Thursday, August 17, 2017

Lit Bits: Aug 17, 2017

From the recent medical literature...

1. Acute HF in the ED: Door-to-Furosemide Time Matters

Megan Brooks. Medscape. July 07, 2017

CIBA, JAPAN — For acute heart failure (HF) patients arriving in the emergency department (ED), administration of intravenous (IV) furosemide within 1 hour is independently associated with lower in-hospital mortality, according to results of the observational REALITY-AHF study[1].
Yet only about a third of these patients are treated within the first hour, the study found. "That was the most surprising finding for us, because we assumed that we are doing much better," Dr Yuya Matsue (Kameda Medical Center, Ciba, Japan) told|Medscape Cardiology.
"We don't know exactly what causes this delay, but our results are suggesting that we are treating very obvious AHF quickly, but when the diagnosis is not clear from their symptoms, we are taking our time even though such patients could be at high risk," added Matsue.
The emergency department is a "major stage" for hospitalized patients with acute HF, Matsue and colleagues point out in their report, published June 27, 2017 in the Journal of the American College of Cardiology. More than one million ED visits annually in the US involve acute HF, and most result in hospital admission.

"The importance of the emergency-department phase in managing AHF has become increasingly apparent as recent post hoc studies have highlighted that although patient characteristics are important, the efficacy of any intervention/treatment may be time dependent," they write. Recent HF guidelines and recommendations also emphasize the importance of immediate diagnosis and treatment of patients presenting with acute HF….

Matsue Y, et al. Treatment and Mortality in Patients Hospitalized with Acute Heart Failure
JACC 2017;69:3042-51.

Background Acute heart failure (AHF) is a life-threatening disease requiring urgent treatment, including a recommendation for immediate initiation of loop diuretics.

Objectives The authors prospectively evaluated the association between time-to-diuretic treatment and clinical outcome.

Methods REALITY-AHF (Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure) was a prospective, multicenter, observational cohort study that primarily aimed to assess the association between time to loop diuretic treatment and clinical outcome in patients with AHF admitted through the emergency department (ED). Door-to-furosemide (D2F) time was defined as the time from patient arrival at the ED to the first intravenous furosemide injection. Patients with a D2F time less than 60 min were pre-defined as the early treatment group. Primary outcome was all-cause in-hospital mortality.

Results Among 1,291 AHF patients treated with intravenous furosemide within 24 h of ED arrival, the median D2F time was 90 min (IQR: 36 to 186 min), and 481 patients (37.3%) were categorized as the early treatment group. These patients were more likely to arrive by ambulance and had more signs of congestion compared with the nonearly treatment group. In-hospital mortality was significantly lower in the early treatment group (2.3% vs. 6.0% in the nonearly treatment group; p = 0.002). In multivariate analysis, earlier treatment remained significantly associated with lower in-hospital mortality (odds ratio: 0.39; 95% confidence interval: 0.20 to 0.76; p = 0.006).

Conclusions In this prospective multicenter, observational cohort study of patients presenting at the ED for AHF, early treatment with intravenous loop diuretics was associated with lower in-hospital mortality.

2. Angiotensin II for the Treatment of Vasodilatory Shock.

Khanna A, et al. N Engl J Med. 2017 Aug 3;377(5):419-430.

BACKGROUND: Vasodilatory shock that does not respond to high-dose vasopressors is associated with high mortality. We investigated the effectiveness of angiotensin II for the treatment of patients with this condition.

METHODS: We randomly assigned patients with vasodilatory shock who were receiving more than 0.2 μg of norepinephrine per kilogram of body weight per minute or the equivalent dose of another vasopressor to receive infusions of either angiotensin II or placebo. The primary end point was a response with respect to mean arterial pressure at hour 3 after the start of infusion, with response defined as an increase from baseline of at least 10 mm Hg or an increase to at least 75 mm Hg, without an increase in the dose of background vasopressors.

RESULTS: A total of 344 patients were assigned to one of the two regimens; 321 received a study intervention (163 received angiotensin II, and 158 received placebo) and were included in the analysis. The primary end point was reached by more patients in the angiotensin II group (114 of 163 patients, 69.9%) than in the placebo group (37 of 158 patients, 23.4%) (odds ratio, 7.95; 95% confidence interval [CI], 4.76 to 13.3; P less than 0.001). At 48 hours, the mean improvement in the cardiovascular Sequential Organ Failure Assessment (SOFA) score (scores range from 0 to 4, with higher scores indicating more severe dysfunction) was greater in the angiotensin II group than in the placebo group (-1.75 vs. -1.28, P=0.01). Serious adverse events were reported in 60.7% of the patients in the angiotensin II group and in 67.1% in the placebo group. Death by day 28 occurred in 75 of 163 patients (46%) in the angiotensin II group and in 85 of 158 patients (54%) in the placebo group (hazard ratio, 0.78; 95% CI, 0.57 to 1.07; P=0.12).

CONCLUSIONS: Angiotensin II effectively increased blood pressure in patients with vasodilatory shock that did not respond to high doses of conventional vasopressors.

3. New or additional antiplatelet may be needed after TIA, stroke

Patients who have had a transient ischemic attack or stroke while taking aspirin may reduce their risk of future cardiovascular events or recurrent stroke by adding another antiplatelet medication to preventive therapy or switching to a new one, according to an analysis of studies in Stroke. Making the change within days of the initial TIA or stroke was associated with the best results.

Lee M, et al. Antiplatelet Regimen for Patients With Breakthrough Strokes While on Aspirin
A Systematic Review and Meta-Analysis. Stroke. 2017 July 12 [Epub ahead of print]

Background and Purpose—Optimal antiplatelet therapy after an ischemic stroke or transient ischemic attack while on aspirin is uncertain. We, therefore, conducted a systematic review and meta-analysis.

Methods—We searched PubMed (1966 to August 2016) and bibliographies of relevant published original studies to identify randomized trials and cohort studies reporting patients who were on aspirin at the time of an index ischemic stroke or transient ischemic attack and reported hazard ratio for major adverse cardiovascular events or recurrent stroke associated with a switch to or addition of another antiplatelet agent versus maintaining aspirin monotherapy. Estimates were combined using a random effects model.

Results—Five studies with 8723 patients with ischemic stroke or transient ischemic attack were identified. Clopidogrel was used in 4 cohorts, and ticagrelor was used in 1 cohort. Pooling results showed that addition of or a switch to another antiplatelet agent, versus aspirin monotherapy, was associated with reduced risks of major adverse cardiovascular events (hazard ratio, 0.68; 95% confidence interval, 0.54–0.85) and recurrent stroke (hazard ratio, 0.70; 95% confidence interval, 0.54–0.92). Each of the strategies of addition of and switching another antiplatelet agent showed benefit versus continued aspirin monotherapy, and studies with regimen initiation in the first days after index event showed more homogenous evidence of benefit.

Conclusions—Among patients who experience an ischemic stroke or transient ischemic attack while on aspirin monotherapy, the addition of or a switch to another antiplatelet agent, especially in the first days after index event, is associated with fewer future vascular events, including stroke.

4. Falling Back in Love with Emergency Medicine

Austin AL. Ann Emerg Med. 2017;70:255-6.

“The most empathetic you’ll ever be is today,” said a weary surgical resident to me on my first day of medical school clerkships. I internally scoffed at the callousness of his statement. This was surely the greatest job in the world and he would not squash my exuberance to see patients.

During internship, I was enchanted by emergency medicine. I was head over heels in love with the specialty. As a mentor once described emergency medicine, “You’re the doctor that steps up on the plane.” Whether it’s a newborn with a fever or an octogenarian with chest pain, we respond. Of course, I was drawn to the harrowing cases, but I reveled in the mundane. I loved that we accepted everyone at any hour and day of the week.

Then a strange thing started to happen. When I was a second-year resident, the love was lost. I didn’t like my job; and most startling, I didn’t like my patients. I found myself sitting at my desk a little longer, often dreading going into a room. Once in the room, I immediately began to dread the upcoming presentation to the attending, and worse, the notes. I hated the notes. The seemingly minor complaint began to annoy me. “Really? They think this is an emergency?”

Although we’re fairly sheltered as residents, I began to see some of the challenges of emergency medicine. We are increasingly expected to be faster, more accurate, and do it less expensively. And document; get every cent of reimbursement possible for our groups and hospitals. Don’t forget patient satisfaction. Oh, and the opioid epidemic: Make sure your patient is 100% satisfied, but don’t create more opioid addicts. Malpractice scared me. All of these troubles weighed on me during a shift. I smiled and put up a good front, but I was seriously questioning my choice of specialty and the field of medicine in general.

I am fortunate that I attended a residency that is very attuned to physician wellness and burnout. We completed burnout surveys every 6 months. We talked about self-care. If you ask any of my friends or family, I’m the queen of spa days and relaxation. Days off, spas, epic vacations weren’t filling me up. I didn’t like how I felt about my job or patients, and these negative feelings compounded the problem. I felt guilty. I was still that eager third-year medical student trapped in an older, somewhat embittered body.

I’m back in LOVE with emergency medicine. It took a period of reconciliation and some new rules. I stayed with emergency medicine, but I’m worried there’re a lot of good physicians suffering from work dysphoria, a term I did not understand until after I had already developed a strategy.1 Schmitz et al1 make a compelling case for a comprehensive wellness program, and certainly we must do more to retain and enrich our emergency medicine careers. Although each individual’s stressors and coping mechanisms differ, below are the top 5 strategies that have positively affected my shifts.

1. Stop complaining about patients. Emergency medicine takes all people at all times; we will treat a hangnail at 3 am. Quibbling over the “why” is exhausting. The patient is there and a negative attitude colors the interaction with the patients and staff. If it is a minor complaint, I embrace the “easy” chart, and look for a way to make it an awesome, quick, and maybe even pleasant visit for the patient. My patients are happier, and sure enough, I am too.

2. Embrace the interruptions. We’re all used to a lot of interruptions in emergency medicine. There are certain shifts when the intrusions grate on me. Although we are not immune to disruptions at the bedside, there is some sanctity behind the curtain or door. This patient interaction becomes a momentary solace among the chaos, one in which I may get to know and help one of my fellow human beings.

3. Recognize medicolegal risk but don’t allow it to paralyze. This is someone’s mom, dad, daughter, son who came to me for help. I may get sued. This will be terrible, painful, and challenging. Good physicians are sued and bad physicians may go their entire career without a lawsuit. Yet lawsuits are infrequent. I care about my patients and I love this profession. I educate myself on medicolegal topics because knowing the high-risk chief complaints and case features, along with the strategies to provide good care and document appropriately, help me feel like I can mitigate a lot of the risk. I do my best to do right by my patients and document accordingly. This has to be enough; the alternative is that we drive ourselves crazy and demonize our patients.

4. No more charting in the room. I dislike charting, and thus I refuse to combine it with my patient interactions. I truly believe the electronic medical record has created huge chasms in our patient interactions. I strive to give the patient my undivided attention. I fully understand and, albeit rarely, have experience with medical providers who don’t let the computer overtake the patient-physician interaction; but I haven’t found a way to combine the two effectively.

5. Forget perfection. I haven’t had a perfect ED shift. I don’t think I ever will. There’s always something that could go better: an interaction with a patient, colleague, or staff member, a quicker diagnosis, a smoother procedure, better documentation, you name it. The list is endless. As another one of my mentors often says, this is a practice. That really annoys me. I want perfection; I believe my patients deserve perfection, but this is not truly attainable. I strive for the best emergency care and experience for all my patients and colleagues, but the ED is a rough-and-tumble place. We must remain humble, open to feedback, and resilient. Bad interactions, depleting shifts, and stressful procedures come with the territory. Positive self-talk is a learned behavior. Most of us learned the model of “you suck,” ie, be your toughest critic. Self-love, care, and kindness should at least equal our critiques, and we are seldom capable of a fair self-critique in the heat of an ED shift.

Third year of medical school was 7 years ago. I can honestly say that I am more empathetic now. Empathy is the ability to share another’s emotions and experience. The more patients we see, the more we are truly present and connect with our patients, thus deepening our capacity for empathy. Although I fully support the movement for physician wellness, I believe the missing key is a real discussion about empathy. The greatest burnout I’ve experienced is during periods of depersonalization and the intense guilt I felt for these feelings. Our capacity for empathy is lessened with fatigue and stress, but empathy can be the salve on our professional souls. Sometimes when I’m most tired on a shift, taking a break, biting into a piece of chocolate doesn’t really help. Rather, sitting down with another patient, turning down the surrounding chaos, and opening myself to that most special patient-physician bond does a soul good.

5. Bronchiolitis with Hypoxia? Order Oxygen to Go

ED-initiated Home Oxygen for Bronchiolitis: A Prospective Study of Community Follow-up, Caregiver Satisfaction, and Outcomes.

Freeman JF, et al. Acad Emerg Med. 2017 Aug;24(8):920-929.

OBJECTIVE: Retrospective studies have shown home oxygen to be a safe alternative to hospitalization for some patients with bronchiolitis living at high altitudes. We aimed to prospectively describe adverse events, follow-up, duration of home oxygen, factors associated with failure, and caregiver preferences.

METHODS: This was a prospective observational study of hypoxemic bronchiolitis patients ages 3 to 18 months who were discharged from a tertiary care pediatric emergency department on home oxygen over three winters (2011-2014). Caregivers were contacted on postdischarge days ~3, 7, 14, and 28 while on oxygen. Caregivers not reached by phone were sent a survey and their primary care physicians were contacted. Records of admitted subjects were reviewed. Outcome measures included hospital readmission, positive pressure ventilation (noninvasive or intubation), outpatient follow-up, duration of home oxygen therapy, and caregiver satisfaction.

RESULTS: A total of 274 patients were enrolled. Forty-eight (17.5%) were admitted and 225 (82.1%) were discharged on oxygen. The median age was 8 months. Eighteen subjects were lost to follow-up. A total of 196 (87.1%) were successfully treated with outpatient oxygen, and 11 (4.9%) failed outpatient therapy and were hospitalized. Only one hospitalized patient required invasive ventilation. The median duration of home oxygen was 7 days. Child noncompliance was the most common problem (reported by 14%). The median caregiver comfort level with home oxygen was 9 of 10. Eighty-eight percent of caregivers would again choose home oxygen over admission.

CONCLUSIONS: This study confirms that outpatient oxygen therapy can reduce hospitalizations due to bronchiolitis in a relatively high-altitude setting, with low failure and complication rates. Caregivers are comfortable with home oxygen and prefer it to hospitalization.

6. Ketamine Corner

A. A prospective randomized, double-dummy trial comparing IV push low-dose ketamine to short infusion of low-dose ketamine for treatment of pain in the ED

Motov S, et al. Amer J Emerg Med. 2017;35:1095-1100.

STUDY OBJECTIVE: Compare adverse effects and analgesic efficacy of low-dose ketamine for acute pain in the ED administered either by single intravenous push (IVP) or short infusion (SI).

METHODS: Patients 18-65, presenting to ED with acute abdominal, flank, or musculoskeletal pain with initial pain score≥5, were randomized to ketamine 0.3mg/kg by either IVP or SI with placebo double-dummy. Adverse effects were evaluated by Side Effects Rating Scale for Dissociative Anesthetics (SERSDA) and Richmond Agitation-Sedation Scale (RASS) at 5, 15, 30, 60, 90, and 120min post-administration; analgesic efficacy was evaluated by Numerical Rating Scale (NRS).

RESULTS: 48 patients enrolled in the study. IVP group had higher overall rates of feeling of unreality on SERSDA scale: 92% versus 54% (difference 37.5%; p=0.008; 95% CI 9.3-59.5%). At 5min median severity of feeling of unreality was 3.0 for IVP versus 0.0 for SI (p=0.001). IVP also showed greater rates of sedation on RASS scale at 5min: median RASS -2.0 versus 0.0 (p=0.01). Decrease in mean pain scores from baseline to 15min was similar across groups: 5.2±3.53 (95% CI 3.7-6.7) for IVP; 5.75±3.48 (95% CI 4.3-7.2) for SI. There were no statistically significant differences with respect to changes in vital signs and need for rescue medication.

CONCLUSION: Low-dose ketamine given as a short infusion is associated with significantly lower rates of feeling of unreality and sedation with no difference in analgesic efficacy in comparison to intravenous push.

The push dose was given over 5 minutes
The short infusion was mixed in 100 mL 0.9% sodium chloride and was given over 15 minutes

B. Medically Clear: Get from Agitation to ‘oK’ Faster with Special K

Ballard DW, et al. Emerg Med News. 2017:39(8):7.

The call from EMS was for a psychotic patient who was ripping the siding off a neighbor's house with his bare hands. The medic who gave the report sounded distracted and a bit frightened. No response to intranasal midazolam, he said. They arrive, and you're immediately a bit frightened too.

The patient is built like an All-American linebacker, and his rippling musculature barely fits on the gurney. He is handcuffed and restrained on a backboard that bends with each of his freedom-seeking abdominal crunches. Blood trickles from his wrists, and you hear crunching from his mouth. He is actually cracking his own teeth, and attempting to spit them against his facemask. A few pockets of foam bubble out above his philtrum.

You note the diameter and superficiality of his mid-arm veins, wishing for access to an IV dart device, each vessel a prime target from across the room. Alas, sedation will start with the standard approach—a B52 of intramuscular haloperidol 5 mg/lorazepam 2 mg. The backboard is really creaking now. Could it actually snap? Boom, the B52 has landed. Minutes pass, the contorting, spitting, crunching, and grunting continue. It's just a matter of time before this patient seriously hurts himself or someone else. What next?

We've all had patients like this, but we'd like to thank our colleague Jason Nau, MD, for sharing this particular story. Like Dr. Nau, we would consider more Haldol and Ativan, droperidol, or RSI. There is no consensus on the best approach yet, but perhaps an old therapy is the key to safe sedation for the profoundly agitated…

C. Ketamine or Ketofol: Do we have enough evidence to know which one to use?

Miner J. Acad Emerg Med. 2017 Aug 12 [Epub ahead of print].

Ketamine and propofol are both commonly used emergency department (ED) procedural sedation agents. Their concurrent administration, often referred to as "ketofol", is widely used for procedural sedation. A simple google search can lead to a lot of opinions on why we should use propofol, ketamine, or ketofol in a given situation for moderate or deep procedural sedation in the ED, but finding evidence that supports differences these opinions assume is much harder to come by.

7. Haloperidol undermining gastroparesis symptoms (HUGS) in the ED

Ramirez R, et al. Am J Emerg Med. 2017 Aug;35(8):1118-1120.

BACKGROUND: Gastroparesis associated nausea, vomiting & abdominal pain (GP N/V/AP) are common presentations to the emergency department (ED). Treatment is often limited to antiemetic, prokinetic, opioid, & nonopioid agents. Haloperidol (HP) has been shown to have analgesic & antiemetic properties. We sought to evaluate HP in the ED as an alternative treatment of GP N/V/AP.

METHODS: Using an electronic medical record, 52 patients who presented to the ED w/GP N/V/AP secondary to diabetes mellitus and were treated w/HP were identified. Patients who received HP were compared to themselves w/the most recent previous encounter in which HP was not administered. ED length of stay (LOS), additional antiemetics/prokinetics administered, hospital LOS, and morphine equivalent doses of analgesia (ME) from each visit were recorded. Descriptive statistics, categorical (Chi Square Test or Z-Test for proportion) and continuous (Wilcoxon Signed Rank Test) comparisons were calculated. Statistical significance was considered for two tail p-values less than 0.05.

RESULTS: A statistically significant reduction in ME (Median 6.75 [IQR 7.93] v 10.75 [IQR12]: p=0.001) and reduced admissions for GP (5/52 v 14/52: p=0.02) when HP was administered was observed. There were no statistically significant differences in ED or hospital LOS, and additional antiemetics administered between encounters in which HP was administered and not administered. No complications were identified in patients who received HP.

CONCLUSIONS: The rate of admission and ME was found to be significantly reduced in patients with GP secondary to diabetes mellitus who received HP. HP may represent an appropriate, effective, and safe alternative to traditional analgesia and antiemetic therapy in the ED management of GP associated N/V/AP.

8. ED CT Use

A. Implementation of the Canadian CT Head Rule and Its Association with Use of CT Among Pts with Head Injury

Sharp AL, et al. Ann Emerg Med. 2017 Jul 21 [Epub ahead of print]

STUDY OBJECTIVE: Approximately 1 in 3 computed tomography (CT) scans performed for head injury may be avoidable. We evaluate the association of implementation of the Canadian CT Head Rule on head CT imaging in community emergency departments (EDs).

METHODS: We conducted an interrupted time-series analysis of encounters from January 2014 to December 2015 in 13 Southern California EDs. Adult health plan members with a trauma diagnosis and Glasgow Coma Scale score at ED triage were included. A multicomponent intervention included clinical leadership endorsement, physician education, and integrated clinical decision support. The primary outcome was the proportion of patients receiving a head CT. The unit of analysis was ED encounter, and we compared CT use pre- and postintervention with generalized estimating equations segmented logistic regression, with physician as a clustering variable. Secondary analysis described the yield of identified head injuries pre- and postintervention.

RESULTS: Included were 44,947 encounters (28,751 preintervention and 16,196 postintervention), resulting in 14,633 (32.6%) head CTs (9,758 preintervention and 4,875 postintervention), with an absolute 5.3% (95% confidence interval [CI] 2.5% to 8.1%) reduction in CT use postintervention. Adjusted pre-post comparison showed a trend in decreasing odds of imaging (odds ratio 0.98; 95% CI 0.96 to 0.99). All but one ED reduced CTs postintervention (0.3% to 8.7%, one ED 0.3% increase), but no interaction between the intervention and study site over time existed (P=.34). After the intervention, diagnostic yield of CT-identified intracranial injuries increased by 2.3% (95% CI 1.5% to 3.1%).

CONCLUSION: A multicomponent implementation of the Canadian CT Head Rule was associated with a modest reduction in CT use and an increased diagnostic yield of head CTs for adult trauma encounters in community EDs.

B. Physicians Are Not Aware of How Their Utilization of CT Compares to Their Peers'

A study of actual and self-reported utilization demonstrates variability and poor insight

Kadhim-Saleh A, et al. CJEM 2017 Jul 4.

OBJECTIVES: Physician variation in the use of computed tomography (CT) is concerning due to the risks of ionizing radiation, cost, and downstream effects of unnecessary testing. The objectives of this study were to describe variation in CT-ordering rates among emergency physicians (EPs), to measure correlation between perceived and actual CT-ordering rates, to assess attitudes that influence decisions to order imaging tests, and to identify EP attitudes associated with higher CT utilization.

METHODS: This study was a retrospective review of imaging and administrative billing records at two emergency department sites of a tertiary care adult teaching hospital. The study also included a cross-sectional survey of EPs at this hospital. We asked physicians about their perceived ordering behaviour, and what factors influenced their decision to order a CT. We examined correlations between perceived and actual CT-ordering rates. We adjusted ordering rates for shift distribution using a logistic regression model and identified outlier physicians whose ordering rate was significantly lower or higher than expected. We used multivariable regression analysis to determine which survey responses predicted higher CT utilization.

RESULTS: During the study period, 59 EPs saw 45,854 patients, and ordered 6,609 CTs - a mean ordering rate of 14.4% (standard deviation (SD)=4.3%). The ordering rate for individual physicians ranged from 5.9% to 25.9%. Of the 59 EPs, 13 EPs were low-ordering outliers; 12 were high-ordering outliers. Forty-five EPs (76.3%) completed the survey. Mean perceived ordering rate was 12.6%, and was weakly correlated with actual ordering (r=0.19, p=0.21). 42 EPs (93.3%) believed they ordered "about the same" or "fewer" CTs than their peers. Of the 17 EPs in the two highest ordering quintiles, only 3 (18%) knew they were high orderers. In the multivariable analysis, higher ordering was associated with increasing strength of response to the following predictors: medico-legal risk (relative risk [RR]=1.18, 95% CI: 1.03-1.21), risk of contrast (RR=1.14, 95% CI: 1.07-1.22), what colleagues would do (RR=1.09, 95% CI: 0.99-1.19), risk of missing a diagnosis (RR=1.08, 95% CI: 0.98-1.21), and patient wishes (RR=1.07, 95% CI: 0.97-1.17).

CONCLUSIONS: There is large variation in CT ordering among EPs. Physicians' self-reported ordering rate correlates poorly with actual ordering. High CT orderers were rarely aware that they ordered more than their colleagues. Higher rates of ordering were observed among physicians who reported increased concern with 1) risk of missing a diagnosis, 2) medico-legal risk, 3) risk of contrast, 4) patient wishes, and 5) what colleagues would do.

9. More on Appendicitis

A. Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children.

Serres SK, et al. JAMA Pediatr. 2017 Aug 1;171(8):740-746.

IMPORTANCE: Management of appendicitis as an urgent rather than emergency procedure has become an increasingly common practice in children. Controversy remains as to whether this practice is associated with increased risk of complicated appendicitis and adverse events.

OBJECTIVE: To examine the association between time to appendectomy (TTA) and risk of complicated appendicitis and postoperative complications.

DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study using the Pediatric National Surgical Quality Improvement Program appendectomy pilot database, 2429 children younger than 18 years who underwent appendectomy within 24 hours of presentation at 23 children's hospitals from January 1, 2013, through December 31, 2014, were studied.

EXPOSURES: The main exposure was TTA, defined as the time from emergency department presentation to appendectomy. Patients were further categorized into early and late TTA groups based on whether their TTA was shorter or longer than their hospital's median TTA. Exposures were defined in this manner to compare rates of complicated appendicitis within a time frame sensitive to each hospital's existing infrastructure and diagnostic practices.

MAIN OUTCOMES AND MEASURES: The primary outcome was complicated appendicitis documented at operation. The association between treatment delay and complicated appendicitis was examined across all hospitals by using TTA as a continuous variable and at the level of individual hospitals by using TTA as a categorical variable comparing outcomes between late and early TTA groups. Secondary outcomes included length of stay (LOS) and postoperative complications (incisional and organ space infections, percutaneous drainage procedures, unplanned reoperation, and hospital revisits).

RESULTS: Of the 6767 patients who met the inclusion criteria, 2429 were included in the analysis (median age, 10 years; interquartile range, 8-13 years; 1467 [60.4%] male). Median hospital TTA was 7.4 hours (range, 5.0-19.2 hours), and 574 patients (23.6%) were diagnosed with complicated appendicitis (range, 5.2%-51.1% across hospitals). In multivariable analyses, increasing TTA was not associated with risk of complicated appendicitis (odds ratio per 1-hour increase in TTA, 0.99; 95% CI, 0.97-1.02). The odds ratios of complicated appendicitis for late vs early TTA across hospitals ranged from 0.39 to 9.63, and only 1 of the 23 hospitals had a statistically significant increase in their late TTA group (odds ratio, 9.63; 95% CI, 1.08-86.17; P = .03). Increasing TTA was associated with longer LOS (increase in mean LOS for each additional hour of TTA, 0.06 days; 95% CI, 0.03-0.08 days; P  less than  .001) but was not associated with increased risk of any of the other secondary outcomes.

CONCLUSIONS AND RELEVANCE: Delay of appendectomy within 24 hours of presentation was not associated with increased risk of complicated appendicitis or adverse outcomes. These results support the premise that appendectomy can be safely performed as an urgent rather than emergency procedure.

B. Outcomes of Nonoperative Management of Uncomplicated Appendicitis

Bachur RG, et al. Pediatr. 2017;140(1): e20170048.

BACKGROUND AND OBJECTIVES: Nonoperative management (NOM) of uncomplicated pediatric abstract appendicitis has promise but remains poorly studied. NOM may lead to an increase in
resource utilization. Our objective was to investigate the trends in NOM for uncomplicated appendicitis and study the relevant clinical outcomes including subsequent appendectomy, complications, and resource utilization.

METHODS: Retrospective analysis of administrative data from 45 US pediatric hospitals.
Patients less than 19 years of age presenting to the emergency department (ED) with appendicitis between 2010 and 2016 were studied. NOM was defined by an ED visit for uncomplicated appendicitis treated with antibiotics and the absence of appendectomy at the index encounter. The main outcomes included trends in NOM among children with uncomplicated appendicitis and frequency of subsequent diagnostic imaging, ED visits, hospitalizations, and appendectomy during 12-month follow-up.

RESULTS: 99 001 children with appendicitis were identified, with a median age of 10.9 years.
Sixty-six percent were diagnosed with nonperforated appendicitis, of which 4190 (6%) were managed nonoperatively. An increasing number of nonoperative cases were observed over
6 years (absolute difference, +20.4%). During the 12-month follow-up period, NOM patients were more likely to have the following: advanced imaging (+8.9% [95% confidence interval
(CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to 13.2%]), and hospitalizations
(+43.7% [95% CI 41.7% to 45.8%]). Among patients managed nonoperatively, 46% had a subsequent appendectomy.

CONCLUSIONS: A significant increase in NOM of nonperforated appendicitis was observed over
6 years. Patients with NOM had more subsequent ED visits and hospitalizations compared with those managed operatively at the index visit. A substantial proportion of patients initially managed nonoperatively eventually had an appendectomy.

C. The Threat of Diagnostic Uncertainty in the Medical Management of Uncomplicated Appendicitis.

Bachur RG, et al. JAMA Pediatr. 2017 Jun 1;171(6):505-506.

Appendicitis is the most common acute surgical condition, with a lifetime risk of 8%. Over the last 2 decades, there have been significant improvements in the diagnosis and surgical management, which has led to fewer negative appendectomies, shorter hospitalizations, and faster recoveries.1 The prospect of nonoperative management has been proposed as the next major advance in appendicitis care, which shows promise but also brings challenges….

The concept of medical management of uncomplicated appendicitis is attractive, and some of the early studies among adults and children have shown 58% to 75% 1-year cure rates and, importantly, no increase in complications when antibiotics fail.2- 4 Recent studies have provided insight into which patients may be amenable to nonoperative management; those with a more advanced disease, evidence of perforation, or an appendicolith appear to be at higher risk for early failure. Accordingly, recent pediatric comparative trials have only considered nonoperative management if the patient’s symptoms were fewer than 48 hours along with the absence of the following findings: signs of peritonitis by examination, perforation by imaging studies, or significant fever or leukocytosis. Through the patient-centered lens, nonoperative care may be enticing, even with the potential of treatment failure. Furthermore, it provides an opportunity for parents (and patients) to engage in shared decision making in choosing a treatment plan.

The Existing Evidence
Along with the reasonable success rates of nonoperative care, there may be consequences with the loss of diagnostic feedback to clinicians based on definitive pathology reviews. We have concerns over the diagnostic uncertainty associated with medical management and how this uncertainty may result in a drift toward the overdiagnosis and overtreatment of presumed appendicitis. We believe that this may occur through 3 related mechanisms: (1) increasing reliance on ultrasonography as the primary diagnostic imaging modality, (2) transitions toward more liberal interpretations of ultrasonography findings because of the absence of critical feedback from a pathology standard (ie, a higher proportion of positive or borderline-positive study results at the expense of negative or indeterminate study results), and (3) a trend toward a lower threshold for initiating treatment because of the convenience and relatively low morbidity of antibiotic therapy. From the perspective of research integrity and quality assurance, these factors may have important implications on critically evaluating the effectiveness of nonoperative management through comparative effectiveness studies. The intention to measure and better understand these potentially unanticipated effects (if and when they emerge) will be essential to ensure that patients will optimally benefit from this novel treatment approach.
The diagnosis and treatment of suspected appendicitis has evolved considerably over the past few decades. Before widespread diagnostic imaging, negative appendectomy rates were 15% to 20% (and higher among young children); with the rapid increase in computed tomography (CT) use, negative appendectomies were significantly reduced, but increasing concerns over medical radiation led to a shift away from CT and toward ultrasonography as the preferred diagnostic imaging modality. The reported accuracy of an ultrasonography has varied widely across hospitals, and compared with CT, ultrasonography has been associated with a much higher rate of indeterminate and false-positive study results. This is likely because of variation among hospitals in identifying and reporting sonographic findings, which are more subjective and dependent on operator experience as compared with CT.

In the most recent prospective multicenter study of ultrasonography performance, 51% of ultrasounds were found to have indeterminate results.5 When the ultrasonography study is not definitive, current practice demands a decision to obtain further imaging, admit for serial examinations, or proceed with diagnostic laparoscopy. As medical management becomes increasingly applied at institutions that primarily use ultrasonography, the final diagnosis will be uncertain: there will be no pathologic diagnosis to provide a “check and balance” against trends in overreading by well-meaning radiologists or acting on such reads by equally well-meaning pediatric surgeons. Without such feedback, we anticipate a shift away from conservative toward more liberal reads, with a relative increase in the proportion of studies interpreted as having borderline or positive results at the expense of indeterminate and negative results.

A parallel drift toward the overtreatment of patients with equivocal or borderline ultrasonography results is also possible, as the threshold for initiating treatment is likely to be lower for antibiotics compared with an operative exploration, especially when considering the consequences of a “wrong” treatment decision. The sum effect is that early appendicitis may become an increasingly more common diagnosis with a reduced threshold for initiating treatment unless a novel biomarker or other diagnostic imaging modality (other than CT) emerges with an improved diagnostic certainty to keep such “drift” in check. Regarding the latter, magnetic resonance imaging holds promise but has limited use because of availability and cost considerations.6 The potential effect on antibiotic stewardship by such practices is another important consideration, especially given that appendicitis currently ranks fourth among all pediatric conditions with respect to relative antibiotic use.7
It is important to emphasize that the intent of this Viewpoint is not to challenge the promise of nonoperative therapy as an important advancement in the management of appendicitis. On the contrary, ongoing efforts should be well supported to inform a disciplined diagnostic approach, standardize treatment strategies, and further characterize outcomes associated with this approach. However, we must also be vigilant in identifying unanticipated consequences of nonoperative management, as well as challenges posed by such consequences in tracking and comparing relevant outcomes for the purpose of research and quality assurance. Regarding the latter, future comparative effectiveness studies must be transparent in their reporting of the diagnostic approaches used for both operative and nonoperative treatment arms. This must include not only the relative distribution of diagnostic imaging studies used among each comparison group, but also the relative frequency (and predictive value) of specific ultrasonographic findings when ultrasonography is used as the definitive imaging modality. Finally, as medical management of suspected appendicitis is increasingly implemented, newer quality metrics will be needed to monitor the blurring of the diagnosis, prevent the overuse of antibiotics, preserve the restricted use of CT, and balance the cost of an appendectomy against the ongoing care required for many patients with medically managed appendicitis.

10. Images in Clinical Practice

Crusted Scabies

Xanthomas in Familial Hypercholesterolemia


Nystagmus from Wernicke’s Encephalopathy

Severe Plantar Warts in an Immunocompromised Patient

Bronchoscopic Removal of an Obstructing Broncholith

Coronary-Artery Vasospasm

Elderly Female With Elbow Pain

Young Girl With Swollen Wrists and Ankles

Young Male With Severe Ankle Pain

Woman with right upper quadrant pain

11. Does the Intranasal Route Pass the Sniff Test?

Joshi N, et al. Ann Emerg Med. 2017 Aug;70(2):212-214.

Medication Route Options
Physicians and scientists have developed creative and varied routes of medication administration to patients. Some of the many options include intravenous, intramuscular, intrathecal, intraosseous, per os, subcutaneous, intravaginal, and per rectum routes. The intravenous route is further divided into peripheral and central and use, depending on the clinical situation. For example, line infiltration of specific drugs can lead to necrosis; thus, these drugs should be given only through central access. Another intravenous access, the umbilical line, is available only at certain times, typically only within the first week of life.1 The latest up-and-comer is the intranasal route, which has increased application in many different clinical scenarios and is potentially underused in many emergency departments (EDs). But does it pass the sniff test?

How do we choose the ideal route for each medication and each patient? There are so many factors to consider that we may not even consciously acknowledge the many decision points in choosing a route. Different routes vary in bioavailability and time of onset of drug effect. Some routes are more operator dependent and some take longer to obtain. Some routes cause more discomfort, are more invasive, or can put patients at risk for adverse events. Certain drugs can be administered to target specific body parts and limit systemic absorption and adverse effects, such as the intrathecal route or nebulized medications. In a pinch, the intraosseous route can be lifesaving for many resuscitation medications, but taking a drill to a patient’s bone is less palatable to the general public for obvious reasons. Although the per os route clearly uses the fewest resources and has minimal patient discomfort, the bioavailability is delayed and patients who cannot protect their airway are clearly not candidates. We rely on the intramuscular route when per os is less effective but intravenous placement is unnecessary. In the ED, the careful, longer process of obtaining intravenous access is much less preferable for agitated patients because a great benefit is placed on decreasing time during which a provider wields a sharp object in a small tornado of chaos.

Anecdotally, the intranasal route is frequently discussed in the literature and used in pediatrics, but less often for adults, despite their having the same pain receptors and perhaps a more matured and refined fear of needles. Considering that the intranasal route is well tolerated, easy to administer, and effective, perhaps it should be more frequently used for adult patients. Aren’t they just big kids anyway?

Why Intranasal?
The purpose of this review is to reflect specifically on the intranasal route as described as well in the recent publication by Rech et al.2 Let's (nose) dive right into it!

The benefits of intranasal administration are clear: absorption is independent of body habitus, hydration, or nutrition. There is no need for painful and potentially dangerous needles, and a minimal level of technical skill is needed to administer medications.

Intranasal medications vary from pain control (fentanyl), to sedation (eg, midazolam, dexmedetomidine), to opioid overdose reversal (naloxone), to seizure cessation (midazolam). A free Web site called Intranasal.net3 is a helpful resource to learn more about intranasal medication administration and to review available references supporting its use.

Here are 3 general pharmacokinetic or pharmacodynamic principles that explain why intranasal administration is effective. First, the nose contains a full vascular plexus that provides a straight path into the bloodstream. Small-molecule, nonionized, lipid-soluble drugs can cross mucous membranes more easily and work better for intranasal administration. Second, most orally administered medications undergo first-pass metabolism before reaching their target within the body. Intranasal administration, on the other hand, bypasses this first-pass effect, which can produce higher drug concentrations (bioavailability) faster. So intranasal administration might be the best route in emergency settings such as seizure, trauma, agitation, or severe pain. Similarly, drugs that must undergo first-pass metabolism for activation would not be ideal candidates for intranasal administration. Third, as you will remember from your rigorous medical school anatomy training, the nose is geographically close to the brain. Therefore, absorption across the nasal mucosa produces cerebrospinal fluid drug concentrations that in some studies exceeded plasma concentrations. This is particularly useful in centrally acting drugs such as antiepileptics. There is also some evidence that some drugs administered intranasally are directly transported to the brain.4, 5, 6

For intranasal administration, a potential drawback is that only 1 mL can be maximally absorbed per naris, with ideal volume less than 0.5 mL. Therefore, depending on the medication, higher concentrations may be needed than are normally stocked in the ED or by emergency medical services (EMS). For example, the midazolam used for intravenous or intramuscular administration is commonly a solution of 1 mg/mL, but for intranasal administration, the 5 mg/mL concentration is preferred. Stocking more than one concentration in the ED can increase the risk for medication errors. When intranasal protocols or guidelines are created, it is important to consider how and where different concentrations will be stocked and how staff will be trained to minimize the risk of error.

Here are 4 important concepts to consider with intranasal administration7, 8: minimize barriers to absorption and ensure that the nasal mucosa is available and free of secretions and blood, minimize the volume and maximize drug concentration to stay below the 1-mL volume limitation, take advantage of maximal absorption by using both nostrils, and use a delivery system that maximizes drug dispersion.

What Is an Atomizer?
Next, to highlight real-life application, let's discuss how to administer intranasal medications and options for delivery systems…

12. Clinical Mimics: An EM-Focused Review of Asthma Mimics.

Kann K, et al., J Emerg Med. 2017;53(2):195-201.

BACKGROUND: Asthma is a common diagnosis or preexisting condition, and many patients with acute asthma exacerbation may present to the emergency department with wheezing and respiratory distress. However, many conditions may mimic this presentation.

OBJECTIVES: This review provides an overview of common asthma mimics and an approach to evaluation and management.

DISCUSSION: Asthma is characterized by an obstructive pulmonary disease with recurrent exacerbations. The disease may present with a variety of symptoms, including wheezing, chest tightness, shortness of breath, and even respiratory failure. Mimics include anaphylaxis, angioedema, central airway obstruction, heart failure, allergic reaction, foreign body aspiration, pulmonary embolism, and vocal cord dysfunction. The approach to evaluation and management of these patients includes assessment for life-threatening conditions while treatment and resuscitation is underway. Providers should assess for red flags, including no history of asthma, lack of severe asthma, and no improvement with standard treatments. Focused assessment with history, physical examination, chest imaging, electrocardiogram, and laboratory studies may provide benefit. Through consideration of these mimics and treatment, providers can provide rapid management.

CONCLUSIONS: While asthma is a common disease, many asthma mimics exist. Through consideration of other diseases with wheezing and assessing for red flags, such as patients presenting without a history of asthma or patients with a history of only mild asthma presenting with severe symptoms, emergency providers may decrease the chance of early diagnostic closure and anchoring while improving the care of these patients.

13. IV Lidocaine Beats IV Morphine for Pts with Renal Colic in the ED

Blast from the Past: Something Worth Repeating; from our Jan 13, 2013 Issue of Lit Bits

Soleimanpour H, et al. BMC Urol. 2012;12(13)

Affecting 1–5 % of the population in industrialized countries, renal colic is considered as a major concern in medicine. Renal colic has been reported to be experienced by 20 % of white males and 5-10 % of white females. [1] The classic presentation of acute renal colic includes sudden pain onset radiating from the flank to the lower extremities which is usually accompanied by microscopic hematuria (85 % of cases), nausea and vomiting. Costovertebral angle tenderness is a common finding as well. [2]

To relieve the pain until being discharged or undergoing the required operation is mostly performed in emergency departments. [1] To achieve this, numerous medications including antiemetics, narcotics, non-steroidal anti-inflammatory drugs, antispasmodics, anti-diuretics, ketorolac, nifedipine, prednisone, acetaminophen and prochlorperazine have been introduces. [2]

Lidocaine, being an appropriate choice in treating visceral and central pain, might also be useful wherever narcotics are inefficient or lead to undesirable side effects. Intravenous lidocaine is effective in controlling neuropathic pains such as: diabetic neuropathy, post-operative pain, post-herpetic pain, headaches and neurological malignancies. [3,4] Therefore we aimed at investigating and reviewing the analgesic effects of intravenous lidocaine compared with intravenous morphine in patients with renal colic.

Background: Despite the fact that numerous medications have been introduced to treat renal colic, none has been proven to relieve the pain rapidly and thoroughly. In this study, we aimed at comparing the effects of intravenous lidocaine versus intravenous morphine in patients suffering from renal colic.

Methods: In a prospective randomized double-blind clinical trial performed in the emergency department of Imam Reza educational hospital of Tabriz, Iran, we studied 240 patients, 18–65 years old, who were referred due to renal colic. Patients were divided into two groups. In group I (120 people) single-dose intravenous lidocaine (1.5 mg/kg) was administered and in group II (120 people) single-dose intravenous morphine (0.1 mg/kg) was administered slowly. Visual Analogue Pain Scale (VAS) was recorded while admission, 5, 10, 15 and 30 minutes after injection. Statistical data and results were studied using descriptive statistics as percentage and Mean ± SD. To compare the response to treatment, Mann–Whitney U-test was used in two groups. Consequently, the data were analyzed using the SPSS16 software.

Results Pain score measured in two groups five minutes after the injection of lidocaine and morphine were 65 % and 53 % respectively (95% CI 0.60 - 0.69, CI 0.48 – 0.57, p = 0.0002).108 (90 %) patients (95 % CI 0.84 – 0.95) from group I and 84 (70%) patients (95 % CI 0.62 - 0.78) from group II responded appropriately at the end of the complete treatment. The difference was statistically significant (p = 0.0001).

Conclusions Changing the smooth muscle tone and reducing the transmission of afferent sensory pathways, lidocaine causes a significant reduction in pain.

14. C-spine evaluation and clearance in the intoxicated pt: a prospective western trauma association multi-institutional trial and survey.

In intoxicated pts, if the CT of the C spine is negative, believe it. You’re done.

Martin MJ, et al. J Trauma Acute Care Surg. 2017 Jul 19 [Epub ahead of print]

INTRODUCTION: Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal CT scan. We evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice.

METHODS: A prospective multicenter study (2013-2015) at 17 centers. All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT, with follow-up thru discharge. EtOH and drug intoxicated patients (TOX+) were identified by serum and/or urine testing. Primary outcomes included the incidence and type of Csp injuries, the accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A 36-item survey querying local protocols, practices, and opinions in the TOX+ population was administered.

RESULTS: 10,191 patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were male (67%), vehicular trauma or falls (83%), with mean age=48, and mean ISS=11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 vs 51, p less than 0.01) but with similar mean ISS (11) and GCS (13). The TOX+ cohort had a lower incidence of Csp injury vs non-intoxicated (8.4 vs 11.5%, p less than 0.01). In the TOX+ group, CT had a sens=94%, spec=99.5%, and NPV=99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV=100%). When CT Csp was negative, TOX+ led to longer immobilization vs sober patients (mean 8 hrs vs 2 hrs, p less than 0.01), and prolonged immobilization (over 12hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on this data.

CONCLUSIONS: For intoxicated patients undergoing Csp imaging, CT scan was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization. There was wide disparity in practices, definitions, and opinions among the participating centers.

15. Medication Corner

A. Reminder: Steroids are Helpful for Sick Pts with Pneumonia

Wu WF, et al. Efficacy of corticosteroid treatment for severe community-acquired pneumonia: A meta-analysis. Am J Emerg Med. 2017 Jul 15 [Epub ahead of print]

BACKGROUND: The benefits and adverse effects of corticosteroids in the treatment of severe community-acquired pneumonia (CAP) have not been well assessed. The aim of this systematic review of the literature and meta-analysis was to evaluate the clinical efficacy of adjuvant corticosteroid therapy in patients with severe CAP.

METHODS: The following databases were searched: PubMed, the Cochrane database, Embase, Wanfang, the China National Knowledge Infrastructure (CNKI), and the WeiPu (VIP) database in Chinese. Published randomized controlled clinical trial results were identified that compared corticosteroid therapy with conventional therapy for patients with severe CAP, up to November 2016. The relative risk (RR), weighted mean difference (WMD), and 95% confidence interval (CI) were evaluated. Statistical analysis was performed using STATA 10.0. The quality of the published studies was evaluated using the Oxford quality scoring system (Jadad scale).

RESULTS: Ten randomized controlled trials (RCTs) were identified that included 729 patients with severe CAP. Data analysis showed that corticosteroid therapy did not have a statistically significant clinical effect in patients with severe CAP (RR: 1.19; 95% CI: 0.99-1.42), mechanical ventilation time (WMD: -2.30; 95% CI: -6.09-1.49). However, corticosteroids treatment was significantly associated with reduced in-hospital mortality (RR: 0.49; 95% CI: 0.29-0.85), reduced length of hospital stay (WMD: -4.21; 95% CI: -6.61 to -1.81).

CONCLUSION: Corticosteroids adjuvant therapy in patients with severe CAP may reduce the rate of in-hospital mortality, reduce the length of hospital stay, and reduce CRP levels.

B. Clinical Review: Loperamide Toxicity

Wu PE, et al, Ann Emerg Med. 2017;70:245-52.

Loperamide is a nonprescription opioid widely used for the treatment of diarrhea. Although it is relatively safe at therapeutic doses, increasing reports describe its misuse and abuse at very high doses either for euphoric effects or to attenuate symptoms of opioid withdrawal. Life-threatening loperamide toxicity can result from the relatively new clinical syndrome of loperamide-induced cardiac toxicity. These patients are often young and may present in cardiac arrest or with unheralded, recurrent syncope in conjunction with ECG abnormalities, including marked QT-interval prolongation, QRS-interval widening, and ventricular dysrhythmias. Features of conventional opioid toxicity may also be present. The mainstays of treatment include advanced cardiac life support and supportive care, although selected patients may be candidates for overdrive pacing, intravenous lipid emulsion, or extracorporeal membrane oxygenation. In patients who survive loperamide toxicity, consideration should be given to the treatment of an underlying opioid use disorder, if present.

C. FDA Puts the Kibosh on Fluoroquinolones – So Should You

The latest “black box” warning focuses on an array of neurological problems associated with these antibiotics.

By Richard Bukata, MD. EP Monthly. July 17, 2017

Bottom line – Don’t prescribe fluoroquinolones unless they are absolutely needed and there are no good alternatives (and there usually are at least a few). It will be very difficult to defend your practice if a patient is seriously harmed, as there was an FDA Black Box about the side effect caused, and there were other alternatives. It is surprising that more hospitals haven’t responded to this new Black Box despite the medicolegal risks they may incur by not warning their medical staffs about the use of these drugs. Compare the response to the current fluoroquinolone Black Box with the exaggerated response to the Black Box on droperidol regarding arrhythmias. Most hospitals quickly made droperidol unavailable while nothing similar has occurred regarding the quinolones.

Quinolones: review of psychiatric and neurological adverse reactions:

FDA warning: “Because the risk of these serious side effects generally outweighs the benefits for patients with acute bacterial sinusitis, acute exacerbation of chronic bronchitis and uncomplicated urinary tract infections, the FDA has determined that fluoroquinolones should be reserved for use in patients with these conditions who have no alternative treatment options. For some serious bacterial infections, including anthrax, plague and bacterial pneumonia among others, the benefits of fluoroquinolones outweigh the risks and it is appropriate for them to remain available as a therapeutic option.”

D. Cannabis for Medical Purposes?

D1. The Effects of Cannabis Among Adults with Chronic Pain and an Overview of General Harms: A Systematic Review

Nugent SM, et al. Ann Intern Med 2017 Aug 15 [Epub ahead of print].

Background: Cannabis is increasingly available for the treatment of chronic pain, yet its efficacy remains uncertain.

Purpose: To review the benefits of plant-based cannabis preparations for treating chronic pain in adults and the harms of cannabis use in chronic pain and general adult populations.

Data Sources: MEDLINE, Cochrane Database of Systematic Reviews, and several other sources from database inception to March 2017.

Selection: Intervention trials and observational studies, published in English, involving adults using plant-based cannabis preparations that reported pain, quality of life, or adverse effect outcomes.

Data Extraction: Two investigators independently abstracted study characteristics and assessed study quality, and the investigator group graded the overall strength of evidence using standard criteria.

Data Synthesis: From 27 chronic pain trials, there is low-strength evidence that cannabis alleviates neuropathic pain but insufficient evidence in other pain populations. According to 11 systematic reviews and 32 primary studies, harms in general population studies include increased risk for motor vehicle accidents, psychotic symptoms, and short-term cognitive impairment. Although adverse pulmonary effects were not seen in younger populations, evidence on most other long-term physical harms, in heavy or long-term cannabis users, or in older populations is insufficient.

Limitation: Few methodologically rigorous trials; the cannabis formulations studied may not reflect commercially available products; and limited applicability to older, chronically ill populations and patients who use cannabis heavily.

Conclusion: Limited evidence suggests that cannabis may alleviate neuropathic pain in some patients, but insufficient evidence exists for other types of chronic pain. Among general populations, limited evidence suggests that cannabis is associated with an increased risk for adverse mental health effects.

D2. Benefits and Harms of Plant-Based Cannabis for Posttraumatic Stress Disorder: A Systematic Review

O’Neil ME, et al. Ann Intern Med, 2017 Aug 15 [Epub ahead of print].

Conclusion: Evidence is insufficient to draw conclusions about the benefits and harms of plant-based cannabis preparations in patients with PTSD, but several ongoing studies may soon provide important results.

16. Predatory Journals Hit By ‘Star Wars’ Sting

By Neuroskeptic | July 22, 2017

A number of so-called scientific journals have accepted a Star Wars-themed spoof paper. The manuscript is an absurd mess of factual errors, plagiarism and movie quotes. I know because I wrote it.

Inspired by previous publishing “stings”, I wanted to test whether ‘predatory‘ journals would publish an obviously absurd paper. So I created a spoof manuscript about “midi-chlorians” – the fictional entities which live inside cells and give Jedi their powers in Star Wars. I filled it with other references to the galaxy far, far away, and submitted it to nine journals under the names of Dr Lucas McGeorge and Dr Annette Kin.

Four journals fell for the sting. The American Journal of Medical and Biological Research (SciEP) accepted the paper, but asked for a $360 fee, which I didn’t pay. Amazingly, three other journals not only accepted but actually published the spoof. Here’s the paper from the International Journal of Molecular Biology: Open Access (MedCrave), Austin Journal of Pharmacology and Therapeutics (Austin) and American Research Journal of Biosciences (ARJ) I hadn’t expected this, as all those journals charge publication fees, but I never paid them a penny.

All of the above journals have now deleted the paper, so I’ve made it available on Scribd.

So what did they publish? A travesty, which they should have rejected within about 5 minutes – or 2 minutes if the reviewer was familiar with Star Wars. Some highlights:

“Beyond supplying cellular energy, midichloria perform functions such as Force sensitivity…”

“Involved in ATP production is the citric acid cycle, also referred to as the Kyloren cycle after its discoverer”

“Midi-chlorians are microscopic life-forms that reside in all living cells – without the midi-chlorians, life couldn’t exist, and we’d have no knowledge of the force. Midichlorial disorders often erupt as brain diseases, such as autism.”

Ironically, I’m not even a big Star Wars fan. I just like the memes.

To generate the main text of the paper, I copied the Wikipedia page on ‘mitochondrion’ (which, unlike midichlorians, exist) and then did a simple find/replace to turn mitochondr* into midichlor*. I then Rogeted the text, i.e. I reworded it (badly), because the main focus of the sting was on whether journals would publish a ridiculous paper, not whether they used a plagiarism detector (although Rogeting is still plagiarism in my book.)

For transparency, I admitted what I’d done in the paper itself. The Methods section features the line “The majority of the text of this paper was Rogeted [7]”. Reference 7 cited an article on Rogeting followed by “The majority of the text in the current paper was Rogeted from Wikipedia: Apologies to the original authors of that page.”

Credit where credit’s due, a number of journals rejected the paper: Journal of Translational Science (OAText); Advances in Medicine (Hindawi); Biochemistry & Physiology: Open Access (OMICS).

Two journals requested me to revise and resubmit the manuscript. At JSM Biochemistry and Molecular Biology (JSciMedCentral) both of the two peer reviewers spotted and seemingly enjoyed the Star Wars spoof, with one commenting that “The authors have neglected to add the following references: Lucas et al., 1977, Palpatine et al., 1980, and Calrissian et al., 1983”. Despite this, the journal asked me to revise and resubmit.

At the Journal of Molecular Biology and Techniques (Elyns Group), the two peer reviewers didn’t seem to get the joke, but recommended some changes such as reverting “midichlorians” back to “mitochondria.”

Finally, I should note that as a bonus, “Dr Lucas McGeorge” was sent an unsolicited invitation to serve on the editorial board of this journal.

So does this sting prove that scientific publishing is hopelessly broken? No, not really. It’s just a reminder that at some “peer reviewed” journals, there really is no meaningful peer review at all. Which we already knew, not least from previous stings, but it bears repeating.
This matters because scientific publishers are companies selling a product, and the product is peer review. True, they also publish papers (electronically in the case of these journals), but if you just wanted to publish something electronically, you could do that yourself for free. Preprint archives, blogs, your own website – it’s easy to get something on the internet. Peer review is what supposedly justifies the price of publishing.

All of the nine publishers I stung are known to send spam to academics, urging them to submit papers to their journals. I’ve personally been spammed by almost all of them. All I did, as Lucas McGeorge, was test the quality of the products being advertised.

More from the Neuroskeptic at Discover:

17. Push-Dose Pressors

A. Safety considerations and guideline-based safe use recommendations for “bolus- dose” vasopressors in the ED.

Holden D, et al. Ann Emerg Med. 2017 June 7 [Epub ahead of print]

The use of intermittently administered doses of vasopressors to correct hypotension in the emergency department (ED), commonly referred to as bolus-dose pressors, push-dose pressors, Neo-sticks, or phenyl sticks, has been widely advocated outside of the traditional printed medical literature. No outcomes data of this practice exist to demonstrate benefits over traditional continuous infusion of vasopressors. Use of bolus-dose vasopressors in the ED setting raises a number of patient safety concerns, and misuse and errors in the preparation and administration of bolus-dose vasopressors may result in patient harm. A systems-based approach should be implemented to maximize safety and patient benefits if bolus-dose vasopressors are used. This article discusses the wide range of issues to consider when evaluating the role of bolus-dose vasopressors in the ED and provides recommendations based on current safe medication practices guidelines.

B. Scott Weingart Weighs In.

EMCrit Podcast. August 7, 2017

Today, an update on Push-Dose Pressors. I coined the name Push-Dose Pressors (PDPs) way back on episode 6. The idea was not new, anesthesiologists and resus docs have been using bolus-dose vasopressors for decades. I just thought the name was dumb, these are not boluses in the way I have always thought of them (a brief iv drip). I also thought it was crazy that the concept had not really penetrated very far into emergency medicine and the ICU–at least in the States. My prehospital doc friends told me it was common in their world. Since the podcast, I have received 100s of emails describing the use of PDPs to lifesaving effect (or at least code-preventing), but there has been scant published literature on this technique in EM. Recently that has all changed.

C. Brief Lit Review

Weingart S. Push-dose pressors for immediate BP control. Clin Exp Emerg Med. 2015 Jun 30;2(2):131-132.

Acquisto NM, et al. Medication errors with push dose pressors in the ED and ICUs. Am J Emerg Med 2017 July 7 [Epub ahead of print].

Holden D, et al. Safety Considerations and Guideline-Based Safe Use Recommendations for "Bolus-Dose" Vasopressors in the ED. Ann Emerg Med. 2017 Jun 7 [Epub ahead of print].

Gottlieb M. Bolus dose of epinephrine for refractory post-arrest hypotension. CJEM. 2017 Jan 10:1-5 [Epub ahead of print].

Bolus-Dose Vasopressors in the ED: First, Do No Harm; Second, More Evidence Is Needed

18. Psychology Corner

A. Facial Features Predict Rise to Leadership 

Looking Leadership in the Face. Association of Psychological Science

Is there such a thing as simply looking like a leader? A large body of research suggests yes.
In a recent article published in Current Directions in Psychological Science, John Antonakis (University of Lausanne) and Dawn L. Eubanks (University of Warwick) provide an overview of several studies suggesting that getting to the top of the corporate ladder may depend, at least in part, on the structure of a person’s face.

“Given what we know about the predictors of leaders’ ability, facial appearance should play a small or a very limited role in observers’ selection of leaders; however, research convincingly shows otherwise,” Antonakis and Eubanks write.

When judging candidates for a leadership position, selectors need accurate information on the competence and trustworthiness of the individuals concerned, the researchers explain. Ideally, company board members choosing a CEO or voters choosing a politician will rely on accurate cues of these characteristics to make their decisions. But do they?

“Research has shown that facial appearance matters considerably for leader selection,” Antonakis and Eubanks explain. “In literally milliseconds, observers use slivers of information to make inferences about a target’s character.”

When we don’t have much information to go on about a person’s ability or trustworthiness, we may have to rely on anything we can use, including looks, to make inferences about a leader’s abilities.

A number of experiments have shown that people can pick the winner of an election at rates better than chance, just by comparing a couple of photos. For example, in a 2009 experiment by Antonakis and Olaf Dalgas, 681 Swiss children were shown the faces of politicians from French parliamentary runoff elections. The black and white photos paired 57 political rivals running against each other (matched so that both individuals were the same sex and race). The children were asked to pick the more competent individual. The average probability of a child correctly choosing the winner of the runoff was a stunning 71%.

“The results were fascinating because child participants’ choices of political candidates—in this case, in a poorly publicized election in another country—were indistinguishable from those of adult participants who rated the targets on competence, intelligence, and leadership ability,” the researchers write. “That children with little experience evaluating leaders do so in ways similar to adults suggests that it is not experiential learning driving these results but something else.”

In business settings, research has found that individuals with faces that are perceived as looking more powerful or competent are more likely to be selected for leadership positions. Studies have also found that people are unexpectedly good at identifying a person’s profession based on nothing more than a cropped photo.

B. A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making

Dehon E, et al. Acad Emerg Med. 2017 Aug;24(8):895-904.

OBJECTIVES: Disparities in diagnosis and treatment of racial minorities exist in the emergency department (ED). A better understanding of how physician implicit (unconscious) bias contributes to these disparities may help identify ways to eliminate such racial disparities. The objective of this systematic review was to examine and summarize the evidence on the association between physician implicit racial bias and clinical decision making.

METHODS: Based on PRISMA guidelines, a structured electronic literature search of PubMed, CINAHL, Scopus, and PsycINFO databases was conducted. Eligible studies were those that: 1) included physicians, 2) included the Implicit Association Test as a measure of implicit bias, 3) included an assessment of physician clinical decision making, and 4) were published in peer-reviewed journals between 1998 and 2016. Articles were reviewed for inclusion by two independent investigators. Data extraction was performed by one investigator and checked for accuracy by a second investigator. Two investigators independently scored the quality of articles using a modified version of the Downs and Black checklist.

RESULTS: Of the 1,154 unique articles identified in the initial search, nine studies (n = 1,910) met inclusion criteria. Three of the nine studies involved emergency providers including residents, attending physicians, and advanced practice providers. The majority of studies used clinical vignettes to examine clinical decision making. Studies that included emergency medicine (EM) providers had vignettes relating to treatment of acute myocardial infarction, pain, and pediatric asthma. An implicit preference favoring white people was common across providers, regardless of specialty. Two of the nine studies found evidence of a relationship between implicit bias and clinical decision making; one of these studies included EM providers. This one study found that EM and internal medicine residents who demonstrated an implicit preference for white individuals were more likely to treat white patients and not black patients with thrombolysis for myocardial infarction. Evidence from the two studies reporting a relationship between physician implicit racial bias and decision making was low in quality.

CONCLUSIONS: The current literature indicates that although many physicians, regardless of specialty, demonstrate an implicit preference for white people, this bias does not appear to impact their clinical decision making. Further studies on the impact of implicit racial bias on racial disparities in ED treatment are needed.

19. Predictive Utility of the Total GCS Versus the Motor Component of the GCS for Identification of Pts with Serious Traumatic Injuries.

Chou R1, et al. Ann Emerg Med. 2017 Aug;70(2):143-157.e6.

STUDY OBJECTIVE: The motor component of the Glasgow Coma Scale (mGCS) has been proposed as an easier-to-use alternative to the total GCS (tGCS) for field assessment of trauma patients by emergency medical services. We perform a systematic review and meta-analysis to compare the predictive utility of the tGCS versus the mGCS or Simplified Motor Scale in field triage of trauma for identifying patients with adverse outcomes (inhospital mortality or severe brain injury) or who underwent procedures (neurosurgical intervention or emergency intubation) indicating need for high-level trauma care.

METHODS: Ovid MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Health and Psychosocial Instruments, and the Cochrane databases were searched through June 2016 for English-language cohort studies. We included studies that compared the area under the receiver operating characteristic curve (AUROC) of the tGCS versus the mGCS or Simplified Motor Scale assessed in the field or shortly after arrival in the emergency department for predicting the outcomes described above. Meta-analyses were performed with a random-effects model, and subgroup and sensitivity analyses were conducted.

RESULTS: We included 18 head-to-head studies of predictive utility (n=1,703,388). For inhospital mortality, the tGCS was associated with slightly greater discrimination than the mGCS (pooled mean difference in [AUROC] 0.015; 95% confidence interval [CI] 0.009 to 0.022; I2=85%; 12 studies) or the Simplified Motor Scale (pooled mean difference in AUROC 0.030; 95% CI 0.024 to 0.036; I2=0%; 5 studies). The tGCS was also associated with greater discrimination than the mGCS or Simplified Motor Scale for nonmortality outcomes (differences in AUROC from 0.03 to 0.05). Findings were robust in subgroup and sensitivity analyses.

CONCLUSION: The tGCS is associated with slightly greater discrimination than the mGCS or Simplified Motor Scale for identifying severe trauma. The small differences in discrimination are likely to be clinically unimportant and could be offset by factors such as convenience and ease of use.

See also “Glasgow Coma Scale Motor Component ("Patient Does Not Follow Commands") Performs Similarly to Total Glasgow Coma Scale in Predicting Severe Injury in Trauma Patients.” Abstract:

See alsoHow to Measure the Glasgow Coma Scale” Green SM et al. Ann Emerg Med 2017;70(2):158-60. Full-text (free):

20. When High Deductibles Hurt: Even Insured Pts Postpone Care

By Pauline Bartolone. California Healthline July 27, 2017

In November 2015, Tina Heck was in her garage lifting 40-pound bags of wood pellets to fuel her heating stove, when something went very wrong with her back.

“The next day, I could barely walk,” said the 55-year-old who lives on an acre of land in Nevada City, Calif., 60 miles northeast of Sacramento. The cause: a bulging disc in her lower spine, which shoots pain down her leg and makes her back stiff.

The injury wasn’t Heck’s only setback. The initial MRI, cortisone shot and doctor visit cost her $3,000 because her health plan requires her to shell out $5,000 before insurer payments kick in. She doesn’t want to explore other treatment options because of that high deductible. Heck, who makes $68,000 a year in marketing for a nonprofit, is not willing to add more debt on top of her credit-card and mortgage payments.

“I’m in pain every day,” she said, but “it’s not bad enough to go into debt.”

The concept behind high-deductible plans was to lower premiums and reduce overall health costs by ensuring that consumers shared the financial burden of their own health care decisions. But evidence is mounting: High deductibles have actually forced people to delay care that could prevent health emergencies later or improve their quality of life.

Regardless of what happens to the Affordable Care Act, such plans are likely to become more widespread as health care costs continue to rise. Just over half of people with health plans from their employers now have a deductible of $1,000 or more, up from 10% in 2006, according to the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

“People who have medical problems that can be put off tend to do so much more now because of the high deductible,” said Dr. Ted Mazer, a San-Diego based head and neck surgeon who is president-elect of the California Medical Association.

Annual deductibles can amount to many thousands of dollars on some plans. Covered California bronze plans, with the lowest premiums available on the exchange, carry deductibles of $6,300 for an individual and $12,600 for a family. A Kaiser Family Foundation survey released this year showed that 43% of insured people reported having trouble paying their deductible, up from 34% in 2015.

In one study by the liberal advocacy group Families USA, more than a quarter of people in high-deductible plans delayed some type of medical service such as a doctor visit or diagnostic test. And 44% of adults with high out-of-pocket expenses put off medical care, according to a nonpartisan Commonwealth Fund study. Another recent study by researchers at the University of California-Berkeley and Harvard University found that people with high-deductible plans spent 42% less on health care before meeting their deductibles, primarily by reducing the amount of health care they received, not by shopping around for a better price.

Jonathan Kolstad, associate professor of economics at UC-Berkeley’s business school and co-author of the study, said patients dropped both needed care, such as diabetes medication, and potentially unnecessary care, such as imaging for headaches. “Left to their own devices, people [in high-deductible plans] seem ill-equipped to make their own decisions” about what care they need, and what care they don’t, Kolstad said.

Mazer said that, in his practice, people have delayed all kinds of treatment that may not save “life or limb” but involved medical conditions that interfered with breathing or sleeping. He said he’s had patients who needed a biopsy to determine if an abnormal vocal cord was cancerous, and they put it off because of the cost.

“I have to make the phone call and say, ‘We’re looking at a mass that may be malignant and if you put it off you’re putting yourself at risk,’ ” Mazer said. “And I’ll tell you, we’ve had people take that risk.”

Recent Republican proposals to repeal Obamacare have promoted the use of high-deductible plans by allowing people to put away more tax-free dollars into the health savings accounts that consumers use in conjunction with those plans. And experts said the proposals would also spur the growth of these plans — by cutting the subsidies available through exchanges, inducing customers to look for cheaper plans with higher deductibles. Conservatives say insurance that promotes personal financial responsibility helps tamp down overall health costs. Hoover Institution analysts, for example, argue that high deductibles encourage patients to “choose wisely.”

But new evidence suggests that putting off care can be dangerous and, eventually, more costly to patients. A March 2017 Harvard study found that low-income patients with diabetes who had high-deductible plans delayed visits for complications such as skin infections and pneumonia. They wound up getting more expensive care later on.

Patients may try to treat their conditions at home, or hope they go away — but if that approach fails, “they then have to seek care at the emergency department,” said Frank Wharam, a health policy researcher at Harvard Medical School and lead author of the study.

Wharam said the middle-income earners he studied didn’t suffer any adverse effects from health care choices they made in high-deductible plans, adding that more studies are needed on that group.

Sabrina Corlette, from the Georgetown University Center on Health Insurance Reforms, said that until national health policy addresses the “underlying costs of care,” patients in high-deductible plans will likely be stuck with the difficult task of figuring out what medical attention they need or can afford.

Heck said the symptoms from her back injury have changed — the pain is in a different part of the body than it was right after the injury. But she’s not even considering a trip to a nearby clinic for a new assessment. That would require another MRI, she said, which could cost at least $1,500, and it might not even help her. If her deductible weren’t as high, she’d feel “freer” to explore other health care options, she said.

For now, she’s taking a lot of ibuprofen and seeing a chiropractor. “A lot of people get stuck in this place,” she said.

21. Micro Bits

A. Your kitchen sponge harbors zillions of microbes. Cleaning it could make things worse

Guglielmi G. Science Mag. Jul. 28, 2017 , 2:01 PM

That sponge in your kitchen sink harbors zillions of microbes, including close relatives of the bacteria that cause pneumonia and meningitis, according to a new study. One of the microbes, Moraxella osloensis, can cause infections in people with a weak immune system and is also known for making laundry stink, possibly explaining your sponge’s funky odor. Researchers made the discovery by sequencing the microbial DNA of 14 used kitchen sponges, they report this month in Scientific Reports. Surprisingly, boiling or microwaving the sponges didn’t kill off these microbes. Indeed, sponges that had been regularly sanitized teemed with a higher percentage of bacteria related to pathogens than sponges that had never been cleaned. This could be because pathogen-related bacteria are more resistant to cleaning and rapidly recolonize the areas abandoned by their susceptible brethren—similar to what happens to our gut after an antibiotic treatment, the scientists say. When the researchers put the sponges under the microscope, they discovered that a single cubic centimeter could be packed with more than 5 x 1010 bacteria, which corresponds to about seven times the number of people inhabiting Earth. Such bacterial densities, the scientists say, are found only in feces. But don’t worry—the solution to a clean sponge is simple: Just replace it every week.

B. The Power of Perception: Just Thinking You're Slacking On Exercise Could Boost Risk Of Death

Angus Chen. NPR. All Things Considered. July 20, 2017.

In a fitness-crazed land of spin classes and CrossFit gyms, Octavia Zahrt found it can be tough to feel as though you're doing enough. "When I was in school in London, I felt really good about my activity. Then I moved to Stanford, and everyone around me seems to be so active and going to the gym every day," she says. "In the San Francisco Bay Area, it's like 75 percent of people walk around here wearing exercise clothes all day, every day, all the time, and just looking really fit."

She wasn't less active than when she lived in London, Zahrt says, but in comparison she began to feel a bit like a slacker. "I felt unhealthy. I was very stressed about fitting in more exercise," she says.

And just feeling less fit in comparison to others might trim away years of life, says Zahrt, a Ph.D. candidate in health psychology at the Stanford University Graduate School of Business. That's the conclusion of a study she co-authored, published Thursday in Health Psychology.

Past studies have suggested that mindsets concerning one's own health can have physiological consequences. In 2007, Stanford psychologist Alia Crum ran a study on hotel attendants. "These women were getting lots of exercise, but when we asked them they didn't have the mindset that their work was good exercise," Crum says.

She gave some of the hotel staff a presentation explaining that their work, which involves heavy lifting and walking, is good exercise, and then tracked them for a month. "The women who started to look at their work as good exercise had improvements in blood pressure and body fat," she says.

Crum and Zahrt collaborated on the new study, which looks at what might happen decades down the line. They analyzed data from two large national health surveys, the National Health Interview Survey and the National Health and Nutrition Examination Survey. Along with a litany of health metrics including activity, weight and smoking status, these surveys also ask participants to assess how much they believe they exercise compared to others their own age.
"Individuals who thought they were less active than other people their age were more likely to die, regardless of health status, body mass index, and so on," Crum says.

That was true even though the researchers looked at people who were roughly the same in every way, including how much they actually exercised based on self-report and step-tracking data, obesity and heart health, except for how much they thought they worked out compared to others…

Full-text (free):

C. Gabapentin and Pregabalin for Pain — Is Increased Prescribing a Cause for Concern?

D. 38% of Americans received opioid Rx in 2015. Really??!!

An estimated 38% of American adults were prescribed an opioid painkiller in 2015, according to a National Institute on Drug Abuse study published in Annals of Internal Medicine. Researchers found that around 5% of US adults did not follow physicians' orders for use of the drugs, and 1% had an opioid use disorder, which was more common among people with no health insurance, those who lacked jobs and those with lower family incomes.

E. Have Smartphones Destroyed a Generation?

More comfortable online than out partying, post-Millennials are safer, physically, than adolescents have ever been. But they’re on the brink of a mental-health crisis.

Jean Twenge. The Atlantic. September 2017

One day last summer, around noon, I called Athena, a 13-year-old who lives in Houston, Texas. She answered her phone—she’s had an iPhone since she was 11—sounding as if she’d just woken up. We chatted about her favorite songs and TV shows, and I asked her what she likes to do with her friends. “We go to the mall,” she said. “Do your parents drop you off?,” I asked, recalling my own middle-school days, in the 1980s, when I’d enjoy a few parent-free hours shopping with my friends. “No—I go with my family,” she replied. “We’ll go with my mom and brothers and walk a little behind them. I just have to tell my mom where we’re going. I have to check in every hour or every 30 minutes.”

Those mall trips are infrequent—about once a month. More often, Athena and her friends spend time together on their phones, unchaperoned. Unlike the teens of my generation, who might have spent an evening tying up the family landline with gossip, they talk on Snapchat, the smartphone app that allows users to send pictures and videos that quickly disappear. They make sure to keep up their Snapstreaks, which show how many days in a row they have Snapchatted with each other. Sometimes they save screenshots of particularly ridiculous pictures of friends. “It’s good blackmail,” Athena said. (Because she’s a minor, I’m not using her real name.) She told me she’d spent most of the summer hanging out alone in her room with her phone. That’s just the way her generation is, she said. “We didn’t have a choice to know any life without iPads or iPhones. I think we like our phones more than we like actual people.”

I’ve been researching generational differences for 25 years, starting when I was a 22-year-old doctoral student in psychology. Typically, the characteristics that come to define a generation appear gradually, and along a continuum. Beliefs and behaviors that were already rising simply continue to do so. Millennials, for instance, are a highly individualistic generation, but individualism had been increasing since the Baby Boomers turned on, tuned in, and dropped out. I had grown accustomed to line graphs of trends that looked like modest hills and valleys. Then I began studying Athena’s generation.

Around 2012, I noticed abrupt shifts in teen behaviors and emotional states. The gentle slopes of the line graphs became steep mountains and sheer cliffs, and many of the distinctive characteristics of the Millennial generation began to disappear. In all my analyses of generational data—some reaching back to the 1930s—I had never seen anything like it…

F. Rotavirus vaccine tied to lower pediatric diarrhea hospitalizations, costs

More than 380,000 diarrhea-related hospitalizations among children younger than 5 were prevented between 2008 and 2013 after routine rotavirus vaccination was implemented in 2006, resulting in medical cost savings of about $1.2 billion, researchers reported in the Journal of the Pediatric Infectious Diseases Society.

G. Tenecteplase Not Better or Safer in Ischemic Stroke: First head-to-head trial shows no advantage against alteplase

H. Some scientists suggest it might be better not to finish course of antibiotics

The long-held belief that a course of antibiotics must be completed even if the patient is feeling better after a few days is not based on solid scientific evidence, according to an opinion piece published in The BMJ. Routinely advising patients to finish their antibiotics may actually encourage antibiotic resistance, write lead author and infectious disease expert Martin Llewelyn and his colleagues.

Link to the BMJ essay (requires subscription):

I. Poison center calls about dietary supplements increase 50%

Calls to poison control centers about dietary supplements rose nearly 50% from 2005 to 2012, according to a study in the Journal of Medical Toxicology. Researchers found 70% of exposures concerned children under age 6 and 99% of those were unintentional exposures.

J. Study looks at use of secure messaging systems in hospitals

A study in the Journal of Hospital Medicine showed that just 26% of hospital-based clinicians reported that their organization implemented a secure messaging option used by some clinicians, while only 7% said their organization had a secure messaging option that was used by most clinicians. Meanwhile, 79.8% of respondents said they were given pagers for communication, 49% of whom receive patient care-related communication through these devices.

K. Statin Denialism Is 'A Deadly Internet-Driven Cult': Steve Nissen says the battle for patients' hearts and minds is being lost

A leading cardiologist has unleashed a blistering attack on "statin denial," which he calls "an internet-driven cult with deadly consequences."

In an editorial in Annals of Internal Medicine, Steve Nissen (Cleveland Clinic) expressed grave concerns over statistics showing that only 61% of people given a prescription for a statin were adherent at 3 months. "For a treatment with such well- documented morbidity and mortality benefits, these adherence rates are shockingly low. Why?" he asks.

Nissen writes that "we are losing the battle for the hearts and minds of our patients to Web sites developed by people with little or no scientific expertise…

L. Healthy living adds years to life, study finds

Healthy lifestyle habits, such as not smoking and maintaining a healthy weight, could increase a person's lifespan by five to seven years, researchers reported in Health Affairs. The added longevity comprised years of good health without physical limitations, and they underscore the importance of prevention, the authors said.