Sunday, September 17, 2017

Lit Bits: Sept 17, 2017

From the recent medical literature...

1. Oxygen Therapy in the ED

A. Suspected AMI

Hofman R, et al. N Engl J Med 2017 Aug 28 [Epub ahead of print].

Background The clinical effect of routine oxygen therapy in patients with suspected acute myocardial infarction who do not have hypoxemia at baseline is uncertain.

Methods In this registry-based randomized clinical trial, we used nationwide Swedish registries for patient enrollment and data collection. Patients with suspected myocardial infarction and an oxygen saturation of 90% or higher were randomly assigned to receive either supplemental oxygen (6 liters per minute for 6 to 12 hours, delivered through an open face mask) or ambient air.

Results A total of 6629 patients were enrolled. The median duration of oxygen therapy was 11.6 hours, and the median oxygen saturation at the end of the treatment period was 99% among patients assigned to oxygen and 97% among patients assigned to ambient air. Hypoxemia developed in 62 patients (1.9%) in the oxygen group, as compared with 254 patients (7.7%) in the ambient-air group. The median of the highest troponin level during hospitalization was 946.5 ng per liter in the oxygen group and 983.0 ng per liter in the ambient-air group. The primary end point of death from any cause within 1 year after randomization occurred in 5.0% of patients (166 of 3311) assigned to oxygen and in 5.1% of patients (168 of 3318) assigned to ambient air (hazard ratio, 0.97; 95% confidence interval [CI], 0.79 to 1.21; P=0.80). Rehospitalization with myocardial infarction within 1 year occurred in 126 patients (3.8%) assigned to oxygen and in 111 patients (3.3%) assigned to ambient air (hazard ratio, 1.13; 95% CI, 0.88 to 1.46; P=0.33). The results were consistent across all predefined subgroups.

Conclusions Routine use of supplemental oxygen in patients with suspected myocardial infarction who did not have hypoxemia was not found to reduce 1-year all-cause mortality.

Journal Watch review: Suspected MI and Normal Oxygen Saturation? Don't Bother with Supplemental Oxygen

B. High-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy but not to noninvasive mechanical ventilation on intubation rate: a systematic review and meta-analysis

Zhao H, et al. Critical Care 2017;21:184

BACKGROUND: High-flow nasal cannula oxygen (HFNC) is a relatively new therapy used in adults with respiratory failure. Whether it is superior to conventional oxygen therapy (COT) or to noninvasive mechanical ventilation (NIV) remains unclear. The aim of the present study was to investigate whether HFNC was superior to either COT or NIV in adult acute respiratory failure patients.

METHODS: A review of the literature was conducted from the electronic databases from inception up to 20 October 2016. Only randomized clinical trials comparing HFNC with COT or HFNC with NIV were included. The intubation rate was the primary outcome; secondary outcomes included the mechanical ventilation rate, the rate of escalation of respiratory support and mortality.

RESULTS: Eleven studies that enrolled 3459 patients (HFNC, n = 1681) were included. There were eight studies comparing HFNC with COT, two comparing HFNC with NIV, and one comparing all three. HFNC was associated with a significant reduction in intubation rate (OR 0.52, 95% CI 0.34 to 0.79, P = 0.002), mechanical ventilation rate (OR 0.56, 95% CI 0.33 to 0.97, P = 0.04) and the rate of escalation of respiratory support (OR 0.45, 95% CI 0.31 to 0.67, P less than 0.0001) when compared to COT. There was no difference in mortality between HFNC and COT utilization (OR 1.01, 95% CI 0.67 to 1.53, P = 0.96). When HFNC was compared to NIV, there was no difference in the intubation rate (OR 0.96; 95% CI 0.66 to 1.39, P = 0.84), the rate of escalation of respiratory support (OR 1.00, 95% CI 0.77 to 1.28, P = 0.97) or mortality (OR 0.85, 95% CI 0.43 to 1.68, P = 0.65).

CONCLUSIONS: Compared to COT, HFNC reduced the rate of intubation, mechanical ventilation and the escalation of respiratory support. When compared to NIV, HFNC showed no better outcomes. Large-scale randomized controlled trials are necessary to prove our findings.

C. British Thoracic Society Guideline for Oxygen Use in Adults in Healthcare and Emergency Settings

O'Driscoll BR, et al. BMJ Open Respir Res. 2017;4(1)

Executive summary: Philosophy of the guideline
Oxygen is a treatment for hypoxaemia, not breathlessness. Oxygen has not been proven to have any consistent effect on the sensation of breathlessness in non-hypoxaemic patients.
The essence of this guideline can be summarised simply as a requirement for oxygen to be prescribed according to a target saturation range and for those who administer oxygen therapy to monitor the patient and keep within the target saturation range.
The guideline recommends aiming to achieve normal or near-normal oxygen saturation for all acutely ill patients apart from those at risk of hypercapnic respiratory failure or those receiving terminal palliative care.

In myocardial infarction and acute coronary syndromes, aim at an oxygen saturation of 94–98% or 88–92% if the patient is at risk of hypercapnic respiratory failure (grade D).

2. Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis.

Coster JE, et al. Acad Emerg Med. 2017;24(9):1137-1149.  

OBJECTIVES: Rising demand for emergency and urgent care services is well documented, as are the consequences, for example, emergency department (ED) crowding, increased costs, pressure on services, and waiting times. Multiple factors have been suggested to explain why demand is increasing, including an aging population, rising number of people with multiple chronic conditions, and behavioral changes relating to how people choose to access health services. The aim of this systematic mapping review was to bring together published research from urgent and emergency care settings to identify drivers that underpin patient decisions to access urgent and emergency care.

METHODS: Systematic searches were conducted across Medline (via Ovid SP), EMBASE (via Ovid), The Cochrane Library (via Wiley Online Library), Web of Science (via the Web of Knowledge), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; via EBSCOhost). Peer-reviewed studies written in English that reported reasons for accessing or choosing emergency or urgent care services and were published between 1995 and 2016 were included. Data were extracted and reasons for choosing emergency and urgent care were identified and mapped. Thematic analysis was used to identify themes and findings were reported qualitatively using framework-based narrative synthesis.

RESULTS: Thirty-eight studies were identified that met the inclusion criteria. Most studies were set in the United Kingdom (39.4%) or the United States (34.2%) and reported results relating to ED (68.4%). Thirty-nine percent of studies utilized qualitative or mixed research designs. Our thematic analysis identified six broad themes that summarized reasons why patients chose to access ED or urgent care. These were access to and confidence in primary care; perceived urgency, anxiety, and the value of reassurance from emergency-based services; views of family, friends, or healthcare professionals; convenience (location, not having to make appointment, and opening hours); individual patient factors (e.g., cost); and perceived need for emergency medical services or hospital care, treatment, or investigations.

CONCLUSIONS: We identified six distinct reasons explaining why patients choose to access emergency and urgent care services: limited access to or confidence in primary care; patient perceived urgency; convenience; views of family, friends, or other health professionals; and a belief that their condition required the resources and facilities offered by a particular healthcare provider. There is a need to examine demand from a whole system perspective to gain better understanding of demand for different parts of the emergency and urgent care system and the characteristics of patients within each sector.

3. Lung-Protective Ventilation Initiated in the ED (LOV-ED): A Quasi-Experimental, Before-After Trial.

Fuller BM, et al. Ann Emerg Med. 2017 Sep;70(3):406-418.e4.

STUDY OBJECTIVE: We evaluated the efficacy of an emergency department (ED)-based lung-protective mechanical ventilation protocol for the prevention of pulmonary complications.

METHODS: This was a quasi-experimental, before-after study that consisted of a preintervention period, a run-in period of approximately 6 months, and a prospective intervention period. The intervention was a multifaceted ED-based mechanical ventilator protocol targeting lung-protective tidal volume, appropriate setting of positive end-expiratory pressure, rapid oxygen weaning, and head-of-bed elevation. A propensity score-matched analysis was used to evaluate the primary outcome, which was the composite incidence of acute respiratory distress syndrome and ventilator-associated conditions.

RESULTS: A total of 1,192 patients in the preintervention group and 513 patients in the intervention group were included. Lung-protective ventilation increased by 48.4% in the intervention group. In the propensity score-matched analysis (n=490 in each group), the primary outcome occurred in 71 patients (14.5%) in the preintervention group compared with 36 patients (7.4%) in the intervention group (adjusted odds ratio 0.47; 95% confidence interval [CI] 0.31 to 0.71). There was an increase in ventilator-free days (mean difference 3.7; 95% CI 2.3 to 5.1), ICU-free days (mean difference 2.4; 95% CI 1.0 to 3.7), and hospital-free days (mean difference 2.4; 95% CI 1.2 to 3.6) associated with the intervention. The mortality rate was 34.1% in the preintervention group and 19.6% in the intervention group (adjusted odds ratio 0.47; 95% CI 0.35 to 0.63).

CONCLUSION: Implementing a mechanical ventilator protocol in the ED is feasible and is associated with significant improvements in the delivery of safe mechanical ventilation and clinical outcome.

4. Can low-dose of ketamine reduce the need for morphine in renal colic? [Yes!] A double-blind randomized clinical trial.

Abbasi S, et al. Am J Emerg Med. 2017 Aug 14 [Epub ahead of print]

BACKGROUND: The combination of morphine with low doses of ketamine (MK) has been utilized in the Emergency Department (ED) compared with morphine and placebo (MP) for the treatment of acute pain in few studies. The purpose of this study was to compare the effect of MP with MK for the treatment of severe pain with renal colic of patients who had been referred to the ED.

METHODS: This study is a double blind randomized clinical trial on patients with severe renal colic pain who were referred to the ED. Patients were enrolled with pain severity of at least 6 of the 10 visual analogue scales (VAS). Patients were divided into two groups: Morphine 0.1mg/kg and placebo (MP group) and morphine 0.1mg/kg and ketamine 0.15mg/kg (MK group). Pain of patients was studied in 10, 30, 60, 90, and 120min after injection.

RESULTS: Totally, 106 patients were enrolled in study groups. Assessment of the average pain during 120min at 10 and 30min after the start in the drug, MK group was significantly lower than the MP group (p=0.019 and p=0.003 respectively).

CONCLUSION: Given that combinations of morphine with low doses of ketamine in patients with renal colic pain causes more pain and morphine consumption reduction then this combination is suggested as an alternative treatment that could be utilized in patients with renal colic.

5. Categorical Risk Perception Drives Variability in Antibiotic Prescribing in the ED: A Mixed Methods Observational Study.

Klein EY, et al. J Gen Intern Med. 2017 Jun 20 [Epub ahead of print]

BACKGROUND: Adherence to evidence-based antibiotic therapy guidelines for treatment of upper respiratory tract infections (URIs) varies widely among clinicians. Understanding this variability is key for reducing inappropriate prescribing.

OBJECTIVE: To measure how emergency department (ED) clinicians' perceptions of antibiotic prescribing risks affect their decision-making.

DESIGN: Clinician survey based on fuzzy-trace theory, a theory of medical decision-making, combined with retrospective data on prescribing outcomes for URI/pneumonia visits in two EDs. The survey predicts the categorical meanings, or gists, that individuals derive from given information.

PARTICIPANTS: ED physicians, residents, and physician assistants (PAs) who completed surveys and treated patients with URI/pneumonia diagnoses between August 2014 and December 2015.

MAIN MEASURES: Gists derived from survey responses and their association with rates of antibiotic prescribing per visit.

KEY RESULTS: Of 4474 URI/pneumonia visits, 2874 (64.2%) had an antibiotic prescription. However, prescribing rates varied from 7% to 91% for the 69 clinicians surveyed (65.2% response rate). Clinicians who framed therapy-prescribing decisions as a categorical choice between continued illness and possibly beneficial treatment ("why not take a risk?" gist, which assumes antibiotic therapy is essentially harmless) had higher rates of prescribing (OR 1.28 [95% CI, 1.06-1.54]). Greater agreement with the "antibiotics may be harmful" gist was associated with lower prescribing rates (OR 0.81 [95% CI, 0.67-0.98]).

CONCLUSIONS: Our results indicate that clinicians who perceive prescribing as a categorical choice between patients remaining ill or possibly improving from therapy are more likely to prescribe antibiotics. However, this strategy assumes that antibiotics are essentially harmless. Clinicians who framed decision-making as a choice between potential harms from therapy and continued patient illness (e.g., increased appreciation of potential harms) had lower prescribing rates. These results suggest that interventions to reduce inappropriate prescribing should emphasize the non-negligible possibility of serious side effects.

6. ED Boarders: Problems and Solutions

A. Delayed Second Dose Antibiotics for Patients Admitted From the Emergency Department With Sepsis: Prevalence, Risk Factors, and Outcomes

Leisman D, et al. Crit Care Med. 2017;45(6):956-965.

OBJECTIVE: 1) Determine frequency and magnitude of delays in second antibiotic administration among patients admitted with sepsis; 2) Identify risk factors for these delays; and 3) Exploratory: determine association between delays and patient-centered outcomes (mortality and mechanical ventilation after second dose).

DESIGN: Retrospective, consecutive sample sepsis cohort over 10 months.

SETTING: Single, tertiary, academic medical center.

PATIENTS: All patients admitted from the emergency department with sepsis or septic shock (defined: infection, ≥ 2 systemic inflammatory response syndrome criteria, hypoperfusion/organ dysfunction) identified by a prospective quality initiative.

EXCLUSIONS: less than 18 years old, not receiving initial antibiotics in the emergency department, death before antibiotic redosing, and patient refusing antibiotics.

INTERVENTIONS: We determined first-to-second antibiotic time and delay frequency. We considered delay major for first-to-second dose time greater than or equal to 25% of the recommended interval. Factors of interest were demographics, recommended interval length, comorbidities, clinical presentation, location at second dose, initial resuscitative care, and antimicrobial activity mechanism.

MEASUREMENTS AND MAIN RESULTS: Of 828 sepsis cases, 272 (33%) had delay greater than or equal to 25%. Delay frequency increased dose dependently with shorter recommended interval: 11 (4%) delays for 24-hour intervals (median time, 18.52 hr); 31 (26%) for 12-hour intervals (median, 10.58 hr); 117 (47%) for 8-hour intervals (median, 9.60 hr); and 113 (72%) for 6-hour intervals (median, 9.55 hr). In multivariable regression, interval length significantly predicted major delay (12 hr: odds ratio, 6.98; CI, 2.33-20.89; 8 hr: odds ratio, 23.70; CI, 8.13-69.11; 6 hr: odds ratio, 71.95; CI, 25.13-206.0). Additional independent risk factors were inpatient boarding in the emergency department (odds ratio, 2.67; CI, 1.74-4.09), initial 3-hour sepsis bundle compliance (odds ratio, 1.57; CI, 1.07-2.30), and older age (odds ratio, 1.16 per 10 yr, CI, 1.01-1.34). In the exploratory multivariable analysis, major delay was associated with increased hospital mortality (odds ratio, 1.61; CI, 1.01-2.57) and mechanical ventilation (odds ratio, 2.44; CI, 1.27-4.69).

CONCLUSIONS: Major second dose delays were common, especially for patients given shorter half-life pharmacotherapies and who boarded in the emergency department. They were paradoxically more frequent for patients receiving compliant initial care. We observed association between major second dose delay and increased mortality, length of stay, and mechanical ventilation requirement.

B. Impact of inpatient Care in ED on outcomes: a quasi-experimental cohort study.

Lateef A, et al. BMC Health Serv Res. 2017 Aug 14;17(1):555.

BACKGROUND: Hospitals around the world are faced with the issue of boarders in emergency department (ED), patients marked for admission but with no available inpatient bed. Boarder status is known to be associated with delayed inpatient care and suboptimal outcomes. A new care delivery system was developed in our institution where boarders received full inpatient care from a designated medical team, acute medical team (AMT), while still residing at ED. The current study examines the impact of this AMT intervention on patient outcomes.

METHODS: We conducted a retrospective quasi-experimental cohort study to analyze outcomes between the AMT intervention and conventional care in a 1250-bed acute care tertiary academic hospital in Singapore. Study participants included patients who received care from the AMT, a matched cohort of patients admitted directly to inpatient wards (non-AMT) and a sample of patients prior to the intervention (pre-AMT group). Primary outcomes were length of hospital stay (LOS), early discharges (within 24 h) and bed placement. Secondary outcomes included unplanned readmissions within 3 months, and patient's bill size. χ2- and Mann-Whitney U tests were used to test for differences between the cohorts on dichotomous and continuous variables respectively.

RESULTS: The sample comprised of 2279 patients (1092 in AMT, 1027 in non-AMT, and 160 in pre-AMT groups). Higher rates of early discharge (without significant differences in the readmission rates) and shorter LOS were noted for the AMT patients. They were also more likely to be admitted into a ward allocated to their discipline and had lower bill size compared to non AMT patients.

CONCLUSIONS: The AMT intervention improved patient outcomes and resource utilization. This model was noted to be sustainable and provides a potential solution for hospitals' ED boarders who face a gap in inpatient care during their crucial first few hours of admissions while waiting for an inpatient bed.

7. Development and Validation of a Tool to Identify Patients with Type 2 Diabetes at High Risk of Hypoglycemia-Related ED or Hospital Use.

Karter AJ, et al. JAMA Intern Med. 2017 Aug 21 [Epub ahead of print]

IMPORTANCE: Hypoglycemia-related emergency department (ED) or hospital use among patients with type 2 diabetes (T2D) is clinically significant and possibly preventable.

OBJECTIVE: To develop and validate a tool to categorize risk of hypoglycemic-related utilization in patients with T2D.

DESIGN, SETTING, AND PARTICIPANTS: Using recursive partitioning with a split-sample design, we created a classification tree based on potential predictors of hypoglycemia-related ED or hospital use. The resulting model was transcribed into a tool for practical application and tested in 1 internal and 2 fully independent, external samples. Development and internal testing was conducted in a split sample of 206 435 patients with T2D from Kaiser Permanente Northern California (KPNC), an integrated health care system. The tool was externally tested in 1 335 966 Veterans Health Administration and 14 972 Group Health Cooperative patients with T2D.

EXPOSURES: Based on a literature review, we identified 156 candidate predictor variables (prebaseline exposures) using data collected from electronic medical records.

MAIN OUTCOMES AND MEASURES: Hypoglycemia-related ED or hospital use during 12 months of follow-up.

RESULTS: The derivation sample (n = 165 148) had a mean (SD) age of 63.9 (13.0) years and included 78 576 (47.6%) women. The crude annual rate of at least 1 hypoglycemia-related ED or hospital encounter in the KPNC derivation sample was 0.49%. The resulting hypoglycemia risk stratification tool required 6 patient-specific inputs: number of prior episodes of hypoglycemia-related utilization, insulin use, sulfonylurea use, prior year ED use, chronic kidney disease stage, and age. We categorized the predicted 12-month risk of any hypoglycemia-related utilization as high (greater than 5%), intermediate (1%-5%), or low (less than 1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% were categorized as high, intermediate, and low risk, respectively, with observed 12-month hypoglycemia-related utilization rates of 6.7%, 1.4%, and 0.2%, respectively. There was good discrimination in the internal validation KPNC sample (C statistic = 0.83) and both external validation samples (Veterans Health Administration: C statistic = 0.81; Group Health Cooperative: C statistic = 0.79).

CONCLUSIONS AND RELEVANCE: This hypoglycemia risk stratification tool categorizes the 12-month risk of hypoglycemia-related utilization in patients with T2D using only 6 inputs. This tool could facilitate targeted population management interventions, potentially reducing hypoglycemia risk and improving patient safety and quality of life.

8. Tongue-in-Cheek: Critical Research that Escaped the Press

A. Report: Saying ‘Smells Okay’ Precedes 85% Of Foodborne Illnesses Annually

ATLANTA—Presenting research with significant implications for public health, a report published Wednesday by the Centers for Disease Control and Prevention revealed that saying the phrase “smells okay” precedes 85 percent of foodborne illnesses in the United States annually. “We analyzed data from thousands of cases involving food-related ailments over the last decade and concluded that most individuals had given a quick once-over to leftovers and uttered some variation of ‘probably still good’ before spending the next several hours suffering intense stomach pain and vomiting,” said Dr. Robert Husted, director of the CDC’s Division of Foodborne, Waterborne, and Environmental Diseases, adding that cases of E. coli and botulism had been directly linked to individuals observing that the contaminated food “hasn’t been sitting out for that long.”

“In addition, determining that grayish chicken Alfredo simply needed to be stirred or that an improperly covered week-old meatloaf would be fine once an outer layer was cut off almost tripled the chances of contracting salmonella.” The report also confirmed that thousands of Americans across the country are infected with a foodborne illness every year shortly after being asked by a friend or family member to “try this.”

Courtesy of the Onion.

B. Study Finds Health Benefits Associated with Seriously Considering Going Vegetarian for A While Now

ROCKVILLE, MD—In what researchers describe as a major discovery in the field of dietetics, a study published in the American Journal Of Clinical Nutrition Tuesday linked long-term health benefits to seriously thinking about going vegetarian for a while now. “Our research found that people who actively toss around the idea of cutting meat out of their diet exhibited substantial and lasting improvements in their physical well-being,” said study lead author Dr. Olivia Marlow, adding that regularly telling others about one’s plan to transition to an exclusively plant-based diet sometime in the near future was strongly associated with dramatic reductions in heart disease, diabetes, and even cancer.

“The results also demonstrated a robust correlation between improved cardiovascular health and telling acquaintances that while avoiding bacon would be hard, it wasn’t like you were eating a steak every night to begin with. In addition, the positive relationship between browsing vegetarian cookbooks and restaurants online and overall longevity seems especially promising.” The researchers went on to state, however, that the benefits of considering a vegetarian diet still paled in comparison to those enjoyed by individuals who inform friends they were now officially meat-free and haven’t had a burger in more than a week.

Courtesy of the Onion.

C. Report: Americans Most Physically Active When Getting Comfy

BETHESDA, MD—Saying such activities overwhelmingly accounted for calories burned in the U.S., a report released Tuesday by the National Institutes of Health found that Americans are most physically active when getting comfy. “Key indicators of physical activity such as increased heart rate and respiration reach their peak when Americans are rolling over in bed or wiggling around in order to find a more optimal sitting posture on the couch,” the report read in part, adding that researchers observed an exceptionally high flow of oxygen to muscles when participants lifted their legs onto an ottoman or enlisted their upper body to spread a comforter when they were chilly.

“Using fitness trackers, we discovered that Americans take most of their daily steps when walking back and forth in their home to ensure that their desired snacks and the remote control were in reach while they’re watching TV. Furthermore, most of their cardiovascular endurance can be attributed to the regular, almost daily practice of throwing on sweatpants immediately after getting home from work.” The report also noted, however, that most serious injuries are sustained by Americans overexerting themselves while stacking a second pillow behind the first.

Courtesy of the Onion.

D. Boring PowerPoints New Leading Cause of Death Among Health Care Practitioners

BY DR. 99

ATLANTA, GA – A new study published in the latest issue of the Journal of Small Font & Uninteresting Topics (JSFUT) revealed that sinfully boring PowerPoint presentations is now the leading cause of death among health care practitioners worldwide, overtaking both heart disease and cerebrovascular disease.  The study led by Dr. Steven Doldrums and Dr. Mara Tedium of Georgia Medical Center has sent shockwaves through the medical community, waking everyone up abruptly.

“Monotonous PowerPoint presentations are lethal even in the smallest doses,” wrote JSFUT editor Michael Ennui.  “First, it’s altered mental status, bradycardia, and respiratory depression, then eventual progression to catatonia, coma, and ultimately death by boredom.  What’s fascinating is that this occurs independent of a health care practitioner’s sleep deprivation status.”

Tedium states that standard PowerPoint presentation (SPPs) have a kill rate of 33% while “the most boring of boring” PowerPoints (TMBBPPs) have a kill rate of 100%...

According to the study, certain types of PowerPoint presentations led to higher mortality rates.  As number of PowerPoint slides or journal references increased, so did the death rates among vulnerable health care practitioners.  Boredom-induced death increased in direct proportion to how much the presenter simply read off of the PowerPoint slides.  The death rate was inversely proportional to both the number of pictures present and the size of font utilized.  Finally, topics presented by hospital administrators had a kill rate of 100%.

A PowerPoint slide with a funny cartoon, furry animal, or cute child was protective for fifteen seconds but risk of death increased with progression to the next dull slide.  Interestingly, PowerPoint presentations about diabetic foot infections or intestinal worms didn’t cause death, but did produce high rates of paroxysmal vomiting when given during lunch hour conferences.

Next week, the Food & Drug Administration (FDA) is expected to start placing black box warnings on PowerPoint presentations informing health care practitioners of the risk for death upon exposure to its contents.

Courtesy of Gomer Blog

E. A Study on the Coffee Spilling Phenomena in the Low Impulse Regime

Han J. Achieve Life Sci. 2016;10(1):87-101.

When a half-full Bordeaux glass is oscillated sideways at 4 Hz, calm waves of wine gently ripple upon the surface. However, when a cylindrical mug is subject to the same motion, it does not take long for the liquid to splash aggressively against the cup and ultimately spill. This is a manifestation of the same principles that also make us spill coffee when we walk. In this study, we first investigate the physical properties of the fluid-structure interaction of the coffee cup…

9. Annals Brief Reviews

A. Update: D-dimer Test for Excluding the Diagnosis of PE

Take-Home Message
Patients with a low pretest probability for pulmonary embolism according to a structured clinical prediction rule and a negative D-dimer result are unlikely to have pulmonary embolism, particularly among those younger than 65 years.

B. Do Inhaled Anticholinergic Agents in Addition to β-Agonists Improve Outcomes in Acute Asthma Exacerbations?

Take-Home Message
The addition of inhaled anticholinergic agents to β-2 agonists reduced hospitalization and improved pulmonary function testing, but was also associated with increased rates of mild adverse events.

10. Images in Clinical Practice

Young Adult Male in a Coma

Middle-Aged Female With Chest Pain—Fleischner’s sign on CXR (classic PE, right?)

Boy With Muscle Spasms—tetanus—in the US—in an immunized boy!

Male With Severe Headache

Boy With Fever and Cough

Man With Suprapubic Pain

Man With Shortness of Breath

Eczema Herpeticum

Venous Congestion in Ischemic Bowel

Eosinophilic Bronchitis

Sturge–Weber Syndrome

Neobladder Stone

Left Ventricular Free-Wall Rupture


Image Diagnosis: Rapidly Enlarging Scrotal Hematoma: A Complication of Femoral Access?

11. The HII Score - A Novel Tool to Assess Impairment from Alcohol in ED Pts.

Hack JB, et al. Acad Emerg Med. 2017 Jul 30 [Epub ahead of print]

BACKGROUND: Over 35 million alcohol impaired (AI) patients are cared for in Emergency Departments (EDs) annually. Emergency physicians are charged with ensuring AI patients' safety by identifying resolution of alcohol induced impairment. The most common standard evaluation is an extemporized clinical examination, as ethanol levels are not reliable or predictive of clinical symptoms. There is no standard assessment of ED AI patients.

OBJECTIVE: To evaluate a novel standardized emergency department assessment of alcohol impairment - Hack's Impairment Index (HII score), in a busy urban Emergency Department.

METHODS: A retrospective chart review was performed for all AI patients seen in our busy urban ED over 24 months. Trained nurses evaluated AI patients with both "usual" and HII score every 2 hours. Patients were stratified by frequency of visits for AI during this time: high (≥ 6), medium (2-5), and low (1). Within each category, comparisons were made between HII scores, measured ethanol levels, and usual nursing assessment of AI. Changes in HII scores over time were also evaluated.

RESULTS: 8074 visits from 3219 unique patients were eligible for study, including 7973 (98.7%) with ethanol levels, 5061 (62.7%) with complete HII scores, and 3646 (45.2%) with HCP assessments. Correlations between HII scores and ethanol levels were poor (Pearson's R2 = 0.09, 0.09, and 0.17 for high-, medium-, and low-frequency strata). HII scores were excellent at discriminating nursing assessment of AI, while ethanol levels were less effective. Omitting extrema, HII scores fell consistently an average 0.062 points per hour, throughout patients' visits.

CONCLUSIONS: The HII score applied a quantitative, objective assessment of alcohol impairment. HII scores were superior to ethanol levels as an objective clinical measure of impairment. The HII declines in a reasonably predictable manner over time, with serial evaluations corresponding well with HCP evaluations.

12. Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records.

Bhise V, et al. Am J Med. 2017 Aug;130(8):975-981.

PURPOSE: With this study, we set out to identify missed opportunities in diagnosis of spinal epidural abscesses to outline areas for process improvement.

METHODS: Using a large national clinical data repository, we identified all patients with a new diagnosis of spinal epidural abscess in the Department of Veterans Affairs (VA) during 2013. Two physicians independently conducted retrospective chart reviews on 250 randomly selected patients and evaluated their records for red flags (eg, unexplained weight loss, neurological deficits, and fever) 90 days prior to diagnosis. Diagnostic errors were defined as missed opportunities to evaluate red flags in a timely or appropriate manner. Reviewers gathered information about process breakdowns related to patient factors, the patient-provider encounter, test performance and interpretation, test follow-up and tracking, and the referral process. Reviewers also determined harm and time lag between red flags and definitive diagnoses.

RESULTS: Of 250 patients, 119 had a new diagnosis of spinal epidural abscess, 66 (55.5%) of which experienced diagnostic error. Median time to diagnosis in error cases was 12 days, compared with 4 days in cases without error (P less than .01). Red flags that were frequently not evaluated in error cases included unexplained fever (n = 57; 86.4%), focal neurological deficits with progressive or disabling symptoms (n = 54; 81.8%), and active infection (n = 54; 81.8%). Most errors involved breakdowns during the patient-provider encounter (n = 60; 90.1%), including failures in information gathering/integration, and were associated with temporary harm (n = 43; 65.2%).

CONCLUSION: Despite wide availability of clinical data, errors in diagnosis of spinal epidural abscesses are common and involve inadequate history, physical examination, and test ordering. Solutions should include renewed attention to basic clinical skills.

13. Usefulness of lab and radiological investigations in the management of SVT

Ashok A, et al. Emerg Med Australas. 2017 Aug;29(4):394-399.

OBJECTIVE: Although ED patients presenting with supraventricular tachycardia (SVT) are commonly investigated, the value of these investigations has been questioned. We aimed to determine the frequency and utility of investigations in patients with SVT.

METHODS: We undertook an explicit retrospective medical record audit of patients with SVT who presented to a single ED (January 2004 to June 2014). Data on demographics, presenting complaints, investigations and outcomes were extracted. The outcomes were nature and utility of investigations.

RESULTS: A total of 633 patients were enrolled (mean [SD] age 55.4 [17.7] years, 62% female). Laboratory investigations were common: electrolytes (83.7% of patients), full blood count (81.2%), magnesium (57.5%), calcium (39.3%) and thyroid function (30.3%). These investigations revealed many mildly abnormal results but resulted in electrolyte supplementation in only 19 patients: eight with mild hypokalaemia (potassium 3.0-3.5 mmol/L) and 11 with mild hypomagnesia (magnesium 0.49-1.1 mmol/L). Troponin was ordered for 302 (47.7%) patients, many of whom had no history or risk factors for cardiac disease, or ischaemic symptoms associated with their SVT. The troponin was normal, mildly and moderately elevated in 65.2, 24.5 and 10.2% of cases, respectively. Only seven (1.1%) patients were diagnosed with acute myocardial ischemia. Although 190 (30.0%) patients had a chest X-ray (CXR), it was normal in 78.4% of cases. All CXR abnormalities were incidental and not relevant to the immediate ED management.

CONCLUSION: Patients with uncomplicated SVT are over-investigated. Guidelines for ED SVT investigation are recommended. Further research is recommended to determine the indications for each investigation in the setting of SVT.

14. External Validation of the Universal Termination of Resuscitation Rule for Out-of-Hospital Cardiac Arrest in British Columbia

Grunau B, et al. Ann Emerg Med. 2017 Sep;70(3):374-381.e1.

STUDY OBJECTIVE: The Universal Termination of Resuscitation Rule (TOR Rule) was developed to identify out-of-hospital cardiac arrests eligible for field termination of resuscitation, avoiding futile transportation to the hospital. The validity of the rule in emergency medical services (EMS) systems that do not routinely transport out-of-hospital cardiac arrest patients to the hospital is unknown. We seek to validate the TOR Rule in British Columbia.

METHODS: This study included consecutive, nontraumatic, adult, out-of-hospital cardiac arrests treated by EMS in British Columbia from April 2011 to September 2015. We excluded patients with active do-not-resuscitate orders and those with missing data. Following consensus guidelines, we examined the validity of the TOR Rule after 6 minutes of resuscitation (to approximate three 2-minute cycles of resuscitation). To ascertain rule performance at the different time junctures, we recalculated TOR Rule classification accuracy at subsequent 1-minute resuscitation increments.

RESULTS: Of 6,994 consecutive, adult, EMS-treated, out-of-hospital cardiac arrests, overall survival was 15%. At 6 minutes of resuscitation, rule performance was sensitivity 0.72, specificity 0.91, positive predictive value 0.98, and negative predictive value 0.36. The TOR Rule recommended care termination for 4,367 patients (62%); of these, 92 survived to hospital discharge (false-positive rate 2.1%; 95% confidence interval 1.7% to 2.5%); however, this proportion steadily decreased with later application. The TOR Rule recommended continuation of resuscitation in 2,627 patients (38%); of these, 1,674 died (false-negative rate 64%; 95% confidence interval 62% to 66%). Compared with 6-minute application, test characteristics at 30 minutes demonstrated nearly perfect positive predictive value (1.0) and specificity (1.0) but a lower sensitivity (0.46) and negative predictive value (0.25).

CONCLUSION: In this cohort of adult out-of-hospital cardiac arrest patients, the TOR Rule applied at 6 minutes falsely recommended care termination for 2.1% of patients; however, this decreased with later application. Systems using the TOR Rule to cease resuscitation in the field should consider rule application at points later than 6 minutes.

15. IV Corticosteroid Premedication Administered 5 Hours Before CT Compared with a Traditional 13-Hour Oral Regimen.

Mervak BM, et al. Radiology. 2017 Jul 26 [Epub ahead of print]

Purpose To determine if the allergic-like breakthrough reaction rate of intravenous corticosteroid prophylaxis administered 5 hours before contrast material-enhanced computed tomography (CT) is noninferior to that of a traditional 13-hour oral regimen. Materials and Methods Institutional review board approval was obtained and informed consent waived for this retrospective noninferiority cohort study.

Subjects (n = 202) who completed an accelerated 5-hour intravenous corticosteroid premedication regimen before low-osmolality contrast-enhanced CT for a prior allergic-like or unknown-type reaction to iodine-based contrast material from June 1, 2008, to June 30, 2016, were identified. The breakthrough reaction rate was compared by using the Farrington and Manning noninferiority likelihood score to test subjects premedicated with a traditional 13-hour oral regimen (2.1% [13 of 626]). All subjects were premedicated for a prior allergic-like or unknown-type reaction to iodine-based contrast material. A noninferiority margin of 4.0% was selected to allow for no more than a clinically negligible 6.0% breakthrough reaction rate in the cohort that received 5-hour intravenous corticosteroid prophylaxis.

Results The breakthrough reaction rate for 5-hour intravenous prophylaxis was 2.5% (five of 202 patients; 95% confidence interval: 0.8%, 5.7%), which was noninferior to the 2.1% (13 of 626 patients; 95% confidence interval: 1.1%, 3.5%) rate for the 13-hour regimen (P = .0181). The upper limits of the confidence interval for the difference between the two rates was 3.7% (0.4%; 95% confidence interval: -1.6%, 3.7%), which was within the 4.0% noninferiority margin. All breakthrough reactions were of equal or lesser severity to those of the index reactions (two severe, one moderate, and one mild reaction).

Conclusion Accelerated intravenous premedication with corticosteroids beginning 5 hours before contrast-enhanced CT has a breakthrough reaction rate noninferior to that of a 13-hour oral premedication regimen

16. More Prognostic Tools

A. Severe Hyperkalemia: Can the ECG Risk Stratify for Short-term Adverse Events?

Durfey N, et al. West J Emerg Med. 2017;18(5)963-971.

Introduction: The electrocardiogram (ECG) is often used to identify which hyperkalemic patients are at risk for adverse events. However, there is a paucity of evidence to support this practice. This study analyzes the association between specific hyperkalemic ECG abnormalities and the development of short-term adverse events in patients with severe hyperkalemia.

Methods: We collected records of all adult patients with potassium (K+) ≥6.5 mEq/L in the hospital laboratory database from August 15, 2010, through January 30, 2015. A chart review identified patient demographics, concurrent laboratory values, ECG within one hour of K+ measurement, treatments and occurrence of adverse events within six hours of ECG. We defined adverse events as symptomatic bradycardia, ventricular tachycardia, ventricular fibrillation, cardiopulmonary resuscitation (CPR) and/or death. Two emergency physicians blinded to study objective independently examined each ECG for rate, rhythm, peaked T wave, PR interval duration and QRS complex duration. Relative risk was calculated to determine the association between specific hyperkalemic ECG abnormalities and short term adverse events.

Results: We included a total of 188 patients with severe hyperkalemia in the final study group. Adverse events occurred within six hours in 28 patients (15%): symptomatic bradycardia (n=22), death (n=4), ventricular tachycardia (n=2) and CPR (n=2). All adverse events occurred prior to treatment with calcium and all but one occurred prior to K+-lowering intervention. All patients who had a short-term adverse event had a preceding ECG that demonstrated at least one hyperkalemic abnormality (100%, 95% confidence interval [CI] [85.7-100%]). An increased likelihood of short-term adverse event was found for hyperkalemic patients whose ECG demonstrated QRS prolongation (relative risk [RR] 4.74, 95% CI[2.01-11.15]), bradycardia (HR less than 50) (RR 12.29, 95%CI [6.69-22.57]), and/or junctional rhythm (RR 7.46,95%CI 5.28-11.13). There was no statistically significant correlation between peaked T waves and short-term adverse events (RR 0.77, 95% CI [0.35-1.70]).

Conclusion: Our findings support the use of the ECG to risk stratify patients with severe hyperkalemia for short-term adverse events.

B. Predicting Short-Term Risk of Arrhythmia among Patients with Syncope: The Canadian Syncope Arrhythmia Risk Score.

Thiruganasambandamoorthy V, et al. Acad Emerg Med. 2017 Aug 9 [Epub ahead of print]

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

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

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

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

C. Validation of the No Objective Testing (NOT) Rule and Comparison to the HEART Pathway.

Stopyra JP, et al. Acad Emerg Med. 2017;24(9):1165-68.  

BACKGROUND: The no objective testing rule (NOTR) is a decision aid designed to safely identify emergency department (ED) patients with chest pain who do not require objective testing for coronary artery disease.

OBJECTIVES: The objective was to validate the NOTR in a cohort of U.S. ED patients with acute chest pain and compare its performance to the HEART Pathway.

METHODS: A secondary analysis of 282 participants enrolled in the HEART Pathway randomized controlled trial was conducted. Each patient was classified as low risk or at risk by the NOTR. Sensitivity for major adverse cardiac events (MACE) at 30 days was calculated in the entire study population. NOTR and HEART Pathways were compared among patients randomized to the HEART Pathway in the parent trial using McNemar's test and the net reclassification improvement (NRI).

RESULTS: Major adverse cardiac events occurred in 22/282 (7.8%) participants, including no deaths, 16/282 (5.6%) with myocardial infarction (MI), and 6/282 (2.1%) with coronary revascularization without MI. NOTR was 100% (95% confidence interval [CI] = 84.6%-100%) sensitive for MACE and identified 78/282 patients (27.7%, 95% = CI 22.5-33.3%) as low risk. In the HEART Pathway arm (n = 141), both NOTR and HEART Pathway identified all patients with MACE as at risk. Compared to NOTR, the HEART Pathway was able to correctly reclassify 27 patients without MACE as low risk, yielding a NRI of 20.8% (95% CI = 11.3%-30.2%).

CONCLUSIONS: Within a U.S. cohort of ED patients with chest pain, the NOTR and HEART Pathway were 100% sensitive for MACE at 30 days. However, the HEART Pathway identified more patients suitable for early discharge than the NOTR.

17. Central venous catheter placement in coagulopathic patients: risk factors and incidence of bleeding complications.

van de Weerdt EK, et al. Transfusion. 2017 Aug 30 [Epub ahead of print]

BACKGROUND: Central venous catheters are frequently inserted into patients with coagulation disorders. It is unclear whether preprocedural correction of hemostasis is beneficial. We determined the incidence of bleeding complications after central venous catheter placement in patients who had severe coagulopathy and identified potential risk factors for bleeding.

STUDY DESIGN AND METHODS: The MEDLINE and Cochrane Library databases were systematically searched through November 2015. To be included, articles must have reported on hemorrhagic complications with specification of abnormal coagulation testing results. Severe coagulopathy was defined as a reduced platelet count of 50 × 109 /L or less, and/or an elevated international normalized ratio of 1.5 or greater, and/or a partial thromboplastin time of 45 seconds or greater.

RESULTS: We included one randomized controlled trial and 21 observational studies. In total, there were 13,256 catheter insertions, including 4213 in patients with severe coagulopathy. Before 3150 central venous catheter placements, coagulopathy was not corrected. The bleeding incidence varied from 0 to 32%. The severity of coagulopathy did not predict the risk of bleeding. No study demonstrated a beneficial effect from the prophylactic administration of platelets or fresh-frozen plasma to prevent bleeding complications. Retrospective observational studies suggested that no preprocedural correction is required up to a platelet count of 20 × 109 /L and an international normalized ratio of 3.0.

CONCLUSION: The incidence of major bleeding complications after central venous catheter placement is low, even in coagulopathic patients. Based on a systematic research of the literature, strong evidence supporting the correction of hemostatic defects before central venous catheter insertion is lacking. However, well-powered randomized controlled trials will be necessary to determine the minimal platelet count, the maximal international normalized ratio, and an activated partial thromboplastin time that is safe before central venous catheter insertion.

18. Day-Supply of Opioid Rx Factor in Likelihood of Long-Term Use

Doctors should prescribe for the minimum numbers of days, researchers say

WEDNESDAY, Aug. 23, 2017 (HealthDay News) -- The days supplied is far more important than the dosage level or even the type of pain being treated in risk of opioid use disorder following opioid prescription, according to a study published recently in The Journal of Pain.

Bradley Martin, Pharm.D., Ph.D., a pharmacist at the University of Arkansas for Medical Sciences in Little Rock, and colleagues examined 2006 to 2015 medical records for 1,353,902 patients who were prescribed opioids for the first time.

The overwhelming majority of patients discontinued opioid use, the researchers found. Patients were more likely to continue using the opioids if they were initially prescribed medications for a longer time.

"Comparing someone who has a one- or two-day supply of opioids with someone who has a week's supply, the risk of use doubles," Martin said in a university news release. "This is something clinicians can easily modify when they prescribe opioids." He and his team suggested prescribers use "the minimum effective opioid dose and duration to reduce unintended long-term use."

Factors Influencing Long-Term Opioid Use Among Opioid Naive Patients: An Examination of Initial Prescription Characteristics and Pain Etiologies.

Shah A, et al. J Pain. 2017 Jul 13 [Epub ahead of print]

The relationships between the initial opioid prescription characteristics and pain etiology with the probability of opioid discontinuation were explored in this retrospective cohort study using health insurance claims data from a nationally representative database of commercially insured patients in the United States.

We identified 1,353,902 persons aged 14 years and older with no history of cancer or substance abuse, with new opioid use episodes and categorized them into 11 mutually exclusive pain etiologies. Cox proportional hazards models were estimated to identify factors associated with time to opioid discontinuation. After accounting for losses to follow-up, the probability of continued opioid use at 1 year was 5.3% across all subjects. Patients with chronic pain had the highest probability for continued opioid use followed by patients with inpatient admissions. Patients prescribed doses ≥90 morphine milligram equivalents (hazard ratio [HR] = .91; 95% confidence interval [CI], .91-.92), initiated with tramadol (HR = .89; 95% CI, .89-.90) or long-acting opioids (HR = .79; 95% CI, .77-.82) were less likely to discontinue opioids. Increasing days' supply of the first prescription was consistently associated with a lower likelihood of opioid discontinuation (HRs, CIs: 3-4 days' supply = .70, .70-.71; 5-7 days' supply = .48, .47-.48; 8-10 days' supply = .37, .37-.38; 11-14 days' supply = .32, .31-.33; 15-21 days' supply = .29, .28-.29; ≥22 days supplied = .20, .19-.20). The direction of this relationship was consistent across all pain etiologies. Clinicians should initiate patients with the lowest supply of opioids to mitigate unintentional long-term opioid use.

PERSPECTIVE: This study shows that characteristics of the first opioid prescription, particularly duration of the prescription, are significant predictors of continued opioid use irrespective of the indication for an opioid prescription. These data should encourage prescribers to initiate patients using the minimum effective opioid dose and duration to reduce unintended long-term use and could motivate policies that restrict the initial supply of opioids.

19. Pediatric Corner

A. Is Tachycardia at Discharge from the Pediatric ED a Cause for Concern? A Nonconcurrent Cohort Study.

Wilson PM, et al. Ann Emerg Med. 2017;70(3): 268–276.e2

STUDY OBJECTIVE: We evaluate the association between discharge tachycardia and (1) emergency department (ED) and urgent care revisit and (2) receipt of clinically important intervention at the revisit.

METHODS: The study included a nonconcurrent cohort of children aged 0 to younger than 19 years, discharged from 2 pediatric EDs and 4 pediatric urgent care centers in 2013. The primary exposure was discharge tachycardia (last recorded pulse rate ≥99th percentile for age). The main outcome was ED or urgent care revisit within 72 hours of discharge. Additional outcomes included interventions received and disposition at the revisit, prevalence of discharge tachycardia at the index visit, and associations of pain, fever, and medications with discharge tachycardia. Multivariable logistic regression determined relative risk ratios for revisit and receipt of clinically important intervention at the revisit.

RESULTS: Of eligible visits, 126,774 were included, of which 10,470 patients (8.3%) had discharge tachycardia. Discharge tachycardia was associated with an increased risk of revisit (adjusted RR 1.3; 95% confidence interval 1.2 to 1.5), increased risk of tachycardia at the revisit (relative risk 3.1; 95% confidence interval 2.6 to 3.7), and of the receipt of certain clinically important interventions (supplemental oxygen, respiratory medications and admission, antibiotics and admission, and peripheral intravenous line placement and admission). However, there was no increased risk for the composite outcome of receipt of any clinically important intervention or admission on revisit.

CONCLUSION: Discharge tachycardia is associated with an increased risk of revisit. It is likely that tachycardia at discharge is not a critical factor associated with impending physiologic deterioration.

B. Risk Factors for Adverse Events in ED Procedural Sedation for Children: Ketamine is Safest

Bhatt M, et al. JAMA Pediatr. 2017 Aug 21 [Epub ahead of print]

Importance: Procedural sedation for children undergoing painful procedures is standard practice in emergency departments worldwide. Previous studies of emergency department sedation are limited by their single-center design and are underpowered to identify risk factors for serious adverse events (SAEs), thereby limiting their influence on sedation practice and patient outcomes.

Objective: To examine the incidence and risk factors associated with sedation-related SAEs.

Design, Setting, and Participants: This prospective, multicenter, observational cohort study was conducted in 6 pediatric emergency departments in Canada between July 10, 2010, and February 28, 2015. Children 18 years or younger who received sedation for a painful emergency department procedure were enrolled in the study. Of the 9657 patients eligible for inclusion, 6760 (70.0%) were enrolled and 6295 (65.1%) were included in the final analysis.

Exposures: The primary risk factor was receipt of sedation medication. The secondary risk factors were demographic characteristics, preprocedural medications and fasting status, current or underlying health risks, and procedure type.

Main Outcomes and Measures: Four outcomes were examined: SAEs, significant interventions performed in response to an adverse event, oxygen desaturation, and vomiting.

Results: Of the 6295 children included in this study, 4190 (66.6%) were male and the mean (SD) age was 8.0 (4.6) years. Adverse events occurred in 736 patients (11.7%; 95% CI, 6.4%-16.9%). Oxygen desaturation (353 patients [5.6%]) and vomiting (328 [5.2%]) were the most common of these adverse events. There were 69 SAEs (1.1%; 95% CI, 0.5%-1.7%), and 86 patients (1.4%; 95% CI, 0.7%-2.1%) had a significant intervention. Use of ketamine hydrochloride alone resulted in the lowest incidence of SAEs (17 [0.4%]) and significant interventions (37 [0.9%]). The incidence of adverse sedation outcomes varied significantly with the type of sedation medication. Compared with ketamine alone, propofol alone (3.7%; odds ratio [OR], 5.6; 95% CI, 2.3-13.1) and the combinations of ketamine and fentanyl citrate (3.2%; OR, 6.5; 95% CI, 2.5-15.2) and ketamine and propofol (2.1%; OR, 4.4; 95% CI, 2.3-8.7) had the highest incidence of SAEs. The combinations of ketamine and fentanyl (4.1%; OR, 4.0; 95% CI, 1.8-8.1) and ketamine and propofol (2.5%; OR, 2.2; 95% CI, 1.2-3.8) had the highest incidence of significant interventions.

Conclusions and Relevance: The incidence of adverse sedation outcomes varied significantly with type of sedation medication. Use of ketamine only was associated with the best outcomes, resulting in significantly fewer SAEs and interventions than ketamine combined with propofol or fentanyl.

C. Reliability of Examination Findings in Suspected Community-Acquired Pneumonia in Kids.

Florin TA, et al. Pediatrics. 2017 Sep;140(3). pii: e20170310. doi: 10.1542/peds.2017-0310.

BACKGROUND: The authors of national guidelines emphasize the use of history and examination findings to diagnose community-acquired pneumonia (CAP) in outpatient children. Little is known about the interrater reliability of the physical examination in children with suspected CAP.

METHODS: This was a prospective cohort study of children with suspected CAP presenting to a pediatric emergency department from July 2013 to May 2016. Children aged 3 months to 18 years with lower respiratory signs or symptoms who received a chest radiograph were included. We excluded children hospitalized ≤14 days before the study visit and those with a chronic medical condition or aspiration. Two clinicians performed independent examinations and completed identical forms reporting examination findings. Interrater reliability for each finding was reported by using Fleiss' kappa (κ) for categorical variables and intraclass correlation coefficient (ICC) for continuous variables.

RESULTS: No examination finding had substantial agreement (κ/ICC over 0.8). Two findings (retractions, wheezing) had moderate to substantial agreement (κ/ICC = 0.6-0.8). Nine findings (abdominal pain, pleuritic pain, nasal flaring, skin color, overall impression, cool extremities, tachypnea, respiratory rate, and crackles/rales) had fair to moderate agreement (κ/ICC = 0.4-0.6). Eight findings (capillary refill time, cough, rhonchi, head bobbing, behavior, grunting, general appearance, and decreased breath sounds) had poor to fair reliability (κ/ICC = 0-0.4). Only 3 examination findings had acceptable agreement, with the lower 95% confidence limit over 0.4: wheezing, retractions, and respiratory rate.

CONCLUSIONS: In this study, we found fair to moderate reliability of many findings used to diagnose CAP. Only 3 findings had acceptable levels of reliability. These findings must be considered in the clinical management and research of pediatric CAP

20. Overtreatment in the United States: Physicians say 15% to 30% of medical care is unnecessary

Lyu H, et al. PLoS One. 2017 Sep 6;12(9):e0181970.

BACKGROUND: Overtreatment is a cause of preventable harm and waste in health care. Little is known about clinician perspectives on the problem. In this study, physicians were surveyed on the prevalence, causes, and implications of overtreatment.

METHODS: 2,106 physicians from an online community composed of doctors from the American Medical Association (AMA) masterfile participated in a survey. The survey inquired about the extent of overutilization, as well as causes, solutions, and implications for health care. Main outcome measures included: percentage of unnecessary medical care, most commonly cited reasons of overtreatment, potential solutions, and responses regarding association of profit and overtreatment.

FINDINGS: The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures. The most common cited reasons for overtreatment were fear of malpractice (84.7%), patient pressure/request (59.0%), and difficulty accessing medical records (38.2%). Potential solutions identified were training residents on appropriateness criteria (55.2%), easy access to outside health records (52.0%), and more practice guidelines (51.5%). Most respondents (70.8%) believed that physicians are more likely to perform unnecessary procedures when they profit from them. Most respondents believed that de-emphasizing fee-for-service physician compensation would reduce health care utilization and costs.

CONCLUSION: From the physician perspective, overtreatment is common. Efforts to address the problem should consider the causes and solutions offered by physicians.

21. Another benefit of propofol ! Who would have guessed ??

Propofol Decreases Endoplasmic Reticulum Stress-Mediated Apoptosis in Retinal Pigment Epithelial Cells.

Zhou X, et al. PLoS One. 2016 Jun 16;11(6):e0157590

Full-text (free), for you science nerds:
22. Micro Bits

A. What Happens When a Hurricane Hits a Hospital

Alice Park. TIME. Aug 28, 2017

When a hurricane hits Houston, it also threatens some of the world's leading medical care.

South Texas has been enduring the worst storm to hit the U.S. in years in Hurricane Harvey, with flooded streets expected to persist for days. With more than 10 million patient visits each year, and more than a dozen hospitals and medical facilities, the Texas Medical Center (TMC) in the heart of Houston is the largest medical complex in the world. The largest children’s hospital, as well as the largest cancer hospital, are also housed in the city.

As Harvey gathered steam before making landfall late Friday night, the more than 106,000 TMC employees were prepared, but no one could have predicted the sheer volume of water that would inundate the city. The lobby of MD Anderson Cancer Center resembled a wading pool, and some of TMC’s facilities effectively ended up in a moat, surrounded by water that prevented anyone from getting in or out…

B. Education and coronary heart disease: mendelian randomisation study

Conclusions This mendelian randomisation study found support for the hypothesis that low education is a causal risk factor in the development of coronary heart disease. Potential mechanisms could include smoking, body mass index, and blood lipids. In conjunction with the results from studies with other designs, these findings suggest that increasing education may result in substantial health benefits.

C. Conventional vs invert-grayscale X-ray for diagnosis of pneumothorax in the emergency setting

Conclusion: Inverted gray-scale imaging is not a superior imaging modality over digital-conventional X-ray for the diagnosis of pneumothorax. Prospective studies should be performed where diagnostic potency of inverted gray-scale radiograms is tested against gold standard chest CT. Further research should compare inverted grayscale to lung ultrasound to assess them as alternatives prior to CT.

D. Exploring the best predictors of fluid responsiveness in patients with septic shock

Conclusion: Ultrasound assessment of ΔIVC and ΔVpeak brach, especially ΔCDPV, could predict fluid responsiveness and might be recommended as a continuous and noninvasive method to monitor functional hemodynamic parameter in mechanically ventilated patients with septic shock.

E. Comparison of UTI antibiograms stratified by ED patient disposition

Conclusions: We found higher antibiotic sensitivities in ED-Only than the IP-Only Study-Specific Antibiograms. Our Study-Specific Antibiograms offer an alternative guide for antibiotic selection in the ED.

F. How can we identify patients with delirium in the emergency department? A review of available screening and diagnostic tools

Tamune H, et al. Am J Emerg Med. 2017;35: 1332–1334.

Delirium is a widespread and serious but under-recognized problem. Increasing evidence argues that emergency health care providers need to assess the mental status of the patient as the “sixth vital sign”. A simple, sensitive, time-efficient, and cost-effective tool is needed to identify delirium in patients in the emergency department (ED); however, a stand-alone measurement has not yet been established despite previous studies partly because the differential diagnosis of dementia and delirium superimposed on dementia (DSD) is too difficult to achieve using a single indicator. To fill up the gap, multiple aspects of a case should be assessed including inattention and arousal. For instance, we proposed the 100 countdown test as an effective means of detecting inattention. Further dedicated studies are warranted to shed light on the pathophysiology and better management of dementia, delirium and/or “altered mental status”. We reviewed herein the clinical questions and controversies concerning delirium in an ED setting.

G. FDA panel recommends against pediatric cough medicine with opioids

The FDA's Pediatric Advisory Committee voted almost unanimously that cough medicines with opioids such as codeine and hydrocodone had greater health risks than benefits and shouldn't be given to youths younger than 18. Some doctors on the panel said there is a lack of evidence that the treatments work to suppress cough, but they can have serious side effects.

H. What We Can Learn from a Mindful ER

An emergency physician shares what she has learned about embedding mindfulness practice into a busy, complex, and chaotic ER.

BY SHAHINA BRAGANZA | Greater Good Science Center, SEPTEMBER 13, 2017

I. Diagnostic Accuracy of Ultrasound for Identifying Shoulder Dislocations and Reductions: A Systematic Review of the Literature

Ultrasound may be considered as an alternative diagnostic method for the detectionof shoulder dislocation and reduction, but further studies are necessary before routine use. [West JEmerg Med. 2017;18(5)937-942.]

J. Study looks at prevalence of chronic cough after respiratory illness in youths

Twenty-five percent of children treated for acute respiratory illness continued to have a chronic cough after 28 days, with 35% of those children having a wet cough and 26% having a dry cough, according to an Australian study in the Archives of Disease in Childhood. Lead author and physician Kerry-Ann O'Grady urged parents of youths with cough lasting more than a month, especially those with a wet cough, to seek medical advice.

K. Dental procedures, antibiotic prophylaxis, and endocarditis among people with prosthetic heart valves: nationwide population based cohort and a case crossover study

Conclusion Invasive dental procedures may contribute to the development of infective endocarditis in adults with prosthetic heart valves.

L. Accuracy of Cardiovascular Risk Prediction Varies by Neighborhood Socioeconomic Position: A Retrospective Cohort Study

Conclusion: Neighborhood disadvantage may be a powerful regulator of ASCVD event risk. In addition to supplemental risk models and clinical screening criteria, population-based solutions are needed to ameliorate the deleterious effects of neighborhood disadvantage on health outcomes.

M. Many patients may have undetected A-fib

About 1 in 3 patients at risk of atrial fibrillation were found to have undiagnosed disease, following evaluation using long-term cardiac monitor implants, researchers reported in JAMA Cardiology. Many patients were ages 75 and older and had other health problems, and about 90% had atrial fibrillation-related symptoms.

N. Don't Tell John McCain to Fight His Cancer

Arthur L. Caplan, PhD. Medscape. July 25, 2017

Director, Division of Medical Ethics, NYU Langone Medical Center, New York, New York

Cancer Doesn't Care If You're a Fighter

It is very common when learning that someone has been newly diagnosed with a life-threatening cancer that well-meaning family and friends weigh in with encouragement to fight. It is also unfortunate.

Cancer could not care less whether you are a fighter or not. What evidence there is does not show that adopting a fighting stance helps in terms of survival. I have seen many fighters die of cancer, and some who chose not to be seen as fighters live longer than others who did.

And there is an implication that if you are not a fighter, then you must be a coward or worse. This suggests that the only option available to anyone who is courageous is to choose to fight—to utilize every surgery, complementary medicine, chemotherapy, and experimental option. This is unfortunate as well, because it takes courage to decide not to battle fatal cancers, but rather to enjoy a better quality of life in the time that remains.

The latest example of this "you must be a fighter" ethic is John McCain.

The senator from Arizona just found out he has a glioblastoma, a very nasty form of brain cancer. Upon announcing his diagnosis, McCain was greeted by a chorus of friends and admirers urging him to fight and calling on him to be courageous in taking on the cancer.

This is advice McCain does not need.

People Mean Well, But It's the Wrong Tactic

Here is a sample from Twitter. Barack Obama said, "John McCain is an American hero, and one of the bravest fighters I've ever known. Cancer doesn't know what it's up against. Give it hell, John." Joe Biden: "He is strong, and he will beat this."

Gabrielle Giffords: "You're tough! You can beat this. Fight, fight, fight!" Mike Pence: "Cancer picked on the wrong guy. John McCain is a fighter, and he'll win this fight too." A bunch of editorials in many newspapers across the nation echoed similar thoughts.

This is advice McCain does not need.

The odds of beating this cancer are long. Whether he does or doesn't has nothing to do with his character or courage. That is not, despite some incredibly disrespectful comments President Trump made about him in the run-up to the presidential election, up for dispute.

McCain is a military hero. The genuine article. The former Navy pilot spent five and a half years in a notorious North Vietnamese prison known as the "Hanoi Hilton," where he spent 2 years in solitary confinement and was brutally tortured despite being severely injured when he bailed out of his plane. Concerned about his fellow prisoners, he would not accept an early release.

Whatever cancer does to John McCain and however he chooses to treat it or not, he is a brave man who is certainly a fighter. As with anyone, he will find his own best path to dealing with a grim diagnosis. Whatever that is, he will remain a hero and a fighter.

O. Less than half of mothers place sleeping infants supine

P. Hospice Compare website goes live to the public

The CMS launched its Hospice Compare website this week, including data from almost 4,000 hospice providers and covering seven quality measures on hospice and palliative care that are endorsed by the National Quality Forum. An AAFP policy statement notes that family physicians are in a position to provide leadership in hospice care and serve as medical staff or medical directors.

Q. Medical Education in the Era of Alternative Facts

Wenzel RP. N Engl J Med 2017; 377:607-609.

Students currently entering U.S. medical schools arrive in an era of increasing distrust of large institutions, expanded use of social media for information, a political lexicon in which uncomfortable facts are derided as “fake news” while fabrications masquerade as reality, and the erosion of truth that such trends entail. The challenges for medical education are imminent and formidable. How do we, as teachers, merit the trust of future physicians? How do we pass on to them science’s preeminent legacy of propelling advances in understanding, preventing, and curing illnesses? How do we instill in them a lifelong appreciation for the importance of hypothesis testing, peer review, and critical analysis of research? These questions should prompt an immediate review of the goals and processes of education and the values we need to emphasize in day-to-day interactions with students.

A useful early step in earning the warrants of students is a transparent review of the history of ideas in medicine. Such a survey would make clear that some ideas have worked, some have failed, and some have turned out to be built on scientific fraud — but that developing and testing hypotheses that might not pan out are essential to the scientific method. New ideas have often been rebuffed strongly by people in authority who had reason to fear challenges to the status quo. Some investigators didn’t live long enough to see their novel ideas become widely accepted. Those who succeeded, however, evinced not only unyielding perseverance, but also integrity and dedication not for personal gain but for the public good. Renewing a strong curriculum in the history of medicine would thus lay a foundation for a realistic yet hopeful appreciation for the potential, advances, and truths of science.

On the hopeful front, a related and necessary building block for students is the intellectual curiosity to both identify and question those truths. We can let medical students know that whereas throughout their previous schooling they were judged by their answers, in their medical education and their careers they will often be judged predominantly by their questions. We should applaud students for curiosity and inquiry and for showing reasoned doubt about what they read and hear. We can challenge them to pursue reliable information beyond the classroom or ward discussions, as we avoid the pitfalls of trying to transfer all our knowledge to them during our face-to-face time. As William Butler Yeats (probably paraphrasing Plutarch) wrote, “Education is not the filling of a pail but the lighting of a fire.” Providing the spark is our job.