1. New Guidelines: CVA and Pancreatitis
- Prevention of deep vein thrombosis for immobile patients during the hospital stay should focus on intermittent pneumatic compression (upgraded to class I) instead of heparin, which was downgraded from a Ia to IIb recommendation
- Candidates for carotid endarterectomy should be evaluated for that within 24 hours and surgery should occur within 7 days
- Acute blood pressure management recommendations got downgraded to reflect increasingly equivocal evidence of benefit
- Oral feeding should be given within 24 hours as tolerated rather than following the “nothing by mouth” or nil per os (NPO) practice;
- Enteral rather than parenteral nutrition should be used in patients who are unable to feed orally;
- Cholecystectomy should be performed at initial admission in patients with acute biliary pancreatitis, rather than after they are discharged; and
- A brief alcohol intervention should be performed during admission in patients with acute alcohol-induced pancreatitis.
Guidelines: Crockett SD, et al. Gastroenterol. 2018 Feb 3 [Epub ahead of print]
2. ED Patients with Chest Pain
Myths in EM: Even if Stress Tests Found Patients at High Risk for MI (They Don't), To What End?
Spiegel R. Emerg Med News. 2018;40(1):10-11
Whether you are aware of it or not, you make three major assumptions every time you employ any diagnostic strategy in the emergency department—that the diagnostic test will identify patients at risk of a poor outcome because of an undiagnosed process, that an effective intervention will avert that outcome, and that discovering this process early will make the intervention more effective than if we had waited for the disease to manifest clinically obvious characteristics.
These assumptions are frequently based purely on physiological reasoning and good intentions, but these are poor surrogates for patient-oriented outcomes and often fail to survive the test of scientific inquiry. Such is the case for noninvasive cardiac testing. Multiple studies suggest its ineffectiveness, but the stress test has maintained its lofty position for managing patients presenting to the ED with chest pain.
A recent study by Sandhu, et al., utilized a large insurance claims database to identify patients who presented to the ED with chest pain and compared outcomes in patients who did or did not undergo noninvasive testing. (JAMA Intern Med 2017;177:1175.) The authors used a fairly novel and elegant approach to control for the many imbalances one would expect from such a large, heterogeneous, nonrandomized cohort.
Using what is called an instrumental-variables approach, the authors exploited the fact that care is not delivered consistently across all seven days of the week. Their premise, according to previous data, was that patients seen in the ED on the weekend (Friday-Sunday) were less likely to undergo stress testing than those who presented Monday-Thursday, based not on differences in patient-level characteristics, but rather the universal distaste of working on the weekend.
The researchers excluded patients with diagnoses suggestive of acute ischemia and those whose chest pain could be explained with an alternate diagnosis, and they identified 926,633 unique adult ED visits from 2011 to 2012. Unsurprisingly, patients who received testing were older, with more risk factors than patients who did not undergo testing. Conversely, patients who presented on the weekend appeared to be fairly similar at baseline when compared with those who presented during the week.
As the authors predicted, patients evaluated on the weekend underwent less stress testing when compared with those who presented during the week (18.18% vs 12.30%). They also observed more early angiography (2.10% vs 1.30%) and downstream testing, defined as any invasive or noninvasive testing done over the next 30 days (26.10% vs 21.35%). Even after adjusting for possible bias, not controlled for with their instrumental approach, the authors noted an increase in the rates of invasive angiography in patients who presented on the weekday when compared with those who presented on the weekend. They also noted that this increase in invasive or noninvasive testing did not lead to an observed decrease in the rate of myocardial infarction.
Despite the elegance with which these authors manipulated this large unwieldy dataset, its innate structure creates the potential for multiple sources of bias that cannot be controlled by any statistical manipulations. That said, their results are fairly consistent with the majority of the previous literature examining noninvasive stress testing. More importantly, the stress test has failed to meet the three initial assumptions required when examining any diagnostic testing strategy.
The concept that noninvasive stress tests identify a population at higher risk for a myocardial infarction is based on poor data. Amsterdam, et al., using a prospective dataset, claimed that patients with positive stress tests were at significantly higher risk of adverse events than those with negative tests (17% vs 0.16%). (J Am Coll Cardiol 2002;40:251.)…
The rest of the myth-busting review (full-text free):
3. Sex Differences in AMI and CVA
4. Pediatric Corner
5. Blunt Head Trauma in Pts on Blood Thinners
Inohara T, et al. JAMA. 2018 Jan 25 [Epub ahead of print]
IMPORTANCE: Although non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used to prevent thromboembolic disease, there are limited data on NOAC-related intracerebral hemorrhage (ICH).
OBJECTIVE: To assess the association between preceding oral anticoagulant use (warfarin, NOACs, and no oral anticoagulants [OACs]) and in-hospital mortality among patients with ICH.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 141 311 patients with ICH admitted from October 2013 to December 2016 to 1662 Get With The Guidelines-Stroke hospitals.
EXPOSURES: Anticoagulation therapy before ICH, defined as any use of OACs within 7 days prior to hospital arrival.
MAIN OUTCOMES AND MEASURES: In-hospital mortality.
RESULTS: Among 141 311 patients with ICH (mean [SD] age, 68.3 [15.3] years; 48.1% women), 15 036 (10.6%) were taking warfarin and 4918 (3.5%) were taking NOACs preceding ICH, and 39 585 (28.0%) and 5783 (4.1%) were taking concomitant single and dual antiplatelet agents, respectively. Patients with prior use of warfarin or NOACs were older and had higher prevalence of atrial fibrillation and prior stroke. Acute ICH stroke severity (measured by the National Institutes of Health Stroke Scale) was not significantly different across the 3 groups (median, 9 [interquartile range, 2-21] for warfarin, 8 [2-20] for NOACs, and 8 [2-19] for no OACs). The unadjusted in-hospital mortality rates were 32.6% for warfarin, 26.5% for NOACs, and 22.5% for no OACs. Compared with patients without prior use of OACs, the risk of in-hospital mortality was higher among patients with prior use of warfarin (adjusted risk difference [ARD], 9.0% [97.5% CI, 7.9% to 10.1%]; adjusted odds ratio [AOR], 1.62 [97.5% CI, 1.53 to 1.71]) and higher among patients with prior use of NOACs (ARD, 3.3% [97.5% CI, 1.7% to 4.8%]; AOR, 1.21 [97.5% CI, 1.11-1.32]). Compared with patients with prior use of warfarin, patients with prior use of NOACs had a lower risk of in-hospital mortality (ARD, -5.7% [97.5% CI, -7.3% to -4.2%]; AOR, 0.75 [97.5% CI, 0.69 to 0.81]). The difference in mortality between NOAC-treated patients and warfarin-treated patients was numerically greater among patients with prior use of dual antiplatelet agents (32.7% vs 47.1%; ARD, -15.0% [95.5% CI, -26.3% to -3.8%]; AOR, 0.50 [97.5% CI, 0.29 to 0.86]) than among those taking these agents without prior antiplatelet therapy (26.4% vs 31.7%; ARD, -5.0% [97.5% CI, -6.8% to -3.2%]; AOR, 0.77 [97.5% CI, 0.70 to 0.85]), although the interaction P value (.07) was not statistically significant.
CONCLUSIONS AND RELEVANCE: Among patients with ICH, prior use of NOACs or warfarin was associated with higher in-hospital mortality compared with no OACs. Prior use of NOACs, compared with prior use of warfarin, was associated with lower risk of in-hospital mortality.
Full-text (free): https://jamanetwork.com/journals/jama/fullarticle/2670103
6. NEJM Essays on Physician Burnout
7. Cardiac Standstill: What Do We know?
8. On Pulmonary Embolism
9. Geriatric Emergency Medicine
10. Improving ED Atrial Fibrillation Management
- Older pts were less commonly treated because physicians were more worried about bleeds than strokes—a sizable miscalculation. Strokes are far more dangerous than bleeds in the older anticoagulated AF population.
- High-risk pts who converted in the ED were less likely to receive stroke prevention medication, as though paroxysmal AF that flipped back into NSR significantly reduced stroke risk. It doesn’t. Intermittent AF warrants thromboprophylaxis as much as persistent AF.
11. Images in Clinical Practice
Calcified Spleen and Gallstones
ECG Changes in Hypothermia
A 76-year-old woman with a history of dementia and coronary heart disease was brought to the emergency department after she had been found lying outdoors for an undetermined period; her core body temperature was 26°C (78.8°F) at presentation. An electrocardiogram showed prominent Osborn waves, also known as J waves (Panel A, arrows), along with prolonged QRS duration and corrected QT interval.
Phlegmasia Cerulea Dolens with Compartment Syndrome
An 81-year-old man with hypertension presented to the emergency department with pain and swelling of the left thigh and lower leg that had developed during the previous several hours. He had no history of recent surgery or trauma and no known personal or family history of clotting disorders. The left lower leg was tender, cold, and swollen (Panel A), and the left dorsalis pedis pulse was not palpable.
Man With Bumps on His Shin
Man With Chest Pain and Lump in Neck
Male With Sore Throat
Infant With a Diffuse Rash and a Fever
Hyperactive Child With Chest Pain
Elderly Woman With Decreased Right-Sided Vision
Adolescent With a Non-Healing Thigh Injury
Man With Rash
Child With Diffuse Bullous Rash
Adult Male With Chest Pain After a Fall
Man With Abdominal Pain
Elderly Woman With Abdominal Pain
Young Boy With Roughening in the Inner Eyelids
12. Computer-Interpreted ECGs: Benefits and Limitations.
Schläpfer J, Wellens HJ. J Am Coll Cardiol. 2017 Aug 29;70(9):1183-1192.
Computerized interpretation of the electrocardiogram (CIE) was introduced to improve the correct interpretation of the electrocardiogram (ECG), facilitating health care decision making and reducing costs. Worldwide, millions of ECGs are recorded annually, with the majority automatically analyzed, followed by an immediate interpretation. Limitations in the diagnostic accuracy of CIE were soon recognized and still persist, despite ongoing improvement in ECG algorithms. Unfortunately, inexperienced physicians ordering the ECG may fail to recognize interpretation mistakes and accept the automated diagnosis without criticism. Clinical mismanagement may result, with the risk of exposing patients to useless investigations or potentially dangerous treatment. Consequently, CIE over-reading and confirmation by an experienced ECG reader are essential and are repeatedly recommended in published reports. Implementation of new ECG knowledge is also important. The current status of automated ECG interpretation is reviewed, with suggestions for improvement.
Full-text (requires subscription): https://www.sciencedirect.com/science/article/pii/S0735109717387946
Commentary: How Computer-Interpreted ECGs May Lead to Errors
By Amal Mattu, MD. Medscape, Nov 28, 2017
ECG was invented more than 100 years ago. Despite many technical advances in the field of emergency cardiology, the basic 12-lead ECG still remains a cornerstone test in the acute diagnosis of many types of cardiac conditions, both acute and chronic.
Automated ECG analysis was initiated in the 1950s in an attempt to assist providers who had less training in ECG interpretation. Unfortunately, despite improvements in the automated interpretations over the past 60 years, computer ECG interpretations remain far from perfect. Despite the common teaching that we should not trust the computer interpretations, many healthcare providers still rely heavily on these interpretations in their clinical practice.
The following review provides some excellent information regarding the benefits and limitations of the computer interpretation programs.
- The authors reviewed technical specifications about the various computer programs and also numerous articles regarding accuracy data on the various algorithms. The following is a list of key points they made.
- There is no international accepted standard for computer interpretations. As a result, significant variability exists among interpretations from different manufacturers' algorithms.
- Direct comparative evaluations of the various commercially available computer-interpreted ECG (CIE) programs has never been performed.
- A 1991 study of nine CIE programs versus eight cardiologists demonstrated consistently lower accuracy among the CIEs compared with the cardiologists, and also (surprisingly) significant variation in accuracy among the various programs.
- CIE programs have a frequent tendency to overcall atrial fibrillation, especially in elderly persons, potentially leading to inappropriate administration of harmful medications.
- CIE programs have a tendency to double-count the rate due to large T-waves (eg, in the setting of hyperkalemia).
- CIE programs are particularly inaccurate in diagnosing pacemaker rhythms.
- CIE programs demonstrate wide variations in the false-positive (0%-42%) and false-negative (22%-42%) rates of diagnosis of ST-segment myocardial infarction; therefore, it is not recommended that CIEs be used as a sole means of activation of the cardiac catheterization lab.
- CIE programs frequently tend to underestimate the QT interval, especially in the presence of artifact or improperly placed leads.
- The authors cite a 2008 study indicating that "It has been roughly estimated that [CIE] misdiagnoses may account for up to 10,000 adverse effects or avoidable deaths worldwide annually."
- The authors summarize, "Computer-based analysis of the ECG may lead to erroneous diagnosis with useless, inappropriate, or even dangerous care of the patient."
This article sheds some much-needed light on the true accuracy of CIE programs. Although these programs may help providers who are inexperienced in ECG interpretation, they appear to decrease the accuracy of experienced providers by frequently providing a false sense of security with benign interpretations and also by encouraging less scrutiny of the ECG. I truly believe that if the computer interpretations were removed, providers would pay closer attention to the ECG, resulting in more accurate interpretations and fewer errors. I also believe that our trainees would feel compelled to work harder at their ECG interpretation skills if the computer interpretations were removed.
During the past 15 years, I've seen at least a half-dozen malpractice cases in which the computer interpretation simply indicated "nonspecific" findings on ECGs that demonstrated fairly obvious ischemia. In each of these cases, the treating physician was misled by the computer, and only in retrospect, too late, did the physician recognize the ischemic findings. These cases are typically nearly impossible to defend.
ECG interpretation is a life-saving skill. Proficiency is a must for us all. We must exercise extreme caution regarding the utility of these CIE programs and gain enough skill and confidence to avoid using them entirely.
13. “Sometimes You Feel Like the Freak Show”: A Qualitative Assessment of Emergency Care Experiences Among Trans and Gender Non-Conforming Patients
Samuels EA, et al. Ann Emerg Med. 2018;71(2):170–182.e1
STUDY OBJECTIVE: Transgender, gender-variant, and intersex (trans) people have decreased access to care and poorer health outcomes compared with the general population. Little has been studied and documented about such patients' emergency department (ED) experiences and barriers to care. Using survey and qualitative research methods, this study aims to identify specific areas for improvement and generate testable hypotheses about the barriers and challenges for trans individuals needing acute care.
METHODS: A survey and 4 focus groups were conducted with trans individuals older than 18 years who had been to an ED in the last 5 years. Participants were recruited by trans e-mail listservs; outreach to local trans organizations; and lesbian, gay, bisexual, and transgender periodical advertisements. The interview guide was reviewed by qualitative research and trans health content experts. Deidentified participant demographic information was collected with a standardized instrument. All discussions were captured on digital audio recorders and professionally transcribed. Interview coding and thematic analysis were conducted with a grounded theory approach.
RESULTS: Among 32 participants, 71.9% were male identified and 78.1% were white. Nearly half (43.8%) reported avoiding the ED when they needed acute care. The factors that had the greatest influence on ED avoidance were fear of discrimination, length of wait, and negative previous experiences. There were 4 overarching discussion themes: system structure, care competency, discrimination and trauma, and avoidance of emergency care. Improvement recommendations focused on staff and provider training about gender and trans health, assurance of private gender identity disclosure, and accurate capture of sex, gender, and sexual orientation information in the electronic medical record.
CONCLUSION: Efforts to improve trans ED experiences should focus on provider competency and communication training, electronic medical record modifications, and assurance of private means for gender disclosure. Future research directions include quantifying the frequency of care avoidance, the effect of avoidance on trans patient morbidity and mortality, and comparing ED patient outcomes by gender identity. Further research with increased inclusion of transwomen and people of color is needed to identify themes that may not have been raised in this preliminary investigation.
14. Differences Between Snakebites with Concomitant Use of Alcohol or Drugs and Single Snakebites.
Schulte J, et al. South Med J. 2018 Feb;111(2):113-117.
OBJECTIVES: Published reports have suggested that the concurrent use of alcohol or drugs occurs among some snakebite victims, but no national assessment of such data exists.
METHODS: We used data from US poison control centers collected during telephone calls in calendar years 2000-2013 to compare snake envenomations with concomitant use of drugs, alcohol, or both to snakebites lacking such use.
RESULTS: A total of 608 snakebites with 659 instances of concomitant alcohol/drug use were reported, which represent approximately 1% of 92,751 snakebites reported to US poison control centers. An annual mean of 48 snakebites with concomitant use of alcohol/drugs was reported, compared with a mean of 6625 snakebites per year with no concomitant use of alcohol/drugs. Most cases involved men, peaked during the summer months, and involved copperheads or rattlesnakes, which mirrored overall trends. Snakebite victims who also used alcohol/drugs were more likely than victims with only a snakebite reported to be bitten by rattlesnakes, to be admitted to the hospital, and die. Alcohol was the most common reported concomitant substance, but other substances were reported.
CONCLUSIONS: Snakebites with concomitant use of alcohol/drugs are uncommon, accounting for approximately 1% of the snakebite envenomations reported annually to US poison control centers; however, snakebite victims also reporting alcohol/drug use are more likely to be bitten by rattlesnakes, be admitted to a healthcare facility, and die.
15. Sepsis Research
A. No Evidence Underpinning the U.S. Government–Mandated Hemodynamic Interventions for Sepsis: A Systematic Review
Pepper DJ, et al. Ann Intern Med. 2018 Feb 20 [Epub ahead of print]
Background: The Severe Sepsis and Septic Shock Early Management Bundle (SEP-1), the sepsis performance measure introduced by the Centers for Medicare & Medicaid Services (CMS), requires up to 5 hemodynamic interventions, as many as 141 tasks, and 3 hours to document for a single patient.
Purpose: To evaluate whether moderate- or high-level evidence shows that use of SEP-1 or its hemodynamic interventions improves survival in adults with sepsis.
Data Sources: PubMed, Embase, Scopus, Web of Science, and ClinicalTrials.gov from inception to 28 November 2017 with no language restrictions.
Study Selection: Randomized and observational studies of death among adults with sepsis who received versus those who did not receive either the entire SEP-1 bundle or 1 or more SEP-1 hemodynamic interventions, including serial lactate measurements; a fluid infusion of 30 mL/kg of body weight; and assessment of volume status and tissue perfusion with a focused examination, bedside cardiovascular ultrasonography, or fluid responsiveness testing.
Data Extraction: Two investigators independently extracted study data and assessed each study's risk of bias; 4 authors rated level of evidence by consensus using CMS criteria. High- or moderate-level evidence required studies to have no confounders and low risk of bias.
Data Synthesis: Of 56 563 references, 20 studies (18 reports) met inclusion criteria. One single-center observational study reported lower in-hospital mortality after implementation of the SEP-1 bundle. Sixteen studies (2 randomized and 14 observational) reported increased survival with serial lactate measurements or 30-mL/kg fluid infusions. None of the 17 studies were free of confounders or at low risk of bias. In 3 randomized trials, fluid responsiveness testing did not alter survival.
Limitation: Few trials, poor-quality and confounded studies, and no studies (with survival outcomes) of the focused examination or bedside cardiovascular ultrasonography.
Conclusion: No high- or moderate-level evidence shows that SEP-1 or its hemodynamic interventions improve survival in adults with sepsis.
B. Prognostic Accuracy of the Quick Sequential Organ Failure Assessment for Mortality in Patients with Suspected Infection: A Systematic Review and Meta-analysis.
Fernando SM, et al. Ann Intern Med. 2018 Feb 20;168(4):266-275.
BACKGROUND: The quick Sequential Organ Failure Assessment (qSOFA) has been proposed for prediction of mortality in patients with suspected infection.
PURPOSE: To summarize and compare the prognostic accuracy of qSOFA and the systemic inflammatory response syndrome (SIRS) criteria for prediction of mortality in adult patients with suspected infection.
DATA SOURCES: Four databases from inception through November 2017.
STUDY SELECTION: English-language studies using qSOFA for prediction of mortality (in-hospital, 28-day, or 30-day) in adult patients with suspected infection in the intensive care unit (ICU), emergency department (ED), or hospital wards.
DATA EXTRACTION: Two investigators independently extracted data and assessed study quality using standard criteria.
DATA SYNTHESIS: Thirty-eight studies were included (n = 385 333). qSOFA was associated with a pooled sensitivity of 60.8% (95% CI, 51.4% to 69.4%) and a pooled specificity of 72.0% (CI, 63.4% to 79.2%) for mortality. The SIRS criteria were associated with a pooled sensitivity of 88.1% (CI, 82.3% to 92.1%) and a pooled specificity of 25.8% (CI, 17.1% to 36.9%). The pooled sensitivity of qSOFA was higher in the ICU population (87.2% [CI, 75.8% to 93.7%]) than the non-ICU population (51.2% [CI, 43.6% to 58.7%]). The pooled specificity of qSOFA was higher in the non-ICU population (79.6% [CI, 73.3% to 84.7%]) than the ICU population (33.3% [CI, 23.8% to 44.4%]).
LIMITATION: Potential risk of bias in included studies due to qSOFA interpretation and patient selection.
CONCLUSION: qSOFA had poor sensitivity and moderate specificity for short-term mortality. The SIRS criteria had sensitivity superior to that of qSOFA, supporting their use for screening of patients and as a prompt for treatment initiation.
16. Beware the Danger Lurking Under the Shroud of Alcohol
Sheehy M, et al. Ann Emerg Med 2018;71(3):289-91.
An alcohol-dependent patient well known to your emergency department (ED) presents with…drumroll please…alcohol intoxication. A Good Samaritan called 911 after finding the patient asleep on a park bench. His chart is overflowing with ED visits for alcohol intoxication and usually conclude with an early-morning discharge. His vital signs are pulse rate 98 beats/min, respiratory rate 18 breaths/min, blood pressure 156/76 mm Hg, and oxygen saturation 97% on room air. On examination, he appears intoxicated—alcohol on his breath, opens his eyes and speaks confused words to painful stimuli—and is protecting his airway. There are no signs of acute head trauma or other injury.
So what’s the plan? Does this patient need laboratory tests, head computed tomography (CT), or withdrawal prevention?
You have probably treated a patient like this recently. The statistics sure say you have. Rates of alcohol intoxication ED visits are increasing out of proportion to overall ED visits.1 Average blood alcohol concentrations (BACs) are increasing too!2 So patients are getting more intoxicated more frequently. Although many simply require observation until clinically sober, with an eventual turkey sandwich, badness may lurk beneath the shroud of alcohol…and it may be hard to identify on initial evaluation.
Klein et al3 looked for badness retrospectively in 31,364 cases of low-risk acute alcohol intoxication. One percent of their study cohort, or 325 patients, required critical care resources while in the ED. Included patients were deemed to be at low risk according to triage nurse and emergency physician assessment after a mandatory alcohol level and fingerstick glucose-level test.3 The rate of badness, therefore, among all comers with presumed alcohol abuse is undoubtedly higher; hence, the common refrain, “Alcoholics were put on this earth to humble emergency physicians.”
What can we learn from this study? Indicators for potential badness were abnormal vital signs, hypoglycemia, or need for chemical sedation. Although these red flags may seem obvious in hindsight, they can be easily dismissed with seemingly benign explanations. Tachycardia and hypotension may be attributed to dehydration, a coingestion, or anxiety, especially when anchored on a diagnosis of alcohol intoxication. This article reminds us to always consider other causes for the patient’s altered mental status. And make sure there is a full set of vital signs recorded. What was our example patient’s temperature? Oh, it wasn’t taken?!
Full-text (free): http://www.annemergmed.com/article/S0196-0644(18)30045-3/fulltext
Klein’s abstract: https://www.ncbi.nlm.nih.gov/pubmed/28844504
17. Association of Clinician Denial of Patient Requests with Patient Satisfaction.
Jerant A, et al. JAMA Intern Med. 2018 Jan 1;178(1):85-91.
IMPORTANCE: Prior studies suggesting clinician fulfillment or denial of requests affects patient satisfaction included limited adjustment for patient confounders. The studies also did not examine distinct request types, yet patient expectations and clinician fulfillment or denial might vary among request types.
OBJECTIVE: To examine how patient satisfaction with the clinician is associated with clinician denial of distinct types of patient requests, adjusting for patient characteristics.
DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional observational study of 1319 outpatient visits to family physicians (n = 56) by 1141 adults at one Northern California academic health center.
MAIN OUTCOMES AND MEASURES: We used 6 Consumer Assessment of Healthcare Providers and Systems Clinician and Group Adult Visit Survey items to measure patient satisfaction with the visit physician. Standardized items were averaged to form the satisfaction score (Cronbach α = 0.80), which was then percentile-transformed. Seven separate linear mixed-effects models examined the adjusted mean differences in patient satisfaction percentile associated with denial of each of the following requests (if present)-referral, pain medication, antibiotic, other new medication, laboratory test, radiology test, or other test-compared with fulfillment of the respective requests. The models adjusted for patient sociodemographics, weight, health status, personality, worry over health, prior visit with clinician, and the other 6 request categories and their dispositions.
RESULTS: The mean (SD) age of the 1141 patients was 45.6 (16.1) years, and 902 (68.4%) were female. Among 1319 visits, 897 (68.0%) included at least 1 request; 1441 (85.2%) were fulfilled. Requests by category were referral, 294 (21.1%); pain medication, 271 (20.5%); antibiotic, 107 (8.1%); other new medication, 271 (20.5%); laboratory test, 448 (34.0%); radiology test, 153 (11.6%); and other tests, 147 (11.1%). Compared with fulfillment of the respective request type, clinician denials of requests for referral, pain medication, other new medication, and laboratory test were associated with worse satisfaction (adjusted mean percentile differences, -19.75 [95% CI, -30.75 to -8.74], -10.72 [95% CI, -19.66 to -1.78], -20.36 [95% CI, -29.54 to -11.18], and -9.19 [95% CI, -17.50 to -0.87]), respectively.
CONCLUSIONS AND RELEVANCE: Clinician denial of some types of requests was associated with worse patient satisfaction with the clinician, but not for others, when compared with fulfillment of the requests. In an era of patient satisfaction-driven compensation, the findings suggest the need to train clinicians to deal effectively with requests, potentially enhancing patient and clinician experiences.
18. Pain Reduction in Trauma Patients
A. Acetaminophen equal to NSAIDs in Acute Musculoskeletal Trauma: A Multicenter, Double-Blind, RCT
Ridderikhof ML, et al. Ann Emerg Med. 2018 Mar;71(3):357-368.e8.
STUDY OBJECTIVE: We determine whether pain treatment with acetaminophen was not inferior to nonsteroidal anti-inflammatory drugs or the combination of both in minor musculoskeletal trauma.
METHODS: The Paracetamol or NSAIDs in Acute Musculoskeletal Trauma Study was a double-blind, randomized, clinical trial conducted in 2 general practices and 2 emergency departments in the Netherlands. A total of 547 adults, aged 18 years and older, with acute blunt minor musculoskeletal extremity trauma were randomly assigned in a 1:1:1 ratio to acetaminophen 4,000 mg/day, diclofenac 150 mg/day, or acetaminophen 4,000 mg/day+diclofenac 150 mg/day during 3 consecutive days. Patients, health care staff, and outcome assessors were blinded for treatment allocation. Follow-up for each patient was 30 days. Primary outcome measures were between-group differences in mean numeric rating scale (NRS) pain scores in rest and with movement at 90 minutes after initial drug administration compared with baseline pain scores with a predefined noninferiority margin of 0.75 NRS points. Secondary outcomes included NRS pain scores during 3 consecutive days and need for additional analgesia.
RESULTS: One hundred eighty-two patients were treated with acetaminophen, 183 with diclofenac, and 182 with combination treatment. Intention-to-treat analysis revealed mean NRS reduction in rest -1.23 (95% confidence interval [CI] -1.50 to -0.95) and -1.72 (95% CI -2.01 to -1.44) with movement, both for acetaminophen at 90 minutes compared with baseline. Pairwise comparison in rest with diclofenac showed a difference of -0.027 (97.5% CI -0.45 to 0.39) and -0.052 (97.5% CI -0.46 to 0.36) for combination treatment. With movement, these numbers were -0.20 (97.5% CI -0.64 to 0.23) and -0.39 (97.5% CI -0.80 to 0.018), respectively. All differences were well below the predefined noninferiority margin.
CONCLUSION: Pain treatment with acetaminophen was not inferior to that with diclofenac or the combination of acetaminophen and diclofenac in acute minor musculoskeletal extremity trauma, both in rest and with movement.
B. How Effective Is a Regional Nerve Block for Treating Pain Associated with Hip Fractures?
Gottlieb M, et al. Ann Emerg Med. 2018 Mar;71(3):378-380.
Regional nerve blockade reduces pain on movement, risk of pneumonia, and time to first mobilization among patients with hip fractures with no major complications.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(17)31703-1/fulltext
19. Quick Lit Reviews
From BMJ’s Rapid Recommendations
From Ann Emerg Med
A. Does Prestroke Antiplatelet Therapy Increase the Risk of Symptomatic Intracranial Hemorrhage in Patients Receiving tPA for Acute Ischemic Stroke?
Take home: In patients receiving prestroke aspirin and clopidogrel combination therapy, thrombolysis in acute ischemic stroke is associated with an increased risk of symptomatic intracranial hemorrhage, yet there is no evidence for increased mortality or worse functional outcomes.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(17)30291-3/fulltext
B. Do IV Benzodiazepines or Benzodiazepines by an Alternative Route (Nonintravenous) Abort Seizures Faster [in pts without initial IV access]?
Take home: Benzodiazepines by an alternative route abort seizures faster and possess superior efficacy compared with intravenous benzodiazepines in patients without intravenous access.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(17)30734-5/fulltext
20. On Being Sued for Malpractice
21. Effect of ED and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients
22. The Newest Threat to ED Procedural Sedation.
- What Happened to Deep Sedation?...
- An Anesthesiologist Guideline to Govern All Specialties?...
- Propofol and Ketamine: “Medications Intended for General Anesthesia”…
22. Hemorrhagic Shock Review
Cannon JW. N Engl J Med 2018;378(4):370-379.
Understanding the pathophysiology of the body’s response to hemorrhage has led to improvements in prehospital care, more rapid hemostasis, avoidance of massive crystalloid resuscitation, and improved survival.
Full-text (subscription required): http://www.nejm.org/doi/full/10.1056/NEJMra1705649
23. Micro Bits
A. Study ties influenza to elevated heart attack risk
A study in The New England Journal of Medicine found individuals with influenza had a six times increased likelihood of having a heart attack during the first seven days of flu diagnosis. The findings, based on 364 heart attacks from mid-2008 to mid-2015 among 332 patients aged 35 or older, showed a slightly, but not statistically significant, higher heart attack risk among those older than 65 and those with influenza type B.
B. Regular dental care can reduce risk of stroke
Regular dental care was linked to a 50% reduction in the risk of stroke, compared with not seeing a dentist regularly, a study in the journal Stroke found. The risk of stroke increased with the severity of periodontal disease.
C. Increased screen time tied to lower psychological well-being in teens
Adolescents who spent more time watching TV, playing computer games, texting, and using social media and the internet had lower self-esteem, less happiness and reduced life satisfaction, compared with those who spent more time on nonscreen activities, researchers reported in the journal Emotion. The findings, based on 1991 to 2016 Monitoring the Future study data involving 1.1 million eighth-, 10th- and 12-grade students, also showed the greatest happiness among those who had less than an hour of daily screen time.
LA Times: http://www.latimes.com/science/sciencenow/la-sci-sn-teens-phones-happiness-20180123-story.html
D. Walking is associated with lower mortality, even if recommended levels are not met
This cohort study examined the relationship between walking, the most common physical activity for older adults, and total mortality. Compared with inactivity, walking below minimum recommended levels is associated with lower all-cause mortality. Walking at or above physical activity recommendations is associated with further decreased risk of mortality. Walking was most strongly associated with lower risk of respiratory disease mortality followed by cardiovascular disease mortality and cancer mortality.
E. Does a Healthy Diet Protect Against Depression in Adolescence?
Oddy WH et al. Brain Behav Immun 2018 Jan 12
More-frequent consumption of healthy nutrients at age 14 was associated with fewer depressive symptoms at age 17.
Journal Watch. Daniel D. Dressler, MD, MSc, SFHM, FACP reviewing Mortensen MB and Nordestgaard BG. Ann Intern Med 2018 Jan 16.
They vary substantially in the proportions of patients who are deemed to be eligible for statin therapy.
G. People with anxiety are more likely to be bitten by dogs
Cuddling with your pet is usually a good way to unwind after a particularly challenging day. However, a new study indicates that you might want to think twice before getting too close to your dog when you’re feeling anxious as it could make them more likely to bite.
Study full-text: http://jech.bmj.com/content/early/2018/01/08/jech-2017-209330
H. What Google Can do with Big Data to Predict Clinical Outcomes
Rajkomar AR, et al. Scalable and accurate deep learning for electronic health records.
Predictive modeling with electronic health record (EHR) data is anticipated to drive personalized medicine and improve healthcare quality. Constructing predictive statistical models typically requires extraction of curated predictor variables from normalized EHR data, a labor-intensive process that discards the vast majority of information in each patient's record.
We propose a representation of patients' entire, raw EHR records based on the Fast Healthcare Interoperability Resources (FHIR) format. We demonstrate that deep learning methods using this representation are capable of accurately predicting multiple medical events from multiple centers without site-specific data harmonization. We validated our approach using de-identified EHR data from two U.S. academic medical centers with 216,221 adult patients hospitalized for at least 24 hours. In the sequential format we propose, this volume of EHR data unrolled into a total of 46,864,534,945 data points, including clinical notes. Deep learning models achieved high accuracy for tasks such as predicting in-hospital mortality (AUROC across sites 0.93-0.94), 30-day unplanned readmission (AUROC 0.75-0.76), prolonged length of stay (AUROC 0.85-0.86), and all of a patient's final discharge diagnoses (frequency-weighted AUROC 0.90). These models outperformed state-of-the-art traditional predictive models in all cases. We also present a case-study of a neural-network attribution system, which illustrates how clinicians can gain some transparency into the predictions.
We believe that this approach can be used to create accurate and scalable predictions for a variety of clinical scenarios, complete with explanations that directly highlight evidence in the patient's chart.
Cornell University Library (full-text free, select pdf): https://arxiv.org/abs/1801.07860v1
I. Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival
Bodai BI, et al. Perm J 2018
Full-text (free): http://www.thepermanentejournal.org/issues/2018/winter/6536-lifestyle-medicine.html
J. Concussions Can Be Detected With New Blood Test Approved by F.D.A.
K. Opioid Analgesic Use Increases Risk for Invasive Pneumococcal Diseases: A Nested Case–Control Study
L. Study finds many ibuprofen users exceed daily dosing limit of NSAIDs
A study in Pharmacoepidemiology & Drug Safety found around 15% of adults using nonsteroidal anti-inflammatory drugs were taking the drugs at a higher daily dose than the maximum recommended dose, raising their risk for heart attacks, internal bleeding and other serious side effects. The findings, based on 1,326 ibuprofen users who completed an online daily medication diary for a week, showed 16% used ibuprofen daily, 55% took the drug at least three days a week and 37% used at least one other nonsteroidal anti-inflammatory drug during the week.
M. Differences of energy expenditure while sitting versus standing: A systematic review and meta-analysis
Results: By substituting sitting with standing for 6 hours/day, a 65 kg person will expend an additional 54 kcal/day. Assuming no increase in energy intake, this difference in energy expenditure would be translated into the energy content of about 2.5 kg of body fat mass in 1 year.
N. Aspirin use not tied to better outcomes in HF without AFib
A study in JACC: Heart Failure found patients with heart failure but without atrial fibrillation who used low-dose aspirin did not have a significantly lower risk of all-cause mortality or hospital admission for stroke or myocardial infarction. However, low-dose aspirin treatment was tied to a slightly higher risk of readmission for heart failure and to an elevated risk of myocardial infarction, according to the findings, based on nearly 12,300 individuals with new-onset heart failure enrolled in a Danish registry.
O. Simulation Leaders Will Appreciate This
Proceedings of the 2017 AEM Consensus Conference: Catalyzing System Change Through Healthcare Simulation