Monday, June 18, 2018

Lit Bits: June 18, 2018

From the recent medical literature...

1. Clinical Trial of Fluid Infusion Rates for Pediatric DKA

Kuppermann N, et al. N Engl J Med. 2018;378:2275-2287.

Diabetic ketoacidosis in children may cause brain injuries ranging from mild to severe. Whether intravenous fluids contribute to these injuries has been debated for decades.

We conducted a 13-center, randomized, controlled trial that examined the effects of the rate of administration and the sodium chloride content of intravenous fluids on neurologic outcomes in children with diabetic ketoacidosis. Children were randomly assigned to one of four treatment groups in a 2-by-2 factorial design (0.9% or 0.45% sodium chloride content and rapid or slow rate of administration). The primary outcome was a decline in mental status (two consecutive Glasgow Coma Scale scores of less than 14, on a scale ranging from 3 to 15, with lower scores indicating worse mental status) during treatment for diabetic ketoacidosis. Secondary outcomes included clinically apparent brain injury during treatment for diabetic ketoacidosis, short-term memory during treatment for diabetic ketoacidosis, and memory and IQ 2 to 6 months after recovery from diabetic ketoacidosis.

A total of 1389 episodes of diabetic ketoacidosis were reported in 1255 children. The Glasgow Coma Scale score declined to less than 14 in 48 episodes (3.5%), and clinically apparent brain injury occurred in 12 episodes (0.9%). No significant differences among the treatment groups were observed with respect to the percentage of episodes in which the Glasgow Coma Scale score declined to below 14, the magnitude of decline in the Glasgow Coma Scale score, or the duration of time in which the Glasgow Coma Scale score was less than 14; with respect to the results of the tests of short-term memory; or with respect to the incidence of clinically apparent brain injury during treatment for diabetic ketoacidosis. Memory and IQ scores obtained after the children’s recovery from diabetic ketoacidosis also did not differ significantly among the groups. Serious adverse events other than altered mental status were rare and occurred with similar frequency in all treatment groups.

Neither the rate of administration nor the sodium chloride content of intravenous fluids significantly influenced neurologic outcomes in children with diabetic ketoacidosis.

Michelle Lin at ALiEM summarize the trial and undertook an interview with Kuppermann and Glaser, study co-authors, here:

2. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Pts with Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial.

Driver BE, et al. JAMA. 2018 Jun 5;319(21):2179-2189.

The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect of routine bougie use on first-attempt intubation success is unclear.

To compare first attempt intubation success facilitated by the bougie vs the endotracheal tube + stylet.

The Bougie Use in Emergency Airway Management (BEAM) trial was a randomized clinical trial conducted from September 2016 through August 2017 in the emergency department at Hennepin County Medical Center, an urban, academic department in Minneapolis, Minnesota, where emergency physicians perform all endotracheal intubations. Included patients were 18 years and older who were consecutively admitted to the emergency department and underwent emergency orotracheal intubation with a Macintosh laryngoscope blade for respiratory arrest, difficulty breathing, or airway protection.

Patients were randomly assigned to undergo the initial intubation attempt facilitated by bougie (n = 381) or endotracheal tube + stylet (n = 376).

The primary outcome was first-attempt intubation success in patients with at least 1 difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization). Secondary outcomes were first-attempt success in all patients, first-attempt intubation success without hypoxemia, first-attempt duration, esophageal intubation, and hypoxemia.

Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups.

In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings.

See also: EM Cases Episode 110 – Airway Pitfalls Live from EMU 2018.

The last decade has seen a torrent of literature and expert opinion on emergency airway management. It is challenging to integrate all this new information into a seamless flow when faced with a challenging airway situation. In this live podcast recorded at North York General’s Emergency Medicine Update Conference 2018, Scott Weingart and Anton Helman put together the latest in emergency airway management by outlining 6 common airway pitfalls: Failure to prepare for failure, failure to position the patient properly, failure to optimize oxygenation, failure to optimize hemodynamics, failure to consider an awake intubation and failure to prepare for a cricothyrotomy…

3. Specific Viruses Tied to Asthma Treatment Failure in Kids

Veronica Hackethal, MD. Medscape, June 04, 2018

Children with moderate to severe asthma exacerbations who are also infected with respiratory viruses, and especially respiratory syncytial virus, influenza, and parainfluenza, are at increased risk of not responding to asthma treatments, according to results published online today in Pediatrics.

The results come from the largest study of its kind and suggest children with moderate to severe asthma exacerbations may need a different workup and more intense management.

About 60% to 80% of asthma exacerbations are triggered by respiratory pathogens, but until now, researchers haven't known exactly which pathogens cause the problem.

"This is the first time we've been able to disentangle the risk of non-response to asthma treatment with the presence of specific viruses — specifically, influenza and rhinovirus. The more than 20-per-cent higher absolute risk of treatment failure in flu cases is very significant," senior author Caroline Quach, MD, said in a press release. Quach is chair of the Quebec Immunization Committee, chair of the National Advisory Committee on Immunization of the Public Health Agency of Canada, and affiliated with McGill University and the University of Montreal.

The results also highlight the importance of prevention, using the influenza vaccine. The authors encouraged easy access to vaccination at the point of care in asthma, respiratory, and general pediatric clinics.

"These kids should get their flu shot and they should get it systematically — it's worth it," study coauthor Francine Ducharme, MD, from the University of Montreal, Quebec, Canada, said in the news release.

"We now know that if these kids get the flu the risks are very high that emergency treatment for an asthma attack will fail," she added. "Instead of having an overall 17-per-cent risk of treatment failure, with flu their risk rises to almost 40 per cent."

Respiratory Viruses and Treatment Failure in Children with Asthma Exacerbation

Merckx J, et al. Pediatrics 2018 June 04 [Epub ahead of print]

OBJECTIVES: Respiratory pathogens commonly trigger pediatric asthma exacerbations, but their impact on severity and treatment response remains unclear.

METHODS: We performed a secondary analysis of the Determinants of Oral Corticosteroid Responsiveness in Wheezing Asthmatic Youth (DOORWAY) study, a prospective cohort study of children (aged 1–17 years) presenting to the emergency department with moderate or severe exacerbations. Nasopharyngeal specimens were analyzed by RT-PCR for 27 respiratory pathogens. We investigated the association between pathogens and both exacerbation severity (assessed with the Pediatric Respiratory Assessment Measure) and treatment failure (hospital admission, emergency department stay over 8 hours, or relapse) of a standardized severity-specific treatment. Logistic multivariate regressions were used to estimate average marginal effects (absolute risks and risk differences [RD]).

RESULTS: Of 958 participants, 61.7% were positive for ≥1 pathogen (rhinovirus was the most prevalent [29.4%]) and 16.9% experienced treatment failure. The presence of any pathogen was not associated with higher baseline severity but with a higher risk of treatment failure (20.7% vs 12.5%; RD = 8.2% [95% confidence interval: 3.3% to 13.1%]) compared to the absence of a pathogen. Nonrhinovirus pathogens were associated with an increased absolute risk (RD) of treatment failure by 13.1% (95% confidence interval: 6.4% to 19.8%), specifically, by 8.8% for respiratory syncytial virus, 24.9% for influenza, and 34.1% for parainfluenza.

CONCLUSIONS: Although respiratory pathogens were not associated with higher severity on presentation, they were associated with increased treatment failure risk, particularly in the presence of respiratory syncytial virus, influenza, and parainfluenza. This supports influenza prevention in asthmatic children, consideration of pathogen identification on presentation, and exploration of treatment intensification for infected patients at higher risk of treatment failure.

4. Systematic Reviews from Acad Emerg Med.

A. Excited Delirium: A Systematic Review.

Gonin P, et al. Acad Emerg Med. 2018;25(5):552-565.

We aimed to clarify the definition, epidemiology, and pathophysiology of excited delirium syndrome (ExDS) and to summarize evidence-based treatment recommendations.

We conducted a systematic literature search of MEDLINE, Ovid, Web of Knowledge, and Cochrane Library for articles published to March 18, 2017. We also searched the gray literature (Google Scholar) and official police or medical expert reports to complete specific epidemiologic data. Search results and full-text articles were independently assessed by two investigators and agreements between reviewers assessed with K statistics. We classified articles by study type, setting, and evidence level.

After reviewing the title and abstract of 3,604 references, we fully reviewed 284 potentially relevant references, from which 66 were selected for final review. Six contributed to the definition of ExDS, 24 to its epidemiology, 38 to its pathophysiology, and 27 to its management. The incidence of ExDS varies widely with medical or medicolegal context. Mortality is estimated to be as much as 8.3% to 16.5%. Patients are predominantly male. Male sex, young age, African-American race, and being overweight are independent risk factors. Pathophysiology hypotheses mostly implicate dopaminergic pathways. Most cases occur with psychostimulant use or among psychiatric patients or both. Proposed treatments are symptomatic, often with rapid sedation with benzodiazepines or antipsychotic agents. Ketamine is suggested as an alternative.

The overall quality of studies was poor. A universally recognized definition is lacking, remaining mostly syndromic and based on clinical subjective criteria. High mortality rate may be due to definition inconsistency and reporting bias. Our results suggest that ExDS is a real clinical entity that still kills people and that has probably specific mechanisms and risk factors. No comparative study has been performed to conclude whether one treatment approach is preferable to another in the case of ExDS.

B. Homelessness and Emerg Med: A Review of the Literature

Salhi BA, et al. Acad Emerg Med. 2018;25(5):577-593.

We aimed to synthesize the available evidence on the demographics, prevalence, clinical characteristics, and evidence-based management of homeless persons in the emergency department (ED). Where appropriate, we highlight knowledge gaps and suggest directions for future research.

We conducted a systematic literature search following databases: PubMed, Ovid, and Google Scholar for articles published between January 1, 1990, and December 31, 2016. We supplemented this search by cross-referencing bibliographies of the retrieved publications. Peer-reviewed studies written in English and conducted in the United States that examined homelessness within the ED setting were included. We used a qualitative approach to synthesize the existing literature.

Twenty-eight studies were identified that met the inclusion criteria. Based on our study objectives and the available literature, we grouped articles examining homeless populations in the ED into four broad categories: 1) prevalence and sociodemographic characteristics of homeless ED visits, 2) ED utilization by homeless adults, 3) clinical characteristics of homeless ED visits, and 4) medical education and evidence-based management of homeless ED patients.

Homelessness may be underrecognized in the ED setting. Homeless ED patients have distinct care needs and patterns of ED utilization that are unmet by the current disease-oriented and episodic models of emergency medicine. More research is needed to determine the prevalence and characteristics of homelessness in the ED and to develop evidence-based treatment strategies in caring for this vulnerable population.

C. Protocolized Laboratory Screening for the Medical Clearance of Psychiatric Patients in the ED: A Systematic Review.

Conigliaro A, et al. Acad Emerg Med. 2018;25(5):566-576.

Emergency department (ED) patients with psychiatric chief complaints undergo medical screening to rule out underlying or comorbid medical illnesses prior to transfer to a psychiatric facility. This systematic review attempts to determine the clinical utility of protocolized laboratory screening for the streamlined medical clearance of ED psychiatric patients by determining the clinical significance of individual laboratory results.

We searched PubMed, Embase, and Scopus using the search terms "emergency department, psychiatry, diagnostic tests, laboratories, studies, testing, screening, and clearance" up to June 2017 for studies on adult psychiatric patients. This systematic review follows the recommendations of Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement. The quality of each study was rated according to the Newcastle-Ottawa quality assessment scale.

Four independent reviewers identified 2,847 publications. We extracted data from three studies (n = 629 patients). Included studies defined an abnormal test result as any laboratory result that falls out of the normal range. A laboratory test result was deemed as "clinically significant" only when patient disposition or treatment plan was changed because of that test result. Across the three studies the prevalence of clinically significant results were low (0.0%-0.4%).

The prevalence of clinically significant laboratory test results were low, suggesting that according to the available literature, routine laboratory testing does not significantly change patient disposition. Due to the paucity of available research on this subject, we could not determine the clinical utility of protocolized laboratory screening tests for medical clearance of psychiatric patients in the ED. Future research on the utility of routine laboratory testing is important in a move toward shared decision making and patient-centered health care.

5. Physicians Experience Highest Suicide Rate of Any Profession

Pauline Anderson. Medscape. May 07, 2018

NEW YORK — With one completed suicide every day, US physicians have the highest suicide rate of any profession. In addition, the number of physician suicides is more than twice that of the general population, new research shows.

A systematic literature review of physician suicide shows that the suicide rate among physicians is 28 to 40 per 100,000, more than double that in the general population.

Physicians who die by suicide often suffer from untreated or undertreated depression or other mental illnesses, a fact that underscores the need for early intervention, study investigator Deepika Tanwar, MD, Psychiatric Program, Harlem Hospital Center, New York City, told Medscape Medical News.

"It's very surprising" that the suicide rate among physicians is higher than among those in the military, which is considered a very stressful occupation, Tanwar told Medscape Medical News.

The findings were presented here at the American Psychiatric Association (APA) 2018 annual meeting.

Stigma, Access to Lethal Means
Using MEDLINE and PubMed, the investigators conducted a systematic literature review of physician suicide that included articles published in peer-reviewed journals during the past 10 years.

The review showed that the physician suicide rate was 28 to 40 per 100,000; in the general population, the overall rate was 12.3 per 100,000.

The results also showed that although female physicians attempt suicide far less often than women in the general population, the completion rate for female physicians exceeds that of the general population by 2.5 to 4 times and equals that of male physicians.

Experts are trying to understand why physician suicide rates are so high, said Tanwar. She pointed out that their review shows that some of the most common diagnoses were mood disorders, alcoholism, and substance abuse.

One study showed that depression affects an estimated 12% of male physicians and up to 19.5% of female physicians, a prevalence that is on par with that of the general population.

Depression is more common in medical students and residents, with 15% to 30% screening positive for depressive symptoms.

The remainder of the essay:

6. Feeding Children Honey After They Swallow A Small Battery Can Prevent Serious Injury

Anfang RR, et al. pH‐neutralizing esophageal irrigations as a novel mitigation strategy for button battery injury. Laryngoscope 2018 June 7 [Epub ahead of print].

Ingestion of button batteries (BB) can rapidly lead to caustic esophageal injury in infants and children, resulting in significant morbidity and mortality. To identify novel mitigation strategies, we tested common weakly acidic household beverages, viscous liquids, and Carafate® for their ability to act as protective esophageal irrigations until endoscopic removal of the BB.

Study Design
Cadaveric and live animal model.

Apple juice, orange juice, Gatorade®, POWERADE®, pure honey, pure maple syrup, and Carafate® were screened using a 3 V lithium (3 V‐CR2032) BB on cadaveric porcine esophagus. The most promising in vitro options were tested against a saline control in live American Yorkshire piglets with anode‐facing placement of the BB on the posterior wall of the proximal esophagus for 60 minutes. BB voltage and tissue pH were measured before battery placement and after removal. The 10 mL irrigations occurred every 10 minutes from t = 5 minutes. Gross and histologic assessment was performed on the esophagus of piglets euthanized 7 ± 0.5 days following BB exposure.

Honey and Carafate® demonstrated to a significant degree the most protective effects in vitro and in vivo. Both neutralized the tissue pH increase and created more localized and superficial injuries; observed in vivo was a decrease in both full‐thickness injury (i.e., shallower depths of necrotic and granulation tissue) and outward extension of injury in the deep muscle beyond surface ulcer margins (P  less than  .05).

Ingestion of honey in the household setting and Carafate® in the clinical setting has the potential to reduce injury severity and improve patient outcomes.

7. Adjunct Ketamine Improves Delirium Tremens Management

Pizon AF, et al. Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal. Crit Care Med. 2018 May 8 [Epub ahead of print].

OBJECTIVES: Ketamine offers a plausible mechanism with favorable kinetics in treatment of severe ethanol withdrawal. The purpose of this study is to determine if a treatment guideline using an adjunctive ketamine infusion improves outcomes in patients suffering from severe ethanol withdrawal.

DESIGN: Retrospective observational cohort study.

SETTING: Academic tertiary care hospital.

PATIENTS: Patients admitted to the ICU and diagnosed with delirium tremens by Diagnostic and Statistical Manual of Mental Disorders V criteria.

INTERVENTIONS: Pre and post guideline, all patients were treated in a symptom-triggered fashion with benzodiazepines and/or phenobarbital. Postguideline, standard symptom-triggered dosing continued as preguideline, plus, the patient was initiated on an IV ketamine infusion at 0.15-0.3 mg/kg/hr continuously until delirium resolved. Based upon withdrawal severity and degree of agitation, a ketamine bolus (0.3 mg/kg) was provided prior to continuous infusion in some patients.

MEASUREMENTS AND MAIN RESULTS: A total of 63 patients were included (29 preguideline; 34 postguideline). Patients treated with ketamine were less likely to be intubated (odds ratio, 0.14; p less than 0.01; 95% CI, 0.04-0.49) and had a decreased ICU stay by 2.83 days (95% CI, -5.58 to -0.089; p = 0.043). For ICU days outcome, correlation coefficients were significant for alcohol level and total benzodiazepine dosing. For hospital days outcome, correlation coefficients were significant for patient age, aspartate aminotransferase, and alanine aminotransferase level. Regression revealed the use of ketamine was associated with a nonsignificant decrease in hospital stay by 3.66 days (95% CI, -8.40 to 1.08; p = 0.13).

CONCLUSIONS: Mechanistically, adjunctive therapy with ketamine may attenuate the demonstrated neuroexcitatory contribution of N-methyl-D-aspartate receptor stimulation in severe ethanol withdrawal, reduce the need for excessive gamma-aminobutyric acid agonist mediated-sedation, and limit associated morbidity. A ketamine infusion in patients with delirium tremens was associated with reduced gamma-aminobutyric acid agonist requirements, shorter ICU length of stay, lower likelihood of intubation, and a trend toward a shorter hospitalization.

8. And Here’s Why CTCA Is Useless

In the Emergency Department, that is, at least.

By Ryan Radecki. EM Lit of Note. June 6, 2018

A few years ago, there were several major studies evaluating the safety of a CT coronary angiogram-based study for the evaluation of chest pain in the Emergency Department. These studies consistently found the CTCA is sensitive for coronary artery plaque – and, thus, patients with troponin-negative chest pain syndromes and clear coronary arteries could be discharged from the ED.

The constant challenge, however, has been specificity – not only with respect to whether the CT can accurately detect stenoses, but the clinical relevance of the stenoses. Non-obstructive, moderate, and high-grade stenoses detected on CTCA all trigger further evaluation – either non-invasive or invasive, with subsequent interventions of uncertain clinical value.

This small propensity-matched study from a cohort of 25,251 patients undergoing CTCA picked out 234 pairs of patients, matching those who had an acute coronary syndrome during follow-up with those who did not. And, yes, those with ≥50% or ≥70% stenosis were more likely to suffer an ACS, but not my much. The vast majority – 62% – of those with an ACS in follow-up had non-obstructive coronary disease. Indeed, just over half of patients with an ACS even had their culprit lesion identified on the initial CTCA. The degree of stenosis was mildly predictive of future ACS, but plaque burden between those who suffered an event and those who did not was similar. The most predictive feature, however, was composition of non-obstructive plaque, including fibrofatty features and necrotic core.

This is why CTCA is unhelpful in the Emergency Department. It does, yes, accurately detect patients without coronary disease – but this target “low-risk” population already has such a low pretest likelihood of poor outcome the added value is nil. Then, the “true positives” from these studies – stenoses and interventions – are not equivalent to ACS prevented.

Friends don’t let friends do CTCA in the ED – it doesn’t add value or prevent adverse outcomes.

Reference: Chang HJ, et al. Coronary Atherosclerotic Precursors of Acute Coronary Syndromes. J Am Coll Cardiol. 2018 Jun 5;71(22):2511-2522.

9. Should We Anticoagulate Patients with Isolated Subsegmental PE?

Ali S. Raja, MD, MBA, MPH. Journal Watch

Not necessarily, and without evidence to guide us, patients and physicians need to decide together.

The widespread use of computed tomography (CT) pulmonary angiography has facilitated the rapid diagnosis of pulmonary embolism (PE), but sometimes the only CT abnormality is the presence of one or several subsegmental emboli. Are these findings clinically important, and is it necessary to anticoagulate patients with subsegmental emboli? A recent meta-analysis forces us to think carefully about the management of these patients.

The meta-analysis included 14 observational studies involving 15,563 symptomatic patients (NEJM JW Emerg Med Apr 2018 and Acad Emerg Med 2018 Mar 2; [e-pub]). All patients underwent CT pulmonary angiography for suspected PE and had at least 30 days of follow-up to assess rates of recurrent PE or deep venous thrombosis (DVT) and bleeding complications. In the pooled population, the prevalence of subsegmental PE was 4.6%. Among those with subsegmental PE, there were no significant differences between anticoagulated patients and nonanticoagulated patients in incidence of recurrent PE/DVT (5.3% and 3.9%, respectively) or death (2.1% and 3.0%). However, administration or withholding of anticoagulation was not randomized, and the incidence of bleeding was only reported for anticoagulated patients (8.1%). Notably, most of the studies did not provide information regarding the presence of concurrent DVT at the time of PE diagnosis, so we don't know whether these subsegmental emboli were truly isolated or not. The one study that included only patients with isolated subsegmental PE (i.e., without detectable DVT) showed no difference in recurrent PE/DVT between patients who were and were not anticoagulated.

To put these findings in perspective, some background information is worth considering. Prior to 20 years ago, PE was usually diagnosed by ventilation-perfusion lung scanning. The landmark 1990 PIOPED study suggested that patients with subsegmental perfusion defects who were not anticoagulated had benign clinical outcomes (JAMA 1990; 263:2753). In the 1990s, CT pulmonary angiography became available, and a 2011 study found that — although the incidence of diagnosed PE doubled between 1993 and 2006 — mortality associated with PE remained the same, suggesting that we might be overdiagnosing PE and possibly overtreating clinically benign cases (NEJM JW Gen Med Jun 15 2011 and Arch Intern Med 2011; 171:831). In addition, a recent study found that roughly one quarter of CT pulmonary angiograms initially interpreted as positive might actually have been false-positive scans, owing in part to various scanning artifacts; in that study, a majority of false-positive readings involved subsegmental locations. Yet another often-overlooked question is whether some subsegmental “emboli” actually represent in situ thrombosis within the pulmonary artery — as has been postulated, for example, in patients with sickle cell disease (NEJM JW Gen Med Dec 15 2011 and Am J Respir Crit Care Med 2011; 184:1022).

What do guidelines say about anticoagulating patients with subsegmental PE? The 2016 guideline from the American College of Chest Physicians suggests “clinical surveillance over anticoagulation” for patients with subsegmental PE who have no more-proximal pulmonary artery involvement, no proximal leg DVT, and low risk for recurrent venous thromboembolism (Chest 2016; 149:315). In contrast, the guideline suggests “anticoagulation over clinical surveillance” for patients deemed at high risk for recurrent venous thromboembolism. The authors acknowledge that the quality of the evidence is low, and that bleeding risk and patient preferences should play a role. Guidelines from the European Society of Cardiology state that decisions to treat patients with isolated subsegmental PE and no proximal DVT “should be made on an individual basis, taking into account the clinical probability [of PE] and the bleeding risk” (Eur Heart J 2014; 35:3033). And finally, just three months ago, the American College of Emergency Physicians issued a “Clinical Policy” on management of PE and DVT that included the following statement: “Given the lack of evidence, anticoagulation treatment decisions for patients with subsegmental PE without associated DVT should be guided by individual patient risk profiles and preferences” ( The authors acknowledge that this is a “Level C” recommendation, based on consensus and not randomized trials.

Wrap Up
Clinicians have a strong intuitive desire to anticoagulate all patients with PE; action is often favored over inaction. But treatment is not without risk, and severe intracranial and gastrointestinal bleeding complications are especially regrettable if the original indications for anticoagulation were marginal or uncertain. Potential bleeding complications should obviously be discussed with all PE patients who receive anticoagulation, regardless of PE size and location. However, for patients with isolated subsegmental PE — especially those we believe to be at high risk for bleeding — we should be willing to consider observation rather than treatment (after excluding concurrent DVT). In my view, not anticoagulating is not only as safe as, but perhaps even safer than, anticoagulation in selected patients with isolated subsegmental PE. In these cases, patient preferences should be an important element of the shared decision-making process.

10. Images in Clinical Practice

Tinea Capitis in a Newborn

Retinal Vasculitis in Takayasu’s Arteritis

Severe Vulvovaginal Varicosities in Pregnancy

Pemberton’s Sign in a Patient with a Goiter

Left Main Coronary Artery Aneurysm

Thumbprinting in Ischemic Colitis

Macroglossia in Light-Chain Amyloidosis

11. A Sacred Cow Slaughtered: Eliminating the Glasgow Coma Scale from Trauma Field Triage

Journal Watch. Daniel J. Pallin, MD, MPH reviewing Hopkins E et al. Ann Emerg Med 2018 May 2

A large two-center validation study provides good evidence that “patient does not follow commands” is just as predictive as the more-complex Glasgow Coma Scale.

A signature contribution of modern prehospital care has been to regionalize trauma care. Under regionalization, severely injured patients are not transported to the nearest hospital — instead, they go to the region's designated trauma center (they are “up-triaged”). But how do prehospital personnel decide? They use the CDC's Guidelines for Field Triage of Injured Patients. These guidelines direct prehospital personnel to up-triage when a patient has a Glasgow Coma Scale (GCS) score of less than 14 or meets one of the other numerous criteria for up-triage.

Because the GCS is a hassle for paramedics to learn and calculate, investigators have proposed using instead a simpler triage tool: if an injured person is not following commands, up-triage. Now investigators report on a two-center validation study comparing the predictive value of this dichotomous triage tool with that of the full GCS. This analysis of nearly 48,000 trauma patients found that “patient does not follow commands” had the same predictive value as GCS less than 14 for all studied trauma outcomes, with slightly superior positive likelihood ratios (e.g., those for mortality, 2.37 vs. 2.13) offsetting slightly inferior negative ones (e.g., those for mortality, 0.25 vs. 0.24).

Take a look at the Field Triage Guidelines linked above. They could stump a rocket scientist (or a brain surgeon, for that matter). To minimize time in the field, the expert panel that owns these guidelines should simplify them. The first step? Eliminate the Glasgow Coma Scale, and instead just up-triage if the patient is not following commands.

Hopkins’ abstract: Ann Emerg Med. 2018 May 2 [Epub ahead of print].

Study objective
Out-of-hospital personnel worldwide calculate the 13-point Glasgow Coma Scale (GCS) score as a routine part of field trauma triage. We wish to independently validate a simpler binary assessment to replace the GCS for this task.

We analyzed trauma center registries from Loma Linda University Health (2003 to 2015) and Denver Health Medical Center (2009 to 2015) to compare the binary assessment “patient does not follow commands” (ie, GCS motor score less than 6) with GCS score less than or equal to 13 for the prediction of 5 trauma outcomes: emergency intubation, clinically significant brain injury, need for neurosurgical intervention, Injury Severity Score greater than 15, and mortality. As a secondary analysis, we similarly evaluated 3 other measures simpler than the GCS: GCS motor score less than 5, Simplified Motor Score, and the “alert, voice, pain, unresponsive” scale.

In this analysis of 47,973 trauma patients, we found that the binary assessment “patient does not follow commands” was essentially identical to GCS score less than or equal to 13 for the prediction of all 5 trauma outcomes, with slightly superior positive likelihood ratios (eg, those for mortality 2.37 versus 2.13) offsetting slightly inferior negative ones (eg, those for mortality 0.25 versus 0.24) and its graphic depiction of sensitivity versus specificity superimposing the GCS prediction curve. We found similar results for the 3 other simplified measures.

In this 2-center external validation, we confirmed that a simple binary assessment—“patient does not follow commands”—could effectively replace the more complicated GCS for field trauma triage.

12. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA

Johnston SC, et al. N Engl J Med. 2018 May 16 [Epub ahead of print]

Background Combination antiplatelet therapy with clopidogrel and aspirin may reduce the rate of recurrent stroke during the first 3 months after a minor ischemic stroke or transient ischemic attack (TIA). A trial of combination antiplatelet therapy in a Chinese population has shown a reduction in the risk of recurrent stroke. We tested this combination in an international population.

Methods In a randomized trial, we assigned patients with minor ischemic stroke or high-risk TIA to receive either clopidogrel at a loading dose of 600 mg on day 1, followed by 75 mg per day, plus aspirin (at a dose of 50 to 325 mg per day) or the same range of doses of aspirin alone. The dose of aspirin in each group was selected by the site investigator. The primary efficacy outcome in a time-to-event analysis was the risk of a composite of major ischemic events, which was defined as ischemic stroke, myocardial infarction, or death from an ischemic vascular event, at 90 days.

Results A total of 4881 patients were enrolled at 269 international sites. The trial was halted after 84% of the anticipated number of patients had been enrolled because the data and safety monitoring board had determined that the combination of clopidogrel and aspirin was associated with both a lower risk of major ischemic events and a higher risk of major hemorrhage than aspirin alone at 90 days. Major ischemic events occurred in 121 of 2432 patients (5.0%) receiving clopidogrel plus aspirin and in 160 of 2449 patients (6.5%) receiving aspirin plus placebo (hazard ratio, 0.75; 95% confidence interval [CI], 0.59 to 0.95; P=0.02), with most events occurring during the first week after the initial event. Major hemorrhage occurred in 23 patients (0.9%) receiving clopidogrel plus aspirin and in 10 patients (0.4%) receiving aspirin plus placebo (hazard ratio, 2.32; 95% CI, 1.10 to 4.87; P=0.02).

Conclusions In patients with minor ischemic stroke or high-risk TIA, those who received a combination of clopidogrel and aspirin had a lower risk of major ischemic events but a higher risk of major hemorrhage at 90 days than those who received aspirin alone.

Editorial: What is the take-home message for the clinician?

The evidence from the SAMMPRIS, CHANCE, and POINT trials is that the combination of aspirin plus clopidogrel reduces the chance of recurrent ischemic stroke during the high-risk period in the first few weeks after a TIA or noncardioembolic ischemic stroke. However, to conform to the results of the POINT trial, if dual therapy is used, it should be confined to the first 3 weeks after a TIA or minor stroke and then transitioned to monotherapy. If patient follow-up and adherence to therapy are not reliable, then dual therapy perhaps should not be considered. Dual therapy may also not be advisable in patients with an uncertain diagnosis of TIA, who either would have been excluded from the trial or did not benefit. Finally, patients who are at increased risk for bleeding, such as those with cerebral microbleeding or a history of brain or systemic bleeding, were excluded from this trial and may not be appropriate candidates for such dual therapy. The POINT trial has provided useful data to help us further personalize our efforts in preventing recurrent stroke.

13. Safety of Lumbar Puncture Performed on Dual Antiplatelet Therapy.

Carabenciov ID, et al. Mayo Clin Proc. 2018 May;93(5):627-629., Hawkes MA2, Hocker S2.

Practice guidelines generally recommend delaying lumbar puncture (LP) in patients on dual antiplatelet therapy, with these recommendations often citing an increased risk of hemorrhagic complications, specifically the development of epidural hematomas. However, no data exist about the risks of performing an LP in the setting of dual antiplatelet therapy and conclusions are often based on data from spinal anesthesia literature.

We reviewed the medical records of 100 patients who underwent LP while taking dual antiplatelet therapy. We recorded the number of traumatic and bloody cerebrospinal fluid results as well as the presence of any complications occurring within 3 months of the procedure. Complications requiring imaging or hospitalization were considered serious.

The most common complication was back pain, which was reported by 2 patients, only 1 of which was ultimately found to be attributable to the procedure. No serious complications occurred. Cerebrospinal fluid analysis was consistent with a traumatic LP, defined as having at least 100 red blood cells per microliter, in 8% of cases. Bloody LP, defined as having 1000 red blood cells per microliter, occurred in 4% of cases. The percentage of traumatic or bloody LPs was within the range reported previously for LPs performed in any setting.

Although this is a small study and additional review is necessary, performing LPs in the setting of dual antiplatelet therapy may not pose an increased risk of serious complications.

14. Effectiveness of a Specialized Brief Intervention for At-risk Drinkers in an ED: Short-term Results of a RCT

Bruguera P, et al.. Acad Emerg Med. 2018;25(5):517-525.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs have been developed, evaluated, and shown to be effective, particularly in primary care and general practice. Nevertheless, effectiveness of SBIRT in emergency departments (EDs) has not been clearly established.

We aimed to evaluate the feasibility and efficacy of an SBIRT program conducted by highly specialized professionals in the ED of a tertiary hospital.

We conducted a randomized controlled trial to study the feasibility and efficacy of an SBIRT program conducted by alcohol specialists for at-risk drinkers presenting to the ED, measured with the three-item version of the Alcohol Use Disorder Identification Test (AUDIT-C). Patients were randomized to two groups, with the control group receiving two leaflets-one regarding alcohol use and the other giving information about the study protocol. The intervention group received the same leaflets as well as a brief motivational intervention on alcohol use and, where appropriate, a referral to specialized treatment. The primary outcomes were the proportion of at-risk alcohol use measured by AUDIT-C scale and the proportion of patients attending specialized treatment at 1.5 months.

Of 3,027 patients presenting to the ED, 2,044 (67%) were potentially eligible to participate, 247 (12%) screened positive for at-risk drinking, and 200 agreed to participate. Seventy-two percent of the participating sample were men, and the mean (±SD) age was 43 (±16.7) years. Follow-up rates were 76.5%. At 1.5 months, the intervention group showed greater reductions in alcohol consumption and fewer patients continuing with at-risk alcohol use (27.8% vs. 48.1%; p = 0.01). The SBIRT program also increased the probability of attending specialized treatment, compared to the control condition (23% vs. 9.8%, p = 0.0119)

CONCLUSION: The SBIRT program in the ED was found to be feasible and effective in identifying at-risk drinkers, reducing at-risk alcohol use, and increasing treatment for alcohol problems.

15. Patients on Opioids OK with Lower Doses

ROBERT PREIDT, HealthDay Reporter. June 8, 2018

Even patients who have taken high doses of opioid painkillers for long periods of time aren't unhappy with their care when their doctor lowers their dose, new research suggests.

The study included nearly 2,500 patients with chronic pain who had been on high doses of opioids for at least six straight months. The researchers compared patient satisfaction scores between those whose opioid dose was reduced to the recommended level for at least 30 days and those who stayed on high doses.

The study found that 86 percent of patients in the reduced-dose group remained satisfied with their care, and that the likelihood of a favorable satisfaction rating was higher when opioid doses were reduced by a patient's regular primary care doctor rather than another doctor.

"Physicians are often concerned they will receive lower satisfaction scores if they reduce opioids for patients who are accustomed to high opioid doses to manage chronic pain," said study author Dr. Adam Sharp, from Kaiser Permanente's Southern California department of research & evaluation.

"This study showed that following current recommendations and reducing opioids for chronic pain did not result in lower satisfaction scores," he added in a Kaiser Permanente news release.

"If you are a physician, you should do the right thing and you should feel comfortable you will not receive lower patient satisfaction scores. Our results should reassure physicians and help promote use of recommended guidelines," Sharp said.

"Even if you are in the small subset of physicians reducing opioids for people who are not your regular patients, there is still only a small difference in overall patient satisfaction," he noted.

Sharp said high doses of opioids for chronic pain are more likely to hurt than benefit patients, and that patients "should be reassured that your physician wants to follow guidelines designed to improve your health and well-being."

So, he concluded, "At times, your doctor may be helping you most by prescribing less."

Sharp AL, Shen E, Wu YL, Wong A, Menchine M, Kanter MH, Gould MK. Satisfaction with Care After Reducing Opioids for Chronic Pain. Am J Manag Care. 2018;24(6):e196-e199.

16. Readmissions are down, unless you consider rise in OBSERVATION stays

John Cummins. Health Leaders. MAY 31, 2018.

When the rising numbers of non-admitted patients held for observation is factored in, declines in readmissions disappear. Are hospitals trying to skirt readmissions penalties, or are there valid reasons for the increase in observational status?A study out today in the New England Journal of Medicine suggests that the much-ballyhooed reduction in hospital readmissions in recent years all but disappears when researchers factor in the increase in non-admitted patients being kept for observational stays.

Study co-author Brad Wright, an associate professor of Health Management and Policy at University of Iowa in Iowa City, spoke with HealthLeaders Media on the subject.

The following is an edited transcript.

HLM: Does your study mean we've made no progress in lowering readmissions?

Wright: Yes, more or less. There is still a very small reduction in readmissions but yeah, you're reading that correctly. But that is only when we include observation in both components of the calculation. That is not just looking at people who were hospitalized who bounced back and now we are putting them all on observation. That takes away some of the reduction in readmissions but not all of it. It's when you also include the observation stays as initial index events. That's where the wipe out happens.

HLM: Are hospitals gaming the system?

Wright: I hesitate to say that. It's difficult to say that from the claims data. It could happen, but more than likely what we are seeing is simply the result of two different things. One being the increase in the use of observations, which is happening for a host of reasons alongside the readmissions reduction program. The argument we are making is not that hospitals are somehow purposely and malevolently gaming the system. It's just a confluence of events and these are the implications.

HLM: If it's not gaming, how else could this be explained?

Wright: One piece, and this is gaming of another sort, is audits from Medicare contractors. If they are denying payments for shorter inpatient stays that they think are inappropriate and should have been handled as observations, hospitals obviously don’t want to forego payment. So, there is pressure to put more patients in observation. From the clinical side, you've given physicians a space where, as technology has improved, patients who would have at one time been handled in the inpatient setting can now be handled appropriately in an outpatient observation setting.  The other piece is that you create a space for physicians to ensure patient safety. Patients in the past would have been discharged home. You now have created an avenue for them to be kept in the hospital to rule out potentially life-threatening causes for whatever is going out with them.

HLM: Given your findings, has this effort to reduce readmissions been a big waste of time?


NEJM editorial (subscription required):

17. Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial

Sprigg N, et al. Lancet. 2018;391(10135): 2107–2115.

Tranexamic acid can prevent death due to bleeding after trauma and post-partum haemorrhage. We aimed to assess whether tranexamic acid reduces haematoma expansion and improves outcome in adults with stroke due to intracerebral haemorrhage.

We did an international, randomised placebo-controlled trial in adults with intracerebral haemorrhage from acute stroke units at 124 hospital sites in 12 countries. Participants were randomly assigned (1:1) to receive 1 g intravenous tranexamic acid bolus followed by an 8 h infusion of 1 g tranexamic acid or a matching placebo, within 8 h of symptom onset. Randomisation was done centrally in real time via a secure website, with stratification by country and minimisation on key prognostic factors. Treatment allocation was concealed from patients, outcome assessors, and all other health-care workers involved in the trial. The primary outcome was functional status at day 90, measured by shift in the modified Rankin Scale, using ordinal logistic regression with adjustment for stratification and minimisation criteria. All analyses were done on an intention-to-treat basis. This trial is registered with the ISRCTN registry, number ISRCTN93732214.

We recruited 2325 participants between March 1, 2013, and Sept 30, 2017. 1161 patients received tranexamic acid and 1164 received placebo; the treatment groups were well balanced at baseline. The primary outcome was assessed for 2307 (99%) participants. The primary outcome, functional status at day 90, did not differ significantly between the groups (adjusted odds ratio [aOR] 0·88, 95% CI 0·76-1·03, p=0·11). Although there were fewer deaths by day 7 in the tranexamic acid group (101 [9%] deaths in the tranexamic acid group vs 123 [11%] deaths in the placebo group; aOR 0·73, 0·53-0·99, p=0·0406), there was no difference in case fatality at 90 days (250 [22%] vs 249 [21%]; adjusted hazard ratio 0·92, 95% CI 0·77-1·10, p=0·37). Fewer patients had serious adverse events after tranexamic acid than after placebo by days 2 (379 [33%] patients vs 417 [36%] patients), 7 (456 [39%] vs 497 [43%]), and 90 (521 [45%] vs 556 [48%]).

Functional status 90 days after intracerebral haemorrhage did not differ significantly between patients who received tranexamic acid and those who received placebo, despite a reduction in early deaths and serious adverse events. Larger randomised trials are needed to confirm or refute a clinically significant treatment effect.

18. World’s First Airport ER Opens At DFW International.

The Dallas Morning News (6/7, Ortega, 1.05M) reports Dallas Fort Worth International Airport “is now home to what’s being touted as the first airport emergency room in the world,” sporting an 8,160-square-foot facility “pitched by Texas company Code 3 ER and Urgent Care in 2015 and approved by the airport’s board in 2016.” Open Friday, the facility “has CT scanners, a full lab, a pharmacy, and X-ray and ultrasound machines.”

19. FDA says don't use OTC teething products that contain benzocaine

Over-the-counter teething products that contain benzocaine pose a "serious risk to infants and children" and offer no benefit, according to an FDA warning. Teething gels, sprays, ointments, solutions and lozenges that contain benzocaine could cause the fatal blood condition methemoglobinemia, the FDA said, and the agency is asking manufacturers to stop marketing the products for pediatric use.

What can we do when our children have symptoms of teething?

Here’s what the American Academy of Pediatrics recommends:
How to ease your baby’s discomfort: Teething occasionally may cause mild irritability, crying, a low-grade temperature (but not over 101 degrees Fahrenheit or 38.3 degrees Celsius), excessive drooling, and a desire to chew on something hard. More often, the gums around the new teeth will swell and be tender. Try gently rubbing or massaging the gums with one of your fingers. Teething rings are helpful, too, but they should be made of firm rubber. (The teethers that you freeze tend to get too hard and can cause more harm than good.) Pain relievers and medications that you rub on the gums are not necessary or useful since they wash out of the baby’s mouth within minutes. Some medication you rub on your child’s gums can even be harmful if too much is used and the child swallows an excessive amount. Stay away from teething tablets that contain the plant poison belladonna and gels with benzocaine. Belladonna and benzocaine are marketed to numb your child's pain, but the FDA has issued warnings against both due to potential side effects.​ If your child seems particularly miserable or has a fever higher than 101 degrees Fahrenheit (38.3 degrees Celsius), it’s probably not because she’s teething, and you should consult your pediatrician.

20. Immune Checkpoint Inhibitors, the Most Recent Onc Emergency: What Emergency Physicians Need to Know

Simmons D, Lang E. Cureus. 2017 Oct 13;9(10):e1774.

Immune checkpoint inhibitors targeting cytotoxic T-lymphocyte associated protein 4 (CTLA-4) and programmable cell death protein 1 (PD-1)/PD-L1 have shown antitumor activity in cancers such as melanoma, non-small cell lung cancer, renal cell carcinoma, and urothelial cancer. Certain checkpoint inhibitors have been approved for use in Canada, and are becoming a mainstay in the treatment of melanoma and other malignancies.

These drugs have a unique side effect profile and are known to cause immune-related adverse events (irAEs). These adverse events often appear to originate from an infectious etiology, when in fact they result from the enhanced immune response caused by immune checkpoint therapy. IrAEs are primarily treated with corticosteroids, which suppress the overactive immune response that is secondary to the treatment. IrAEs can occur in any organ system, but adverse events in the skin, gastrointestinal, endocrine, and pulmonary systems are among the most common. As an emergency physician, one must be familiar with these drugs and their adverse events in order to identify patients presenting with irAE and treat them accordingly.

This paper provides a brief introduction to immune checkpoint inhibitors, discusses the most common irAEs relevant to emergency physicians, and gives suggestions on how to manage patients presenting to the emergency department (ED) suffering from irAEs.

See also Pallin DJ, et al. Immune-related Adverse Events in Cancer Patients. Acad Emerg Med 2018 May 05 [Epub ahead of print].

The U.S. Food and Drug Administration has approved immune checkpoint inhibitors and chimeric antigen receptor T cells (CAR-T cells) as immunotherapy strategies for cancer. These therapies cause a wide variety of adverse events, which mimic other disease states and may emerge months after completion of treatment. This is important because ascertaining a past medical history of cancer treatment within the past year becomes necessary for many presentations. This narrative review summarizes the biology, pathophysiology, and adverse events associated with checkpoint inhibitors and CAR-T cells and provides a rational approach to management. Proper treatment begins with heightened awareness, rapid diagnosis, and discussion with the patient's oncologist. Treatment of these adverse effects requires only corticosteroids, infliximab, tocilizumab, or fluids or vasopressors when clinically indicated.

21. Docs who under-estimate their opioid prescribing can reduce their prescribing when presented with the data: A RCT

Michael SS, et al. Acad Emerg Med. 2018;25(5):482-493.

Little is known about accuracy of provider self-perception of opioid prescribing. We hypothesized that an intervention asking emergency department (ED) providers to self-identify their opioid prescribing practices compared to group norms-and subsequently providing them with their actual prescribing data-would alter future prescribing compared to controls.

This was a prospective, multicenter randomized trial in which all attending physicians, residents, and advanced practice providers at four EDs were randomly assigned either to no intervention or to a brief data-driven intervention during which providers were: 1) asked to self-identify and explicitly report to research staff their perceived opioid prescribing in comparison to their peers and 2) then given their actual data with peer group norms for comparison. Our primary outcome was the change in each provider's proportion of patients discharged with an opioid prescription at 6 and 12 months. Secondary outcomes were opioid prescriptions per hundred total prescriptions and normalized morphine milligram equivalents prescribed. Our primary comparison stratified intervention providers by those who underestimated their prescribing and those who did not underestimate their prescribing, both compared to controls.

Among 109 total participants, 51 were randomized to the intervention, 65% of whom underestimated their opioid prescribing. Intervention participants who underestimated their baseline prescribing had larger-magnitude decreases than controls (Hodges-Lehmann difference = -2.1 prescriptions per hundred patients at 6 months [95% confidence interval {CI} = -3.9 to -0.5] and -2.2 per hundred at 12 months [95% CI = -4.8 to -0.01]). Intervention participants who did not underestimate their prescribing had similar changes to controls.

Self-perception of prescribing was frequently inaccurate. Providing clinicians with their actual opioid prescribing data after querying their self-perception reduced future prescribing among providers who underestimated their baseline prescribing. Our findings suggest that guideline and policy interventions should directly address the potential barrier of inaccurate provider self-awareness.

22. Micro Bits

A. Providing Bias-Free Patient Care is a Journey — Take Your First Steps Today
Unconscious Bias in Clinical Practice is a FREE ACEP-sponsored online course to help you learn about the physiologic basis of unconscious bias, discover the negative effects of unconscious bias in clinical scenarios, and employ strategies to minimize the negative effects of unconscious bias in clinical care.

B. Diagnostic accuracy of point-of-care BNP testing for chronic HF in ambulatory care: systematic review and meta-analysis

C. Report shows link between obesity, cancer

A World Cancer Research Fund report showed an association between obesity and an increased risk of 12 cancers, including breast, esophagus, gallbladder, kidney and liver cancers. The report also recommends being physically active; limiting consumption of fast food, high-fat products, red and processed meats, alcohol and sugar; and eating a diet rich in beans, fruit, whole grains and vegetables to reduce cancer risks.

D. Research Finds Acupuncture Effective for Chronic Pain

May 21, 2018 — A new meta-analysis published in the Journal of Pain has found that acupuncture is effective for the treatment of chronic pain, which may have implications for the way family physicians treat patients with this condition.

E. As Paroxysmal Afib Burden Rises, So Does Stroke Risk: Some 'low-risk' patients may need preventive treatment, data suggest

A greater burden of even intermittent atrial fibrillation (Afib, or AF) was associated with a significantly higher stroke risk and could warrant anticoagulation, according to a retrospective study of continuous ambulatory heart monitoring data.

Compared with paroxysmal Afib patients with the lowest burden, those in the highest tertile had a more than threefold risk (adjusted hazard ratio 3.13; 95% CI 1.5-6.56) after adjusting for ATRIA stroke risk score, reported researchers led by Alan Go, MD, of Kaiser Permanente Northern California in Oakland.

F. New Biologics for Asthma: monoclonal antibodies against type 2 inflammation

G. CDC Officials Advise People With Diarrhea To Stay Out Of Pools.

The AP (5/17, Stobbe) says that on Thursday, CDC officials released their annual report on safe swimming that advises people with diarrhea to stay out of pools, hot tubs, and water playgrounds. The report highlights outbreaks of stomach bugs from 2000 through 2014 that were linked to swimming or bathing in treated recreational water spots. According to the report, “in an average year, there were 15 such outbreaks and about 1,800 related illnesses. Overall, a third were tied to hotels.” Cryptosporidium caused most of the outbreaks.
On its website, ABC News (5/17, Strachan, 2.58M) reports that “over half of the cases were due to a parasite called Cryptosporidium, which causes gastrointestinal symptoms, like diarrhea, with the infection beginning when contaminated water is ingested.” Some strains of Cryptosporidium can survive in chlorinated water for over a week. Between 2000 and 2007, outbreaks related to Cryptosporidium increased by about 25 percent per year.
CNN (5/17, Scutti, 80.64M) says on its website that during the 15-year period examined in the report, a total of 493 outbreaks linked to treated recreational water were reported in 46 states and Puerto Rico.

H. CDC: Suicide rate rising in US

The average annual rate of suicide among individuals ages 10 and older in the US rose by 25% between 1999 and 2016, increasing by a low of 6% in Delaware to over 57% in North Dakota, according to a CDC Vital Signs report. Contributing factors include social isolation, poor access to mental health care, misuse of drugs and alcohol, and gun ownership; and common precursors include termination of a relationship, financial problems, substance abuse and eviction.

I. Pediatric adenoid, tonsil removal tied to disease risk in adulthood

People who had adenoid or tonsil removal before age 10 were two to three times as likely to develop upper respiratory tract diseases and had increased odds of developing allergic and infectious diseases through age 30, researchers reported in JAMA Otolaryngology -- Head & Neck Surgery. The findings also found a 2% increase in absolute risk of infectious diseases following adenotonsillectomy.

J. A fresh look at shortsightedness

We want you to read The BMJ, but perhaps it should carry a health warning. Research published this week includes a worrying finding: more study worsens eyesight (doi:10.1136/bmj.k2022). Each year spent in education raised myopic refractive error by an average −0.27 dioptres, the researchers found.

K. FDA Approves Lokelma for Hyperkalemia

Troy Brown, RN. May 18, 2018
The US Food and Drug Administration (FDA) has approved sodium zirconium cyclosilicate (Lokelma, AstraZeneca) — a medication that rapidly restores normal potassium levels — for adults with hyperkalemia.

Formerly known as ZS-9, the drug is a "highly-selective, oral potassium-removing agent," the company explains in a company news release.

"We are pleased by today's FDA approval of Lokelma as it enables us to help address a long-standing clinical need with a new medicine that offers rapid and sustained treatment for adults with hyperkalemia. The consequences of hyperkalemia can be very serious and it's reassuring for treating physicians that Lokelma has demonstrated lowering of potassium levels in patients with chronic kidney disease, heart failure, diabetes and those taking [renin-angiotensin-aldosterone system (RAAS)] inhibitors," Sean Bohen, MD, PhD, executive vice president, Global Medicines Development, and chief medical officer, AstraZeneca, said in the news release.

The FDA considered data from three double-blind, placebo-controlled trials and two open-label trials. The onset of action was at 1 hour and the median time until patients achieved normal serum potassium levels was 2.2 hours. Most (92%) patients reached normal potassium levels within 48 hours from baseline. The treatment effect continued for as long as 12 months, according to the company.

L. FDA Approves AI-Based Software for Wrist Fracture Detection

The US Food and Drug Administration (FDA) approved computer-aided detection and diagnostic software called OsteoDetect to speed the diagnosis of wrist fractures in adults, the agency announced yesterday.

OsteoDetect, from Imagen, in New York City, uses an artificial-intelligence algorithm to detect fractures in the distal radius by analyzing standard x-ray images. The software then marks the image for further review by a clinician.

M. Task force report highlights 22% decrease in opioid Rx

The American Medical Association Opioid Task Force's 2018 report found more than a 22% decrease in opioid prescriptions between 2013 and 2017, and a decrease for the fifth year in a row. Prescriptions for naloxone more than doubled, from 3,500 weekly to 8,000 in 2017, and treatment capacity increased 42% in the past 12 months.

N. Study finds links between breastfeeding, gut microbiome, weight

The gut microbiome in breastfed babies differs from that of babies fed mostly formula, and breastfed babies are less likely than their formula-fed peers to develop obesity, suggesting that obesity starts early and is linked to gut bacteria. The study, published in the Journal of Pediatrics, found an association between a proliferation of certain gut bacteria and healthy weight, and revealed that occasional formula feeding does not raise the risk of overweight.

O. Research finds variation in personal health care access, quality worldwide

The Healthcare Access and Quality index varied significantly across 195 countries, territories and subnational locations, from a high of 97.1 in Iceland to a low of 18.6 in the Central African Republic, according to a study in The Lancet. Researchers analyzed the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 and found that "alongside initiatives to strengthen public health programs, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view -- and subsequent provision -- of quality health care for all populations."

P. Complex regional pain syndrome: Signs and symptoms

Complex regional pain syndrome may develop as a complication after limb trauma or lesions of the peripheral nervous system. Typical features are continuing pain, sensory, vasomotor, sudomotor, motor and trophic changes as well as edema. This article provides a retrospective analysis of 1,043 CRPS patients in comparison with 421 patients suffering from other pain disorders. The results could potentially facilitate a more reliable and earlier diagnosis of CRPS, a better differentiation from other pain disorders, and ultimately in a more targeted and effective therapy.

Q. Suicide Rates Spike Across United States, Says CDC

June 12, 2018 08:43 am Chris Crawford – In 2016, nearly 45,000 Americans age 10 or older took their own lives -- a figure that reflects the unfortunate fact that suicide rates in the country have risen nearly 30 percent since 1999. That's the word from a pair of reports the CDC released June 7; that timing, unhappily, coincided with the high-profile suicides of Kate Spade on June 5 and Anthony Bourdain on June 8.

R. Antiplatelet Restart May Be OK after Brain Bleed

Functional independence, quality of life similar in mild to moderate ICH

Restarting antiplatelet therapy in patients with mild to moderate intracerebral hemorrhage (ICH) is not associated with worse functional outcomes, a retrospective analysis suggests.

Patients who had mild to moderately severe ICH had no difference in functional independence outcomes or health-related quality of life metrics whether or not they resumed antiplatelet therapy, reported Ching-Jen Chen, MD, of the University of Virginia in Charlottesville and colleagues in Neurology.

"In patients with intracerebral hemorrhage who were on antiplatelet therapy, clinicians are often faced with the decision of whether or not to restart antiplatelet therapy at the time of discharge," Chen said.

"Although antiplatelet use after ICH is associated with decreased incidence of ischemic cardiovascular events without an elevated risk of recurrent ICH, functional outcomes and health-related quality of life measures in these circumstances remained unclear," he told MedPage Today. "These measures may not be accurately portrayed by incidences of ischemic cardiovascular events or recurrent ICH alone."

The effectiveness of antiplatelet therapy in preventing primary and secondary ischemic events has led to wider use which, despite overall benefits, may elevate the risk of spontaneous ICH. For patients who survive an initial hemorrhagic stroke, a second ICH is linked to further morbidity and mortality.