%). Median length of stay for home discharge patients (excluding those who arrived with a new pulmonary embolism diagnosis) was 6.0 hours (interquartile range 4.6 to 7.2 hours) and 81% received consultations. On adjusted analysis, ambulance arrival, abnormal vital signs, syncope or presyncope, deep venous thrombosis, elevated cardiac biomarker levels, and more proximal emboli were inversely associated with home discharge. Thirteen patients (7.2%) who were discharged home had a 5-day pulmonary embolism–related return visit. Thirty-day major hemorrhage and recurrent venous thromboembolism were uncommon and similar between patients hospitalized and those discharged home. All-cause 30-day mortality was lower in the home discharge group (1.1% versus 4.4%).

Home discharge of ED patients with acute pulmonary embolism was uncommon and varied significantly between facilities. Patients selected for outpatient management had a low incidence of adverse outcomes.

Excerpts from the Discussion
The low 5-day and 30-day adverse events we observed in the outpatient cohort suggest that emergency physicians and their consultants can identify patients eligible for safe and effective ambulatory management. These reassuring outcomes were noted even though some patients in the outpatient cohort had higher-risk attributes. For example, at least 10% of those discharged home had a history of cancer; moderate tachypnea (respiratory rate 24-30 breaths/min), mild tachycardia (pulse 100-110 beats/min), or low oxygen saturation (90-94%) at some point in their pre-hospital or ED stay; or had a PE in the main pulmonary artery. About one-third of our cohort were categorized as higher risk by the PE Severity Index (classes III-V), a proportion similar to ED patients with acute PE safely discharged home from Ottawa Hospital. As we have shown elsewhere, a patient’s estimated 30-day all-cause mortality is an important variable in the initial site-of-care calculus, but it is not the only variable that influences the disposition decision. There are multiple psychosocial, co-morbid, and PE-related factors to consider. Patients in a low-mortality class might have relative contraindications for home management, whereas patients in a higher-risk mortality class may have minimal physiologic insult despite advanced age or chronic illness and may be suitable for home care.

Home discharge of ED patients with acute PE in the U.S. ranges from 0-25%, lower than reports from London, the Netherlands and Canada (28%-55%). The disparity is highlighted by the similarity in patient characteristics across these studies. These disparate site-of-care decisions suggest that most U.S. physicians may not be considering outpatient management for eligible patients who could safely avoid the costs and inconveniences of hospitalization. Though physicians in our study were specific in their patient selection (those chosen for home care were appropriate candidates), their selection nevertheless was insensitive (many not chosen were also good candidates according to validated risk scores). 

In our study, over one-third of hospitalized patients were categorized as Classes I-II on the PE Severity Index. In a validation study of the performance of the PE Severity Index in the MAPLE cohort, we found the 30-day all-cause mortality of these low-risk patients (Classes I-II) to be 0.3% (95% CI, 0.1%-0.8%). Many of these low-risk, low-mortality patients may have been appropriate candidates for outpatient treatment. If even half of these were free of relative contraindications to outpatient management (a conservative estimate based on a large multi-national randomized trial of patients with explicit PE Severity Index classification), our percentages of home discharge would have increased from 7.5 to 19.5, more consistent with U.S. medical centers that have implemented outpatient care pathways.

Ottawa Hospital in Ontario, Canada, has achieved its distinctive pattern of care (55% safely discharged home) by adopting “an opt-out paradigm”: patients with acute PE are slated for outpatient care unless reasons can be found that they require hospitalization. This approach is similar to that embodied in the Hestia criteria for outpatient management of adults with acute PE. The default is that patients are going home from the ED, unless one of the exclusion criteria disqualifies them from outpatient management. When applied prospectively in 12 academic medical centers in the Netherlands, the Hestia criteria allowed for direct outpatient management of 28% of their cohort and discharge home after a short hospital stay (<24 23="" admitted="" all="" another="" around-the-clock.="" available="" avoided="" been="" briefly="" could="" had="" have="" hospitalization="" hours="" imaging="" in="" needed="" o:p="" outcomes.="" overnight="" patients="" reassuring="" short-term="" studies="" the="" were="" who="" with="">

Reducing unnecessary hospitalization will require physician education, but education alone may be insufficient to overcome the inertia of entrenched practice patterns.…

B. Is a normal CT pulmonary angiography safe to rule out acute PE in patients with a likely clinical probability? A patient-level meta-analysis.

van der Hulle T, et al. Thromb Haemost. 2017;117(8):1622-1629.

A normal computed tomography pulmonary angiography (CTPA) remains a controversial criterion for ruling out acute pulmonary embolism (PE) in patients with a likely clinical probability. We set out to determine the risk of VTE and fatal PE after a normal CTPA in this patient category and compare these risk to those after a normal pulmonary angiogram of 1.7 % (95 %CI 1.0-2.7 %) and 0.3 % (95 %CI 0.02-0.7 %).

A patient-level meta-analysis from 4 prospective diagnostic management studies that sequentially applied the Wells rule, D-dimer tests and CTPA to consecutive patients with clinically suspected acute PE. The primary outcome was the 3-month VTE incidence after a normal CTPA.

A total of 6,148 patients were included with an overall PE prevalence of 24 %. The 3-month VTE incidence in all 4,421 patients in whom PE was excluded at baseline was 1.2 % (95 %CI 0.48-2.6) and the risk of fatal PE was 0.11 % (95 %CI 0.02-0.70). In patients with a likely clinical probability the 3-month incidences of VTE and fatal PE were 2.0 % (95 %CI 1.0-4.1 %) and 0.48 % (95 %CI 0.20-1.1 %) after a normal CTPA. The 3-month incidence of VTE was 6.3 % (95 %CI 3.0-12) in patients with a Wells rule >6 points.

In conclusion, this study suggests that a normal CTPA may be considered as a valid diagnostic criterion to rule out PE in the majority of patients with a likely clinical probability, although the risk of VTE is higher in subgroups such as patients with a Wells rule >6 points for which a closer follow-up should be considered.

C. PE Testing Among ED Patients Who Are PERC Negative

Buchanan I, et al. Acad Emerg Med. 2017 Nov;24(11):1369-1376.

OBJECTIVE: Previous studies have demonstrated that rates of pulmonary embolism (PE) testing have increased without a concomitant decrease in PE-related mortality. The Pulmonary Embolism Rule-out Criteria (PERC) intend to reduce testing for PE in the emergency department (ED) by identifying low-risk patients ("PERC-negative") who do not require D-dimer, computed tomography pulmonary angiogram (CTPA), or ventilation/perfusion (VQ) scan for PE. This study assesses PE testing rates among PERC-negative patients presenting to an urban academic ED.

METHODS: We prospectively enrolled a convenience sample of ED patients with chest pain and/or shortness of breath presenting between June 2010 and December 2015. We recorded baseline variables at the time of ED presentation, information on testing performed in the ED, and the diagnosis of acute PE during the ED visit. We classified patients as PERC-positive or PERC-negative utilizing baseline variables and clinical characteristics.

RESULTS: Of the 3,024 study patients, 54.8% (95% confidence interval = 53%-56.5%) were female and the mean age was 51.7 (51.1-52.3) years. A total of 17.5% (16.2%-18.9%) of study patients were PERC-negative and 33.7% (32%-35.4%) of all patients underwent testing for PE. A total of 25.5% (22%-29.4%) of PERC-negative patients had PE testing compared to 35.4% (33.6%-37.3%) of PERC-positive patients (p less than 0.001). A total of 7.2% (5.3%-9.7%) of PERC-negative patients had advanced imaging without a D-dimer compared to 19.2% (17.8%-20.8%) of PERC-positive patients (p less than 0.001). In multivariate analysis, factors associated with PE testing in PERC-negative patients included age, white non-Hispanic race/ethnicity, pleuritic chest pain, and a complaint of both chest pain and shortness of breath. Two PERC-negative patients (0.4%) were diagnosed with an acute PE in the ED compared to 2.2% of PERC-positive patients (p = 0.008). The overall testing yield for PE was 1.6% (0.4%-9.2%) among PERC-negative patients versus 6.3% (4.9%-8.1%) among PERC-positive patients (p = 0.017).

CONCLUSION: In an academic ED, a significant proportion of PERC-negative patients underwent testing for PE, including CT or VQ scan without D-dimer risk stratification. Future areas of research may include evaluating factors that lead clinicians to pursue PE testing in PERC-negative patients and implementing clinical pathways to minimize practice variability among these patients.

5. ED Pain Management

A. IV APAP no better than po APAP

Furyk J, et al. IV versus oral paracetamol for acute pain in adults in the ED setting: a prospective, double-blind, double-dummy, RCT. Emerg Med J 2017 Dec 15 [Epub ahead of print]

Objective To determine if intravenous paracetamol was superior to oral paracetamol as an adjunct to opioids in the management of moderate to severe pain in the ED setting.

Methods A prospective, randomised, double-blind, double-dummy, controlled trial was conducted at a single academic tertiary care ED. Adult patients with moderate to severe pain were randomly assigned to receive either the intravenous paracetamol or oral paracetamol. The primary outcome was Visual Analogue Scale (VAS) pain reduction at 30 min. A clinically significant change in pain was defined as 13 mm.

Results 87 participants were included in the final analysis, with a median age of 43.5 years and 59.8% were female. Overall mean baseline VAS pain score was 67.9 mm (±16.0). Both formulations achieved a clinically significant mean pain score reduction at 30 min, with no significant difference between the groups with 16.0 mm (SD 19.1 mm) in the intravenous group and 14.6 mm (SD 26.4) in the oral group; difference −1.4 mm (95% CI −11.6 to 8.8, P=0.79). Secondary outcomes, including postintervention intravenous opioid administration, patient satisfaction, side effects and length of stay, did not differ between groups.

Conclusions Overall, there was a small but clinically significant decrease in pain in each group. No superiority was demonstrated in this trial with intravenous paracetamol compared with oral paracetamol in terms of efficacy of analgesia and no difference in length of stay, patient satisfaction, need for rescue analgesia or side effects.

B. A Review of Current and Emerging Approaches to Pain Management in the ED

Todd KH. Pain and Therapy. 2017;6(2):193-202.

Introduction: Pain is the most common symptom prompting an emergency department visit and emergency physicians are responsible for managing both acute pain and acute exacerbations of chronic pain resulting from a broad range of illnesses and injuries. The responsibility to treat must be balanced by the duty to limit harm resulting from analgesics. In recent years, opioid-related adverse effects, including overdose and deaths, have increased dramatically in the USA. In response to the US opioid crisis, emergency physicians have broadened their analgesic armamentarium to include a variety of non-opioid approaches. For some of these therapies, sparse evidence exists to support their efficacy for emergency department use. The purpose of this paper is to review historical trends and emerging approaches to emergency department analgesia, with a particular focus on the USA and Canada.

Methods: We conducted a qualitative review of past and current descriptive studies of emergency department pain practice, as well as clinical trials of emerging pain treatment modalities. The review considers the increasing use of non-opioid and multimodal analgesic therapies, including migraine therapies, regional anesthesia, subdissociative-dose ketamine, nitrous oxide, intravenous lidocaine and gabapentinoids, as well as broad programmatic initiatives promoting the use of non-opioid analgesics and nonpharmacologic interventions.

Results: While migraine therapies, regional anesthesia, nitrous oxide and subdissociative-dose ketamine are supported by a relatively robust evidence base, data supporting the emergency department use of intravenous lidocaine, gabapentinoids and various non-pharmacologic analgesic interventions remain sparse.

Conclusion: Additional research on the relative safety and efficacy of non-opioid approaches to emergency department analgesia is needed. Despite a limited research base, it is likely that non-opioid analgesic modalities will be employed with increasing frequency. A new generation of emergency physicians is seeking additional training in pain medicine and increasing dialogue between emergency medicine and pain medicine researchers, educators and clinicians could contribute to better management of emergency department pain.

C. AAEM White Paper on Acute Pain Management in the ED

Motov S, et al. Approved by the American Academy of Emergency Medicine Board of Directors, October 24, 2017

Effective, efficient, and safe pain management is a cornerstone of state-of-the-art patient care in the Emergency Department and is a specialty-defining skill. The AAEM endorses this document with the hope that all ED patients experiencing acute pain have the option to receive appropriate expeditious, effective, and safe analgesia. The Academy emphasizes that acute pain management in the ED should be patient-specific, pain syndrome-targeted, and based on
appropriate non-pharmacological and pharmacological approaches.

Acute Pain Management in the ED
EM clinicians and associates who work in an ED should acknowledge and assess a patient’s pain in an empathetic manner by expressing an understanding of the patient’s suffering and a willingness to alleviate pain using a multimodal analgesic approach. EM clinicians should communicate to patients that the goal of ED pain management, particularly in patients who are being discharged, includes restoration of functional ability and is not simply reducing pain; specifically, both emergency physicians and patients must recognize that clinicians are charged with managing pain while managing the potential for some pain medications to cause harm. 1-3

Management of acute pain in the ED should be patient-centered, meaning that emergency medicine clinicians should engage patients in shared decision-making by providing patients with details about overall treatment goals and expectations, the natural trajectory of the specific painful condition, and analgesic options including short-term and long-term benefits and risks of adverse effects.4-5…

D. Blast from the Past: Oral Ibuprofen as Good as IM/IV Ketorolac (but way cheaper)

D1. Intramuscular ketorolac vs oral ibuprofen in ED patients with acute pain.

Neighbor ML, et al. Acad Emerg Med. 1998 Feb;5(2):118-22.

OBJECTIVE: To determine whether i.m. ketorolac is superior to oral ibuprofen in patients presenting to an ED in moderate to severe pain.

METHODS: This prospective, randomized, double-blind study involved a convenience sample of 119 patients aged > or = 18 years who presented to an urban teaching hospital ED with a self-assessed pain intensity score of 5, 6, 7, or 8 (on a numerical rating scale of 0-10). Patients were randomized to receive either 60 mg of i.m. ketorolac and a placebo capsule or 800 mg of oral ibuprofen and a saline injection. Pain scores were measured at 0, 15, 30, 45, 60, 90, and 120 minutes after dosing. Supplemental analgesics were allowed in accordance with standard medical practice.

RESULTS: There were 18 patients excluded who did not remain in the ED for the full 2-hour study period. Of those completing the trial, 53 patients received ketorolac and 48 patients received ibuprofen. There were no significant differences in pain scores between ketorolac and ibuprofen at any time during the study. However, there was a statistically significant decrease in pain over time in both treatment groups. Yet, 40% of the patients continued to report pain intensity scores of 5-8 at 2 hours after treatment.

CONCLUSIONS: I.m. ketorolac and oral ibuprofen provide comparable levels of analgesia in ED patients presenting with moderate to severe pain. Unfortunately, 40% of all the patients had inadequate pain relief (pain score > or = 5) from either ketorolac or ibuprofen.

D2. Preemptive pain control in patients having laparoscopic hernia repair: a comparison of ketorolac and ibuprofen.

Mixter CG 3rd, et al. Arch Surg. 1998 Apr;133(4):432-7.

OBJECTIVES: To determine if nonsteroidal anti-inflammatory drugs provide adequate pain control for patients having laparoscopic hernia repair and to compare the effectiveness of ketorolac tromethamine with ibuprofen in reducing postoperative laparoscopic hernia pain.

DESIGN AND SETTING: Prospective double-blind randomized study at a 100-bed community hospital.

PATIENTS: Seventy patients ranging in age from 16 to 83 years scheduled for elective laparoscopic inguinal hernia repair.

INTERVENTIONS: Patients undergoing laparoscopic hernia repair were enrolled in a double-blind randomized study to compare the 2 treatments. Group 1 received a placebo capsule 1 hour before surgery and ketorolac tromethamine, 60 mg intravenously, at the time of trocar insertion. Group 2 received ibuprofen, 800 mg an hour before surgery, and isotonic sodium chloride solution, 2 mL intravenously, at the time of trocar insertion. In addition, all patients received local infiltration of 30 mL of bupivacaine hydrochloride into their trocar sites. All patients were discharged within 5 hours of the operation and were instructed to take 400 mg of ibuprofen orally every 4 hours for 24 hours whether or not they were experiencing pain. A 24-hour supply of ibuprofen was provided to all study patients. Pain was assessed using the Visual Analog Pain Scale with a maximum pain rating of 100. Assessments were done at the time of and 18 hours after discharge.

MAIN OUTCOME MEASURE: Postoperative pain 18 and 24 hours after discharge was assessed using a standardized questionnaire in a telephone interview by a registered nurse from the Outpatient Surgical Unit.

RESULTS: There was no significant difference in the level of pain experienced by 35 patients who received ketorolac intravenously and 35 who received ibuprofen orally. There was no significant difference between the 2 treatment groups in the amount of pain experienced at discharge and 18 hours after discharge.

CONCLUSIONS: Pain relief from ibuprofen, 800 mg, administered orally an hour before laparoscopic hernia repair was not statistically different from that obtained with intravenous ketorolac, 60 mg, administered intraoperatively when comparing the hospital discharge pain score and the mean and highest pain scores 18 hours after discharge. Ibuprofen offers equivalent pain control at a lower cost and reduced potential for adverse drug events compared with intravenous ketorolac in patients having laparoscopic hernia repair. No patient required narcotic supplementation, and pain control was judged satisfactory by all the patients.

D3. IM ketorolac versus oral ibuprofen for pain relief in first-trimester surgical abortion: a RCT

Braaten KP, et al. Contraception. 2014 Feb;89(2):116-21.

OBJECTIVE: Oral nonsteroidal antiinflammatory medications (NSAIDs) have been shown to reduce pain with first-trimester surgical abortion compared to placebo, but it is unclear if one NSAID is better than another. Some providers administer intramuscular ketorolac, though data regarding its efficacy in abortion are limited. This study was designed to compare oral ibuprofen to intramuscular ketorolac for pain management during first-trimester surgical abortion.

STUDY DESIGN: This was a randomized, double-blind, controlled trial. Women undergoing first-trimester surgical abortion with local anesthesia were randomized to preprocedural oral ibuprofen, 800 mg given 60-90 min preprocedure, or intramuscular ketorolac, 60 mg given 30-60 min preprocedure. The primary outcome was pain with uterine aspiration on a 21-point, 0-100, numerical rating scale. Secondary outcomes included pain with cervical dilation, postoperative pain and patient satisfaction.

RESULTS: Ninety-four women were enrolled; 47 were randomized to ibuprofen and 47 to ketorolac. The groups did not differ with regards to demographics, reproductive history or Depression Anxiety Stress Scale scores. Mean pain scores for suction curettage did not differ between groups (52.3 vs. 56.2, p=.53). There was also no difference in pain with cervical dilation (41.6 vs. 45.4, p=0.48) or postoperative pain (22.3 vs. 15.0 p=.076), though patients in the ketorolac group experienced significantly greater arm pain than those who received a placebo injection (30.4 vs. 15.6, p less than .001). Satisfaction with pain control did not differ significantly by group.

CONCLUSIONS: Intramuscular ketorolac does not offer superior pain control compared to oral ibuprofen for first-trimester surgical abortion.

IMPLICATIONS: Intramuscular ketorolac does not offer superior pain control over oral ibuprofen during first-trimester surgical abortion, is more expensive and causes patients significant arm discomfort. Its use should therefore be reserved for patients who cannot tolerate oral NSAIDs.

6. A reminder: Atraumatic vs conventional LP needles: a systematic review and meta-analysis.

Nath S, et al. Lancet. 2017 Dec 6 [Epub ahead of print]

BACKGROUND: Atraumatic needles have been proposed to lower complication rates after lumbar puncture. However, several surveys indicate that clinical adoption of these needles remains poor. We did a systematic review and meta-analysis to compare patient outcomes after lumbar puncture with atraumatic needles and conventional needles.

METHODS: In this systematic review and meta-analysis, we independently searched 13 databases with no language restrictions from inception to Aug 15, 2017, for randomised controlled trials comparing the use of atraumatic needles and conventional needles for any lumbar puncture indication. Randomised trials comparing atraumatic and conventional needles in which no dural puncture was done (epidural injections) or without a conventional needle control group were excluded. We screened studies and extracted data from published reports independently. The primary outcome of postdural-puncture headache incidence and additional safety and efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. This study is registered with the International Prospective Register of Systematic Reviews, number CRD42016047546.

FINDINGS: We identified 20 241 reports; after exclusions, 110 trials done between 1989 and 2017 from 29 countries, including a total of 31 412 participants, were eligible for analysis. The incidence of postdural-puncture headache was significantly reduced from 11·0% (95% CI 9·1-13·3) in the conventional needle group to 4·2% (3·3-5·2) in the atraumatic group (relative risk 0·40, 95% CI 0·34-0·47, p less than 0·0001; I2=45·4%). Atraumatic needles were also associated with significant reductions in the need for intravenous fluid or controlled analgesia (0·44, 95% CI 0·29-0·64; p less than 0·0001), need for epidural blood patch (0·50, 0·33-0·75; p=0·001), any headache (0·50, 0·43-0·57; p less than 0·0001), mild headache (0·52, 0·38-0·70; p less than 0·0001), severe headache (0·41, 0·28-0·59; p less than 0·0001), nerve root irritation (0·71, 0·54-0·92; p=0·011), and hearing disturbance (0·25, 0·11-0·60; p=0·002). Success of lumbar puncture on first attempt, failure rate, mean number of attempts, and the incidence of traumatic tap and backache did not differ significantly between the two needle groups. Prespecified subgroup analyses of postdural-puncture headache revealed no interactions between needle type and patient age, sex, use of prophylactic intravenous fluid, needle gauge, patient position, indication for lumbar puncture, bed rest after puncture, or clinician specialty. These results were rated high-quality evidence as examined using the grading of recommendations assessment, development, and evaluation.

INTERPRETATION: Among patients who had lumbar puncture, atraumatic needles were associated with a decrease in the incidence of postdural-puncture headache and in the need for patients to return to hospital for additional therapy, and had similar efficacy to conventional needles. These findings offer clinicians and stakeholders a comprehensive assessment and high-quality evidence for the safety and efficacy of atraumatic needles as a superior option for patients who require lumbar puncture.

7. Steroid Bursts: Helpful for Hives? Maybe Not. Harmful for Diabetes. Maybe So.

A. Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial.

Barniol C, et al. Ann Emerg Med. 2018 Jan;71(1):125-131.e1.

Acute urticaria is a relatively common cause for consultation in the emergency department (ED). It accounts for 7% to 35% of dermatologic conditions presenting at the ED. Of the symptoms of this condition, pruritus is the most bothersome because it may impair daily activities and cause sleep disturbances. ED management of acute urticaria without angioedema or wheezing is usually limited to avoidance of the allergen, when it can be identified, and to symptomatic treatment with H1 antihistamines. The 2013 update of international guidelines for the definition, classification, diagnosis, and management of urticaria states that a short course of oral corticosteroids may be helpful to reduce disease duration and activity in acute urticaria.

Only 2 studies have suggested that corticosteroids may be effective in the treatment of acute urticaria. Patient condition improved more quickly and more completely when corticosteroids were added to antihistamines. One study was a randomized controlled trial performed with 43 patients treated with old first-generation H1 antihistamines, whereas the other was a nonrandomized cohort study on the causes and treatment of acute urticaria.

Physicians use glucocorticoids as ancillary therapeutic agents in the treatment of acute urticaria. In Italy, 93% of patients attending an ED for this condition, most of them without angioedema, received corticosteroids in 2011. The effect of corticosteroids as first-line ED treatment of acute urticaria needs to be studied in a randomized clinical trial of patients receiving a modern second-generation antihistamine. Use of modern nonsedative H1 antihistamines is recommended because they have a better safety profile than first-generation sedative H1 antihistamines.

Goals of This Investigation
We designed a prospective, randomized, placebo-controlled, double-blind, parallel-group study on the efficacy of a short course of prednisone in addition to levocetirizine for the treatment of acute urticaria in ED patients. The primary outcome variable was complete resolution of itching, defined by an itch score of 0 of 10 at 2-day follow-up. Secondary endpoints were rash resolution, relapses, and adverse events.

STUDY OBJECTIVE: We evaluate the efficacy of a 4-day course of prednisone added to antihistamine for the management of acute urticaria in an emergency department (ED).

METHODS: In this double-blind randomized clinical trial, patients were eligible for inclusion if aged 18 years or older and with acute urticaria of no more than 24 hours' duration. Patients with anaphylaxis or who had received antihistamines or glucocorticoids during the previous 5 days were not included. In addition to levocetirizine (5 mg orally for 5 days), patients were assigned to receive prednisone (40 mg orally for 4 days) or placebo. The primary endpoint of the study was itching relief 2 days after the ED visit, rated on a numeric scale of 0 to 10. Secondary endpoints were rash resolution, relapses, and adverse events.

RESULTS: A total of 100 patients were included, 50 in each group. Seven patients in the prednisone group and 8 in the placebo group discontinued treatment. At 2-day follow-up, 62% of patients in the prednisone group had an itch score of 0 versus 76% of those in the placebo group (Δ 14%; 95% confidence interval -31% to 4%). Thirty percent of patients in the prednisone group and 24% in the placebo group reported relapses (Δ 6%; 95% confidence interval -23% to 11%). Mild adverse events were reported by 12% of patients in the prednisone group and 14% in the placebo group.

CONCLUSION: The addition of a prednisone burst did not improve the symptomatic and clinical response of acute urticaria to levocetirizine. This study does not support the addition of corticosteroid to H1 antihistamine as first-line treatment of acute urticaria without angioedema

B. Longitudinal Study of Short-term Corticosteroid Use by Working-Age Adults with DM: Risks and Mitigating Factors.

Short-term oral corticosteroid use among patients with diabetes increased their risk for adverse events, such as fracture, sepsis and venous thromboembolism, compared with those who did not use the drug.

Rogers MAM. et al. J Diabetes. 2017 Nov 28 [Epub ahead of print]

BACKGROUND: We assessed the frequency of short-term oral corticosteroid use in adults with diabetes, and examined the incidence of fractures, venous thromboembolism (VTE) and hospitalization for sepsis after corticosteroid use. We also evaluated whether preventative medications mitigated adverse events.

METHODS: We conducted a longitudinal study of 1,548,945 adults (ages 18-64 years) who received healthcare coverage through a large national health insurer, years 2012-2014. Incidence rate ratios (IRR) were calculated using conditional Poisson regression.

RESULTS: Short-term oral corticosteroids were used by 23.9% of adults with type 2 diabetes, 20.8% with type 1, and 20.9% without diabetes during the 3-year period (p less than 0.001). Baseline risks of fracture, VTE, and sepsis were greater for individuals with diabetes than those without (p less than 0.001). The combined effect of having diabetes and using corticosteroids was greater than the sum of the individual effects (synergy indices of 1.17, 1.23, 1.30 for fracture, VTE and sepsis, respectively). The IRR for venous thromboembolism was 3.62 (95% CI, 2.41-5.45) in the 5-30 days after corticosteroid use. Fractures increased in the 5-30 days after corticosteroid use (IRR=2.06, 95% CI: 1.52, 2.80), but concomitant use of ergocalciferol mitigated this risk (IRR=1.13; 95% CI: 0.12, 11.07). The risk of hospitalization for sepsis was elevated with corticosteroid use (IRR=3.79; 95% CI: 2.05, 7.01) but was mitigated by the concomitant use of statins.

CONCLUSIONS: Short-term oral corticosteroid use is common in adults with diabetes and is associated with an elevated, but low, risk of adverse events. Our findings suggest that preventative medications may mitigate risk.

8. Helpful Reviews from Ann Emerg Med

A. Are α-Blockers Beneficial for Outpatient Management of Uncomplicated Ureteric Stones?

Take-Home Message
α-Blockers may accelerate passage and prevent complications such as hospital admission or surgery when ureteric stones are 5 to 10 mm, but there is no evidence to support their use in stones less than 5 mm. Benefits appear to be similar regardless of location in the ureter.

B. What Is the Efficacy of Droperidol for the Management of Acute Psychosis-Induced Agitation?

Take-Home Message
Droperidol is effective for the treatment of acute psychosis-induced aggression or agitation, with a low risk of adverse events compared with placebo, olanzapine, haloperidol, and midazolam.

C. Do Corticosteroids Improve Mortality or Shock Reversal in Patients With Septic Shock?

Take-Home Message
No studied corticosteroid regimen is superior to placebo or any other regimen in patient-centered outcomes including mortality; however, hydrocortisone infusion improves shock reversal compared with placebo or methylprednisolone.

D. Is Early Goal-Directed Therapy or Standard Therapy More Effective in Decreasing Mortality Among Patients With Sepsis?

Take-Home Message
Time to antibiotic administration is the main factor explaining mortality differences between sepsis patients treated with early goal-directed therapy versus standard care in recent observational trials. Early goal-directed therapy was associated with increased mortality risk in patients with severe sepsis.

E. Can a Negative High-Sensitivity Troponin Result Rapidly Rule Out Acute Myocardial Infarction?

Take-Home Message
A single, undetectable, high-sensitivity, cardiac troponin T (hs-cTnT) test in combination with a nonischemic ECG result may effectively rule out acute myocardial infarction in emergency department (ED) patients presenting greater than 3 hours after symptom onset.

F. What Baseline Clinical Features Are Associated With Survival or Good Neurologic Outcome After Extracorporeal Cardiopulmonary Resuscitation?

Take-Home Message
In refractory out-of-hospital cardiac arrest patients, initial shockable cardiac rhythm, shorter cardiopulmonary resuscitation (CPR) duration, higher admission arterial pH, and lower admission serum lactate level may help predict favorable outcome after extracorporeal CPR.

G. Acute Kidney Injury After CT: A Meta-analysis.

Aycock RD, et al. Ann Emerg Med. 2018 Jan;71(1):44-53.e4.

STUDY OBJECTIVE: Computed tomography (CT) is an important imaging modality used in the diagnosis of a variety of disorders. Imaging quality may be improved if intravenous contrast is added, but there is a concern for potential renal injury. Our goal is to perform a meta-analysis to compare the risk of acute kidney injury, need for renal replacement, and total mortality after contrast-enhanced CT versus noncontrast CT.

METHODS: We searched MEDLINE (PubMed), the Cochrane Library, CINAHL, Web of Science, ProQuest, and Academic Search Premier for relevant articles. Included articles specifically compared rates of renal insufficiency, need for renal replacement therapy, or mortality in patients who received intravenous contrast versus those who received no contrast.

RESULTS: The database search returned 14,691 articles, inclusive of duplicates. Twenty-six unique articles met our inclusion criteria, with an additional 2 articles found through hand searching. In total, 28 studies involving 107,335 participants were included in the final analysis, all of which were observational. Meta-analysis demonstrated that, compared with noncontrast CT, contrast-enhanced CT was not significantly associated with either acute kidney injury (odds ratio [OR] 0.94; 95% confidence interval [CI] 0.83 to 1.07), need for renal replacement therapy (OR 0.83; 95% CI 0.59 to 1.16), or all-cause mortality (OR 1.0; 95% CI 0.73 to 1.36).

CONCLUSION: We found no significant differences in our principal study outcomes between patients receiving contrast-enhanced CT versus those receiving noncontrast CT. Given similar frequencies of acute kidney injury in patients receiving noncontrast CT, other patient- and illness-level factors, rather than the use of contrast material, likely contribute to the development of acute kidney injury.

9. Applying the Ottawa SAH rule on a cohort of ED patients with HA

Chu KH, et al. Eur J Emerg Med. 2017 Dec 5 [Epub ahead of print]

OBJECTIVE: The Ottawa subarachnoid haemorrhage (SAH) rule suggests that alert patients older than 15 years with a severe nontraumatic headache reaching maximum intensity within 1 h and absence of high-risk variables effectively have a SAH ruled out. We aimed to determine the proportion of emergency department (ED) patients with any headache fulfilling the entry criteria for the Ottawa SAH rule.

PATIENTS AND METHODS: The Ottawa SAH rule was applied retrospectively in a substudy of a prospective snapshot of 34 EDs in Queensland, Australia, carried out over 4 weeks in September 2014. Patients older than 18 years or more with a nontraumatic headache of any potential cause were included. Clinical data and results of investigations were collected.

RESULTS: Data were available for 644 (76%) patients. A total of 149 (23.1%, 95% confidence interval: 20.0-26.5%) fulfilled and 495 (76.9%, 95% confidence interval: 73.5-80.0%) did not fulfil the entry criteria. In patients who fulfilled the entry criteria, 30 (less than 5% overall) did not have any high-risk variables for SAH. In patients who fulfilled the entry criteria and had at least 1 high-risk feature, almost half (46%) received a computed tomographic brain. No SAH were missed.

CONCLUSION: In this descriptive observational study, the majority of ED patients presenting with a headache did not fulfil the entry criteria for the Ottawa SAH rule. Less than 5% of the patients in this cohort could have SAH excluded on the basis of the rule. More definitive studies are needed to determine an accepted benchmark for the proportion of patients receiving further work-up (computed tomographic brain) after fulfilling the entry criteria for the Ottawa SAH rule.

10. Images in Clinical Practice

Oesophageal coins invisible on chest radiography: a case report

Recognizing a Rare Phenomenon of Angiotensin-Converting Enzyme Inhibitors: Visceral Angioedema Presenting with Chronic Diarrhea—A Case Report

Image Diagnosis: Nasal Furunculosis - A Dangerous Nose Infection

Ventriculoperitoneal-Shunt Placement for Normal-Pressure Hydrocephalus

Clinical Diagnosis of Hidradenitis Suppurativa

Tubular Opacities in the Gastrointestinal Tract

Caterpillar Sign in Infantile Hypertrophic Pyloric Stenosis

An Unconscious Patient with a DNR Tattoo

Pneumatosis Cystoides Intestinalis
A 48-year-old woman with a prolonged history of glucocorticoid use presented with abdominal fullness. Computed tomography showed numerous gas-containing cysts within the colonic wall.

Ecthyma Gangrenosum
A 21-year-old woman with acute myeloid leukemia who was undergoing induction chemotherapy presented with a lesion on her left knee. Blood and wound cultures grew Pseudomonas aeruginosa, and a diagnosis of ecthyma gangrenosum was made.

ECG-Induced Koebner Phenomenon
A 53-year-old man with psoriasis presented to the dermatology clinic with new psoriatic lesions on his chest where electrodes had recently been placed during electrocardiography.

Zenker’s Diverticulum
A 67-year-old man with an 8-month history of dysphagia and regurgitation presented to the gastroenterology clinic. A barium swallow examination showed an outpouching esophageal lesion consistent with a Zenker’s diverticulum.

Man With Bulging Blisters

Young Woman With Black Spot on Foot

Elderly Male With Shortness of Breath

Elderly Woman With Vomiting

11. Procedural Sedation Agents: Which to Choose for the Hypotensive or At-Risk-for-Hypotension Patient?

A. Adverse Events With Ketamine Versus Ketofol for Procedural Sedation on Adults: A Double-blind, Randomized Controlled Trial.

Lemoel F, et al. Acad Emerg Med. 2017 Dec;24(12):1441-1449.

OBJECTIVES: The goal of our study was to compare the frequency and severity of recovery reactions between ketamine and ketamine-propofol 1:1 admixture ("ketofol").

METHODS: We performed a multicentric, randomized, double-blind trial in which adult patients received emergency procedural sedations with ketamine or ketofol. Our primary outcome was the proportion of unpleasant recovery reactions. Other outcomes were frequency of interventions required by these recovery reactions, rates of respiratory or hemodynamic events, emesis, and satisfaction of patients as well as providers.

RESULTS: A total of 152 patients completed the study, 76 in each arm. Compared with ketamine, ketofol determined a 22% reduction in recovery reactions incidence (p less than 0.01) and less clinical and pharmacologic interventions required by these reactions. There was no serious adverse event in both groups. Rates in hemodynamic or respiratory events as well as satisfaction scores were similar. Significantly fewer patients experienced emesis with ketofol, with a threefold reduction in incidence compared with ketamine.

CONCLUSION: We found a significant reduction in recovery reactions and emesis frequencies among adult patients receiving emergency procedural sedations with ketofol, compared with ketamine.

B. Editorial: Ketamine or Ketofol: Do We Have Enough Evidence to Know Which One to Use?

Miner J. Acad Emerg Med 2017 Dec;24(12):1511-1513.

Ketamine and propofol are both commonly used emergency department (ED) procedural sedation agents. Their concurrent administration, often referred to as “ketofol,” is widely used for procedural sedation. A simple Google search can lead to many opinions on why we should use propofol, ketamine, or ketofol in a given situation for moderate or deep procedural sedation in the ED, but finding evidence that supports differences these opinions assume is much more difficult to come by. There is a growing body of research on these agent's relative strengths and weaknesses, but substantial differences among the agents that support many commonly held notions have been difficult to find in research studies. Much of this is due to the fact that the outcome measures we use in sedation trials lack the precision to detect subtle clinical differences. In the absence of improved accuracy and precision of the measurements we use in clinical trials, we are left to interpret what we have when we select an agent. In this issue of Academic Emergency Medicine, Lemoel et al.[1] took a slightly different approach to sedation research and compared ketamine to ketofol for procedural sedation in adults using recovery reactions as the primary outcome rather than the more typical measures of respiratory depression or cardiovascular function.

We've all heard that ketamine preserves respiratory capacity relative to propofol, but when ketamine and propofol are compared, ketamine appears to have the same as or a greater rate than subclinical respiratory depression and a similar need for preventive airway interventions that of propofol.[2-4] While studies are limited to relatively healthy (American Society of Anesthesiologist Physical Status Score 1–2) patients at low risk of adverse events, there does not appear to be a big difference in the capacity of these drugs to cause airway problems at deep sedation doses. We have also seen very strong opinions regarding propofol's lack of analgesic properties and that since ketamine is an analgesic, it will be better for sedation, but this does not pan out in research. Recalled pain, satisfaction, and postprocedure pain are typically reported as the same between these agents.[1, 2, 5-7] Even a small study of catecholamine levels did not detect a difference in stress levels for patients treated with and without an opioid added to propofol.[8, 9] For the brief painful procedures typical of ED procedural sedation, it's unlikely that the negative effects of brief unrecalled pain are substantial enough to play a major role in our decision about which agents to use for sedation.

In terms of cardiovascular effects, however, we have seen differences in the agents, and it appears that ketamine causes less hypotension than propofol.[1, 3, 7] This has also been found for ketofol.[6, 7, 10-13] Since most of the patients in sedation studies are relatively stable, this effect is difficult to appreciate as clinically significant, but when we look at sedation in unstable and critically ill patients, hypotension and bradycardia are more pronounced and likely to be significant.[14] We can extrapolate these findings to assume that in critically ill patients or patients at risk, available studies would indicate that ketamine and ketofol are safer approaches to sedation than propofol and are less likely to cause hypotension.

In terms of brief procedures on relatively stable in the ED, respiratory depression and pain do not appear to be have big differences that would guide our use between ketamine, propofol, and ketofol. Hypotension, on the other hand, appears worse with propofol than with ketofol[10-12] or ketamine.[2] This leaves us asking, in patients that are at risk for hypotension, should we use ketofol or ketamine? Studies that examine hypotension in ketamine versus ketofol in patients that are likely to experience hemodynamic compromise, such as patients with a ASA physical status score > 2, remain to be done.

The other difference studies consistently find between ketamine, ketofol, and propofol is recovery agitation. This is variably defined in studies, but it appears that this event is very rare for propofol[4, 15, 16] and less common with ketofol[10-12] but occurs in 10% to 30% of ketamine sedations.[1, 3] Since we know that propofol is more associated with hypotension than ketofol or ketamine, the difference in recovery agitation may be an important differentiator between ketamine and ketofol.

The study in this issue of Academic Emergency Medicine by Lemoel et al.[1] asks the question of what is the difference in recovery agitation between ketofol and ketamine, to give us an idea of the effect of ketofol relative to ketamine and allow us to decide to use it or not. This study was not designed to precisely detect respiratory depression or hypotension relative to previous works, but the change in primary outcome and emphasis is an important piece of progress in determining the relative strength and weaknesses of agents at our disposal.

So which agents should we use? In a patient at low risk of cardiovascular compromise who needs brief sedation, there is not enough information to discern a difference between ketofol at > 2:1 ratio (higher ketamine proportions have demonstrated prolonged recovery times) and propofol,[7] and there is no safety or analgesic benefit detected for ketamine to justify the risk of recovery agitation. For sicker patients at risk of hypotension, however, it is likely that ketamine and ketofol are superior to propofol. Given the lower rate of recovery agitation noted in the study in this issue of AEM and the equivocal rate of hypotension between ketamine and ketofol, it appears that ketofol is the better choice for patients at risk for hypotension.

12. Novel Telestroke Program Improves Thrombolysis for Acute Stroke Across 21 Hospitals of an Integrated Healthcare System 

Nguyen-Huynh MN, et al. KPNC Stroke FORCE Team. Stroke. 2018 Jan;49(1):133-139.

BACKGROUND AND PURPOSE: Faster treatment with intravenous alteplase in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California redesigned its acute stroke workflow across all 21 Kaiser Permanente Northern California stroke centers to (1) follow a single standardized version of a modified Helsinki model and (2) have all emergency stroke cases managed by a dedicated telestroke neurologist. We examined the effect of Kaiser Permanente Northern California's Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke program on door-to-needle (DTN) time, alteplase use, and symptomatic intracranial hemorrhage rates.

METHODS: The program was introduced in a staggered fashion from September 2015 to January 2016. We compared DTN times for a seasonally adjusted 9-month period at each center before implementation to the corresponding 9-month calendar period from the start of implementation. The primary outcome was the DTN time for alteplase administration. Secondary outcomes included rate of alteplase administrations per month, symptomatic intracranial hemorrhage, and disposition at time of discharge.

RESULTS: This study included 310 patients treated with alteplase in the pre-EXpediting the PRrocess of Evaluating and Stopping Stroke period and 557 patients treated with alteplase in the EXpediting the PRrocess of Evaluating and Stopping Stroke period. After implementation, alteplase administrations increased to 62/mo from 34/mo at baseline (P less than 0.001). Median DTN time decreased to 34 minutes after implementation from 53.5 minutes prior (P less than 0.001), and DTN time of less than 60 minutes was achieved in 87.1% versus 61.0% (P less than 0.001) of patients. DTN times less than 30 minutes were much more common in the Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke period (40.8% versus 4.2% before implementation). There was no significant difference in symptomatic intracranial hemorrhage rates in the 2 periods (3.8% versus 2.2% before implementation; P=0.29).

CONCLUSIONS: Introduction of a standardized modified Helsinki protocol across 21 hospitals using telestroke management was associated with increased alteplase administrations, significantly shorter DTN times, and no increase in adverse outcomes.

13. AFF Rate Control with Beta-blockers vs Calcium Channel Blockers in the Emergency Setting: Predictors of Medication Class Choice and Associated Hospitalization

Atzema CL, et al. Acad Emerg Med. 2017 Nov;24(11):1334-1348.

OBJECTIVES: Rate control is an important component of the management of patients with atrial fibrillation (AF). Previous studies of emergency department (ED) rate control have been limited by relatively small sample sizes. We examined the use of beta-blockers (BBs) versus nondihydropyridine calcium channel blockers (CCBs) in ED patients from 24 sites and the associated hospital admission rates.

METHODS: In this preplanned substudy, we examined chart data on AF patients who visited one of 24 hospital EDs in Ontario, Canada, between April 2008 and March 2009. We describe the proportion of patients who received either a BB or a CCB, had a heart rate less than 110 beats/min 2 hours later, and had any complications. We used hierarchical logistic regression modeling to determine the predictors of BB versus CCB use and to assess the between-hospital variation in use of BBs versus CCBs. Solely in patients who had no rhythm control attempts, we examined the difference in the probability of hospital admission after propensity score matching patients by medication class.

RESULTS: Of the 1,639 patients who received either a BB (n = 429) or a CCB (n = 1,210), 70.9% of the patients who received a BB had successful rate control versus 66.1% for a CCB. Complications were rare (2.4%), and the large majority were hypotension (2.0%). In adjusted analyses, predictors of receiving a BB (compared to a CCB) included already being on a BB, being sent in from a doctor's office, or being seen at a teaching hospital. In contrast, patients with evidence of heart failure, prior use of a CCB, a higher presenting heart rate, or a successful pharmacologic cardioversion (vs. no attempt) or who were seen at the highest AF volume EDs were significantly less likely to receive a BB, compared to a CCB. Systematic between-hospital differences accounted for 8% of the variation in BB versus CCB use. Hospital characteristics accounted for the large majority of that variation: after accounting for patient characteristics the between-hospital variation decreased by a relative 2.8%. By further adjusting for hospital characteristics, it decreased by a relative 74.7%. Among propensity score-matched patients with no rhythm control attempts, more CCB patients were admitted (51.6%) compared to BB patients (40.0%; difference of 11.6%; 95% confidence interval = 7.9%-16.2%).

CONCLUSIONS: In this study of 24 EDs, CCBs were used more frequently for rate control than BBs, and complications were rare and easily managed using both agents. Variation between hospitals in BB versus CCB use was predominantly due to hospital characteristics such as teaching status and AF volumes, rather than different case mix. Among patients who did not receive attempts at rhythm control, use of a BB for rate control was associated with a lower rate of hospitalization.

14. Skin Abscess Management: Things are Changing

A. Subgroup Analysis of Antibiotic Treatment for Skin Abscesses.

Talan DA, et al. Ann Emerg Med. 2018 Jan;71(1):21-30.

STUDY OBJECTIVE: Two large randomized trials recently demonstrated efficacy of methicillin-resistant Staphylococcus aureus (MRSA)-active antibiotics for drained skin abscesses. We determine whether outcome advantages observed in one trial exist across lesion sizes and among subgroups with and without guideline-recommended antibiotic indications.

METHODS: We conducted a planned subgroup analysis of a double-blind, randomized trial at 5 US emergency departments, demonstrating superiority of trimethoprim-sulfamethoxazole (320/1,600 mg twice daily for 7 days) compared with placebo for patients older than 12 years with a drained skin abscess. We determined between-group differences in rates of clinical (no new antibiotics) and composite cure (no new antibiotics or drainage) through 7 to 14 and 42 to 56 days after treatment among subgroups with and without abscess cavity or erythema diameter greater than or equal to 5 cm, history of MRSA, fever, diabetes, and comorbidities. We also evaluated treatment effect by lesion size and culture result.

RESULTS: Among 1,057 mostly adult participants, median abscess cavity and erythema diameters were 2.5 cm (range 0.1 to 16.0 cm) and 6.5 cm (range 1.0 to 38.5), respectively; 44.3% grew MRSA. Overall, for trimethoprim-sulfamethoxazole and placebo groups, clinical cure rate at 7 to 14 days was 92.9% and 85.7%; composite cure rate at 7 to 14 days was 86.5% and 74.3%, and at 42 to 56 days, it was 82.4% and 70.2%. For all outcomes, across lesion sizes and among subgroups with and without guideline antibiotic criteria, trimethoprim-sulfamethoxazole was associated with improved outcomes. Treatment effect was greatest with history of MRSA infection, fever, and positive MRSA culture.

CONCLUSION: Treatment with trimethoprim-sulfamethoxazole was associated with improved outcomes regardless of lesion size or guideline antibiotic criteria.

B. Comparison of the loop technique with I&D for soft tissue abscesses: A systematic review and meta-analysis.

Gottlieb M, et al. Am J Emerg Med 2018;36:128-133.

INTRODUCTION: Skin and soft tissue infections are a common presentation to the emergency department. Traditional management of abscesses involves a linear incision through the center of the abscess with packing placed. The loop drainage technique (LDT) is an alternate approach that may reduce pain and scarring, as well as decrease the number of follow up visits needed. This systematic review and meta-analysis aimed to compare the efficacy of the LDT with conventional incision and drainage (CID) in the treatment of soft tissue abscesses.

METHODS: PubMed, CINAHL, Scopus, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and bibliographies of selected articles were assessed for all retrospective, prospective, or randomized controlled trials comparing the LDT to CID with an outcome of treatment failure, as defined by the individual study. Data were double extracted into a predefined worksheet and quality analysis was performed using the Cochrane Risk of Bias tool. Data were summarized and a meta-analysis was performed with subgroup analyses by adult versus pediatric age groups.

RESULTS: This systematic review identified four studies comprising 470 total patients. Overall, the CID technique failed in 25 of 265 cases (9.43%). The LDT failed in 8 of 195 cases (4.10%). There was an odds ratio of 2.63 (95% CI 1.04 to 6.63) in favor of higher failures in the CID group. Funnel plot analysis demonstrated no evidence of publication bias. Subgroups analysis by age group demonstrated improved efficacy of the LDT in pediatric patients, but the adult subgroup did not reach statistical significance.

DISCUSSION: The existing literature suggests that LDT is associated with a lower failure rate than CID. However, the data is limited by small sample sizes and predominantly retrospective study designs. Given the potential for less pain, decreased scarring, and lower associated healthcare costs, this technique should be considered for the treatment of skin and soft tissue abscesses in the ED setting, but further studies are needed.

C. What to Do After You Cut: Recommendations for Abscess Management in the Emergency Setting (from EM-RAP)

Gottlieb M, et al. Ann Emerg Med. 2018 Jan;71(1):31-33.

Annals Case
Anyone out there seen an abscess recently? We are guessing yes! We know ’em. We love ’em. But most important, everything about their management is cut-and-dried (or cut and squeezed)…right? Well, until a new publication throws doubt on the usual management. Much has changed since the old standard practice of anesthetize, cut, blunt dissect, irrigate, and pack. In this edition of Annals, Talan et al published a subgroup analysis on the use of antibiotics for the treatment of skin abscesses, demonstrating an improvement in outcomes regardless of lesion size, a great opportunity to discuss the current data in regard to several aspects of abscess management!

15. ED Utilization

A. The Uninsured Do Not Use the ED More—They Use Other Care Less

The Uninsured Do Not Use The Emergency Department More-They Use Other Care Less.
Zhou RA, et al. Health Aff (Millwood). 2017 Dec;36(12):2115-2122.

There is a popular perception that insurance coverage will reduce overuse of the emergency department (ED). Both opponents and advocates of expanding insurance coverage under the Affordable Care Act (ACA) have made statements to the effect that EDs have been jammed with the uninsured and that paying for the uninsured population’s emergency care has burdened the health care system as a result of the expense of that care. It has therefore been surprising to many to encounter evidence that insurance coverage increases ED use instead of decreasing it. Two facts may help explain this unexpected finding. First, there is a common misperception that the uninsured use the ED more than the insured. In fact, insured and uninsured adults use the ED at very similar rates and in very similar circumstances—and the uninsured use the ED substantially less than the Medicaid population. Second, while the uninsured do not use the ED more than the insured, they do use other types of care much less than the insured.

B. The impact of improving access to primary care.

Glass DP, et al. J Eval Clin Pract. 2017 Oct 6 [Epub ahead of print]

OBJECTIVES: To measure the size and timing of changes in utilization and costs for employees and dependents who had major access barriers to primary care removed, across an 8-year period (2007 to 2014).

STUDY DESIGN AND METHODS: Retrospective observational study examining patterns of utilization and costs before and after the implementation of a worksite medical office in 2010. The worksite office offered convenient primary care services with no travel from work, essentially guaranteed same day access, and no co-pay. Trends in visit rates and costs were compared for an intervention fixed cohort group (employees and dependents) at the employer (n = 1211) with a control fixed cohort group (n = 542 162) for 6 types of visits (primary, urgent, emergency, inpatient, specialty, and other outpatient). Difference-in-differences methods assessed the significance of between-group changes in utilization and costs.

RESULTS: The worksite medical office intervention group had an increase in primary care visits relative to the control group (+43% vs +4%, P less than 0.001). This was accompanied by a reduction in urgent care visits by the intervention group compared with the control group (-43% vs -5%, P less than 0.001). There were no differences in the other types of visits, and the total visit costs for the intervention group increased 5.7% versus 2.7% for the control group (P = 0.008). A sub-group analysis of the intervention group (comparing dependents to employees) found that that the dependents achieved a reduction in costs of 2.7% (P less than 0.001) across the study period.

CONCLUSIONS: The potential for long-term reduction in utilization and costs with better access to primary care is significant, but not easily nor automatically achieved.

16. Tranexamic Acid Is More Effective Than Nasal Packing for Treatment of Epistaxis: Even in Pts on Antiplatelet Agents

Zahed R, et al. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med. 2017 Nov 10 [Epub ahead of print]

OBJECTIVE: We evaluated the efficacy of topical application of the injectable form of tranexamic acid (TXA) compared with anterior nasal packing (ANP) for the treatment of epistaxis in patients taking antiplatelet drugs (aspirin, clopidogrel, or both) who presented to the emergency department (ED).

METHODS: A randomized, parallel-group clinical trial was conducted at two EDs. A total of 124 participants were randomized to receive topical TXA (500 mg in 5 mL) or ANP, 62 patients per group. The primary outcome was the proportion of patients in each group whose bleeding had stopped at 10 minutes. Secondary outcomes were the rebleeding rate at 24 hours and 1 week, ED length of stay (LOS), and patient satisfaction.

RESULTS: Within 10 minutes of treatment, bleeding was stopped in 73% of the patients in the TXA group, compared with 29% in the ANP group (difference = 44%, 95% confidence interval, 26% to 57%; p less than 0.001). Additionally, rebleeding was reported in 5 and 10% of patients during the first 24 hours in the TXA and the ANP groups, respectively. At 1 week, 5% of patients in the TXA group and 21% of patients in the ANP group had experienced recurrent bleeding (p = 0.007). Patients in the TXA group reported higher satisfaction scores (median [interquartile range {IQR}], 9 [8-9.25]) compared with the ANP group (median [IQR] = 4 [3-5]; p less than 0.001). Discharge from the ED in less than 2 hours was achieved in 97% of patients in the TXA group versus 13% in the ANP group (p less than 0.001). There were no adverse events reported in either group.

CONCLUSIONS: In our study population, epistaxis treatment with topical application of TXA resulted in faster bleeding cessation, less rebleeding at 1 week, shorter ED LOS, and higher patient satisfaction compared with ANP.

And don’t forget to teach the pt proper “pinching” technique:
Hajimaghsoudi M, et al. A novel method for epistaxis management: Randomized clinical trial comparing nose clip with manual compression. Am J Emerg Med 2018;36:149-150.

17. Pediatric Corner

A. The TWIST Score: Prospective Validation of Clinical Score for Males Presenting with an Acute Scrotum.

Frohlich LC, et al. Acad Emerg Med. 2017 Dec;24(12):1474-1482.

OBJECTIVE: The objective was to validate the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score among pediatric emergency medicine providers for the evaluation of pediatric males presenting with testicular pain and swelling (acute scrotum).

METHODS: We conducted a prospective cohort study of males 3 months to 18 years old presenting with an acute scrotum. History and physical examination findings, including components of the TWIST score (hard testicle, absent cremasteric reflex, nausea/vomiting, and high riding testicle) as well as diagnostic results (ultrasound, urine, sexually transmitted infection testing) were recorded. Testicular torsion was confirmed by surgical exploration. Frequencies of patient characteristics, TWIST components, and tests were calculated. We performed the kappa statistic for inter-rater reliability and calculated the test characteristics and receiver operator characteristics curves for the TWIST score (range = 0-7).

RESULTS: During the study period 258 males were enrolled in the study; 19 (7.4%) had testicular torsion. The mean (±SD) age was 9.8 (±0.3) years. The high-risk TWIST score of 7 had 100% specificity (95% confidence interval [CI] = 98%-100%) with 100% positive predictive value (95% CI = 40%-100%) for testicular torsion. The area under the curve was 0.82. The kappa statistic for the overall TWIST score was fair at 0.39.

CONCLUSIONS: In this prospective validation of the TWIST score among pediatric emergency providers, the high-risk score demonstrated strong test characteristics for testicular torsion. The TWIST score could be used as part of a standardized approach for evaluation of the pediatric acute scrotum to provide more efficient and effective care.

B. Effectiveness of β-Lactam Monotherapy vs Macrolide Combination Therapy for Children Hospitalized with Pneumonia.

Williams DJ, et al. JAMA Pediatr. 2017 Oct 30 [Epub ahead of print]

IMPORTANCE: β-Lactam monotherapy and β-lactam plus macrolide combination therapy are both common empirical treatment strategies for children hospitalized with pneumonia, but few studies have evaluated the effectiveness of these 2 treatment approaches.

OBJECTIVE: To compare the effectiveness of β-lactam monotherapy vs β-lactam plus macrolide combination therapy among a cohort of children hospitalized with pneumonia.

DESIGN, SETTING, AND PARTICIPANTS: We analyzed data from the Etiology of Pneumonia in the Community Study, a multicenter, prospective, population-based study of community-acquired pneumonia hospitalizations conducted from January 1, 2010, to June 30, 2012, in 3 children's hospitals in Nashville, Tennessee; Memphis, Tennessee; and Salt Lake City, Utah. The study included all children (up to 18 years of age) who were hospitalized with radiographically confirmed pneumonia and who received β-lactam monotherapy or β-lactam plus macrolide combination therapy. Data analysis was completed in April 2017.

MAIN OUTCOMES AND MEASURES: We defined the referent as β-lactam monotherapy, including exclusive use of an oral or parenteral second- or third-generation cephalosporin, penicillin, ampicillin, ampicillin-sulbactam, amoxicillin, or amoxicillin-clavulanate. Use of a β-lactam plus an oral or parenteral macrolide (azithromycin or clarithromycin) served as the comparison group. We modeled the association between these groups and patients' length of stay using multivariable Cox proportional hazards regression. Covariates included demographic, clinical, and radiographic variables. We further evaluated length of stay in a cohort matched by propensity to receive combination therapy. Logistic regression was used to evaluate secondary outcomes in the unmatched cohort, including intensive care admission, rehospitalizations, and self-reported recovery at follow-up.

RESULTS: Our study included 1418 children (693 girls and 725 boys) with a median age of 27 months (interquartile range, 12-69 months). This cohort was 60.1% of the 2358 children enrolled in the Etiology of Pneumonia in the Community Study with radiographically confirmed pneumonia in the study period; 1019 (71.9%) received β-lactam monotherapy and 399 (28.1%) received β-lactam plus macrolide combination therapy. In the unmatched cohort, there was no statistically significant difference in length of hospital stay between children receiving β-lactam monotherapy and combination therapy (median, 55 vs 59 hours; adjusted hazard ratio, 0.87; 95% CI, 0.74-1.01). The propensity-matched cohort (n = 560, 39.5%) showed similar results. There were also no significant differences between treatment groups for the secondary outcomes.

CONCLUSIONS AND RELEVANCE: Empirical macrolide combination therapy conferred no benefit over β-lactam monotherapy for children hospitalized with community-acquired pneumonia. The results of this study elicit questions about the routine empirical use of macrolide combination therapy in this population.

C. The Pediatric Submersion Score Predicts Children at Low Risk for Injury Following Submersions.

Shenoi RP, et al. Acad Emerg Med. 2017 Dec;24(12):1491-1500.

OBJECTIVES: Pediatric submersion victims often require admission. We wanted to identify a cohort of children at low risk for submersion-related injury who can be safely discharged from the emergency department (ED) after a period of observation.

METHODS: This was a single-center retrospective derivation/validation cross-sectional study of children (0-18 years) who presented postsubmersion to a tertiary care, children's hospital ED from 2008 to 2015. We reviewed demographics, comorbidities, and prehospital and ED course. Primary outcome was safe discharge at 8 hours postsubmersion: normal mentation and vital signs. To identify potential scoring factors, any p-value of ≤0.25 was included in binary logistic regression; p-values less than 0.05 were included in the final score. In the validation data set, we generated a one-point scoring system for each normal ED item. Receiver operating characteristic curves with area under the curve (AUC) were generated to test sensitivity and specificity.

RESULTS: The derivation data set consisted of 356 patients and validation data set of 89 patients. Five factors generated a safe discharge score at 8 hours: normal ED mentation, normal ED respiratory rate, absence of ED dyspnea, absence of need for airway support (bag-valve mask ventilation, intubation, and CPAP), absence of ED systolic hypotension (maximum score = 5; range = 0-5). Only the 80 patients with values for all five factors were included in the sensitivity/specificity analysis. This resulted in an AUC of 0.81 (95% confidence interval [CI] = 0.71-0.91; p less than 0.001). Based on the sensitivity/specificity analysis, the discriminative ability peaks at 75% with a score of ≥3.5. A score of 4 or higher in the ED would suggest a safe discharge at 8 hours (sensitivity = 88.2% [95% CI = 72.5%-96.7%]; specificity = 62.9% [95% CI = 44.9%-78.5%]; positive predictive value = 69.8% [95% CI = 53.9%-82.8%]; negative predictive value = 84.6% [95% CI = 65.1%-95.6%]).

CONCLUSIONS: A risk score can identify children at low risk for submersion-related injury who can be safely discharged from the ED after observation.

D. Oral and Dental Aspects of Child Abuse and Neglect

Fisher-Owens SA, et al. Pediatrics. 2017 Aug;140(2).

In all 50 states, health care providers (including dentists) are mandated to report suspected cases of abuse and neglect to social service or law enforcement agencies. The purpose of this report is to review the oral and dental aspects of physical and sexual abuse and dental neglect in children and the role of pediatric care providers and dental providers in evaluating such conditions. This report addresses the evaluation of bite marks as well as perioral and intraoral injuries, infections, and diseases that may raise suspicion for child abuse or neglect. Oral health issues can also be associated with bullying and are commonly seen in human trafficking victims. Some medical providers may receive less education pertaining to oral health and dental injury and disease and may not detect the mouth and gum findings that are related to abuse or neglect as readily as they detect those involving other areas of the body. Therefore, pediatric care providers and dental providers are encouraged to collaborate to increase the prevention, detection, and treatment of these conditions in children.

18. Short-Term Outcomes and Factors Associated with Adverse Events Among Adults Discharged From the ED after Treatment for Acute Heart Failure.

Sax DR, et al. Circ Heart Fail. 2017 Dec 13 [Epub ahead of print].

BACKGROUND: Although 80% of patients with heart failure seen in the emergency department (ED) are admitted, less is known about short-term outcomes and demand for services among discharged patients.

METHODS AND RESULTS: We examined adult members of a large integrated delivery system who visited an ED for acute heart failure and were discharged from January 1, 2013, through September 30, 2014. The primary outcome was a composite of repeat ED visit, hospital admission, or death within 7 days of discharge. We identified multivariable baseline patient-, provider-, and facility-level factors associated with adverse outcomes within 7 days of ED discharge using logistic regression. Among 7614 patients, mean age was 77.2 years, 51.9% were women, and 28.4% were people of color. Within 7 days of discharge, 75% had outpatient follow-up (clinic, telephone, or e-mail), 7.1% had an ED revisit, 4.7% were hospitalized, and 1.2% died. Patients who met the primary outcome were more likely to be older, smokers, have a history of hemorrhagic stroke, hypothyroidism, and dementia, and less likely to be treated in a facility with an observation unit. In multivariable analysis, higher comorbidity scores and history of smoking were associated with a higher odds of the primary outcome, whereas treatment in a facility with an observation unit and presence of outpatient follow-up within 7 days were associated with a lower odds.

CONCLUSIONS: We identified selected hospital and patient characteristics associated with short-term adverse outcomes. Further understanding of these factors may optimize safe outpatient management in ED-treated patients with heart failure.

19. No Easy Way Out: A Case of Physician-Assisted Dying in the ED

Wang DH. Ann Emerg Med. 2017 Oct 12 [Epub ahead of print]

Currently, 1 out of 6 Americans lives within a jurisdiction in which physician-assisted dying is legally authorized. In most cases, patients ingest lethal physician-assisted dying medications at home without involvement of emergency medical services (EMS) or the emergency department (ED). However, occasionally the dying process is interrupted as a result of incomplete ingestion or vomiting of medications, confusion about timing of dying trajectory, familial emotional distress, and other variables.

A case is presented here of a patient who arrived by ambulance to an urban ED after ingesting physician-assisted dying medication. Stepwise analysis of communication and actions between providers (paramedics, emergency physician, and admitting physician), risk management, and family are described chronologically. This case highlights the significant distress experienced by each party, as well as key challenges and learning points.

Guidance is provided to emergency providers about expectations and communication. In states with limited physician-assisted dying experience, many EMS agencies, EDs, and hospitals require comprehensive protocols to handle the complex ethical and psychosocial issues surrounding physician-assisted dying in the ED.

20. Three New Risk Scores to Help Stratify Adult ED Patients at Low Risk for SDH Deterioration, Variceal UGIB, and Arrhythmia following Syncope 

A. A Decision Instrument to Identify Isolated Traumatic SDH at Low Risk of Neurologic Deterioration, Surgical Intervention, or Radiographic Worsening.

Pruitt P, et al. Acad Emerg Med. 2017 Nov;24(11):1377-1386.

OBJECTIVES: Subdural hematoma (SDH) is the most common form of traumatic intracranial hemorrhage. Severity of disease in patients with SDH varies widely. It was hypothesized that a decision rule could identify patients with SDH who are at very low risk for neurologic decline, neurosurgical intervention, or radiographic worsening.

METHODS: Retrospective chart review of consecutive patients age ≥ 16 with Glasgow Coma Score (GCS) ≥ 13 and computed tomography (CT)-documented isolated SDH presenting to a university-affiliated, urban, 100,000-annual-visit ED from 2009 to 2015. Demographic, historical, and physical examination variables were collected. Primary outcome was a composite of neurosurgical intervention, worsening repeat CT, and neurologic decline. Univariate analysis was performed and statistically important variables were utilized to create a logistic regression model.

RESULTS: A total of 644 patients with isolated SDH were reviewed, 340 in the derivation group and 304 in the validation set. Mortality was 2.2%. A total 15.5% of patients required neurosurgery. A decision instrument was created: patients were low risk if they had none of the following factors-SDH thickness ≥ 5mm, warfarin use, clopidogrel use, GCS less than 14, and presence of midline shift. This model had a sensitivity of 98.6% for the composite endpoint, specificity of 37.1%, and a negative likelihood ratio of 0.037. In the validation cohort, sensitivity was 96.3%, specificity was 31.5%, and negative likelihood ratio was 0.127.

CONCLUSION: Subdural hematomas are amenable to risk stratification analysis. With prospective validation, this decision instrument may aid in triaging these patients, including reducing the need for transfer to tertiary centers.

B. Identifying ED Patients at Low Risk for a Variceal Source of Upper GI Hemorrhage

Klein LR, et al. Acad Emerg Med. 2017 Nov;24(11):1405-1409.

BACKGROUND: Assessing the likelihood of a variceal versus nonvariceal source of upper gastrointestinal bleeding (UGIB) guides therapy, but can be difficult to determine on clinical grounds. The objective of this study was to determine if there are easily ascertainable clinical and laboratory findings that can identify a patient as low risk for a variceal source of hemorrhage.

METHODS: This was a retrospective cohort study of adult ED patients with UGIB between January 2008 and December 2014 who had upper endoscopy performed during hospitalization. Clinical and laboratory data were abstracted from the medical record. The source of the UGIB was defined as variceal or nonvariceal based on endoscopic reports. Binary recursive partitioning was utilized to create a clinical decision rule. The rule was internally validated and test characteristics were calculated with 1,000 bootstrap replications.

RESULTS: A total of 719 patients were identified; mean age was 55 years and 61% were male. There were 71 (10%) patients with a variceal UGIB identified on endoscopy. Binary recursive partitioning yielded a two-step decision rule (platelet count > 200 × 109 /L and an international normalized ratio [INR] less than 1.3), which identified patients who were low risk for a variceal source of hemorrhage. For the bootstrapped samples, the rule performed with 97% sensitivity (95% confidence interval [CI] = 91%-100%) and 49% specificity (95% CI = 44%-53%).

CONCLUSION: Although this derivation study must be externally validated before widespread use, patients presenting to the ED with an acute UGIB with platelet count of >200 × 109 /L and an INR of less than 1.3 may be at very low risk for a variceal source of their upper gastrointestinal hemorrhage.

C. Predicting Short-term Risk of Arrhythmia among Patients with Syncope: The Canadian Syncope Arrhythmia Risk Score.

Thiruganasambandamoorthy V, et al. Acad Emerg Med. 2017 Nov;24(11):1315-1326.

BACKGROUND: Syncope can be caused by serious occult arrhythmias not evident during initial emergency department (ED) evaluation. We sought to develop a risk tool for predicting 30-day arrhythmia or death after ED disposition.

METHODS: We conducted a multicenter prospective cohort study at six tertiary care EDs and included adults (≥16 years) with syncope. We collected standardized variables from clinical evaluation and investigations including electrocardiogram and troponin at index presentation. Adjudicated outcomes included death or arrhythmias including procedural interventions for arrhythmia within 30 days. We used multivariable logistic regression to derive the prediction model and bootstrapping for interval validation to estimate shrinkage and optimism.

RESULTS: A total of 5,010 patients (mean ± SD age = 53.4 ± 23.0 years, 54.8% females, and 9.5% hospitalized) were enrolled with 106 (2.1%) patients suffering 30-day arrhythmia/death after ED disposition. We examined 39 variables and eight were included in the final model: lack of vasovagal predisposition, heart disease, any ED systolic blood pressure less than 90 or greater than 180 mm Hg, troponin (above the 99th percentile), QRS duration over 130 msec, QTc interval over 480 msec, and ED diagnosis of cardiac/vasovagal syncope (optimism corrected C-statistic 0.90 [95% CI = 0.87-0.93]; Hosmer-Lemeshow p = 0.08). The Canadian Syncope Arrhythmia Risk Score had a risk ranging from 0.2% to 74.5% for scores of -2 to 8. At a threshold score of ≥0, the sensitivity was 97.1% (95% CI = 91.6%-99.4%) and specificity was 53.4% (95% CI = 52.0%-54.9%).

CONCLUSIONS: The Canadian Syncope Arrhythmia Risk Score can improve patient safety by identification of those at risk for arrhythmias and aid in acute management decisions. Once validated, the score can identify low-risk patients who will require no further investigations.

21. The Iatrogenic Potential of the Physician’s Words

Barsky AJ.  JAMA.  2017;318(24):2425-2426.

Some of the information that physicians convey to their patients can inadvertently amplify patients’ symptoms and become a source of heightened somatic distress, an effect that must be understood by physicians to ensure optimal management of patient care. This effect illustrates the iatrogenic potential of information, as opposed to the iatrogenic potential of drugs and procedures.

Somatic symptoms and underlying disease do not have a fixed, invariable, one-to-one equivalence. Symptoms can occur in the absence of demonstrable disease, “silent” disease occurs without symptoms, and there is substantial interindividual variability in the symptoms resulting from the same pathology or pathophysiology. One mediator of this variability between symptoms and disease is the patient’s thoughts, beliefs, and ideas. These cognitions can amplify symptoms and bodily distress. Although cognitions may not cause symptoms, they can amplify, perpetuate, and exacerbate them, making symptoms more salient, noxious, intrusive, and bothersome…

Pain is particularly sensitive to the beliefs, thoughts, and expectations of patients. The specific language used in describing and preparing patients for painful procedures can affect the pain experience. For example, in a randomized study of women receiving epidural anesthesia or spinal anesthesia (n = 140) for childbirth, those told that the intradermal injection of a local anesthetic would “feel like a bee sting: this is the worst part of the procedure” reported significantly more pain than did those told “the local anesthetic…will numb the area and you will be comfortable during the procedure.”5 The importance of cognitions in the experience of pain is particularly timely, given the current crisis in opiate treatment for chronic, nonmalignant pain…

When obtaining informed consent, physicians must absolutely provide complete and truthful information and must avoid fostering a “paternalistic” patient-physician relationship. But balancing the requirement for full and complete disclosure with the iatrogenic potential of some information is problematic. “Contextualized informed consent” has been proposed as an ethical way of balancing these competing imperatives.9 When prescribing a medication, all serious and medically significant adverse effects are of course described, and the patient is instructed to report all adverse effects; however, if the patient agrees, benign, nonspecific symptoms are not enumerated in advance because it is explained that doing so makes them more likely…

Information is an important mediator of the variability in the relationship between disease and symptoms. Some nonspecific drug adverse effects, undue pain from procedures, and symptoms exacerbated by learning about test results of unclear medical significance can be understood to share similar pathogenic mechanisms and respond to similar strategies of medical management.

22. Academic Life in Emergency Medicine (ALiEM): 2017 Annual Report: Inspiration and Ideas

ALiEM is busy doing cool and useful things for EM residents and faculty.

Check out their annual report for some highlights:

23. Tylenol May Help Ease the Pain Of Hurt Feelings

Allison Aubrey. NPR. 2017-12-04

Nobody likes the feeling of being left out, and when it happens, we tend to describe these experiences with the same words we use to talk about the physical pain of, say, a toothache.

"People say, 'Oh, that hurts,' " says Nathan DeWall, a professor of psychology at the University of Kentucky.

DeWall and his colleagues were curious about the crossover between physical pain and emotional pain, so they began a series of experiments several years back.

In one study, they found that acetaminophen (the active ingredient in Tylenol) seemed to reduce the sting of rejection that people experienced after they were excluded from a virtual ball-tossing game.

The pain pills seemed to dim activity in regions of the brain involved in processing social pain, according to brain imaging. "People knew they were getting left out [of the game], it just didn't bother them as much," DeWall explains.

As part of the study, participants were given either acetaminophen or a placebo for three weeks. None of the participants knew which one they were given. Each evening, participants completed a Hurt Feelings Scale, designed as a standardized measure of emotional pain. They were asked to rank themselves on statements such as: "Today, being teased hurt my feelings." It turned out that the pain medicine reduced reports of social pain.

The emotional dampening documented in these experiments is not huge, but it appears significant enough to nudge people into a less-sensitive emotional state…

24. Micro Bits

A. Four West Virginia Cities Sue The Joint Commission

These four cities teamed up to file suit against The Joint Commission over the organization's handling of pain management standards. The move follows more than a decade of public sparring over the role that the organization may have played in the worsening opioid epidemic.

B. Analysis finds out-of-hospital naloxone use safe, effective

An analysis of 13 studies on the administration and dosing of naloxone in out-of-hospital settings showed higher-concentration intranasal naloxone and intramuscular naloxone had similar rates of efficacy in reversing overdose symptoms and showed no difference in adverse events. Researchers reported in the Annals of Internal Medicine that there was no serious harm associated with not visiting the hospital after using naloxone to reverse an overdose.

C. Prescription Drugs May Cost More With Insurance Than Without It

Having health insurance is supposed to save you money on your prescriptions. But increasingly, consumers are finding that isn’t the case.

Patrik Swanljung found this out when he went to fill a prescription for a generic cholesterol drug. In May, Mr. Swanljung handed his Medicare prescription card to the pharmacist at his local Walgreens and was told that he owed $83.94 for a three-month supply.

Alarmed at that price, Mr. Swanljung went online and found Blink Health, a start-up, offering the same drug — generic Crestor — for $45.89.

It had struck a better deal than did his insurer, UnitedHealthcare. “It’s completely ridiculous,” said Mr. Swanljung, 72, who lives in Anacortes, Wash.

D. AAV5–Factor VIII Gene Transfer in Severe Hemophilia A

An AAV5 vector with a functional factor VIII gene was tested in men with hemophilia A. Men receiving the high dose had a factor VIII level above 5 IU per deciliter at 1 year; most had a normal level. Toxic effects were minimal, and bleeding episodes nearly eliminated.

E. Safety of Magnetic Resonance Imaging in Patients with Cardiac Devices

A total of 1509 patients who had legacy pacemakers or defibrillators underwent 2103 MRIs according to a prespecified safety protocol. No long-term clinically significant adverse events were reported.

F. Patient mortality rates higher for first-year hospitalists

A study in JAMA Internal Medicine found a 30-day patient mortality rate of 10.51% for first-year hospitalists, compared with 9.97% for hospitalists in their second year. "Hospitalists very early in their careers may benefit from additional support and reduced caseloads," the authors wrote.

G. Sodium valproate reduces recurrent stroke risk in study

A study in Stroke found patients who used sodium valproate had a 53% lower risk of recurrent stroke compared with those not taking the drug, and a 56% reduced risk compared with those taking other anti-epileptic medications. The findings were based on data from three prospective studies involving 11,949 patients who had a history of transient ischemic attack or stroke.

H. Review finds no proven way to prevent late-life dementia

Researchers who conducted four systematic evidence reviews found there is no scientifically proven way to prevent dementia in later life. The review in the Annals of Internal Medicine included drugs, supplements, exercise, cognitive training and vitamins, and researcher Mary Butler said the positive findings were consistent with public health messages about healthy lifestyle, good diet, and staying cognitively active and socially engaged.

I. Study links patient satisfaction to readmission risk

A study in BMJ Quality & Safety found hospital patients who reported higher satisfaction levels on post-discharge questionnaires were 39% less likely to be readmitted within 30 days, compared with those who were not satisfied with their care. Patients were 32% less likely to be readmitted if they believed their physicians listened to them.

J. Improving Decisions About Transport to the ED for Assisted Living Residents Who Fall

CONCLUSION: Shared decision making between paramedics and primary care physicians can prevent transport to the emergency department for many residents of assisted living facilities who fall.

K. Screen time before bed may reduce sleep, increase BMI in youths

Children who watched TV or played video games before going to bed had 30 minutes less sleep on average, while those who used cellphones or computers before bed received an hour less sleep on average, compared with those who didn't use such devices, researchers reported in the journal Global Pediatric Health. The findings also showed an association between increased technology use before bedtime and higher body mass index.

L. Coffee's Numerous Health Benefits Detailed in New Analysis

Amy Orciari Herman. Journal Watch, Nov 27, 2017

Coffee consumption — in particular, several cups daily — is associated with a wide range of health benefits, according to an umbrella review of meta-analyses in The BMJ.

The review included over 200 meta-analyses of observational or interventional research into coffee consumption and health outcomes in adults. Among the benefits:

Daily consumption of 3 cups of coffee — regular or decaffeinated — was associated with a 17% lower risk for all-cause mortality, relative to no coffee consumption.

Caffeinated coffee was linked to lower risks for cardiovascular disease, coronary heart disease, and stroke, with benefits highest at 3–5 cups daily.

Caffeinated coffee was associated with lower risks for cancer and liver conditions.

Both regular and decaf coffee appeared to lower risk for type 2 diabetes.

In terms of harms, high coffee consumption in pregnancy was tied to pregnancy loss, low birth weight, and preterm birth. High consumption was also associated with higher fracture risk in women, but not men.

An editorialist writes: "The evidence is so robust and consistent ... that we can be reassured that drinking coffee is generally safe." He adds, however, that pregnant women and those at high fracture risk should be educated about possible adverse effects.

The BMJ editorial (free):

M. Type 3c diabetes: ever heard of that?

Diabetes secondary to pancreatic diseases is commonly referred to as pancreatogenic diabetes or type 3c diabetes mellitus. It is a clinically relevant condition with a prevalence of 5%-10% among all diabetic subjects in Western populations. In nearly 80% of all type 3c diabetes mellitus cases, chronic pancreatitis seems to be the underlying disease. The prevalence and clinical importance of diabetes secondary to chronic pancreatitis has certainly been underestimated and underappreciated so far. In contrast to the management of type 1 or type 2 diabetes mellitus, the endocrinopathy in type 3c is very complex. The course of the disease is complicated by additional present comorbidities such as maldigestion and concomitant qualitative malnutrition.

N. Today’s Teens

1. No Evidence for ‘Narcissism Epidemic’ Among College Students

Association for Psychological Science.

2. Today’s iGens Described

A psychologist mines big data on teens and finds many ways this generation—the “iGens"—is different from Boomers, Gen Xers, and Millennials.

Every generation of teens is shaped by the social, political, and economic events of the day. Today’s teenagers are no different—and they’re the first generation whose lives are saturated by mobile technology and social media.

In her new book, psychologist Jean Twenge uses large-scale surveys to draw a detailed portrait of ten qualities that make today’s teens unique and the cultural forces shaping them. Her findings are by turn alarming, informative, surprising, and insightful, making the book—iGen:Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy—and Completely Unprepared for Adulthood—and What That Means for the Rest of Us—an important read for anyone interested in teens’ lives.